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| Meta Description | Chronic cough, possibly due to toxicant exposure, may be improved by using a low-risk nutrition-centred strategy. A 71-year-old man experiencing chronic cough for the past 25 years presented to the Cleveland Clinic. In recent years, the patient’s ... | |||||||||
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| Boilerpipe Text | Abstract
Chronic cough, possibly due to toxicant exposure, may be improved by using a low-risk nutrition-centred strategy. A 71-year-old man experiencing chronic cough for the past 25 years presented to the Cleveland Clinic. In recent years, the patient’s cough had increased in frequency and intensity despite pulmonary interventions. The patient’s social history revealed exposures as a foundry worker to dimethylethylamine and triethylamine two known respiratory irritants. The patient was placed on a nutrition programme (nutrient dense, low glycaemic index and anti-inflammatory), encouraged to use a sauna each day and placed on nutraceutical supplementation that supports liver detoxification, digestive health and inflammation reduction. Over the course of approximately 1 year, the patient experienced improvement in his cough despite the discontinuation of formal, intensive pulmonary therapy. The patient also experienced weight loss, lower blood pressure and glycaemic status improvement, as well as decreased fatigue and increased energy.
Keywords:
nutrition, exposures, vitamins and supplements, diabetes
Introduction
The relationship between occupational exposures, their impact on healthy physiological function and the appearance of chronic disease are often underappreciated.
1
We employed a functional medicine approach that examined an extensive medical history with multiple medical problems to identify lifestyle choices and occupational exposures that adversely impacted this patient’s long-term health. This approach offered strategic clues as to how best to restore healthy function. We recommended dietary changes, nutraceutical supplementation, and lifestyle modification, along with conventional medical treatment. Over the course of a year of treatment and follow-up, this patient experienced objective and subjective improvements in health. This case report was prepared according to the CARE Guidelines.
2
Case presentation
Initial visit (August 2015)
A 71-year-old man presented to Cleveland Clinic complaining of a 25-year history of cough that had become more frequent and intense over the previous 3 years (
figure 1
). His cough was characterised by both dryness and intermittent bouts of increased mucous production. It was often exacerbated after consumption of certain foods, seasonal weather changes or exposure to allergens. The coughing spells usually occurred continuously throughout the day but worsened after lying down. The patient’s primary goal for the visit was to reduce or eliminate his chronic cough symptoms.
Figure 1.
Medical history timeline. DMEA, dimethylethylamine; TEA, triethylamine.
History
The patient is married with three grown children, all of whom expressed concern for his health. He reported a 20-pack-year smoking history that ended about 25 years ago (
figure 1
). From 1978 to 1998, the patient worked in aerospace manufacturing company and was exposed to various chemicals including aerosolised aluminium, dimethylethylamine (DMEA) and triethylamine (TEA) (
figure 1
).
In addition to his chronic cough, the patient also had a 10+-year history of hyperlipidaemia, gout and type 2 diabetes mellitus (T2DM) without use of insulin therapy (
figure 1
). He reported a family history of cardiovascular disease (father and maternal grandfather, both >55 years old at onset). At his initial visit, the patient indicated the use of multiple medications to manage his T2DM (
table 1
) as well as the use of a point-of-care glucose monitor.
Table 1.
Medication and nutraceutical supplementation list
Name
Prior to initial visit
August* 2015
October 2015
December 2015
August 2016
Pioglitazone and metformin
15–500 mg twice daily
Metformin
500 mg twice daily
Sitagliptin
100 mg QD
Colchicine
0.6 mg QD
0.6 mg PRN
Allopurinol
300 mg QD
Valsartan
80 mg QD
40 mg QD
Simvastatin
40 mg QD
Amitriptyline
10 mg hs
Aspirin, enteric coated
81 mg twice daily
81 mg QD
Glucosamine HCL, oral
Multivitamin (Daily Multiple)
QD
ALA
QD
Pyrophyllite healing clay and activated charcoal
QD
Selenium, milk thistle, NAC, ALA
TID
Milk thistle, artichoke, turmeric, NAC, ALA, luteolin, ascorbyl palmitate
QD
Probiotic 50B CFUs (
Lactobacillus rhamnosus, Lactobacillus casei
and
Bifidobacterium bifidum
)
QD
Modified citrus pectin
QD
Glutathione
QD
Magnesium citrate
QD
Omega-3 fatty acids (EPA/DHA)
4600 mg twice daily
3500 mg
Grey shading denotes use of the medication/supplementation.
*Initial visit.
ALA, alpha-lipoic acid; CFU, colony-forming unit; DHA, docosahexaenoic acid; EPA, eicosapentaenoic acid; hs, hora somni or at bedtime; NAC, n-acetyl-l-cysteine; PRN, pro re nata or as needed; QD, once a day.
From 2012 to 2013, the patient had been evaluated by specialists in pulmonology, gastroenterology, allergy and immunology for his chronic cough (
figure 1
). He was diagnosed with chronic rhinitis and mild pulmonary restriction on pulmonary function testing with normal diffusing lung capacity of oxygen. He also recorded a negative methacholine challenge test. The patient was treated with a course of prednisolone and experienced short-term improvement, but his symptoms returned soon after completion of prednisolone. Numerous other medications that target allergies and inflammation had been ineffective including albuterol sulfate, fluticasone, montelukast, fexofenadine-pseudoephedrine, intranasal triamcinolone acetonide, mometasone and olopatadine. In 2012, the patient sought an initial gastroenterology opinion where an upper gastrointestinal series revealed oesophageal dismotility, and he was diagnosed with duodenitis. In 2013, the patient underwent oesophageal manometry and was diagnosed with duodenitis and laryngopharyngeal reflux and treated with high-dose omeprazole therapy twice daily for at least 4 months with no significant improvement in his cough. The diagnoses of duodenitis and laryngopharyngeal reflux were not felt to be contributing factors to his chronic cough per his treating physician.
Initial clinical findings
The patient presented to the Center for Functional Medicine in August of 2015. In addition to his primary symptoms, he was overweight with isolated systolic hypertension (
table 2
; August 2015). Initial laboratory testing revealed an abnormal high-sensitivity C reactive protein, impaired fasting glucose and well-controlled low-density lipoprotein (LDL) cholesterol levels (
table 3
; August 2015).
Table 2.
Biometric and physical examination results
Biometrics
August 2015
October 2015
December 2015
August 2016
March 2017
Height (inches)
70.9
Weight (kg)
96.16
88.90
83.91
81.65
85.28
BMI (kg/m
2
)
29.64
27.43
25.93
25.24
26.97
Blood pressure (mm Hg)
145/67
114/57
103/52
110/51
120/60
Physical examination*
Mouth—teeth
7 amalgams
7 amalgams
7 amalgams
7 amalgams
Heart
Somewhat distant, but otherwise regular rate and rhythm without murmur, gallop or rubs. No ectopy
Lungs
Clear to auscultation. No wheezing or ronchi
Extremities
Vertical ridging in fingernails
Vertical ridging in fingernails
Vertical ridging in fingernails
*All other physical examination results were within normal limits.
BMI, body mass index.
Table 3.
