OBJECTIVES
The use of the functional / integrative model to approach the metabolic syndrome The link between andropause and non-insulin dependent diabetes mellitus
CASE HISTORY
A 73yr old male presented initially with a history of:
• Type 2 diabetes mellitus
• Hypertension
• Dyslipidaemia
His cardiologist had prescribed
• Crestor 5mgs nocte
• Glucophage 500mgs daily
• Micardis 80mgs daily for the above problems
The reason for his consultation with me was that he preferred taking herbal medication and nutraceuticals supplements and wanted to discuss the side effects related to the allopathic drug he was prescribed. He had agreed to eventually take some allopathic drugs and said that he would like to stop fooling around and take medical advice as he was doing most of it on his own.
Furthermore he was taking a range of herbals and nutraceuticals - and now wants to do it properly without guesswork and trial and error as he was doing this entirely on his own accord. He obviously had immense knowledge on natural medicine as well as homeopathy. He indicated that by trial and error (with research and further reading) he knew exactly what nutraceuticals to take - but has not managed to take it according to exact science- evidence based -1 assume! I immediately realized that (as I was new to this form of naturopathy) I will need to do more research to satisfy this very knowledgeable patient. I was ready for the challenge as I realized he would be my best teacher and patient and we were embarking on a wonderful and extremely interesting journey into this new form of medicine.
He appeared to be a very fussy and fastidious man who wanted everything to an exact science -after all he was an engineer, a physicist and an MBA graduate from all the most prestigious universities from the UK and the U.S. He wants to know exactly how much medication he needs in milligrams and which brand names he needs to take and they should be of the highest quality. He appears to be a person well acquainted with the medication he is taking and has extensive knowledge on his medical condition. He previously worked as an oil merchant in America -BP America! Furthermore his brief to me was that I indicate on a laboratory form of what blood work he requires six monthly and on-going. I initially discussed some of the side effects of his allopathic medicines and told him to supplement with Coenzyme Q10 for his condition .1 told him that I was ready for the challenge.
I realized that he was a highly spiritual man and he protected himself from self-agitation and required all his mental faculties to be sharp and focused -realized, I need to focus on keeping him that way and in total balance - in homeostasis. This would require me to help him stay focused and
prevent his memory from declining. As he was a type 2 diabetic, it would also be necessary to maintain his eye health and therefore prevent complications related to these chronic problems from deteriorating even further. A very remarkable man indeed!
PAST MEDICAL HISTORY
Backache in mid-thirties which made immobile for most of the time Gout - which his managed with a low purine diet Haemarrhoidectomy -1992 Appendicectomy -2003
Benign Prostatic Hyperplasia controlled with herbals-no recurrence Diptheria as a child - needed an emergency tracheostomy Diabetes-type 2-2006 Hypertension - recently past 2009
DIETARY HISTORY
A predominantly Mediterranean diet occasionally mixed with an Indian diet. He takes sufficient olive oil and a cultured drink called kefir (which appeared to be similar to our yoghurt-sourmilk- which he makes himself) - a probiotic. Many cultures have realized the importance of probiotics in their diet. Furthermore he munches heavily on a healthy supply of vegetables, including cruciferous vegetables and fruit.
He does not appear overweight and is fairly well built.
EXERCISE HISTORY
Exercises fairly regularly on a daily basis and does light weight training at home "dumbbells' Takes regular walks
FAMILY HISTORY
The patients' mother developed pulmonary tuberculosis in her thirties and suffered from a peptic ulcer and demised from a secondary metastatic lesion in the lung. The primary carcinoma was thought to be in the stomach. She passed away at the age of 84 years. The patients father was a smoker and developed type 2 diabetes in late years and demised at the age of 86 years
CURRENT MEDICATION
7-ketoDHEA25mgdly
Aloe Vera drink
Billberry
Brain Food
Calcium and Magnesium supplementation
Chromium Polynicotinate 200mcgs bd
Co enzyme Q10 50mgs daily
Eyesbright
Fish oil -omega 3 lOOOmg daily
Flaxseed oil in his salad
Ginkgo Biloba 120mgs daily
Glucobiotics
Homocysteine Lowering formula
Kefir - a cultured drink that provides probiotics
Lecithin powder
Male herbal
Probiotic
Vitamin C lOOomgs
Vitamin D 1000IU daily
VM 2000
Vogels alkaline base powder
This patient does smoke or consume any alcohol
No known allergies
EXAMINATION
On examination he has a good physique and was not overweight with normal vital signs and the rest of the examination was unremarkable.
