How Tanya Regained Her Health and Overcame Insulin Resistance and Other Symptoms: A Case Study

Tanya* was a 42-year-old female who had been trying to lose weight for most of her adult life. She was 5’6” and 240 pounds and was recently diagnosed with insulin resistance and borderline type II Diabetes. While Tanya felt she “always carried a little extra weight,” her weight gain primarily came in the last 5 years after having her twins - she had gained 75 pounds during her pregnancy and breastfeeding, and it had stayed, and she then gained an additional 25 pounds in the following couple of years. Additionally, Tanya had developed sleep issues and anxiety in the same time frame, having bouts of insomnia that would last for 2-3 weeks and almost daily anxiety, which she often chalked up to “being a mom.”  

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CC: Weight Gain, Insulin Resistance, Sleep Problems, Anxiety

Tanya had recently seen her endocrinologist, who prescribed her Semaglutide to help with weight loss. While Tanya was not opposed to trying the injections, she came to us for co-management because she wanted help with her nutrition and lifestyle and didn’t want to stay on Semaglutide long-term.  

Tanya’s health history included a family history of hypothyroidism and insulin resistance. The last time Tanya had had her thyroid hormone levels tested was right after pregnancy, which came back normal (TSH, T4). She had a history of on-and-off constipation and bloating and could never quite figure out what the cause was. Tanya tried various diet programs over the past 5 years, including Noom and Weight Watchers. She might lose a few pounds, but found the programs were hard to stick to or the weight came back as soon as she stopped. In terms of exercise, Tanya was walking and playing with her kids but felt pressed for time when it came to doing more intense workouts, in addition to having some joint discomfort with exercise. 

When it came to her sleep, Tanya felt she had not “slept normally” since the birth of her twins. However, it went beyond just getting disrupted sleep - Tanya would have periods of insomnia lasting for a few weeks where she had to take sleeping medication (Xanax) just to fall asleep, and never really felt well-rested even when she did take medication. Tanya felt anxious most days and felt it was worse when she wasn’t sleeping well. Tanya ran her own business from home as a fractional CFO and was the primary caretaker for her kids. She knew her stress levels were high but wasn’t sure what else she could do to help with that. 

In addition to the Xanax (as needed), Tanya had started weekly Semaglutide injections two weeks prior to meeting with me. She was also taking a multivitamin. Her diet consisted of whole wheat bagels with peanut butter or oatmeal with fruit and a scoop of protein for breakfast, a sandwich with soup or a salad for lunch, and dinner was usually takeout - family favorites included pizza and Italian food. Tanya felt she was good with drinking water, and she typically had one cup of coffee in the morning and a glass of wine at night most nights. She admitted she was also a late-night snacker and tended towards ice cream and other sweet foods.

Lab Work Results

The following specialty labs were run:

Comprehensive Stool Test

A comprehensive stool test (the GI-MAP by Diagnostic Solutions) showed the following results: 

• Pancreatic elastase was low, and steatocrit was high
• Elevated beta-glucuronidase
• Elevated candida spp. + elevation of several opportunistic bacteria spp.
• Low commensal bacterial spp.
• High firmicutes:bacteroidetes ratio

DUTCH Complete Results

Tanya’s DUTCH Complete by Precision Analytical showed elevated estrogens with elevated 16-alpha hydroxyestrone.

Additional Lab Results

Lab Analysis 

Tanya's lab work points to a few different problems that are contributing to her symptoms.

Dysbiosis, Malabsorption, and Other Gut Findings

Tanya’s stool test showed low pancreatic elastase and an elevated steatocrit, indicating low digestive enzyme function and likely malabsorption. This can lead to not absorbing nutrients optimally from her diet and may cause bloating and digestive issues such as constipation, things that Tanya had dealt with on and off for most of her life. Tanya’s GI-MAP test also showed elevated candida levels, indicating her dysbiotic gut has an overgrowth of both bacterial and fungal spp. Candida overgrowth has been studied as a contributor to weight gain and insulin resistance. Tanya also had an elevated Firmicutes:Bacteroidetes ratio, an alteration that has been found in obese populations and that may increase risk for intestinal permeability and activate inflammatory pathways that lead to insulin resistance. Last, she also had elevated beta-glucuronidase, which can indicate suboptimal estrogen metabolism and reactivation of estrogens in the gut. 

Elevated Inflammation 

Tanya had elevated hs-CRP, a sensitive marker of inflammation. She also had a high-risk omega-3 index, indicating inflammation is present. Low vitamin D has also been associated with chronic inflammation, and Tanya had low levels in both serum testing and a micronutrient panel. 

Metabolic Markers

Tanya had elevated fasting insulin, HgBa1c, and glucose, indicating insulin resistance and ending right on the verge of Type II Diabetes. She also had elevated AST and ALT. Elevated ALT/AST has been found to be predictive of NAFLD (non-alcoholic fatty liver disease) and worsening insulin sensitivity in women.  

