November 21, 2017 at 2:35 pm #1244Tess StrömParticipant
Primary presenting symptoms
• This client came to see me 8 months ago for weight loss, he was then 82.9kg (fat – 22.9%)
• In the first 3 months he lost 7kg however then reached a plateau and he has since put on 2 kg. Says he has always struggled with weight.
• Intolerant to gluten, dairy, peanuts since childhood
• Low mood, started after severe work stress 3 years ago
• Low energy (it improved for a while but then reduced again) – he exercises a good amount (running, yoga) when he has the energy
Symptoms which we have resolved:
• Compromised immune system with frequent chest infections and tonsillitis, not had any for 6 months
• Severe sugar cravings
• Problems falling asleep (Stabilium seems to have resolved this)
Family very poor when he was a child so they often went without dinner.
Remembers often suffering from acid reflux and severe bloating, believes he has had issues with gluten ever since childhood. Grew up in Argentina where staple diet was pasta, pizza, bread.
Suffered from tonsilitis every 1-2 months as a child from around 5 years old to 15. Always treated with antibiotics alongside probiotics. Became resistant to amoxicillin then given penicillin.
He was diagnosed with Gilbert’s syndrome as young but always told would not cause any problems.
Grew up near farmland which was regularly sprayed with pesticides.
At 13 – This is when he was at his heaviest at 98kg, partly due to the family doing financially better and partly due to supress various emotions. His family did not agree with his sexual orientation and he believes that by covering his body with fat he made himself asexual. Says always had a more feminine body compared to father who had beard etc.
At this stage started exercising 5 / day – lost weight and was 58kg at the lowest. Slowly increased in weight and was ideal at 68kg, felt better, slept well.
At 17 – had cyst on Adams apple – operated on – non-cancerous.
At 24 – severe stress at work, lots of bullying, ended up leaving. Set up as a freelancer, now doing well but took 2 years to grow it and was very stressful. Put on weight during that process.
At 25 – severe food poisoning when in Ethiopia.
2016 – following Brexit vote, neighbours turned on him and his partner which caused a lot of stress.
Early 2017 – tonsillitis very ill – took penicillin
When he first came to see me, he was gluten free at home however, when out, up to 2 / week was not.
When he had had gluten, stomach was bloated and he was short of breath. If it happened at night, he was unable to sleep at all. Says felt hot from inside. Also describes what sounds like keratosis pilaris on his arms when he had had gluten.
Called himself a sugar addict, had severe sugar cravings and used to eat large amounts of it on daily basis, anything sweet he could get his hands on.
Stress with neighbours continued until my client and his partner finally moved a month or so ago. Said that even when he does lose weight he has fat around his waist.
History of medication
Lots of ABX as a child, also recent intake due to tonsillitis
For his stress he practiced meditation and had been seeing a psychotherapist for 2 years, 1 /week.
He was also taking Mg Bisglycinate and Zn Glycinate for anxiety and muscle pain.
Antecedents – high sugar low nutrient diet / emotional eating due to family issues / high ABX intake /?intestinal permeability / Gilbert’s Syndrome / living near farmland – high pesticides
Triggers – food intolerances / food poisoning / recent emotional and financial stress
Mediators – ?imbalanced cortisol / ?hypothyroid / ?high oestrogen / ?low testosterone / dysbiosis / chronic stress
GI Effects test results showed:
Very high fecal fat – 63.7 (3.2 – 38.6)
Product of protein breakdown 8.3 (1.8 – 9.9)
LCFA 41.9 (1.2 – 29.1)
Beta glucuronidase 2453 (368 – 6266)
Inflammatory markers – normal
Low beneficial bacteria
Citrobacter 2+ (pathogenic at 4+)
Klebsiella oxytoca 1+ (pathogenic at 4+)
TG 0.5mmol/L (0.5-2)
HDL 1.3mmol/L (>1)
LDL 3.8 mmol/L (1-3)
CRP 3.8 (0-5)
HbA1c 5.5 (4.10 – 6)
Vitamin D 83nmol/L (50-150)
DUTCH test – complete hormone
DHEAS 163 (160-2000)
Testosterone 120.9 (25-115) – told this is fine for a 28-year old male
Estrone E1 5.4 (4-12)
Estradiol E2 0.8 (0.5 -1.6)
Estriol E3 2.7 (2-6)
16-OH E1 0.3 (0- 0.8)
4-OH E1 0.4 (0- 0.5)
2-OH E1 2.2 (0-3)
2 Methoxy E1 2.2 (0-2)
Methylation-activity – high
Melatonin 22 (10-85)
Cortisol / Cortisone:
Waking 47.1 (18-80)
Morning 89.1 (50-2000)
Afternoon 14.3 (11-45)
Night 5.3 (0-25)
Free cortisol 156 (100-310)
Metabolised cortisol 3550 (4550 – 10000)
Free cortisone 367 (250 – 500)
I understand it metabolized cortisol is the better marker for cortisol production and in my client it is low, indicating a low HPA axis. As free cortisol is within range could this be due to sluggish clearance? And if so what is the potential cause? I am aware that hypothyroid can be implicated and considering his other symptoms of low energy / mood and issues with weight we also tested his thyroid.