INVESTIGATIONS
Full blood count and ESR
Fasting glucose
HbAlc
IgE
Food Mix IgE
Egg Yolk IgE
Cheddar CheeseIgE
Mould Cheese IgE
Orange IgE
Tomato IgE
CRP
Urea & Electrolytes
Uric acid
No abnormalities
7.1mmol/l
7.4%(4-6)
19.2 lU/ml (0-22)
<0.35IU/ml (0-0.35)
<0.35IU/ml (0-0.35)
<0.35IU/ml
<0.35IU/ml
<0.35IU/ml
<0.35IU/ml
<1 (<2)
Normal
0.45mmol/l (0.21-0.43)
Liver functions
Bilirubin Total
Bilirubin Conjugated
Bilirubin unconjugated
Rest of liver functions
Homocysteine
Total Cholesterol
Triglycerides
HDL
LDL
24umol/l (0-21)
3umol/l (0-5)
21umol/l (0-18)
Normal
16umol/l (<6.7)
3.6umol/l (2.8-4.9)
1.9umol/l (0.5-1.6)
0.8umol/l (1.0-1.6)
1.8umol/l (1.0-2.9)
Microalbumin
Urine creatinine
Microalbumin
Microalbumin/creatinine
TSH
FT4
Cortisol
DHEAS
Total Testosterone
PSA
9.4mmol/l (3.5-23.0)
17mg/ml
1.8 <3.4mg/mmo
1.53mlU/L <2
9.1pmol/l (6.8-18)
260nmol/l (142-651)
4.8umol/l (0.9-6.9)
10.3nmol/l (8-18.7)
l.Olng/ml (0-4)
CASE SUMMARY
TYPE 2 DIABETES MELLITUS DUE TO INSULIN RESISTANCE
Insulin resistance:
The cause of insulin resistance in this patient is due to:
• Eating a high carbohydrate diet,
• Decreased testosterone
• decreased DHEA
• Stress- although not a major contributing factor in this patient
This patient also has the metabolic syndrome:
High triglycerides
Reduced HDL cholesterol
Increased waist circumference
Hypertension
Hyperuricaemia
Probable hyperinsulinaemia
Presently he is on Glucophage XR 1500mg nocte. Previously he was on glucophage 500mg daily. His HbAlc increased recently to 7.4 %( from 6.7%). He wanted me to increase his glucophage as he was now tolerating the allopathic drugs. I then agreed and changed him over to the slow release form of glucophage XR lOOOmg nocte. Later he said that he was monitoring his sugars and was not happy with his glycaemic levels and wanted optimal control -thus I increased the glucophage XR to 1500mgs nocte - this he did not tolerate - as he complains that he had problems with his digestion -"I feel blocked up". His glucophage XR was reduced to lOOOmg nocte and his indigestion settled. This was a relief for me and to him as he was thinking of stopping it all together. Of course we could have treated him quite easily with lifestyle changes and nutraceuticals
Reversing insulin resistance requires
A low GL diet(glycaemic load)
Stress management
Detoxification
Exercise
HRT- testosterone transdermal^
Nutraceuticals to increase insulin sensitivity
The important nutraceuticals to reverse insulin resistance include:
In general I would step up the dosages in my patients as deemed necessary. First start slow and
low.
• Chromium Polynicotinate 200mcgs tds, - exact. Also raises HDL
• Alpha lipoic acid (200- 600mg), - the dual R form of approximately 150mgs daily.
• Vitamin C 1000-3000mg dly, - in this patient I have asked to increase to 2000mgs and continue monitoring
• Magnesium (400-800mg dly)- Bio - Calmag III BD. These six capsules supplies 400mg absorbable calcium glycinate and 200mgs absorbable magnesium glycinate.
