Understanding the cause (client) What do you think has been causing the significant increase in weight? I don’t know, but something is really wrong, I think. Even my periods are going wrong. Your practitioner impression
Suzanne is obviously obese. Your first impression of her is someone who lacks confidence and is quite unsure of herself.

TABLE 4.2 CONTEXT

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
Has anyone else in your family experienced similar problems?	My mum is pretty big, but not as big as I am. Her sister is a lot like me, she’s really big.
Supplements and side effects of medication
Are you taking any supplements or medications from the doctor?	I went to the chemist and got a multivitamin and I also bought some weight-loss tablets, but they haven’t helped my energy or my weight.
Endocrine/reproductive
Did your irregular period cycle come on suddenly or begin to slow down gradually?	I used to be more regular and then it began to slow down and chop and change. Now I get confused about when it’s going to come.
Stress and neurological
Do you feel stressed at the moment?	Yes. I feel so bad about putting on this weight and I know I don’t do enough exercise, but I feel so tired all of the time.
Eating habits and energy
Describe your diet.	Suzanne’s description of her diet indicates it is quite healthy, containing good amounts of whole foods, fresh fruit and vegetables. She insists her portion sizes are normal and on further questioning her description of her portion sizes indicates she is not eating excessive amounts at mealtimes.

TABLE 4.3 CORE

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
Support systems
Do you have a good support system?	I have my parents and some friends.
Emotional health
Do you think you are depressed?	I think I am.
Stress release
How do you manage your stress?	I don’t know, I just usually read or watch TV.
Family and friends
Do you spend much time with family or friends?	I see my parents at least once a week. I haven’t seen my friends much recently since I feel really embarrassed whenever I go out with them. They’re always nice to me, but I just feel they think I should try harder.
Action needed to heal
What do you think you need to do to get better?	I really don’t know, I’ve tried dieting and exercising but it didn’t really work. I’m hoping you can help me.
Long-term goals
What are your long-term goals?	To get slimmer and fitter and to get my energy back. I want to get a job and am thinking of retraining and doing something different.

TABLE 4.4 SUZANNE’S SIGNS AND SYMPTOMS [2, 6–8]

Results of medical investigations

Suzanne has not had any medical investigations.

TABLE 4.5 UNLIKELY DIAGNOSTIC CONSIDERATIONS [2, 7–11]

CONDITIONS AND CAUSES	WHY UNLIKELY
INFECTION AND INFLAMMATION
Chronic salpingo-oophoritis: irregular cycle; can be minimal or excessive menstrual bleed	Usually congestive dysmenorrhoea is the predominant symptom; associated with purulent discharge, fever, period pain and abdominal pain
Postpartum thyroiditis: transient hypothyroid after pregnancy	No pregnancies that we know of
ENDOCRINE/REPRODUCTIVE
Diabetes: anovulatory cycles	Urinalysis NAD
Primary dysmenorrhoea: lower abdominal pain, can get worse with menstrual cycle	Period pain usually begins at menarche and is often associated with no pelvic abnormality, nausea vomiting, headache and dizziness
Secondary dysmenorrhoea: acquired due to pathology; period pain begins several years after menarche and due to a pelvic abnormality	No menstrual pain
Endometriosis: irregular periods	No significant pelvic pain or pain on menstrual bleed reported; no bleeding from the bowel; usually brown discharge with associated abdominal and pelvic pain
Premenstrual syndrome: pain in the abdomen before menses	Will experience premenstrual mood changes, feel teary, bloated and swollen 1–12 days before her period; experiences a dull pelvic ache, abdominal bloating
Ovarian cyst: irregular periods	Ovarian cysts almost never cause heavy menstrual bleeding
Ovulatory bleed: have a bleed mid-cycle as well as regular menses and ovulation has occurred	Feel emotional, premenstrual symptoms such as ovulation pain (mittelschmerz) and mood changes; usually spotting or light bleed at time of ovulation, regular cycle; check basal body temperature as it will be biphasic and fluctuate indicating ovulation has occurred

