Check out these three case studies and discover just how powerful a
personalized approach to healthcare can be ...
Case Study #1
How Rheumatoid Arthritis in a 46 year old was resolved by treating the gut
A 46-year old female came to my office with joint pain in her hands and feet, digestive symptoms that included gas, bloating and constipation, along with cold hands and feet, brain fog, anxiety and insomnia.
Her symptoms had worsened over the previous three months after the death of her mother and the loss of her job.
She had been given a diagnosis of rheumatoid arthritis by her family doctor and prescribed immuno-suppressive drugs, which she refused to take. She occasionally took Advil to manage her pain, but was concerned about its long-term side effects. She had a strong family history of autoimmune conditions.
I ran a full panel of functional tests on Michelle, including a stool test, a small intestinal bacterial overgrowth test, an organic acids test and a hormone panel.
Michelle's stool test found low levels of Lactobacillus and E. coli species, both important beneficial bacteria. It also confirmed the presence of two pathogenic bacteria, Enterobacter cloacae and Klebsiella pneumoniae.
The Klebsiella is of particular concern here, given Michelle's symptoms. This species is associated with conditions that are characterized by joint pain, including ankylosing spondylitis, reactive arthritis, and rheumatoid arthritis. It's also found in cases of irritable bowel syndrome and other digestive conditions.
The association between Klebsiella and autoimmune disease is mediated by the HLA-B27 protein, which is found on the surface of white blood cells. So I tested Michelle for HLA-B27 via a blood test and she was found to be positive.
This finding suggests that Michelle may be more susceptible to autoimmune conditions and that a Klebsiella infection may be more problematic for her than for others who may be HLA-B27 negative.
Her SIBO breath test results indicated methane over-production. This finding confirms small intestinal bacterial overgrowth, which was likely contributing to her constipation.
Her organic acids test confirmed microbial overgrowth and imbalance in her gut, along with several other key findings:
- B vitamin deficiencies
- Oxidative stress
- Impaired carbohydrate metabolism
- Impaired fatty acid metabolism
- Impaired detoxification capacity
Michelle's blood work showed iron overload. She had excessive iron storage, but not hemochromatosis. And her iron elevation wasn't a result of inflammation since her iron saturation and UIBC were abnormal, in addition to high ferritin. High iron levels can contribute to joint pain, cognitive dysfunction and many other symptoms.
Her TSH and thyroid antibodies were normal, but her free T3 was low. This was likely contributing to her cold hands and feet, constipation and brain fog. She also had a low white blood cell count, which is common in autoimmune conditions.
Likely her low free T3 is secondary to her gut dysfunction. Approximately 20% of T4 is converted into T3 in the gut. Inflammation, which is clearly experiencing, also reduces the conversion of T4 to T3.
Finally, Michelle's hormone panel revealed high-normal free cortisol and low metabolized cortisol. Plus her diurnal free cortisol production was out of balance, with high levels at night, high-normal levels upon rising and in the morning, and then low levels in the afternoon.
Elevated cortisol levels reflected her stress response, consistent with her history of job loss and the death of her mother. Hypothyroidism impairs the body's ability to metabolize cortisol so this pattern of high free cortisol with low total metabolized cortisol meant that Michelle had poor thyroid function, consistent with her low free T3.
One of the core principles of Functional Medicine is to address the underlying causes of illness rather than suppress symptoms. Therefore, I chose to start with addressing Michelle's gut imbalances - the small intestinal bacterial overgrowth (SIBO), dysbiosis and infection. After which we planned on re-testing her thyroid markers since there was a good possibility that her thyroid would resolve on its own once her gut function improved and inflammation decreased.
The key goals of Michelle's personalized treatment plan were:
- Reduce overgrowth of Klebsiella and prevent further immune attack.
- Reduce levels of methanogenic microbes in the small intestine by treating SIBO
- Restore nutrient balance and metabolic function by improving digestive absorption of nutrients.
- Increase levels of beneficial bacteria and restore a healthy microbial balance in her intestines.
- Optimize her iron levels.
- Increase her free T3 levels and improve thyroid function indirectly by addressing her gut health.
- Normalize her free cortisol and total cortisol levels indirectly by addressing her gut health.
Supplements included anti-microbials, biofilm disruptors and anti-inflammatories. Therapeutic blood donation was recommended to get her iron levels down.
After the anti-microbial protocol, a combination of fermented foods, fermentable dietary fibers, probiotics and prebiotics were used to restore a healthy gut ecosystem.
Michelle received treatment for 60 days and then we ran another set of tests to assess her progress. Her follow-up testing indicated signficant improvement.
The Klebsiella and Enterobacter were gone. Her beneficial improved, with the exception of Lactobacillus, which still needed attention.
