Nutrional Services

Nutritional Consultation - Chronic Fatigue/Thyroid

May 4, 2004
Revised May 18, 2004

To Whom It May Concern:

Ms. ________ entered my office for a nutritional consultation on May 4, 2004. She is a mentally alert, cooperative female, 47 years of age. She appears enthusiastic and energetic.

REASON FOR CONSULTATION:

Chronic fatigue.
Impaired mental function.
Frustration/questions on direction of care.

OTHER CURRENT MEDICAL COMPLAINTS:

Lower back pain and neck pain.
Depression.
Headaches 1 to 2 times per week.
Food allergies.
A sore throat when she increases her activities of daily living.
Weakness, anxiety, postexercise fatigue, blurry vision, nausea, dizziness, joint pain, and dry eyes and mouth.
Tinnitus
Hypoglycemia.
Positive Epstein-Barr titer.

LIFESTYLE:
Alcohol - denies.
Tobacco - denies.
Caffeine - 2 Diet Cokes per week with an occasional serving of tea.
Dietary sugar - denies.

SLEEP: She gets 9 hours of good quality sleep per night.

EXERCISE:

Once a week she swims for twenty minutes
Once a week she walks for twenty minutes

PAST MEDICAL HISTORY: The patient's stated height is 5 feet 5 inches. Stated weight is 139 pounds. Since last June she has lost 11 pounds. She denies any automobile or other traumatic accidents or injuries; however, she has longstanding neck and back pain. MRI study performed in December 2002 revealed multilevel degenerative disc disease in her lumbar spine. There were 4 mm protrusions at L2-L3 and L5-S1, and 5 mm protrusions at L3-L4 and L4-L5. There was also a cervical spine study performed which showed mild bulging at C5 and C6 with osteoarthrosis at C5-C6 and C6 C7. Although the MRI was unimpressive, her exam findings that provided the MRI were strongly positive; that is, cervical compression test caused sharp neck pain and bilateral radiculopathy, as did the Valsalva maneuver.

Surgical History:

Tonsillectomy.
Fifty percent of her right ovary was surgically removed. Seventy-five percent of her left ovary was surgically removed (the patient states the remainder has atrophied and apparently been resorbed by her body).
Right wrist surgery caused by a fracture.
Cervical conization.
Dilatation and curettage due to a miscarriage.
Cosmetic surgery around her eyes.

Serious Diseases or Illnesses:

Depression and Anxiety
Hypothyroidism.
Chronic fatigue syndrome.
Fibromyalgia.
Candida overgrowth.
Cystic acne, for which she is under care, but which is not visible to this examiner.

FAMILY HISTORY: There is a family history on her mother's side of spinal degenerative disc disease in both her mother and sister. There is a strong history of depression on both sides of her family.

HISTORY OF CURRENT PROBLEM: In the spring of 1999 she had a surgical procedure to her ovaries. She had postoperative fatigue with an increase in her depression and anxiety. Adjusting her antidepressants helped the depression and anxiety but failed to improve her energy. In the fall of 1999 she had a colonoscopy and subsequently had 3 polyps removed. Following this procedure she began to use wheat grass juice and carrot juice and felt better for approximately 1 year. She stopped juicing when she changed jobs. Her new job in escrow sometimes ran from 8 in the morning to 11 at night. She describes it as high pressure. It caused her to eat a lot of junk food and not get enough rest. Her fatigue, which never completely resolved, increased. She combatted this with 3 cups of coffee and 4 Diet Cokes per day. After 3 years her fatigue was to the point where she was no longer able to remain employed and quit her job in mid 2003. Shortly after she quit her job, I performed a detailed nutritional consultation on her and recommended that she review the amount of thyroid and testosterone she was taking. I also wanted her tested for a possible Candida problem, which she states today was strongly positive for yeast overgrowth. She has tried a variety of nutritional supplements and medications but still suffers from chronic fatigue. She has changed her diet due to the Candida problem, which has helped some of her yeast overgrowth symptoms, but has not helped improve her energy at all. Her many treatments for chronic fatigue included 6 months of B12 injections, which did not provide any relief.

ALLERGIES: She is allergic to TETRACYCLINE and nutritional supplements that contain enzymes. She also states that she has problems with dairy, sugar, too much fruit, wheat, and carrot juice.