Case analysis

TABLE 4.6 POSSIBLE DIFFERENTIAL DIAGNOSIS

NOT RULED OUT BY TESTS/INVESTIGATIONS ALREADY DONE [2, 7–11, 56–58]
CONDITIONS AND CAUSES	WHY POSSIBLE	WHY UNLIKELY
FAMILY HEALTH
Familial or idiopathic hirsutism: excess hair growth would not be typically androgenic	Excess hair appearing on hormonal influenced areas of the body where hair will grow, such as the face	Check if family history of excess hair growth for females
ALLERGIES AND IRRITANTS
Food intolerance/allergy	Fatigue, depression; skin and hair changes; constipation	Need to gain more insight into Suzanne’s diet and associated symptoms
CANCER AND HEART DISEASE
Thyroid cancer	Deep voice, thyroid swelling	Will have signs of pain in neck or throat, difficulty swallowing, nodule or lump around laryngeal prominence, trouble breathing, difficulty speaking, hoarse throat; thyroid gland will have a single firm nodule that has developed rapidly
Ovarian, uterine cancer	Heavy irregular bleeding	No vaginal discharge reported
Adult onset and congenital adrenal hyperplasia/adrenal tumour: can cause primary and secondary amenorrhoea anovulatory cycles	Usually presents with severe acne and hirsutism; can present with anovulatory irregular menstrual bleeding	Check if there was rapid development of symptoms and how severe symptoms of virilisation are; usually will be severe and can include symptoms such as frontal balding, enlarged clitoris
TRAUMA AND PRE-EXISTING ILLNESS
Congenital – dyshormonogenesis: genetic defects in synthesis of thyroid hormone – primary cause	Goitre and hypothyroid symptoms	Rare condition; may have associated deafness; need to investigate for family history of thyroid disease; will present with childhood symptoms such as dwarfism, mental retardation, pot belly, delayed bone age
OBSTRUCTION AND FOREIGN BODY
Intestinal obstruction (bowel cancer, adhesions, hernias, faecal impaction with overflow)	Abdominal constipation	No vomiting, abdominal pain and distension
FUNCTIONAL DISEASE
Thyroid benign nodules: follicular adenomas, cysts, focal thyroiditis	Deep voice, thyroid swelling, hypothyroid symptoms	Nodules develop rapidly
Fibromyalgia: pain in axial skeleton with tender points that has lasted more than 3 months	Tiredness, aches and pains more common in women; can be worse from being in cold weather; depression	Will often present with irritable bowel symptoms, difficulty sleeping; normal laboratory results; rule out organic reasons for symptoms
Obstructive sleep apnoea	Fatigue during the day; more common when overweight or obese; does not usually complain of ‘sleepiness’ but fatigue generally	Need to define if Suzanne does not feel well rested in the morning and if she snores during the night; can be made worse by alcohol consumption prior to sleeping
Obesity	BMI 35; lack of exercise; usually general distribution of weight gain	Goitre visible; usually no other abnormal health features other than being overweight; appetite is usually increased; oedema present (unusual); need to define if Suzanne has a family history of obesity; need to define if Suzanne’s weight gain has been gradual with increased caloric intake and/or with eating more sugar
Chronic fatigue syndrome: fatigue for at least 6 months that has no physical, psychoses, bipolar affective disorder, eating disorder or organic brain disease	Severe disabling fatigue affects both mental and physical functioning for at least 6 months; sleeping more, depression, feelings of guilt, social withdrawal, crying spells; muscular aches and pains	Goitre indicates a physical reason for fatigue; need to define if Suzanne’s fatigue improves as the day progresses
Functional constipation	Constipation, lack of exercise, stress	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?
DEGENERATIVE AND DEFICIENCY
Iodine deficiency: iodine required for thyroid hormone synthesis – primary cause	Goitre and hypothyroid or euthyroid	In mountainous areas of Alps, Himalayas, South America, Central Africa; thyroid gland can have multiple nodules
Pernicious anaemia: lack of B12 absorption due to immune destruction of intrinsic factor in atrophic gastritis and loss of stomach parietal cells	Fatigue, slow movements, cognitive impairment, can present with hypothyroidism	Usually low blood pressure and rapid heart rate, shortness of breath, swollen red tongue, diarrhoea, can also present with hyperthyroidism
Anaemia: iron deficiency, pernicious anaemia, due to heavy menstrual bleeding	Fatigue, depression	Usually signs of shortness of breath, palpitations, increased heart rate
INFECTION AND INFLAMMATION
Post-subacute thyroiditis: primary cause	Goitre and hypothyroid symptoms	Would be a transient condition of infective origin rather than the symptoms gradually building up over time; soft tender, sometimes painful goitre
Riedel’s thyroiditis: fibrous tissue infiltrates and replaces the thyroid gland	Goitre hypothyroid symptoms; more common in women	Very hard goitre; rare form of thyroid disease
Osteoarthritis	Pain in many joints and more common in women	Usually develops in older age groups; presents with signs of limited range of movement, bony swellings and instability of joints; not necessarily associated with severe fatigue; need to check family history as it can be congenital and begin at an early age
Postviral infection	Depression, fatigue	Need to rule out if Suzanne has had viral symptoms prior to feeling fatigued and depressed
SUPPLEMENTS AND SIDE EFFECTS OF MEDICATION
Drugs: lithium, antithyroid medication, cytokines	Cause hypothyroid symptoms	Need to check medication history
ENDOCRINE/REPRODUCTIVE
Hypothalamic-pituituary disease: tumour, hypopituitarism is secondary cause of hypothyroidism	Goitre; symptoms of hypothyroid such as irregular periods, depression, weight gain, slow pulse, constipation, low body temperature	Blood tests will rule out secondary causes of hypothyroidism
Hypothyroidism: cause of secondary amenorrhoea due to hyperprolactinaemia and endocrine disorder; anovulatory cycles	Goitre, weight gain, fatigue, depression, irregular periods, heavy menses, constipation, increased facial hair (hirsutism), puffy eyes, deep voice, dry hair, low body temperature, slow pulse, muscle aches, slow movements, change in appetite
Subclinical hypothyroidism [59, 60]	Weight gain, fatigue, depression, irregular periods, heavy menses, constipation, change in appetite	Need to check if serum TSH levels are above limit and T3 and T4 levels present as normal; could indicate clinical hypothyroidism may develop
Pregnancy	Irregular periods; missed periods; most common cause of secondary amenorrhoea; can present with vaginal discharge and pelvic/abdominal pain	Suzanne claims she is not sexually active at the moment and has no partner; pregnancy can present with fever; will have signs of breast tenderness and may have morning sickness
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)	Often maintains normal cycle unless submucosal or nearly extruded
Polycystic ovarian syndrome (PCOS): extremely common cause of secondary amenorrhoea; anovulatory cycles	Irregular menstrual cycles, acne, increased facial hair (hirsutism), weight gain; irregular periods came on slowly	Can occur with androgenic alopecia (thinning of hair on the head such as men have); may not be associated with heavy menstrual bleeding
Cushing’s syndrome: cause amenorrhoea, irregular menstrual cycles	Irregular menstrual cycles, increased facial hair, depression, weight gain, higher scale blood pressure	There was not a rapid development of symptoms; no moon-shaped face or frontal balding; urinalysis NAD and indicating no glucose intolerance or diabetes that can be associated with Cushing’s syndrome
Dysfunctional uterine bleeding (DUB): endometrial hyperplasia, PCOS, from taking exogenous oestrogen; endocrine dysfunction; (not associated with inflammation, tumour or pregnancy) anovulatory hormone-related bleeding is most common	Usually causes bleeding with unpredictable volume and frequency; often accompanied by menorrhagia (heavy bleed with regular cycle) but interval between periods is shorter to make the cycle appear irregular	No use of exogenous oestrogen reported
Anovulatory bleeding: have irregular bleed that appears menstrual although no ovulation has occurred; can be associated with both short and long cycles	Irregular cycle; no significant premenstrual symptoms reported to show evidence of regular association with menses cycle; bleed is painless and unexpected; blood volume can be excessive but irregular; physical findings will often include hirsutism, acne	Check basal body temperature; if anovulatory it will not fluctuate (monophasic)
Oestrogen-withdrawal bleeding: causes intermenstrual bleeding; occurs when the endometrium proliferates and becomes unstable when oestrogen drops below threshold; can happen outside of the secretory phase or in the absence of progesterone	Common cause of irregular periods in reproductive years, especially if ovulation has not occurred; menstrual bleeding is prolonged and profuse when it does occur; bleed is painless
Progesterone-withdrawal bleeding: only occurs when there is an oestrogen-primed endometrium; can occur when oestrogen therapy continued and progesterone stopped; also when progesterone is administered to test endogenous oestrogen	Irregular menstrual bleed; often present in conditions such as amenorrhoea
Oestrogen-breakthrough bleeding – 1st type: when oestrogen levels are low but constant causing sections of endometrium to degenerate	Intermenstrual bleed	Need to investigate if experience any spotting of blood
Oestrogen-breakthrough bleeding – 2nd type: oestrogen levels are well above threshold causing endometrium to become hyperplastic and outgrow blood-borne hormone supply	Causes degeneration of endometrium with prolonged and irregular bleeding	More common in oestrogen-based tumours
AUTOIMMUNE DISEASE
Atrophic thyroiditis: (autoimmune) most common cause of primary hypothyroidism; will cause atrophy and fibrosis of the thyroid gland	Goitre; may be intermittent and recover; symptoms of hypothyroidism; common in women	Check for the presence of antithyroid antibodies and pernicious anaemia; thyroid gland will be enlarged, sometimes painful and soft swelling
Hashimoto’s thyroiditis: [58] important to rule out an autoimmune cause of primary hypothyroidism	Goitre; common in women	More often presents in late middle age
Rheumatoid arthritis	Muscle aches and pain; common in women, fatigue due to anaemia of chronic disease	Check if family history of rheumatoid arthritis
Systemic lupus erythematosus	Generalised aches and pains, skin changes, more common in women, increased fatigue	See if there is a butterfly rash on Suzanne’s face
STRESS AND NEUROLOGICAL DISEASE
Depression: important differential diagnosis to rule out before exploring other possibilities of mental or organic causes for fatigue symptoms
*Primary origins* Primary depression and endogenous depression are associated conditions that are regarded as primary disorders, i.e. that do not occur secondarily to other medical or psychiatric disorders; these terms refer to depression that is caused by internal chemical and biological factors rather than external stressors
Type 1 – major (clinical) depression	Has at least five symptoms of depression every day for more than 2 weeks, which causes considerable incapacity with daily activities; people often describe symptoms in physical terms; depressed daily, loss of interest in daily activities, change of appetite, weight gain, increased fatigue, slower movements, feelings of worthlessness	Need to define if Suzanne feels worse in the morning and has a sense of apprehension; visible goitre indicates the feelings of depression come from a secondary origin
Dysthymia: mild depressive illness	Could be experiencing ‘double depression’ if Suzanne has had intermittent periods of depression in the past; symptoms include tiredness, lack of interest in life and low mood	Lasts intermittently for 2 years or more; need to determine if Suzanne has had a tendency to have episodes of feeling low prior to the onset of her physical changes
*Secondary origins* Reactive depression and associated conditions that occur after or in response to a pre-existing medical or psychiatric disorder; brought on by external life experiences
Seasonal affective disorder: secondary to the winter months	Symptoms include increased sleep, tiredness, change in appetite, weight gain	Need to determine if Suzanne has experienced episodes of depression during the winter months in the past; usually appetite increases
*Psychological* Functional fatigue (depression)	Tiredness that has lasted several months	Need to determine if Suzanne’s fatigue improves as the day progresses; determine if her fatigue began after a specific life event or only when her physical symptoms began
EATING HABITS AND ENERGY
Causal factor:Diet high in brassica and cassava foods: when in excess can cause hypothyroid symptoms	Symptoms of underactive thyroid	Need to ask if Suzanne regularly eats broccoli, spinach, cabbage, cauliflower, brussels sprouts, kale, collard greens, pak choi and tapioca is in Suzanne’s diet
Causal factor:Lack of exercise	Weight gain, fatigue, depression

TABLE 4.7 DECISION TABLE FOR REFERRAL [2, 7–12]

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
• BMI over 30 indicating obesity • Weight gain associated with goitre

• A menstruating woman of any age can bleed from pregnancy complications

• Irregular bleeding in menstrual cycle for years

• Change in volume of menstrual bleed

• Hirsutism associated with menstrual change and other virilising symptoms such as acne

• Weight gain with decreased appetite

• Pattern of premenstrual symptoms have stopped, indicating lack of ovulation

• Social isolation

• Significant depression

• Symptoms have worsened without Suzanne seeking medical help

ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE ISSUES OF SIGNIFICANCE

• Lack of exercise

• Puffy eyes, dry hair and skin

• Significant fatigue although sleeping well at night

• Worsening constipation

• Embarrassed about weight and hirsutism

• Unemployed

• Would like to have children and a husband

• Family pressure regarding marriage

REFERRAL REFERRAL REFERRAL

• Signs and symptoms warrant further investigations for a definitive diagnosis of hypothyroidism [56, 57]; we have a duty of care to Suzanne to encourage her to be informed regarding possible treatment using thyroxine medication [58, 60]

