In an effort to lose weight, Jenny has adapted a version of the Mediterranean diet. She has been on this diet on and off for 3 months. She was keen to show an effort to lose weight before going on GLP-1s 2 months ago.

One of the reasons she's coming to you is because she hasn't felt well on this diet, when she's been able to stick to it. Her stomach feels bloated all the time, her energy has become very low, feeling tired all the time. She tries her best to limit servings of meat, eggs or dairy to 1x day. On days she has an egg for breakfast, she will have a salad for lunch.

Breakfast:

• Usually skips, if not:

• Low fat Greek yogurt with berries

• 2 slices of whole grain toast with peanut butter (he doesn't like the taste or texture of the 'natural' peanut butter) with sugar free jam.

Lunch:

• Subway whole-grain veggie wrap with low-fat dressing

• Pret-manger

  • Greek salad with olives (takes feta out if had too much dairy/meat/egg that day)

  • Avo, olive and toms baguette with low-fat dressing

• Leon

  • VEGAN LOVE BURGER with vegan

    cheeze and chili sauce

  • Krunchy Korean chicken wrap with LEON vegan mayo

Dinner:

• Charlie Bigham Macaroni Cheese

• Charlie Bigham Spaghetti carbonara

• Charlie Bigham Chicken and Mushroom Pie

• Dominoes pepperoni pizza

Drinks:

• Tea with skim milk 3-4x day

• 1-2 glasses water

• Diet Coke with lunch / dinner sometimes

Sofa Snacks:

• Pop-chips

• occasional chocolate bars

• Candy Kittens

  • Salted Peanuts

  • Wild Strawberry

• Height is 1.67m (5’ 4’’)

• Weight is 104.8kg (16st 7lbs).

• Apple shaped.

• BMI 39

• She has been this weight for 10 years.

• For most of her life she has been overweight.

• Online GLP-1s

Motivating event: six weeks ago, experienced chest pain when going up a flight of stairs.

Jenny has three main reasons for consulting a Nutritional Therapist:

1. High blood pressure – and getting worse. Last BP reading was 146/100 two weeks ago, it does get higher. GP has warned her is at high risk of a stroke.

2. High stress levels and fatigue – ‘I find it hard to relax and feel rushed most of the time’.

3. Weight concerns – ‘I have tried lots of diets to lose weight, but nothing has really worked. I lost a lot of weight in my early 20s but since then I’ve gained more, and I struggle to lose it now. I am feeling a bit depressed about this’. She believes she's tried every diet there is: Atkins, Paleo, South Beach, Slimming World, Keto, Intermittent Fasting, cabbage soup diet! GLP-1 injections appear to be working, but she's worried if she stops it will all come back

4. Elevated cholesterol, her GP is concerned. See results below

• raised alanine transferase 38 iu/L (NR 10-35)

• raised gamma GT 106 iu/L (NR 9-35)

• elevated fibrinogen 414 mg/dl (NR 180-400)

• elevated retinol 3.30 umol/L (NR 1.05-2.97)

• See advanced lipid panel below

• Poor Memory √

  Poor concentration √

  Headache (Migraine) √

  Irregular or skipped heartbeat √

  Rapid or pounding heartbeat √

  Chest pain √

  Pain in upper legs at night √

  Pains in elbows, wrist, thumb, forefingers and ankles√

  Right knee swelling

  Nausea √

  Bloated feeling √

  Constipation √

  Binge eating or drinking √

  Cravings for certain foods √

  Compulsive eating √

  Excessive thirst √

  Mood change before period √

  Mood changes √

  Mood swings √

  Anxiety, fear or nervousness √

  Depression – low mood √

  Fatigue, sluggishness

  New onset Allergies (cat and silicone)

What else do we want to know?

Are there any red flags?

•Premature birth – induced early, wgt. 2.2kg (1959)

•Not breast fed

•In childhood tonsils removed.

•Boils (staphylococcal bacteria) up to age 8.

•In her early 20’s she was diagnosed with diverticulosis (barium enema).

•Constipation is an on-going problem since childhood.

•From childhood to current diffuse pain in upper legs at night.

•As a young women she experienced severe dysmenorrhea, put on birth control at age 13 to present.

•Fibroid embolization in her late 30’s helped to stop the pain.

•In late 40’s the fibroid grew again, repeated embolization was unsuccessful.

•She is considering a hysterectomy.

