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Chief Complaint: Fatigue, Weight Gain, Poor Sleep
Rebecca is a 44 yo female who came into the clinic for her annual physical. She feels very fatigued and is dragging through the day. She has gained about 10 lbs in the last year and is having some new knee pain when she goes hiking. She has had a lot of stress at work over the last year and has traveled for at least one week every month. Her sleep has been disrupted with jet lag and early morning flights. She has not been exercising consistently and has been eating mostly on the go without much thought into what or when she is eating. She is not taking any supplements.
Overall, she feels less vibrant than she was a year ago and wants to “get back on track” and focus on her health.
Past Medical History
- She has had mild elevations in her cholesterol in the past with her LDL-C running between 110-130 on past lipid panels. Her triglycerides were less than 100 on prior labs.
- She has always had a normal fasting glucose and a Hgba1c less than 5.5.
This year, in addition to the usual labs we ordered for her annual, we added some advanced metabolic markers from Boston Heart to better understand her metabolic risk factors.
Starting Lab Results
Evidence of Insulin Resistance
At face value, Rebecca’s Hgba1c is within the normal range. Hgba1c is a measure of glycosylation of red blood cells that gives us a proxy of average blood sugar levels over the lifetime of a red blood cell. If any health problems affect the size or quantity of red blood cells, it can alter the Hgba1c and render it a less effective proxy for average blood sugar. In Rebecca’s blood work, the increased size of the red blood cell (noted by the increased value of her MCV) artificially lowers her Hgba1c. You can see that her fasting insulin level is quite elevated, suggesting significant insulin resistance, which is not being reflected in her Hgba1c.
Significant increase in LDL-C/ApoB and Triglycerides
Rebecca’s LDL-C/ApoB and Triglycerides are significantly elevated and are above her usual baseline of triglycerides <100 and an LDL-C of around 100-130. Insulin resistance is strongly associated with an increase in triglycerides, a decrease in HDL, and an increase in the small dense sub-particles of LDL. These new abnormalities in her lipid profile further support our diagnosis of insulin resistance.
Deficiency in B vitamins with an elevated Homocysteine
Rebecca has multiple signs of B vitamin deficiencies, including an elevated MCV, elevated homocysteine, borderline low serum b12, low RBC folate.
Over the last year, Rebecca has had a significant increase in stress, disrupted sleep, and decreased exercise, contributing to weight gain and the onset of insulin resistance. The insulin resistance is likely the root cause of her worsening lipid profile, so I chose to focus on managing her insulin resistance first and then reassessing her lipids after we improved her insulin resistance.
Rebecca’s Prescribed Treatment Plan
- Wear a continuous glucose monitor and aim to keep the post-prandial glucose spikes below 140
- Start a B complex supplement
- Exercise to the point of sweating for 30-45 minutes at least 3x a week.
Continuous glucose monitors are small wearable devices that measure the glucose level in the interstitial fluid. They give the wearer real-time feedback on how their glucose level responds to various foods they eat and behaviors such as exercise, sleeping, etc. People are often surprised by how their bodies respond to foods they consider “healthy” and can quickly adjust their diets based on real-time feedback. Many patients find this type of immediate feedback very motivating, and it often allows for rapid behavioral change.
Note: Continuous glucose monitors are only approved for use in insulin-dependent diabetics, so this will be an out-of-pocket expense for most patients and can be an expensive intervention for people to try.
Follow up Labs 3 Months Later
Rebecca found her continuous glucose monitor very helpful. She had previously been eating oatmeal for breakfast but noticed a significant glucose spike every time she tried it. She switched to eating a protein bar and stopped adding sugar to her coffee. Within two weeks, she completely eliminated her high morning glucose spike.
Over the one month she wore her monitor, she scaled back on her carbohydrates and started walking after larger meals like lunch or dinner. She was able to maintain these changes after she stopped wearing the monitor but thinks she would like to do it again in a few months for added motivation.
She is taking the B complex with no side effects.
She has started going for short jogs after lunch 3x a week to get her exercise in and has been really enjoying that.
Overall, she feels a dramatic change in her energy and an improving sense of vitality. She didn’t expect it, but she has noticed a profound improvement in her sleep from these diet and exercise changes. She falls asleep easily and wakes up feeling more refreshed. She is also thrilled that she has lost 5lbs.
Reviewing her blood work, we can see that her fasting insulin and her Hgba1c have improved. Her lipids have also trended back toward her baseline, and her B vitamin markers have also improved. I encouraged her to keep up these new diet and exercise habits with the plan to repeat her blood work again in 3-4 months.
Insulin resistance is often a root cause of cellular problems that can lead to many physical symptoms as well as abnormalities in other biomarkers.
Decreasing dietary carbohydrates, increasing exercise, and improving sleep can all help reverse the metabolic dysfunction seen in insulin resistance. Sustained motivation can be challenging when it comes to dietary and exercise interventions. Coaches, nutritionists, and wearable technologies such as continuous glucose monitors can all help support motivation and turn these changes into lifelong habits. Identifying insulin resistance early gives patients the time and the knowledge to make these personal changes and prevent the onset of diabetes.
Other Articles You May Be Interested In
- What Is Insulin Resistance?
- A Functional Medicine Approach to Insulin Resistance
- How Functional Medicine Providers Look at "Optimal" Lab Values