52 year old Male presented to the clinic with the following complaints:
Main issues:
- General joint pain with reoccurring tendon pain in both elbows with overuse
- Benign Prostate Hyperplasia
- Poor sleep patterns with frequently waking after 3am
- Increasing anxiety and mood fluctuations
- Low energy
- No gall bladder - removed 20 years ago
- Some weight around the tummy he is keen to shift.
Blood markers:
Previous panel not available but patients reports all within normal conventional ranges on last check. I would personally question normal vs optimal though.
Current lifestyle and previous interventions - Patient exercises 3-4 times per week. Works long hours. Has a busy family life with 4 children aged between 12 and 21 years old. Previous physiotherapist had helped the elbow pain but even with ongoing exercises the pain keeps returning.
Current medications:
- Valdoxan (anti-depressant)
- Flomaxtra (prostate medication)
Current diet (Typical day):
Breakfast - Oats, honey, x1 banana, piece of toast and flat white.
Mid morning - Apple or Grapes
Lunch - Sandwich on wholewheat bread
Mid afternoon snack - varies but often a few biscuits
Dinner - Generally meat and vegetables and/or rice. Pasta twice a week.
Dessert - ice cream some nights.
First thoughts:
My initial thinking was the patients symptoms suggest a level of increasing systemic inflammation. When tendon issues keep reoccurring despite exercise intervention they are likely either; being really challenged mechanically, like a builder or, they have a background inflammatory issue that causes a load intolerance.
This patient works in finance and does not do anything requiring significant elbow load so I assumed the latter. He has also been diligent with his exercises so I felt the mechanical input had been sufficient.
When systemic inflammation is present, it can often lead to changes in mood and brain function. The patient reported no increasing life or work stress so I wondered whether this was another manifestation of increasing inflammation. He had tried meditation and mindfulness before but struggled to stick to it.
My other concern was his BPH. This is a difficult disease process and whilst the medications help relax the muscles around the prostate, I believe this only corrects the symptom and does not reduce any further growth. The largest growth stimulant in the body would be elevated insulin due to dietary factors. Insulin is a signal in the body to grow and store. Long term it would make sense to keep this as low as possible.
Looking at the patients diet it has a high carbohydrate load each day which would keep insulin elevated. His typical breakfast would roughly be the equivalent of 15 teaspoons of sugar. Whilst some of the carbohydrates chosen are slower release (lower GI), it would still require a major insulin response. Same with the sandwiches for lunch. Two slices of wholewheat toast will spike blood glucose more than a snickers bar for most individuals. Not only does this create a daily insulin level beyond what should occur, a high glucose load as an energy source also causes more inflammation. Fat as a fuel does not produce the same inflammatory response with reduced oxidative stress and free radical damage in the mitochondria. His protein intake appears too low too and he eats within an hour of waking up.
I also had concerns with his high fruit diet. I recommend fruit seasonally and think low sugar fruit such as berries are a much better choice for most. Tropical fruits such as bananas and mangoes are incredibly high in sugar and taking either of these daily must be done with caution. As fructose is mostly metabolised in the liver it can quickly convert to liver fat. He has the occasional juice but likes to make his own smoothies. The patient reported low alcohol intake but I suspected the high fructose diet could potentially be causing liver fat to accumulate. Whilst his doctor had never mentioned ‘fatty liver’ to the patient, I was keen to see his blood markers ALT/AST.
His gall bladder removal meant I was a little wary of suggesting too much fat in his diet so we prioritised protein and cleaner easier to digest fats such as MCT’s.
The medication he was taking is a new form of antidepressant which works primarily on melatonin receptors. I would say it is closer to a sleeping tablet. The issue with it from doing some research is it has a very small half-life and basically wears off after about 4 hours. About the same time the patient wakes up. Whilst mechanistically it is much safer to other pharmaceutical sleep aids, I was not surprised the patient was waking up once it had worn off. My thoughts with sleeping aids is they lead people to not address key aspects around sleep hygiene to create a natural sleep pattern. If you have a tablet to help you sleep, you are less likely to practice good sleep hygiene. I personally turn off all my technology by 8pm, read quietly before bed, perform some breathing exercises and always ensure I get early morning sun. If I don’t do these my sleep is hindered.
