Weight Loss and Insomnia Case Study

Patient X

Female

Age 59

Height 1.60 m

Weight 78 kg

Married with 2 sons aged 28 & 26. Another son died suddenly of complications due to cystic fibrosis 2 years ago, aged 21. The 26 year old son has cystic fibrosis and lives at home.

Job: psychotherapist for victims of abuse

Main goals: to reduce weight and insomnia

Weight: problems since teens, has yoyo dieted throughout life. Family has weight problems. Stocky strong build, with quite good muscle tone on arms and legs. Carries excess weight around middle.

Lost a lot of weight after death of son 2 years ago, but then gradually gained weight and is still gaining despite trying to control intake.

Very active, gardening, decorating, housework, also does step exercises on stairs at home.

Insomnia: has never needed much sleep and does not fret when awake at night, uses the time to study, catch up with paper work etc. Is always on the go. The problem became worse while caring for her sons with cystic fibrosis. Resistant to sleeping tablets/herbal remedies.

Current Symptoms

Digestion:  Generally regular bowel movements x 1 per day, a.m., good consistency and colour, but may become constipated if away from home and out of normal eating pattern. Mild bloating & belching and sometimes suffers from moderate heartburn. Has been diagnosed with Hiatus hernia.

Energy and Emotions: Fluctuates between fatigue and hyperactivity. Feels very tired midafternoon and has recently suffered from bouts of extreme fatigue.

Recently noticed problems with concentration, and bouts of mild dizziness.

Often feels restless, anxious, stressed and sometimes depressed.

Sleeps for just 3-4 hours per night. Often goes to bed after midnight, has problems falling asleep and wakes a few hours later.

Joints/ muscles: Has mild arthritis in one knee and has been recently diagnosed with Carpal Tunnel Syndrome

Skin: Suffers from dry, itchy skin, itchy ears

Other symptoms include a blocked nose and frequent clearing of throat

Appearance: tense, fidgety; eyebrows thin with outer third missing. Dry skin, pallor

Medical history

Usual childhood illnesses

Suffered from fibroids throughout adult life and is now post menopause.

Problems with sinuses throughout life; several operations on sinuses. This has improved, but not cured sinus problems.

Diet

Eats fairly regularly, but has a long gap (6 hours) from lunch till dinner, when she is seeing patients. Sips cold black coffee (3 large mugs perday) throughout the day to keep going, particularly during afternoon.

Several portions of fruit and vegetables per day. Likes salad and raw broccoli

Tries to avoid sweet foods, but admits to eating some when depressed due to comfort eating. Likes icecream and chocolate.

Eats moderate portions of carbohydrates with each meal, but these tend to be refined e.g. white rice, white bread, special K breakfast cereal.

Eats fish including oily fish x 1-2 per week. Red meat x 1 per week. Diet regularly includes processed meats, hard cheeses and moderate amounts of dairy foods.

Calorie intake is not excessive, considering height , weight and activity levels

Drinks a reasonable amount of water (x 3-4 glasses per day). Drinks occasional wine socially with food.

Has good knowledge of calories and some knowledge about nutrition. Does not take any nutritional or other supplements/ remedies.

Personality & background

Polish Jew, family are holocaust survivors. A very intelligent, stoical, compassionate person. Puts others needs before her own. Very driven, always gaining more qualifications in her area, and does everything at home for family as well as working nearly full time.

Current stress levels rated at 8/10 due to concern about son’s health and work stress. Does not relax easily or carry out any activities to relax at present.

Current Medical Diagnosis and Medication

Mild hiatus hernia, takes antacids (Rennies) x 3-4 a month if symptoms are severe.

Arthritis in right knee

Carpal tunnel syndrome, is booked in for an operation.

Takes occasional paracetamol/ibuprofen for pain in knee and hand, but generally avoids medication.

