At six feet tall, fair haired and articulate, Frieda was 46 when she arrived in my office at the beginning of 2015. She weighed 365 pounds and was feeling dejected and overwhelmed. She wrote on her medical questionnaire,
“I get that I’m morbidly obese but years of antidepressants made that worse and even when I work out hard, I can’t lose a damn ounce. It gets very frustrating to be continuously told that it’s ALL MY FAULT! I feel constant fatigue, my fault; can’t lose weight, my fault; can’t sleep, my fault. It’s difficult not to lose hope for help.”
Her energy was non-existent (she gave it the lowest possible number, 1 on a scale of 1-10); she was losing her hair; she couldn’t sleep and her low back, knees and fingers hurt.
Frieda spoke of her lifetime struggle with depression, anxiety and weight issues, all starting when she hit puberty. She reported a suicide attempt during this time, with hospitalization. Her menstrual cycles were irregular for years; she could go for months without a period, but would nonetheless experience monthly severe cramping and debilitating depression. At 36 she was prescribed progesterone and finally started to menstruate regularly.
In her 20s Frieda started binge eating, having significant sugar, dairy and bread cravings. The binge eating was accompanied by anxiety.
In her 30s she developed annual bronchitis and sinusitis, both treated with antibiotics. She also had a number of ear infections. She reported occasional asthma but was not maintained on an inhaler. She was also diagnosed with Hashimoto’s thyroiditis at this time but experienced no obvious benefit from Synthroid.
Over the years, she had many different psychotherapists, and she gained weight on the various antidepressant and anxiolytic medications she tried.
Losartan 50mg/12.5mg was prescribed in her early 40s for hypertension. She also had hyperlipidemia.
Frieda required 10 hours of sleep per night, but woke unrefreshed, sleep being frequently disturbed by hot flashes. She loved to swim, but rarely did so, as she found it highly depleting.
Gastrointestinal function was generally regular, with one or two complete bowel movements per day. When she menstruated, however, constipation alternated with diarrhea.
In addition to hair loss, she had dry skin, hives, rashes and brittle nails. She reported some hearing loss and tinnitus (after lots of rock concerts).
Frieda worked with an integrative doctor in 2013, was prescribed Armour thyroid (120mg in the morning and 60mg at noon), bioidentical hormones and botanicals for adrenal support; a lower sugar diet was recommended. She responded very well to this protocol but stopped when the doctor relocated her practice.
Frieda was vaginally delivered and breast fed. She was healthy during infancy and childhood. As a child and into her teens, lots of heavy, home-cooked German food was the norm but not many desserts or sugary foods. She was, however, exposed to much secondhand smoke; and had a few bouts of strep throat, for which she was treated with antibiotics.
Frieda craved cheese, especially pizza, and sugary foods, especially chocolate. She ate a full diet and reported no food restrictions, although she suspected something in her diet was influencing her blood pressure. She had a 10 pack-year history of smoking.
Her supplement protocol (St. John’s Wort, DHA, probiotics, 5HTP and zinc) she reported to be somewhat helpful for depression. Prescribed medications were Losartan and Armour thyroid.
Family history was significant for heart disease, type II diabetes (T2DM), depression, kidney disease, hypertension and hyperlipidemia. Her father and mother both died from myocardial infarctions at 74 and 80 years of age respectively. There were many relatives with rheumatoid arthritis on her mother’s side, as well as an aunt with Parkinson disease.
Frieda’s goals for our work together were to lose weight, resolve depression, sleep better and increase energy. She stated that her motivation to change was very high.
Frieda’s baseline medical symptoms questionnaire (MSQ) was 96 (see Figure 1 below), demonstrating moderate toxicity. Areas with the highest scoring included weight, emotions, musculoskeletal, and energy.
Her physical exam was remarkable in that she had a thick white coat on her tongue, consistent with thrush. She had angular chelitis and mild rosacea. She had keratosis pillaris on her lateral upper arms; mild ichthyosis vulgaris on her legs. She had a number of acrochordon (skin tags) on her axillae and neck. Her fingernails were brittle with multiple leukonycia (white spots) and paronychia (irritation around the nail folds). Her waist-to-hip ratio was elevated at 0.92. Her blood pressure was 145/85 (LAS, with medication).