Thyroid test results
T4 7.5 (5.8 – 16.1)
TSH 1.52 (0.4 – 4)
FT4 14.2 (11.5 – 22.7)
FT3 4.9 (2.8 – 6.5)
FT4 / FT3 2.9
RT3 0.23 (0.14 – 0.54)
TG <32 (<=40)
TPO <14 (<=34)
These results seem fine to me and although antibodies are slightly raised, they are still within range, would you agree?
Diet and Supplement
We initially cleaned up his diet and took foods such as gluten, dairy, sugar and peanuts out.
We also worked on blood sugar balancing with plenty of protein, high vegetables including some starchy veg, low grains as well as healthy fats included in moderate amounts (oily fish, avocado, some seeds, no nuts).
Plenty of liver nurturing greens and cruciferous vegetables
Fermented foods such as coconut kefir as well as prebiotic foods and stewed apples.
After a month or so we introduced one fasting day per week, he says he feels so much better, more energy and clearer thinking after a day of fasting. Initially he was also losing weight however, not anymore.
He is also practicing meditation as well as breathing techniques for stress reduction.
Ca-D-Glucarate (now stopped)
Digestive enzymes (Dipan-9)
I am not really sure of the next best step – My client is not severely overweight, however, I know that he feels best at around a stone less than present weight and I do not want him to get dispirited from the present lack of weight loss.
What am I missing? If thyroid is not the cause of low metabolized cortisol, could it be purely stress that’s implicated? Could that alone be why he is struggling to lose more weight? Apart from Stabilium, what supplement/s would be good for adrenal support? I am considering Adrenotone, Adrenal C Fomula, Super Adrenal Stress Formula.
Could weight issue also be linked to detoxification issues due to Gilbert’s Syndrome? When researching I found that in Gilbert’s syndrome fasting may lead to weight gain however, it seems to indicate that is only linked to long fasts, is this correct? What about dysbiosis? Could this be linked to weight loss issue? Considering he still experiences bloating, I am considering a month of plant tannins.
Posted By Tess Ström 21/11/17
March 17, 2019 at 2:41 pm #1245Carrie Decker, NDModerator
Thank you for contributing this case here. It sounds like this man has struggled with some issues surrounding weight and food as a focal point in his life off and on. Given your description of his history it sounds like focusing on the food and weight at times has been in effort to control other things. I am glad that he has been working with a therapist for the last couple years as well.
Given the results of the stool testing it sounds like there is significant fat malabsorption. I am surprised he does not have more digestive symptoms. In addition to the supplement Beta-TCP, you may want to consider supplemental bile to support his fat absorption. Given the poor fat absorption he also may benefit from supplemental fat-soluble vitamins. As hormones, including cortisol, are made from fats, making sure his body is absorbing the fats in his diet is important. Adequate bile flow is important for healthy gastrointestinal motility and flora balance as well.
Although the support team for the DUTCH test may have additional input, from my perspective he could use adrenal support given his low DHEA-S as well as overall cortisol numbers which all are on the lower end. I personally like to work with glandular and botanical support when the collective levels are significantly depressed, and symptoms also suggest a hypofunctioning state. By supporting the body with glandular substances you are also providing necessary precursors for the body to use as food such that normal function of the gland can be restored.
Although both whole adrenal glandular and just the cortex are available, given his symptoms associated with mood as well I would suggest working with the whole glandular tissue. If he does not tolerate the whole glandular, you may want to switch to adrenal cortex alone. The adrenal medulla is the principal site of the conversion of the amino acid tyrosine into the catecholamines; epinephrine, norepinephrine, and dopamine. As these neurotransmitters have importance for his mood, the whole adrenal glandular may also improve this. At times, people who are higher on the end of anxiety do not do as well on the whole glandular, and for that reason you may want to use the adrenal cortex alone.