Family Medical History

Cardio-vascular disease and cancer

The case history highlights symptoms across multiple systems. The inter-relationship between the client’s diet and lifestyle, physiological imbalances, symptoms and potential future conditions related to her current status is illustrated in the mind map in appendix 1. These symptoms need to be interpreted and linked to possible imbalances driving them and the potential causes for these imbalances. Once the imbalances analysed priorities for treatment can be drawn up and then a management plan.

In clients struggling to loose weight thyroid dysfunction is frequent concern. In the case history there are symptoms and potential causes of thyroid dysfunction.  The client’s fatigue, increased weight, dry skin and depression are all symptoms of hypothyroidism (Ladenson et al 2010). Further the itchy skin and ears, thinning of the eyebrows and carpal tunnel syndrome are all possible symptoms of myxedema, resulting from untreated hypothyroidism (Mansourian 2010). Additionally the insomnia may be related to myxedema (Mansourian 2010). However, typically myxedema causes a lack of desire for sleep and the importance of desire for sleep in the client’s insomnia remains to be ascertained. The inability to clear the throat can be a symptom of compression as a result of benign and malignant thyroid disease (Banks et al 2012). Typically other symptoms would coexist but the possibility of compression needs to be considered. The client will likely have had elevated cortisol levels from their diet (Hutchinson 2002, Corti et al 2002) and her work and life stressors (Sapolsky et al 1986) which are known to inhibit thyroid function (Duick and Wahner 1979). Interestingly the case history mentions the unusual habbit of consuming raw broccoli. Broccoli is a known goitrogen (Latte et al 2011) and will be more potent when consumed raw.

The case history shows multiple symptoms of adrenal dysfunction, which may be driven by stress of different types. Of the patient’s symptoms fluctuating between fatigue and hyperactivity (Wilson 2006), fatigue, decreased concentration, needing stimulants in the afternoon, depression, anxiousness (Anderson 2008), visceral fat (Whitworth 2005) and insomnia (Head and Kelly 2009) have all been linked with adrenal dysfunction. Indeed the symptoms of hypothyroidism may be caused by an inadequate stress response caused by adrenal insufficiency (Chrosous and Gold 1992). This may result from an elevated cortisol level directly inhibiting thyroid function in the alarm phase  (Duick and Wahner 1979). It is the stress response that appears to be a key driver of the patient’s possible adrenal dysfunction symptoms. Stress is summated in the body (Sapolsky et al 1986). In this case the patients mental emotional stress and dietary habits may both have caused chronic stimulation of the hypothalamic-pituitary adrenal axis. The blood sugar imbalances from regular coffee consumption and yoyo dieting (Hutchinson 2002) will have elevated cortisol levels (Corti et al 2002). Further her work stress, life stresses and lifestyle driven by her personality type will have elevated her cortisol levels. Over time the chronic elevation of cortisol levels causes desensitisation and damage to hippocampus receptors, which leads to feed forward over-production of cortisol (Sapolsky et al 1986). It is unknown if this damage is permanent. The symptom profile suggests the patient has passed through the alarm reaction and resistance phase and is entering the exhaustion phase (Selye 1978).

Insulin resistance can be at least partly caused by elevated cortisol (Walker 2006, Wang 2005). The clearest indications of insulin resistance in this client are fluctuating from hyperactivity to fatigue, increased visceral body fat (Whitworth et al 2005), decreased concentration, the need for coffee in the afternoon and her increased body fat (Kelly 2000). The clients coffee consumption (Hutchinson 2011), yo-yo dieting (Corti et al 2002), high carbohydrate diet and consumption of high glycaemic foods (Kelly 2000) could have contributed towards insulin resistance. Similarly, the psychogenic stress from her work and life stressors may have caused further short-term blood sugar spikes (Kelly 2000). Interestingly blood insulin resistance has been linked with hypercortisolism (Fossati and Fontaine 1993) and leptin resistance (Kelly 2000). Thus further illustrating the interlinking of her symptoms.

