Case Study – adrenal insufficiency – burn out or over trained athletes

I was looking through some old case studies and this one from 2006/2007 – was on adrenal insufficiency in an elite rugby player.

I thought it might be useful to some of you who work with burn out or over trained athletes.

Case study 1 is an elite rugby player. I chose him as approximately half my time is spent dealing with elite sports individuals, as such this is reflective of much of my day to  day work.

1. Assessing the client’s needs and the appropriateness of nutritional therapy
2. As an elite rugby player within the ERFU you are required to receive nutritional support – as such I have to look after 62 players whether they present with distinct symptoms or not. In the case of player 1 at our first consultation he presented with the following symptoms;

INITIAL CONSULTATION

Purpose to assess current status, useful future interventions and further investigations;
           
a) PRESENTATION
Fatigue – especially in the afternoon
Difficulty sleeping
Under recovery following training sessions
Excess body fat despite following a strict dietary regime
A number of psychological symptoms including low grade depression

In his words he was just not ‘feeling right’.

At the initial consultation we discuss symptoms, performance both on and off the pitch, a day in the life of including 24 hour recall of foods and supplements, detailed anthropometric analysis through the use of calipers and a tape measure.

These findings are then backed up with a detailed symptom questionnaire and blood tests. Sometimes I’ll also do some type of functional screening or other assessment as well.

Ragland’s sign was positive, as was pupil dilation test. 120/80 – followed by 103/70 – player 1 also reported feeling dizzy on standing.

Player 1’s diet was as follows;

LIFESTYLE AND DIET DAILY HABITS

Training on an empty stomach 1st thing in the morning followed by BCAAs drink and protein shake. Water was drunk according to thirst throughout the morning.

The first meal was eaten at lunch, consisting of proteins and vegetable based foods with no starchy carbohydrates at this time.

The afternoon training session was completed with another protein shake after which player 1 would go home for an afternoon nap of 1-2 hours.

After this craving symptoms would occur causing a grazing effect on all kinds of higher GI foods, starchy carbohydrates and comfort based foods until later in the evening.
The player’s skinfold readings were higher than optimal for his position with a high subscapular reading – this can indicate a genetic intolerance to carbohydrates.

Family history reveled both parents to be overweight with the father having significant problems with cholesterol and taking a statin medication to control this.

Player 1 was taking some supplements in a sporadic and unplanned manner. These consisted of ‘green drinks’ (Jarrow green defense, multi nutrients, and omega complete). Details are in phase 1 supplementation in appendix.

Rational – My initial hypothesis centeredaround a likely case of over training combined with a low intake of quality carbohydrates in sufficient amounts to allow full muscle recovery and protein synthesis.

Player 1 HPA system would have been taxed hard through intensive training sessions done on an empty stomach which would have raised and depleted his stress hormones.

In addition to this long periods of eating little food, followed by over-feeding would have upset his blood glucose balance. I also suspected a deficiency in minerals, b-vitamins and co factors. As well as possible protein malabsorption due to low stomach acid from prolonged stress and a higher than normal intake of protein from animal and supplemental sources.

As the player was within a group club rugby setting he has plenty of peer support from coaches, and strength and conditioning specialists. The club also provided a breakfast and lunch meal, along with recovery based supplements after each training session. A key point of support would be required once the player left the club and attended to his own cooking and food selection at home.

I was going to begin the player on a supplement programme but I had the additional resource available to me of blood testing for deficiencies in the next medical camp. My plan was to begin treating his symptoms at this consultation and then review the supplement programme based on what available evidence we could gather from further investigations in a months time.

EDUCATION

a) EXPLAIN THE SELECTION OF ASSESSMENT METHODS USED TO DETERMINE CLIENT TREATMENT
some of these items are discussed above; 24 hour recall, questionnaire, blood work, presenting symptoms, visual cues, more are detailed in further visits. The initial screening is less comprehensive than the first follow up and acts as more of an information gathering process.

Dietary wise I began by stressing the importance of taking in nutrients ahead of his morning training sessions. We discussed using amino acid supplementation PRE- training as opposed to just afterwards. In addition to this I took the player off all stimulant based fat burning tablets and switched him to green tea extract.

This was to reduce the likely stress on his adrenals.

The basics of blood glucose regulation and fat burning were explained and then supported with client education handouts (attached). The key elements were feeding little and often with whole protein foods as opposed to whey shakes, to reduce insulin drive from the whey, combined with good fats, grow above the ground vegetables and starchy foods from wholegrains and root vegetables in measured amounts to complement and support his training requirements.

Supplementation wise I began player 1 on; Jarrow Glucose Optimizer, Jarrow Adrenal Optimizer, fish oils (omega plus) with each meal, and multi nutrients (Jarrow) with each meal.

PHASE 1 SUPPLEMENTATION PLAYER INFORMATION& RATIONAL; FULL DETAILS IN APPENDIX

Player 1 was already taking BCAAs and protein based recovery drinks so these were not included in my supplement prescriptions.

