Chapter 7 Cardiovascular/haematological systems
Hypertension
Case history
Tom’s father had two heart attacks shortly after he turned 60, and is now on medication that has stabilised his blood pressure. Tom currently lives alone, has no children and has never been married. It is Tom’s father who encouraged him to visit a CAM therapist because he feels his health was improved significantly by changing his lifestyle and diet to help encourage a healthy heart after his own heart attacks. Now that Tom is approaching the age his father was when he developed cardiac symptoms, Tom is keen for guidance about improving his lifestyle to prevent heart disease. Tom doesn’t think there isn’t anything significantly wrong with his health at the moment, so he didn’t feel it was necessary to see a GP for a medical check-up. He feels dietary and lifestyle advice from a CAM practitioner is all that he needs right now.
| Analogy: Skin of the apple |
I can see you are surprised to have a high blood pressure reading. Can I ask you some more questions so we can consider the possibilities?
Did you feel anxious about having your blood pressure taken today?
Were you feeling stressed before coming for your consultation today?
Did you feel cold while I was taking your blood pressure?
Did you experience physical pain while I was taking your blood pressure?
Did you drink coffee just before coming in for your consultation today?
| Analogy: Core of the apple with the seed of ill health | Core: Holistic assessment to understand the client |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Emotional health | |
| Do you ever feel sad or depressed? | Sometimes, not often. |
| Occupation | |
| Home life | |
| Who is at home with you? | Just me. At the moment I’m by myself. |
| Education and learning | |
| Action needed to heal | |
| Long-term goals | |
TABLE 7.4 TOM’S SIGNS AND SYMPTOMS [1–5]
| Pulse | 100 bpm irregular |
| Blood pressure | 160/100 (moderate hypertension) |
| Temperature | 36.3°C |
| Respiratory rate | 16 resp/min |
| Body mass index | 31 |
| Waist circumference | 100.3 cm |
| Face | Red and flushed appearance |
| Urinalysis | No glucose or protein; pH normal; no blood or leucocytes detected |
Results of medical investigations
No medical investigations have been carried out.
TABLE 7.5 UNLIKELY DIAGNOSTIC CONSIDERATIONS [3–5, 9, 12, 47, 55]
| CONDITIONS AND CAUSES | WHY UNLIKELY |
|---|---|
| CANCER AND HEART DISEASE | |
| Malignant hypertension: brain lesion/tumour; high blood pressure; intermittent headaches, low temperature, high diastolic reading; headache on waking | Usually symptoms of nausea, severe headache, disturbed speech, vision, unusual sensations, lack of concentration and paralysis; usually slow regular pulse rate; throbbing headache rather than dull |
| Phaeochromocytoma (tumours of sympathetic nervous system where 90% occur in the adrenal gland) high pulse rate, hypertension | Very rare; no sign of fever; no weight loss or diarrhoea or anxiety reported |
| TRAUMA AND PRE-EXISTING ILLNESS | |
| Renal impairment: occurs late in benign and early in malignant hypertension; can cause occipital headache | Urinalysis NAD |
| Subarachnoid haemorrhage: occipital headache | Usually neck stiffness reported and headache is severe with a sudden-onset, not recurrent; usually low regular pulse rate |
| OBSTRUCTION AND FOREIGN BODY | |
| Renal calculi: long-term alcohol and dairy, caffeine consumption, lack of water in diet | No significant acid/alkaline detected in urinalysis; confirm with biochemistry blood test |
| Vascular complications: aneurysms; high blood pressure | Would present as sudden, extreme and life-threatening; clarify whether blood pressure has suddenly increased or this has been a gradual process; no BP history known in this initial consultation |
| INFECTION AND INFLAMMATION | |
| Causal factor: Acute viral or bacterial illness | No signs in full blood count of recent fever or infection |
| Temporal arteritis: cause of headaches for clients over 50 years of age; visual deterioration | Uncommon, more often experienced by elderly women; usually presents as unilateral with low-grade fever; dull ache is not aggravated by bending over |
| Sinus headache: headache worse on waking in the morning | No upper respiratory symptoms mentioned, no frontal facial pain reported; dull ache is not aggravated by bending over |
| ENDOCRINE/REPRODUCTIVE | |
| Diabetes mellitus: overweight and increased alcohol intake are risk factors, headaches can be experienced, high diastolic reading can be associated; palpitations can be common | Urinalysis detected no excess glucose; confirm with fasting blood glucose blood test |
| Cushing’s syndrome: overweight, high blood pressure | No glucose in urine, muscle wasting or weakness reported; typical moon-shaped face not observed |
| STRESS AND NEUROLOGICAL DISEASE | |
| Migraine headache: stress can exacerbate | Severe painful headaches; often unilateral and located in the front and temporal regions of the head; headaches not aggravated by sound or light; headaches usually improve upon waking and after sleep; no indication of nausea and vomiting associated with the headache |
| Cluster headaches: common to begin in males between the ages of 40 and 60; no family history associated with cluster headaches | Extremely severe headaches, stabbing and burning; usually unilateral and pain behind eye radiating to the front of the face |
Case analysis
| Not ruled out by tests/investigations already done [1, 3–5, 8–10, 12, 46–56] | ||
| CONDITION | WHY POSSIBLE | WHY UNLIKELY |
| ALLERGIES AND IRRITANTS | ||
| Causal factor: Food intolerance amine sensitivity | Headaches, drinking red wine, dairy, may be delayed sensitivity | Headaches are in the morning on waking rather than after eating particular foods; usually cause migraine headaches |
| CANCER AND HEART DISEASE | ||
| Congenital cardiac disorder: e.g. coarctation of the aorta | High blood pressure, headaches | No clubbing of finger nails; no nose bleeds reported or cold legs |
| Hyperaldosteronism: (adrenal tumour) increase sodium in blood increases blood volume | High blood pressure | No reported muscle cramps, weakness, urination at night or increased urination |
| Causal factor: Poor left ventricular function [48, 49] | High blood pressure, heart racing on exertion; systemic hypertension | No breathlessness, or difficulty breathing during sleep reported |
| Essential systemic hypertension | High alcohol and sodium intake, obesity, stress, high systolic and diastolic reading; sustained fast irregular pulse rate (atrial fibrillation); congenital (Tom’s father has a history of heart disease) | It is not common for people with hypertension to experience headaches, however, it may develop for some individuals; unknown BP history |
| Symptomatic arrhythmia (sustained): abnormal heart beat; ventricular or atrial; palpitations when tachycardia heart rate sustains > 100 beats per minute or bradycardia sustains < 60 beats per minute [48, 49] | Pulse is 100 beats per minute and irregular; can be due to exercise, alcohol, caffeine, anxiety; less tolerance to stimulants with age; the combination of Tom experiencing sustained palpitations with high blood pressure is a more serious indication of heart disease; atrial fibrillation common in hypertension | |
| TRAUMA AND PRE-EXISTING ILLNESS | ||
| Hypertensive retinopathy | Associated with high blood pressure, eyesight strained | Usually no intermittent headaches |
| Causal factor: Liver disease | High alcohol intake, increased dairy and fatty foods, dull headaches | Usually low pulse regular rate, no jaundice or yellow sclera |
| OBSTRUCTION AND FOREIGN BODY | ||
| Atherosclerosis | High alcohol intake, hypertension, heart racing on exertion | No chest pain |
| OCCUPATIONAL TOXINS AND HAZARDS | ||
| Causal factor: Sick building syndrome | Headaches worse after working a few days in a row | Tom has not mentioned respiratory complaints or fatigue |
| FUNCTIONAL DISEASE | ||
| Causal factor: Obesity | BMI 31, increased caloric intake with drinking alcohol; lack of exercise; usually general distribution of weight gain; can be associated with high blood pressure | Usually no other health features other than being overweight; need to determine if any familial history of obesity; need to determine if weight gain has been gradual and if oedema is present |
| Hyperdynamic circulation | Rapid pulse rate after exercise | Check if Tom’s symptoms occur after intense emotion, stress; pulse usually rapid and regular |
| Causal factor: Sleep apnoea | High blood pressure, drinking alcohol at night, increased weight | No significant fatigue reported |
| Causal factor: TMJ dysfunction | Headache on waking | Tom did not mention pain in his jaw or ear; check if he grinds his teeth at night |
| Causal factor: Postural cause | Possible postural issues when sleeping | Check what mattress and pillow Tom is using |
| Causal factor: Exertional headache | Headache | Check if the headache also comes on after exercise, cough or sexual intercourse |
| Causal factor: Eye strain | Dull headaches at the base of the head (occiput area) typical of eye strain; Tom’s work requires close vision work; headaches will generally occur after working for a few days in a row | |
| DEGENERATIVE AND DEFICIENCY | ||
| Anaemia | Heart racing on exertion, no red meat in diet; headaches can be a symptom | Unsure if Tom is fatigued |
| Paget’s disease: causes increase cardiac output and often located in the skull (rapid bone remodelling causing calcium excess) | High blood pressure, dull headache, more often seen in those over 40 years of age | Can present with alkaline urine (high pH) |
| INFECTION AND INFLAMMATION | ||
| Cervical arthritis | Headache at the base of the head/neck area; more likely to develop in this age group | No specific neck pain reported |
| SUPPLEMENTS AND SIDE EFFECTS OF MEDICATION | ||
| Causal factor: Drug-induced hypertension: NSAIDs, steroids, alcohol, thyroid medication, amphetamines, epinephrine, nasal decongestants, caffeine | High blood pressure, fast pulse rate, drinking alcohol and caffeine every day | Check if Tom is taking any stimulant drugs or medications such as amphetamines, cocaine, digitalis glycosides, psychotropic agents, thyroid hormone; check if Tom has ever taken over-the-counter weight-loss products |
| ENDOCRINE/REPRODUCTIVE | ||
| Hypothyroidism | Obesity, low temperature, can sometimes have high blood pressure | Usually low regular pulse rate |
| Hyperthyroidism | High blood pressure, increased pulse rate that is irregular and sustained | Usually weight loss, increased heat intolerance, sweating, skin changes |