There are also multiple signs of other biochemical imbalances. The history of yo-yo dieting may be linked with low serotonin levels (Jimerson et al 1992). Additionally depression is well known to be associated with low serotonin levels (Karg et al 2011). Her stress levels may have caused this as cortisol has an inverse relationship with serotonin levels (Field et al 2005). Elevated cortisol may also have caused the gastrointestinal symptoms (Stengel and Taché 2010) and food intolerance symptoms (Zopf et al 2009).  However, the association between stress and gastrointestinal symptoms is complex as gastric symptoms are related to the formation of a proximal acid pocket in the postprandial period (Rohof et al 2012). The reduced gastric activity due to hypothalamic-pituitary adrenal axis stimulation may facilitate this process but there is a paucity of work discussing the minutia. Struggling to clear the throat and sinus problems are linked with excessive mucus formation possibly as a result of food intolerances (Hodge et al 2009).  These symptoms may be more completely viewed as part of the adrenal dysfunction picture. The prolonged stress results in an increased immune response in the resistance stage (Selye 1978), which has been linked with the onset of food intolerances (Gabby 1998). The metabolic effects of stress are associated with oestrogen dominance (McKern 2009), which may be at the root of her previous fibroids (Davis 2009). In addition the clients age and the fact they are post menopause increase the likelihood oestrogen dominance.

The case history shows symptoms linking back to thyroid dysfunction, adrenal dysfunction and insulin resistance most prominently. In addition there are weaker signs of low serotonin levels, food intolerance and a low stomach pH. There appears to be a common cause to all the patient’s imbalances of prolonged exposure to both psychogenic and dietary stress. Using Selye’s general adaptation syndrome the client looks to have progressed to the exhaustion phase.

References

Andreson, D.C. (2008) Assessment and nutraceutical management of stress-induced adrenal dysfunction. Integrative medicine, 7 (5), p.18-25.

Banks, C.A. Ayers, C.M. Hornig, J.D. Lentsch, E.J. Day, T.A. Nguyen, S.A. and Gillespie, M.B. (2012) Thyroid disease and compressive symptoms. The Laryngoscope, 22 (1), p.13-16.

Chrosous, G.P. and Gold, P.W. (1992) The concepts of stress and stress system disorders:  Overview of physical and behavioral homeostasis. Journal of the American Medical Association,  257 (9), p.1244-1252.

Corti, R. Binggeli, C. Sudano, I. Spieker, L. Hänseler, E. Ruschitzka, F. Chaplin, W.F, Lüscher, T.F. and Noll, G. (2002) Coffee acutely increases sympathetic nerve activity and blood pressure independently of caffeine. Circulation, 106, p.2935-2940.

Davis, C.J. (2009) The surgical management of polycystic ovarian syndrome. Diagnosis and management of polycystic ovary syndrome, 4, p.259-263.

Duick, D.S. and Wahner, H.W. (1979) Thyroid axis in patients with Cushing’s syndrome. Archives of internal medicine, 139 (7), p.767-772.

Field, T. Hernandez-Reif, M. Diego, M. Schanberg, S. and Kuhn, C. (2005) Cortisol decreases and serotonin and dopamine increase following massage therapy. International journal of neuroscience, 115 (10), p.1397-413.

Fossati, P. and Fontaine, P. (1993) Endocrine and metabolic consequences of massive obesity. Revue du praticien, 43, p.1935-1939.

Gaby, A.R. (1998) The role of hidden food allergy/intolerance in chronic disease.

Alternative medicine review, 3 (2), p.90-100.

Head, K.A. and Kelly, G.S. (2009) Nutrients and botanicals for treatment of stress: Adrenal fatigue, neurotransmitter imbalance, anxiety, and restless sleep. Alternative medicine review, 14 (2), p.114-140.

Hutchinson, E. (2011) Systems neuroscience: The stress of dieting. Nature Reviews Neuroscience, 12, p.65.