CHOICE OF SUPPLEMENT SUPPLIER

When choosing supplements always use companies who produce products to a high standard,GMP and also drug screened at HFL. I read through the labels and compare them to SONA’s and safe upper limit amounts.I will start to base my safety choices on the current European recommended guidelines. I base my recommendations on past experience and successful outcomes with clients. I also base my choices on personal use. I don’t tend to recommend any supplement which I have not either had personal or close knowledge of someone who has taken the supplement to good positive effect and without any side effects. I was also confident the high dosages of b-vitamins (above RDA) would cause no problems in the shorter term (4 weeks) being water soluble until we had the blood results to work through. I’m aware of the negative effects of high dose b6.

I check for drug-supplement interactions using the book and accompanying CD-Rom: Herb, Nutrient and Drug Interactions; Clinical Implications and Therapeutic Strategies by Stargrove, Treasure & McKee (Publisher: Mosby, Elsevier; 2008). 
LIFESTYLE
Lifestyle wise for this month was simple; take time to relax in the evenings and make sure that he snacked on real food before heading home. In addition to this I was very strict with his afternoon sleeping time; 5 minutes to settle down, 20 minutes snooze and then 5 minutes to get up and make a cup of green tea.

As well as this I described an excellent way of controlling cravings and lowering the impact food has on blood glucose so to eat his evening meal in the following way;

1. Eat earlier in the evening ideally finish eating 3 hours before bed time
2. Begin with raw vegetables – celery, peppers, etc
3. Have a broth based soup before you main meal
4. Eat your protein foods and cooked vegetables
5. Eat you chosen sources of starch if you are still hungry
6. Stop eating if you become more thirsty than hungry you can always return to finish what’s left as a snack later in the evening

I was clear in my recommendations and sure that if player 1 could follow them as directed he make improvements in his symptoms. I was keen to do further investigations and these are what took place one month later.

AUGUST 2008 MEDICAL CAMP CONSULTATION AND REPORT

In this medical based camp I use a detailed symptom questionnaire, VARK scores (to allow me to present the information to the player in the most suitable manner), blood tests – see attachment for full details of testing. These include but are not limited to standard biochemistry, liver, kidney, thyroid function, and red and white blood cells, vitamin D, total iron profile, folate, b12, RBC fatty acids and blood group.

All bloods are reviewed with a sports medicine Dr and in the case of player 1 I suggested the following alterations in his programme; the full details of his written report are in the appendix under; August 2008 medical camp consultation report.

SUMMARY

August 2008 medical camp findings and update;

Poor cholesterol profile
Excess protein intake
Poor RBC fatty acids
Poor fasting insulin / disglycemia
Suboptimal vitamin D
High ferritin

Player 1 was found to have a poor cholesterol profile; this tied in with his family history and high subscapular skinfold reading. His blood work indicated that potentially a higher than adequate amount of protein was being consumed (high bicarbonate, urea and creatinine) but these levels were only just outside the normal range suggesting a small adjustment would be necessary to bring things into the normal range. Although even this small increase may have been putting additional strain on the detoxification systems associated with proper protein breakdown and excretion.

His essential fatty acids were out of balance in terms of omega 3 to omega 6 ratios, suggesting a slight lean towards a pro inflammatory state, although c-reactive protein and high sensitivity crp were both normal. Fasting insulin was high and glucose normal suggesting a degree of insulin insensitivity when viewed through the HOMA score.

Vitamin D levels were found to be in the normal lab range but outside an optimal range of 116-126nmol/L which we aim to keep elite athletes at during the competitive season.

Ferritin was high suggesting a potential for additional inflammation, iron levels were within the normal range.

All these findings are explained in player 1’s feedback form and report.

Player 1 was provided with detailed information on how to gradually alter some of his habits in order to improve his blood results. These included cholesterol moderating habits, fully referenced. As well as advice on sugar handling, adrenal support, a low allergy based diet, antioxidant status, supplements to assist with sleep and a new supplement programme as follows;
From the information you’ve given me I suggest the following supplementation;

PHASE 2 SUPPLEMENTATION

These items were to be worked through at monthly intervals across the next 12 months and a follow up blood test was arranged for cholesterol, RBC fatty acids and vitamin D within a 3 month window.

REFLECTIONS

The testing confirmed some of the suspicions I had about player 1. I was surprised by his level of fasting insulin and also the raised ferritin levels. His cholesterol was also some cause for concern but 1 test alone obviously only gives a snap shot of a person’s health, and as we know cholesterol is only one of many risk factors which need to be taken into account when reviewing cardiovascular risk in the longer term.

These factors did potentially explain though when he found it difficult to lose the last few % in body fat that he needed for optimal performance.