(Note that at first glance the level of yeast may look like a fungal overgrowth, however one of the probiotics in her treatment plan was Saccharomyces boulardii, which would account for this finding.)
Her follow-up SIBO results were normal.
Her organic acids test also improved significantly, with only two markers in the low-normal range. Obviously, treating the gut effectively supplied Michelle with critical nutrients that, in turn, improved her metabolism.
Her iron saturation dropped to 28% after two blood donations. Her ferritin returned to the normal range, although still high normal. Further blood donations were indicated.
Her free T3 improved dramatically without any specific focus on her thyroid. That being said, her TSH and reverse T3 remained high-normal, which indicated an ongoing stressor that is not influenced by her gut function.
Finally, her hormone tests results normalized. This also illustrates the importance of addressing the deepest causes first.
Most importantly, Michelle's symptoms improved dramatically. Her joint pain was reduced by 80 to 90% and she no longer needed pain medication to manage it.
Her body temperature normalized and she no longer had cold hands and feet. Her constipation, which had been present for over a decade, resolved - as did her gas and bloating. She was able to think more clearly and concentrate for longer periods and she no longer felt anxious.
For the first time in many years she was sleeping deeply through the night and waking up in the mornings feeling refreshed and energized.
Case Study #2
How Mental and Physical performance were optimized in a 41 year old CEO
Macy was a 42-year old mother of four and business owner that came into my office with fatigue, especially in the afternoons, as her main concern. One of her children was on the autism spectrum.
She never felt like she had enough energy to make it through the day. She woke up in the morning feeling unrefreshed and her exhaustion worsened as the day progressed.
Macy had difficulty sleeping without medication. She worked out at a CrossFit gym a few times a week and reported that her performance and exercise tolerance had declined steadily over the past 18 months. She also recently noticed fat gain around her waistline and underneath her chin.
During our appointment I noticed that several aspects of her current diet and lifestyle could be responsible for, or at least contributing significantly to, her primary concerns. For example:
- Due to the increasing demands of her business and her ongoing familial obligations, she was averaging just under six hours of sleep per night.
- She did high-intensity CrossFit workouts a few times a week, despite increasing feelings of fatigue.
- She started a strict Paleo diet 18 months previously, which corresponded with the decline in her energy and exercise tolerance.
In short, Macy was burning the candle at both ends - a perfect recipe for HPA axis dysregulation / hormone imbalances. What's more, I suspected that her intake of both calories and carbohydrates was insufficient for her activity level and energy needs.
After analyzing Macy's three day food diary I confirmed she was significantly undereating both calories and carbohydrates. Her average calorie intake was about 1400 to 1600 per day, with less than 50 grams of carbohydrates on most days.
On her CrossFit training days, Macy should have been eating 2200 calories - a full 600 to 800 more than she was typically consuming. On her resting days she should have been eating 1900 calories, which was still 300 to 500 more calories than she regularly ate.
Macy's carbohydrate intake was 13% - far below the recommended threshold of 30% for athletes or high active people.
Here are the targets for total calorie, carbohydrate, fat and protein intake that I suggested for Macy:
In addition to the dietary changes, I suggested she get at least 8 hours of sleep each night. This meant giving up her use of Facebook and other social media at night. She also hired two employees to help her with her business.
These changes were not easy, but Macy was willing to make them because she was alarmed by the recent changes in her health - and because I explained to her that HPA axis dysfunction is not possible without adequate sleep.
I also recommended that she dial back her exercise routine significantly. I asked her to avoid CrossFit entirely until she was able to start sleeping better and her energy levels recovered.
Finally, I suggested that Macy being a meditation practice in order to help her manage her stress and anxiety. Given her technology orientation (her company was a tech start-up), busy lifestyle, and several unsuccessful attempts to start meditating in the past, I suggested Macy try using the Headspace app. This worked well for her.
After three months of treatment, Macy experienced some remarkable changes:
- She began falling asleep without medication and sleeping through the night on most nights.
- She woke up feeling refreshed and no longer felt tired during the day or had energy crashes in the afternoon.
- Much to her surprise, adding carbohydrates to her diet not only didn't lead to weight gain, but it had the opposite effect: the extra fat she had gained around her midsection and under her chin began to decrease.
- She reported feeling less anxiety and greater stress tolerance, despite the fact that the circumstances of her busy life hadn't changed much.
- Her exercise tolerance gradually improved and she was again able to start increasing her performance at the gym.
Once Macy's energy levels and sleep were better, I then suggested she work with the trainers at her gym to create a routine that was more appropriate for her particular circumstances and needs. She was able to return to training three days a week, but at a lower intensity than she was before.
A straight-forward protocol of dietary and lifestyle changes over three months led to increased energy, restorative sleep, weight loss, less anxiety and better stress tolerance.