• Dietary assessment

• Medical assessment on associated menstrual, metabolic and virilising symptoms

• Mental health assessment and counselling

• Career advice

TABLE 4.8 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [2, 6–11, 13, 57, 60]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE 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
Musculoskeletal examination	Back strain, trauma, deformities, inflammation
Human chorionic gonadotropin (HCG) blood test/radioimmunoassay (RIA)	Pregnancy, ectopic pregnancy
Full blood count	Check for signs of infection, virus or allergic reaction; rule out anaemia
Thyroid function test Thyroid stimulating hormone (TSH) Thyroid hormones (T4, T3 synthesised in the thyroid gland)	TSH: High in primary and subclinical hypothyroidism; normal or low in secondary hypothyroidism (hypothalamic-pituitary cause) T4: Low in primary and secondary hypothyroidism; normal reading in subclinical hypothyroidism T3: Low in primary and secondary hypothyroidism; normal reading in subclinical hypothyroidism
‘Free’ T4: available for tissue action	Measures only the unbound active T4 hormone; will be low in hypothyroid
Thyroxine-binding globulin (TBG) – binds T4 and T3 in plasma	Will be increased in hypothyroidism
Thyroid antibody: blood test thyroid perioxidase antibody, antithyroglobulin antibody	Autoimmune causes of hypothyroidism
Serum cholesterol	Can be raised in hypothyroidism
ESR/CRP	Inflammation such as in systemic lupus erythematosus (SLE) and rheumatoid arthritis
Progesterone level	Test 7 days before menstruation due to see if ovulation has occurred; 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)	Normal: PCOS, pregnancy, anorexia, weight loss, excess exercise Raised: ovarian failure, menopause Low: polycystic ovarian disease, anorexia, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal tumour/hyperplasia
LH (luteinising hormone) due to pulsatile action of this hormone it may not be accurately measured on one random sample	Normal: pregnancy, anorexia, weight loss, excess exercise Raised: PCOS, polycystic ovarian disease, ovarian failure, menopause Low: anorexia, weight loss, excess exercise, hypothyroidism, Cushing’s syndrome, adrenal tumour/hyperplasia
PRL (prolactin) commonly raised in secondary amenorrhoea	Normal: ovarian failure, anorexia, weight loss, excess exercise, adrenal tumour/hyperplasia Raised: PCOS (mildly), hypothyroidism, Cushing’s syndrome, pregnancy, amenorrhoea Low: pituitary destruction from tumour
Testosterone	Normal: ovarian failure, anorexia, weight loss, excess exercise, hypothyroidism, pregnancy Raised: PCOS, Cushing’s syndrome, adrenal tumour/hyperplasia, testicular tumour, ovarian tumour Low: corticosteriod use
SHBG (sex hormone-binding globulin)	Low SHBG would indicate the presence of elevated levels of free androgens
Fasting blood glucose test	Raised levels can indicate diabetes mellitus, Cushing’s syndrome
Cervical smear	To detect cervical cancer
HOME TESTS:
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
Ovulation prediction kits	Designed to detect an increase in urinary luteinising hormone (LH) excretion 24–36 hrs prior to ovulation
Diet dairy	Assess caloric intake and possible food sensitivities
IF NECESSARY:
Serum aspartate transferase	Will be increased from muscle and liver in hypothyroid
Serum creatine kinase levels	Increased with associated myopathy in hypothyroidism
Sodium levels	Low due to increase in ADH and slow free water clearance
Thyrotropin releasing hormone (TRH)	TRH is released in the hypothalamus to stimulate release of TSH from pituitary; determine hypothalamic-pituitary disease
Anti-nuclear antibody	Autoimmune disorders, SLE, rheumatoid arthritis
RH factor	Rheumatoid arthritis
Epstein-Barr virus blood test	Postviral symptoms, may show that Suzanne has had this virus in the past without realising it
Abdominal and pelvic x-ray/ultrasound	Most accurate diagnosis of PCOS, ovarian mass, ovarian cyst or tumour, retroverted uterus, tubo-ovarian abscesses, fibroids, trauma; intestinal obstruction
Brain scan CT/MRI	Pituitary tumour
Back x-ray CT scan and MRI	Degenerative disc disease, disc prolapse, Ankylosing spondylitis, Paget’s disease, osteoporosis

Confirmed diagnosis

Suzanne and hypothyroidism

Suzanne is a 32-year-old woman who has come to the clinic asking for help with weight loss – she has now reached a BMI of 35. Additionally Suzanne is experiencing significant fatigue despite sleeping long hours at night, has worsening constipation, a lack of appetite and is depressed. She has also been experiencing irregular and heavy periods, has developed facial hair growth and acne, dry skin and hair and suffers from generalised aches and pains in her body. On the whole Suzanne is feeling very low about herself and this is not made any better by her family being disappointed that she does not yet have a husband and children. Suzanne is currently unemployed and does not leave her home often. She is not exercising because she is too embarrassed to do so outside of her home and is not motivated on her own.

On physical examination it became evident that Suzanne has a visible goitre, deep voice, puffy eyes, slow movements and speech, low body temperature and pulse rate and high blood pressure. Suzanne required immediate referral for a medical and mental health assessment. A medical diagnosis of hypothyroidism was confirmed, which explains the range of symptoms she has been experiencing.

Hypothyroidism is an ailment characterised by under-activity of the thyroid gland (i.e. insufficient production of thyroid hormones). The most ‘observable’ sign of hypothyroidism is a goitre and low basal temperature in the morning. Other symptoms include fatigue, weight gain, memory and mental impairment, dry skin, cold intolerance, decreased concentration, constipation, depression, loss of hair, coarse hair, muscle and joint pain, goitre, hyperlipidaemia, irregular periods, infertility, hoarseness, yellow skin, lowered body temperature, drooping swollen eyes, reduced or excessive sweating, brittle nails, diminished sex drive and slow healing.

Hypothyroidism occurs most frequently in women over the age of 40 (however, men and teenagers may also have hypothyroidism). It is possible for a woman or man to have symptoms of subclinical hypothyroidism for many years before developing a clinical manifestation of the disease. Approximately 50 per cent of people with hypothyroidism are unaware they have the condition [56]. Although clients with this disorder can be asymptomatic, some clients have subtle findings including alteration in lipid metabolism as well as abnormalities in cardiac, gastrointestinal, neuropsychotic and reproductive functions [57].

General references used in this diagnosis: 2, 7, 8, 10, 11, 56–58

Prescribed medication

• Thyroxine

TABLE 4.9 DECISION TABLE FOR TREATMENT

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
• Improve thyroid function and endogenous production of thyroid hormones via recommendations to increase dietary intake of nutrients essential for thyroid hormone production • Improve thyroid function and endogenous production of thyroid hormones via physical therapy suggestions and recommendation to increase exercise • Improve thyroid function and endogenous production of thyroid hormones by identifying and addressing chemical or heavy metal exposure, which may affect thyroid function

• Dietary and supplement recommendations to assist with weight loss

• Recommendation for Suzanne to increase physical activity to assist with weight loss, improve metabolic rate and improve general health

• Herbal tea to assist with weight loss

• Increasing antioxidant intake to enhance general health and protect against damage from oxidative stress through diet, herbal tea and nutritional supplements

• Dietary and nutritional supplementation recommendations to assist with balancing reproductive hormones

• Recommendation to increase physical activity to assist with stress and depression

• Herbal liquid or tablets with anxiolytic and adaptogenic properties

• Recommendations to improve dietary intake of essential fatty acids and essential nutrients to help improve depression

• Recommendation for counselling or cognitive behavioural therapy to help improve Suzanne’s body image and general emotional health

• Improve thyroid function and endogenous production of thyroid hormones by reducing or avoiding exposure to dietary and environmental substances that may adversely affect thyroid function, e.g. avoiding fluoride, caffeine and goitrogens

• Improve thyroid function and endogenous production of thyroid hormones via nutritional supplement suggestions

• Improve thyroid function and endogenous production of thyroid hormones via herbal tincture or tablets

NB: Collaborative management of Suzanne’s case is essential to ensure potential interactions between prescribed thyroxine and herbal and nutritional supplements are managed appropriately; it may be possible to reduce the dose of thyroxine as the dietary, lifestyle, herbal and supplement treatments improve Suzanne’s thyroid function

Treatment aims

• Improve thyroid function and increase endogenous production of T4 [14, 15].

• Optimise nutritional status and ensure adequate dietary intake of nutrients required for hormone production and conversion of T4 to T3 [14, 15, 32].