SUPPLEMENTS: The patient is currently taking the following nutritional supplements:

Coenzyme Q10, 100 mg per day.
Magnesium, 400 mg at bedtime.
Milk thistle extract, 1 capsule a day. I failed to note the milligram amount.
Chromium picolinate, 200 mcg 3 times a day (600 mcg total).
DLPA (DL-phenylalanine), 500 mg at bedtime.
A fibromyalgia supplement consisting of 2 tablets twice a day which at 4 a day total 1200 mg of malic acid, 300 mg of magnesium, and 100 mg of vitamin B1 and vitamin B6.
Zinc, 60 mg per day.
Vitamin C, 200 mg per day.
Lipoic acid, 100 mg per day.
DMAE (dimethylamino ethanol), 50 mg a day.
Standardized garlic extract, two 320 mg capsules twice a day (1300 mg a day total).
Calcium, 250 mg (from carbonate 125 mg, from citrate 75 mg, and hydroxyapatite 50 mg), and magnesium, 60 mg.
Acidophilus capsules, 2 twice a day.
Relora, 250 mg once a day (an herbal preparation consisting of magnolia and philodendron extracts).

MEDICATIONS:

Armour thyroid, 90 mg.
Paxil, 20 mg.
Vicodin as needed.
Glucophage (on occasion).
Bioidentical estrogen, 1.25 mg.
DHEA and testosterone (I believe both are in topical preparations).

DIET ANALYSIS: A food recall interview revealed the following:

Breakfast: 4 days a week - a whey protein powder sweetened with sucralose, a noncaloric sweetener, mixed with water. Once a week she will blend in an apple. The protein container (and label) were not available for my review.
1 day a week - 2 scrambled eggs.
2 days a week - another kind of protein* mixed with 2 strawberries.

* Note: This mix was recommended by someone at a healthfood store who stated that she was probably allergic to whey. When I questioned her about this, I asked her if when she consumed the whey protein she had a similar reaction to foods that she clearly is allergic to; that is, bread, sugar, and milk. She smiled and stated that she does not get any of the negative effects when she drinks the whey protein that are present after consuming dairy, wheat, and sugar. Therefore, we determined she no longer has to consume the other protein, which she states has a very foul taste.

Midmorning Snack: She denies a midmorning snack.

Lunch: 2 days a week - canned tuna with mayonnaise and a small amount of relish.
2 days a week - Chinese chicken salad consisting of lettuce and chicken.
3 days a week - leftovers from dinner which usually break down to once a week steak, once a week chicken, and once a week some type of fish.

Afternoon Snack: Raw macadamia nuts and/or almonds.

Dinner: 3 days a week - barbecued steak.
2 days a week - barbecued chicken.
1 day a week - barbecued fish.
1 day a week - she has dinner out and normally will try to order aChinese chicken salad with dressing on the side.

These meals are accompanied by a salad with cucumbers, onions, tomatoes, mushrooms, cabbage, carrots, and lettuce along with a homemade olive oil and vinegar dressing. Sometimes these dishes will be accompanied by a steamed vegetable mix consisting of broccoli, cauliflower, asparagus, and green beans. Once a week, instead of steamed vegetables or salad, the meat or poultry will be accompanied by a stir fry which consists of broccoli, asparagus, carrots, onions, and bell peppers.

Note: Since she was diagnosed with candidiasis (yeast overgrowth), she has stopped all alcohol and dessert consumption.

IMPRESSION:

Atypical chronic fatigue syndrome.
Atypical yeast overgrowth.
Altered cellular receptors and/or membrane-binding dynamics negatively affecting both pharmaceutical and nutritional therapeutics.
Rule out unidentified hormonal (and/or downstream intermediate metabolite) imbalance.
Clinical depression.
Multilevel herniated nucleus pulposus of the lumbar spine.
Degenerative disc disease of the cervical spine.

CLINICAL COMMENTS: This is a very complex case, and Ms. ______ frustration, to this examiner, is completely understandable. There are many issues. I will attempt to break them down by category in no particular order and hope these findings will help the decision-making process of each provider she encounters.

Depression and anxiety. Although depression is commonly seen with chronic fatigue syndrome (CFS), Ms. ______ reports that she suffered from depression long before her fatigue and CFS were diagnosed. She notes that depression runs in both her mother's and father's sides of the family. In my notes on May 5, 2003 (one year ago), following a treatment for her low back pain, we had a long discussion and at that time I felt that a review of the amount of antidepressant medication she was taking was warranted. She followed up per my recommendation and successfully adjusted her dosage, which delivered a noticeable benefit. Long-term use of such medicines may alter physiological response to both nutritional and pharmaceutical substances.

