Patient Overview
J.B. is a 37-year-old male, 5’8”, 220 lb (BMI ~33.5), presenting with stage 1 hypertension, impaired glucose tolerance, central adiposity, and symptoms consistent with chronic stress physiology. His medical history is notable for prior successful weight loss on a low-carbohydrate diet, followed by weight regain over the past several months during a period of increased occupational stress, reduced sleep, and inconsistent self-care.
Presenting Concerns and Goals
J.B.’s primary goals were to:
- Improve blood pressure control
- Normalize blood sugar regulation
- Reduce body weight, particularly central adiposity
- Address chronic stress and elevated cortisol
Vital Signs and Anthropometrics
- Blood pressure (initial): 150/95 mmHg
- Resting heart rate: 82 bpm
- Waist circumference: 43 inches
- Weight: 220 lb
- Height: 5’8”
- BMI: 33.5
Key Laboratory Findings
Glycemic Markers
- Fasting glucose: 97 mg/dL
- 1-hour postprandial glucose (home monitoring using GGM): 140–155 mg/dL
- Hemoglobin A1c: 5.6%
- Fasting insulin 19 μU/mL
Nutrient Status
- Vitamin D (25-OH): 24 ng/mL (low)
- Vitamin B12: 312 pg/mL (low-normal, functionally suboptimal)
- Zinc (serum): 62 µg/dL (low)
Interpretation: Nutrient insufficiencies contributing to metabolic inefficiency, impaired insulin signaling, immune activation, and HPA axis stress.
Gastrointestinal Testing
SIBO Breath Test
- Hydrogen-dominant SIBO
- Peak hydrogen: 65 ppm
Symptoms correlated with GERD, bloating, and loose stools
GI Effects Comprehensive Stool Test
- Dysbiosis with reduced beneficial flora
- No inflammatory markers elevated (calprotectin & EPX normal)
- Elevated fecal secretory IgA
Interpretation: Mucosal immune activation likely driven by microbial imbalance and intestinal permeability, contributing to systemic inflammation and metabolic stress.
Adrenal Function (DUTCH Test)
- Elevated total cortisol (daily output)
- Elevated free cortisol
- High cortisol awakening response (CAR)
Interpretation: Chronic HPA axis overactivation consistent with stress-driven hypertension, visceral fat accumulation, and difficulty with weight loss.
Clinical Assessment
J.B.’s hypertension was assessed as multifactorial, driven primarily by:
- Insulin resistance and metabolic syndrome physiology
- Chronic psychological and physiologic stress with elevated cortisol. He is working 50+ hours per work, commuting to work 1 hour each way, he has two young children and has a sick father he tries to care for.
- Gut dysbiosis and SIBO contributing to systemic inflammation and neuroendocrine signaling
- Micronutrient insufficiencies impairing vascular tone and glucose metabolism
Intervention Strategy
Nutrition Plan
- Continued very-low-carbohydrate diet (<10% of calories) initially to stabilize blood sugar and insulin levels
- Targeted carbohydrate reintroduction:
- ~30 g whole-food carbohydrates post-workout (sweet potato, white potato, or fruit) to blunt cortisol response and support training recovery
- Emphasis on:
- Potassium-rich foods (potatoes, plantains, leafy greens)
- Magnesium-rich foods (pumpkin seeds, dark leafy greens)
- Adequate protein for glycemic control and lean mass preservation
- Elimination of refined carbohydrates, sugar-sweetened beverages, and ultra-processed foods
Gut Support
- MegaSporeBiotic soil-based probiotic for microbial diversity
- Galactomune prebiotic to support immune tolerance and beneficial flora
- Dietary emphasis on fermented foods as tolerated (increased amounts once SIBO was treated and resolved)
- SIBO treatment staged conservatively with an antimicrobial protocol focused on methanogen overgrowth to avoid exacerbating cortisol burden
Supplement Protocol
- Metabolic Synergy and GlucoSupreme to improve insulin sensitivity and postprandial glucose control
- CoQ10 (100–200 mg daily) for endothelial support and blood pressure reduction
- HPA Balance to support cortisol regulation and stress resilience
- Vitamin D3 to replete levels to 40–60 ng/mL
- Methylated B12 to support neurologic and metabolic function
- Zinc repletion for immune and metabolic support
Lifestyle and Behavioral Interventions
Stress Regulation
- Mind-body practices 3–4 times per week (mindfulness, progressive relaxation)
- Education on the direct relationship between stress, cortisol, and blood pressure
- Discussed a hybrid model of work with his employer and was able to work from home 2 days per week
Sleep Optimization
- Increased sleep from ~6 hours to 7–8 hours nightly
- Consistent bedtime routine and sleep hygiene reinforcement
- Screening considerations discussed for sleep apnea given metabolic risk profile
Physical Activity
- Resistance training continued
- Emphasis on non-exercise physical activity (daily walking, reduced sitting time)
- Avoidance of excessive high-intensity training during periods of cortisol elevation
Clinical Outcomes
Short-Term (2–3 Months)
- Fasting glucose consistently <90 mg/dL
- 1-hour postprandial glucose 110–120 mg/dL, with return to baseline by 2 hours
- Improved energy and reduced GI symptoms after SIBO treatment and resolution.
- Nutrient levels improved to optimal levels to support health
- Repeat SIBO test negative
Medium-Term (6 Months)
- Weight reduced from 220 lb to 190 lb
- Blood pressure normalized to an average of 124/80 without medication
- Improved subjective stress tolerance
Ongoing Focus
Residual central adiposity and persistent cortisol elevation indicated the need for continued work on:
- HPA axis regulation
- Sleep consistency
- Stress load modification
- Continued exercise and movement adjustments to help support his bandwidth and tolerance
Closing thoughts…
This case highlights an increasingly common but often misunderstood presentation of hypertension in younger adults, where elevated blood pressure is not a primary cardiovascular disease but rather a downstream signal of metabolic dysfunction, chronic stress physiology, and gut-driven immune activation. In J.B.’s case, impaired glucose tolerance and insulin resistance created persistent sympathetic nervous system activation, while elevated cortisol output and a pronounced cortisol awakening response contributed to central adiposity, vascular tone dysregulation, and difficulty sustaining weight loss.
Compounding this picture, hydrogen-dominant SIBO and dysbiosis with elevated fecal secretory IgA reflected ongoing gut-immune stress, reinforcing systemic inflammation and neuroendocrine signaling that can directly influence blood pressure regulation. Meaningful improvements in blood pressure occurred only after interventions targeted the true drivers, stabilizing blood sugar, supporting gut integrity, correcting micronutrient insufficiencies, improving sleep duration, and reducing allostatic load through consistent stress regulation practices.
This case underscores that in functional medicine, durable blood pressure normalization often follows improvements in metabolic health, HPA axis balance, and lifestyle alignment, rather than relying solely on sodium restriction or antihypertensive medications.
