Patient Initials: PO
Patient Age: 67
Gender: Female
Occupation: Secretary
Initial Consult: October 18, 2012
SUBJECTIVE COMPLAINTS:
Chronic back pain, neck pain, bilateral knee pain. Dyspnea, periodic wheezing upon exertion and occasionally upon arising in the mornings. Occasional chest pain. Swelling of legs bilaterally, right greater than left.
Onset: Progressively over the past approximately 30 years as she became pregnant at age 37 and had her first and only child at age 38. She gained approximately 55 pounds during this pregnancy, being at 195 when she delivered. She lost 35 pounds after delivery. In addition, she stopped smoking and gained 40 pounds, and the weight gain continued over the years, culminating in a weight at the time of this study of 268 pounds.
Provoking Mechanisms: Patient is a self-described “food addict” stating that food is her “drug of choice.” She eats for any reason and no reason at all. She uses food when she is happy, sad, depressed, celebrating, or bored.
Quality of Symptoms: Back pain is sharp and progressive, occurring to varying degrees throughout most days. It is worse when she has to be on her feet for any period of time and/or with movement, such as walking. The back pain always radiates and includes her neck pain. Her dyspnea and wheezing become worse with activity, as does the swelling in her legs. Chest pain occurs frequently with these symptoms and is relieved with rest. She states it is often a “heavy” feeling, and sometimes sharp or shooting.
Radiating Symptoms: As stated above, back pain radiating to her neck, and chest pain, tightness and shortness of breath, worse upon activity. The shortness of breath often causes neck and upper back soreness and stiffness, along with the “tightness” sensation in her chest.
Site of Symptomatology: Neck, cervical, thoracic regions.
Duration of Symptoms: Dyspnea daily. Constant neck and back pain in varying degrees, worse when she works at her computer all day, less on weekends when she is not constantly at a computer. Patient takes Soma, 350 mg, as a muscle relaxant, daily if needed and definitely every night at bedtime to relax.
Prior contributory health history: Strong history of alcoholism in the family, dating back to the fraternal grandfather, and depression and suicide in the maternal grandfather; her father was a severe alcoholic. She is very aware that she, herself, has an addictive personality, and that food is her drug or drink of choice. She has always been overweight. She struggled with it as a child, and in her teens began the lose/gain cycle, which has continued until the present. It is of note that she never began menses, and was told at age 22 after multiple tests and one surgery (ovarian resection), that her body simply did not produce eggs, therefore, there was nothing there to be fertilized, and that she would never bear children.
At age 37, she began regular menstruation (q 29 days) for one year, then became pregnant with her first and only child. Pregnancy was uneventful and she delivered on her due date, after only 45 minutes of labor.
OBJECTIVE FINDINGS:
Diagnostic test results:
Patient presents with a series of laboratory, cardiac, MRI and colonoscopy evaluations to include Complete Metabolic Panel (14) from 01-09-10, indicating elevated levels of cholesterol (284 total), triglycerides (256), VLDL cholesterol (51), LDL (171), T. chol/HDL ratio (4.6), and a very high TSH (25.270).
Nuclear stress test and echocardiogram, which showed good heart muscle and normal values.
MRI of the Lumbar Spine dated 09-28-10, which showed Bilateral L5 pars interarticularis defects, with Grade 1 anterolisthesis of L5 on S1. There is moderate right and severe left neural foraminal narrowing at this level; in addition, there is mild, multilevel disc disease from L1-2 through L4-5.
Several results of yearly mammograms indicating no signs of breast cancer.
Colonoscopy results from 06-13-13, indicating diverticulosis, an otherwise normal colon, and no sign of cancer.
NOTE – After patient was on the SHAPE Program for two months, repeat laboratory panel indicated the following: total cholesterol (136), triglycerides (91), VLDL cholesterol (18), LDL (73), T chol/HDL ratio (1.6), and TSH (0.154 – low – thyroid Rx adjusted by her PCP).
Patient began the SHAPE Program on 10-18-12; above panel run on 12-03-12. At that time patient had lost 36 pounds.
Symptoms observed: Anxiety, fatigue, cardiac dysfunction (dyspnea).
Patient appearance: Neat and well groomed, but bloated.
Working Diagnosis: Morbid obesity; Cervical and lumbar disc degeneration
TREATMENT PROTOCOL:
Bi-weekly adjustments times four weeks, then re-assess and possibly reduce to weekly visits until pain is stable and manageable.
Weekly visits as follow-up on SHAPE Program protocol.
The patient maintained the treatment protocol as advised, and between her chiropractic visits and her tremendous weight loss on the SHAPE Program of 120 pounds, she is pain free 95% of the time, with the exception of the occasional need for an adjustment. After eating according to the SHAPE Nutrition Protocol for over one year, she is rarely in need of any adjustments and takes no pain medication of any kind. Patient states she is virtually pain-free and attributes this to her continuance of the SHAPE protocol’s anti-inflammatory eating style.
SUPPLEMENTAL/NUTRITION/HERBS RECOMMENDED:
Cataplex, Vitamin B complex, calcium, trace minerals, Thymex – all Standard Process whole food supplements.
RESULTS:
This patient no longer suffers from the symptoms of pain, dyspnea, wheezing, leg swelling or chest pain associated with her morbid obesity. She has now lost 120 pounds on the SHAPE Program, and even her back and neck symptoms are almost negligible. She, of course, still has the above-noted spinal abnormalities as noted in her MRI, however, they almost never flare up since her significant weight loss. This weight loss occurred for the most part over a 10-month period, from October 2012 through August 2013. Patient remains on the SHAPE Nutrition Protocol and continues to maintain her weight loss and states she would like to lose a little more weight. Her overall health remains excellent.
COMMENTS FROM PATIENT:
Patient is “a different person” since her weight loss, being able now to exercise, actually “feel healthy” as well, and has gone from a size 26 to a size 8 in a period of approximately 10 months. =She states she now has first-hand realization of what proper nutrition can do for health and has become an advocate of the healthy anti-inflammatory lifestyle.
COMMENTS FROM TREATING PCP:
Patient’s M.D. has monitored patient throughout the SHAPE Program and supervised the downward titration of all of patient’s eight medications; physician states she has never seen anything like it. Patient remained exceptionally healthy throughout her weight loss, and has been able to be discontinued from eight medications, for hypertension, hypercholesterolemia, GERD, anxiety meds, water pills, and muscle relaxants. She was monitored at three-month intervals throughout this period of time.
Submitted by Dr. Michael Fiscella
Dr. Todd’s Teaching Assessment
There simply is nothing else to add to this successful case study. Every clinic should have this type of success if they have embraced the value of this program and are introducing it to all their inflamed and overweight patients.