Laboratory results
Test
Reference range
August 2015
October 2015
December 2015
August 2017
March 2017
November 2017
hsCRP (mg/L)
<1.0
5.4
Fasting glucose (mg/dL)
65–99
102
89
Insulin, total (uU/mL)
1–24
5.2
HbA1c (%)
4.3–5.6
6.3
5.7
6.0
5.8
5.8
Total cholesterol (mg/dL)
125–200
121
LDL-C (mg/dL)
<130
57
HDL-C (mg/dL)
≥40
47
Triglycerides (mg/dL)
<150
83
Non-HDL-C (mg/dL)
<130
73
ALT (U/L)
9–46
11
AST (U/L)
10–35
17
Vitamin D (ng/mL)
31.0–80.0
41.3
Bold, abnormal results.
ALT, alanine aminotransferase; AST, aspartate aminotransferase; HbA1c, glycated haemoglobin; HDL-C, high-density lipoprotein cholesterol; LDL, low-density lipoprotein cholesterol.
Investigations
Diagnostic assessment
His chronic cough was thought to be secondary to tobacco use and also related to his long-term occupational exposure to DMEA and TEA, in part because previous interventions with steroids and a proton-pump inhibitor had not resolved the cough. In addition, the occupational health literature reports that DMEA, TEA and small silica sand particles produced during foundry processes can result in respiratory conditions that may present as persistent cough.
3
Treatment
Recommendations
The patient was placed on an anti-inflammatory, low glycaemic index, nutrient-dense food plan under the supervision of a registered dietitian working in partnership with the treating physician. Nutraceutical supplementation was also recommended to augment gut function and elimination of environmental toxicants (
table 1
; August 2015). The patient was directed to sit in a dry sauna 30–60 min and drink 3 to 4 L of natural spring water each day. If able, the patient was also encouraged to participate in aerobic exercise such as walking or swimming multiple times each week. Statin therapy was discontinued as a shared medical decision based on the patient’s LDL cholesterol results, well-controlled T2DM and concurrent presenting complaint of fatigue and muscle discomfort suggesting statin myopathy.
i
Outcome and follow-up
Follow-up and outcomes
Prior to his first follow-up visit, the patient reported fasting morning glucose values in the upper 80 s to mid-90s. Based on this information, his sitagliptin was discontinued, but he remained on pioglitazone/metformin combination therapy.
At his first follow-up visit in 6 weeks, the patient reported that his cough was 75% improved. He noted less mucous production and no severe coughing spells for 3 to 5 weeks prior to the date of the follow visit. His wife and other family members also reported noticeably less coughing. Additionally, the patient had lost 7.26 kilograms and lowered his blood pressure during the first 6 weeks (
table 2
; October 2015). The patient reported low energy and some irritability that he attributed to the food plan and sauna therapy.
Based on the improvement in anthropometric and metabolic measurements (
table 2
; October 2015), the patient was able to reduce his dose of valsartan and discontinue use of pioglitazone but continued the use of metformin monotherapy (
table 1
; October 2015). Allopurinol was also discontinued due to absence of gout attacks for 2 years, and the patient was advised to use colchicine as needed for flare ups (
table 1
; October 2015).
During four sequential follow-up visits, the patient reported continued improvement in his chronic cough. In addition, he continued to lose weight and experience reduction in his blood pressure (
table 2
). At the December 2015 visit, the patient was directed to progressively wean off of his supplementation but remains on an omega-3 fatty acid supplement, metformin, valsartan, baby aspirin and colchicine (as needed) (
table 1
).
At his 1-year follow-up visit in August 2016, the patient reported that his chronic cough symptoms continued to resolve. He maintained his weight loss, reduced blood pressure, adhered to the recommended exercise programme and reported having more energy (
table 2
; August 2016). The glycated haemoglobin (HbA1c) value reported by his primary care physician was 6.0% with occasional morning glucose values no higher than 115–120 mg/dL (
table 3
; August 2016). In March 2017, approximately half year after discharge, the patient reported his HbA1c value to be 5.8% (
table 3
) and has maintained his weight loss and reduced blood pressure (
table 2
). The HbA1c value of 5.8% was maintained through November 2017 (
table 3
).
Discussion
The incidence of chronic disease in the USA has become an epidemic due to various factors including poor diet, inactivity, stress and environmental exposures.
4
This patient’s chronic medical problems appeared to be related to many of these factors, and he improved with a functional medicine approach that targeted changes in diet and lifestyle, combined with conventional medications and nutraceutical supplementation.
5
Our working hypothesis was that a reduction in the inflammatory burden related to a history of occupational exposures, T2DM and cardiovascular disease was likely to respond to an anti-inflammatory diet, nutraceutical supplementation and lifestyle changes. This approach supports a reduction in inflammation and upregulation of metabolic detoxification.
6
DMEA and TEA are gas catalysts used in the foundry process during core production.
7
Both compounds along with free silica particulates are made airborne during the foundry process. They have been implicated in various conditions including silicosis and pulmonary fibrosis and can produce abnormalities consistent with reduced pulmonary function testing
3 8
which this patient had recorded in 2012 (
figure 1
). DMEA and TEA have deleterious physiological effects on the body when absorbed through the skin and respiratory and gastrointestinal tracts. Dermal exposure to DMEA and TEA can be corrosive to the skin.
7
Further, when both compounds are aerosolised they can irritate the mucous membranes of the eye and result in visual disturbances.
7
Additionally, these compounds can irritate the nose or throat and result in cough and respiratory distress.
3 7
Systemically, these tertiary amines can also initiate the release of histamine from mast cells.
7
It is pertinent to mention that a chest X-ray in November 2012 was not suspicious for silicosis or pulmonary fibrosis. Ideally, laboratory measurement of DMEA and TEA levels in the body by way of a clinical reference laboratory prior to and following treatment would demonstrate the effectiveness of treatment, but such tests were not available when we saw this patient. Therefore, we sought to manage the patient using a low-risk biotransformation and elimination strategy (
table 4
) focused on the improvement of his chronic cough symptoms.
Table 4.
Biotransformation and elimination strategy
Supporting detoxification
Recommendation
Minimise exogenous toxic exposure
Eat fresh, non-processed, organic (if possible) foods.
Ensure adequate hydration
Increase water intake to facilitate expulsion of toxicants.
Promote healthy toxin binding and excretion
Pyrophyllite healing clay and activated charcoal as toxicant binders. Use magnesium citrate to facilitate expulsion of toxicants via stool.
Gastrointestinal microbiological restoration/balance
Supplement with modified citrus pectin and a prebiotic/probiotic.
Assist and balance endogenous biotransformation of toxicants
Ensure adequate protein source for enzyme production.
Supplement with NAC and ALA (conjugate precursors for phase II reactions) as well as vitamin B
12
, selenium and milk thistle (enzymatic cofactors for phase I and phase II reactions).
Increase sweating
Use a dry sauna and increase aerobic/anaerobic exercise.
Enhance antioxidants
Supplement with NAC and ALA and consume fresh, colourful foods.
Downregulate inflammation with essential fatty acids
Supplement with omega-3 fatty acids.
ALA, alpha-lipoic acid; NAC, n-acetyl-l-cysteine.
The patient was placed on an anti-inflammatory, low glycaemic index, nutrient-dense food plan under the supervision of a registered dietitian working in partnership with the treating physician. Nutraceutical supplementation was employed as an adjunct to nutritional recommendations to improve micronutrient levels.
9
The food plan encouraged the consumption of fresh, non-processed foods (mostly vegetables), and the elimination of highly processed foods and foods containing dairy, sugar and gluten. This food plan works to optimise the function of the gut, improve phase I and phase II detoxification processes and reduce the inflammatory burden on the immune system.