Heart and lung sounds were normal/clear. MSK exam was visually unremarkable, although discomfort was reported with passive rotation of wrists, fingers, knees. Her neck was supple with no masses, thyroid was smooth and non-tender.
Laboratory testing included: Metabolic markers, lipids, inflammatory markers; IgE foods and inhalants, IgG foods, celiac serology and genes; homocysteine; thyroid, adrenal and sex hormones including testosterone; antibodies: thyroid, ANA, RF, CCP; broad nutrient evaluation including minerals, fatty acids, vitamins, oxidative stress markers & organic acids; toxic metals; stool test.
Functional Medicine Matrix (populated using baseline assessment and pertinent baseline laboratory results):
Assimilation (gut/lungs/skin): PMS-related constipation/diarrhea, carbohydrate craving, thrush/angular chelitis, rosacea, multiple courses of antibiotics, dysbiosis (D-lactate 12 (<=5.6); multiple IgG+ foods (dairy, gluten, corn, eggs). (Celiac serology/genetics negative)
Defense and Repair (immune/inflammation): Hashimoto thyroiditis (thyroid peroxidase antibodies 367); inflammatory arthritis (anti-CCP, ANA, RF negative); annual sinusitis and bronchitis, otitis media, asthma; rosacea, keratosis pillaris, hives; depression/anxiety; elevated hsCRP (5.0) & fibrinogen (544); multiple IgG+ foods (dairy, gluten, corn, eggs). (Celiac serology/genetics negative). FMH: autoimmunity
Communication (endocrine): Metabolic syndrome/hyperinsulinemia (fasting insulin 35; fasting blood sugar 97, A1C 5.2, urine microalbumin not detected; creatinine 1.1; previous oral glucose tolerance testing was normal); acrochordon (skin tags); obesity/weight loss resistance; PMS with depression, anxiety, pain & carbohydrate craving; lower progesterone (relative estrogen dominance); hot flashes & insomnia; Hashimoto thyroiditis, alopecia, brittle nails, ichthyosis vulgaris; adrenal fatigue (4-point salivary cortisol demonstrated low total output and low morning cortisol). FMH: Heart disease, T2DM & kidney disease, obesity
Transportation (cardiovascular/lymphatics): Hypertriglyceridemia (205) with elevated LDL particle number and elevated small & medium LDL; hypertension, hyperinsulinemia, elevated hsCRP (5.0), fibrinogen (544), homocysteine (10.4). FMH: Heart disease, T2DM & kidney disease, obesity
Energy (mitochondrial health): Fatigue (organic acid energy assessment and oxidative stress biomarkers were normal)
Our plan was relatively straight-forward. My strong suspicion was that in part, Frieda’s GI bugs were “running the show,” stimulating potent sugar cravings and contributing to depression, anxiety and metabolic syndrome (research in this area is rapidly emerging). Giving into the cravings was, in turn, contributing to the metabolic syndrome, weight gain, inflammation, depression, anxiety, hyperlipidemia and estrogen dominance. (Frieda’s family history suggests a genetic component here, too).
Thus, I was confident that as long as she was willing to endure the potentially difficult but very short-term journey of “sugar detoxing,” she’d get to the other side — her cravings would subside and her health would rebound. I also suspected that as we balanced hormones, improved her sleep and energy, her metabolism would further progress. To that end, I prescribed an organic, limited processed, high greens, lower carbohydrate diet (about 60 grams/day), free of IgG-positive foods (dairy, gluten, corn & eggs), with a protein-rich morning smoothie. Allowed fruits were berries. Snacks were nuts and seeds. No calorie counting. My nutritionist Romilly worked very closely with Frieda.