Hormonal issues. Ms. _______ states that the Armour Thyroid helps. She denies ever seeing an endocrinologist. My records show a recommendation for thyroid medication adjustment on the same day (May 5, 2003) mentioned above, and my notes indicate that she also followed through with this recommendation. Her physician stated the dose did not need to be changed. In either 2002 or early 2003 she had her sex hormones measured and states that the results showed DHEA and testosterone levels that were almost nonexistent. She began hormone-replacement therapy, which improved her laboratory profile. Curiously, she did not feel any difference when her laboratory values of testosterone and DHEA improved (no improvement in energy or feeling of well-being). She stated there was a slight increase in libido. She stated that the DHEA reduced the amount of hypotension she suffers from. Last year she self-suspended testosterone, DHEA, and estrogen therapies after reading negative reports in the press. Six months ago she resumed DHEA and testosterone and stated that although the libido increase was very subtle, when she discontinued these hormones the decrease in sex drive was quite noticeable. After reading a new book by Suzanne Somers (an advocate of hormone-replacement therapy), she resumed her bioidentical estrogen-replacement therapy 30 days ago. Because she traces her chronic fatigue syndrome to directly following the removal of her ovaries, I feel a thorough review is warranted to determine what percentage of her symptom complex, if any, is an undiscovered hormonal imbalance.

Ms. ______also recalls that some time last year she took a blood test, the results of which showed blood sugar at a level that would diagnostically categorize her as suffering from hypoglycemia. She states that she will occasionally take Glucophage as her symptoms dictate.

Second opinion. At this appointment (May 4, 2004), her frustration level is high. She asks if she should stay with her primary care physician or consult someone different. As previously stated, I feel that the person she needs to see is an endocrinologist. She went on to say that she is dissatisfied with her musculoskeletal specialist who feels she should return to work. Ms.______states that she would love to go back to work but does not feel she could tolerate it. Due to the rather extensive multilevel degenerative joint disease of her lumbar spine, I feel it is prudent that she maintain a relationship with an orthopedist or a physiatrist.

Chronic fatigue. Her CFS continues. She states that after she does her 20 minute swim, she has postexercise malaise that will last for at least 48 hours. The same also occurs after a weekly 20 minute walk. I recommend some changes in her exercise program.

She is taking many nutritional supplements that have literature-supported effects in some CFS patients. Specifically, coenzyme Q10, zinc, and magnesium are commonly recommended for CFS patients, none of which have provided a noticeable benefit. Last year, for 6 months, she administered B12 injections at levels that in some blinded studies helped over 80% of CFS sufferers. She discontinued the vitamin B12 because she felt no effect. It should also be noted that she states activities of daily living such as going to the mall or a ball game "wipe me out."

A very interesting aspect of her CFS (?) is her sleep. The patient reports that she sleeps 9 quality hours a night. She cannot attribute this to any drug or supplement. Since my last nutritional appointment on June 27, 2003, she has moved in with her boyfriend. In my experience, a consistent good night's sleep with people who have full-blown CFS is very, very unusual. In fact, I have never seen a CFS patient who has no problems sleeping.

Other supplements that have helped CFS patients were discussed. L-carnitine (which I recommended last year) helped her when she was taking it. She does not know why she stopped except that she has so many supplements it is hard to keep track. L carnitine is an endogenous dipeptide that delivers fatty acids across both the outer and inner mitochondrial membranes. L carnitine synthesis is low in many CFS sufferers. Creatine monohydrate has also helped some CFS patients. It increases ATP production. NADH, a vitamin B3 derivative used in electric transport system, also has been helpful for some CFS patients. It is now available in nutritional supplement form. I do not want to introduce any more supplements until it is determined what percentage of her fatigue, if any, is generated by complex hormonal abnormalities. In my opinion, there is definitely a chance that what has been treated as chronic fatigue may largely be a multifactorial hormonal problem possibly exasperated by binding site or receptor abnormalities some of which may have been caused by long term use of various pharmaceuticals.

Per my recommendation last year, she was tested for yeast overgrowth which, according to the patient, was strongly present. Six months of nystatin had very little effect on her symptom complex. In my experience, this is quite unusual. Removal of dietary sugar, bread, most fruit, and alcohol has been subjectively helpful to the patient. When she does not take her acidophilus, her gastrointestinal pain and bloating is noticeably worse. Her history of antibiotic use, oral contraceptives, along with her craving for sweets, breads, and alcohol, along with her fatigue, self-described "brain fog," depression, gastrointestinal symptoms, low libido, paresthesias, and muscle aches are consistent with Candida overgrowth. However, most of the symptoms, with the exception of the gastrointestinal problems, are still present.

Food allergy/hypersensitivity. In addition to the above-mentioned foods, the patient states that if she eats more than 1 serving of fruit a day she has gastrointestinal irritation. She does not know which fruits cause problems, but she does know that apples are well tolerated. It is my opinion that we also need to determine if her wheat problem is actually a yeast problem, due to the fact that although breads irritate her, oatmeal does not. Oatmeal contains proteins similar to wheat. Because she can tolerate the oatmeal, I plan to introduce Trader Joe's High-Fiber cereal (without the milk) as a snack food or in her protein drink. This is due to the fact that her diet lacks fiber and that she needs 400 mg of magnesium at bedtime to maintain regularity.

