Vol.1 Issue 1
Dyslipidemia

CASE STUDY

HP is a 54-year old African American male who presents to the general medicine clinic for an insurance-mandated physical examination. He denies any complaints.

Past Medical History
30-year history of bronchial asthma that is relieved with prn inhaled bronchodilators.

Lifestyle History
Drinks ~2 cans of beer daily
Denies current or previous drug use
Smoked 2 packs of cigarettes/day from age 15 to age 40
Eats "junk food and lots of sweets"; eats few fruits, vegetables, or whole grains
Sedentary lifestyle, rarely exercises

Family History
Mother: 87 years old with type 2 diabetes and hypertension
Father: died at age 63 d/t myocardial infarction
Siblings: 2 sisters, aged 48 & 51, alive & well

Medications
Albuterol inhaler prn
Acetaminophen prn

Physical Assessment Data
Height: 69 inches
Weight: 225 lbs.
Pulse: 90
BP: 136/90
Review of systems all WNL

Fasting Chemistry Values
Glucose: 122 mg/dL
Cholesterol
    Total: 240 mg/dL
    HDL: 32 mg/dL
    LDL: 166 mg/dL
Triglycerides: 210 mg/dL

Moderator: Dr. Braun, as a conventional Western practitioner, how would you manage this patient’s dyslipidemia?

Dr. Braun: When managing dyslipidemia, I evaluate all risk factors and follow the current ATP III clinical guidelines. According to the ATP III guidelines, HP has the following risk factors: elevated LDL cholesterol, low HDL, hypertension, and age.

HP’s 10-year risk for CHD is 12%. For patients with > two risk factors and 10-year risk of 10-20%, drug therapy should be considered when LDL > 130 mg/dL. For this reason, I would initiate both therapeutic lifestyle changes and low-dose statin therapy (e.g., simvastatin 10 mg daily) to lower the LDL to the goal of < 130 mg/dL.

HP also has metabolic syndrome, evidenced by his obesity (BMI is 33.2 kg/m2), elevated triglycerides, and elevated fasting glucose. Components of the metabolic syndrome respond well to therapeutic lifestyle changes (diet and increased physical activity). I would provide dietary counseling to reduce intake of saturated fat and cholesterol, to restrict calories for weight loss, and to limit carbohydrate intake (sweets, pasta, bread, rice, etc.), since triglycerides are elevated. I would also ask him to eliminate daily intake of beer to reduce triglycerides. I would advise to begin a daily walking program with a goal of 3-4 miles in 1 hour.

Dr. Lo: This patient has two main problems. First, he has dyslipidemia which reflects an imbalance between the Liver-Gall Bladder and Spleen-Pancreas. Second, he’s at risk for diabetes mellitus, which is classified as "Xiao Ke" disease (thirsting and wasting). The principal organs involved in these problems may include the Lungs, Spleen-Pancreas, and the Kidney. When the Lungs are involved, the main symptoms include thirst and dryness. Spleen-Pancreas symptoms include sweet/carbohydrate cravings, fatigue, digestive dysfunction, anemia, and immune dysfunction. Kidney symptoms include urinary frequency, nocturia, low back pain, head hair loss, sexual dysfunction, and peripheral neuropathy of the feet. If the functional energy (Qi) of the Kidney is depleted then cardiac symptoms may arise including palpitations, chest pain, exertional shortness of breath, angina, and coronary artery disease. If the patient were questioned carefully, he would state that he had many of these symptoms.

My suggestions would include dietary modifications, including eliminating all refined sugar, processed flours, and deep fried foods. He also needs to increase his intake of vegetables, especially green cooked vegetables, such as chard, kale, dandelion greens, and mustard greens. Drinking green tea will lower his cholesterol and promote weight loss.

I agree with Dr. Braun that he should begin aerobic activity, but I would also recommend that he begin a program of stretching (yoga or tai chi) and Qigong, which can help manage his hypertension.

I would recommend herbal supplements, including Hawthorne berry to normalize lipids, lower blood pressure, and improve cardiac function. Liver detoxification may be helpful and can be achieved by using milk thistle, dandelion root, bupleurum, and N-acetyl cysteine. I would also consider chromium picolinate to balance sugar metabolism and decrease cravings for sweets.

Finally, I would perform acupuncture to balance organ function. Points that would be targeted include Large intestine 4 and 11; Gall bladder 34 and 41; Liver 2, 3, and 8; Stomach 36; Spleen 6; and Pericardium 6.

Moderator: Dr. Reynes, we’ve heard some seemingly disparate approaches to the management of this patient. How can both of these approaches be utilized in a model of integrative care?