| STRESS AND NEUROLOGICAL DISEASE | ||
| Causal factor: Stress | High blood pressure, palpitations, busy employment, working full time | |
| Causal factor: Anxiety | Working long hours, palpitations, taking many stimulants, dull headaches, fast pulse | |
| Causal factor: Hyperventilation | Anxiety, palpitations | Tom has not mentioned dizziness or tingling in his hands or feet |
| Causal factor: White coat syndrome [57] | High blood pressure in a clinical setting | Tom has other lifestyle factors that put him in the risk category for hypertension such as alcohol intake, weight gain, lack of exercise, family history of cardiac disease |
| Causal factor: Muscle contraction: tension headache | Dull headaches; usually due to a psychogenic cause influenced by work; can be caused by prolonged mental concentration, family and home issues; often occipital and on waking | Need to ask if the intensity increases during the day and lessens in the evening; more common in females |
| EATING HABITS AND ENERGY | ||
| Causal factor: Dehydration | Lack of water in diet, dull headaches, drinking excess tea and coffee, drinking alcohol | |
TABLE 7.7 DECISION TABLE FOR REFERRAL [3–6, 8, 9, 11]
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Referral for presenting complaint | Referral for all associated physical, dietary and lifestyle concerns | Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors |
| REFERRAL FLAGS | REFERRAL FLAGS | REFERRAL FLAGS |
TABLE 7.8 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1–5, 9, 10, 59]
| TEST/INVESTIGATION | REASON FOR TEST/INVESTIGATION |
|---|---|
| FIRST-LINE INVESTIGATIONS: | |
| Blood pressure testing: multiple times | Definite hypertension; a persistence of hypertensive readings once all variables have been ruled out |
| Chest examination: auscultation, palpation | Arrhythmia |
| Urinalysis: multiple times | Blood and protein indicating renal cause for hypertension, diabetes |
| Electrocardiogram | Sinus rhythm will tell if there is cardiac arrhythmia or organic heart disease |
| Fasting blood lipid test | When in excess they deposit in fatty tissues and cause a risk of coronary and vascular disease; can rise with alcohol ingestion and fatty foods |
| Cholesterol blood test | Risk of heart disease |
| Fasting blood glucose test | More definitive test for risk of diabetes |
| Eye test | Check if degeneration of sight affecting symptoms |
| Full blood count | Indicates infection and anaemia; platelet count |
| ESR | Temporal arteritis |
| Urea, creatinine and electrolytes (sodium, potassium, chloride, bicarbonate) blood test | Signals muscle breakdown and tissue damage and gives an indicator for renal excretory function as urea and blood creatinine is excreted entirely by the kidneys; this will show in renal abnormalities and diabetes; impaired renal function can cause hypertension; electrolyte values can give an indication of a danger of cardiac arrest and cardiac arrhythmia |
| Cardiac enzymes: creatine kinase, aspartate transferase, lactic dehydrogenase | Raised in silent myocardial infarction presenting as arrhythmia |
| Liver function test | High concentrations of biliary enzyme GGT (gamma-glutamyl transpeptidase) are found in liver and heart; can be raised in high alcohol ingestion, even at small intakes |
| Forced hyperventilation for 3–4 minutes in a paper bag | Check if palpitations occur after hyperventilation |
| Eye test | May need glasses for reading and working on the computer for long hours |
| Muscle testing: grade 0–5 | Paralysis associated with hypertension |
| Headache diary | Track the pattern of the headaches more closely |
| IF NECESSARY: | |
| Stress echocardiography [59] | Exercise or pharmacologically induced |
| Chest x-ray | Exclusion or confirmation of organic heart disease |
| Neurological examination | Tumours affecting nerves and the brain |
| Serum cortisol blood test | Phaeochromocytoma, aldosteronism (adrenal tumour or hyperplasia) |
| Glucagon stimulation test | Phaeochromocytoma |
| Thyroid function test | Thyroid function contributing to weight gain |
| Radiograph of TMJ | Teeth grinding and muscle contraction in jaw |
| Radiograph of cervical spine | Cervical arthritis |
| Brain and cardiac CT scan or MRI | Signs of malignancy or tumour; to confirm or rule out brain tumour/lesion; heart muscle damage |
Confirmed diagnosis
Tom and essential systemic hypertension
Tom is a 55-year-old man who has come to the CAM clinic for a general check-up and guidance to improve his lifestyle and diet to enhance his general health, and cardiac health in particular. Tom’s father encouraged him to come to the clinic because he suffered two heart attacks around the age Tom is now and found CAM very helpful to improve his health and wellbeing. Tom has a busy lifestyle and lives alone. He enjoys cooking and drinking wine in the evenings. Tom has been experiencing dull early morning headaches during the working week. He knows he is overweight and unfit, but has not pursued exercise after he experienced exercise-induced palpitations on more than one occasion. Overall Tom is convinced his general health is fine and because of this has not had a medical check-up for some time. During the consultation he is very surprised to learn that his blood pressure is 160/100 and his resting pulse rate is 100 beats per minute. During the consultation it is explained why immediate referral for a medical opinion is necessary in order to rule out definitive primary and secondary causes of high blood pressure before CAM treatment or medicines can be prescribed.
It is extremely important to diagnose the cause of hypertension correctly to avoid unnecessary prescription of medication which eventuates in side effects that are better to avoid [46]. The decision to commence drug therapy may be delayed for up to six months while lifestyle and environmental changes are implemented. Regular monitoring of blood pressure occurs during this time. In other circumstances where the blood pressure is extremely elevated, it may be deemed necessary to commence drug treatment sooner while evaluating possible primary and secondary causes.
General references used in this diagnosis: 3–5, 9, 12, 46, 52–54
Prescribed medication [46, 58, 60]
• Statin drugs will be considered if Tom’s cholesterol continues to increase
• Blood pressure monitor to check Tom’s blood pressure levels on a daily basis
TABLE 7.9 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)
• Lifestyle and physical therapy recommendations to improve fitness, assist weight loss and improve general health
• Dietary recommendations to improve general nutrition and overall health
• Dietary recommendations to reduce alcohol and coffee consumption and to replace with herbal tea and water
• Dietary recommendations and supplements to normalise triglycerides and cholesterol
• Herbal tonic or tablet containing herbs with antioxidant, adaptogenic, cardiotonic and hepatoprotective properties
• Nutritional supplements with antioxidant, cardioprotective and cholesterol and triglyceride-lowering action
• Lifestyle and physical therapy suggestions to help reduce stress
• Recommendation for Tom to engage in social interactions outside of work
• Herbal tonic or tablets containing adaptogenic, anxiolytic and nervine herbs
• Herbal tea to replace coffee with anxiolytic herbs to help reduce Tom’s stress levels
Treatment aims
• Reduce Tom’s blood pressure using DASH (dietary approaches to stop hypertension) [13, 15] and lifestyle changes [13–16].
• Prevent complications of hypertension such as stroke and myocardial infarction [15].
• Weight loss: bring Tom’s BMI into normal range [14–16].
• Significantly reduce or avoid alcohol consumption [13–16].
• Reduce coffee consumption [14–16].
• Reduce dietary sodium intake [13–16] and increase dietary potassium intake [13–16].
• Support Tom’s liver function (history of excessive alcohol consumption).
• Improve Tom’s blood lipid profile.
Lifestyle alterations/considerations
• Encourage Tom to make changes to his lifestyle to reduce stress [14–16] and live a more balanced lifestyle.
• Tom may find stress-reduction techniques, such as meditation, relaxation exercises and yoga, are beneficial [15, 16, 31]. Transcendental meditation has been shown to reduce blood pressure [30].
• Weight loss of 10 per cent is likely to reduce both systolic and diastolic blood pressure [13, 32, 33]; therefore, a weight-loss program aiming to bring Tom back into a normal BMI range would be most beneficial [14–16].
• Ideally Tom should try dietary modification and lifestyle measures to reduce his blood pressure [16]. He may also choose to utilise nutritional supplements and herbal therapy; however, the long-term goal is for diet and lifestyle changes to maintain his blood pressure at normal levels without the need for supplemental nutrients, herbal therapy or drug therapy [13–16].
• Encourage Tom to consider socialising with other people outside of work. He may find attending cooking classes is helpful because he can combine his love of cooking with a social activity.
Dietary suggestions
• Encourage Tom to restrict or eliminate sodium chloride (salt) intake [13–16, 32] and consume less than 2 g sodium (less than 1 tsp salt) from all sources daily [13]. Tom can replace table salt with potassium salt [15].
• Encourage Tom to reduce intake of refined sugar and refined carbohydrates [14].
• Encourage Tom to increase consumption of garlic and onions [14, 15]. Consuming 600–900 mg of fresh garlic (bruised, crushed or chewed) each day can reduce his blood pressure [14, 15, 17].
• Encourage Tom to restrict consumption of saturated fat [15, 16, 41] and avoid trans fats [41]. Encourage consumption of foods containing omega-3 fatty acids [15, 41] and oils from nuts, seeds and avocado [14].
• Encourage Tom to reduce consumption of dairy products [15]. If he chooses to consume dairy products, he should have low-fat or fat-free dairy products only [13, 14, 16].
• Encourage Tom to increase consumption of whole, antioxidant-rich foods from a wide range of whole foods, fruit and vegetables [13–16].
• Encourage Tom to follow the DASH recommendations [13, 16]. These include doubling the average daily serving of fruit and vegetables, and reducing consumption of fats and oils by half, red meat by two-thirds and snacks and sweets by three-quarters [13].
• Encourage Tom to include cold-pressed extra virgin olive oil in his diet every day [14, 16].
• Encourage Tom to increase consumption of soluble fibre and legumes [14, 16].
