Two Challenging Cases from Two Contrasting Clients – Ian Craig

Most published case studies detail clear intervention strategies and happy endings. Ian Craig shares two very contrasting clients with challenging cases whom he recently had the fortune to learn from.

I might consider sharing with you a perfect case study in which I outline the case history and challenges of the individual, followed by a neat intervention that the client followed, resulting in textbook results. However, I don’t have many of those; life is often more challenging, especially with many of the overwhelmed individuals I consult with in Johannesburg – the stress capital of Africa.

Here, I present two individuals I found to be challenging cases to work with. Both came to see me with stock-standard sports nutrition goals, but both had underlying metabolic dysfunctions that could not be ignored.

Challenging Case 1: Anton (38) – The Business Owner

After years of running his businesses and being successful financially, Anton started getting into better shape at the start of 2014. Because he shifted attention to his diet and increased his gym work, he dropped from around 100kg to sub-90kg in a few weeks. At that point, his weight stagnated, with some residual fat around his belly.

He came to see me in September with the remit that he wanted me to help him maximise the time spent in the gym, with the goal of increasing muscle mass and decreasing fat mass.

Taking a deeper look at this challenging case, Anton presented with:

• • Thyroid – Hashimoto’s disease; he had consulted with an endocrinologist in May, who diagnosed him with ‘hypothyroidism’ and put him on euthyrox (see Table 1)

• • Gastrointestinal (GI) function – good except for mild sluggishness when consuming pizza and pasta

• • Energy – stable, but less than two years previously

• • Sleep – had been waking at 4 am for a few months

• • Stress – at a good financial stage in his life, but he was experiencing more anxiety than he used to, despite no higher stress levels

• • Immune – the standard colds twice per year and chronic fungal infections in years prior

• • Training – he did a 4-day split weight training routine, a Pilates session, and sometimes mountain biking or hiking at the weekend

Analyte	Result – June 2014	Result – Nov 2014	Reference Range
TSH	5.10	4.20	0.27 – 4.20
T4	12.4	18.1	10.16 – 22.0
T3	3.8	3.5	2.6 – 5.7
Anti-TG Antibody	62.77	71.19	< 4.11
Anti-TPO Antibody	194.62	582.39	< 5.61
Vitamin D		38.4	30 – 100

Intervention

My first question was why a young, apparently fit and healthy man had such incredibly high thyroid antibodies. For this state of auto-immunity, it was important to check a number of things. As always, I started with his gut and ran an IgG food sensitivity panel. This revealed a very high reading for cow’s milk (81), reasonably high readings for baker’s yeast (45) and brewer’s yeast (38) and a borderline reading for wheat (29). For this particular test, the ‘green zone’ ends at 23, so for foods that display higher values, it becomes progressively more important to rotate that food or eliminate it from the diet. We excluded these particular foods for the most part – he liked his wine (containing yeast), but in pursuit of thyroid health, he was content with two glasses per week.

Supplement-wise, I started with a powdered gut and detox support, along with five grams of l-glutamine, a shot of aloe vera juice, and probiotics for three weeks, even though he didn’t display GI symptoms – experience has told me that there doesn’t always need to be symptoms for there to be imbalance or pathology.

In terms of stress, I wanted to help reduce his levels of anxiety and also improve his durations of sleep – of course, both could be affecting one another. I suggested a sleep routine of turning all electrical devices off one hour prior to bed, soaking in an Epsom salt bath and taking either a melatonin or herbal sleep supplement. Additionally, I asked him to complete the Braverman Nature Questionnaire, which is an excellent aid to the understanding of neurotransmitter status. It revealed particularly low levels of GABA and serotonin, leading me to add in a trial of GABA and 5-hydroxy-tryptophan (5HTP) supplementation. 

Food wise, apart from avoiding food sensitivities, I helped him to establish a dietary pattern that was less stressful to his body. All the rage in South Africa at the time, he had been following a low-carb, high-fat approach – this had aided in a loss of 3kg, which had stagnated. Considering his sluggish body fat and suspected insulin resistance, being careful with carbohydrates was appropriate, but not blindly following a high-fat diet, which may compromise insulin receptor sensitivity. Additionally, he was training intensley almost daily and needed improved blood sugar support that small amounts of low-glycaemic carbohydrates may have provided.

In addition to GABA and 5HTP, I recommended that he take a multi-nutrient, a thyroid nutrient formula, and Vitamin D3 drops. Vitamin D deficiency has been implicated in cases of auto-immunity, and although not clinically deficient, his levels were much lower than modern research might suggest as optimal.

Reflective learnings

Bearing in mind that I only started working with him a month or so before his second set of test results, I didn’t blame myself for the massive rise in thyroid antibodies five months previously! But it certainly wasn’t the results I’d been hoping for. This presented as a challenging case. So, I deemed it important to recruit another set of eyes, plus somebody with prescribing powers – I referred him to an integrative medical doctor who worked on Anton’s case with me. At the time of writing, we were waiting for further endocrine and GI test results to come back prior to proceeding further with his case.

Anton sent me a reflective email after he visited the integrative doctor, saying: “She (the doctor) looks quite excited and positive about the project, so I’m very happy; it just goes to show that you need the right people to assist with these things, as you guys make my initial doctor and endocrinologist look like monkeys… the medical system and its approach to treating the symptoms and not the cause is becoming very apparent to me, and I would much rather have you guys on my team.”