10
The food plan also supported insulin sensitisation and in this patient resulted in appropriate weight loss.
11–13
The beneficial effects of plant-based nutrition for the prevention and treatment of chronic conditions such as obesity, T2DM, cardiovascular disease and hypertension are well documented.
14 15
While the patient was not on a strict vegetarian diet, he was encouraged to eat fresh, bright-coloured vegetables and low glycaemic index fruits. Both contain large amounts of fibre and phytonutrients which have been shown to improve insulin resistance
15
and reduce inflammatory status.
16
In addition, the consumption of fibre from fruits may reduce the incidence of chronic respiratory symptoms (ie, cough with phlegm)
17 18
and improve pulmonary function.
18
Thermal depuration, or sweating, is an essential lifestyle recommendation and has many positive effects. Sweating mimics the physiological effects of exercise,
19
facilitates the removal of environmental toxins from the body
20
and improves function in those with respiratory conditions.
21
Once the patient felt well enough to exercise, he was able to reduce the frequency of visits to the sauna.
An extensive medical history and detailed timeline reveals many factors that may influence a patient’s long-term health and the development of chronic disease. This may help identify proximal causes of chronic disease that can give rise to low-risk, high-impact treatment strategies. In addition, therapies that leverage and support the body’s intrinsic resilience mechanisms—particularly nutrition—may promote sustainable health and wellness.
Conclusion
This case illustrates how a low-risk approach that leverages nutrition and lifestyle changes may support the self-healing capacities of the body. Given the patient’s occupational exposure history, previous evaluations and interventions, we hypothesised that his respiratory exposure to DMEA and TEA may have been, in part, responsible for his cough. In addition, benefits of a treatment strategy that focuses on nutrition may extend beyond an individual’s chief complaint positively impacting multiple domains of health.
Patient’s perspective.
For 25 years I lived with a chronic cough. Since I began the programme with Functional Medicine, I’ve reduced my chronic cough by 85%. By going gluten-free and also following a very controlled diet I’ve lost 55 pounds and gained control of my blood sugar count. I have also reduced my prior medications by 50%.
Learning points.
A functional medicine approach may lead to better outcomes in alignment with a patient’s healthcare goals. This low-risk approach leverages nutrition and lifestyle changes to support the self-healing capacities of the body.
Occupational exposures may contribute to chronic cough, physiological dysfunction and complex, chronic disease.
Low-risk nutritional interventions along with nutraceutical supplementation that support biotransformation and elimination may be beneficial for patients with chronic cough secondary to occupational exposures.
Acknowledgments
The authors would like to thank Cleveland Clinic Center for Functional Medicine. The authors would also like to thank Dr Patrick Hanaway and Dr Mark Hyman for their editorial contributions.
Footnotes
i
The 2013 ACC/AHA Guidelines which state that diabetes is a coronary equivalent were discussed with the patient. The patient had no known personal history of heart disease or early-onset family history of heart disease.
Contributors:
NB: Patient management, collection of data, writing and editing. DSR: Editing and structuring of case. MB: Writing, review of literature, editing and structuring of case.
Funding:
The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests:
None declared.
Patient consent:
Obtained.
Provenance and peer review:
Not commissioned; externally peer reviewed.
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# Diet and lifestyle recommendations for the treatment of chronic cough and chronic disease
[Nathaniel Bergman](https://pubmed.ncbi.nlm.nih.gov/?term="Bergman%20N"[Author])
### Nathaniel Bergman
1Cleveland Clinic, Cleveland, Ohio, USA
Find articles by [Nathaniel Bergman](https://pubmed.ncbi.nlm.nih.gov/?term="Bergman%20N"[Author])
1, [David S Riley](https://pubmed.ncbi.nlm.nih.gov/?term="Riley%20DS"[Author])
### David S Riley
2Integrative Medicine Institute, Portland, Oregon, USA
Find articles by [David S Riley](https://pubmed.ncbi.nlm.nih.gov/?term="Riley%20DS"[Author])
2, [Michelle Beidelschies](https://pubmed.ncbi.nlm.nih.gov/?term="Beidelschies%20M"[Author])
### Michelle Beidelschies
1Cleveland Clinic, Cleveland, Ohio, USA
Find articles by [Michelle Beidelschies](https://pubmed.ncbi.nlm.nih.gov/?term="Beidelschies%20M"[Author])
1
- Author information
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1Cleveland Clinic, Cleveland, Ohio, USA
2Integrative Medicine Institute, Portland, Oregon, USA
✉
Correspondence to Dr Michelle Beidelschies, beidelm2@ccf.org
### Series information
Case Report
Accepted 2018 Mar 21; Collection date 2018.
© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
[PMC Copyright notice](https://pmc.ncbi.nlm.nih.gov/about/copyright/)
PMCID: PMC5935174 PMID: [29724872](https://pubmed.ncbi.nlm.nih.gov/29724872/)
## Abstract
Chronic cough, possibly due to toxicant exposure, may be improved by using a low-risk nutrition-centred strategy. A 71-year-old man experiencing chronic cough for the past 25 years presented to the Cleveland Clinic. In recent years, the patient’s cough had increased in frequency and intensity despite pulmonary interventions. The patient’s social history revealed exposures as a foundry worker to dimethylethylamine and triethylamine two known respiratory irritants. The patient was placed on a nutrition programme (nutrient dense, low glycaemic index and anti-inflammatory), encouraged to use a sauna each day and placed on nutraceutical supplementation that supports liver detoxification, digestive health and inflammation reduction. Over the course of approximately 1 year, the patient experienced improvement in his cough despite the discontinuation of formal, intensive pulmonary therapy. The patient also experienced weight loss, lower blood pressure and glycaemic status improvement, as well as decreased fatigue and increased energy.
**Keywords:** nutrition, exposures, vitamins and supplements, diabetes
## Introduction
The relationship between occupational exposures, their impact on healthy physiological function and the appearance of chronic disease are often underappreciated.[1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R1) We employed a functional medicine approach that examined an extensive medical history with multiple medical problems to identify lifestyle choices and occupational exposures that adversely impacted this patient’s long-term health. This approach offered strategic clues as to how best to restore healthy function. We recommended dietary changes, nutraceutical supplementation, and lifestyle modification, along with conventional medical treatment. Over the course of a year of treatment and follow-up, this patient experienced objective and subjective improvements in health. This case report was prepared according to the CARE Guidelines.[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R2)
## Case presentation
### Initial visit (August 2015)
A 71-year-old man presented to Cleveland Clinic complaining of a 25-year history of cough that had become more frequent and intense over the previous 3 years ([figure 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#F1)). His cough was characterised by both dryness and intermittent bouts of increased mucous production. It was often exacerbated after consumption of certain foods, seasonal weather changes or exposure to allergens. The coughing spells usually occurred continuously throughout the day but worsened after lying down. The patient’s primary goal for the visit was to reduce or eliminate his chronic cough symptoms.
#### Figure 1.
[](https://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=5935174_bcr-2017-223685f01.jpg)
[Open in a new tab](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/figure/F1/)
Medical history timeline. DMEA, dimethylethylamine; TEA, triethylamine.
