Nutrition Case Reflection

Name
/student STATTON, Brett, S0278838 
number
Patient/ Age / Sex
subject 34 F 
information
   
  Presentation  Female patient (MB) presented as thin, somewhat unkept, and
with a flat demeanor. Posture was somewhat stooped in nature,
 
with minimal eye contact made.
MB resided on rural New South Wales and felt like she had to quit
employment just to have enough strength to get through the
days. She had also mentioned she struggled with short term
memory while she was working, which made work difficult. This
resulted in her feeling more isolated as she had recently moved
and had no friends or family nearby.
When asked about current nutritional intake she replied “some
days I only have enough energy for one meal”. At the time
physical activity was minimum, with most days spent in bed.
MB reported she has experienced this fatigue for almost 1.5 year.
   
  Investigations/approaches  MB had multiple visits over 2 months to her GP with no diagnosis
made. However, a full blood test was done including iron levels
 
and thyroid function tests, which were reported as normal.

She then enlisted a naturopath who referred her to another GP

who had experience with patients presenting with chronic fatigue.
Further lab testing was done including, fecal, urine and blood
tests.

The last blood test showed low iron, vitamin D and vitamin B12,
this may be explained by her recent change to a vegan diet1.
Biometrics    weight BP …………. ……… ……… ……….
… … .

1 year ago pre  47kg  NA        

 present post  54kg  118/83        

Relevant Medication Dosage Before Dosage After

  Intervention Intervention

Patient was taking a women’s multi vitamin when she first felt her once a day 0
fatigue, but eventually stopped taking them a few months after her
diagnosis

   
  Diagnoses  Chronic fatigue syndrome (CFS) also known as myalgic
  encephalomyelitis (ME)2.

CFS is difficult to diagnose as there are no biological markers, a

diagnosis is made by exclusion of other pathologies 2,3.
treatment/ Nutrition  A discussion was made about reasons for her vegan diet, some
intervention general nutritional advice was also given by her GP. MB decided
to continue her vegan diet and a referral to a nutritionist was
  given.
 
The nutritionist advised of the merits of the Mediterranean diet
and how it may help with her chronic fatigue syndrome. It helps
by providing a good balance of nutrient dense food rich in good
fats and is promoted as anti-inflammatory 4.

At this stage MB choose to continue her vegan diet, the

nutritionist recommended a variety of legumes and soy products
for a complete source of proteins5. Advice on iron rich vegetables
was also made and the importance of eating three balanced meals
a day1.
Physical activity/rehabilitation  
 Increased physical activity was prescribed by all three allied
health practitioners, including the nutritionist, GP and
chiropractor. It was also prescribed to help improve her mood and
regulate her appetite6.

However, MB found even regular walks difficult to due to her CF

Chiropractic Management
Co-management/interdisciplinary
management
and could not commit to going to a gym.
 
 MB regularly visited a chiropractor who was unaware of her
chronic fatigue syndrome until approximately one year after her
diagnosis. The chiropractor advised of the importance of vitamin
D and how to it can play an important role in fatigue and
musculoskeletal pain7. As the main sources of vitamin D are fish
and dairy products the chiropractic advised 15 minutes of sun safe
exposure every day7.
 While she was B12 deficient her GP administered B12 injections
and her levels were closely managed while her nutritionist helped
her understand the benefits of food fortified with B12.

Clinical Process /  One year after her diagnosis and with very little improvement MB decided to change
summary management / her diet and follow the Mediterranean diet. She was not happy with the change but
review decided something had to change and she couldn’t continue with CFS and had to try
alternative options.

Also helping her to make the decision to end the vegan diet was becoming pregnant and
MB wanted to ensure the health of her child.
 Outcomes /   Following up on MB after another year and after approximately six months after
results childbirth she described her health as being great. She was still on the Mediterranean
diet and was incorporating physical activity into her daily life.

She notes that while she does have some fatigue still, she feels overall much better and
puts the fatigue down to a busy lifestyle. She has gained part time work and now goes
for short jogs and regular strength gym sessions.

Reflections/ This was an interesting case to follow up on for many reasons. Firstly, because CFS is a diagnosis by exclusion
Notes and at this stage there is no clear medical understanding of the cause 2,6,8. Therefore, there is no proven
(500-750 words method for treatment of CFS8-10. Secondarily, there is the stigma associated with someone with CFS as just
as a guide) being lazy, as its not understood by the general public. However, CFS can cause significant distress and
(use a separate disability for those affected by it8. Thirdly, did the Mediterranean diet help or did pregnancy hormones play
sheet if desired) some role in the patient feeling like they had overcome CFS.

There has be some interesting research done exploring physical exercise and its relation to CFS. A 2019
Cochrane systematic review investigated whether exercise therapy was more effective than cognitive based
therapy (CBT) and passive treatments8. It was widely thought that CFS was worsened by physical and mental
exertion, however the review found that there was moderate quality evidence suggesting the opposite 3,8. It
should also be noted the review concluded that although exercise had a positive effect on daily functioning,
it was not however more effective than CBT8.
This demonstrates that a rehab program can be implemented to chiropractic patients who may be suffering
from CFS in conjunction with other allied health professionals, such as psychologists.