• Identify and address any environmental chemical or heavy metal exposure, which may be implicated in the development and/or progression of Suzanne’s condition [15, 35].

• Identify and correct any nutritional deficiencies that may be contributing to Suzanne’s condition [14, 15, 32].

• Improve Suzanne’s nutritional and antioxidant status. This is essential for both normal thyroid function [14, 15, 31, 32], to reduce oxidative stress associated with hypothyroidism [14, 31, 32] and to help manage symptoms of depression [14, 15].

• Improve Suzanne’s reproductive hormone balance [14].

• Improve Suzanne’s associated symptoms of dry skin, hair and nails, excessive fatigue, musculoskeletal pain and psychological symptoms [2, 8, 14].

• Assist Suzanne with weight loss.

• Improve Suzanne’s physical activity levels [14, 15].

• Support Suzanne’s cardiovascular health and manage hyperhomocysteinaemia, hyperlipidaemia and insulin resistance if present [14, 32, 33].

• Support Suzanne’s emotional health.

Lifestyle alterations/considerations

• Encourage Suzanne to exercise daily. Exercise stimulates thyroid hormone secretion and increases tissue sensitivity to the thyroid hormone [14, 15, 22, 23]. Exercise also helps improve depression and anxiety [47].

• Encourage Suzanne not to eat a very low calorie diet in an effort to lose weight. It can reduce metabolic rate as the body seeks to conserve energy [14, 24].

• Suzanne may benefit from a course of cognitive behavioural therapy [25, 28]. Improving thyroid function is likely to improve response to psychological treatment [26, 27].

Dietary suggestions

• Encourage Suzanne to avoid or significantly reduce consumption of foods containing goitrogens and thiocanates (cabbage, cauliflower, brussels sprouts, soy fibre, apples, walnuts, almonds) [14, 15]. If Suzanne chooses to eat goitrogenic foods they should be cooked to reduce levels of goitrogens [15, 29, 30].

• If Suzanne eats soy-based foods it is important to ensure her iodine intake is adequate to ensure thyroid function is not affected [17, 38].

• Encourage Suzanne to increase consumption of foods containing iodine, selenium, copper, iron, zinc, B-group vitamins and tyrosine, which are essential nutrients for thyroid function [14, 15].

• Encourage Suzanne to eat whole organic foods [14] and increase consumption of antioxidant-rich foods [14, 15, 31].

• Encourage Suzanne to increase her dietary intake of essential fatty acids, particularly omega-3 and -6 fatty acids and decrease consumption of saturated fats [15, 34]. Omega-3 fatty acids are essential to reduce or treat depression [48].

• Suzanne’s weight-loss program should incorporate a higher protein and lower carbohydrate intake and include adequate levels of essential fatty acids [36, 37] that comprise low GI/GL foods. This is likely to assist Suzanne with weight loss [46].

• Suzanne would benefit from incorporating turmeric into her diet for its antioxidant, anti-inflammatory and liver function enhancing properties [14, 17, 18].

• Suzanne should reduce consumption of caffeinated beverages [15, 40].

Physical treatment suggestions

• Cold hydrotherapy can stimulate thyroid function [14, 55].

• Cold sitz baths to prevent heavy menstrual bleeding [50]. Place an ice pack on the inside of the thighs to stop heavy bleeding [50].

• Whole body cold mitten friction for circulation and depression [51].

• Constitutional hydrotherapy [50, 52, 53].

• For constipation place a hot compress on the abdomen, then cover in plastic with a hot water bottle/heating pad on top for 12 minutes, followed by cold mitten friction for 30 seconds (repeat process three times) [54].

• Alternating hot and cold showers to improve immune function and decrease fatigue [51, 53].

• Arm, wrist, ankle cold shower affusions for fatigue [50, 53, 54].

• Neutral baths (note: whole body heat treatments contraindicated) [54].

• Exercise therapy program incorporating resistance training to support metabolic function and weight loss [14, 15, 22, 23, 49].

TABLE 4.10 HERBAL TEA

Alternative to tea and coffee
HERB	FORMULA	RATIONALE
Green tea Camellia sinensis Decaffeinated [40]	4 parts	Thermogenic [17, 39]; antioxidant [17]; may be beneficial to aid weight loss [17, 39]
Ginger root powder Zingiber officinale	½ part	Anti-inflammatory [17, 18]; antioxidant [17]
Bitter orange peel Citrus aurantium	3 parts	Antioxidant [17]; may be beneficial to aid weight loss [17]
Infusion: 1 tsp per cup – 3–4 cups daily

TABLE 4.11 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

HERB	FORMULA	RATIONALE
Withania Withania somnifera	70 mL	Adaptogen [17, 18]; tonic [18]; anti-inflammatory [17, 18, 19]; stimulates thyroid activity [17, 41]; enhances serum T4 concentration [17, 41]
Brahmi Bacopa moniera	65 mL	Adaptogen [17]; nervine tonic [19]; increases T4 concentration [17, 42]
Bladderwrack Fucus vesiculosus	50 mL	Thyroid stimulating [20]; aids with weight loss [20]; contains iodine [20]
Korean ginseng Panax ginseng	15 mL	Adaptogenic [17, 18]; tonic [17, 18]; antioxidant [17]
Supply:	200 mL	Dose: 10 mL twice daily
Suzanne’s thyroid hormone levels should be monitored regularly due to the potential for interaction with thyroxine [17]

TABLE 4.12 TABLET ALTERNATIVE TO HERBAL LIQUID: MAY IMPROVE COMPLIANCE

HERB	DOSE PER TABLET	RATIONALE
Bladderwrack Fucus vesiculosus	440 mg	See above
Brahmi Bacopa moniera	1000 mg	See above
Withania Withania somnifera	250 mg	See above
Dose: 1 tablet 3 times daily. Suzanne’s thyroid hormone levels should be monitored regularly due to the potential for interaction with thyroxine [17]

TABLE 4.13 NUTRITIONAL SUPPLEMENTS

SUPPLEMENT AND DOSE	RATIONALE
Iodine 250 mcg daily [16, 17, 21, 43] If Suzanne choose not to take the herbal liquid or tablets that contain bladderwrack Suzanne’s thyroid hormone levels should be monitored regularly due to the potential for interaction with thyroxine [17]	Essential for the manufacture of T4 and T3 [16, 17, 21] and for normal thyroid function [43]; combines with tyrosine to form thyroid hormones [16]; deficiency may be associated with decreased plasma levels of T4 and T3 [21] and hypothyroidism [16, 21, 43]; supplementation of 250 mcg takes into account recommendations to increase dietary intake of iodine [14, 15] and to ensure Suzanne does not exceed the upper prescribing limit for iodine [16, 17, 21, 43]
Zinc citrate 50 mg elemental zinc daily [16, 21]	Necessary for normal thyroid function [44]; antioxidant [16, 17, 21, 43]; required for normal function of the reproductive system and reproductive hormones [17, 43]
Selenium 200 mcg daily [16, 17, 21, 43] 2 mg daily of copper to be included if zinc supplement taken for more than a month [16]	Required for thyroid hormone synthesis [21]; facilitates conversion of T3 to T4 [16, 17, 43]; regulates thyroid hormones [17, 43, 44]; antioxidant [16, 17, 21, 43]; necessary for normal function of reproductive hormones [21]; reduces heavy metal toxicity [17, 21]
Vitamin C 1000 mg twice daily [16, 17, 21, 43]	Required for thyroid hormone synthesis [14, 17]; antioxidant [16, 17, 21, 43]
High-potency practitioner-strength multivitamin and antioxidant supplement providing therapeutic doses of B-group vitamins [16, 17, 21, 45]	There is an increased need for antioxidant intake in hypothyroidism [14, 31, 32]; thyroid hormone insufficiency increases the need for vitamin B2 [17]; deficiency of B-group vitamins adversely effects mitochondrial energy production [45]; vitamin B6 is essential for reproductive hormone synthesis [16, 17, 21, 43]; inadequate nutritional status is implicated in depression [14, 15]
Tyrosine 1500 mg daily in divided doses [17, 21] Suzanne’s thyroid hormone levels should be monitored regularly due to the potential for interaction with thyroxine [17]	Thyroid hormone precursor [17, 21]; combines with iodine to form thyroid hormones [16]; low levels of tyrosine can be associated with hypothyroidism [17, 21]; supplementation may be beneficial to improve stress adaptation [17, 21]; improve energy levels [17] and aid with weight loss [17]

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Diabetes mellitus: type 2

Case history

Anita Bloom is a 58-year-old medical secretary who has come to the clinic for help with a personal health problem she is finding very embarrassing. Anita has chosen to come to the clinic because she is too shy about talking to her boss, who is also her GP. She would prefer to deal with this problem without having to consult any of the doctors at work. She feels it is just too personal to talk about with people she works with.