I would have liked to have completed an adrenal stress index test, but at this visit he was markedly improved in symptoms, having far less fatigue and improved sleeping pattern, training ability and performance in games. As this was the case I wanted him to continue on his current regime but with a few small changes based on other symptoms identified in his questionnaire.

In addition Ragland’s test was normal. 123/82 – followed by 120/81.I didn’t do the pupil test as I’d forgotten my pen.

I find the athletes screening questionnaire as excellent tool for gathering information and also for tracking changes in severity of symptoms. Often people forget how bad they were unless you can show them the numbers!

The next few months went by without any real items of concern. Player 1 continued to develop and decrease his body fat % whilst also gaining an increased awareness of blood glucose control and his energy levels gradually returned to normal.

After 3 months it appeared unnecessary to continue with the adrenal or blood glucose support. We continued on essential fatty acids, a multi vitamin and mineral alongside his amino acid and protein consumption.

DECEMBER 2008 TEST RESULTS

See follow up test section in appendix for test results;

Vitamin D deficient
Cholesterol profile still out of balance, similar to previous readings
Omega 3 – results didn’t come through due to poor blood storage

MONTHLY FOLLOW UPS DECEMBER 2008 – JULY 2009

As he was going through this process I pushed him quite hard at times, through lower carbohydrate phases and carbohydrate cycling on a weekly basis. I also raised his protein consumption for short periods of time (pre season) to accommodate the fast increase in volume of intensive exercise and training he was undergoing.

JULY 2009 FOLLOW UP

Player 1 was advised to separate his fatty acid supplementation and on key aminos which may support proper growth hormone release naturally when taken before bed time. Player 1 had been investigating this area himself and needed some clarification as to which supplements work best and what amounts to take them in.

MOST RECENT CONSULTATION AND RESULTS

I wanted to go through his final (most recent) consultation and set of results from his clinical testing.

Having worked with some of the standard functional screening of blood chemistry profiles for a few year I was beginning to realize the shortfall in some of the information we were gathering and also feedback which I can continue to give to players to improve their performance. An example of this is serum mineral screening as opposed to red or white blood cell mineral screening.

As such I wanted to trial a new test by Genova; the NutraEval test. Player 1’s results are in the appendix. To learn more about the test I spent some time on the phone with the Dr who pioneered this particular test Dr Patrick Hanaway.

Summary  ofNutraEval test results for player 1 are as follows;

A higher requirement for fat soluble antioxidants
Damaged fats – within the cell – lipid peroxides
Possible causes – a back ground toxicity – maybe from mercury fillings
Malabsorption of proteins and B vitamins
Possible bacterial overgrowth
Low levels of Cu, Mg and valine

Overall it was interesting to see an improvement in player 1 symptoms, body fat, fitness and strength scores and ultimately ability to play the game at the level he desired.

However without the benefit of the in depth testing we do with our athletes I would never have been able to track the various health, nutrition and performance parameters to implement the best strategies for the player at a particular time.

Also with the pressure and desire to alter body composition to extreme levels and assist in retaining of a high muscle mass – we have to be aware of the impact this has on antioxidant systems in the body, digestive wellness and other areas of potential toxicity.

These were highlighted in the NutraEval test and would not have been apparent on our normal screening process.

Also some of the single aminos given to support adrenal function may have interacted with others, the nutraeval test enabled me to identify which areas were in need of balance.

The GH secretagogues mentioned in July 2009 follow up seemed to have potentially altered some of the amino acid balance in player 1’s urine sample. Once again highlighting the need for periods of ‘wash out’ from supplementation and also taking a broad spectrum amino complex to balance out any single amino acid supplementation.

A key message for me going forwards is to integrate periods of ‘clearing out’ and working with a minimal level of supplementation.

Combined with periods of complete rest from all supplementation in a graded and planned withdrawal.

Another concern of mine with player 1 was his tendency to self-supplement. This makes it difficult to monitor closely some of the interactions between my supplementation programme and one that he may use. We have good communication and he up dates me each time we meet. However on at least 2 occasions

Key items considered at this consultation were;

Care to be taken chewing and digesting food
Cut back on red meats
Increase fish and white meats
Avoid all mercury heavy fish sources
Take regular sauna 3 times per week for 45 minutes

PHASE 3 SUPPLEMENTATION

As phase 2, plus;

Use HCL and digestive enzymes with each meal to ensure proper assimilation of nutrients. Zyme Aid by country Life.

Take high strength pro biotics for 2 months 25 billion active cultures with food b.i.d.

THE FUTURE

As I continue to work with player 1 we now pay more attention to cycling supplementation and to supplementing according to test results as opposed to what we feel a client may need.

I’m hoping also to do a comprehensive cardiovascular screening test for player 1 at his next medical camp.

Overall I learnt that the simple things normally work the best – eating slowly, proper digestion, sleep and taking time to relax as an athlete are critical to success.

Without these even the most comprehensive supplementation and testing protocols will not assist performance or help with an athlete’s health and wellness.