Donal Collins Hyperinsulinemia Case Study 2021
Personalia
Mary is 30 and has waist circumference 120cm, her weight is 117kg and height 172cm.
History
Mary has experienced a slowly increasing waist circumference since her early teenage years. She has always noticed that her hunger seems to be more pronounced than those around her. She learned from dietitians that eating complex carbohydrates and more frequently would help control her hunger.
More recently she settled into a big bowl of porridge with fruit and bananas to get on top of hunger early. At 11 o’clock she had tea with a healthy breakfast biscuit (meaning that it was advertised as “Healthy”). Lunch would be pasta or rice with mayonnaise and variety of meats or fish. Sandwich around 4 pm. Then dinner with baked potatoes/rice and pudding. And sometimes to finish off the day, hot chocolate and small slice of cake before bed. This was “all in moderation and mostly aligned with our healthy eating pyramid”.
Medical File
No known medical conditions mentioned. Mary has been trying to become pregnant for last year. She has been feeling tired of late, but reassured by her GP that recent blood tests were normal. She did not know the actual numbers of the tests, but was reassured she did not have diabetes and her “cholesterol” was “ok”. She was told that she did not have to change anything, other than eat less and move more to lose a bit of weight.
In our current paradigm, if HbA1C and total cholesterol are normal, then most NHS GPS would not be concerned about this. This is not a criticism but a recognition of the current protocol and reality. Before I recently commenced my own research into metabolic health, I did not know what to do with the rising triglyceride epidemic, and a rising abnormal liver function test epidemic.
Previously I would have just advised patients to eat less, move more, and reduce alcohol. If this failed then send to hepatology clinic, and repeat triglycerides in 6 months.
Presentation
Issue: Mary was feeling tired and she had heard there were some metabolic tests that could give her more information about her health status.
Patient Objectives: She wants to have more energy and wishes to become pregnant soon.
Diagnostics
75g Glucose Kraft Curve
https://humanalyse.com/dashboard/snapshot/L6fe72RnPU3hPFsrYV1A01uV5ueKV8ou
The response curve at this link is a classic case of what Kraft called occult diabetes with normal Glucose - following OGTT of 75g glucose. This is one of the most important use cases of insulin measurement to screen for pre-clinical diabetes to allow for early intervention.
Management
After discussion and realization of high levels of insulin following a glucose challenge. We discussed what insulin resistance is and how it can manifest.
We agreed to cut out all rapidly absorbing carbohydrates and processed foods.
For example, switch to cheesy omelette for breakfast, put some cream in coffee. This will help kill the hunger by having little effect on insulin, which means satiety hormones will work.
For lunch dinner to eat “whole” foods and meat/fish as it comes from butcher/fishmonger (so as little processing as possible).
Metabolic Science Opinion – Gabor Erdosi
A typical case of following bad dietary advice. When put on the quick-absorbing carb roller-coaster, hunger is back after the mild hypoglycemia, which predictably follows the surge in insulin, at around 120 minutes. Research has shown that the glucose drop coincides with a surge in ghrelin, the ‘hunger hormone’, and the brain perceives this combination, but not either one separately, as a danger signal and hunger ensues.
Graph Analysis
In this case, as shown by the graph, there is no pronounced drop in blood glucose. Perhaps larger BG fluctuation could be observed with more frequent sampling. The insulinemia required to keep BG in the normal range is apparently high. In high carbohydrate feeding scenarios, one of the first processes to become unresponsive is insulin clearance in the liver and therefore a higher systemic insulin concentration. To including C-Peptide measurements could provide good hints at the relationship between insulin secretion and insulin clearance, and thereby of liver insulin resistance. If low clearance is confirmed, it could make sense to check for fatty liver as well. One of the markers that often correlates with a fatty, insulin resistant liver is triglycerides, both fasting and postprandial.
Management suggestions
Removing the worst dietary offenders, following a hunger suppressing food order and eliminating snacking usually works wonders.