It is also interesting that 200 mcg of chromium picolinate 3 times a day definitely helps with what she describes as "blood sugar abnormalities." This is most interesting considering that her current diet is very high in low glycemic index foods. As previously mentioned, I am also unfamiliar with any nondiabetic patient who "will occasionally use Glucophage" when they eat too many or the wrong kind of carbohydrates.

Musculoskeletal pain. I had not seen Ms. _____ since November of 2003 for back pain. She informed me that she had learned to manage her condition using a low dose of Vicodin (250-500 mg per day) along with being cautious and careful when performing daily activities. Furthermore, she lacks the energy to be consistently overactive. In May 2004 she presented to my office with a flare-up of her lower back pain. She is currently under my care as a chiropractor for this flare-up. As of May 16th her pain had decreased 50-60%. After treating in my office she had an appointment with physiatrist _________. She informed me that Dr. _______ told her he thought she was ready to return to work. Ms. _______ disagreed with this assessment, which will be discussed below.

I strongly feel if we can identify the main source of her multifactorial fatigue and can reduce it by only 50%, this would enable Ms. ______ to begin a strength/stabilization program for her spine. There is no question in my mind that the patient's deconditioning contributes to her back and neck problems. Unfortunately, she does not have the energy to exercise at a level required to build either stamina or strength.

Patient frustration. Ms. _____ is very frustrated with her care and condition. This is not to say that she dislikes her providers-quite the opposite. When Dr. _____ told her to "just go back to work," because "you're doing fine today," she left his office in very low spirits. By the time she returned to her home in North Orange County, the long drive had both irritated her back as well as fatigued her. She stopped to pick a week and in doing so caused her back to go into marked spasm. It is my belief that Ms. ______ truly wants to return to work. It is also my belief that her upbeat personality can give providers (especially when the length of the encounter is short) an impression of a person of high energy and low pain. In reality, this is the opposite. Because I am acting as both her chiropractor and nutritionist, I am in a unique position to have multiple lengthy encounters with the patient. I can assure all who read this report that there are no secondary gain issues here, nor is this a patient who is content on disability. She truly wants control of her life back.

RECOMMENDATIONS:

Supplements: My goals are:

Reduce the total number of supplements that she consumes.
Focus on her central problem-pain and fatigue.
Address peripheral issues such as tinnitus when her core problems are controlled.
My only supplement recommendations are as follows:
Reduce zinc to RDA level.
Reduce magnesium to RDA level.
L-carnitine, creatine monohydrate, NADH, as well as more aggressive dosing of selected current supplements will be considered once the results of the endocrinologist consultation are available and a central hormonal imbalance is either confirmed or denied. Until I have this information I do not want to add or subtract anything from her current regimen that could possibly cause a symptom change that would be interpreted as a response to new medication.

Diet:

Eat one-half cup of Trader Joe's high-fiber cereal per day. This can be mixed in morning protein drink or consumed as a snack. This will determine whether her food allergy is, in fact, a grain-based protein issue or whether it is caused from the yeast present in bread. This is also being recommended to help with her regularity that is currently controlled by excessive magnesium supplementation.

Referrals:

Continue with primary care physician, Dr. ________.
I recommend she maintain a relationship with an orthopedic specialist, to support my chiropractic management of her degenerative joint disease in her spine and determine if she is a candidate for other types of medical intervention.
I recommend an appointment with _______, MD, endocrinologist, for reasons previously discussed.
Give a copy of this report to each provider.

Exercise:

Change current exercise program from a 20 minute swim and 20 minute walk twice a week to a 5 minute swim and a 5 minute walk 4 or 5 times a week.

Therapy:

I will continue to treat her cervical and lumbar problems as her symptoms dictate. It had been 5 months since I last performed therapy on Ms. ______. She has been responding well to my treatment of electrical stimulation, heat or ice (depending on her presentation), and soft moderate or deep tissue manual therapy on and about areas of pain, discomfort, and hypertonicity. Therefore, I am optimistic that she will once again display a favorable response to conservative care in my office.

Should the patient or any providers have any questions concerning my care or the information contained in this report, please to not hesitate to contact me at my office.

Sincerely,

G. Douglas Andersen, DC

GDA/sdm

916 E. Imperial Hwy., Brea, CA 92821 Ph. 714-990-0824 Fax. 714-990-1917

gdandersen@earthlink.net
www.andersEnchiro.com