### History
The patient is married with three grown children, all of whom expressed concern for his health. He reported a 20-pack-year smoking history that ended about 25 years ago ([figure 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#F1)). From 1978 to 1998, the patient worked in aerospace manufacturing company and was exposed to various chemicals including aerosolised aluminium, dimethylethylamine (DMEA) and triethylamine (TEA) ([figure 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#F1)).
In addition to his chronic cough, the patient also had a 10+-year history of hyperlipidaemia, gout and type 2 diabetes mellitus (T2DM) without use of insulin therapy ([figure 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#F1)). He reported a family history of cardiovascular disease (father and maternal grandfather, both \>55 years old at onset). At his initial visit, the patient indicated the use of multiple medications to manage his T2DM ([table 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T1)) as well as the use of a point-of-care glucose monitor.
#### Table 1.
Medication and nutraceutical supplementation list
| | | | | | |
|---|---|---|---|---|---|
| Name | Prior to initial visit | August\* 2015 | October 2015 | December 2015 | August 2016 |
| Pioglitazone and metformin | 15–500 mg twice daily | | | | |
| Metformin | | | 500 mg twice daily | | |
| Sitagliptin | 100 mg QD | | | | |
| Colchicine | 0\.6 mg QD | | 0\.6 mg PRN | | |
| Allopurinol | 300 mg QD | | | | |
| Valsartan | 80 mg QD | | 40 mg QD | | |
| Simvastatin | 40 mg QD | | | | |
| Amitriptyline | 10 mg hs | | | | |
| Aspirin, enteric coated | 81 mg twice daily | 81 mg QD | | | |
| Glucosamine HCL, oral | | | | | |
| Multivitamin (Daily Multiple) | QD | | | | |
| ALA | | QD | | | |
| Pyrophyllite healing clay and activated charcoal | | QD | | | |
| Selenium, milk thistle, NAC, ALA | | TID | | | |
| Milk thistle, artichoke, turmeric, NAC, ALA, luteolin, ascorbyl palmitate | | QD | | | |
| Probiotic 50B CFUs (*Lactobacillus rhamnosus, Lactobacillus casei* and *Bifidobacterium bifidum*) | | QD | | | |
| Modified citrus pectin | | QD | | | |
| Glutathione | | QD | | | |
| Magnesium citrate | | QD | | | |
| Omega-3 fatty acids (EPA/DHA) | | 4600 mg twice daily | | 3500 mg | |
[Open in a new tab](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/table/T1/)
Grey shading denotes use of the medication/supplementation.
\*Initial visit.
ALA, alpha-lipoic acid; CFU, colony-forming unit; DHA, docosahexaenoic acid; EPA, eicosapentaenoic acid; hs, hora somni or at bedtime; NAC, n-acetyl-l-cysteine; PRN, pro re nata or as needed; QD, once a day.
From 2012 to 2013, the patient had been evaluated by specialists in pulmonology, gastroenterology, allergy and immunology for his chronic cough ([figure 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#F1)). He was diagnosed with chronic rhinitis and mild pulmonary restriction on pulmonary function testing with normal diffusing lung capacity of oxygen. He also recorded a negative methacholine challenge test. The patient was treated with a course of prednisolone and experienced short-term improvement, but his symptoms returned soon after completion of prednisolone. Numerous other medications that target allergies and inflammation had been ineffective including albuterol sulfate, fluticasone, montelukast, fexofenadine-pseudoephedrine, intranasal triamcinolone acetonide, mometasone and olopatadine. In 2012, the patient sought an initial gastroenterology opinion where an upper gastrointestinal series revealed oesophageal dismotility, and he was diagnosed with duodenitis. In 2013, the patient underwent oesophageal manometry and was diagnosed with duodenitis and laryngopharyngeal reflux and treated with high-dose omeprazole therapy twice daily for at least 4 months with no significant improvement in his cough. The diagnoses of duodenitis and laryngopharyngeal reflux were not felt to be contributing factors to his chronic cough per his treating physician.
### Initial clinical findings
The patient presented to the Center for Functional Medicine in August of 2015. In addition to his primary symptoms, he was overweight with isolated systolic hypertension ([table 2](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T2); August 2015). Initial laboratory testing revealed an abnormal high-sensitivity C reactive protein, impaired fasting glucose and well-controlled low-density lipoprotein (LDL) cholesterol levels ([table 3](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T3); August 2015).
#### Table 2.
Biometric and physical examination results
| | | | | | |
|---|---|---|---|---|---|
| Biometrics | August 2015 | October 2015 | December 2015 | August 2016 | March 2017 |
| Height (inches) | 70\.9 | | | | |
| Weight (kg) | 96\.16 | 88\.90 | 83\.91 | 81\.65 | 85\.28 |
| BMI (kg/m2) | 29\.64 | 27\.43 | 25\.93 | 25\.24 | 26\.97 |
| Blood pressure (mm Hg) | 145/67 | 114/57 | 103/52 | 110/51 | 120/60 |
| Physical examination\* | | | | | |
| Mouth—teeth | 7 amalgams | 7 amalgams | 7 amalgams | 7 amalgams | |
| Heart | Somewhat distant, but otherwise regular rate and rhythm without murmur, gallop or rubs. No ectopy | | | | |
| Lungs | Clear to auscultation. No wheezing or ronchi | | | | |
| Extremities | Vertical ridging in fingernails | Vertical ridging in fingernails | | Vertical ridging in fingernails | |
[Open in a new tab](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/table/T2/)
\*All other physical examination results were within normal limits.
BMI, body mass index.
#### Table 3.
Laboratory results
| | | | | | | | |
|---|---|---|---|---|---|---|---|
| Test | Reference range | August 2015 | October 2015 | December 2015 | August 2017 | March 2017 | November 2017 |
| hsCRP (mg/L) | \<1.0 | **5\.4** | | | | | |
| Fasting glucose (mg/dL) | 65–99 | **102** | 89 | | | | |
| Insulin, total (uU/mL) | 1–24 | | 5\.2 | | | | |
| HbA1c (%) | 4\.3–5.6 | | **6\.3** | 5\.7 | **6\.0** | **5\.8** | **5\.8** |
| Total cholesterol (mg/dL) | 125–200 | **121** | | | | | |
| LDL-C (mg/dL) | \<130 | 57 | | | | | |
| HDL-C (mg/dL) | ≥40 | 47 | | | | | |
| Triglycerides (mg/dL) | \<150 | 83 | | | | | |
| Non-HDL-C (mg/dL) | \<130 | 73 | | | | | |
| ALT (U/L) | 9–46 | 11 | | | | | |
| AST (U/L) | 10–35 | 17 | | | | | |
| Vitamin D (ng/mL) | 31\.0–80.0 | 41\.3 | | | | | |
[Open in a new tab](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/table/T3/)
Bold, abnormal results.
ALT, alanine aminotransferase; AST, aspartate aminotransferase; HbA1c, glycated haemoglobin; HDL-C, high-density lipoprotein cholesterol; LDL, low-density lipoprotein cholesterol.