Hormone Imbalances

In an updated thyroid panel, Tanya showed elevated TSH and a low free T3 for optimal ranges, indicating subclinical hypothyroidism. It’s possible her results initially went unnoticed because some lab reference ranges include TSH as “normal” up to 4.5, and her thyroxine levels (T4) are normal. Additionally, she had elevated estradiol and low progesterone, indicating a state of estrogen dominance. High estrogen levels can increase insulin resistance, while low progesterone has been linked to sleep issues. The elevation of the urinary metabolite 16-alpha hydroxyestrone found in her DUTCH test has also been linked to higher inflammation. Tanya also showed borderline high testosterone, which has been associated with insulin resistance and metabolic syndrome in women. Last, Tanya also showed irregular cortisol levels, with low waking cortisol followed by elevated cortisol levels the rest of the day right into the evening. High cortisol levels can lead to sleep issues as it suppresses melatonin production and can interfere with restful sleep. 

Multiple Micronutrient Depletions

Tanya had several vitamin and mineral depletions that showed up on her micronutrients panel, including low zinc, magnesium, selenium, iron, vitamin D, and CoQ10.  Zinc is an important mineral for the conversion of T4 to T3, and it also plays an important role in the regulation of insulin. CoQ10 has been studied for its potential role in minimizing the progression of prediabetes to diabetes.

Interventions

Tanya’s endocrinologist agreed to co-manage her case as she was the provider prescribing Semaglutide. Her therapeutic plan recommendations are listed below.

Supplementation

Started basic supplementation to help reduce symptoms and start addressing nutrient deficiencies:

• Started magnesium glycinate, 400mg at night
• Started vitamin D3, 4000 IU once/day (Apex Energetics Liqua-D)
• Started comprehensive digestive enzyme to help support food breakdown and nutrient absorption (Apex Energetics Enzymix-Pro)
• Started having digestive bitters prior to meals to help stimulate stomach acid and digestive enzyme production.
• Trace Minerals by Thorne (contains zinc, selenium, and other minerals) once/day
• CoQ10 100mg/day
• Cortisol Manager by Integrative Therapeutics, 1 tablet taken at night
• Antioxidant reds + greens powder 1 scoop per day in water to help reduce inflammation
• Started 3g fish oil daily to help reduce inflammation and improve thyroid signaling.  

We began with a gut repair plan, using both supplements and therapeutic nutrition (outlined below) to address the dysbiosis and elevated candida found in Tanya’s GI Map results

• Gi-MicrobX, an antimicrobial blend to help eradicate opportunistic microbes in the gut
• Caprylic acid, which has been found to be as effective as prescription antifungals in reducing candida 
• Binder taken at night to help minimize die-off side effects 
• Repairvite (Apex Energetics) to support healing the gastric and gut lining and improve the health of the mucosa throughout the gut
• We followed this up with probiotic rotations, including Lactobacillus spp. which have been found to be effective in eradicating candida, in addition to prebiotic and probiotic foods in the diet.

Nutritional Changes

Nutritionally, we emphasized an anti-inflammatory, whole food, nutrient-dense Paleo diet rich in low-glycemic fruits, vegetables, healthy fats, and protein.  

• For Tanya, we focused on having quality protein (such as grass-fed beef, poultry, fish), fat (such as avocado, olive oil, and flaxseed), and fiber with each meal to keep energy levels balanced while limiting sugar, refined carbohydrates, and fast food. Due to the presence of candida overgrowth and the various elevated metabolic markers, we wanted to move Tanya away from “white” foods (such as pasta, breads made from white flour, and refined sugar) as much as possible and focus on foods that kept her blood sugar more regulated, so we used a continuous glucose monitor (CGM) to help personalize this approach for her. 
• Additionally, we included functional fibers to help support the growth of beneficial gut bacteria, including sources of inulin, beta-glucan, and fructo-oligosaccharides. 
• We had Tanya focus on hydration and increasing her water intake as well, and started to switch her to half-caf coffee before transitioning over to green tea to help cut down on her caffeine intake and coffee dependence. We also had her transition away from a nightly glass of wine to sparkling water or functional beverages like Recess.
• We also focused on eating hygiene: chewing food well, slowing down and stepping away from work while eating, and taking a few slow breaths before starting a meal. Tanya also started journaling about her eating to help identify any stress-related eating or other emotional patterns. 

