65 year old female
Main issues
- Neck pain - intermittent for years but worse last year
- Migraines with visual aura - 2-3 per month.
- Recent osteoporosis diagnosis
- Bloating and occasional constipation
- Energy could be better
Blood markers
Last one over a year ago. Nothing she could recall of note. Osteoporosis diagnosed via bone density scan.
Current lifestyle and previous interventions
Patients works 3 days a week in an office. She attends 1 yoga class per week. Walks daily. Eats mostly a plant based diet. Has never found a pattern to migraine. Takes occasional ibuprofen for neck pain. Has a massage fortnightly for the neck pain and attends physio when neck has a flare up.
Medications and supplements
Occasional ibuprofen
Sumatriptan (migraine medication)
Vitamin D3 and calcium combined supplement (since osteoporosis diagnosis)
Multivitamin
Current diet - Typical day
Breakfast - fruit (berries and banana) and yoghurt. Adds LSA and honey.
Snack - Cliff bar or energy bar
Lunch - Avacado on toast with feta and tomatoes
Evening Meal - fish and chicken with vegetables or salad
Dessert - dark chocolate 70%. Sometimes strawberries and yoghurt.
First thoughts
Osteoporosis
The patients exercise routine lacks resistance and strength. Whilst yoga and walking are two things I recommend to most of my patients, I don’t think it is quite enough for bone density benefits. A good body weight strengthening program would be wise.
Im not a big fan of calcium as a supplement. It has repeatably been shown to increase cardiovascular risks.
https://onlinelibrary.wiley.com/doi/full/10.1111/jch.13010
I think a better approach would be to switch the calcium and vitamin D3 supplement to vitamin D3 and K2. vitamin D allows your body to absorb more calcium but it is the K2 that directs the calcium into the bones. Without K2 (which the patients diet also lacks), you risk having the calcium go into the wrong places such as soft tissue and even arteries. I would also like to see what the patients D is in her blood. Even with supplementation it can still be low. I like to see D above 100nmol/L. Conventional ranges aim for above 40nmol/L which is woefully low. I’d also like to check PTH (parathyroid hormone). When calcium levels are too low, the glands release PTH. It would give us a better idea of why calcium is low. I’d also like to see fasting Insulin as insulin blocks cholesterol converting into D. I would also like to see a higher protein intake in her diet. Protein supports bone health not opposes it contrary to a previous unsupported claim.
Migraines
I really like Dr Angela Stanton’s approach to migraine. She refers to migraine as a ‘channelopathy.’ She concludes that migraine can be fully preventable by doing two things:
- Reduce or eliminate carbohydrates from diet
- Greatly increase salt in the diet
I myself had migraines for many years with visual aura. These completely stopped once I changed my diet to a lower carbohydrate approach. I found Dr Stanton’s work after I had this change. She is very clear and easy to follow for anyone looking for a different approach to migraine and her best chat is attached below. The patient has a reasonably high carbohydrate diet and never adds salt to her food. This must change to help the migraines.
Bloating and constipation
This is a very common issue for many patients and most patients just think this is normal. I do not believe this to be the case. I think most bloating is caused by high amounts of microbes in the upper intestine. It is sometimes referred to as SIBO (small intestine bacterial overgrowth) and I find the best approach to this is doing a low FODMAP diet. Effectively taking away feeding of the bacteria via diet. Sometimes antimicrobial herbs can be used in addition but I think the change in diet is a good place to start. This pattern also causes constipation and would be helped by the change in diet.
Neck pain
I really like breathing exercises when it comes to neck pain. I find many people have a vertical breathing pattern where they use their neck muscles to breathe. Neck muscles are there to move the neck and not support breathing. When I checked the patient she had this pattern so I figured it would be a good avenue to approach. There’s a wonderful chat on breathing I send to many patients attached below. I also think the changes to inflammation and bone density via the diet could help the neck too.
Medications
I’m really not a fan of NSAIDS such as ibuprofen. They only treat the symptom of inflammation but not the cause. They also block the resolution pathway and cause damage to the lining of the digestive track. I like to switch patients to fish oil in the form of SPM’s by metagenics and curcumin. Getting to the root cause of the inflammation is the key and I think that should be achieved via diet changes. The patients migraine medications is also just treating the symptoms and not the cause. They also cause rebound effects and worsen the migraine in the long-run.
