Case Study: Insulin Resistance in a Sedentary Professional

Earlier articles in this library described the individual tools of Integrated Functional Medicine. This article brings them together in a single case, followed from the first consultation to 12 months later. The case is an illustrative composite, built from presentations common in practice, and is designed to show not only what was done but why, and where the plan could have gone wrong.

Presentation

A 44 year old software architect is referred by his doctor, who has found an HbA1c of 45 mmol/mol, raised triglycerides and a mildly raised ALT, with an ultrasound showing a fatty liver. He reports fatigue, afternoon energy crashes, poor concentration and weight gain of 12 kg over 6 years. His doctor has suggested he “eat less and exercise more”; he has tried several diets without lasting success. His goal: “I don’t want to end up like my father, on insulin at 55.”

History highlights

• Work: remote work since 6 years ago; 10 hour days at a desk; frequent late evening calls with colleagues in other time zones.
• Sleep: bed at 1 am, up at 7 am on workdays; sleeps until 10 am at weekends; snores according to his partner.
• Diet: skips breakfast; large lunch of rice or pasta; snacks on biscuits and crisps in the afternoon; late dinner at 10 pm; 3 sugary coffees a day; beer 2 or 3 evenings a week.
• Activity: about 2,500 steps a day; played football until his late twenties.
• Stress: high workload, perfectionism, difficulty switching off.
• Medicines and supplements: none prescribed; a multivitamin and an online “metabolism booster” containing green tea extract.
• Family: father with type 2 diabetes and a heart attack at 60; mother with hypothyroidism.
• Red flags: none.

Timeline

Matrix

Investigations

His doctor had already arranged HbA1c, lipids, liver tests and ultrasound. Additional tests requested through his doctor: fasting glucose and insulin (fasting insulin raised, consistent with compensated insulin resistance), FIB 4 score (low risk), thyroid function (normal), ferritin (mildly raised, consistent with fatty liver), hepatitis B and C serology (negative), and a sleep apnoea screening questionnaire (high risk), leading to a sleep study.

Prioritisation

The phased plan

Phase one, weeks 0 to 4

• Stop the metabolism booster; continue the multivitamin for now.
• Sleep study referral.
• Fixed wake time of 7 am every day; aim for bed by midnight, moving earlier gradually; no calls after 9 pm on 3 evenings a week, negotiated with his team.
• Unsweetened coffee; replace afternoon biscuits with nuts or fruit.

Phase 2, weeks 4 to 8

• Protein rich breakfast; plate model at lunch; dinner by 8 pm on most days.
• A 10 minute walk after lunch and dinner.
• Beer limited to one evening a week.

Phase 3, weeks 8 to 12 and beyond

• Resistance training twice a week, with physiotherapy advice for his knee.
• Structured approach to work stress: scheduled breaks, a shutdown routine, brief mindfulness practice.

Follow up

Week 1 check in: he has stopped the supplement and switched to unsweetened coffee; the fixed wake time is hard at weekends.

Week 4: the sleep study confirms moderate obstructive sleep apnoea; treatment starts. He is sleeping 6 and a half hours, has fewer afternoon crashes and has lost 2 kg. Phase 2 begins.

Week 8: a product launch disrupts his routine; late calls return for 2 weeks. The plan is simplified to wake time, breakfast and post meal walks. He resumes afterwards.

Week 12: weight down 5 kg; waist down 6 cm; HbA1c 41 mmol/mol; triglycerides and ALT improved; average steps 6,800; fatigue score halved. Phase 3 begins.

6 months: weight down 8 kg; strength training twice weekly; ALT normal; blood pressure 126/80.

12 months: weight maintained; HbA1c 39 mmol/mol; repeat ultrasound shows reduced liver fat. He describes more energy than at any time in the past decade.

What could have gone wrong

• Missing the sleep apnoea, which would have limited progress and left a cardiovascular risk untreated.
• Continuing the green tea extract, with its potential for liver injury in a man with a fatty liver.
• Changing everything at once, leading to overwhelm and abandonment during the product launch.
• Ignoring work patterns, the distal driver behind late eating and short sleep.
• Relying on weight alone as the measure of success, rather than waist, HbA1c, liver tests, fatigue and function.
• Failing to coordinate with his doctor, who needed to know about the sleep apnoea and his progress.

Reflections

No single intervention explains this patient’s improvement. The timeline revealed how his work had reshaped his sleep, eating and activity; the matrix showed how those mediators converged on insulin resistance and fatty liver; prioritisation put safety and sleep first; phasing kept the plan manageable; and follow up adapted it when life intervened. The method, not any one technique, made the difference.