Hypertension & Type 2 Diabetes Case Study: Functional Medicine Series

Show Summary:

IWelcome to a special series on the Capital Integrative Health Podcast! I am your host, Dr. Andrew Wong, and this is a podcast dedicated to exploring the root causes of both disease and wellness.

I am a co-founder of Capital Integrative Health, a clinic with a mission to create a revolution in healthcare by educating, leading and inspiring people towards optimal health and true wellbeing.

We’re excited to offer you this series as an insightful look into functional medicine and walk you through case studies that exemplify how we think about and approach care with our patients.

These cases are de-identified and names used are placeholders.

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Full Transcript:

Dr. Andrew Wong 

Welcome friends to a special series on the Capitol Integrative Health podcast. I'm your host, Dr. Andrew Huang. And this is a podcast that is dedicated to exploring the root causes of both disease and wellness. I am honored to be a co founder of Capitol Integrative Health Clinic in Washington DC area with a mission to create a global revolution in health care by educating, leading and inspiring people towards optimal health and true well being.

One of the key modalities we utilize in our clinic to help patients and be of service is functional medicine. We're excited to offer you this series is an insightful look into functional medicine, otherwise known as root cause resolution medicine, and walk me through case studies that emphasize how we think about and approach holistic care with our patients. Let's get into our case study for today on heart health and how we take a functional medicine approach to this. So we have a case study, we have a patient who will call Mary she's a 56 year old female, and Mary was diagnosed with hypertension in her early 40s. She was also diagnosed with type two diabetes and her 50s and her current decade, her body mass index is 30 that is technically technically considered obese. Anything 13 above is considered obese. And then she does have a family history of cardiovascular disease with her dad suffering from a heart attack in the 60s, and she has been managing her cardio metabolic conditions like hypertension and diabetes with medication. She has had some weight fluctuations throughout her life, she hasn't been she has been able to lose some weight, you know, up to 3020 30 pounds, but then she's gained it back over you know the next year or two repeatedly as kind of this sine wave yo yo cycle over the last 20 years.

Recently, Mary gained 10 pounds in the last year despite trying to increase her activity levels. She's also experiencing shortness of breath with exertion. She also has had rising blood sugar levels, an increase in her and her blood sugar control requirements meaning that she's needing higher doses of metformin because of the worsening diabetes. Mary also has generally low energy levels throughout the day. And as a result relies on coffee throughout the day, which I know a lot of us, you know rely on something for like an energy drink, but it's kind of propping her up at bed.

Mary also reports anxiety, she's feeling overwhelmed with her health concern. She's concerned she's gonna end up like her, her dad or other family, family members that have heart disease and she doesn't want to go down that same path.

So in terms of Mary's lifestyle, Mary eats a beige diet. She eats cereal for breakfast, she eats a sandwich with fruit for lunch, and then she has a protein typically steak or chicken, also a baked potato or rice and then one vegetable for dinner.

The vegetable may be green beans or something like that. She does work as a librarian has doesn't really how much stress from that that type of work. I think most people are checking out books now at the electronic checkout counter instead of her helping them she also has a main surface of stress as her family dynamic. She is divorced and doesn't have a great relationship with her ex husband has some kids that are nearby but but they are somewhat stressful for her as well. And then she also stressed out by her own health by by again the fact of being worried about her current health and her future health potentially. Mary as a librarian does have a pretty sedentary job job she just tried to walk outside three days a week, it's getting a little hotter now. So she's not able to do as much outside because she's sweating too much it gets a little bit shorter breath when she walks in the hills in her neighborhood. She is able to walk some at home she does have a treadmill that's parked close to her television.

