Case Study: Advanced Type 2 Diabetes

In early 2022 I was living in a small Mexican village. I was called into service on a number of occasions because there were few healthcare practitioners available, and a great need for individualized care. This is a case study of an elderly client with type 2 diabetes, and how the power of individualized, functional medicine was used to obtain real results.

In March of 2022, on a Friday evening I was having dinner at a local restaurant, when the owner, Elizabeth came up to me and asked me for assistance for her ailing mother, Angela. The home was upstairs and so within a few moments I was in her bedroom.

The situation was this: Angela is an 84-year old type 2 diabetic. She had her left leg amputated several years prior, due to diabetes complications. Presently, the family gathered around and explained to me that they were at a loss for what to do with Angela’s condition. They informed me that the doctor in the nearby village had prescribed 30 units of insulin to be given daily. However, upon giving her 20 units, her glucose had plummeted from 250 to 55. They then had to give her sugar water to bring her glucose back up. This situation was ongoing daily. One of the family members remarked that if he had given her the 30 units of insulin prescribed by the “best doctor in town” she would have died.

In addition to this, she was taking a blood pressure medication.

She is legally blind and she also has dementia, with a short term memory deficit.

Her appearance: Greenish yellow color, jaundice, cold, responsive but half awake.

I got hold of the latest blood work, which was done several days prior.

I entered her results into my TrueReport FBCA (functional blood chemistry analyzer) software. I built this clinical software tool as a way to analyze my client’s test results. It’s proven to be a game changer in cases like these. Below are screenshots for the FBCA of my client.

Here were some of the main findings:

Interpretation of Her Blood Test

Blood Sugar Handling, Kidney Function, Electrolyte Imbalance

There is a significant loss of blood sugar handling, as evidenced by both the high glucose and A1C values. There is advanced kidney disease as evidenced by significantly elevated creatinine, and BUN. She also presented with proteinuria in the urinalysis of 25mg/dl. There is marked anemia present, with a decreased red blood cell count and hemoglobin. The anemia is likely a secondary consequence of a loss of renal function because the kidneys regulate the synthesis of red blood cells via erythropoietin. There is a significant loss of cellular charge due to electrolyte imbalances. There is a marked hypochloremia, hyponatremia and hyperkalemia. These are likely also a consequence of advanced renal dysfunction.

Liver Function

Her liver function is more stable, with a slightly decreased albumin, and slight elevation of enzymes, AST, ALT and GGT. However the Lactate Dehydrogenase (LDH) is more than two times above the top of the reference range. Since LDH drives the reaction involved in the reversible conversion of lactate into pyruvate, the elevation may indicate an increase in glycolysis, a common finding in type 2 diabetes. There is evidence from the literature that an elevated LDH can be associated with increased free fatty acids (FFA’s), another common finding in diabetes. Given that the glucose is as high as it is, and the albumin is decreased somewhat, there’s a high probability her albumin is glycosylated. Since albumin carries most of the free fatty acids in plasma, the situation is critical because she would have a high oxidized to reduced albumin ratio. This equals severe oxidative stress.

Inflammatory Markers

There is a pronounced Lymphopenia and a significantly elevated neutrophil to lymphocyte ratio of 8.1. According to the literature, a neutrophil to lymphocyte ratio greater than 2.3 is strongly associated with diabetic nephropathy and diabetic complications. The decreased bilirubin value also indicates inflammation, as bilirubin is an important antioxidant in plasma. While there is no data on her level of Free Fatty Acids (FFA’s), these are expected to be elevated, because a) an elevated LDH corresponds to elevated FFA’s, b) Type 2 Diabetes is known to feature elevated FFA’s as a primary etiological factor, c) kidney disease involves the infiltration of FFA’s to the glomeruli, and these are associated with the degeneration of renal cells. When free fatty acids accumulate, there is an increased risk of mortality, vascular disease, thrombosis and numerous adverse events.

Blood Lipid Markers

The triglycerides are moderately elevated which is associated with Diabetes mellitus and may possibly implicate steatosis (fatty liver). LDL and Total Cholesterol values are not elevated. However, from a clinical point of view, I’m more concerned about her cholesterol values dropping too low, as this is strongly associated with increased morbidity in the elderly. Cholesterol possesses anti-inflammatory properties, and is actively engaged in lipid defense mechanisms at the cellular level.