• Vitamin D in high doses (1000-5000IU per day) - in this patient I would use 5000IU . Here we would require 10 tabs of 500IU to provide 5000IU. A more practical approach would be to take one tablet of a 50 000 IU once a week - calciferol (aspen)
• Fibre (30-50gms).
• Coenzyme Q10 (30-200mgs)- in this patient I would use a minimum of 100 mgs as he is on a statin and has hypertension. Some drug companies are combining their statins now with coenzyme QIO!
• B complex vitamins (50-100mgs) - 50mgs daily then eventually TID.
Vitamins all above the required dosages. B vitamins are required for almost every metabolic and enzymztic reaction in the body. Supermega B Dose of I BID with or shortly after meals. This product contains Vit B1.B2, B3 of 50mg each. It also contains Vitamin B5, B6, folic acid PABA B12, Inositol, and Biotin in sufficient quantities.
Ideal dose of Chromium for insulin resistance is 600mcgs daily. It does all you want it to do with an abnormal lipogram and aids in fat loss and helps insulin work more efficiently. Helps raise DHEA levels, burns calories, decreases Cortisol levels.
Vitamin C - step up the dose to 2000 mgs per day
Alpha lipoic acid- ALA is an antioxidant and is both water and fat soluble. ALA the antioxidants antioxidant and thus enhances the power of all other antioxidants in the body. It increases levels of vitamin E and C, glutathione and coenzyme Q10. Hence, in this patient, using higher dosages of ALA would be beneficial. Its main role is to burn glucose, improves memory, helps prevent cataracts-hence a great benefit in diabetes mellitus. A very important function of ALA is that it stimulates the sprouting of nerve fibres - hence a great benefit for the peripheral neuropathy in diabetes mellitus. It is great for the aging process as it prevents glycation and therefore assists with the aging process and for brain health -protects the brain-prevents age related memory loss/hearing loss/eyesight loss, arteriosclerosis- which is what the patient requires. ALA pure R form .It is believed that 150mgs of the dual R form is equivalent to 300mgs of the ordinary ALA. The ideal dosage for this patient of the dual R form is 300mgs daily- equal to the 600mgs of the ordinary ALA. If he had a peripheral neuropathy the dosage would be much higher but one needs to monitor him for hypothyroidism. Also important in energy production- a cofactor of mitochondrial enzymes needed for energy production. It also stops NF kappa B activation in the cells which lead to heart disease. ALA is also important for detoxification which is necessary in this patient.
Magnesium is involved in almost every chemical reaction in the body and has a wide range of functions. The important ones in this patient would be:
Heart function - hypertension
Muscle relaxation
Nerve functions
Skeletal muscle function
Decrease blood vessel constriction
Energy production
Enhances insulin sensitivity
Enhances the function of brain antioxidants
Natural tranquilizer
Maintains heart rhythm
Increase HDL
Improves muscle strength and endurance
Improves fatigue
Magnesium deficiency associated with hypertension
Ideal dosage in this patient would be 600-800mgs per day. Patients with hypertension may require 300-600mgs per day. Bio Cal Mag - a combination of calcium and magnesium is very well absorbed and supplies 400mg calcium and 200mgs magnesium per six capsules - taken three caps twice a day. This supplies and ideal 2 :1 ratio of calcium : magnesium
METABOLIC SYNDROME
• He will require an abdominal sonar of to exclude a fatty liver as there are a few deranged liver markers
• The metabolic syndrome is the unifying theme for a range of conditions involving insulin resistance, dysglcaemia, excess body fat, dyslipidaemia, and endothelial inflammation.