Lifestyle Recommendations 

• Tanya continued to walk daily, and we had her get set up with a personal trainer to start strength training 2-3 times per week. Strength training is important while taking Semaglutide to help preserve lean mass, and resistance training also helps reduce insulin resistance and improve metabolic health. After a month of getting into this routine, we had Tanya add in more cardiovascular exercise twice per week in the form of at-home, time-efficient HIIT workouts or using a stationary bike she and her husband had in their garage. HIIT and moderate-intensity exercise have both been shown to improve insulin sensitivity and metabolic markers.
• Additionally, we focused on bringing more “breaks” into Tanya’s day, which involved short walks, getting outside, or doing something fun with her kids that she enjoyed to break up her work schedule and get her up and moving.
• We had Tanya incorporate stress reduction and nervous system regulation strategies, including breathwork and meditation, to help address her high stress levels and support the regulation of hormones. These were time-efficient strategies to help bring more mindfulness and restorative time into her daily routines. 
• We focused on consistent sleep hygiene and had Tanya create a “winding down” routine, power down technology after dark as much as possible, and incorporate guided meditation to help her sleep.

After two months, Tanya had completed her gut rebalancing protocol, and we focused more on increasing her movement and supporting her nutrition and lifestyle. We continued with probiotic rotations but removed the antimicrobial supplementation and the digestive bitters. At this point, she had lost 12 pounds and was feeling more energized and less anxious. She was having consistent daily bowel movements and found she really enjoyed having a consistent exercise plan. Over the next three months, we continued to fine-tune her exercise program, her diet, and her lifestyle to support stress reduction and better sleep. We also added the following things to better support her overall hormone and metabolic health:

• Calcium D-glucarate to help reduce beta-glucuronidase and support estrogen metabolism
• T3 Conversion Booster by Weston Childs to help support T4-T3 conversion
• Bioidentical progesterone per Tanya’s endocrinologist
• Nutritionally, Tanya was happy with how she felt on the Paleo-type diet and continued on this plan. She initially had some issues with sugar cravings for the first few weeks, but things had balanced out, and she wasn’t feeling the urge to snack or grab late-night sweets. We added in some more insulin-sensitizing strategies and used her CGM to gauge effectiveness: apple cider vinegar (1 tbsp in water) prior to meals, short walks after meals, and moving her carbs closer to her workouts or at dinnertime. For Tanya, limiting carbs earlier in the day kept her blood glucose more balanced while having her carbs peri-workout or at dinner helped her workout performance and her sleep. 

Follow-Up Labs 5 Months Later

GI-MAP & Micronutrient Testing Follow-Up Results: 

Tanya’s micronutrient re-test came with all results within normal limits, demonstrating that her plan was helping to restore her vitamin and mineral levels.  

Additionally, her GI-MAP results improved to normal ranges:

• Pancreatic elastase was normal (initially low)
• Steatocrit was normal (initially high)
• Beta-glucuronidase was normal (initially high)
• No detectable candida spp., opportunistic bacteria levels had rebalanced
• Improvement in commensal bacterial spp. growth (initially low)

Follow-Up Interpretations and Continued Interventions

Over the course of five months, Tanya implemented all recommendations with regular check-ins and guidance. She had an easier time adhering to recommendations after the first weeks once her sugar cravings at night had gone away, and as her energy and anxiety improved, Tanya felt more and more motivated to stick to the plan. We had Tanya do an InBody body composition scan once per month to ensure she wasn’t losing lean mass on the weight loss medication, and at the end of five months, Tanya had lost a total of 40 pounds and had gained 6 pounds of muscle along the way, which she was thrilled about.  

While Tanya’s fasting insulin and blood glucose dropped into normal conventional ranges, fasting insulin greater than 7 still carries a higher risk of metabolic syndrome and diabetes, so ideally, with time, her levels will continue to fall.  

Tanya was sleeping well most nights, unless one of her daughters woke her up, and had more energy throughout the day as a result.  She found that her anxiety almost disappeared after switching off wine and coffee, and she still enjoyed a cup of decaf in the morning. Her digestion overall felt great, and she was having 1-2 bowel movements per day with minimal bloating. She found that too much nut butter or nuts did make her feel bloated, and kept these minimal in her diet.  

All of Tanya’s lab markers returned to normal ranges, with her omega-3 index rising to the intermediate risk range. She planned to continue her omega-3, antioxidant powder, magnesium, vitamin D, Cortisol Manager, trace minerals, and progesterone and wean off the other supplements. Tanya also planned to continue her exercise plan and stress management strategies and found that she really enjoyed guided meditations both during the day and before bed to help her de-stress. She and her endocrinologist planned to continue the weight loss medication to lose another 30-40 pounds and then hoped to wean off that as well.

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This case highlights some important aspects of weight loss, including addressing underlying inflammation and imbalances in the body as well as emphasizing muscle preservation while taking weight loss injections. With a coordinated care team and a highly personalized plan, Tanya was able to lose primarily fat mass on her weight loss medication and actually built some lean muscle, which will help support optimal metabolic health. As her case continues, the focus will be primarily on weight loss, improving insulin sensitivity, and maintaining her hormone health.