The symptom causing Anita the most embarrassment is an itchy bottom. She has taken worming tablets and has tried a number of creams from the pharmacy. Sometimes she notices blood on the toilet paper after passing a bowel motion but experiences no discomfort or pain when passing a motion. When you ask her about her bowel habits, Anita tells you she has regular bowel motions and hasn’t noticed any abdominal bloating, wind or pain. She has not noticed whether any food or drink makes her symptoms better or worse.

Anita tells you she feels there is something just ‘not right’ in her body recently. She feels ‘sluggish’ and has been gaining weight over the past six months. She is aware that she has been eating far too many lollies and biscuits recently. Because they are being sold from a stand on the reception desk at work it is just too tempting for her to resist.

Anita tells you she has been waking several times a night to urinate, and thinks this is why she is feeling so tired. Some days she feels so exhausted that she just drags herself through the day and collapses in a chair when she gets home.

Anita is more thirsty recently and has been drinking more tea and coffee. Her appetite has also increased. Anita enjoys a wide range of foods, she enjoys cooking and particularly likes red wine, cheese, fish and fresh salads. She tells you she is a sociable person who enjoys spending time with friends and usually laughs a lot. She often has friends and colleagues over for dinner parties, where she enjoys serving her own home-grown organic vegetables. Anita has been living alone for the past 10 years, a situation she is more than happy with.

Anita went through menopause about nine years ago and didn’t experience any problems. Up until recently she has felt very well. Anita has not been exercising much recently because her muscles ache and she feels weak. She is also concerned that her eyesight isn’t as good as it used to be. She hasn’t gone to the optometrist for an eye check because she is afraid they will find something wrong with her eyes. Anita loves reading and needlework, and is concerned that eye problems will stop her from being able to do these favourite pastimes.

TABLE 4.14 COMPLAINT

Analogy: Skin of the apple

Complaint: Define the presenting complaint and symptoms; understand the complaint

Itchy bottom

Feeling ‘something is not right’

AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS CLIENT RESPONSES Onset

When did you start noticing your bottom was itchy?

When did you start feeling something wasn’t right?

It started about 6 or 8 months ago, and comes and goes.

I suppose I haven’t been feeling completely myself for about 18 months.

Understanding the cause (client) What do you think might be causing your problem? I really don’t know. I thought it might be ‘intestinal worms’ but it wasn’t. Exacerbating factors Have you noticed if anything makes it worse? Not really. Relieving factors Have you noticed if anything makes it better? Anti-fungal creams help, but it keeps coming back. Your practitioner impression
Anita is quite overweight and appears slightly anxious.

TABLE 4.15 CONTEXT

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
What is your family health history?	My father passed away from bowel cancer, but he had been a smoker most of his life. My mum is still with us; she has diabetes. My sister and brothers are fairly healthy although one has arthritis.
Allergies and irritants
Is the itching worse after being in contact with particular soaps, bath oils, bubble baths, perfume or lubricants?	I don’t think so.
Recreational drug use
How much alcohol would you usually have per week? Do you take any recreational drugs?	Probably about 3 or 4 glasses a week, perhaps more when I’m socialising. No.
Degenerative and deficiency
Did you experience a sudden onset of blurred vision in both eyes? (changes in blood-sugar levels)	Yes, sometimes my vision is blurry when I feel a bit faint … and yes, it will be in both eyes.
Supplements and side effects of medications
Are you taking any supplements or medications?	Just a multivitamin, which I thought might help improve my energy levels.
Stress and neurological diseaseDid the increased need to pass urine develop after menopause? (stress incontinence connected with oestrogen deficiency)	I didn’t have any of these symptoms initially after going through menopause, they just seemed to creep up on me.
Eating habits and energy
Can you tell me about your diet?	Anita’s diet appears to be quite healthy, with plenty of fresh whole foods, although she snacks on sugary biscuits and lollies and has been drinking more tea and coffee recently.

TABLE 4.16 CORE

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
Tell me about your daily routine.	I usually get up around 6.30 and have breakfast. I get to work by 8 and get home around 5.30. I try to walk in the mornings, but recently I’ve felt too tired. Dinner is around 7.30 and I’m usually in bed by 10 or 10.30.
Occupation
Do you enjoy your work?	I love my work; the doctors and other staff at the medical centre are all great. It’s just that I feel this problem is too personal to share with work colleagues.
Family and friends
What about your family and friends?	I have a wonderful daughter and son-in-law. They have a little boy and another on the way. I really love spending time with them all. I have great friends and we often go out on the weekends or they come to my house and I cook for all of us.
Action needed to heal
How are you hoping I can help you?	I was hoping you might know what was wrong with me and what I could do about it. I suppose I need to stop eating all the biscuits and lollies and exercise more. If I had more energy I think I would get back to walking every morning.

TABLE 4.17 ANITA’S SIGNS AND SYMPTOMS [1–3]

Results of medical investigations

No medical tests have been carried out.

TABLE 4.18 UNLIKELY DIAGNOSTIC CONSIDERATIONS [4–8]

CONDITIONS AND CAUSES	WHY UNLIKELY
CANCER AND HEART DISEASE
Congestive heart failure: weight gain (need to determine if weight gain is due to fluid increase)	No protein in urine, no hypertension, extreme tachycardia, shortness of breath; changes in weight due to fluid usually occur suddenly
Systemic hypertension	Anita’s blood pressure is within normal range but in the ‘high’ normal end of the scale
OBSTRUCTION AND FOREIGN BODY
Renal calculi – hypercalcaemia	Most common causes are hyperparathyroidism, vitamin D ingestion and sarcoidosis
Renal calculi – hypercalciuria	Most common metabolic abnormality detected in calcium stone-formers; causes can be due to excess dietary intake of calcium, excess resorption of calcium from the skeleton in prolonged immobilisation, idiopathic reasons where there is an increased absorption of calcium from the gut; these conditions would usually present with alkaline urine (high pH)
FUNCTIONAL DISEASE
Primary renal diseases	Medullary sponge kidney, renal tubular acidoses
Female urethral syndrome: irritative bladder symptoms in the absence of urologic findings; pain in the urethra; can be a component of interstitial cystitis; usually does not present with blood in the urine; urinalysis usually detects no bacteria; fever is usually not present	Will experience pain on urination, increased frequency, pelvic pain, associated with sexual activity; onset of symptoms over 2–7 days; level of urinary urgency not noted yet in Anita’s history; female urethral syndrome does not necessarily have nocturia as a symptom
Paget’s disease	Rapid bone remodelling causing calcium excess
DEGENERATIVE AND DEFICIENCY
Osteoporosis	Lower back pain, rapid bone remodelling causing calcium excess
Osteomalacia	Buffering of H⁺ by Ca²⁺ in bone resulting in depletion of calcium from bone; excess calcium excretion can develop
INFECTION AND INFLAMMATION
Interstitial cystitis: painful bladder syndrome; middle aged, marked frequency, nocturia	No significant recurrent pain on urination and pelvic pain reported
Glomerulonephritis (advanced kidney infection): common in diabetes due to diabetic nephropathy	Would show protein in the urine and possible macrocytic blood; low specific gravity, and would present often with high blood pressure and high fever
SUPPLEMENTS AND SIDE EFFECTS OF MEDICATION
*Causal factor:* Lithium intake	Lithium can cause hypercalcaemia
*Causal factor:* Vitamin D intoxication	Can cause excess calcium levels due to producing excess bone resorption
ENDOCRINE/REPRODUCTIVE
Primary parahyperthyroidism	Caused by single or multiple adenomas or by hyperplasia of the parathyroid gland, or compensatory response due to renal failure or vitamin D deficiency
Hyperthyroidism	Excess calcium