So I would first ask Mary about kind of how how did she get to this point I usually like to ask people in the beginning of a visit let's say when was the last time when was the most recent time that you felt well right because one of the things about you know patient care and really listening to a person is understanding their story but also understanding where where they want to go now sometimes where people want to go and their health journey you know, at some point potentially the the patient felt well so just having that light at the end of the tunnel so to speak or even like a boomerang situation where it's like okay, when when did you feel most recently well, and you know, how can we get back to that point? It's just like if someone if you take a vacation somewhere you travel somewhere eventually you know all the different stops along the way are great and you're you're seeing a bunch of stuff or maybe it's really frightening and and and hard or something but either way you want to go back home. So how can we bring Mary back home to the birth rate that she

Has which is wellness, which is feeling well, which is really activating her own body's any potential to heal and to recover and to rejuvenate. So I think the first thing for Mary, because really, a lot of times in medicine, what happens is we go to the doctor, we go to the practitioner, and then we are told something like, Well, you have, you know, you have hypertension, you have diabetes, and you're going to take this medicine for the rest of your life, we're going to make sure you put the pill in the pillbox, not distinct medications, we also in our clinic, you know, do a lot of medication prescribing, but medications are not the only answer. And medications are not getting the root cause of why this patient is having these issues. One of the things that happens when someone gets a diagnosis, it's almost like a tyrannical type of situation, often in medicine, where it's, you know, functional medicine, we call it the tyranny of the diagnosis. So if someone has a diagnosis of diabetes, then automatically in mind from like, what they read on ads are, you know, they're talking to their friends and their family, and diabetes, that is basically a a life sentence, you know, in their mind, like, oh, I have diabetes, I have to take medication for the rest of my life, I'm going to try to prevent amputations and things like that. So when we reverse that script, and change that script, change that novel, then we're really going to be looking at how can we reverse that diabetes potentially? Or how can we at least give Mary some hope that lifestyle changes, and different factors that are within Mary's control, allows Mary to take charge of her own health and be the CEO of her own health? So the first thing I'm going to ask Mary is, you know, not only when was the last time when was the most recent time that she felt well, right to put a picture in her mind that, hey, maybe she can get back there. But also things like, like, why, why does she want to change? You know, why does she want to change her lifestyle? Why does she want to get better, because if people don't have a sense of why they wouldn't want to get better, they're not going to get better. So having a sense of why and typically, the Y is something very, you know, near and dear to their heart, and it could be a motivational thing. Like, I want to play with my grandkids or something, or I want to go out and play golf, I want to do dancing, you know, I want to be on the dance floor and dance socially and things like that. I want to enjoy nature more without my knees creaking without feeling shortness of breath, I want to really enjoy the sunlight and the earth and different things like that. And so we're could be like, I want to be be here longer. So I can I can spend time with my loved ones and spend quality time with them. So these are questions that will invigorate the patient and viguerie and also generate some hope for the patient. Okay. So very, very important to kind of start the context of, of you been talking to Mary like this, besides this, we would, we would kind of start to take a bit of a history of her timeline. So really, she really, it sounds like she started having, you know, weight fluctuations and some health conditions, probably in her in her 30s You know, she she had like two kids, and she started having kids in her 30s. And at that point, she started to maybe not take care of herself as much problems were happening in her marriage, she was drinking some alcohol, she was starting to smoke a little for stress. And then she was able to, you know, she was able to cook but you know, a lot of times with her her job and and taking care of the kids and like kind of juggling and I'm sure if you're listening to this, you you understand this, there's an idea called Team Up syndrome. So team up syndrome is, is a CH exclusive, but we'll just say it is to not really exclusive, it's really universal, it's really the too much on your plate syndrome. So if someone has too much on their plate, then sometimes when you juggle those plates, those plates are going to break, okay, because there's just too much happening. So for Mary, there's too much happening too much in her life, too much stress, too little time for self care. And she her health started to fall apart in her 30s. So, so just kind of understanding sometimes the story of where Mary's been, can really paint that hopeful picture of where where we want to lead or we want to partner with Mary I should say, for her own health. So she's had some weight fluctuates and throughout her life, one thing we might want to ask her is, you know, when she's lost and gained weight repeatedly over the last 20 years, what has worked for her what has not worked for her just to try to get some patterns of going on. And when we talk to Mary about this, it was really that what happened was she was in a certain period of her life where there's there was lower stress. And she was able to focus on her health and made that a priority. And then she started to lose weight so to eat better