Physiological & Therapeutic Objectives

These items represent my thought processes and the initial protocol at the time of my assessment. Because I was in a small, Mexican village with limited resources, I had limited access to nutraceutical products.

Stabilize glucose immediately and get off of the insulin as soon as possible. Insulin is potentially deadly for a type 2 diabetic. The issue at hand with diabetes mellitus has much more to do with a loss of GLUT signaling and the cellular loss of insulin receptor sensitivity. Giving insulin as a treatment does nothing to improve GLUT signaling (yet some evidence suggests insulin inhibits AMPK/GLUT). The roller coaster ride of insulin that the family was told to use by physicians, nearly caused her death on several occasions. Eliminate all sugars and carbohydrates. Change the diet to lower any sugar burden. The diet was changed to the following: 16-ounces of Very low carbohydrate, fresh, raw vegetable juice and smoothies (celery, romaine, parsley, asparagus, spinach) given twice daily along with 3 raw eggs (6 daily). Add additional fiber in the form of flax seeds for bowel function and microbiome modification.

Maximize antioxidant function to control the destructive effect of free fatty acids and inflammation. The following was immediately made actionable:

• Deploy the use of TUDCA (1,000mg daily), a bile acid with notable insulin receptor sensitizing and anti-inflammatory properties.
• N-acetyl cysteine (NAC): 2,000mg 2x daily (4,000mg daily)
• L-Carnitine Tartrate: 1,000mg 2x daily (2,000mg daily)
• CoQ10: 100mg 2x daily (200mg daily)
• L-Taurine: 500mg 2x daily (1,000mg daily)
• Fish Oil: EPA/DHA: 1,000mg daily

Stabilize Anemia. I did not use Iron to address anemia. Iron is a double-edged sword. In addition to its function as the formative basis of hemoglobin, iron is also a catalyst in many oxidative reactions, including in the formation of potent hydroxyl radicals via the Fenton reaction. The proven choice for even the most severe types of anemia is Testosterone applied topically at a low dose. The clinical efficacy of Testosterone androgel for anemia is unsurpassed from my experience, and it works immediately as evidenced by enhanced circulation, body temperature regulation, and immediate reduction of anemia symptoms. Testosterone is a regulatory steroidal hormone that controls the expression of both Hepcidin (which is the master regulator of iron homeostasis), and increases the expression of erythropoietin. I was able to obtain testosterone androgel over-the counter at a local pharmacy. The dose was conservative, about 1/5th of a sachet applied to the tibia, split twice daily.

Reduce inflammation. In addition to the use of NAC, Taurine, Carnitine, CoQ10, Testosterone and TUDCA, I was administering twice daily a Lipid Bound Sulfur formula. This was originally formulated by Emanuel Revici, MD as a Hydropersulfide compound. Hydropersulfides have recently been characterized as having stronger antioxidant actions than glutathione. Additionally given was magnesium thiosulfate, which is a negative valent form of sulfur that has proven clinically useful for kidney disease, controlling calcium dynamics, and reducing hypertension.

Additional magnesium supplementation was given daily. Magnesium acts as a catalyst for hundreds of enzymatic reactions, and the literature identifies the inverse relationship between ionized magnesium and triglycerides. Hence, if triglycerides are elevated, consider magnesium deficiency is present on some level.

Blood sugar finger prick testing was monitored 2-3x daily. Blood pressure was closely monitored twice daily. Symptoms were carefully monitored continuously.

Clinical Responses

Within 72 hours she was completely off of the insulin and her glucose began to stabilize, coming down consistently under 140, even post prandial. No doubt, the change in diet and the addition of TUDCA, magnesium and Carnitine were very important for this aspect. Blood sugar spikes did not occur. Within 3 days, her symptoms of anemia were markedly improved. She was warmer, her skin tone was more flushed, and she was more ambient and alert.