Rhodiola rosea is an herb that is considered an adaptogen, however it also can positively impact mood, memory, and weight. It can be found in one of the adrenal supportive combinations detailed in the suggestions below. This herb also has evidence for reducing binging behaviours.
Cifani C, et al. Effect of salidroside, active principle of Rhodiola rosea extract, on binge eating. Physiol Behav. 2010 Dec 2;101(5):555-62. https://tinyurl.com/yd5vxwly
Perfumi M, Mattioli L. Adaptogenic and central nervous system effects of single doses of 3% rosavin and 1% salidroside Rhodiola rosea L. extract in mice. Phytother Res. 2007 Jan;21(1):37-43. https://tinyurl.com/ybdf9kmd
DHEA supplementation in combination with a low energy, high fibre diet has been shown to improve weight loss in animal studies. The 7-keto metabolite of DHEA also supports healthy thyroid function, which generally looks to be fine for this man, but additional support may promote weight loss. Research has shown that 7-keto DHEA increases thermogenic enzyme activity, which may enhance the body’s basal metabolic rate, helping to promote weight loss without requiring significant alterations to caloric intake or activity levels.
MacEwen EG, Kurzman ID. Obesity in the dog: role of the adrenal steroid dehydroepiandrosterone (DHEA). J Nutr. 1991 Nov;121(11 Suppl):S51-5. http://tinyurl.com/qje3o5e
Although the stool test did not find pathogens or significant dysbiosis, in the future you may want to consider testing for small intestinal bacteria overgrowth (SIBO) which often presents with symptoms of gas and bloating. However, additional support for bile may help alleviate these symptoms as well. SIBO can be assessed for with a breath test through Regenerus Labs (codes which cover SIBO are CMI26 and CMI27), and they can be contacted at http://www.regeneruslabs.com or by email on email@example.com or tel +44 (0)333 9000 979. Biolab in London also offer a breath test for SIBO and can be contacted at http://www.biolab.co.uk or tel 020 7636 5959 / 5905.
The topic of Gilbert’s syndrome has been addressed quite extensively in multiple discussions on the Clinical Education Group. Please do see some of the discussions pertaining to this topic at http://tinyurl.com/nromlyx & http://tinyurl.com/pxm9st5 & http://tinyurl.com/keusflm & http://tinyurl.com/oetfw6u.
If you are not yet familiar with it, you may find the Control-IT Programme from Antony Haynes available on the Nutri Link Ltd Clinical Education site also to be useful in supporting healthy weight loss – http://tinyurl.com/38lvpzb.
The following supplements are suggested for you to consider in light of your relevant expertise and understanding of the needs of your client or patient. They may be used in isolation or as part of a multi supplement strategy, but at all times the consideration of their use should be tied into the specific needs of the individual you are responsible for.
To support fat digestion:
Beta Plus (BRC): 1 tablet before meals. http://tinyurl.com/otttdvv Provides bile salts, digestive enzymes.
Ox Bile (ARG): 1 capsule before meals. https://tinyurl.com/yc4wspgq
Vitamin D3 Complete (ARG): 1 gelcap once daily with meal. http://tinyurl.com/q3dnzcr Provides fat-soluble vitamins.
Support for adrenal function and healthy weight:
ADB5-Plus (BRC): 2 tablets once a day in AM. https://tinyurl.com/yclspwb6 Contains vitamins and minerals to support adrenal function as well as adrenal glandular and rhodiola.
7-Keto-Zyme (BRC): 1 tablet once daily between meals. http://tinyurl.com/prt24ey 7-keto-DHEA supports normal metabolic function.
If ADB5-Plus is too stimulating, consider:
Adrenal Cortex (ARG): 1 capsule in AM. https://tinyurl.com/y8ssb3kd Sensitive individuals may need to start with lower dosage (1/2 capsule) which can be added to food or liquid.
Please consider these suggestions in light of the other clinical information pertaining to this individual. If you have any more information about the specific problems this individual is experiencing, further refinement of these suggestions may be considered. I hope this information is helpful, and if you have any further questions or information specific to the problems this individual is experiencing, please do provide feedback.
- You must be logged in to reply to this topic.
Registered Nutritional Therapist Helen Perks is collaborating with Clinical Education to bring you the first-ever Functional Medicine book club for Practitioners.
- No Replies