We used a number of supplements over the early phases of treatment, including high potency B-vitamins (for homocysteine, adrenal fatigue, estrogen dominance); high-dose EPA/DHA (for inflammation, estrogen dominance, triglycerides and lipids, joint pain), magnesium (blood sugar, joint pain), berberine (blood sugar and gut health), as well as an enteric coated oil of oregano (for D-lactate). She rinsed a few times per day with a diluted oil of oregano for the thrush. Siberian rhubarb and topical progesterone were used at bedtime for hot flashes, insomnia and estrogen balancing. Phenylated GABA was prescribed as needed for sleep. Very low dose hydrocortisone was prescribed short-term (adrenal fatigue), and Armour thyroid dosage was reduced (based on testing, which revealed suppressed TSH and elevated free T3). Sustained release arginine was used for blood pressure.
I recommended she continue for the time being with St. John’s Wort and 5HTP, as she reported these to be useful.
Supplements to be rotated in later included a probiotic (after we lowered D-lactate); vitamin D and K2; adrenal botanicals (ashwaganda, rhodiola, licorice).
Frieda was instructed engage in daily self-care, such as meditation or other contemplative activity; to monitor blood pressure daily; and return to swimming, an activity she loved.
Follow-up (see figures 2 & 3, Frieda’s follow-up multiple symptoms questionnaire below)
Frieda responded well to the plan. She made it through the “sugar detox” period without incident, and reported cravings to be largely gone. She began losing weight immediately, and was down a full 79 pounds (and four sizes) six months into treatment. (She states she’s confident that she’ll achieve a normal weight in 2016.) Her blood pressure normalized and Losartan was discontinued after five months. Hot flashes resolved immediately. Thrush cleared. PMS symptoms reported as much better. Energy is improving. No episodes of sinusitis, bronchitis, asthma or otitis media thus far.
Frieda stated that her lifetime struggle with depression and anxiety became “non-existent at start of the diet.”
When we initiated Frieda’s food challenge (that is, reintroducing the foods that were eliminated one at a time every three days, accompanied by a tracking matrix to note symptoms), she identified that dairy caused gas, bloating and joint pain. She tolerated eggs and was happy to reintroduce omelets. The biggest challenge came with trialing grains (gluten and gluten-free). She wrote:
“First, [I] noticed bloating in my belly and swelling in my fingers. Plus weight loss slowed to maybe 0.5 pounds a week when non-veggie type carbs were added. I struggled with energy. The worst, however, [was that] it truly sent my cravings into overdrive and I struggled to regain control of my eating! Holy hell, awful, not only for things like bread, pasta, typical carby stuff, but then also sent me into sugar animal mode… I just wanted to lick the sugar packets, LOL! Truly, I started obsessing about all things carbs like an addict with just a little added in for a couple days. Awful…… Honestly, I’m happy just sticking with veggies, protein, a little fruit once in a while and leave it at that. I feel best, more balanced, when I stick to it. At this point, I’m happy with having been able to add eggs and soy back into the diet without issue.
The rest just seem to trigger the carb animal in me and I struggle with weight loss again.”
For labs, we monitored fasting insulin closely. Baseline was 35- very elevated. First follow-up eight weeks into treatment, insulin was down to 20. Then 8. After a brief spike back to 20 (reported as due to eating “lots of fresh cherries”), it’s now back down. Throughout these months, A1C and fasting blood sugar have remained the same (5.2, low 90s).
Thyroid peroxidase antibodies have dropped to 340, lipid particles and size have improved. Triglycerides are 115, previously 205. Further follow-up labs (stool testing, organic acids/D lactate, fibrinogen, homocysteine, adrenal panel) are pending.
Frieda’s journey has been a remarkable one. She has profoundly altered the course of her health, and feels very empowered. She’s inspiring those around her, including the physicians co-managing her. While we’re still “fine-tuning”, overall, Frieda is a well and happy woman!
Figure 1. Frieda’s Baseline Medical Symptom Questionnaire.
Figure 2. Frieda’s Follow-Up Medical Symptom Questionnaire, page 1. (12 months later)
Figure 3. Frieda’s Follow-Up Medical Symptoms Questionnaire page 2 (12 months later)
Fantastic overview and great case, Dr. Kara!
Yes! Treating the root cause is so important. Look up Dr. Scott Shannon on Youtube, he works with micronutrients with his mental health patients and his work is bringing functional medicine to the forefront of mental health!
Thanks for the tip, Jenn! DrKF