After several days, her body began to purge. Yellow and orange colored diarrhea would fill her diaper. The heightened number of liver-stimulating supplements may have set off a type of liver detoxification event, that continued for 7 days. During this time, as we gave her body permission to proceed through its phases of healing, she was carefully monitored and attention was given to maximizing hydration. On around the 7-day period, the purging suddenly and inexplicably ceased. The only residual symptom was that her cognitive function was diminished. She was not as alert or cognizant as she had been following the first few days under my care. I immediately thought of adding amino acids, but I wanted to act cautiously because of her advanced kidney disease. I settled on MAP amino acids (3 tablets in AM and 2 in PM), and L-Glutamine (5 grams daily). MAP is a special amino acid formula, boasting only 1% nitrogen waste, and as such is an ideal candidate for renal disease. MAP contains a blend of: BCAA’s, methionine, tryptophan, lysine, threonine, tryptophan, phenylalanine. Glutamine was added because it is a conditionally essential amino acid, which is in high demand under increased oxidative conditions.

Sure enough, the addition of MAP and Glutamine resulted immediately in improved cognition. The entire protocol was maintained daily with careful monitoring and slight adjustments and modifications. Melatonin and CBD were later added for sleep, and metabolic function.

I was doing rounds visiting her and monitoring her closely, twice daily for the next 3 months. The family did a phenomenal job in keeping everything working. After a month or so the testosterone was not needed.

Her improvements were dramatic. Her mental function and quality of life, despite her dementia, improved dramatically and continued to improve weekly. To watch an 84-year old woman go from ‘on her way out’ to this state of renewed life is something remarkable to witness. She repeatedly would thank me, and would tell me she feels like a 15-year old Quinceanera. A Quinceanera is a type of Mexican celebration done for 15-year old girls.

Her blood pressure eventually would become much more stable. There were periods where she took no pharmaceuticals. The decision was made to use Lisinopril, but only if needed, and only at 1/4 of the standard dose, given every 3-4 days. 10mg was given as needed but this was used only on occasion if her blood pressure would become markedly elevated. Eventually it was discovered that a daily, intramuscular injection of a B-vitamin combination (namely B-1, B-6 and B-12) was working to control her blood pressure. This was not expected to happen, but it did.

Approximately 5.5 Months following the initiation of the protocol, the blood test was repeated. Below are the comparative results.

Discussion

There are several notable improvements. Glucose is much more stable, with a near 120-point reduction in fasting levels, and a notable drop in A1C from 7.5 to 6.7. The A1C values are expected to improve further in coming months. Glucose stabilization was evident by day-day monitoring over several months. There were periods where her day-day glucose levels were consistently less than 100. The anemia markers have all improved. Her hemoglobin increased from 10.2 to 11.7. Her MCV (which measures the size of red blood cells) increased from 81 to 84.7. Her red blood cell count has normalized from 3.69 to 4.38. It is worth noting that neither iron supplementation nor high iron foods were used for anemia. Testosterone was used, as well as lowering her inflammation.

The albumin level has improved to normal, from 3.8 to 4.1. All liver enzymes improved/normalized. LDH had the most dramatic improvement from 486 to 162, and that may directly be related to reduced free fatty acids, and/or the improvement in glycolytic energy metabolic pathways.

Most dramatically, her Creatinine level has dropped from 2.15 to 1.50. This is a significant improvement, and with that the normalization of her RBC and improvement of electrolytes suggests much more stable kidney function that previously. Her BUN level, however is higher than previously, which is concerning.

Her neutrophil to lymphocyte ratio also significantly improved. According to literature, an elevated neutrophil to lymphocyte ratio greater than 2.3 is associated with diabetic nephropathy, and diabetic complications (1). Her initial ratio of N/L was 8.1, and on the follow-up test was 3.1.

Her serum potassium value is 1.0 point lower than baseline, although still considerably elevated upon follow-up. A low potassium diet was not used to lower her serum potassium level.

The family reported she enjoys life much more, is ambient and alert, and regularly engages in conversations. Her body weight has become more normal and she looks more alive. Following the results of the follow-up test, I did recommend adding a selenium/Vitamin E combination, as well as Lion’s mane (for memory/cognition).

This is a case study example demonstrating that even with advancing age, failing kidney function, the human body is capable of healing and regeneration. The primary end goal was met: improve quality of life so that she could enjoy it with her family.

As one watches carefully the process unfold, it can be understood that there are stages of healing that occur. In Angela’s case, the initial period of liver purging was a necessary stage of improvement. Once she had gone through that, she progressively improved.

As you can see, the TrueReport FBCA has helped lay out the results in an easy to interpret manner that enables users to prioritize therapeutics.