## Investigations
### Diagnostic assessment
His chronic cough was thought to be secondary to tobacco use and also related to his long-term occupational exposure to DMEA and TEA, in part because previous interventions with steroids and a proton-pump inhibitor had not resolved the cough. In addition, the occupational health literature reports that DMEA, TEA and small silica sand particles produced during foundry processes can result in respiratory conditions that may present as persistent cough.[3](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R3)
## Treatment
### Recommendations
The patient was placed on an anti-inflammatory, low glycaemic index, nutrient-dense food plan under the supervision of a registered dietitian working in partnership with the treating physician. Nutraceutical supplementation was also recommended to augment gut function and elimination of environmental toxicants ([table 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T1); August 2015). The patient was directed to sit in a dry sauna 30–60 min and drink 3 to 4 L of natural spring water each day. If able, the patient was also encouraged to participate in aerobic exercise such as walking or swimming multiple times each week. Statin therapy was discontinued as a shared medical decision based on the patient’s LDL cholesterol results, well-controlled T2DM and concurrent presenting complaint of fatigue and muscle discomfort suggesting statin myopathy.[i](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#fn1)
## Outcome and follow-up
### Follow-up and outcomes
Prior to his first follow-up visit, the patient reported fasting morning glucose values in the upper 80 s to mid-90s. Based on this information, his sitagliptin was discontinued, but he remained on pioglitazone/metformin combination therapy.
At his first follow-up visit in 6 weeks, the patient reported that his cough was 75% improved. He noted less mucous production and no severe coughing spells for 3 to 5 weeks prior to the date of the follow visit. His wife and other family members also reported noticeably less coughing. Additionally, the patient had lost 7.26 kilograms and lowered his blood pressure during the first 6 weeks ([table 2](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T2); October 2015). The patient reported low energy and some irritability that he attributed to the food plan and sauna therapy.
Based on the improvement in anthropometric and metabolic measurements ([table 2](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T2); October 2015), the patient was able to reduce his dose of valsartan and discontinue use of pioglitazone but continued the use of metformin monotherapy ([table 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T1); October 2015). Allopurinol was also discontinued due to absence of gout attacks for 2 years, and the patient was advised to use colchicine as needed for flare ups ([table 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T1); October 2015).
During four sequential follow-up visits, the patient reported continued improvement in his chronic cough. In addition, he continued to lose weight and experience reduction in his blood pressure ([table 2](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T2)). At the December 2015 visit, the patient was directed to progressively wean off of his supplementation but remains on an omega-3 fatty acid supplement, metformin, valsartan, baby aspirin and colchicine (as needed) ([table 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T1)).
At his 1-year follow-up visit in August 2016, the patient reported that his chronic cough symptoms continued to resolve. He maintained his weight loss, reduced blood pressure, adhered to the recommended exercise programme and reported having more energy ([table 2](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T2); August 2016). The glycated haemoglobin (HbA1c) value reported by his primary care physician was 6.0% with occasional morning glucose values no higher than 115–120 mg/dL ([table 3](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T3); August 2016). In March 2017, approximately half year after discharge, the patient reported his HbA1c value to be 5.8% ([table 3](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T3)) and has maintained his weight loss and reduced blood pressure ([table 2](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T2)). The HbA1c value of 5.8% was maintained through November 2017 ([table 3](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T3)).
## Discussion
The incidence of chronic disease in the USA has become an epidemic due to various factors including poor diet, inactivity, stress and environmental exposures.[4](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R4) This patient’s chronic medical problems appeared to be related to many of these factors, and he improved with a functional medicine approach that targeted changes in diet and lifestyle, combined with conventional medications and nutraceutical supplementation.[5](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R5) Our working hypothesis was that a reduction in the inflammatory burden related to a history of occupational exposures, T2DM and cardiovascular disease was likely to respond to an anti-inflammatory diet, nutraceutical supplementation and lifestyle changes. This approach supports a reduction in inflammation and upregulation of metabolic detoxification.[6](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R6)
DMEA and TEA are gas catalysts used in the foundry process during core production.[7](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R7) Both compounds along with free silica particulates are made airborne during the foundry process. They have been implicated in various conditions including silicosis and pulmonary fibrosis and can produce abnormalities consistent with reduced pulmonary function testing[3 8](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R3) which this patient had recorded in 2012 ([figure 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#F1)). DMEA and TEA have deleterious physiological effects on the body when absorbed through the skin and respiratory and gastrointestinal tracts. Dermal exposure to DMEA and TEA can be corrosive to the skin.[7](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R7) Further, when both compounds are aerosolised they can irritate the mucous membranes of the eye and result in visual disturbances.[7](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R7) Additionally, these compounds can irritate the nose or throat and result in cough and respiratory distress.[3 7](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R3) Systemically, these tertiary amines can also initiate the release of histamine from mast cells.[7](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R7)
It is pertinent to mention that a chest X-ray in November 2012 was not suspicious for silicosis or pulmonary fibrosis. Ideally, laboratory measurement of DMEA and TEA levels in the body by way of a clinical reference laboratory prior to and following treatment would demonstrate the effectiveness of treatment, but such tests were not available when we saw this patient. Therefore, we sought to manage the patient using a low-risk biotransformation and elimination strategy ([table 4](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T4)) focused on the improvement of his chronic cough symptoms.
### Table 4.
Biotransformation and elimination strategy
| | |
|---|---|
| Supporting detoxification | Recommendation |
| Minimise exogenous toxic exposure | Eat fresh, non-processed, organic (if possible) foods. |
| Ensure adequate hydration | Increase water intake to facilitate expulsion of toxicants. |
| Promote healthy toxin binding and excretion | Pyrophyllite healing clay and activated charcoal as toxicant binders. Use magnesium citrate to facilitate expulsion of toxicants via stool. |
| Gastrointestinal microbiological restoration/balance | Supplement with modified citrus pectin and a prebiotic/probiotic. |
| Assist and balance endogenous biotransformation of toxicants | Ensure adequate protein source for enzyme production. Supplement with NAC and ALA (conjugate precursors for phase II reactions) as well as vitamin B12, selenium and milk thistle (enzymatic cofactors for phase I and phase II reactions). |
| Increase sweating | Use a dry sauna and increase aerobic/anaerobic exercise. |
| Enhance antioxidants | Supplement with NAC and ALA and consume fresh, colourful foods. |
| Downregulate inflammation with essential fatty acids | Supplement with omega-3 fatty acids. |
[Open in a new tab](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/table/T4/)
ALA, alpha-lipoic acid; NAC, n-acetyl-l-cysteine.
The patient was placed on an anti-inflammatory, low glycaemic index, nutrient-dense food plan under the supervision of a registered dietitian working in partnership with the treating physician. Nutraceutical supplementation was employed as an adjunct to nutritional recommendations to improve micronutrient levels.[9](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R9) The food plan encouraged the consumption of fresh, non-processed foods (mostly vegetables), and the elimination of highly processed foods and foods containing dairy, sugar and gluten. This food plan works to optimise the function of the gut, improve phase I and phase II detoxification processes and reduce the inflammatory burden on the immune system.[10](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R10) The food plan also supported insulin sensitisation and in this patient resulted in appropriate weight loss.[11–13](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R11)
The beneficial effects of plant-based nutrition for the prevention and treatment of chronic conditions such as obesity, T2DM, cardiovascular disease and hypertension are well documented.[14 15](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R14) While the patient was not on a strict vegetarian diet, he was encouraged to eat fresh, bright-coloured vegetables and low glycaemic index fruits. Both contain large amounts of fibre and phytonutrients which have been shown to improve insulin resistance[15](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R15) and reduce inflammatory status.[16](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R16) In addition, the consumption of fibre from fruits may reduce the incidence of chronic respiratory symptoms (ie, cough with phlegm)[17 18](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R17) and improve pulmonary function.[18](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R18)
Thermal depuration, or sweating, is an essential lifestyle recommendation and has many positive effects. Sweating mimics the physiological effects of exercise,[19](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R19) facilitates the removal of environmental toxins from the body[20](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R20) and improves function in those with respiratory conditions.[21](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R21) Once the patient felt well enough to exercise, he was able to reduce the frequency of visits to the sauna.