This case is a great example of the importance of focusing on the basics: a thorough intake and history, coupled with personalized diet and lifestyle recommendations.
Case Study #3
How hypothyroidism was resolved in a 26 year old
A 26 year old female named Janel came to see me after being diagnosed with hypothyroidism. She was overweight, her hands and feet "felt like icicles," her hair was falling out, and she was constipated.
Her doctor prescribed levothyroxine, a synthetic thyroid hormone, but Janel wanted to know why her thyroid wasn't working properly and whether there was something she could do to address her condition without resorting to medication.
I ran a thyroid panel, complete blood count, comprehensive metabolic panel and additional blood tests, including iron and vitamin D. Because of her constipation and hypothyroid symptoms, I also ran tests on her gastrointestinal function, including a small intestinal bacterial overgrowth (SIBO) breath test, a stool analysis, and urinary organic acids to look for dysbiosis. I also ordered a panel to look at her hypothalamic-pituitary-adrenal (HPA) axis function and an urine iodine test.
Janel's thyroid stimulating hormone (TSH) was significantly elevated. Here total and free T4 were well within the normal reference range, but both her total T3 and free T3 were low-normal. Her Total T3 and free T3 are below what I consider to be optimal.
Janel also had low levels of vitamin D and high levels of iron, both of which are associated with poor thyroid function.
Breath testing revealed the presence of bacterial overgrowth in the small intestine. SIBO may impair the absoprtion of several nutrients that important for thyroid health, such as zinc, selenium and iodine.
Some studies have shown that hypothyroidism may contribute to SIBO by decreasing intestinal motility.
Janel's stool test showed a 3+ growth for Citrobacter koseri, a species of bacteria that can be pathogenic when overrepresented in the GI tract. Janel had adequate levels of beneficial flora but some imbalanced flora were accumulating.
Janel's stool test further revealed elevations in lactoferrin and lysozyme. When only mildly elevated they often represent inflammation secondary to pathogenic microbes or other causes.
She had a very high secretory IgA, a marker of immune function in the GI tract. This high level suggested that her immune system was in overdrive, possibly due to bacterial overgrowth or another underlying inflammatory condition.
Her urine organic acids test (OAT) had several markers for gut dysbiosis, particularly an overgrowth of Clostridia species (HPHPA) that produce known neurotoxins and a marker that may be associated with fungal overgrowth.
The SIBO, stool and organic acids tests showed that Janel had moderate dysbiosis.
A hormone test assessing her hypothalamic-pituitary-adrenal (HPA) axis function revealed high free cortisol, but low metabolized cortisol. Hypothyroidism impairs the body's ability to metabolize cortisol, so this pattern suggested that Janel had poor thyroid function.
This test also showed a disrupted diurnal cortisol rhythm. She had high cortisool in the morning, afternoon and night.
As I reviewed Janel's dietary survey, I noticed that she didn't eat seafood or seaweed and that she used sea salt rather than iodized salt. I also noted that she was consuming a green smoothie with large amounts of raw kale every morning. Kale is a goitrogen that can inhibit iodine uptake in the thyroid gland.
Because of her low intake of iodine and high intake of raw kale, I suspected she was iodine deficient, which I confirmed with a 24-hour urine iodine test.
For treatment, I started Janel on an iodine protocol and asked her to eat more selenium-rich food, such as Brazil nuts. I recommended she limit her goitrogenic foods to three to six servings a week and make sure to cook those foods to reduce their effects on thyroid function.
I also prescribed a high-vitamin, extra virgin cod liver oil to bring up her vitamin D levels.
I treated her SIBO, bacterial overgrowth and inflammatory markers by using a botanical anti-microbial protocol for 30 days. Plus we added specific probiotics (beneficial bacteria) that are known to degrade methane.
I addressed her HPA axis dysregulation with a comprehensive program including circadian regulation, stress management, adaptogens and other nutrients to support HPA axis function and improve cortisol metabolism.
Finally, I advised her to donate blood to reduce her iron levels into an optimal range.
After three months on this program, her hypothyroid symptoms had improved dramatically and her TSH and other thyroid markers had normalized - without any medication at all.
Her HPA axis function improved, with normalization of her total free cortisol production as well as the free cortisol diurnal rhythm. Her follow-up testing showed a decreased free cortisol and an increased metabolized cortisol, placing her in the normal ranges for both results.
Her cortisol levels decreased and she had normal cortisol upon waking, in the morning, afternoon and night.
Janel no longer complained of cold hands and feet and her hair loss slowed down dramatically until it wasn't an issue anymore. She started having regular bowel movements. She was pleased and wmpowered to resolve her thyroid condition without taking medications.