Treatment Approach:
- Lower carb diet. I swapped his grain and fruit heavy breakfast for eggs and/or fish. Sometimes an avocado and spinach. His lunchtime sandwich to a salad. Dessert in the evening switched to a piece of 85% dark chocolate. Whilst I’m not a big fan of counting my own macros, the patient described himself as ‘numbers guy’ so he tried to keep his carbohydrates below 75g a day. I suggested he priorities protein and restrict his carbohydrates to one meal per day.
- Intermittent fasting. Patient adopted a 16/8 protocol of 16 hours fasted by night and 8 hours eating window. This will aid insulin sensitivity and reinforces good circadian biology.
- Better sleep hygiene. I introduced sleep hygiene habits similar to my own. His aim was to be in bed a little earlier, switch off technology at least an hour before bed and be mindful of artificial light exposure in the evening. Once the kids went to bed he would only go by a very gentle bedside lamp. He also started going for a morning walk at sunrise.
- Adopt breathings exercises. As the patient found mindfulness and medication boring I trialled the Wim Hoff method. What I like about this approach is the increased intensity to it and it feels closer to performing exercises like you would in the gym. My patient clearly has discipline but maybe just hasn’t found the approach that works for him.
- Reviewed tendon based strengthening exercises
Supplements:
- magnesium for mood and sleep
- SPM’s by metagenics for reducing inflammation
- Curcumin for inflammation
- MCT oil added (milk replaced) to coffee in the morning to help him fast until 16 hours.
3 week review:
Patient reports significant reduction in tendon pain, improved mood and clearer thinking. Energy initially struggled with changing diet but now feeling more energised and less hungry. He has been training harder in the gym with resistance training due to decreased elbow pain. Patient went to doctors for blood tests.
Blood test results:
The good
Fasting insulin: 4
Blood glucose: 5.0
Triglycerides: 1.0 (fat in the blood)
HDL: 1.6 (generally called the good cholesterol)
HS-CRP: 0.4 (inflammation marker)
Needs improving:
ALT: 41 AST: 42 (liver enzymes - fatty liver marker)
Vit D: 62 (in normal range but far from optimal)
Added intervention:
Due to the blood chemistry panel I was happy with the low carb diet and the effects on insulin. I like to see insulin below 7. Conventional medicine has the range below 15 but I wouldn’t want my own insulin about 7 so I aim for the same with my patients. Particularly a patient trying to reduce his prostrate growth. His inflammation appears low and his cholesterol panel showing good response to the diet changes. I keep an eye on this with a higher fat diet as some genetic variations will respond poorly to increased saturated fat in the diet. I think HDL and triglycerides are the key to monitor.
What I felt he needed to improved upon still was his liver enzymes and vit D. I thought this could be potentially the same issue as choline deficiency. You require choline for good bile flow and to clear fat from the liver. Some individuals have lower choline production genetically so struggle with bile flow. They tend to have their gall bladder removed when simple choline supplementation could have corrected the problem. I consequently added a bile salt supplement and choline supplement to his life. I also recommended a Vit D3 and K2 supplement. Vit D is a fat soluble vitamin so it ties in with bile flow again. You absorb less of the fat soluble vitamins A,D, E and K with poor bile.
Final ongoing health plan for patient:
- Continue lower carb diet and avoid all processed food.
- Intermittent Fasting 16/8 with 3 meals a day not 5.
- Continue Wim Hof method
- Sleep hygiene protocol
- More daily doses of sunlight when possible
- Daily physio strengthening exercises
- Supplements as advised
- Re-test blood markers in 3 months
Disclaimer. The case study is not intended as medical advice. Please consult your medical professional before trying anything suggested.
Podcasts to support and explain approach:
- Why low carb Dr Peter Brukner https://youtu.be/4WPF3RMPI9k
- Fasting/time restricted eating with Jason Fung https://youtu.be/rQsMRjAwcFo
- Game level interactions https://youtu.be/NiCoklaCnDk
- Wim Hof Method https://youtu.be/TM6WKeZ43s4
- Benefits of magnesium https://youtu.be/qPy4TArgRuY
- Choline and fatty liver https://youtu.be/2xfAUq1cawI