An extensive medical history and detailed timeline reveals many factors that may influence a patient’s long-term health and the development of chronic disease. This may help identify proximal causes of chronic disease that can give rise to low-risk, high-impact treatment strategies. In addition, therapies that leverage and support the body’s intrinsic resilience mechanisms—particularly nutrition—may promote sustainable health and wellness.
## Conclusion
This case illustrates how a low-risk approach that leverages nutrition and lifestyle changes may support the self-healing capacities of the body. Given the patient’s occupational exposure history, previous evaluations and interventions, we hypothesised that his respiratory exposure to DMEA and TEA may have been, in part, responsible for his cough. In addition, benefits of a treatment strategy that focuses on nutrition may extend beyond an individual’s chief complaint positively impacting multiple domains of health.
### Patient’s perspective.
For 25 years I lived with a chronic cough. Since I began the programme with Functional Medicine, I’ve reduced my chronic cough by 85%. By going gluten-free and also following a very controlled diet I’ve lost 55 pounds and gained control of my blood sugar count. I have also reduced my prior medications by 50%.
### Learning points.
- A functional medicine approach may lead to better outcomes in alignment with a patient’s healthcare goals. This low-risk approach leverages nutrition and lifestyle changes to support the self-healing capacities of the body.
- Occupational exposures may contribute to chronic cough, physiological dysfunction and complex, chronic disease.
- Low-risk nutritional interventions along with nutraceutical supplementation that support biotransformation and elimination may be beneficial for patients with chronic cough secondary to occupational exposures.
## Acknowledgments
The authors would like to thank Cleveland Clinic Center for Functional Medicine. The authors would also like to thank Dr Patrick Hanaway and Dr Mark Hyman for their editorial contributions.
## Footnotes
i
The 2013 ACC/AHA Guidelines which state that diabetes is a coronary equivalent were discussed with the patient. The patient had no known personal history of heart disease or early-onset family history of heart disease.
**Contributors:** NB: Patient management, collection of data, writing and editing. DSR: Editing and structuring of case. MB: Writing, review of literature, editing and structuring of case.
**Funding:** The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
**Competing interests:** None declared.
**Patient consent:** Obtained.
**Provenance and peer review:** Not commissioned; externally peer reviewed.
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***
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| Readable Markdown | ## Abstract
Chronic cough, possibly due to toxicant exposure, may be improved by using a low-risk nutrition-centred strategy. A 71-year-old man experiencing chronic cough for the past 25 years presented to the Cleveland Clinic. In recent years, the patient’s cough had increased in frequency and intensity despite pulmonary interventions. The patient’s social history revealed exposures as a foundry worker to dimethylethylamine and triethylamine two known respiratory irritants. The patient was placed on a nutrition programme (nutrient dense, low glycaemic index and anti-inflammatory), encouraged to use a sauna each day and placed on nutraceutical supplementation that supports liver detoxification, digestive health and inflammation reduction. Over the course of approximately 1 year, the patient experienced improvement in his cough despite the discontinuation of formal, intensive pulmonary therapy. The patient also experienced weight loss, lower blood pressure and glycaemic status improvement, as well as decreased fatigue and increased energy.
**Keywords:** nutrition, exposures, vitamins and supplements, diabetes
## Introduction
The relationship between occupational exposures, their impact on healthy physiological function and the appearance of chronic disease are often underappreciated.[1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R1) We employed a functional medicine approach that examined an extensive medical history with multiple medical problems to identify lifestyle choices and occupational exposures that adversely impacted this patient’s long-term health. This approach offered strategic clues as to how best to restore healthy function. We recommended dietary changes, nutraceutical supplementation, and lifestyle modification, along with conventional medical treatment. Over the course of a year of treatment and follow-up, this patient experienced objective and subjective improvements in health. This case report was prepared according to the CARE Guidelines.[2](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R2)
## Case presentation
### Initial visit (August 2015)
A 71-year-old man presented to Cleveland Clinic complaining of a 25-year history of cough that had become more frequent and intense over the previous 3 years ([figure 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#F1)). His cough was characterised by both dryness and intermittent bouts of increased mucous production. It was often exacerbated after consumption of certain foods, seasonal weather changes or exposure to allergens. The coughing spells usually occurred continuously throughout the day but worsened after lying down. The patient’s primary goal for the visit was to reduce or eliminate his chronic cough symptoms.
#### Figure 1.
[](https://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=5935174_bcr-2017-223685f01.jpg)
Medical history timeline. DMEA, dimethylethylamine; TEA, triethylamine.
### History
The patient is married with three grown children, all of whom expressed concern for his health. He reported a 20-pack-year smoking history that ended about 25 years ago ([figure 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#F1)). From 1978 to 1998, the patient worked in aerospace manufacturing company and was exposed to various chemicals including aerosolised aluminium, dimethylethylamine (DMEA) and triethylamine (TEA) ([figure 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#F1)).
In addition to his chronic cough, the patient also had a 10+-year history of hyperlipidaemia, gout and type 2 diabetes mellitus (T2DM) without use of insulin therapy ([figure 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#F1)). He reported a family history of cardiovascular disease (father and maternal grandfather, both \>55 years old at onset). At his initial visit, the patient indicated the use of multiple medications to manage his T2DM ([table 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T1)) as well as the use of a point-of-care glucose monitor.
#### Table 1.
Medication and nutraceutical supplementation list
| | | | | | |
|---|---|---|---|---|---|
| Name | Prior to initial visit | August\* 2015 | October 2015 | December 2015 | August 2016 |
| Pioglitazone and metformin | 15–500 mg twice daily | | | | |
| Metformin | | | 500 mg twice daily | | |
| Sitagliptin | 100 mg QD | | | | |
| Colchicine | 0\.6 mg QD | | 0\.6 mg PRN | | |
| Allopurinol | 300 mg QD | | | | |
| Valsartan | 80 mg QD | | 40 mg QD | | |
| Simvastatin | 40 mg QD | | | | |
| Amitriptyline | 10 mg hs | | | | |
| Aspirin, enteric coated | 81 mg twice daily | 81 mg QD | | | |
| Glucosamine HCL, oral | | | | | |
| Multivitamin (Daily Multiple) | QD | | | | |
| ALA | | QD | | | |
| Pyrophyllite healing clay and activated charcoal | | QD | | | |
| Selenium, milk thistle, NAC, ALA | | TID | | | |
| Milk thistle, artichoke, turmeric, NAC, ALA, luteolin, ascorbyl palmitate | | QD | | | |
| Probiotic 50B CFUs (*Lactobacillus rhamnosus, Lactobacillus casei* and *Bifidobacterium bifidum*) | | QD | | | |
| Modified citrus pectin | | QD | | | |
| Glutathione | | QD | | | |
| Magnesium citrate | | QD | | | |
| Omega-3 fatty acids (EPA/DHA) | | 4600 mg twice daily | | 3500 mg | |
Grey shading denotes use of the medication/supplementation.
\*Initial visit.