Jimerson, D.C. Lesem, M.D. Kaye, W.H. and Brewerton, T.D. (1992) Low serotonin and dopamine metabolite concentrations in cerebrospinal fluid from bulimic patients with frequent binge episodes. Archives of general psychiatry, 49 (2), p.132-8.

Karg, K. Burmeister, M. Shedden, K. and Sen, S. (2011) The serotonin transporter promoter variant (5-HTTLPR), stress, and depression meta-analysis revisited evidence of genetic moderation. Archive of general psychiatry, 68 (5), 444-454.

Kelly, G.S. (2000) Insulin resistance: Lifestyle and nutritional interventions. Alternative medicine review, 5 (2), p.109-32.

Ladenson, P.W. Singer, P.A. Ain, K.B. Bagchi, N. Bigos, S.T. Levy, E.G. Smith, S.A. Daniels, G.H. and Cohen, H.D. (2000) American Thyroid Association guidelines for detection of thyroid dysfunction. Archives of internal medicine, 12, 160 (11), p.1573-5.

Latté, K.P. Appel, K.E. and Lampen, A. (2011) Health benefits and possible risks of broccoli – An overview. Food and chemical toxicology, 49 (12), p.3287-3309.

Mansourian, A.R. (2010) A review on post puberty hypothyroidism: A glance at myxedema. Pakistan journal of biological sciences, 13 (8), p.866-878.

McKern, J. (2009) Hormone balancing.Journal of complementary medicine, 8 (1), p.12-18.

Rohof, W.O. Bennink, R.J. de Ruigh, A.A. Hirsch, D.P. Zwinderman, A.H. and Boeckxstaens, GE. (2012) Effect of azithromycin on acid reflux, hiatus hernia and proximal acid pocket in the postprandial period. Gut. [Epub ahead of print]. Available from;  [Accessed 11^th May 2012].

Sapolsky, R.M. Kry, L.C. and McEwen, B.S. (1986) The neuroendocrinology of stress and aging: The glucocorticoid cascade hypothesis. Endocrine review, 7 (3), p.284-301.

Selye H. (1978) The stress of life. 2^nd ed. New York, NY:  McGraw-Hill.

Stengel, A. and Taché, Y. (2010) Corticotropin-releasing factor signaling and visceral response to stress. Experimental biology and medicine, 235 (10), p.1168-1178.

Walker, B.R. (2006) Cortisol – cause and cure for metabolic syndrome? Diabetic medicine, 23 (12), p.1281-1288.

Wang, M. (2005) The role of glucocorticoid action in the pathophysiology of the metabolic syndrome. Nutrition and metabolism, 2, 3.

Whitworth, J.A. Williamson, P.M. Mangos, G. and Kelly, J.J. (2005) Cardiovascular consequences of cortisol excess. Vascular health and risk management, 1 (4), p.291-299.

Wilson, J.L. (2006) Adrenal fatigue: The 21st century stress syndrome. Petaluma, CA: Smart.

Zopf, Y. Hahn, E.G. Raithel, M. Baenkler, H.W. and Silbermann, A., 2009. The Differential Diagnosis of Food Intolerance. Deutsches ärzteblatt international, 106 (21), p.359–370.

It is critical initially to clear the patient for potential red flags and any need for medical referral. This client doesn’t report any of the Nutritional Therapy Council’s (NTC) red flag symptoms (NTC 2007).  However, the case history does show fatigue, increased weight, skin abnormalities, thinning of the eyebrows and carpal tunnel syndrome all possible symptoms of myxedema, resulting from untreated hypothyroidism (Mansourian 2010). Additionally the patient mentions feelings of depression. Kendrick and Peveler (2010) highlight the importance of screening for depression. In particular their recommendations of a 2-week follow up for those patients with active symptoms illustrate the urgency of the referral.  The client also mentions symptoms of inability to clear the throat, which can be a symptom of compression as a result of benign and malignant thyroid disease (Banks et al 2012). Consequently, this client should be referred back to their GP, with the client’s consent, with a referral letter highlighting the key symptoms they’ve reported, the therapist’s concerns and politely asking for the GP’s input and guidance as shown in appendix 2. This paves the way for the clinician to follow up with the client explaining that they would like them to return to their GP but there are some elements of the initial assessment, which require clarification.

