Case Study Examples

Case study: IBS

The following case study aims to show you how I work with a client as a Nutritional Therapist.  Irritable Bowel Syndrome (IBS) is one of the most common conditions that clients come to see me for. Many aim to see relief from an array of symptoms such as constipation, reflux, diarrhoea, wind, headaches, bloating and food intolerances alongside a host of additional symptoms that they did not know could be related, including joint aches and pains, weight loss or gain and fatigue. In this case study I will show you how a client’s symptoms may present and how functional diagnostic testing and Nutritional Therapy can help.

James

James was a 50-year-old gentleman when he first came to see me. He had been suffering from a range of IBS symptoms for over 25 years which began after a particularly stressful period in his life. His symptoms included constipation, diarrhoea, flatulence and abdominal pain alongside extreme fatigue and insomnia. More recently, he had begun to experience joint pain which, alongside his fatigue, was preventing him from leading the active life he previously had. He had been to see his Doctor who had recommended a colonoscopy, endoscopy and some blood tests. However, all the results came back within the ‘normal’ range. Despite this evaluation, his symptoms persisted.

James ate quite a healthy and well-balanced diet. Because of this, he was even more confused as to why his symptoms were so bad. He had already identified that certain foods were problematic for him, and had tried removing these, however although initially his symptoms had lessened, the relief was not long lasting.

First consultation

During his first consultation, James and I discussed all of his symptoms in great detail. I spoke to James about the need to get additional blood works from his Doctor and also spoke about a functional stool test. A stool test is a test which is able to provide a comprehensive picture of your gastrointestinal tract- the results of which can therefore ensure that any intervention is based upon your specific needs. If you are struggling to break down and absorb the nutrients in your food, then problems can arise elsewhere in your body, even if you eat a healthy diet. 

The results of James’ stool test highlighted several issues. It demonstrated that he had an overgrowth of some bacteria that would generally not be present in a healthy gut. He also had an overgrowth of yeast and a parasite. In addition to this, several markers in the stool test were raised, indicating that his immune system had been triggered. The triggering of this immune response indicated an immune response to both the overgrowth of these bacteria, the parasite and specific trigger foods.

We discussed his results and I explained how his symptoms (such as constipation and bloating) were associated with the presence of these bacteria, yeast, the parasite and that the food intolerances that he was experiencing can develop as a consequence of a reduced integrity of the intestinal lining- or ‘leaky gut’ as it is commonly known.

Protocol introduced:

Due to the presence of a parasite and an overgrowth of both bacteria and yeast in James’ gastrointestinal tract, the approach we used was based upon the 5 R protocol. Although the protocol appears to be linear, some of these stages can be introduced concurrently depending upon your symptoms:

  1. Remove
    Food allergens were identified and removed and the bacterial and yeast parasites were removed using a combination of herbs and other supplements.
  2. Replace
    At the same time as removing triggers of inflammation, I supported James’ digestion using specific digestive enzymes (which the stool test had highlighted as being low). James’ diet was tweaked to ensure that it was nutrient dense and could nourish his health.
  3. Reinoculated
    Once the parasites, bacteria and yeast infection had been cleared to as great an extent as possible, probiotics were introduced carefully to help reinoculated his gut with beneficial bacteria.
  4. Repair
    Specific nutrients that help repair the intestine lining were then added whilst ensuring to keep inflammatory foods out of his system.
  5. Rebalance
    We ensured to focus on other factors that were possible triggers of James’ inflammation, including stress and reduced sleep- both of which can affect the health of your intestine.

The results:

Within 8 weeks of following the nutritional therapy programme, the long-lasting abdominal pain that James had been experiencing, had more or less gone. James was having a regular ‘normal’ bowel movement daily and felt more in control of his health and symptoms. After 4 months on the plan, he reported that not only had his gut health improved dramatically, so too had his sleep, skin health and mental wellbeing. He also had more energy and was starting to return to exercise.

You may have had your symptoms for years; you may be struggling to cope – however there is hope. Understanding and addressing the cause of your concerns is central to ensuring that your health will improve.

Case study: Chronic Fatigue

The following case study aims to show you how I work with a client as a Nutritional Therapist.  Many clients who come to see me have a diagnosis of chronic fatigue or are suffering with persistent, ongoing fatigue. Many clients also experience a host of additional varied symptoms, including (amongst many others) joint pain, reduced mobility, light and sound sensitivity, restless leg syndrome, digestive health concerns (such as diarrhoea, constipation, flatulence, food intolerances), insomnia, heart palpitations, impaired cognitive function and changes in their weight. Women also often experience menstrual pain, fatigue, irritability, breast tenderness and headaches.  Many clients are also taking a range of prescription medications for a range of reasons, for example to try and support their appetite, reduce their pain or improve their sleep. In this case study I will show you how a client’s symptoms may present and how functional diagnostic testing and Nutritional Therapy can help.