• Encourage Tom to increase consumption of foods high in potassium [13–16] and magnesium [35].
• Encourage Tom to eliminate or significantly reduce coffee consumption [14–16].
• Encourage Tom to eliminate or significantly reduce alcohol consumption [13–16].
Physical treatment suggestions
• Tom may find benefit from acupuncture to reduce both stress [26] and blood pressure [24, 25].
• Massage therapy is likely to reduce Tom’s stress [27] and blood pressure [27, 28].
• Aerobic exercise reduces blood pressure [29]. Tom should exercise for 30–40 minutes at 70 per cent of his heart rate maximum (HRMAX) at least three times per week [16]. Tom would be wise to undertake a supervised exercised program to ensure he does not put excessive stress on his cardiovascular system [29].
• Hydrotherapy: alternating arm and foot baths with the hot component no longer than 15 minutes and cold for five minutes – up to three times a day [37]. Note: ice cold applications can initially increase blood pressure [37]. Low workload, full-body water exercise [38]. Constitutional hydrotherapy [39, 40]. A hot compress (two minutes) alternating with cold compress (30 seconds) over tired eyes [37].
| Alternative to coffee | ||
| HERB | FORMULA | RATIONALE |
| Passionflower Passiflora incarnata |
2 parts | Anxiolytic [17, 23]; sedative [17, 23]; to reduce stress |
| Peppermint Mentha × piperita |
1 part | CNS sedative [17, 19]; analgesic [17, 19]; antioxidant [17]; enhances cognitive performance [17]; useful to alleviate headache [17, 19]; pleasant taste helps to improve compliance |
| Lime flowers Tilia cordata |
1 part | Mild sedative [20, 23]; peripheral vasodilator [20, 23]; indicated in hypertension [20, 23] |
Infusion: 1 tsp per cup – 1 cup 3 times daily
TABLE 7.11 HERBAL FORMULA (1:2 LIQUID EXTRACTS)
| Made with ethanolic extract herbal liquids (alcohol removed) | ||
| HERB | FORMULA | RATIONALE |
| Hawthorn leaves Crataegus spp |
50 mL | Hypotensive [17, 19]; antiarrythmic [17, 19]; cardiotonic [17, 19]; antioxidant [17, 19]; lipid lowering [17, 19]; beneficial effects are expected within 2–6 weeks of continuous use [17] |
| Motherwort Leonurus cardiaca |
30 mL | Hypotensive [22]; cardiotonic [22]; antiarrhythmic [20, 22] |
| St Mary’s thistle Silybum marianum |
50 mL | Hepatoprotective [17, 19]; hepatic trophorestorative [17, 19]; antioxidant [17, 19]; hypolipidaemic [17, 19]; beneficial to protect against alcoholic liver damage [19] |
| Coleus Coleus forskohlii |
70 mL | Hypotensive [18]; antiplatelet [18]; cardiotonic [18] |
| Supply: | 200 mL | Dose: 10 mL twice daily |
| Tablet alternative to herbal liquid: may improve compliance | ||
| HERB | DOSE PER TABLET | RATIONALE |
| Dan shen Salvia miltiorrhiza |
500 mg | Hypotensive [18]; cardioprotective [18]; hepatoprotective [18]; anticoagulant [18] |
| Hawthorn
Cratageus spp |
750 mg | See above |
| Coleus Coleus forskolii |
700 mg | See above |
| Valerian
Valeriana officinalis |
450 mg | Anxiolytic [17, 19]; relieves stress [17, 19] |
Dose: 2 tablets twice daily
TABLE 7.13 NUTRITIONAL SUPPLEMENTS
| SUPPLEMENT AND DOSE | RATIONALE |
|---|---|
| Coenzyme Q10 100 mg daily [13, 16, 17] |
Antihypertensive [17, 21, 43]; cardioprotective [17]; antioxidant [17, 42] |
| Magnesium citrate Providing 600 mg elemental magnesium daily in divided doses [16, 17] |
Antihypertensive [14, 16, 17]; magnesium acts as a natural calcium channel blocker, reducing vasoconstriction [16]; decreased serum magnesium levels contribute to arterial stiffness in hypertension [34]; magnesium deficiency is implicated in hypertension [35] |
| High-potency practitioner-quality multivitamin, mineral and antioxidant supplement providing therapeutic doses of essential micronutrients and antioxidants along with a daily dose of 100 mg vitamin B6, 250 mcg vitamin B12 and 500 mcg folate [14, 15, 17, 42] Dosage as recommended by manufacturer to achieve the abovementioned daily doses |
A broad range of balanced nutrients and antioxidants; supplementation with a broad-spectrum multivitamin and antioxidant supplementation may lower the risk of cardiovascular disease [36]; supplemental vitamin B6, B12 and folate reduce homocysteine levels [13, 17, 21, 42]; elevated homocysteine levels are associated with hypertension and cardiovascular disease [44, 45] |
| Omega-3 fish oil 7000 mg daily in divided doses [14, 17] |
Omega-3 oils are effective in lowering blood pressure [14–17, 22]; omega-3 oils significantly lower triglyceride levels [17, 21, 22]; beneficial for the secondary prevention of coronary heart disease [22] |
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[42] Jamison J. Clinical Guide to Nutrition & Dietary Supplements in Disease Management. Edinburgh: Churchill Livingstone; 2003.
[43] Rosenfeldt F.L., Haas S.J., Krum H., Hadj A., Ng K., Leong J., et al. Coenzyme Q10 in the treatment of hypertension: A meta-analysis of the clinical trials. Journal of Molecular and Cellular Cardiology. 2007;42:S125–S128.
[44] Sutton-Tyrrell K., Bostom A., Selhub J., Zeigler-Johnson C. High homocysteine levels are independently related to isolated systolic hypertension in older adults. Circulation. 1997;96(6):1745–1749.
[45] Sundström J., Sullivan L., D’Agostino R.B., Jacques P.F., Selhub J., Rosenberg I.H., et al. Plasma Homocysteine, Hypertension Incidence, and Blood Pressure Tracking: The Framingham Heart Study. Hypertension. 2003;42:1100–1105.
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[49] Zimetbaum P., Josephson M.E. Evaluation of patients with palpitations. N Engl J Med. 1998;338:1369–1373.
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[51] Ressel G.W. AAFP and ACP release practice guideline on management of newly detected atrial fibrillation. Am Fam Physician. 2004;69(10):2474–2475.
[52] Vasan R.S., et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med. 2001;345:1291–1297.
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Hypercholesterolaemia
Case history
Helene also tells you that she has been under a fair bit of stress in the past four months due to the new house being built, the forthcoming move and preparing for retirement. She feels she has probably taken less care with her diet and exercise because of this and is looking forward to being able to relax and take things more slowly once they move into the new house and she retires. She confesses she is concerned that if her symptoms of fatigue do not improve she may not be able to enjoy her new life. Helene confides to you that she did not tell her doctor she is constantly worrying about this and has had problems falling asleep at night because she is thinking so much about everything. Helene usually sleeps very well and hopes you can suggest a natural remedy to help with this.
| Analogy: Skin of the apple | Complaint: Define the presenting complaint and symptoms; understand the complaintElevated cholesterol |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Onset | |
| When did you start to feel something was not right with you? | Probably about 4 or 5 months ago. I realised I was not improving so I went to the doctor who told me my cholesterol was up. |
| Understanding the cause (client) | |
| Do you understand what elevated cholesterol means and how it can occur? | I think so. The doctor told me it can be due to diet or family history. I need to get it down so I don’t end up with heart disease. |
| Exacerbating factors | |
| Is there anything that makes your fatigue worse? | When I’m very busy or stressed. |
| Relieving factors | |
| Is there anything that makes your fatigue better? | Rest and on the weekends when I’m not quite so busy. |
| Analogy: Flesh of the apple | Context: Put the presenting complaint into context to understand the disease |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Family health | |
| Is there a family history of heart disease or elevated cholesterol? | Yes, my father died of a heart attack and my mother has diabetes and heart disease. |
| Obstruction and foreign body | |
| Do you experience day time sleepiness, decreased alertness and feel a desire to sleep? (drowsiness, sleep apnoea) | No, I just feel tired during the day. |
| Recreational drug use | |
Is the fatigue often present and worse in the morning? (functional origin)
Has the fatigue been of long duration? (functional origin, depression)
Did the fatigue begin at a time of emotional trauma or major life change? (functional origin)
Is the fatigue always associated with periods of prolonged physical or mental activity, inadequate rest, poor sleep, dieting, sedentary lifestyle or mental stress? (physiologic fatigue)
Rest definitely helps, but it does not necessarily get better during the day.
It tends to fluctuate depending on how full on my life is getting – but lately it has been all of the time – so it is getting worse.
Yes, it does get worse with effort, but I feel like my whole health is suffering at the moment so I do not bounce back as well as I used to.