Further subjective information would inform the choice of potential functional assessments and aid the formation of a management programme. Establishing the types of cancer her family members have experienced may point the clinician towards potential bowel pathology or more oestrogen dominant cancers. Similarly, it would be prudent to establish if the client received hormone replacement therapy during her menopause, which could point towards oestrogen dominance. It would be interesting to know if the client was interested in learning a relaxation technique due to the role  psychogenic stress appears to play in their symptoms (Lee et al 2010) and the case history suggests she may not be competent in relaxing. Lastly further questioning on how long she has had the insomnia and how it has progressed over time would be helpful. In particular asking when she started to loose the desire for sleep and how this correlated with her symptoms. This would provide an indication as to the involvement of myxedema contributing towards her symptom profile. Answers to these questions would help narrow the focus of the management programme.

The late Broda Barnes (1942) was an advocate of using axillary basal body temperature as a diagnostic tool for hypothyroidism. Unfortunately there is a dearth of peer-reviewed papers discussing the validity and application of this approach. There is support from understanding the physiology of the thyroid gland and the association of low triiodothyronine (T3) with low body temperature (Nogues et al 1995).  Although it should be noted that Nogues et al’s work had several flaws in its analysis and methodology highlighted by Mosse (1995). Nonetheless the link between T3 and temperature was accurately assessed.

A difference of opinion exists on what tests are necessary to assess thyroid function. Volpe (1997) state that for initial screening or clients where thyroid dysfunction is unlikely serum thyroid stimulating hormone (TSH) assay is all that is required. TSH remains the most reliable indicator of thyroid dysfunction (Landerson et al 2010). However, it has been demonstrated that using TSH alone leads to under reporting hypopituitarism (Wardle et al 2001).  As the suspicion in this case is that the patient may have an underactive thyroid, serum TSH and T4 should assessed (Schiefer and Fatourechi 2008). It seems logical to think there may be more benefit from assessing free T4 levels as free hormones are presumed to be the only hormones that are physiologically active (Midgley 1993). However, it’s known that free T4 (fT4) rises during the second and third trimester of pregnancy without any known physiologic effect (Midgely 1993). This doesn’t mean there is no effect but this is the currently accepted belief amongst endocrinologists. Despite this it’s necessary to measure serum free thyroxine (T4) to assess for cases of secondary hypothyroidism (Ladenson et al 2010).  After receiving the referral it is likely based on the client’s symptoms profile their GP would assess the clients, TSH, fT4 and fT3 levels (NHS 2012).

Deeper functional testing for potential subclinical hypothyroidism is also indicated. Subclinical hypothyroidism is defined as an elevated serum TSH concentration in the presence of serum thyroid-hormone concentrations within the population-based reference range (Feldt-Rasmussen 2009). Gaby (2004) highlighted that elevated TSH levels may not be necessarily be essential for Hypothyroidism to be present. For example the level may be elevated relative the individual norm. Reverse T3 needs to be assessed to check for peripheral conversion of T4 to active T3. Thyroid antibodies should also be screened to clear for potential autoimmune disease and to potentially detect metabolic irregularities. Further clinical significance can be gleaned from testing by comparing either 8 am TSH or 4 pm TSH with time-of-day normal range (Rose 2010). This can identify TSH elevation. Low am/pm TSH ratio (FT4 in lowest one-third of normal) confirms central hypothyroidism. Although this research was conducted in children and there’s a paucity of evidence investigating this phenomenon in adults the similarity of the physiology is valid. However, this is not yet readily commercially available. Consequently the comprehensive thyroid assessment offered by Genova diagnostics will provide further insight for a justifiable cost to benefit.