THIS CONDITION REQUIRES THE FOLLOWING
A simple lifestyle and dietary adjustments - i.e. moderate caloric restriction
Low Gl and GL foods. Limit intake of alcohol limit trans-fats(except CLA) limit saturated fats and increase high fibre intake
Nutraceuticals for the metabolic syndrome include
• Olive oil -2 tablespoons per day,
• Omega 3 - EPA 900-1800mg/d and DHA 600-1200mg /day,
• Alpha lipoic acid- 300-1800mg/day( also assists in peripheral neuropathy in diabetes)-monitor for hypothyroidism at these dosages
• vitamin D(1300-2000IU),
• Vitamin C,
• N- acetyl cysteine as an antioxidant and liver support,
• Coenzyme Q10(120- 200mg),
• Fibre,
• DHEA,
• Magnesium(300-500mg/d),
• Chromium (lOOOmg more effective in severe cases in the metabolic syndrome
Botanicals of importance in the metabolic syndrome and insulin resistance include:
• Gymnema sylvestre
• Turmeric
• EGC6- green tea
• American Ginseng
• Cinnamon
Olive oil
• Activates PPAR gamma
• Improves glycaemic control
• Inhibits oxidation of LDL-C
• Reduces BP
• Increase HDL
• Reduces TC, VLDL, LDL & triglycerides
Omega 3 Fatty Acids: DHA/EPA
• Activates PPAR gamma & alpha
• Anti-inflammatory
• Improves insulin secretion & sensitivity, FBG,PPG
• Reduce triglycerides
• Increases HDL
• Reduce Ml, arrhythmias, CHD,
• Inhibit cytokine induced NFKB activation
• Reduces BP & HR
• Dosage
o DHA 600 - 1200mgs per day
o EPA 900 - 1800mgs per day
Each capsule of fish oil has 120-300mg DHA and 180-420mg EPA. This equates to about two to four capsules a day of fish oil.
Coenzyme Q10
• Fat soluble antioxidant
• Enhances mitochondrial function
• Reduces HbAlc (0.4%)
• Lowers BP
• Dosage 120mgs per day improves glycaemic control & BP
• 200mgs improves HbAlc & BP in NIDDM Patients In this patient high dosages of coenzyme Q10 and higher dosages of ALA would benefit many other parameters in this patient
Magnesium
• Dosage for metabolic syndrome: 300-500mgs bid to tid (with Vitamin B6 50- lOOmgs)
• Vitamin D Supplement with 13001 U/d resulted in 70% of T2DM patients achieving normal 25(OH)D3 levels
Green Tea
• Increases metabolic rate
• Improves blood sugar metabolism
• Lowers risk of cardiovascular disease
o Lowers BP
o Lowers LDL-C
o Prevents LDL oxidation
o Hepatoprotective
• Active ingredients
o Catechins - EGCG
o Cholro genie acid
o Theanine
o Theaflavin
o Caffeine and Methylxanthines
o Chlorophyll Antioxidant Anti- inflammatory Induces phase II detoxification Reduces FBG & PPG Enhances insulin sensitivity
Reduces weight, visceral fat, hepatic fat, leptin and hyperinsulinaemia Reduces gluconeogenesis
Gymnema Sylvestre- Gurmar
Ayurvedic remedy
Regenerates pancreatic B cells & increases insulin secretion
Reduces gluconeogenesis in liver
Increases weight loss
Lowers LDL & TG
Lowers HbAlc
Dose - 400mgs - of water soluble leaf extract
HYPERTENSION
Hypertension is a consequence of the interaction of our environment and genetics
Non pharmacologic therapy should be an initial and adjunctive therapy to drug therapy.
Weight reduction (to ideal body weight).
Reduction in visceral adipose tissue(waist circumference)
Weight loss improves cardiac output
Discontinue smoking
Reduce oxidative stress
Reduce or limit caffeine intake
Reduce alcohol intake
Aerobic and resistance exercise and physical resistance
Stress management
o Relaxation exercises
o Yoga
o Pilates
o Psychotherapy - cognitive behavioural therapy
o Hypnosis
o Meditation
o Spirituality
o Massage
o Music therapy
o Breathing exercises
o A movie Discontinue all meds that raise BP
Optimize nutrition with selected vitamins, minerals, antioxidants and nutraceutical supplements
NUTRITION, VITAMINS, MINERALS, ANTIOXIDANTS & SUPPLEMENTS