Is the fatigue associated with restlessness, irritability, increased sweating or heart palpitations? (chronic anxiety)
| Analogy: Core of the apple with the seed of ill health | Core: Holistic assessment to understand the client |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Stress release | |
|
I’m very stressed. I can’t wait to move into our new house and retire so I can take time out to relax. Not very well at the moment. I try to walk as often as I can, but haven’t had the time to exercise as much as I would like. I try and take some time out every day to read a book or listen to some soothing music. |
|
| Family and friends | |
| Tell me about your family and friends. | My daughter is just about to have her first baby and we are all really looking forward to that. I can’t wait to be a grandma! My son lives overseas at the moment but is talking about coming back home in the next couple of years. Jack and I have some very good friends and I’m hoping to spend more time with them soon. |
| Action needed to heal | |
| How do you hope I can help you? | Dietary and lifestyle advice. Maybe some natural remedies that will help my sleep and stress as well as reducing my cholesterol. |
| Long-term goals | |
| What do you hope to be doing in five years? | Spending time with my grandchildren, travelling with Jack, growing organic vegetables and enjoying my life. |
TABLE 7.17 HELENE’S SIGNS AND SYMPTOMS [1, 2, 6]
| Pulse | 82 bpm (regular) |
| Blood pressure | 125/80 |
| Temperature | 36.9°C |
| Respiratory rate | 18 resp/min |
| Body mass index | 27 |
| Waist circumference | 86 cm |
| Face | Normal appearance, good colour |
| Eyes | Corneal arcus around the boundary of the iris caused by cholesterol crystals; yellow cholesterol plaques around the eyelids |
| Urinalysis | No abnormality detected (NAD) |
TABLE 7.18 RESULTS OF MEDICAL INVESTIGATIONS [1, 2, 6–8]
| TEST | RESULTS |
|---|---|
| Full blood count | NAD |
| ESR (erythrocyte sedimentation rate indicates inflammation in general) | NAD |
| CRP | NAD |
| Fasting blood lipid test (chylomicrons are primarily trigylcerides, LDLs are primarily cholesterol, VLDLs primarily triglycerides, HDLs are predominantly proteins) | Total cholesterol elevated; LDL high, HDL low; triglycerides slightly elevated |
| Cholesterol blood test (usually includes VLDL value) | Moderately raised |
| Homocysteine blood test | Slightly raised |
| Electrolyte blood test | NAD |
| Fasting blood glucose test | NAD |
| Liver function test | NAD |
| Thyroid function test | NAD |
TABLE 7.19 UNLIKELY DIAGNOSTIC CONSIDERATIONS [2, 7–9, 65]
| CONDITIONS AND CAUSES | WHY UNLIKELY |
|---|---|
| FAMILY HEALTH | |
| Heterozygous familial hypercholesterolaemia: usually not many physical signs; family history of heart disease | Usually high LDL cholesterol reading (alone); can be unresponsive to dietary treatment and often associated with family history of cardiovascular disease; two clinical findings include thickening, yellow nodules (xanthomata) of Achilles tendons and extensor tendons of fingers due to deposits of lipids |
| Homozygous familial hypercholesterolaemia | High LDL cholesterol (alone); very rare where there are no LDL receptors in the liver; usually death in late childhood or adolescence from ischaemic heart disease |
| CANCER AND HEART DISEASE | |
| Atherosclerosis risk | No hypertension and CRP not raised |
| Low-density lipoprotein disorders: alone | High LDL cholesterol reading (alone) |
| Very low density lipoprotein disorders and chylomicrons: alone (hypertriglyceridaemia) | Excess VLDLs (alone) circulating; hypertriglyceridaemia; often family history of pancreatitis, retinal vein thrombosis and familial hypertriglyceridaemia |
| HDL disorders: normal total cholesterol and triglycerides (Tangier disease) | Low HDL (alone) concentration; total cholesterol is not usually raised; secondary complications such as cardiovascular disease, corneal opacities and polyneuropathy can occur |
| Combined hyperlipidaemia remnant hyperlipidaemia – raised cholesterol and triglycerides; family history | Rare disorder; diagnostic features include thickened skin (xanthoma) over palmar creases and knees, elbows |
| TRAUMA AND PRE-EXISTING ILLNESS | |
| Mutations in the apoprotein B-100 gene | High LDL cholesterol – alone; common single gene disorder |
| Polygenic hypercholesterolaemia | High LDL serum cholesterol (alone) without any monogenic disorders |
| Renal disease (nephrotic syndrome): high cholesterol | Urinalysis and electrolyte blood test NAD |
| Liver disease (biliary cirrhosis, hepatoma, glycogen storage disease and obstructive jaundice): high cholesterol | Liver function test NAD, no yellow sclera or signs of jaundice |
| SUPPLEMENTS AND SIDE EFFECTS OF MEDICATION | |
| Drug-induced hypercholesterol | Helene not taking exogenous oestrogen, corticosteroids, thiazides, β-adrenergic blocking agents |
| ENDOCRINE/REPRODUCTIVE | |
| Diabetes mellitus: high cholesterol common | Urinalysis and fasting blood glucose test NAD |
| Hypothyroid: high cholesterol, fatigue, weight gain and sore legs common | Thyroid function test NAD |
TABLE 7.20 CONFIRMED DIAGNOSIS
| CONDITION | RATIONALE |
|---|---|
| Combined hyperlipidaemia: most common client group | High LDL and low HDL concentration |
| Familial combined hyperlipidaemia | Very common; raised cholesterol and triglycerides; family history of heart disease; no typical physical signs present |
Case analysis
| Not ruled out by tests/investigations already done [2, 7, 9–11, 64–68, 70–72] | ||
| CONDITIONS AND CAUSES | WHY POSSIBLE | WHY UNLIKELY |
| ALLERGIES AND IRRITANTS | ||
| Causal factor: Food intolerance | Fatigue, recent dietary change since feeling low; may be eating more of certain foods than she did before her marriage; taken over comfortable threshold | Need to gain more insight into Helene’s previous and current diet and associated symptoms |
| OBSTRUCTION AND FOREIGN BODY | ||
| Causal factor: Sleep apnoea | Doesn’t usually complain of ‘sleepiness’ but rather fatigue generally | Need to determine if she wakes feeling unrefreshed and if she snores during the night |
| RECREATIONAL DRUG USE | ||
| Causal factor: Passive smoking | Increase homocysteine levels | |
| FUNCTIONAL DISEASE | ||
| Fibromyalgia | Tiredness, weakness in the legs; more common in women | No multiple sites of muscle pain reported |
| Causal factor: Physiologic fatigue | Can be caused by depression, sleep changes, intense emotions; diagnostic studies to date are mostly within normal limits | Symptoms present for less than 14 days and not usually associated with changes in self-esteem, social difficulties or overall mood |
| DEGENERATIVE AND DEFICIENCY | ||
| Osteoporosis | Menopausal, weakness in legs; commonly develops in this age group | |
| Causal factor: Nutritional deficiencies (low B vitamins) | Slightly raised homocysteine levels, increase in stress and worry, history of exposure to cigarette smoke | |
| Causal factor: Organic fatigue | Tired, sleep disturbances, no major physical abnormalities | Shorter duration than functional fatigue; need to determine if Helene’s fatigue worsens during the day |
| ENDOCRINE/REPRODUCTIVE | ||
| Causal factor: Passed menopause | Increase homocysteine levels, risk of osteoporosis | |
| STRESS AND NEUROLOGICAL DISEASE | ||
| Depression | Tiredness that has lasted several months, began after building new house; preparing to retire | Has many aspects of her life that give her joy |
| Causal factor: Hyperventilation syndrome – functional breathing concern (causes increased CO2, fatigue, muscle pain, digestive complaints) | Breathing quickly, fatigue; muscle weakness felt in the legs; hyperventilation syndrome can be a consequence of chronic anxiety, irritability; habitual patterns of breathing are developed to keep CO2 levels low that leads to anxiety-provoking consequences | No significant shortness of breath reported |
| Causal factor: Emotional stress | Tired, concerns about health affecting her retirement plans, retiring soon from long-term employment and job security; longer duration than acute organic origin of tiredness; can increase cholesterol levels | No irritability or shortness of breath reported |
| Causal factor: Extreme worrier | Restlessness, difficulty sleeping; symptoms presented as significantly intense although her GP has said everything is OK | Need to determine if Helene has experienced loss of appetite |
| Causal factor: Functional fatigue (depression) | Tiredness that has lasted several months | Need to define if Helene’s fatigue improves during the day |
| EATING HABITS AND ENERGY | ||
| Causal factor: Increase of saturated fatty acids and carbohydrates in diet | Eats more red meat, cheese and bread than she used to; increased cholesterol | |
| Causal factor: Lack of activity | Increased stress, weight gain, elevated homocysteine levels; decreased fitness, disturbed sleep, increased risk of heart disease | |
Working diagnosis
Helene and hypercholesterol
Helene is a 58-year-old woman who has been referred by her GP to your clinic for assistance with dietary and lifestyle strategies to reduce cholesterol levels. If Helene’s cholesterol levels have not reduced sufficiently after three months of dietary and lifestyle changes, her GP will prescribe a cholesterol-lowering medication. Helene is currently in a period of major life change, as she is approaching retirement and finally fulfilling her dream of moving into a newly built home with her husband Jack. Helene originally saw her GP to discuss the increased fatigue and weakness in the legs she has been experiencing. Several investigations were performed, which revealed she has combined hyperlipidaemia with raised total cholesterol, decreased high-density lipoproteins (HDLs) and raised low-density lipoproteins (LDLs).