•She has never tolerated perfumes, sprays etc. these cause migraines.

•Recently has developed a silicone allergy (contact).

•Lately she has had crippling inflammatory pains (bursts) in elbows, wrist and thumb and forefingers and ankles - ‘Like a hot poker has been thrust through my ankle’.

•Right knee swells, increasingly walks with a stick.

• She gets bouts of unexplained nausea in the morning but no vomiting.

•Aged 47, she was diagnosed with high blood pressure. She tried several medications to reduce her BP including beta blockers and ACE inhibitors. However, she stopped all drugs due to their excessive side-effects and she is very adverse to try anything else.

•Her GP is aware of her reluctance to take medication and knows she is seeking lifestyle and dietary approaches.

•Jenny has confided she had a very unhappy childhood and adult relationship with her now deceased mother. She feels she has no life and uses food for comfort in times of bingeing, when she's "off" her diet.

•Father stroke died at 56 years of age.

•Mother: constant weight issues, Type II diabetes, high BP, depression, possible OCD, hypothyroid, first stroke at 47, died age 52 by refusing dialysis.

•Maternal aunt died at 41 ischemia.

•Sister (younger) OCD and hypothyroid.

She does not drink alcohol, neither does she smoke.

Work:

She finds her job very stressful at times and generally stressful most of the time.

Sleep:

She wakes up early most mornings as she is worried about her work. Jenny will often stay up late, watching TV, writing reports (laptop) or marking (online). She finds the light in her office too bright and night driving difficult. She does not sleep well. Her bedroom window faces a street with lighting.

Social Life:

Jenny has very little social life, she used to dance, swim and walk when younger.

Motivation:

Issues with pill burden. Not good at remembering to take tablets. Jenny is willing to try anything that might help her condition and feels she can cope with a moderate amount of change although realises something drastic might be needed. She is very motivated as she does not want to end up like her mother and have a stroke at an early age.

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General Diet

• optimal nutrition as intake will be limited as on GLP 1- increase protein and good fats

• liver detox - dandelion tea or coffee, rocket leaves, gentian

• possible intermittent fasting with larger window so not to cause too much stress

Breakfast

• soaked oats, chia seeds, berries, greek yoghurt, nuts, flax seeds

• eggs and smoked salmon, green leaves and olive oil, kimchi, sourdough toast

Lunch

• chicken broth

• cold potato salad

  
  

Dinner

• vegetable stew - could be asparagus, artichok

• sardines, red pesto with steamed veg

Snack

• humous and carrot sticks

• power balls - date/nut balls

• dark chocolate

Recommendations:

Top recommendation :

1. Stress management - mindfulness, chair yoga

2. Sleep hygiene

3. Regular sit down mealtimes

4. Moving from desk once an hour

5. Gentle walk after lunch and dinner

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Top recommendation :

1. Eye masks for sleep

2. Blackout curtains

3. Meditation; mindfulness

4. sleep hygiene

5. Exercise and incorporate short periods of movement throughout the day

6. Anti-bluelight covers for laptops or screen; anti-bluelight eyeglasses

7. Community-based activity for support network and motivation for movements

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General Diet

• .Real whole food / lower UPF

• . Lower refined carbs

• .Protein at every meal

• Low fodmap veg with meals

• Reducing caffeine in drinks

• Reduce salt (less UPF)

• More hydration ( Herbal teas, water, decaf drinks)

Breakfast

• .Plain yogurt with berries, nuts and flaxseed

• .Eggs and avocado and smoked salmon on 1 piece of sour dough

Lunch

• .Chicken and green salad, tomato soup

• .Greek salad with hummus (keep feta in)

  
  

Dinner

• .Sweet potato and lentil curry with cauliflower rice (slow cooker)

• .Roasted veg tray bake with fish or chicken

Snack

• .Berries with plain popcorn and dark chocolate

• .Hummus and veg sticks

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General Diet

• Increase hydration

• Increase fibre

• Low-carbohydrate / low GL

• Increase Antioxidants

• Whole food diet/ remove UPF's

Breakfast

• 5% greek yoghurt with ground flaxseed and berries, Overngiht oats/porridge

• Weekend when more time, sourdough with eggs/Omlet with vegetables.