Case analysis

TABLE 4.19 POSSIBLE DIFFERENTIAL DIAGNOSIS

NOT RULED OUT BY TESTS/INVESTIGATIONS ALREADY DONE [2, 4–8]
CONDITIONS AND CAUSES	WHY POSSIBLE	WHY UNLIKELY
FAMILY HEALTH
Rare genetic causes of type 2 diabetes: insulin receptor mutations, maternally inherited diabetes and deafness, Wolfram syndrome, severe obesity and diabetes, disorders of intracellular insulin signalling	Weight gain, insulin resistance, glucose in urine, visual disturbances	No skin pigmentation, no deafness, usually occurs in younger age group; no significant mental deficiencies are evident
ALLERGIES AND IRRITANTS
Food intolerance/allergy	Fatigue, potential recent dietary change with eating more sugar since feeling low; may be eating foods she did not previously; itchy skin [50]	Need to gain more insight into Anita’s previous and current diet and associated symptoms
CANCER AND HEART DISEASE
Acromegaly/pituitary tumour	Glucose in urine; can develop diabetes; visual disturbance, tiredness, weight gain, increased urination, muscle weakness	No significant change in the size of the hands and feet or change in appearance mentioned; no goitre, excess sweating, headaches, deeper voice; no increase in body and facial hair, oedema
Bowel cancer/polyps	Blood on toilet paper	Need to determine if itching is associated with a lump or discharge
Pancreatic cancer/insulinomas	Sugar cravings, visual disturbances and weakness; can have recurrent hypoglycaemia for a long time before diagnosis	Need to determine whether Anita is experiencing double vision, sweating, palpitations, loss of concentration or seizures; symptoms are worse with fasting or exercise
Transient ischaemic attack [51]	Visual disturbance	Need to establish if blurred vision or double vision comes and goes and is associated with dizziness
Carotid atherosclerosis	Acute and painless loss of vision; more common in older age group	No hypertension or prior myocardial infarction; need to test blood lipids
High ‘normal’ blood pressure [52]	Leading to hypertension; risk factor for diabetes, cardiovascular and kidney conditions	Need to test several times to see if get the reading remains constant
TRAUMA AND PRE-EXISTING ILLNESS
Seasonal affective disorder	Secondary to the winter months; symptoms include tiredness, increased appetite, weight gain	Need to determine whether Anita has experienced episodes of depression during winter months in the past
OBSTRUCTION AND FOREIGN BODY
Renal calculi: primary hyperoxaluria, hyperuricaemia and hyperuriosuria, and cystinuria	Acidic urine, increased urination, increased thirst; increased risk of developing if Anita has diabetes	Back pain has not been reported as a predominant symptom; normal appetite
FUNCTIONAL DISEASE
Fibromyalgia	Tiredness, aching and weakness in body; more common in women	Need more specific information regarding the multiple sites of muscle pain
Ophthalamic migraine	Visual disturbances, prodromal migraine symptoms without developing the migraine headache
Obesity [46, 52]	Anita’s BMI is 32 and waist circumference is 109 cm; increased caloric intake, eating more sugar, increased appetite and lack of exercise; usually general distribution of weight gain can cause increased fatigue	Usually no other health features other than being overweight; need to determine whether there is any family history of obesity; need to determine whether Anita’s weight gain has been gradual and if there is any oedema present (which is unusual for obesity without a cardiovascular condition)
Eye conditions of older adults: cataracts, glaucoma, senile macular degeneration, drug side effects, dry eyes [47, 48]	Visual changes	Need to establish if Anita experiences significant visual blurring; are the visual changes unilateral or happening in both eyes; is the visual disturbance constant or does it come and go; does Anita have visual field loss or see halos around objects
Obstructive sleep apnoea	Feels tired; often occurs in those who are overweight; can be made worse with drinking alcohol prior to sleeping; does not usually complain of ‘sleepiness’ but rather fatigue generally	Need to determine if Anita does not feel not well rested in the morning and if she snores during the night
Nocturnal polyuria syndrome	Nocturia and increased volume of urine; common in older people from conditions such as diabetes, heart disease and from certain medications
Anal fissures Haemorrhoids Anal skin tags

Blood on toilet paper; itchy rectum Need to determine whether stools with blood may be secondary to inflammatory bowel disease; need to determine if the itching is associated with a discharge or if pain is experienced on passing a bowel motion INFECTION AND INFLAMMATION Chronic pancreatitis Glucose in urine, diabetes can be a complication of chronic pancreatitis No jaundice, abdominal pain or mucus in stools Ischaemic colitis Blood from rectum; usually occurs in older people; may have underlying cardiovascular disease (CVD) Abdominal pain; usually presents suddenly Candidiasis (moniliasis, Candida albicans) Itchy bottom, having sweet cravings; common in diabetes Need to determine if Anita experiences external pain or irritation on urination and whether there is vaginal discharge; more likely if she has taken antibiotics or other medication recently Recurrent cystitis (lower urinary tract infection/bladder infection) Increased urination at night; common due to diabetic neuropathy and bladder dysfunction; acidic urine can indicate infection/bacteria These symptoms not present at this stage: painful passing of urine, blood in urine, smelly urine, exacerbated by sexual intercourse, high temperature; symptoms develop quickly; recurrent same symptoms; urinalysis nitrates, leukocytes (pyuria), blood, foul odour to urine; pain on urination with pus (pyuria) in urine is diagnostic for cystitis Parasites/infestations: scabies, lice, pinworms Itchiness in rectum; no associated discharge Need to determine if itching is worse at night and associated with a rash and excoriation (scabies, lice) or if it is worse in morning (pinworm) SUPPLEMENTS AND SIDE EFFECTS OF MEDICATION Medication/recreational drug reaction Can get symptoms of thrush, increased weight due to increased appetite; increased fatigue and sugar cravings; visual changes; contribute to dysbiosis of the bowel to cause fungal overgrowth Need to determine if Anita has recently taken antibiotics (resulting in overgrowth of fungi), laxatives, antihypertensives, NSAIDs, steroids, antihypertensives, antidepressants, lithium or oestrogens; need to establish if weight gain has a basis of fluid retention; psychotropic drugs can cause an increase in craving for carbohydrates; propranolol may cause weight gain due to hypoglycaemia; quitting smoking can increase weight gain; increased alcohol intake causes increased caloric intake and risk of weight gain due to fluid increase, liver and heart conditions; anticholinergic, antihypertensive and psychotropic agents cause blurred vision and defects in accommodation of the vision; chronic corticosteroid use can cause cataract formation and visual blurring; antihistamines decrease tear production and cause hot, dry eyes; chocolate and red wine can provoke migraine visual prodromal symptoms; hormone replacement therapy (HRT) can cause dry eyes ENDOCRINE/REPRODUCTIVE Asymptomatic diabetes/renal glycosuria: inherited low renal threshold for glucose Glucose in urine Requires further investigation to identify causes for glucose detected in urine; usually no other symptoms of ill-health present Diabetes mellitus: non-insulin dependent diabetes (NIDDM) [52] Glucose in urine, weight gain, sugar craving, increased thirst, frequent urination during the evening, eyesight worsening, pruritis ani, fatigue, muscle weakness; Anita is in the common age group for NIDDM to develop Need to determine if Anita’s muscle weakness is proximal (upper arms, shoulders, legs) or distal (fingers and feet) and there is clawing of the toes; need to determine whether she is experiencing numbness and tingling in the toes and fingers (common in diabetes) Cushing’s syndrome Glucose in urine, weight gain, muscle weakness; could have diabetes Usually accompanied by increased body and facial hair, hypertension, moon-shaped face, ‘buffalo hump’, acne, oedema; Anita has not reported pain on urination Hypothyroidism Fatigue, weight gain, aches and feeling weak; itchy skin [50] Usually associated with a decrease in appetite, dry and coarse skin and hair, loss of eyebrows, low hoarse voice, goitre, puffy skin and face; need to establish if Anita is intolerant to cold weather; no significant constipation reported Diabetic eye conditions: refractive errors, diabetic retinopathy, oculomotor palsies (rare) [47, 49] Increased urination, increased thirst, nocturia, eyesight worsening Need to determine whether Anita experiences impaired night vision, visual field loss with blurred vision; need to determine if Anita’s visual changes were sudden and occurred in both eyes Impaired glucose tolerance (IGT) [52, 53, 56] Risk factor for future development of diabetes; weight gain and lack of exercise Do not develop eye complications as is the case with diabetes; can be due to liver disease or taking certain medications; can be pre-diabetic state where there is a mild impairment to glucose metabolism Impaired fasting glucose (IFG) [53] Risk factor for future development of diabetes and CVD STRESS AND NEUROLOGICAL DISEASE Type 2 – minor depression Anita would need to show 2–4 symptoms of depression that have lasted 2 weeks; can be mild or moderate depression; significant change in appetite nearly every day with weight gain; fatigue or loss of energy nearly every day; may eat excessively when feeling depressed and celebrate with people with good food and alcohol to alleviate depression Need to establish if Anita is as happy living on her own as she expresses; are there underlying fears, concerns or sadness she experiences that may affect her appetite? Neurologic disease: multiple sclerosis (MS), spinal cord injury, cauda equina syndrome, brain tumour

