Metabolic Syndrome

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A Case Study Submitted by Scott Rigden, MD

Profile: http://plminstitute.org/scott-rigden-md/

 

For centuries, Native American Pima Indians were a self-sufficient farming people with a talent for irrigation in a harsh desert environment. This gentleman’s Pima ancestors farmed in the Gila and Salt River region of what is now Arizona, but the river died with the diversion of water for non-Native development, and they could no longer grow their own food. There was famine, starvation, and, over time, loss of their cultural moorings. Now their traditional subsistence diet has been replaced by foods laden with processed flour, sugar, and lard. Modern-day Pimas suffer from drastically high rates of obesity and diabetes compared with the larger US population, and also struggle with alcoholism.

Consistent with the PLMI philosophy, this  study shows that until four separate metabolic issues were identified and regulated, the patient seemed to have little hope for improvement. These included the presence of Metabolic syndrome, with its associated hyperinsulinemia and insulin resistance, obstructive sleep apnea, hypothyroidism, and hypogonadism. In addition, he has been immersed in a lifestyle modification program involving diet, exercise, behavior modification and “mindful eating” techniques.

Initial Presentation

Mr. Z presented as a 43 year old Pima Native American to our office with a weight of 473 pounds. Other than fatigue, dyspnea with exertion, and mild knee pain, his past medical history and review of systems was relatively unremarkable. Our metabolic work-up discovered a mild hypothyroid condition with a TSH of 6.78, a borderline A1C of 6.2, and elevated fasting insulin of 30. With a diagnosis of Metabolic Syndrome and hypothyroidism we initiated a high protein, low carbohydrate diet and prescription of Levothyroxine. He lost about 50 pounds and had improved lab work, but due to a variety of reasons he was lost to follow-up after one year.

Two Years Later

Mr. Z returned to our office two years later and had maintained his weight of 427 pounds. However, he had not been regularly taking thyroid replacement and now reported two other areas of medical problems: (1) he could not increase muscle mass even with aggressive weight lifting, had developed gynecomastia, and had markedly decreased libido, which taken together suggested hypogonadism; (2) he was snoring severely at night with irregular, sometimes long pauses between breathing and was somnolent during the day. Evaluation at this time revealed TSH of 7.21, fasting insulin of 27, and total testosterone of 107 (normal 325-1000), a free testosterone of 17.2 (normal 35-79). It was interesting to note his fasting glucose was 90, total cholesterol 181, triglycerides 179, HDL 35, and LDL 117. His triglyceride to HDL ratio of 5.2 corroborated persistent insulin resistance. A sleep study confirmed obstructive sleep apnea and CPAP was initiated.

 

ASSESSMENT

1.       Ethnicity, “Apple ” fat distribution, elevated insulin levels, borderline A1C, an elevated triglyceride/HDL ratio, all confirming or contributing to  Metabolic  Syndrome.

2.       Hypothyroidism-sub-optimally regulated

3.       Hypogonadism

4.       Obstructive Sleep Apnea requiring CPAP

Treatment Plan

Low Glycemic Load Diet with medical food designed to regulate blood sugar and insulin, workout 60 minutes 3-4 times week, micronutrient support with chromium, lipoic acid, cinnamon compounds, EPA/DHA one gram twice daily. Take 225 mcg levothyroxine daily, regularly use CPAP, regulate testosterone with an injection of 5 mg every 2-4 weeks.

FOUR YEARS LATER

Initial         4 Years Later

Weight                                     473 lb.        309 lb.

TSH                                         6.8              2.59

FBS                                         130             86

A1C                                         6.2              5.3

Fasting Insulin                       30               8

Testosterone                        107             533

Cholesterol                           181             157

TG                                           179             90

LDL                                         117             95

HDL                                        35               45

 

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