Even though we hadn’t yet sorted his raging thyroid gland, good client relations had resulted in Anton being a very positive and appreciative person, and one likely to follow interventions closely, hopefully obtaining good results, when we had figured out the best line of treatment following his challenging case.

Case 2: Eric (37), The Investment Banker

Eric was referred to me by my exercise physiology colleague. He had been suffering from chronic fatigue for about 10 years. His energy levels had been at an estimated 4 out of 10 for the past 2-3 years, likely linked to falling down the stairs and ending up in a comma two years prior. His energy wasn’t bad enough that he couldn’t function – he had two serious cycling races on the horizon (100km and 200km).

Presenting as a challenging case, Eric’s signs and symptoms were many:

• • Immune – he had experienced Epstein Barr virus and encephalitis in the past

• • Mental – despite still working long days, he lacked drive and focus in his work; he used to enjoy stress, but not at that time of his life

• • Libido – was low to nothing, highly unusual for a man in his 30s

• • Hormones – endocrinology tests one year ago had revealed all steroid hormones to be low apart from cortisol, which was chronically raised

• • Digestion – was generally okay except when he had followed a low-carb, high-fat diet and became constipated.

• • Blood sugars – often low and would need regular feeding

• • Exercise – he trained on his bike about five times per week and in the gym once

Since he had consulted with his GP, an endocrinologist and an integrative medicine consultant before he got to me, and he was on a huge array of drugs and supplements adding to his challenging case:

• • Medications – pregnenolone, DHEA, euthyrox, tetroxin (T4 – T3 conversion), a testosterone stimulator, a brain wave regulator, and Viagra

• • Supplements – a multi-nutrient, S Boulardii, adrenal glandular, herbal adrenal support, zinc-magnesium, detox support, blood sugar support, Vitamin D3, and a bone formula

Intervention

I wanted to work with him on his chronic fatigue as a priority, so I ran a mitochondrial test without changing any protocols already in place (Acumen Labs, Devon). Results were as follows in Table 2:

Analyte	Result – Oct 2014	Ref Range
ATP (with Mg added)	1.52	1.6 – 2.9
ATP (endogenous Mg)	0.73	0.9 – 2.7
ADP to ATP conversion	57.6%	> 60%
ATP translocation out of mitochondria	345	410 – 950
ADP translocation into mitochondria	62	140 – 330
Cell-free DNA	10.2	< 9.5
Niacin status	14.8	14.0 – 30.0
Zinc-copper SOD	220	240 – 410

In a nutshell, his mitochondria were operating consistently below the normal range, including their available ATP, their ability to convert ADP to ATP, their ability to get ATP into the cell’s cytosol, and their ability to get ADP back into the mitochondria for recycling. Additionally, his elevated Cell-free DNA indicated cellular damage and ageing, he was borderline for niacin (Vitamin B3) status, and his zinc/copper-dependent superoxide dismutase (antioxidant) levels were low.

In terms of his diet, it was pretty spot-on perfect, if there was such a thing. He used an app to track his food intake. He ate high-quality organic food, juiced daily, and consumed sufficient calories and an appropriate macronutrient balance to support his training.

But, despite eating well and being on 101 supplements and drugs, his body was in a horrendous state. I tidied up what could be improved in his diet, and I consolidated his huge supplement list into must-haves so that I could add in a mitochondria-specific formula.

However, there are times when you can tell that dietary and supplement improvements will not make much difference to a client’s health. He was dealing with a long-term state of metabolic fatigue, which included pituitary, thyroid and adrenal dysfunction, along with under-functioning mitochondria. He was already taking high-quality supplements, and if Viagra was not sufficient to restore his flagging libido and erectile dysfunction, his body as a whole was under-responsive.

So, as I do with most over-functioning, under-performing executive clients, I turned to the role of psychologist. I reasoned with him about the impact that years of stress and lack of listening to his body had on his physiology, and it was clear that he understood what I was saying intellectually. I played hardball and told him he needed a complete shift in priorities to return his energy levels to normal. His wife was going through fertility treatment at the time, and I’d hoped that I could motivate him towards change down the lines of being able to provide his wife with a child. Again, he understood intellectually.

Reflective learnings

By the time I got home from my clinic, though, I was receiving a flurry of emails regarding getting his already perfect diet even more perfect and performing better at his upcoming races. I then made a fatal error; I gave him email support without charging for my time, I was drawn into his stressful life, as can be the case when you are dealing with a challenging client.

I saw him twice in total, and both times I had hit him with hard realities that should have made the toughest of people take stock. When I used to personally train executive clients in London, we would assess all our clients for personality. Eric was what I would term an unrelenting ‘red’, and he needed to hear very direct language with very specific guidelines.

If I was tough on myself but I couldn’t have helped him more at the time, because he wasn’t ready to help himself. Hopefully, I’ve sown the seeds towards a shift in his behaviour patterns. Still, like many individuals, he may need to progress to a state of debilitating chronic fatigue to hear the lessons. I don’t know what became of Eric, but I certainly learned from him, and I will never put any case down as a failure if I know that I’ve used good clinical judgement, given sound advice, and tried as hard as possible!

To continue learning about Integrative Sports Nutrition, where health feeds performance, click here to access CISN’s library of articles.

Click to listen to Ian Craig’s ‘The Science and Strategy of Personalizing Nutrition‘ interview on the Nutra-preneur podcast here.