Visual disturbances; symptoms of lower urinary tract symptoms; more common in women; increased urination, nocturia; weakness or tingling in lower limbs

Usually advanced stages of MS; no significant trauma or injury mentioned in health history so far; need to define if the visual disturbance comes and goes; visual disturbance prior to MS is usually unilateral and caused by optic neuritis; need to establish if Anita has double vision; need to establish if Anita has central vision defects (brain tumour and aneurysm)

TABLE 4.20 DECISION TABLE FOR REFERRAL [4–8,11,12]

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
• Glucose detected in urinalysis • Anita is experiencing a persistent increase in passing urine	• Blood when passing stools • Blood pressure on the high side of the normal scale • Acidic urine can indicate urinary tract infections or renal stones, which can be very problematic for diabetes • BMI is on the obese scale • Dehydration • Visual changes • Pruritis ani, which may be related to intestinal dysbiosis resulting from hyperglycaemia or from haemorrhoids	• Unwillingness to seek medical assistance due to embarrassment • Fear of losing her eyesight preventing Anita from seeking assistance from an optometrist or ophthalmologist
ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE	ISSUES OF SIGNIFICANCE
Nil	• Extreme fatigue and muscle aches • Increased consumption of sugar • Increased consumption of tea and coffee	• Lives alone
REFERRAL	REFERRAL	REFERRAL
• Referral for medical assessment and management	• Refer for medical opinion re: blood from rectum • Blood pressure needs to be monitored • Dietary assessment • Musculoskeletal assessment • Referral to optometrist [45, 49]	• Referral to optometrist and ophthalmologist • Referral to a new GP (who is not known to Anita) for further medical investigations or counselling

TABLE 4.21 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1–8]

TEST/INVESTIGATION	REASON FOR TEST/INVESTIGATION
FIRST-LINE INVESTIGATIONS:
Random blood glucose test [54, 55]	< 5.3 mmol/L diabetes unlikely; if between 5.3 and 11.1 further investigation with fasting blood glucose is necessary
Fasting blood glucose test [54, 55]	Can differentiate between diabetes, impaired fasting glycaemia (IFG) and impaired glucose tolerance (IGT); raised levels can indicate diabetes mellitus, Cushing’s disease, acromegaly, pancreatic cancer, pancreatitis, drug therapy or acute stress response; decreased levels can indicate hypothyroidism, hypopituitarism, Addison’s disease, liver disease
Full blood count	Anaemia, inflammation, infection, tumour
Blood lipids	Carotid atherosclerosis, cardiovascular risk, blood cholesterol
CRP (C-reactive protein) [56], ESR	Infection, cancer, inflammation, temporal arteritis
Kidney function: 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
Eye tests: visual	Looking through a pinhole will improve vision if caused by a refractive error and shows that retinal function is good; if double vision is improved by holding one eye, it may be due to paralysis or a weakness of the extraocular muscles of the eye (causes can be neuropathy, MS, thyroid disease, diabetes, trauma, tumour or aneurysm); if increasing illumination improves the vision then a cataract is suspected; if dimming the lights or looking beside the object improves vision then macular degeneration is probable; early changes in diabetic neuropathy include microaneurysms/haemorrhages in the eye, changes in the blood-retinal barrier, capillary closure, neuronal and glial cell changes in the retina [45, 49]
Snellen chart	Visual acuity
Relative afferent pupillary defect (RAPD): the client looks into distance while a light is shone in one eye, causing a papillary constriction in that eye and should cause simultaneous constriction in the pupil of the adjacent eye; the light is quickly moved in front of the other pupil to constrict the eye further; if the pupil dilates instead, RAPD is present	RAPD is present in optic nerve disease, chronic glaucoma and retinal damage; absent in macular degeneration and cataracts; no eye inflammation or RAPD (cataracts, vitreous opacities, macular degeneration); if there is white eye and RAPD (chronic glaucoma)
Funduscopic examination	Senile macular degeneration, diabetic retinopathy
Stool test	Occult blood, parasites
Rectal examination	Haemorrhoids
IF NECESSARY:
Endoscopy	Rule out rectal carcinoma, polyps, haemorrhoids
Blood cortisol levels	Cushing’s syndrome
Thyroid function test	Hypothyroidism: TSH, T4, T3 TSH: high T4: low in hypothyroidism
Growth hormone levels	Acromegaly, pituitary tumour
Liver function test	Alcohol abuse, cirrhosis, hepatitis
Sleep centre: polysomnogram	Sleep apnoea
Musculoskeletal asssesment	Fibromyalgia
MRI: brain scan	Brain tumour

Confirmed diagnosis

Anita and diabetes mellitus (non-insulin dependent) and haemorrhoids

Anita is a 58-year-old woman who has developed myriad symptoms. Anita has been experiencing symptoms of pruritus ani (itchy bottom), feeling sluggish, weight gain, increased sugar cravings, nocturia, blood on the toilet paper after passing a bowel motion, increased appetite and thirst, general fatigue and weakness in her body. Anita works as a medical secretary and is embarrassed to share her health concerns with the doctors she works for. In her personal life, Anita enjoys living on her own and having time to socialise with friends where she can entertain and cook meals at home. Another passion of Anita’s is reading books in her spare time. She is currently very concerned about deteriorating eyesight and she is experiencing anxiety about having the cause professionally diagnosed in case she receives a negative prognosis.

Anita has developed several symptoms that are common in non-insulin dependent diabetes mellitus (NIDDM) such as: increased appetite; unexplained fatigue and weakness; pruritus ani and/or vulvovaginitis; and blurred vision [49, 50, 52]. The condition is a secondary form of diabetes where insulin resistance develops over time and may present as subclinical for several years before diagnosis is made. The incidence increases with age and obesity, lack of exercise and can be accelerated by stress, pregnancy and drug treatments. NIDDM is a condition of impaired insulin response to glucose concentration. Complications of type 2 diabetes extend to hypertension, obesity, decreased HDL blood lipids, diabetic neuropathy, retinopathy and nephropathy [47–49]. Both insulin resistance and insulin secretory failure are involved in type 2 diabetes. This will develop over time when a person cannot secrete enough insulin to overcome the dysfunction with insulin uptake. Whether type 2 diabetes is likely to develop is considered to be influenced significantly by genetics; however, when the condition develops it is more commonly due to lifestyle circumstances.

Haemorrhoids are a secondary complication of diabetes that can cause rectal bleeding and itchinesss. Often the person with haemorrhoids will notice red blood on the toilet paper and perhaps blood around the outside of the stools. Haemorrhoids are the most common cause of rectal bleeding.

General references used in this diagnosis: 2, 4–9, 57

Prescribed medication

• Oral hypoglycaemic medication

TABLE 4.22 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
• Lifestyle recommendations to improve glucose control and insulin sensitivity and self-monitoring of blood glucose to assist with glucose control • Dietary recommendations to reduce blood glucose levels, reduce insulin resistance and improve glucose control • Herbal tonic, tea and nutritional supplements to reduce blood glucose levels, reduce insulin resistance and improve glucose control • Herbal and nutritional therapy to improve vascular integrity, microcirculation and retinal health NB: Collaborative management of Anita’s case is essential to ensure her condition is properly monitored and to ensure any potential interactions between herbal or nutritional treatments and prescribed medication are managed

• Lifestyle recommendations to enhance health and wellbeing and reduce risk factors for CVD and other diabetic complications

• Dietary recommendations to increase dietary intake of antioxidants and essential nutrients to enhance health and wellbeing and reduce risk factors for CVD and other diabetic complications

• Dietary recommendations and nutritional supplements to improve vascular integrity and support eye health

• Dietary recommendations to support normal intestinal microflora and assists with managing haemorrhoids

• Recommendation that Anita finds a medical practitioner from another practice to help reduce her embarrassment

• Recommend Anita immediately seeks assistance from an ophthalmologist

• To increase foods containing bioflavanoids and anthocyanins to support eye health

Treatment aims

• Bring Anita’s blood glucose levels as close as possible to normal range [13, 14].

• Help Anita to lose weight to bring her back into a normal BMI range [13–15] and increase skeletal muscle mass to improve glycaemic control [15].

• Prevent progression of the disease and protect Anita from long-term complications [13, 14].

• Institute dietary measures to keep Anita’s blood glucose within normal range [14, 15].

• Improve insulin function and sensitivity [13, 14, 21].

• Aim for optimal nutritional status [15, 21] and prevent nutritional and oxidative stress [14, 21].

• Institute lifestyle practices that will improve Anita’s overall health and fitness, improve insulin sensitivity, maintain a healthy weight and prevent progression and long-term complications of diabetes [15].