Lunch

• Stick to Pret - Greek salad, wholegrain salads

• Bring a container for homemade salad dressing - EVOO + lemon + sea salt

• Discuss making salad at home with pre-cooked protein chicken, prawns, boiled egg, dark leafy greens, + fresh veg for lunch

• top with easy fibre options, avocado, nuts + seeds,

• add slow release carb to lunch salad, wholegrain crackers, lentil cakes to reduce overeating at night

• Remove LEON + Subway to reduce UPFs, Glycemic load, and refined oils

  
  

Dinner

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General Diet

• Whole food if possible; reduce processed food

• Reduce carbohydrate - Pizzas/ Macaroni Cheese, carbonara (Low-carb)

• Replace saturated fat with polyunsaturated fat (i.e. olive oil, flaxseed oil)

• CYP2A1 genotype - reduce tea (caffeine) - protect heart; switch to herbal tea

• Increase hydration; sparkling water if needed

• Suggest Intermittent fasting

Breakfast

• Add nuts

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Lunch

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• Leon - coleslaw & salad

  
  

Dinner

• Incorporate vegetables

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Snack

• dark chocolate - 75% above - polyphenol -> cardioprotection

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https://padlet.com/nicoletaylor29_1/jenny-case-study-zoafczhxj8c81ei8

Group 1:

https://padlet.com/nicoletaylor29_1/breakout-room/LProvDbggPwg2OMJ-MDj9zyNV3K8qX7Qn

Group 2:

https://padlet.com/nicoletaylor29_1/breakout-room/ke9KqzbAWGPnqYQG-MDj9zyNV3K8qX7Qn

Group 3:

https://padlet.com/nicoletaylor29_1/breakout-room/PkpnqABZolGovD0B-MDj9zyNV3K8qX7Qn

Group 4:

https://padlet.com/nicoletaylor29_1/breakout-room/JZaQvQZWdY0D4nYK-MDj9zyNV3K8qX7Qn

1. Turmeric and Black Pepper

2. Magnesium for sleep, constipation and energy

3. possibly Vitamin D and K2 after testing

4. Bitters, ACV

   
   

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1. Liquid Omega-3 - Does not like pills

2. Tumeric Ginger powder

3. Pycnogenol

4. Co-Q10

5. Berberine

   
   

1. magnesium citrate

2. supplements for liver detox -eg milk thistle

3. pre biotic eg PHGG

4. gut barrier support - l glutamine, glutathione

5. sacc. boulardi

   
   

1. SIBO, gut microbiome test - GI MAP

2. Hormone profile - DUTCH/OAT

3. Thyroid profile

4. U&E, anti CCP, ESR

5. ? food sensitivities

1. Food Sensitivity/Allergy Testing

2. Liver Scan -> NAFLD?

3. ECG

4. Gut Microbiome

5. DUTCH for hormone

1. .cardiac investigation

2. .HBA1c

3. .Opthalmology referal

4. .DUTCH test

5. Renal profile

1. Fe panel

2. Thyroid panel

3. Homer IR

4. Renal panel

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• B12 and folic acid in normal range

• Oxidative Stress Index – indicated reduction in oxidative stress protection

• Received IV Mg 23 & Me Genetic Testing Results:

• A genetic variant in the SLCO1B1 gene rs4149056 that is associated with increased risk for myopathy in people taking simvastatin.

• Ve- APOE4 Genotype: ε2/ε3 variants

• Rapid CYP2C19 gene – PPIs unlikely to work or dose will need increasing Symptoms

• Muscle Performance: CT genotype - one working copy of alpha-actinin-3 in fasttwitch muscle fibre (sprinters and some endurance athletes have this genotype).

• Marker rs762551 AC genotype, slow caffeine metabolizer: drinking coffee increased subjects' heart attack risk. Caffeine is primarily metabolized by the liver enzyme cytochrome P450 1A2 (CYP1A2). The form of the SNP rs762551 a person has determines how fast CYP1A2 metabolizes caffeine. In this study (Cornelis MC et al. (2006) “Coffee, CYP1A2 genotype, and risk of myocardial infarction.” JAMA 295(10):1135-41), people with the slower version of the CYP1A2 enzyme who also drank at least two to three cups of coffee per day had a significantly increased risk of a non-fatal heart attack.

• Marker rs16991615 genotype GG Typical odds of early menopause.

• Ve- the APOB variants. • Does not have any of the variants linked to hereditary hemochromatosis

• 1mg daily

• Started at .25mg bid

• titrated slowly up to current dose to avoid nausea

• started 2 months ago