Further investigations for consideration
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Treatment for the presenting complaint and symptoms | Treatment for all associated symptoms | Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations |
| TREATMENT PRIORITY | TREATMENT PRIORITY | TREATMENT PRIORITY |
• Dietary and supplement suggestions to increase antioxidant status and prevent or reduce oxidation of LDL and progression to atherosclerosis
• Herbal tea, tonic and tablets with anti-inflammatory, antioxidant, antiplatelet and cardioprotective action
• Supplemental nutrients with anti-inflammatory, antioxidant and cardioprotective action
• Lifestyle and physical therapy suggestions to improve Helene’s sleep
• Herbal sleep tea or tablets to improve sleep and reduce anxiety
• Referral to GP for mental health assessment and integrative management of Helene’s anxiety and sleep problems
TABLE 7.23 DECISION TABLE FOR REFERRAL [1, 2, 6, 7, 9, 12]
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Referral for presenting complaint | Referral for all associated physical, dietary and lifestyle concerns | Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors |
| REFERRAL FLAGS | REFERRAL FLAGS | REFERRAL FLAGS |
| ISSUES OF SIGNIFICANCE | ISSUES OF SIGNIFICANCE | ISSUES OF SIGNIFICANCE |
| Nil | ||
| REFERRAL DECISION | REFERRAL DECISION | REFERRAL DECISION |
TABLE 7.24 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [2, 7, 8, 11]
| TEST/INVESTIGATION | REASON FOR TEST/INVESTIGATION |
|---|---|
| FIRST-LINE INVESTIGATIONS: | |
| Musculoskeletal assessment | Fibromyalgia, osteoporosis, neuromuscular disease |
| Nijmegen questionnaire | Hyperventilation |
| Food diary | Diet aggravating high cholesterol, food intolerances |
| Mental health assessment | Depression, anxiety |
| Vitamin D test | Vitamin D deficiency, risk of osteoporosis |
| Vitamin B levels | Increased anxiety and increased homocysteine levels |
| IF NECESSARY: | |
| Bone density | Check risk of osteoporosis |
| Ultracentrifugation of plasma | Remnant hyperlipidaemia |
| Capnometer/pulmonary gas exchange during orthostatic tests | Hyperventilation |
| Sleep clinic observation | Sleep apnoea |
| Epstein-Barr/Ross River virus blood test | Check for postviral infection, fatigue |
Confirmed diagnosis
Hypercholesterol with associated organic fatigue/emotional stress
Prescribed medication
• Statin medication will be prescribed if dietary and lifestyle measures do not bring Helene’s cholesterol levels within acceptable limits
TABLE 7.25 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Treatment for the presenting complaint and symptoms | Treatment for all associated symptoms | Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations |
| TREATMENT PRIORITY | TREATMENT PRIORITY | TREATMENT PRIORITY |
|
• Continue with lifestyle and dietary recommendations to reduce LDL and total cholesterol and increase HDL • Continue with herbal tea, tonic and tablets to help reduce cholesterol NB: Herbal tea, tonic and tablets and nutritional supplements to be reviewed in 3 months when Helene’s cholesterol levels are retested NB: Supplemental nutrients to be reviewed in 3 months when Helene’s cholesterol levels are retested |
• Continue with dietary and supplement suggestions to increase antioxidant status and prevent or reduce oxidation of LDL and progression to atherosclerosis
• Continue with herbal tea, tonic and tablets with anti-inflammatory, antioxidant, antiplatelet and cardioprotective action
• Continue with supplemental nutrients with anti-inflammatory, antioxidant, antihomocysteine and cardioprotective action
• Dietary and lifestyle recommendations for weight loss
• Continue with lifestyle and physical therapy suggestions to improve Helene’s sleep
• Continue with herbal sleep tea or tablets to improve sleep and reduce anxiety
NB: Herbal sleep tea or tablets to be reviewed once Helene has transititioned into her new life
Treatment aims
• Modulate cholesterol metabolism [14, 15] and bring Helene’s cholesterol levels into normal range, increasing HDL and lowering LDL and triglycerides [13–16].
• Reduce homocysteine levels [13–16].
• Improve Helene’s diet and lifestyle [13–16].
• Dietary modification to reduce consumption of saturated fat and increase consumption of healthy fats and soluble fibre [13–16].
• Reduce inflammation within the vascular system to prevent or reduce the risk of atherosclerotic lesions developing [13–16].
• Reduce or prevent excessive platelet aggregation [13, 15].
• Stop or reverse the progression of any lesions already present [35].
• Reduce the risk of cardiovascular disease, stroke and other complications of atherosclerosis [13–16].
• Increase Helene’s antioxidant status to help prevent oxidation of cholesterol [13–15].
• Bring Helene’s weight into normal BMI range [27, 44].
• Support Helene’s stress response during the next few weeks and months until she has adjusted to her new lifestyle.
Lifestyle alterations/considerations
• Encourage Helene to increase physical activity and exercise. There is a positive correlation between increased levels of physical activity and increased HDL [24]. Without exercise, dietary interventions are less successful at lowering LDL [25]. Exercise may reduce inflammation, which is involved in the development of atherosclerotic lesions and cardiovascular disease [26, 27]. Habitual physical activity prevents development of coronary artery disease (CAD) and reduces symptoms in clients with established CAD [27].
• Increasing physical activity will assist Helene with weight loss [27, 44], reducing stress and anxiety [49, 50] and may improve her sleep patterns [53, 54].
• Reducing her stress levels will benefit Helene and reduce her risk of developing CAD [28]. Stress-management activities, such as breathing exercises, meditation and relaxation exercises, can lower CAD risk [29].
• Providing Helene with information and literature about health and lifestyle, specifically relating to elevated cholesterol and cardiovascular disease risk is important. By understanding how the recommended dietary and lifestyle changes will help her health and reduce cardiovascular risk, her anxiety levels are likely to reduce.
Dietary suggestions
• Encourage Helene to significantly reduce consumption of saturated fat [15, 16, 44].
• Encourage Helene to avoid consuming margarine, trans-fatty acids and partially hydrogenated oils [15, 16, 44]. She should also minimise consumption of polyunsaturated fatty acids from corn oil, safflower and cottonseed oil [16].
• Encourage Helene to increase dietary intake of omega-3 fatty acids [15, 16, 23, 44] and monounsaturated fatty acids [16]. She should consume 35 g or more of cold-water fish [13] such as sardines in olive oil.
• Encourage Helene to consume nuts and seeds [13, 15], particularly almonds and walnuts [14, 31]. Nuts are a rich source of arginine, which is beneficial in the prevention and treatment of atherosclerosis [13, 21].
• Helene would benefit from following a Mediterranean diet [16], which consists of high consumption of legumes, fruits, vegetables and whole grains, moderate consumption of alcohol and low to moderate consumption of meat and dairy products [33].
• Cold-pressed olive oil is Helene’s best choice for low-teperature cooking [32] and in salad dressings [17]. Monounsaturated fats such as olive oil as part of a Mediterranean diet reduces the risk of cardiovascular disease [17, 33].
• Encourage Helene to increase consumption of whole foods that are rich in antioxidant and plant sterols [55, 56] from a wide range of whole grains, fruit and vegetables [13–16].
• Helene’s weight-loss program should incorporate higher protein and lower carbohydrate intake and include adequate levels of essential fatty acids [45, 46] that comprise low GI/GL foods [47].
• Encourage Helene to minimise consumption of high GI foods [13, 14].
• Encourage Helene to consume 2–5 g of fresh garlic (bruised, crushed or chewed) [17] in her diet each day [14–16]. Garlic has a modest effect on reducing serum cholesterol levels [17, 18, 37], and has anti-inflammatory [17] and antiatherosclerotic activity [17, 37]. If Helene does not want to eat fresh garlic, she could take it in tablet form.
• Encourage Helene to increase consumption of dietary fibre, particularly soluble fibre [14, 16, 44]. Soluble fibre has a cholesterol-lowering effect [39, 40]. Whole oats are particularly beneficial due to their beta-glucan content [52].
• Encourage Helene to include ginger in her diet [14, 16]. It has hypolipidaemic [17], antiplatelet [17, 18], antioxidant [17] and anti-inflammatory [17, 18] actions.
• Helene will benefit from including 1–3 tsp of lecithin granules in her diet each day [14, 34]. Dietary lecithin modifies cholesterol homeostasis providing benefits in the prevention and treatment of cardiovascular disease [34].
• Helene will benefit from drinking green tea. She may consume the green tea as part of the prescribed herbal tea, or drink green tea on its own if she chooses to take the herbal tonic in preference to the prescribed herbal tea for its antioxidant properties [17, 36]. Green tea can reduce cholesterol [36] and protect against cardiovascular disease [17]. It may also aid weight loss [17, 48].
Physical treatment suggestions
• Helene may find massage is beneficial in reducing her stress levels [30].
• Acupuncture therapy may help reduce Helene’s anxiety [49] and improve her sleep [51].
• Hydrotherapy study revealed positive results to treat high cholesterol with a program of central cooling using whole water bath immersion by decreasing temperature slowly from 22 to 14°C (increasing time from 5 to 20 minutes) over 90 days [57].
• Hydrotherapy: constitutional hydrotherapy [59, 60]. Alternating sitz bath for fatigue [58]. Cold-water arm shower for fatigue [61]. Short, cold head shower for fatigue [62]. Alternate hot and cold showers [61].