Dr. Reynes: The first step is to make a list of all the problems and then look for the underlying dysfunctions or imbalances that can tie the problems together. In this case, our patient has the following problems:

1. Possible diabetes mellitus

2. High total cholesterol

3. Low HDL

4. High triglycerides

5. Obesity

6. Bronchial asthma

I would then identify his risk factors:

1. Poor diet

2. Sedentary life style

3. Family history of diabetes

4. Daily alcohol

HP appears to have a genetic disposition for insulin resistance and his lifestyle may encourage the expression of that gene. In order to manage his dyslipidemia, which is a manifestation of his insulin resistance, we need to improve the function of his insulin. First, I would target his diet. I would encourage him to follow a balanced low glycemic diet. He needs adequate protein with the right kind of fats, such as omega 3 fatty acids, which have been shown to improve the function of insulin receptors. I would encourage him to spread out his calories over several small meals. He also needs to increase his intake of fruits and vegetable, as the flavonoids will help lower his risk of heart disease.

I would next look for deficiencies which may be causing or exacerbating his insulin resistance. Many people with this condition are deficient in chromium, zinc or magnesium. I would do a hair mineral analysis to confirm this and would perform follow up hair testing to monitor his progress. If he shows evidence of deficiency, I would give him supplemental minerals. Typically patients need 600mcg to 1000mcg of chromium, 30-50mg of zinc, 400mg of magnesium daily.

I would recommend that he take a multivitamin with minerals, as well as supplemental vitamin C and E. I agree with Dr. Lo regarding the benefits of omega 3 fatty acids, and would recommend EPA/DHA in the form of fish oil capsules.

Next, I would consider using herbs. The herbs that appear to show the best benefits for insulin resistance and diabetes are Milk Thistle (silymarin), Bitter melon, Fenugreek, gymnemna sylvestre, and garlic.

I would also stress the importance of exercise as a way of improving insulin function. He should start with a daily walking program.

Finally I would ask him to stop drinking alcohol, and I would address any potential stressors in his life and explore ways to adaptively manage those stressors.

It’s important for the patient to understand that he is at high risk for developing hypertension and heart disease if he doesn’t modify his lifestyle. He may also be at a higher risk for cancer, since some studies have suggested that elevated levels of insulin cause cancer. It is also interesting to note that even his asthma may be related to his insulin resistance/dyslipidemia, so I would expect his asthma to improve or resolve with this program.

Dr. Braun: Despite the differences in our approaches, I see some common ground. We all agree that HP has several characteristics of metabolic syndrome, which typically respond well to lifestyle changes. If lifestyle changes were unsuccessful in lowering triglycerides, I would concur that marine oil capsules would be beneficial. However, I would not elect to use antioxidant vitamins for cardioprotection, since current research disputes this notion. The Heart Protection Study, performed in over 20,000 "high risk" men and women of all ages in Great Britain, showed no difference in cardiovascular events and mortality with antioxidant vitamins. However, treatment with simvastatin 40 mg significantly reduced events and mortality. The unique point of this study was that it didn't matter what the baseline LDL level was. Even subjects with an LDL level < 130 mg/dL had a significant risk reduction from drug therapy. This study may be influential in lowering our LDL target levels, plus it adds to the information we have about other benefits to statin therapy besides LDL lowering, e.g., plaque stabilization.

Dr. Lo: I believe that it must be emphasized that lifestyle changes are the critical factors, not medical intervention with drugs. Drug therapy for hyperlipidemia is a "lifetime" treatment that creates huge profits for drug companies that may undermine other treatment options. For example, last year, the FDA banned the use of Chinese Red Yeast Rice (Monascus purpureus), a natural food product that contains HMG-coenzyme A reductase inhibitors, that’s proven to be effective in lowering total cholesterol, LDL and triglyceride levels. Patients should be totally informed about the risks of cholesterol drug therapy, including liver toxicity and death.

Dr. Reynes: I think that we all agree that this patient needs to understand the seriousness of his situation and that he needs to commit to a total program. The first step in this program is a commitment to a change in his diet and increased exercise. In that regard he will need proper instruction, coaching and close follow-up.

Whether to use natural remedies, conventional medicines, or combinations of both, will depend a great deal on patient adherence, as well as the results that can be attained with diet and exercise alone. Some patients who commit to proper diet and exercise are able to reverse the insulin resistance and improve all those parameters associated with insulin resistance (high blood pressure, elevated blood glucose low HDL and elevated triglycerides). However, others, though just as adherent, still do not reach their targets for weight, blood glucose or lipid levels. In these cases, I agree with Dr. Braun that statin use is indicated. I would also consider metformin, pioglitazone, or rosiglitazone if his fasting glucose climbs and persists above 126 mg/dL after using diet, exercise and appropriate supplements as discussed previously.