to exercise a bit more and then in periods of higher stress, she was not able to sort of self regulate or CO regulate with people as much so then what would happen is then she started gaining weight and started to stress eat and wasn't going to the gym as much and was tired because she was eating a beige diet and then that kind of snowballed into this like I don't have enough energy to exercise I'm gonna have enough energy to cook so so it became a a vicious cycle and sort of a virtuous circle. So I think I think definitely Mary is really telling us about her about her health through us understanding and listening to her as a person. There was a very famous physician, I think back in the 1800s. At Hopkins, I believe, but named Francis Peabody. But in any case, Dr. Peabody said in order to know a patient, patient's condition, do you have to know the patient I think is very, very important that is not only about medical questions here that we're asking this patient, but it's about getting to know Mary as a person. I think getting know Mary as a person here is actually very important, probably the most important thing, you know, for the history for her, I would want to ask her about the shortness of breath. So she has shortness of breath with exertion, that is a red flag for potential cardiac angina, which is basically a condition where someone might have what's called ischemic heart disease, meaning they might have a buildup of plaque in their in their arteries, in which case less blood flow is getting to their heart muscle, in which case they might have shortness of breath, or even chest pain is a type. So So Amgen has a type of chest pain that's related to reduce blood flow in the coronary arteries that go into the heart muscle? So this is a very significant concern of Mary's is is shortness of breath with exertion. So we're going to ask her, you know, does this shortness of breath happen with any exertion? Or with just like running a marathon? You know, what does that mean? Is it just a couple blocks up the hill? And is this shortness of breath getting worse, you know, also, these are red flag symptoms that we want to refer her potentially, either to a cardiology specialist, or even to the emergency room, depending on how how severe that is, we know that type two diabetes is a risk factor for heart disease, like risk factor for heart attack or ischemic heart disease. And then the other thing is, diabetes is also a proxy for having a myocardial infarction or heart attack, meaning that if someone has a history of diabetes, then they have as much risk of having a heart attack as a patient that already had a heart attack before and have to have another heart attack. So I think these are very important questions to ask Mary as well as some of these things to make sure that she's currently safe and not in any immediate danger for her health. So you can see that we're really going to ask her very holistic questions about her health, we're going to ask her very medical questions as well about, you know, is this person really in a safe space right now to treat someone longitudinally? Or did it need to go to an acute care type of place like the emergency room? So I think these are these are some of the things here now lifestyle. If you listen to our most recent episode, we kind of detail the smart lifestyle model with sleep, mindfulness, activity, real food and ties, so certainly for her, I wonder about her sleep again, just to make sure she didn't have sleep apnea, she's snoring is she fatigued in the morning after after waking up? Did she get a good night's sleep did she get quality sleep that would be very important because that's gonna affect your energy but also that's gonna affect her cardiovascular health as well. If she doesn't get enough sleep, then that would affect her cardiovascular health and brain health as well. lifestyle factors really for marry have to begin with food it for married really does start with food. Now now food is very emotional for a lot of people, you know, we all kind of grew up with you know, different emotions attached, you know, to our food and eating with certain people and having feelings about that food, you know, association the love or care often when eating certain comfort foods. So I think you know, this, this is all kind of tied in mind body. So nutrition isn't just about putting, you know, putting a piece of food bite into your mouth using your fork or, or whatnot, it's also about the emotions that come up, it's about the memories that you have things like that the visceral experiences that have been stored in your body when you eat a piece of food. So we're going to ask her about her her diet and how did it evolve to this kind of beige diet and try to how to get kind of how to get it to more rainbow type colorful diet ideally, but um, we'll ask her a bit about that and kind of what motivates her to eat this type of diet is it habit is an emotion is it that she likes to taste is it she doesn't have the time to cook a more rainbow type of like more homemade type of diet that's fresh, and with fresh fruits and vegetables and healthy proteins and fats and things like that. So what would definitely want to focus on that and eating a more anti inflammatory diet with healthy fats, healthy oils, healthy protein, I would add some fermented vegetables in here as well, which are really, really good for the gut microbiome if possible, things like kimchi or sauerkraut or things like that. Maybe fermented pickles if people like if Mary likes that, and then because she has a lot of weight gain and diabetes, one of the things that's really key with diabetes as a as a as a risk factor for cardiovascular disease, but also what happens with diabetes with type two diabetes is that initially what happens is the fasting insulin levels, insulin levels go go up. So insulin does drive weight gain. Insulin does drive blood sugar to go up, which then leads to type two diabetes. So having foods that are lower in insulin stimulation would would make a lot of sense to try to help with Mary get to a healthier weight.