| HERB | FORMULA | RATIONALE |
|---|---|---|
| Globe artichoke Cynara scolymus |
55 mL | Antioxidant [17]; hypocholesterolaemic [17, 18]; anticholesterolaemic [18]; choleretic [17, 18]; cholagogue [17, 18]; hepatoprotective [17, 18] |
| Turmeric Curcuma longa |
80 mL | Antioxidant [17, 18]; anti-inflammatory [17, 18]; hypolipidaemic [17, 18]; choleretic [18]; cholagogue [17] |
| Tienchi ginsengPanax notoginseng | 50 mL | Hypocholesterolaemic [22]; anti-inflammatory [22]; cardioprotective [22] |
| Ginger Zingiber officinale |
15 mL | Hypolipidaemic [17]; antiplatelet [17, 18]; antioxidant [17]; anti-inflammatory [17, 18] |
| Supply: | 200 mL | Dose 5 mL 3 times daily |
Garlic tablet containing the equivalent of 5 g fresh garlic Allium sativum (providing approx. 4–5 mg alliin per tablet) twice daily
Helene may prefer to take garlic in tablet form if she is not keen on eating fresh garlic every day
Antioxidant [17, 36]; hypocholesterolaemic [17, 36]; antiatherosclerotic [17, 36]; anti-inflammatory [17, 36]
| Alternative to herbal liquid if Helene prefers to drink herbal tea rather than a tonic – day formula | ||
| HERB | FORMULA | RATIONALE |
| Green tea Camellia sinensis |
3 parts | Antioxidant [17, 36]; green tea consumption is associated with a decrease in total serum cholesterol [36] and is protective against cardiovascular disease [17]; thermogenic [17, 48]; may be beneficial to aid weight loss [17, 48] |
| Lemon balm Melissa officinalis |
1 part | Antioxidant [17]; anxiolytic [17, 19]; hypolipidaemic [37]; hepatoprotective [37] |
| Celery seed Apium graveolens |
½ part | Anti-inflammatory [17]; cholagogue [17]; hypocholesterolaemic [38] |
| Cinnamon bark powder Cinnamomum cassia |
2 parts | Antioxidant [17]; anti-inflammatory [17]; can reduce LDL and total cholesterol [41] |
| Ginger Zingiber officinale |
¼ part | See above |
Infusion: 1 tsp per cup – 1 cup 3–4 times daily
| Evening formula to aid sleep | ||
| HERB | FORMULA | RATIONALE |
| Skullcap Scutellaria lateriflora |
1 part | Nervine tonic [19, 20]; mild sedative [19, 20] |
| Passionflower Passiflora incarnata |
½ part | Sedative [19, 20]; hypnotic [20] |
| Hops Humulus lupulus |
1 part | Hypnotic [17, 19, 20]; mild sedative [17, 19, 20]; beneficial in insomnia in combination with other sedative herbs [17] |
Strong infusion: 2 tsp per cup – 1 cup in the evening before bedtime
TABLE 7.29 HERBAL TABLET ALTERNATIVE
| Tablet alternative to sleep formula herbal tea if Helene prefers a tablet | ||
| HERB | DOSE PER TABLET | RATIONALE |
| Valerian Valeriana officinalis |
700 mg | Anxiolytic [17, 18]; hypnotic [17, 18]; decreases sleep latency and improves sleep quality [17, 18] |
| Passionflower Passiflora incarnata |
500 mg | See above |
| Zizyphus Zizyphus spinosa |
900 mg | Sedative [19, 22]; hypnotic [19, 22]; anxiolytic [19] |
Dose: 2 tablets one hour before bed time
TABLE 7.30 NUTRITIONAL SUPPLEMENTS
| SUPPLEMENT AND DOSE | RATIONALE |
|---|---|
| Omega-3 fatty acids 6000 mg daily in divided doses [13, 17] |
Lowers triglycerides [17, 21]; lowers LDL [13, 15, 21]; improves HDL/trigylceride ratio in postmenopausal women [13]; anti-inflammatory [13, 17, 21]; cardioprotective [13]; beneficial for the secondary prevention of heart disease [13, 42] |
| High-potency practitioner-strength multivitamin, mineral and antioxidant supplement containing therapeutic doses of Vitamins B6, B12 and Folate [14, 15, 16] | Vitamins B6, B12 and folate reverse hyperhomocysteinaemia [15, 16]; increasing Helene’s antioxidant levels helps protect against cardiovascular disease [13–15]; increased requirement for B-group vitamins during times of stress [13, 17, 21] |
| Vitamin E 800 IU daily [43] |
Lipid soluble antioxidant [13, 17, 21, 43]; protects against LDL oxidation [15, 17]; reduces risk of cardiovascular disease [17, 43] |
| Policasanol
5 mg daily [17] |
Lowers total cholesterol [15, 17]; increases HDL cholesterol [15, 17]; lowers LDL cholesterol [15, 17]; reduces oxidation of LDL cholesterol [17]; Helene may prefer to take policasanol as an alternative to cholesterol-lowering medications [17] |
| Coenzyme Q10 100 mg daily [13, 17] |
Antioxidant [13, 17]; cardioprotective [17]; reduces total and LDL cholesterol [17, 63]; reduces side effects of statin drugs, which may be helpful if Helene decides to take cholesterol lowering medication [13, 17] |
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Iron deficiency anaemia
Case history
| Analogy: Skin of the apple |
| Analogy: Flesh of the apple | Context: Put the presenting complaint into context to understand the disease |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Family health | Penny answers: |
| Does anyone else in the family have similar symptoms to Hannah? | No. |
| Functional disease | Penny answers: |
| Does Hannah have any other medical conditions? | Apart from Down’s, no. |
| Degenerative and deficiency | Penny answers: |
| These blood tests indicate Hannah has low iron levels. What did the doctor tell you about that? |
| Analogy: Core of the apple with the seed of ill health | Core: Holistic assessment to understand the client |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Daily activities | Hannah answers: |
| Hannah, tell me what you do every day. | I go to work at the nursery and I go and look after the animals. On the weekend I play on the Wii with my brothers and Amy does scrapbooking with me. Sometimes I go to Friendship Club and see my friends. |
| Action needed to heal | Hannah answers: |
| Hannah, will you take any medicine or eat things I say to help you get better? | Yes. |
| Long-term goals | Hannah answers: |
| Hannah, what would you like to do in the future? | I’m moving into my own house next to Mum and Dad. |
TABLE 7.34 HANNAH’S SIGNS AND SYMPTOMS [1, 2, 6]
| Pulse | 98 bpm |
| Blood pressure | 135/88 |
| Temperature | 36.8°C |
| Respiratory rate | 16 |
| Body mass index | 27 – higher prevalence of obesity in DS women than men [26] |
| Waist circumference | 85 cm |
| Face | Facial skin pale, conjunctiva pale, sores on both sides of mouth; skin appears dry |
| Nails | Fingernails brittle, slightly concave (spoonlike) and skin around nails is dry and split, pale nail bed |
| Urinalysis | No abnormality detected (NAD) |
TABLE 7.35 RESULTS OF MEDICAL INVESTIGATIONS [2, 22, 6–9, 11]
| TEST | RESULTS |
|---|---|
| Neurological examination | No sign of dementia or spinal cord compression |
| Cardiac examination | No sign of heart disease or mitral valve prolapse |
| Ophthalmologic examination | No cataracts and eyesight NAD |
| Pap smear | No cervical cancer |
| Breast examination | NAD |
| Full blood count | |
| Film comments |
Film comments – microcytic hypochromic RBC Microcytic means the red blood cell is a small weight and generally these cells have less haemoglobin Hypochromic means the red blood cell has a deficiency in haemoglobin; the presence of anaemia with microcytosis and hypochromia indicate causes such as iron deficiency, thalassaemia, sideroblastic anaemia and anaemia of chronic disease |
| Serum ferritin | Reduced |
| Serum iron levels | Reduced |
| Total iron binding capacity | Raised |
| Serum soluble transfer receptors | Increased Will be raised in iron deficiency and can differentiate between other types of anaemia; reduce need for bone marrow examination |
| ESR (erythrocyte sedimentation rate indicates inflammation in general) | NAD |
| CRP | NAD |
| Fasting blood lipid test (chylomicrons are primarily trigylcerides, LDLs are primarily cholesterol, VLDLs primarily triglycerides, HDLs are predominantly proteins) | NAD |
| Cholesterol blood test (usually includes VLDL value) | NAD |
| Homocysteine blood test | NAD |
| Electrolyte blood test | NAD |
| Fasting blood glucose test | NAD |
| Liver function test | NAD |
| Thyroid function test (TFT) | TSH slightly raised and T3 and T4 normal range |
TABLE 7.36 UNLIKELY DIAGNOSTIC CONSIDERATIONS [2, 7–10, 12, 22, 57, 60, 61]
| CONDITIONS AND CAUSES | WHY UNLIKELY |
|---|---|
| CANCER AND HEART DISEASE | |
| Heart disease: common for DS | No high cholesterol, BP normal range, homocysteine within normal range |
| Breast or cervical cancer | Examination NAD |
| High cholesterol: common for DS | Within normal range |
| DEGENERATIVE AND DEFICIENCY | |
| Bone marrow fibrosis | Would present with normal-sized cells along with low haemoglobin |
| Sideroblastic anaemia: microcytic blood cells and low haemoglobin | MCV can often be raised, serum iron will be raised, total iron-binding capacity (TIBC) would be normal; serum ferritin would be raised |
| Thalassaemia: microcytic blood cells and low haemoglobin | Normal results would be seen for serum iron, TIBC, serum ferritin, serum soluble transfer receptors |
| Anaemia of chronic diease: microcytic blood cells and low haemoglobin | Would present with normal-sized cells along with low haemoglobin; serum TIBC would be reduced, serum ferritin would be normal or raised, serum soluble transfer receptors would be normal |
| Folate deficiency | Would be macrocytic/megaloblastic |
| Pernicious anaemia: B12 deficiency | Would be macrocytic/megaloblastic due to lack of B12 absorption due to immune destruction of intrinsic factor in atrophic gastritis and loss of stomach parietal cells; can present with hypothyroidism |
| Haemolytic anaemias | Would present with normal size cells along with low haemoglobin |
| Liver disease | Liver function NAD; anaemias of liver disease more often present as macrocytic large blood cells and normoblastic |
| Vision disorders: common for DS | Ophthalamologic examination NAD |
| ENDOCRINE/REPRODUCTIVE | |
| Hypothyroid needs to be tested annually for DS in this age group, fatigue, heavy periods, constipation, dry skin, weight gain | T4 and T3 test within normal range; advanced endocrine disease will more often present with normal size red blood cells along with low haemoglobin; no physical signs of goitre, slow pulse, change in voice, or cold hands as would have in clinical low thyroid condition |
| Diabetes | Urinalysis and fasting blood glucose level NAD |
| Anovulatory bleeding | Usually irregular bleed that appears menstrual although no ovulation has occurred; bleed would be painless and unexpected; physical findings will often include hirsutism, acne |
| Ovarian cyst: irregular periods | Ovarian cysts almost never cause heavy menstrual bleeding |
TABLE 7.37 CONFIRMED DIAGNOSIS [2, 7]
| CONDITION | RATIONALE |
|---|---|