Anna

Anna was a 28-year-old lady when she first came to see me. She was diagnosed with CFS over 5 years ago and despite introducing a range of techniques that were recommended by her GP (such as pacing and shifting, resting, regularly snacking) her fatigue persisted. Anna also reported that she had been experiencing ongoing pain in her joints for which she was taking prescribed medication and over the counter medications alongside introducing distraction techniques and heat therapy.  Anna found the ongoing pain to be particularly problematic and disabling and sought resolution to this pain as a primary goal. Anna was also experiencing chronic stress due to her illness, repeated throat infections (which were regularly treated using antibiotics), insomnia, light and sound sensitivity and cognitive difficulties which, alongside her fatigue and pain, impaired her capacity to work. She had been to see her Doctor and a Consultant, had had a range of blood tests (all the results came back within the ‘normal’ range). Despite this evaluation, her symptoms persisted.

Anna tried her best to eat as well as she could, however because of her fatigue and pain, she struggled to shop and cook and relied heavily upon family members (with whom she lived), to help her. Much of the food she ate was convenience food that was premade. She also frequently relied upon sweet foods and foods high in carbohydrates alongside caffeinated beverages to fuel her depleted energy reserves throughout the day.

First consultation

During her first consultation, Anna and I discussed all of her symptoms in great detail. I requested a copy of her most recent blood tests from her GP and spoke to her about the need to get additional blood works from her Doctor in order to rule out any functional cause of her symptoms.  In addition, we discussed the various functional tests that were most appropriate for her needs and symptoms and consequently both a stool and Organic Acid test were ordered.

The results of Anna’s OAT test highlighted mitochondrial dysfunction and a deficiency of specific nutrients. It also demonstrated reduced absorption and a lowered intake of vital nutrients.  Her stool test demonstrated an overgrowth of some bacteria that would generally not be present in a healthy gut alongside raised inflammatory markers. In addition, her GP blood test results demonstrated the need for additional thyroid testing and supplementation.

At her second consultation, we discussed her results and I explained how her leaky gut and mitochondrial dysfunction were linked and possible causes of these based upon her background medical history, diet, blood test results and lifestyle.  A plan was then introduced to address these problems.

Protocol introduced:

The presence of both bacteria and yeast in Anna’ gastrointestinal tract alongside nutrient deficiencies, were affecting her energy production cycle (Krebs cycle).  A 5 R protocol was introduced whereby we:

  1. Removed
    We identified and removed food allergens (including IgE reactions that were identified in the hospital setting) whilst also introducing specific supplements and dietary protocols to challenge the overgrowth of yeast and bacteria.
  2. Replaced
    At the same time as removing triggers of inflammation, I supported Anna’ digestion with specific nutrients that were highlighted as depleted.  Anna’ diet was also tweaked to ensure that it was nutrient dense and could nourish her health.
  3. Reinoculated
    Once the bacteria and yeast infection had been cleared to as great an extent as possible, and proinflammatory foods had been reduced, various probiotics were slowly introduced carefully to help reinoculated her gut with beneficial bacteria.
  4. Repair
    Specific nutrients that help repair the intestine lining were then added whilst ensuring to keep inflammatory foods out of her system.
  5. Rebalance
    We ensured to focus on other factors that were possible triggers of Anna’ inflammation. Other health care professionals that were able to support additional triggers were introduced.

The results:

Within 8 weeks of following the nutritional therapy programme, the long-lasting abdominal and muscular-skeletal pains that Anna had been experiencing, had more or less gone. Anna was having a regular ‘normal’ bowel movement daily and felt more in control of her diet and lifestyle. Her energy levels started to improve, so too had her digestion, sleep, skin health and mental wellbeing. She was able to concentrate much better and no longer experienced heart palpitations. Anna continues to improve on a daily basis and greatly values having more independence and a greater control and understanding of the underlying causes of her diagnosis. Anna is no longer reliant upon medication to control her symptoms and pain.

You may have had your symptoms for years; you may be struggling to cope – however there is hope. Understanding and addressing the cause of your concerns is central to ensuring that your health will improve.

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