Case study from an integrative pharmacy

November 10, 2015

How to take in the Big Picture, New Pharmacy-style.

Mark BurgerVilfredo Pareto was an Italian civil engineer, economist, and sociologist who discovered a distribution curve that he could apply to scientific, social, geophysical, actuarial, and other types of observable events. I propose that we apply this principle to the patients who come to us for consults. Example follows.

See also: 15 keys to the New Pharmacy

When I began my consulting career, I quickly recognized that gastrointestinal dysfunction plagued most of my patients. They complained of bloating, diarrhea, constipation, gas, bad breath, heartburn, itchy anus, cramping, gut pain, foul-smelling BMs, unformed stools, and discolored stool. They were taking PPIs, H2-blockers, antacids, polyethylene glycol, bismuth subgallate, docusate, phosphate enemas, anti-cholinergics, metoclopramide, domperidone (from Canada), and IBS drugs. Some had had major esophagus surgery, gall-bladder removal, or partial and total removal of the colon. Many had suffered for years, some for decades.

Even if their chief complaint was not digestion, when we drilled down I found that they had digestive dysfunction. Why is that? Hippocrates gave us the answer long ago: "All disease begins in the gut." But I noticed that my patient's doctors rarely asked them about their digestion and even fewer did anything to help it.

It is said that 60% of all illness can be cured or vastly improved upon by fixing digestion. And I find it to be true. No matter who comes through my office door, they leave with something to fix their digestion.

Case in point

Let's look at the example of someone I saw today:

60 yo man, 6', 170 lbs. Fair-skinned/Red-headed, Drama teacher. With CC: 1. skin health; 2. digestion. Seborrheic dandruff, eczema on chest, eczema/psoriasis on feet. Family hx of diabetes. He has had bouts of IBS with diarrhea, but that is not a problem today. His wife is gluten-intolerant so he has reduced, but not eliminated, gluten from his diet. The only labs he could find were lipids and an FBS. The lipids were WNL except for an LDL of 138 (which I don't worry about ... more on that later). The FBS was 105 mg%, but he and the doc wrote this off, since his labs were drawn on January 2. I didn't dismiss it: He has a family Hx of AODM. He has troubles getting an erection (he does not have an erection when he wakes up). He is a teacher with 3 years to go to retirement. High school drama: 5 classes/day. 50-70 hour weeks. 2 shows per school year (rehearsals, builds the sets, promotes, coaches, directs, etc.), which consume, basically, half of his school year.

Do you think he is stressed? Do you think he gets enough sun/vitamin D? Do you think he goes to the bathroom when he needs to? Do you think he eats properly?

I didn't think so, and it turned out he didn't. If he ate breakfast, it was coffee and, maybe, cereal. He has only one bowel movement a day. He avoids the sun. Things get better for him in the summer, when school is out.

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Patient education

I explain: “Breakfast is really important. You need to eat at least 30 grams of protein before 9 a.m. It will help control your insulin by stimulating the "anti-insulin" hormone, aka glucagon.

“You may not feel like eating breakfast, because you don't have enough hydrochloric acid production in your stomach. Without HCl acid, sometimes we don't develop the proper levels of hunger in the morning. This happens with advancing age and stress. When you are stressed, you don't produce enough digestive juices. You must chew your food thoroughly before you swallow.

“I am giving you a digestive enzyme with betaine HCl, so you can activate the enzyme pepsin, digest protein, ionize your minerals properly, kill any parasites/bacteria/viruses in the food you eat, and absorb all of your B vitamins/folate.

“Further, when you chew your food and digest it adequately in the stomach, the small intestine and large colon are not going to be overwhelmed with an unfinished job. This will help to balance the 10 trillion bacteria/fungus/viruses in your lower colon. They, in turn, will produce soothing acids (butyric, lactic, propionic, acetic, formic) to regulate C. albicans overgrowth and allow you to correct the "leaky gut" or "dysbiosis" that has caused your irritable bowel symptoms.

“Lastly, by fixing your digestion, we will prevent the translocation of foreign proteins through your one-cell-thick colon wall into your bloodstream. Your immune system will start to calm down [TH-2:TH-1 ratio will normalize], and you'll stop producing auto-immune B-cells that are attacking your skin and causing the seborrhea/psoriasis/eczema. You will digest the gluten protein more thoroughly, possibly reducing its inflammation of the colon.

“This may take six months. In addition, get your 1,25-OH vitamin D level (goal is 50-80 ng/mL); get an HbA1c done (goal is <5.3%); ask your doctor to order an Lp(a), oxidized cholesterol, and find out your ApoB-gene status.”



These were my recommendations:

1. Get labs and make another appointment when you get results.
2. Start taking a digestive enzyme with betaine HCl with each meal (titrate to heartburn, then take one less than that).
3. Take a probiotic with at least 6 billion CFU.
4. Start taking omega-3s, 2-3 g/day.
5. Take an adrenal support product with adaptogens: two in the morning; one at 12:30 p.m.
6. Eat a good, hearty (30 g protein), low-carb breakfast every morning.
7. Start taking some vitamin D3 (5,000-10,000 IU/day, with food)
8. Start a gym or running or walking or training schedule at least 3 days/week. Focus on improving muscle tone vs. aerobic; muscle is where metabolism happens. You burn fat at 90-115 bpm, not at "cardio" levels of 120 and up. Muscle mass prevents metabolic syndrome/insulin resistance. Wear a 35 lb. backpack when you walk. Work up to >50 lbs.


Obviously there was more than just digestive dysfunction going on with this patient. But look at how many surrogate markers, how much mood enhancement and metabolic balance we get just by correcting digestion: lipids, immune modulation (T-helper cell ratio/B-cell levels), psoriasis, cardiovascular (sugar damages endothelium, cholesterol rises to patch the damage); GERD; IBS-D; normalized stress hormone(s); maybe an increase in endogenous testosterone and/or increased sensitivity of T-receptors as cortisol levels normalize.

What medication(s) can effect as many systems as this? What are the side effects? Adverse drug reactions? Drug interactions? Drug-nutrient depletions?

Bottom line

This approach to your consulting will yield big results that patients tell one another about.

You are effecting changes to core physiology/biology - not putting a "Band-Aid on a bullet hole," but making synergistic changes to body and brain, with no side effects. (There may be a mild Herxheimer reaction if the patient has a lot of C. albicans and the probiotic works quickly, but it goes away in a day or two.)

Remember to schedule a follow-up visit in two months for your patient to check in and bring in any labs that you suggested.

When I started out, I didn't catch even half these clues. I might have missed the stress (it was summer vacation when I saw him). I wouldn't have realized the gravity of the stress/dysbiosis/brain connection. I might not have scheduled a follow-up. I might have let the elevated fasting blood sugar get by me because he was thin and lean. I wouldn't have suggested the vitamin D level.

But, you know what? You don't have to be perfect, and you don't have to fix everything on the first visit. That's what follow-ups are for. Patients can't make all those changes at once, anyway. It takes time for it all to sink in. That's why you teach them and don't just show them.

Take it slow. Do what you can. They'll appreciate it - and they’ll tell a friend or a spouse. Pretty soon, you'll be so busy, you'll have to raise your (cash) price for a consult.

Mark Burgerowns Health First! Pharmacy and Compounding Center in Windsor, California. He welcomes your questions and comments