| Iron deficiency anaemia | Low haemoglobin, reduced MCV, microcytic hypochromic red blood cells, serum iron reduced, serum TIBC raised, serum ferritin reduced and serum-soluble transfer receptors increased; heavy menstrual periods, feeling fatigue gradually over a period of time; anaemia and low serum ferritin can cause heavy menstrual bleeding [19] |
Case analysis
| Not ruled out by tests/investigations already done [2, 7–10, 12, 54, 57–61] | ||
| CONDITION | WHY POSSIBLE | WHY UNLIKELY |
| CANCER AND HEART DISEASE | ||
| Ovarian, uterine cancer | Heavy irregular bleeding; can cause iron deficiency | No vaginal discharge reported |
| TRAUMA AND PRE-EXISTING ILLNESS | ||
| Causal factor: Postviral infection | Fatigue | Need to rule out if Hannah has had viral symptoms prior to feeling fatigued |
| OBSTRUCTION AND FOREIGN BODY | ||
| Causal factor: Obstructive sleep apnoea | Common for people with DS to develop due to hypotonic muscles, feeling tired; fatigue during the day; more common when overweight or obese; do not usually complain of ‘sleepiness’ but rather fatigue generally | Need to determine if feel not well rested in the morning and if snore during the night |
| Causal factor: Intestinal obstruction: bowel cancer, adhesions, hernias, fecal impaction with overflow | Abdominal constipation | No vomiting, abdominal pain and distension |
| FUNCTIONAL DISEASE | ||
| Coeliac disease [22] | Constipation, can develop for people with DS; fatigue, skin changes; often has anaemia as an associated symptom | Need to gain more insight into Hannah’s diet and associated symptoms |
| Causal factor: Hypotonic muscles in digestive tract | Common in DS, causes constipation | |
| Causal factor: Functional constipation | Abdominal constipation | Need to check if more than 1 in 4 bowel motions is lumpy and hard, and causes strain, a feeling of incomplete evacuation or blockage; need to check if manual help is needed to facilitate a bowel motion passing; does she have fewer than 3 evacuations in a week |
| INFECTION AND INFLAMMATION | ||
| Subclinical hypothyroidism | TSH slightly raised and T3 and T4 normal range; TSH levels are higher than previous tests, indicating that Hannah may have subclinical hypothyroidism | Check if there are any reasons why her TSH may be artificially raised – potential presence of thyroid antibody, medication reaction, recovery from illness, rare congenital defect that causes clinical euthyroidism, adrenal glucocorticoid insufficiency, renal failure, undertreated hypothyroidism when thyroxine not at appropriate level |
| ENDOCRINE/REPRODUCTIVE | ||
| Premenstrual syndrome | Can experience pain and fatigue before period | Need to determine if Hannah experiences premenstrual mood changes, feels teary, bloated or swollen 1–12 days before her period and whether she experiences a dull pelvic ache or abdominal bloating |
| Pregnancy | Can still have regular periods when pregnant, of child-bearing age, fatigue; can cause iron deficiency | Need to assess if Hannah is sexually active |
| Perimenopausal | Can develop at an earlier age for those with DS, heavy periods, fatigue | |
| Uterine fibroids and polyps: fibroids form due to excess oestrogen and can cause symptoms of heavy bleeding, uterine enlargement | Usually causes menorrhagia (blood loss of 80 mL per day and lasting more than 7 days); can cause iron deficiency | Often maintains normal cycle unless submucosal or nearly extruded |
| Endometriosis | Pain with heavy menstrual bleed; can cause iron deficiency | No bleeding from the bowel; usually brown discharge with associated abdominal and pelvic pain |
| Dysfunctional uterine bleeding (DUB): endometrial hyperplasia, PCOS, from taking exogenous oestrogen; endocrine dysfunction (not associated with inflammation, tumour or pregnancy) | Often menorrhagia (heavy bleed with regular cycle); can cause iron deficiency | No use of exogenous oestrogen reported; usually causes unpredictable volume and frequency of bleeding; interval between periods can be shorter to appear irregular |
| AUTOIMMUNE DISEASE | ||
| Hashimoto’s disease: autoimmune thyroid disease | Subclinical hypothyroid reading | No goitre visible |
| STRESS AND NEUROLOGICAL DISEASE | ||
| Depression | Fatigue and depression can be common for DS | |
| EATING HABITS AND ENERGY | ||
| Lack of exercise | Weight gain, fatigue, constipation | |
Working diagnosis
Hannah and iron deficiency anaemia
Anaemia is not a diagnosis in itself and the cause should be investigated. The condition is characterised by low levels of haemoglobin in the blood and the three major types of anaemia are hypochromic microcytic (iron deficiency, thalassaemia, anaemia of chronic disease, sideroblastic), normochromic normocytic (acute blood loss, anaemia of chronic disease, renal failure, connective tissue disease, bone marrow fibrosis, endocrine disease and haemolytic anaemias) and macrocytic (vitamin B12 or folate deficiency, liver disease, excess alcohol). Due to compensatory processes in the body, haemoglobin may drop over a period of time and the anaemia may appear to be asymptomatic. However, if blood loss is more rapid then signs and symptoms of anaemia may present as more severe and include non-specific symptoms such as fatigue, headaches, feeling faint, breathless chest pain, palpitations along with signs of pale skin or a fast pulse. Causes can range from blood loss, nutritional deficiency from inadequate diet, malabsorption in the GI tract and abdominal disorders such as coeliac or Crohn’s disease. Other forms of anaemia can develop from bone marrow failure, genetic dysfunction affecting red blood cells and organic diseases affecting the liver or endocrine system.
The body’s iron content is usually maintained within a narrow limit with loss and intake carefully balanced. How much is absorbed is influenced by levels of stored iron. It is not possible to excrete iron once it has been absorbed. Blood loss through heavy menstruation will often result in iron deficiency as increased iron absorption from the gastrointestinal tract cannot adequately compensate for the loss. Iron deficiency anaemia can in turn be a causal factor for heavy menstrual bleeding [19, 48].
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Treatment for the presenting complaint and symptoms | Treatment for all associated symptoms | Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations |
| TREATMENT PRIORITY | TREATMENT PRIORITY | TREATMENT PRIORITY |
• Reduce loss of iron through excessive menstrual bleeding
• Improve menorrhagia by improving iron status [19, 48]
• Dietary recommendations to increase consumption of antioxidants and essential fatty acids to optimise general health and cognitive function
• Recommendation for a multivitamin, mineral and antioxidant supplement designed specifically for the needs of people with DS
• Recommendation to increase intake of essential fatty acids via diet and supplement to enhance general health, cognitive function and reduce risk of Alziehmer’s
• Dietary recommendations and herbal tea to support digestive function and improve absorption of nutrients
• Herbal tonic to increase iron levels, support thyroid function, reproductive hormone balance and cognitive function
• Physical therapy and lifestyle recommendations for exercise to enhance thyroid function and maintain healthy weight
TABLE 7.40 DECISION TABLE FOR REFERRAL [2, 7, 9, 12, 13]
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Referral for presenting complaint | Referral for all associated physical, dietary and lifestyle concerns | Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors |
| REFERRAL FLAGS | REFERRAL FLAGS | REFERRAL FLAGS |
| ISSUES OF SIGNIFICANCE | ISSUES OF SIGNIFICANCE | ISSUES OF SIGNIFICANCE |
| REFERRAL DECISION | REFERRAL DECISION | REFERRAL DECISION |
TABLE 7.41 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [2, 7–12, 62]
| TEST/INVESTIGATION | REASON FOR TEST/INVESTIGATION |
|---|---|
| FIRST-LINE MEDICAL INVESTIGATIONS: | |
| Pelvic, vaginal, abdominal examination | Check for bulging uterus, ovaries can be palpable in PCOS, abdominal rebound tenderness, overactive bowel sounds, genital deformities, signs of trauma |
| Human chorionic gonadotropin (HCG) blood test/radioimmunoassay (RIA) | Pregnancy, ectopic pregnancy |
| Progesterone level | Test 7 days before menstruation is due to see if ovulated; low serum progesterone level in anovulatory cycles |
| Oestradiol |
Normal: PCOS, weight loss, excess exercise Raised: pregnancy, ovarian tumour, testicular tumour, adrenal tumour Low: PCOS, polycystic ovarian disease, ovarian failure, anorexia nervosa, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal hyperplasia, menopause, Turner’s syndrome, failing pregnancy, fetal death |
| FSH (follicle-stimulating hormone) | |
| LH (luteinising hormone): due to pulsatile action of this hormone it may not be accurately measured on one random sample | |
| Basal body temperature | Normally drops 24–36 hours after menses commences; with endometriosis there is often a delay in basal body temperature to the second or third day of menses; a decrease indicates preovulation and an increase of 5 degrees occurs after ovulation; monitors thyroid function; low temperature readings consistently over a period of days can indicate subclinical or clinical hypothyroidism |
| Abdominal and pelvic ultrasound | Most accurate diagnosis of PCOS, ovarian mass, ovarian cyst or tumour, retroverted uterus, tubo-ovarian abscesses, fibroids, trauma; intestinal obstruction |
| Diet diary | Assess caloric intake and possible food sensitivities |
| IF NECESSARY: | |
| Bone marrow examination | Differentiate iron deficiency from other forms of anaemia |
| Epstein-Barr virus blood test | Postviral symptoms, may show that Hannah has had this virus in the past |
| PRL (prolactin) common in secondary amenorrhoea to be raised | |
| Testosterone | |
| TSH, free T4 and T3 | Borderline subclinical hypothyroidism |
| Antithyroid antibody test | Autoimmune thyroid disease causing subclinical thyroid test result |
| Serum cortisol level | Adrenal insufficiency contributing to subclinical hypothyroidism |
| SHBG (sex hormone-binding globulin) | Low SHBG would indicate the presence of elevated levels of free androgens |
Confirmed diagnosis
Hannah and anaemia and subclinical hypothyroidism
Subclinical hypothyroidism is defined as a serum thyroid-stimulating hormone (TSH) level above the defined upper limit of the reference range, with a serum-free thyroxine (T4) within the reference range [2, 53, 54]. Hannah’s TSH levels are slightly raised and have increased since her last thyroid function test. This result indicates she has or is developing subclinical hypothyroidism.