Secondarily, there seems to be a growing body of literature that links gastrointestinal (GI) dysfunction with
CFS3,8,11. This may be contributed to increased inflammatory mediators due to immune activation 3,12.
Research shows that patients with CFS have altered gut microbiota, which may influence mood and
behaviour3,11.
A recent systematic review investigated nutritional interventions in treating CFS, remarkably they concluded
there was insufficient evidence for the use of supplements or modified/elimination diets 8. This was a
surprising finding, as I had imagined as there is the GI link, that nutrition would play a vital role.
Furthermore, the Mediterranean diet rich in anti-inflammatories, showed no changes in fecal bacteria
counts or the microbiota after three months 7. However, the Mediterranean diet has been shown to reduce
chronic pain, anxiety, depression, weight loss and improved sleep patterns 7,13. Interestingly, depression is
also an inflammatory disorder, and perhaps the diet reduced depression and inflammation therefore
decreased immune response10,12,14. The diet has also shown cardioprotective qualities as well reduced
amounts of all types of cancer13,15. Perhaps it could be inferred that there is a psychosocial overlay to CFS
that should also be investigated.

I also wanted to investigate if pregnancy could also relate to CFS in some way, as MB was also pregnant at
the time she started to feel less fatigued. A 2004 study showed that 71% of women felt that their CFS was
unchanged or improved during pregnancy 9,16. This was a small sample size of less than 100 participants, and
a larger sample group would be needed to investigate further. This would be interesting to follow for future
studies to be released.

It would appear there could be multiple factors involved with the treatment of CFS in this case. A well-
designed nutritional diet would be a large contributor to her success I believe, however it is also great to
know that rehab and exercise can also be prescribed with patients with CFS to great success. To what extent
the role of pregnancy was involved cannot easily be determined at this stage.
References:

1. Annika W, Jochen WK, Claus L, Andreas H. Dietary Iron Intake and Iron Status of German Female
Vegans: Results of the German Vegan Study. Ann Nutr Metab. 2004;48(2):103-108.
2. Clayton EW. Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: An IOM Report on
Redefining an Illness. JAMA. 2015;313(11):1101-1102.
3. Lakhan SE, Kirchgessner A. Gut inflammation in chronic fatigue syndrome. Nutr Metab (Lond).
2010;7(1):79-79.
4. Tosti V, Bertozzi B, Fontana L. Health Benefits of the Mediterranean Diet: Metabolic and
Molecular Mechanisms. J Gerontol A Biol Sci Med Sci. 2018;73(3):318-326.
5. McCarty MF. Vegan proteins may reduce risk of cancer, obesity, and cardiovascular disease by
promoting increased glucagon activity. Med Hypotheses. 1999;53(6):459-485.
6. Larun L, Brurberg KG, Odgaard-Jensen J, Price JR. Exercise therapy for chronic fatigue syndrome.
Cochrane Database Syst Rev. 2017;4(4):CD003200.
7. Pagliai G, Giangrandi I, Dinu M, Sofi F, Colombini B. Nutritional Interventions in the Management
of Fibromyalgia Syndrome. Nutrients. 2020;12(9):2525.
8. Campagnolo N, Johnston S, Collatz A, Staines D, Marshall‐Gradisnik S. Dietary and nutrition
interventions for the therapeutic treatment of chronic fatigue syndrome/myalgic
encephalomyelitis: a systematic review. J Hum Nutr Diet. 2017;30(3):247-259.
9. Christley Y, Martin CJH, Martin CR. Perinatal perspectives on chronic fatigue syndrome. British
journal of midwifery. 2012;20(6):389-393.
10. Prins JB, van der Meer JWM, Bleijenberg G. Chronic fatigue syndrome. Lancet.
2006;367(9507):346-355.
11. Persson R, Wensaas K-A, Hanevik K, Eide GE, Langeland N, Rortveit G. The relationship between
irritable bowel syndrome, functional dyspepsia, chronic fatigue and overactive bladder
syndrome: a controlled study 6 years after acute gastrointestinal infection. BMC Gastroenterol.
2015;15(1):66-66.
12. Sotzny F, Blanco J, Capelli E, et al. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome –
Evidence for an autoimmune disease. Autoimmunity reviews. 2018;17(6):601-609.
13. Toledo E, Salas-Salvadó J, Donat-Vargas C, et al. Mediterranean Diet and Invasive Breast Cancer
Risk Among Women at High Cardiovascular Risk in the PREDIMED Trial: A Randomized Clinical
Trial. JAMA Intern Med. 2015;175(11):1-9.
14. Leonard AJ, Marcie LZ, Mark AZ. Myalgic Encephalomyelitis: Symptoms and Biomarkers. CN.
2015;13(5):701-734.
15. Estruch R, Martinez-Gonzalez MA, Corella D, et al. Effects of a Mediterranean-style diet on
cardiovascular risk factors - A randomized trial. Ann Intern Med. 2006;145(1):1-11.
16. Finn R. Pregnancy doesn't worsen chronic fatigue syndrome.(Across Specialties). Clinical
psychiatry news. 2004;32(5):86.