ALA, alpha-lipoic acid; CFU, colony-forming unit; DHA, docosahexaenoic acid; EPA, eicosapentaenoic acid; hs, hora somni or at bedtime; NAC, n-acetyl-l-cysteine; PRN, pro re nata or as needed; QD, once a day.
From 2012 to 2013, the patient had been evaluated by specialists in pulmonology, gastroenterology, allergy and immunology for his chronic cough ([figure 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#F1)). He was diagnosed with chronic rhinitis and mild pulmonary restriction on pulmonary function testing with normal diffusing lung capacity of oxygen. He also recorded a negative methacholine challenge test. The patient was treated with a course of prednisolone and experienced short-term improvement, but his symptoms returned soon after completion of prednisolone. Numerous other medications that target allergies and inflammation had been ineffective including albuterol sulfate, fluticasone, montelukast, fexofenadine-pseudoephedrine, intranasal triamcinolone acetonide, mometasone and olopatadine. In 2012, the patient sought an initial gastroenterology opinion where an upper gastrointestinal series revealed oesophageal dismotility, and he was diagnosed with duodenitis. In 2013, the patient underwent oesophageal manometry and was diagnosed with duodenitis and laryngopharyngeal reflux and treated with high-dose omeprazole therapy twice daily for at least 4 months with no significant improvement in his cough. The diagnoses of duodenitis and laryngopharyngeal reflux were not felt to be contributing factors to his chronic cough per his treating physician.
### Initial clinical findings
The patient presented to the Center for Functional Medicine in August of 2015. In addition to his primary symptoms, he was overweight with isolated systolic hypertension ([table 2](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T2); August 2015). Initial laboratory testing revealed an abnormal high-sensitivity C reactive protein, impaired fasting glucose and well-controlled low-density lipoprotein (LDL) cholesterol levels ([table 3](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T3); August 2015).
#### Table 2.
Biometric and physical examination results
| | | | | | |
|---|---|---|---|---|---|
| Biometrics | August 2015 | October 2015 | December 2015 | August 2016 | March 2017 |
| Height (inches) | 70\.9 | | | | |
| Weight (kg) | 96\.16 | 88\.90 | 83\.91 | 81\.65 | 85\.28 |
| BMI (kg/m2) | 29\.64 | 27\.43 | 25\.93 | 25\.24 | 26\.97 |
| Blood pressure (mm Hg) | 145/67 | 114/57 | 103/52 | 110/51 | 120/60 |
| Physical examination\* | | | | | |
| Mouth—teeth | 7 amalgams | 7 amalgams | 7 amalgams | 7 amalgams | |
| Heart | Somewhat distant, but otherwise regular rate and rhythm without murmur, gallop or rubs. No ectopy | | | | |
| Lungs | Clear to auscultation. No wheezing or ronchi | | | | |
| Extremities | Vertical ridging in fingernails | Vertical ridging in fingernails | | Vertical ridging in fingernails | |
\*All other physical examination results were within normal limits.
BMI, body mass index.
#### Table 3.
Laboratory results
| | | | | | | | |
|---|---|---|---|---|---|---|---|
| Test | Reference range | August 2015 | October 2015 | December 2015 | August 2017 | March 2017 | November 2017 |
| hsCRP (mg/L) | \<1.0 | **5\.4** | | | | | |
| Fasting glucose (mg/dL) | 65–99 | **102** | 89 | | | | |
| Insulin, total (uU/mL) | 1–24 | | 5\.2 | | | | |
| HbA1c (%) | 4\.3–5.6 | | **6\.3** | 5\.7 | **6\.0** | **5\.8** | **5\.8** |
| Total cholesterol (mg/dL) | 125–200 | **121** | | | | | |
| LDL-C (mg/dL) | \<130 | 57 | | | | | |
| HDL-C (mg/dL) | ≥40 | 47 | | | | | |
| Triglycerides (mg/dL) | \<150 | 83 | | | | | |
| Non-HDL-C (mg/dL) | \<130 | 73 | | | | | |
| ALT (U/L) | 9–46 | 11 | | | | | |
| AST (U/L) | 10–35 | 17 | | | | | |
| Vitamin D (ng/mL) | 31\.0–80.0 | 41\.3 | | | | | |
Bold, abnormal results.
ALT, alanine aminotransferase; AST, aspartate aminotransferase; HbA1c, glycated haemoglobin; HDL-C, high-density lipoprotein cholesterol; LDL, low-density lipoprotein cholesterol.
## Investigations
### Diagnostic assessment
His chronic cough was thought to be secondary to tobacco use and also related to his long-term occupational exposure to DMEA and TEA, in part because previous interventions with steroids and a proton-pump inhibitor had not resolved the cough. In addition, the occupational health literature reports that DMEA, TEA and small silica sand particles produced during foundry processes can result in respiratory conditions that may present as persistent cough.[3](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R3)
## Treatment
### Recommendations
The patient was placed on an anti-inflammatory, low glycaemic index, nutrient-dense food plan under the supervision of a registered dietitian working in partnership with the treating physician. Nutraceutical supplementation was also recommended to augment gut function and elimination of environmental toxicants ([table 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T1); August 2015). The patient was directed to sit in a dry sauna 30–60 min and drink 3 to 4 L of natural spring water each day. If able, the patient was also encouraged to participate in aerobic exercise such as walking or swimming multiple times each week. Statin therapy was discontinued as a shared medical decision based on the patient’s LDL cholesterol results, well-controlled T2DM and concurrent presenting complaint of fatigue and muscle discomfort suggesting statin myopathy.[i](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#fn1)
## Outcome and follow-up
### Follow-up and outcomes
Prior to his first follow-up visit, the patient reported fasting morning glucose values in the upper 80 s to mid-90s. Based on this information, his sitagliptin was discontinued, but he remained on pioglitazone/metformin combination therapy.
At his first follow-up visit in 6 weeks, the patient reported that his cough was 75% improved. He noted less mucous production and no severe coughing spells for 3 to 5 weeks prior to the date of the follow visit. His wife and other family members also reported noticeably less coughing. Additionally, the patient had lost 7.26 kilograms and lowered his blood pressure during the first 6 weeks ([table 2](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T2); October 2015). The patient reported low energy and some irritability that he attributed to the food plan and sauna therapy.
Based on the improvement in anthropometric and metabolic measurements ([table 2](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T2); October 2015), the patient was able to reduce his dose of valsartan and discontinue use of pioglitazone but continued the use of metformin monotherapy ([table 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T1); October 2015). Allopurinol was also discontinued due to absence of gout attacks for 2 years, and the patient was advised to use colchicine as needed for flare ups ([table 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T1); October 2015).
During four sequential follow-up visits, the patient reported continued improvement in his chronic cough. In addition, he continued to lose weight and experience reduction in his blood pressure ([table 2](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T2)). At the December 2015 visit, the patient was directed to progressively wean off of his supplementation but remains on an omega-3 fatty acid supplement, metformin, valsartan, baby aspirin and colchicine (as needed) ([table 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T1)).
At his 1-year follow-up visit in August 2016, the patient reported that his chronic cough symptoms continued to resolve. He maintained his weight loss, reduced blood pressure, adhered to the recommended exercise programme and reported having more energy ([table 2](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T2); August 2016). The glycated haemoglobin (HbA1c) value reported by his primary care physician was 6.0% with occasional morning glucose values no higher than 115–120 mg/dL ([table 3](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T3); August 2016). In March 2017, approximately half year after discharge, the patient reported his HbA1c value to be 5.8% ([table 3](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T3)) and has maintained his weight loss and reduced blood pressure ([table 2](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T2)). The HbA1c value of 5.8% was maintained through November 2017 ([table 3](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T3)).