Prescribed medication
• OCP suggested as an option to lighten menstrual bleed
• Thyroid hormone therapy may be prescribed if Hannah’s TSH levels increase further
TABLE 7.42 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Treatment for the presenting complaint and symptoms | Treatment for all associated symptoms | Treatment for mental, emotional, spiritual, constitutional, lifestyle issues and metaphysical considerations |
| TREATMENT PRIORITY | TREATMENT PRIORITY | TREATMENT PRIORITY |
|
• Continue with dietary recommendations to increase iron intake and absorption • Continue with dietary recommendations to reduce inhibition of iron absorption • Continue with recommended iron supplement until tests indicate Hannah’s iron levels have returned to well within normal range • Continue with herbal tonic until tests indicate Hannah’s iron levels have returned to well within normal range |
• Continue to improve iron status to improve menorrhagia [19, 48]
• Ongoing dietary recommendations to increase consumption of antioxidants and essential fatty acids
• Ongoing supplementation with specific multivitamin, mineral and antioxidant supplement for DS
• Ongoing maintenance of essential fatty acid intake via diet and supplement to enhance general health, cognitive function and reduce risk of Alzheimer’s disease
• Ongoing dietary recommendations and herbal tea to support digestive function and improve nutrient absorption
• Ongoing use of herbal tonic to support thyroid function, reproductive hormone balance and cognitive function; review the formula in 3–4 months based on blood test results and changes/improvement in menstrual symptoms
• Ongoing physical therapy and lifestyle recommendations for exercise to enhance thyroid function and maintain healthy weight
• Ongoing hydrotherapy suggestions to support thyroid function; this can be reviewed in 3–4 months based on blood test results
Treatment aims
• Increase and maintain Hannah’s iron levels [14, 19]. This is likely to improve menorrhagia [19, 48].
• Increase Hannah’s dietary intake of iron [14, 19] and improve iron absorption [14, 19].
• Optimise Hannah’s nutritional status, particularly of nutrients essential for absorption and metabolism of iron [14, 19].
• Reduce excessive menstrual bleeding, which is contributing to Hannah’s anaemia [14, 19, 48].
• Optimise Hannah’s thyroid function [17, 53] and minimise any potential effect of subclinical hypothyroidism on her menstrual cycle [2, 19, 20].
• Support Hannah’s cognitive function and delay onset of or reduce the rate of cognitive decline [21, 22].
• Support Hannah’s nutrition and general health [16, 55, 56].
Lifestyle alterations/considerations
• Encourage Hannah to exercise daily. Exercise stimulates thyroid hormone secretion and increases tissue sensitivity to thyroid hormone [16, 17, 23, 24].
• Encourage Penny to monitor Hannah’s weight and help her maintain a normal BMI. There is a higher prevalence of obesity in people with Down syndrome [26].
• Encourage Hannah to continue and strengthen her social interactions in the friendship club and with family to ensure she has a strong social network [25].
• Refer Penny and her husband to local disability support organisations and networks for ongoing support and assistance as they care for Hannah and plan for her future needs [25].
Dietary suggestions
• Encourage Hannah to eat foods containing haem iron [15, 18, 27]. These include lean red meat, fish, poultry, liver, heart, kidney, oysters, clams and shellfish [15, 18, 27]. Haem iron is more easily absorbed than non-haem iron [18, 27].
• Encourage Hannah to also consume non-haem iron-containing foods, particularly those with higher levels of available iron such as citrus fruit, tomatoes, papaya, broccoli, pumpkin, chickpeas and cabbage [15, 18, 27].
• When she is eating non-haem iron-rich foods, Hannah should minimise consumption of foods containing non-haem iron-solubility inhibitors [15, 18, 27]. These include foods containing phytic acid, oxalic acid and calcium [15, 18, 27].
• Encourage Hannah to avoid tea, coffee or other polyphenol-containing beverages when eating iron-containing foods or iron supplements because the polyphenols can significantly inhibit iron absorption [15, 18, 27, 29].
• Encourage Hannah to add acidic dressings such as lemon juice or vinegar to non-haem iron-containing foods [18, 19, 27].
• Hannah will benefit from consuming 100 mg vitamin C with meals to maximise absorption of non-haem iron [15, 18]. Alternatively she may prefer to drink some acidic fruit juice [15, 18].
• Consumption of bitter fruit or vegetables before or during the meal can stimulate the flow of gastric juices and improve absorption of nutrients [18, 19].
• Encourage Hannah to eat an antioxidant-rich whole-food diet [16, 39, 45].
• Encourage Hannah to consume foods high in omega-3 fatty acids [16, 45].
• Hannah should eat foods containing iodine, selenium, copper, iron, zinc, B-group vitamins and tyrosine, which are essential nutrients for thyroid function [16, 17].
Physical treatment suggestions
• Hydrotherapy: cold hydrotherapy to stimulate thyroid function may be beneficial to Hannah [17, 52]. Whole body cold mitten friction to increase circulation in anaemia [50]. Cold sitz bath or icebag between the thighs to prevent heavy menstrual bleeding [49, 50]. Cold sitz bath with simultaneous, hot foot bath to ease congestion (note: hot foot baths can stimulate menstrual bleeding) [49, 50]. For acute period pain, spray a hot hand shower to the pelvic area for two minutes, then alternate and spray with cold water for one minute (repeat three times) [51]. Hot compress/fomentation on the back during menstrual pain [51]. Between periods, weekly contrasting treatments with hot fomentation on the back and abdomen for 15 minutes, followed by 30-second cold mitten friction. Follow that with heat on the pelvic area and back for another 15 minutes, repeat cold mitten friction with the client in the side lying position (repeat alternating procedure three times). End with an abdominal massage [51].
• Exercise incorporating resistance training can support or improve Hannah’s metabolic rate and help her maintain normal weight [16, 17, 23, 24, 28].
| HERB | FORMULA | RATIONALE |
|---|---|---|
| Withania Withania somnifera |
50 mL | Adaptogen [18, 31]; tonic [31]; cognition enhancer [31]; increases haemoglobin and red cell count [31, 42]; stimulates thyroid activity [17, 40]; enhances serum T4 concentration [18, 37] |
| Codonopsis Codonopsis pilosula |
50 mL | Adaptogen [38]; increases RBC and haemoglobin [38, 39] |
| Schisandra Schisandra chinensis |
50 mL | Antioxidant [18, 35]; adaptogen [18, 35]; improves mental, physical and sensory performance [19, 35]; improves detoxifying capacity of the liver [18, 35]; will assist hormonal balance by enhancing hepatic hormonal clearance [19] |
| Ginkgo Ginkgo biloba 2:1 extract standardised to contain approx; 9 mg/mL Ginkgo flavone glycosides |
50 mL | Cognition enhancer [18, 31]; neuroprotective [18, 31]; antioxidant [18, 31]; improves cognitive function in DS [41] |
| Supply: | 200 mL | Dose: 8 mL twice daily |
TABLE 7.44 HERBAL LIQUID TO BE TAKEN DURING MENSTRUAL BLEED (1:2 LIQUID EXTRACTS)
| HERB | FORMULA | RATIONALE |
|---|---|---|
| Tienchi ginseng Panax notoginseng |
60 mL | Antihaemorrhagic [19, 35]; traditionally used in excessive bleeding [19]; indicated for excessive menstrual bleeding |
| Yarrow Achillea millefolium |
40 mL | Haemostatic [34]; traditionally used in the management of excessive bleeding [19, 34] |
| Supply: | 100 mL | Dose: 5 mL 2–3 times daily as required during menstrual period |
| Tablet alternative to herbal liquid for menstrual bleed if compliance is a problem | ||
| HERB | DOSE PER TABLET | RATIONALE |
| Tienchi ginseng Panax notoginseng |
1000 mg | See above |
Dose: 1–4 tablets daily required during menstrual period
| Alternative to tea and coffee | ||
| HERB | FORMULA | RATIONALE |
| Rose hip Rosa canina |
2 parts | Nutrient [30]; mild laxative [30] |
| Nettle leaf Urtica dioica |
2 parts | Nutritive [31, 36]; haemostatic [31, 32]; traditionally used for anaemia and conditions involving blood loss such as menorrhagia [31, 32] |
| Ginger root powder Zingiber officinale |
¼ part | Digestive stimulant [18, 31]; thermogenic [18, 31]; antioxidant [18] |
| Licorice root powder Glycyrrhiza glabra |
½ part | Flavouring agent [18, 31]; antioxidant [18, 31]; mild laxative [31] |
Infusion: 1 tsp per cup – 2–3 cups daily
TABLE 7.47 NUTRITIONAL SUPPLEMENTS
| SUPPLEMENT AND DOSE | RATIONALE |
|---|---|
| Iron amino acid chelate or iron gluconate providing 12 mg elemental iron combined with B-group vitamins and vitamin C [15, 18, 27] in liquid form to enhance absorption [44]. Initially 1 dose twice daily until fatigue and iron status improves, then reduce to once daily [15, 18, 33] | Iron amino acid chelate and iron gluconate have higher bioavailability than iron sulphate [43, 44] and are less likely to cause gastrointestinal problems [43]; combined with nutritional cofactors essential for absorption and metabolism of iron [14, 15, 33] |
| High-potency practitioner-strength multivitamin, mineral and antioxidant supplement specifically designed for the requirements of individuals with DS providing therapeutic doses of essential micronutrientsDose: As recommended by the manufacturerTaken at least 90 minutes away from iron supplement to optimise absorption of supplemental nutrients [27] | Enhancing antioxidant status is beneficial in DS [16, 39, 56] and in reducing the risk of Alzheimer’s disease [39, 45]; contains nutrients essential for optimal thyroid function [16, 17] |
| Omega-3 fish oil 4000 mg daily in divided doses [15, 18] |
Cognition enhancer [18]; EPA reduces the risk of Alzheimer’s disease [18, 45] |
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