Getting insulin level downs down also reduces her risk of dementia, cardiovascular disease and stroke and other chronic diseases like cancer down the line. So very, very important to get the insulin level down. For someone like Mary, I would imagine it would be like a pretty high level most likely and her. So foods that are kind of lower on the on the kind of insulin stimulation type of scale would be, would be fats are pretty low. So healthy fats like olive oil are avocados or nuts. And then also some proteins plant and animal proteins. Proteins do stimulate insulin, but they're going to stimulate insulin to a lesser lesser degree than carbohydrate. So I think just in terms of your three macronutrients of fats, proteins and carbohydrates, fats don't really stimulate insulin, proteins do stimulate insulin to some degree, and then carbohydrates really stimulate insulin so so carbohydrates, we're talking about cereal, and potatoes and rice, and all these things that really are our, that that may or eats, you know quite a bit, you know, fruit can be actually, you know, fruit does turn to fruit is a type of sugar as well. You know, I'm wondering what type of fruit she eats? Does she eat fruit with the with the skin on which is going to add some fiber? It's going to slow down that blood sugar rise? Or does she eat like canned fruit or something like that, or even fruit juice, which is even worse, that's going to really spike her, both her glucose and insulin levels. So these are very important detail questions to ask, ask Mary really, we would also consider food ordering here. So there's certain types of food ordering that will be very helpful to reduce blood sugar spikes, basically eating, eating green vegetables, eating proteins and fats first before the carbohydrates often would reduce what's called the area under the curve of a glucose curve. So this is very important is the order of foods. And then potentially walking or doing some sort of exercise like squats or, you know, some sort of even Catholic calisthenics can be really helpful after meal to try to activate those muscles, because muscles are going to be really helpful. When they're more activated, it's going to take up that blood sugar that you just ate that meal or snack from, and it's going to take that blood sugar out of the bloodstream into the muscles and tissues, and that will have overall less inflammatory effect. So those are some of the big things, you know, from a last lifestyle recommendation perspective.