Treatment Approach
- low FODMAP diet with higher protein intake. I changed her morning breakfast just slightly. I switched her to a high fat Greek yoghurt which was also higher in protein. I asked her to take out the high carbohydrate banana and just stick with the berries. Instead of LSA which can be a problem for the digestive track, I suggested just a few almonds or walnuts instead. I’m not a big fan of anything ground up. It doesn’t reflect how the food is found in nature. I also removed the honey but said we could bring it back in over time. I also added in a scoop of collagen protein. Lunchtime I suggested removing the bread and having the avocado with eggs or fish. The patient was happy switching to an omelette most days instead. Avocado is on the boarder-line with FODMAPs so having a break from it wasn’t a bad idea. Evening meal kept the same but with respect to FODMAP vegetables. Re snacking I asked the patient to try to go without but if she needed to she could have a few nuts, celery or smoked salmon. I switched the 70% dark chocolate to 85%. The reduction in sugar doing this is quite significant. I also suggested using more pink sea salt.
- Breathing exercises. As protocol in podcast. Twice daily for 5 minutes.
- Strength program. I used compound whole body movements included x1 legs, x1 upper body pull, x2 upper body push. Patient also had some hand weights at home which she was happy to add on the days she had more time. Program as follows; 2 sets of 20 squats, 2 sets of 15 rows using suspension straps, 2 sets of 15 supported push-ups on kitchen bench, 2 sets of 15 dips using sofa.
- Increased daily sensible sunlight exposure. Patient would make more effort to be out in the sun particularly in winter with the sun strength weaker. She would often walk covered up but would expose arms and legs more.
Supplements
- SPM’s by metagenics
- Curcumin
- Vitamin D3 with K2
- Electrolytes with sodium, potassium and magnesium.
- Collagen protein from ATP science
Bloods requested
Fasting Insulin (metabolism marker)
HbA1C (an averaged blood glucose marker)
Vit D (a hormone in reality not vitamin)
PTH (serves as a functional calcium marker)
HSCRP (inflammation)
Ferritin (stored iron and inflammation)
2 week review
Patients reports no new migraines and feeling better energy wise. She is really enjoying the breathing exercises and thinks they are helping the neck. She is finding the strengthening program tough but happy to continue. She has stopped taking the ibuprofen completely. Her bloating is better but still a work in progress. Her constipation is about the same.
She was able to obtain new blood markers. These were taken only a few days into the diet so were a reflection on her previous diet and health. They were as follows;
Fasting insulin 9 mU/L
HbA1C 5.3
Fasting Glucose 5.0
D 74 nmol/L
PTH Not tested.
HSCRP 1.7 mg/L
Ferritin; midrange
serum iron; low
This confirms some patterns we are working to improve. Her insulin whilst in conventional normal range, I believe to be too high. Fortunately her blood glucose remains good so insulin is doing a good job. This may not be sustainable though. Her insulin being elevated also may inhibit D production. Her D even with supplementation is too low. Her inflammation as tested via HSCRP is above the range I like to see. We will aim to have this below 1.0 mg/L with the protocol. Her low iron but higher ferritin is a pattern often seen with inflammation and is another marker to suggest bacterial overgrowth. The body stores more iron when inflammation and excess bacteria are possibly present. She was unable to obtain PTH which would have given more information on calcium in the body. She did have serum calcium but I don’t believe this is a marker worth looking at and doesn’t reflect calcium levels functionally.
Added intervention
- Intermittent fasting - I felt to reduce her fasting insulin some fasting would be of benefit. Patient had previously done 5:2 and was happy to try this again. She may consider 16/8 further down the line.
- Removal of all seed oils - after chatting to patient about inflammation I discovered she was using a canola oil to cook with. She also would often cook her chicken in crumbs using this oil. I switched this to either olive oil or coconut oil. I prefer saturated fats such as coconut oil or ghee for cooking. I refer to any chat with Dr Cate Shannahan to understand the dangers of using oils such as canola, vegetable, soy, sunflower etc.
- Supplement change - increase D to 2000IU daily
4 week review
Patient still has not had a migraine and is happy with progress. She will continue with the protocol and have new bloods done next month.
Final ongoing protocol
- Higher protein/lower carb diet
- Higher salt intake
- Low FODMAP diet
- Daily breathing exercises
- Daily resistance exercises
- Daily sun exposure
- Supplement changes as advised.
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
- Dr Angela Stanton on migraine https://youtu.be/Y-BcsGllgmU
- FODMAPS https://youtu.be/UWIYfQEf6ZQ
- DR Cate Shanahan on seed oils https://youtu.be/0hwj3FPZLl8
- Relationship between D and K2 https://youtu.be/9H7tbWVNrXQ
- Protein myths and more https://nourishbalancethrive.com/podcasts/nourish-balance-thrive/why-youre-probably-not-eating-enough-protein-how-k/
- Breathing video https://youtu.be/GHbee3fvqnY