## Discussion
The incidence of chronic disease in the USA has become an epidemic due to various factors including poor diet, inactivity, stress and environmental exposures.[4](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R4) This patient’s chronic medical problems appeared to be related to many of these factors, and he improved with a functional medicine approach that targeted changes in diet and lifestyle, combined with conventional medications and nutraceutical supplementation.[5](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R5) Our working hypothesis was that a reduction in the inflammatory burden related to a history of occupational exposures, T2DM and cardiovascular disease was likely to respond to an anti-inflammatory diet, nutraceutical supplementation and lifestyle changes. This approach supports a reduction in inflammation and upregulation of metabolic detoxification.[6](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R6)
DMEA and TEA are gas catalysts used in the foundry process during core production.[7](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R7) Both compounds along with free silica particulates are made airborne during the foundry process. They have been implicated in various conditions including silicosis and pulmonary fibrosis and can produce abnormalities consistent with reduced pulmonary function testing[3 8](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R3) which this patient had recorded in 2012 ([figure 1](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#F1)). DMEA and TEA have deleterious physiological effects on the body when absorbed through the skin and respiratory and gastrointestinal tracts. Dermal exposure to DMEA and TEA can be corrosive to the skin.[7](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R7) Further, when both compounds are aerosolised they can irritate the mucous membranes of the eye and result in visual disturbances.[7](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R7) Additionally, these compounds can irritate the nose or throat and result in cough and respiratory distress.[3 7](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R3) Systemically, these tertiary amines can also initiate the release of histamine from mast cells.[7](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R7)
It is pertinent to mention that a chest X-ray in November 2012 was not suspicious for silicosis or pulmonary fibrosis. Ideally, laboratory measurement of DMEA and TEA levels in the body by way of a clinical reference laboratory prior to and following treatment would demonstrate the effectiveness of treatment, but such tests were not available when we saw this patient. Therefore, we sought to manage the patient using a low-risk biotransformation and elimination strategy ([table 4](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#T4)) focused on the improvement of his chronic cough symptoms.
### Table 4.
Biotransformation and elimination strategy
| | |
|---|---|
| Supporting detoxification | Recommendation |
| Minimise exogenous toxic exposure | Eat fresh, non-processed, organic (if possible) foods. |
| Ensure adequate hydration | Increase water intake to facilitate expulsion of toxicants. |
| Promote healthy toxin binding and excretion | Pyrophyllite healing clay and activated charcoal as toxicant binders. Use magnesium citrate to facilitate expulsion of toxicants via stool. |
| Gastrointestinal microbiological restoration/balance | Supplement with modified citrus pectin and a prebiotic/probiotic. |
| Assist and balance endogenous biotransformation of toxicants | Ensure adequate protein source for enzyme production. Supplement with NAC and ALA (conjugate precursors for phase II reactions) as well as vitamin B12, selenium and milk thistle (enzymatic cofactors for phase I and phase II reactions). |
| Increase sweating | Use a dry sauna and increase aerobic/anaerobic exercise. |
| Enhance antioxidants | Supplement with NAC and ALA and consume fresh, colourful foods. |
| Downregulate inflammation with essential fatty acids | Supplement with omega-3 fatty acids. |
ALA, alpha-lipoic acid; NAC, n-acetyl-l-cysteine.
The patient was placed on an anti-inflammatory, low glycaemic index, nutrient-dense food plan under the supervision of a registered dietitian working in partnership with the treating physician. Nutraceutical supplementation was employed as an adjunct to nutritional recommendations to improve micronutrient levels.[9](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R9) The food plan encouraged the consumption of fresh, non-processed foods (mostly vegetables), and the elimination of highly processed foods and foods containing dairy, sugar and gluten. This food plan works to optimise the function of the gut, improve phase I and phase II detoxification processes and reduce the inflammatory burden on the immune system.[10](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R10) The food plan also supported insulin sensitisation and in this patient resulted in appropriate weight loss.[11–13](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R11)
The beneficial effects of plant-based nutrition for the prevention and treatment of chronic conditions such as obesity, T2DM, cardiovascular disease and hypertension are well documented.[14 15](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R14) While the patient was not on a strict vegetarian diet, he was encouraged to eat fresh, bright-coloured vegetables and low glycaemic index fruits. Both contain large amounts of fibre and phytonutrients which have been shown to improve insulin resistance[15](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R15) and reduce inflammatory status.[16](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R16) In addition, the consumption of fibre from fruits may reduce the incidence of chronic respiratory symptoms (ie, cough with phlegm)[17 18](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R17) and improve pulmonary function.[18](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R18)
Thermal depuration, or sweating, is an essential lifestyle recommendation and has many positive effects. Sweating mimics the physiological effects of exercise,[19](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R19) facilitates the removal of environmental toxins from the body[20](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R20) and improves function in those with respiratory conditions.[21](https://pmc.ncbi.nlm.nih.gov/articles/PMC5935174/#R21) Once the patient felt well enough to exercise, he was able to reduce the frequency of visits to the sauna.
An extensive medical history and detailed timeline reveals many factors that may influence a patient’s long-term health and the development of chronic disease. This may help identify proximal causes of chronic disease that can give rise to low-risk, high-impact treatment strategies. In addition, therapies that leverage and support the body’s intrinsic resilience mechanisms—particularly nutrition—may promote sustainable health and wellness.
## Conclusion
This case illustrates how a low-risk approach that leverages nutrition and lifestyle changes may support the self-healing capacities of the body. Given the patient’s occupational exposure history, previous evaluations and interventions, we hypothesised that his respiratory exposure to DMEA and TEA may have been, in part, responsible for his cough. In addition, benefits of a treatment strategy that focuses on nutrition may extend beyond an individual’s chief complaint positively impacting multiple domains of health.
### Patient’s perspective.
For 25 years I lived with a chronic cough. Since I began the programme with Functional Medicine, I’ve reduced my chronic cough by 85%. By going gluten-free and also following a very controlled diet I’ve lost 55 pounds and gained control of my blood sugar count. I have also reduced my prior medications by 50%.
### Learning points.
- A functional medicine approach may lead to better outcomes in alignment with a patient’s healthcare goals. This low-risk approach leverages nutrition and lifestyle changes to support the self-healing capacities of the body.
- Occupational exposures may contribute to chronic cough, physiological dysfunction and complex, chronic disease.
- Low-risk nutritional interventions along with nutraceutical supplementation that support biotransformation and elimination may be beneficial for patients with chronic cough secondary to occupational exposures.
## Acknowledgments
The authors would like to thank Cleveland Clinic Center for Functional Medicine. The authors would also like to thank Dr Patrick Hanaway and Dr Mark Hyman for their editorial contributions.
## Footnotes
i
The 2013 ACC/AHA Guidelines which state that diabetes is a coronary equivalent were discussed with the patient. The patient had no known personal history of heart disease or early-onset family history of heart disease.
**Contributors:** NB: Patient management, collection of data, writing and editing. DSR: Editing and structuring of case. MB: Writing, review of literature, editing and structuring of case.
**Funding:** The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
**Competing interests:** None declared.
**Patient consent:** Obtained.
**Provenance and peer review:** Not commissioned; externally peer reviewed.
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