A Case Study from Kara Fitzgerald, ND.
Kara will be speaking on this topic at our conference on 29th October, few seats are still available, book here.
A 62-year-old gentleman named Robert presented to my office recently with a diagnosis of hypertension and hyperlipidemia. He was about to retire from a lifetime of high-stress, demanding technical work. He was motivated to improve the quality of his health so he could maximize enjoyment of his later years with family and friends. (What a fabulous goal!) He presented to me as a relatively healthy American male, balding with mild abdominal adiposity. His blood pressure (left arm sitting) was 130/85. He had moderate hearing loss requiring hearing aids in both ears as a result of receiving ototoxic antibiotics as a small child. He had his hearing checked at regular intervals, which generally showed no change or a slight decline. He ate a relatively healthy diet, lots of nuts and seeds, good fish and veggies. He loved bread and frequently indulged the desire with rolls and baguettes. He enjoyed sweets occasionally. As a former runner, he was of the mind that “carbo-loading” was a good thing, even though he wasn’t exercising with the same intensity or frequency of his youth. He took an ACE inhibitor and a statin at standard dosages. His family history included heart disease and diabetes. Significant symptoms are noted in his baseline Medical Symptom Questionnaire (MSQ) which can be viewed here.
In my practice, I cast a wide biochemical net with laboratory analysis and I use the IFM Matrix to “see inside” my patients to identify what they need to thrive. The Matrix is a systems medicine data sorting tool that is indispensable to my work (see: www.functionalmedicine.org for more information). The Matrix is an organized a set of core clinical imbalances that are linked to the basic physiological processes. These serve to marry the mechanisms of disease with the manifestations and diagnoses of disease. Many common underlying pathways of disease are reflected in these clinical imbalances. The Matrix components include: Assimilation Imbalances, Biotransformation and Elimination Imbalances, Defense and Repair Imbalances, Energy Imbalances, Communication and Transport Imbalances, Structural Integrity Imbalances and Mind, Emotions and Spiritual Imbalances. As the greater medical community embraces individualized, systems-thinking, this model (or similar) will likely be widely adopted.
With Robert, I ordered a comprehensive battery of standard labs, including: chemistry screen, complete blood count, lipid, thyroid and iron panels; insulin, celiac serology and HLA genes, fibrinogen, homocysteine, hs-CRP, Lp(a) and testosterone. Nutrient testing included: amino acids, organic acids, lipid peroxides, essential and toxic elements, vitamin D, E, CoQ10, A, beta carotene, fatty acids, stool microbiota analysis with digestive markers; IgG4 food sensitivities. To identify key areas of imbalance and treatment direction, I placed the significant laboratory findings along with his clinical history and treatment into a table comprised of the key Matrix imbalances (Table 1).
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Table 1. Assessments, Laboratory Findings and Treatments Organized According to the Functional Medicine Matrix
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Clinical Assessment |
Initial Laboratory Results |
Initial Recommended Treatment |
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Fundamental Lifestyle Factors: Nutrient Imbalances |
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| Hypertension
Maldigestion/malabsorption (MSQ: GI) |
Low B12 (elevated urinary methylmalonic acid)
Low serum COQ10 Low serum vitamin D Low fecal elastase (poor digestion)
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Methylcobalamin 5000ug SL QD
CoQ10 300mg PO QD D3 5000IU PO QD HCL 500mg titrate to tolerance Digestive enzymes: 2 with main meals |
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Defense and Repair (e.g. Immune, Inflammation, Infection/microbiota) |
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| Food allergies/sensitivities Dysbiosis
History of antibiotics Intestinal hyperpermeability (MSQ: GI, Joint, Energy) Environmental allergies (MSQ: Nose) Hypovitaminosis D
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Celiac gene: HLADQ2
Low serum vitamin D IgG4 testing” +3 to dairy, mild positives 5 additional foods Stool testing: microbiota imbalance, low fecal elastase |
Vitamin D3, Digestive enzymes, HCL – as noted in “Nutrient Imbalances”