I think the walking is really good for her, we may want to also depending on you know, her her time and her level of interest in this, I would definitely consider, you know, one thing that happens is as we all get older is potentially the risk of sarcopenia. sarcopenia is basically where there's a muscle atrophy or less muscles. Now, when you think about muscle, muscle type, there's different different anatomic locations of our muscles. But between the legs and arms, the legs are the muscles that are more influencing the insulin levels and blood sugar levels. So we're gonna want to make sure to work Mary's quads, you know, do some squats, do some, even some yoga poses can be really helpful for this certain ones, maybe like planks and things like that, that'll, that'll hit both the legs and the core, really a full body workout, they're using weights, you know, using resist resistance training to help to build the muscle, you know, slowly but gradually but safely that way. So I think lifestyle recommendations would be ideally to go to a gym or to use a trainer to help with resistance training and start with that. So that's where I would start with, with Mary and then testing wise, there's a lot of labs, we can start with some of the basic ones, we would definitely want to check her blood sugar, her hemoglobin a one C and insulin. These are metabolic markers that can be really, really helpful to really understand kind of where where she is and things again, we want the ensign level to be below, below five but I think you know, for someone with diabetes, I'm not sure how realistic that is. We'll just kind of see where she is and kind of treat that you know where she is. I would want to check her thyroid panel as well a full thyroid panel which would include things like TSH free T three three T four, reverse T three and thyroid antibodies. She has gained 10 pounds in the last year despite trying to increase her activity levels. So we want to make sure to rule out any thyroid condition that's slowing down her metabolism that might make her that might cause resistance to weight loss. She is on Metformin which is a medication that's used for metabolism, but also for diabetes. And Metformin can deplete a vitamin called vitamin B 12 are also called cobalamin. So we want to check her serum B 12 level based on that. She also drinks coffee and coffee as a diuretic and coffee is going to make us pee out more magnesium make Mary pm or magnesium so we're going to check a red blood cell magnesium level as well.

I would check out a mega check again, which is a mega three level, as well as some basic things like kidney test liver tests, urine micro albumin test to make sure her kidneys are not getting inflamed from the diabetes that she doesn't have diabetic kidney disease, for instance, or hypertensive kidney disease. And then we'll check a blood count, just to make sure she didn't have anemia and things like that. In addition to that, we will consider an advanced lipid panel. So an advanced panel goes a little bit beyond your basic lipid panel, it's going to look at things like particle number and particle size of cholesterol, also called an NMR lipid profile, which stands for nuclear magnetic resonance lipid profile, we'll look at fibrinogen and homocysteine and lipoprotein a, these are all markers that are independent risk factors for for heart disease, and we know that with diabetes, she does have an increased risk of heart disease for someone that didn't have diabetes. So these are very, very important to, to think about for testing. So I would really start more with bloodwork for her at first and then on a practitioner side definitely needs to see a cardiologist, you know, I think anyone with type two diabetes should see a cardiologist because they are at such high risk for cardiovascular disease, would recommend ideally doing a 2d echocardiogram, which is an ultrasound of the heart, potentially an ultrasound of the carotid arteries as well. Because often if there's heart disease or plaque in one area, there's going to be potentially plaque and another area of the of the body of the blood vessels, I would say the other thing we could think about would be if we would, for sure referred to nutrition and to physical therapy here as well.

And I think just making sure that that she really this, Mary really does need a really good, you know, ideally integrated primary care practitioner that's going to really map things out and partner with her and follow up with her. And really make sure that she kind of stays on track. This is a type of situation with hypertension and diabetes, with an increased risk of heart disease. This is a very, these are very lifestyle related diseases. And when it's a lifestyle related disease, it can be reversed. So I think that's really, really important for Mary to understand is that this is not a life sentence. This is not something that she has to be on Metformin for the rest of her life, if she can change her lifestyle on diet with the help of practitioners and dedicated professionals and her own mindset as well in her community support, then Mary will have a chance and will be able to really help herself out now and in the long run.

So top three most important steps, change change Mary's diet food as medicine, low glycemic load type of diet, fats and proteins and vegetables first, and then carbs later, but then less carbs overall. Making sure to increase the exercise specifically for leg exercises, squats, weights using the quad, working the quads, you know, maybe some bone building exercises depending on if she has like osteopenia or osteoporosis. So there's a lot of bone bone classes, bone density classes nowadays, using physical therapy as a professional that can be really, really helpful in this situation. And then managing her stress and really flipping the script on.

I'm going to live with this for the rest of my life versus I'm going to work on this for the rest of my life and reverse this and beat this. So I think these are the key factors for for Mary and we wish Mary the best and we will we will follow up with her to see how she's doing.

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