The case history illustrates signs of hypothyroidism and possibly myxedema, which suggest a referral to her GP is important despite the absence of red flags. The questions outlined will help provide further clues to her imbalances further clarifying the appropriate way to proceed. On the information currently available the key imbalance driving her symptoms may be coming from under-functioning of her thyroid. The basal body temperature readings, GP testing and comprehensive thyroid assessment will then clarify how to proceed with the patient’s programme.

References

Banks, C.A. Ayers, C.M. Hornig, J.D. Lentsch, E.J. Day, T.A. Nguyen, S.A. and Gillespie, M.B. (2012)  Thyroid disease and compressive symptoms. The laryngoscope, 22 (1), p.13-16.

Barnes, B. (1942) Basal temperature versus basal metabolism. Journal of the American medical association, 119 (14), p.1072-1074.

Feldt-Rasmussen, U. (2009) Is the treatment of subclinical hypothyroidism beneficial? Nature reviews endocrinology, 5, p.86-87.

Kendrick, T. and Peveler, R. (2010) Guidelines for the management of depression: NICE work? The British journal of psychiatry, 197, p.345-347.

Ladenson, P.W. Singer, P.A. Ain, K.B. Bagchi, N. Bigos, S.T. Levy, E.G. Smith, S.A. Daniels, G.H. and Cohen, H.D. (2000) American Thyroid Association guidelines for detection of thyroid dysfunction. Archives of internal medicine, 12, 160 (11), p.1573-5.

Lee, R.T. Lovell, B. and Brotheridge, C.M. (2010) Tenderness and steadiness: relating job and interpersonal demands and resources with burnout and physical symptoms of stress in Canadian physicians. Journal of applied social psychology, 40 (9), p.2319-2342 (24).

Mansourian, A.R. (2010) A review on post puberty hypothyroidism: A glance at myxedema. Pakistan journal of biological sciences, 13 (8), p.866-878.

Massé J. (1995) Nutrition, thyroid hormones, body temperature, and mortality of elderly patients with acute illnesses. American journal of clinical nutrition, 62 (3), p.647-9.

Midgley JE. (1993) The free thyroid hormone hypothesis and measurement of free hormones. Clinical chemistry, 39 (6), p.1342-4.

NHS, (2012) Hypothyroidisim. [Online]. Available from; http://www.patient.co.uk/doctor/Hypothyroidism.htm [Accessed 11 May 2012].

Nogues, R. Sitges-Serra, A. Sancho, J.J. Sanz, F. Monne, J. Girvent, M. Gubern, J.M. (1995) Influence of nutrition, thyroid hormones, and rectal temperature on in-hospital mortality of elderly patients with acute illness. American journal of clinical nutrition, 61 (3), p.597-602.

Nutritional Therapy Council, (2007) Core curriculum for training in nutritional therapy. [Online]. Available from; http://www.nutritionaltherapycouncil.org.uk/trainers-1_3_3171181096.pdf [Accessed 11 May 2012].

Rose, S.R. (2010) Improved diagnosis of mild hypothyroidism using time-of-day normal ranges for thyrotropin. Journal of pediatrics, 157 (4), p.662-7; 667.e1.

Schiefer, R. and Fatourechi, V. (2008) Laboratory Diagnosis of Thyroid Disease. Thyroid disorders with cutaneous manifestations, p.23-36. Available from; http://www.springerlink.com/content/u757351472044227/ [Accessed 10 May 2012].

Volpé, R. (1997) Rational use of thyroid function tests. Critical reviews of clinical laboratory science, 4 (5), p.405-38.

Wardle, C.A. Fraser, W.D. and Squire, C.R. (2001) Pitfalls in the use of thyrotropin concentration as a first-line thyroid-function test. Lancet, 357 (9261), p.1013-4.