Glutamine-based GI repair powder Probiotic combination:100 billion CFU per day Dietary changes: Lower carbohydrate, gluten and dairy-free, minimal sugar, protein at all meals. Whole foods, minimally processed, organic diet. Rotate mild reactants. |
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Assimilation (e.g. Digestion, Absorption, microbiota/GI, Respiration) |
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| Dysbiosis
History of antibiotics Intestinal hyperpermeability Maldigestion/malabsorption (MSQ: GI )
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Celiac gene: HLADQ2
(Celiac serology negative) IgG4 testing” +3 to dairy, mild positives 5 additional foods Stool testing: microbiota imbalance |
As noted in “Defense and Repair” |
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Communication (e.g. Endocrine, Neurotransmitters, immune messengers) |
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| Hypertension
Hyperlipidemia Family history of heart disease and diabetes |
Low HDL
Low-normal free testosterone High-normal fasting blood glucose (thyroid panel, essential elements and amino acids all within normal limits)
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Dietary changes as noted in “Defense and Repair”
Cardiovascular exercise prescription DHEA 50mg PO QD
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Energy (e.g. Energy Regulation, Mitochondrial Function) |
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| MSQ: fatigue
Statin rx
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Low serum vitamin D
Low serum CoQ10 B12 deficiency (cardiovascular, inflammatory and oxidative markers all within normal limits) |
Alpha lipoic acid 200mg: 1 tab TID
As noted in “Nutrient Imbalances” |
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Mental, Emotional, Spiritual |
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| High-stress work life | N/A | Pending retirement
Exercise prescription |
Robert adhered to all of the treatment recommendations. His complaints largely resolved, as seen in his follow-up MSQ below. He was able to discontinue his medications. His blood pressure was on average around 110/70. He lost over 20 pounds and became an avid hiker. His success inspired those around him, including his wife and sons, who all moved towards a healthier lifestyle.
As part of the Matrix model, questions we can ask while we are sorting the data that allow us to drill down into and differentiate between the causes and effects of the disease are: what are the ANTECEDENTS, TRIGGERS and MEDIATORS of the disease process in this individual? Understanding the “ATMs” helps us to zero in on areas needing evaluation. When designing treatments, ask: what does our patient NEED TO GET RID OF; what does our patient need to GET?
This case is interesting in that hypertension, Robert’s chief complaint when he presented to me, really didn’t require direct intervention. Rather, an investigation of ATMs led to the identification of a possible pre-celiac malabsorptive condition that likely caused the subtle nutrient deficiencies that contributed to his high blood pressure. A positive finding of the celiac genes without celiac serology has been termed gluten sensitivity and is associated with IBS and non-specific lymphocytic infiltration of the gastrointestinal mucosa (REF). Indeed, when Robert trialed a reintroduction of gluten, his GI symptoms returned and his blood pressure increased. Thus, we could say that the celiac HLADQ2 gene was an antecedent factor, as was his family history of heart disease and diabetes. A disease trigger and mediator in this case could be the ongoing consumption of gluten, which probably contributed to the malabsorptive state. He also noticed a clear correlation with sweets and blood pressure. Gluten intolerance-induced nutrient insufficiency and sugar ingestion have both been associated with hypertension.
Interestingly, it was noted that Robert had lost ½ inch in height at his annual physical exam. A bone density test (DXA scan) revealed osteopenia, also associated with celiac-induced malabsorption.
A final twist to this case is that Robert’s most recent hearing test revealed a mild, but significant improvement, a remarkable finding considering the duration and cause of the impairment. While it cannot be determined what contributed to the improvement specifically, a systems- rather than a symptom- approach to his treatment favors the occurrence of such an event.
For detailed, referenced cases using The Institute for Functional Medicine’s Matrix including extensive laboratory analysis and case discussion, see the updated Textbook for Functional Medicine. Also see: Case Studies in Integrative and Functional Medicine, Fitzgerald and Bralley, published by Metametrix Institute, 2011