• Identify and manage any other conditions or existing complications (e.g. haemorrhoids).

Lifestyle alterations/considerations

• Anita would benefit from a weight-loss program to help her achieve her ideal body weight [13–15].

• Encourage Anita to exercise daily [13, 14, 16]. Exercise improves glycaemic control and insulin resistance [16]. Her exercise regimen should involve both strength training and aerobic exercise [16] and the aim of the program should be to reduce body fat and improve skeletal muscle mass and strength, improving glycaemic control [16].

• Encourage Anita to seek assistance from an ophthalmologist as soon as possible.

• Encourage Anita to self-monitor her blood glucose levels to help her improve blood glucose control [27].

• Suggest Anita removes the lollies and biscuits from her work area [14, 21].

Dietary suggestions

• Encourage Anita to have a low GI/GL diet [13, 15, 21]. She should focus on eating foods with a GI of less then 55 [13] and fibre-rich whole foods such as apples, grapefruit, legumes, onions and garlic, dense grainy breads and wholegrain cereals such as whole oats [13, 14, 21]. This is similar to a Mediterranean-style diet, which can postpone the need for oral hypoglycaemic medication in newly diagnosed type 2 diabetics [30].

• Eliminate simple sugars, processed and concentrated carbohydrates [14, 21].

• Increase consumption of fibre, particularly soluble fibre to at least 40 g daily [13, 15, 21]. Soluble fibre can reduce postprandial glucose, lower cholesterol, enhance glycaemic control and reduce insulin [14, 15]. Good sources of soluble fibre include vegetables, oats, wholegrain rice and legumes [13, 14]. Dietary fibre is also beneficial in the management of haemorrhoids [13] and inulin and FOS in dietary fibre from vegetables and fruit positively influences gastrointestinal microbial ecology [25].

• Reduce consumption of saturated fat [13, 14] and increase consumption of omega- 3-rich foods and monounsaturated fats [13, 15, 21].

• Encourage Anita to eat antioxidant-rich foods containing B-group vitamins and vitamins C and E [13, 15, 21].

• Encourage Anita to eat low-GI bioflavonoid and anthocyanin-rich foods such as blueberries, strawberries, raspberries, blackberries, citrus fruit and onions [13, 15, 21]. Bioflavanoids and anthocyanins have antioxidant and anti-inflammatory properties [13, 15, 17, 22] and are beneficial to prevent and treat diabetic retinopathy [15, 17, 22]. Anthocyanins from blueberries also enhance microcirculation and improve visual function [17, 13]. Flavonoids and anthocyanins are also beneficial in the management of haemorrhoids [17, 22, 13].

• Encourage Anita to consume foods rich in the minerals zinc, chromium, potassium, magnesium and vanadium, which are essential for blood-sugar balance [13, 15, 21].

• 50–100 mL bitter melon juice containing 100 g fruit per 100 mL can reduce fasting and postprandial glucose levels [17].

• Including cinnamon regularly in the diet can help lower postprandial glucose response [24, 44].

• Encourage Anita to reduce the amount of tea and coffee she is consuming; she should drink water instead. Tea and coffee can inhibit absorption of essential nutrients, especially when consumed with or close to meals [26].

Physical treatment suggestions

• Anita may benefit from massage therapy. Some studies have demonstrated massage may have a positive effect on blood glucose levels and be helpful with diabetic retinopathy [28].

• Hydrotherapy: neutral sitz baths for pruritus ani [39]. Full body cold mitten friction to stimulate circulation [39]. Alternating warm/cool contrast foot baths (note: hot or icy cold applications contraindicated due to peripheral neuropathy in diabetes) [40]. A hot apple cider vinegar and water compress on the abdomen for bloating [41]. Alternating warm and cool compress on the eyes to strengthen and tone [40, 41]. Constitutional hydrotherapy for fatigue [42]. Increase energy by running the arms, wrists and ankles under cool water [40, 41]. A short, cool head shower for fatigue [40].

• Acupuncture may be beneficial to Anita because it may help improve symptoms associated with diabetic neuropathy [29].

TABLE 4.23 HERBAL FORMULA (1:2 LIQUID EXTRACTS)

Made with ethanolic extract herbal liquids (alcohol removed)
HERB	FORMULA	RATIONALE
Gymnema Gymnema sylvestre	100 mL	Hypoglycaemic [17, 18]; antidiabetic [17, 18]; hypocholesterolaemic [17, 18]; improves glucose control [15, 17]; suppresses sweet taste perception [15, 17] and aids fat loss [17]; may assist in the development of a higher muscle to fat ratio [18]
Fenugreek seed Trigonella foenum-graecum	60 mL	Hypoglycaemic [17, 19]; hypocholesterolaemic [17, 19]; improves glucose tolerance [15, 17]; improves insulin resistance [17] and improves insulin sensitivity [15, 17]
Ginkgo Ginkgo biloba	40 mL	Antioxidant [17, 20]; increases blood flow, tissue oxygenation and tissue nutrition [20]; increases ocular and cerebral blood flow [17, 20]; helpful to assist with prevention of vascular, neurological and ophthalmologic complications [17, 20]; indicated for the treatment of haemorrhoids [17, 13]
Supply:	200 mL	Dose: 5 mL 3 times daily
Bilberry (Vaccinium myrtillius): vasoprotective [17, 20]; antioxidant [17, 20]; hypoglycaemic [17]; indicated for peripheral vascular disorders [20]; beneficial in a range of ophthalmic conditions [17, 20] and can be used to help prevent and treat diabetic retinopathy [14, 17, 20]; beneficial for haemorrhoids [17, 13] Dose: 20–50 g of fresh fruit daily or extract in tablet or capsule containing 150 mg anthocyanins daily [17]

TABLE 4.24 HERBAL TEA

Alternative to black tea and coffee
HERB	FORMULA	RATIONALE
Green tea leaves Camellia sinensis	2 parts	Antioxidant [17, 32, 34]; has an antidiabetic effect [17, 35, 36]; reduces oxidative stress in diabetes [36]; protects against CVD [17, 32, 34]; thermogenic [17, 32, 33]; may be beneficial to aid weight loss [17, 33]
Phyllanthus Phyllanthus amarus	2 parts	Hypoglycaemic [18, 37]; antioxidant [37]; indicated for use in type 2 diabetes [18, 37]
Cinnamon bark powder Cinnamomum cassia	½ part	Antioxidant [17]; glucose-lowering effect [17, 44]; improves glucose control and lipid levels in type 2 diabetes [38]; antifungal [17, 31]
Infusion: 1 tsp per cup – 1 cup 3–4 times daily NB: In order to ensure optimal absorption of nutritional supplements, Anita should not take supplements with or within 2 hours of drinking her tea formula [17]

TABLE 4.25 NUTRITIONAL SUPPLEMENTS

SUPPLEMENT AND DOSE	RATIONALE
Alpha-lipoic acid 600 µg daily in divided doses [13, 22]	Antioxidant [15, 21, 22]; decreases oxidative stress [21, 22]; improves insulin sensitivity [15, 21, 22]; enhances glucose transport [21, 22]; used for treatment of diabetic neuropathy [13, 15, 21, 22]
Chromium 200 µg daily [13, 21, 22]	Enhances the effects of insulin [22, 23]; reduces skeletal muscle insulin resistance [13, 21]; improves glucose control [13, 22, 23]
Magnesium 400 mg elemental magnesium daily	Magnesium deficiency aggravates insulin resistance [13, 17, 23]; supplemental magnesium improves glucose tolerance [23], metabolism [15, 23] and insulin sensitivity [17, 22, 23]
High-potency practitioner-strength vitamin, mineral and antioxidant supplement providing therapeutic doses of essential micronutrients [15, 21]	To increase Anita’s essential nutrient and antioxidant levels and to reduce oxidative stress [14, 15, 21]; supplemental multivitamins can reduce the incidence of infection and enhance quality of life in diabetes [43]
Omega-3 fish oil 1000 mg 3 times daily [15, 17, 21]	Anti-inflammatory [13, 17, 22]; lowers triglycerides [17, 22]; lowers LDL [17, 22]; supplementation reduces triglyceride levels in type 2 diabetes [13, 17]
Vitamin E 500 IU daily [15, 21, 17]	Lipid antioxidant [13, 23, 17]; reduces oxidative stress in diabetics [23, 17]; supplementation can help reduce vascular complications [13, 21]; improves retinal blood flow [15, 21]; improves insulin action [13, 21]; decreases diabetic retinopathy [15, 21]; improves kidney function [15]; decreases C-reactive protein [13, 15]