Restless Leg Syndrome (RLS) is a sensorimotor condition characterized by debilitating discomfort and an uncontrollable urge to move the body that tends to be exacerbated by rest.
RLS can occur alone or more commonly as a comorbidity of various neurological and systemic conditions, including Parkinson's disease, multiple sclerosis, fibromyalgia, diabetic neuropathy, kidney disease, and chronic digestive conditions.
RLS has been reported to occur between 25-30% of the time in patients with IBS compared to an overall 6% occurrence in the general population, with many theories linking the chronic malabsorption issues of IBS to chronic iron deficiency as well as peripheral and central nervous system inflammation.
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CC: Celiac Disease, Restless Leg Syndrome, Fatigue
Alison was a 30-year-old female who presented to my office with restless leg symptoms on and off for the last ten years. It had been significantly interrupting her sleep the last year, and her energy level had become so low that she could not get through the workday without a cup of coffee every other hour. The high intake of coffee had begun aggravating her stomach and Celiac disease symptoms, which had previously been asymptomatic for the last three years.
Alison was diagnosed with Celiac as a young child and was well managed through a gluten-free diet with occasional aggravations when heavy gluten exposure occurred. She followed up yearly with her gastroenterologist however had not had basic lab work performed since her last visit ten months ago, when symptoms were not as prevalent.
Additional History:
Alison was working as a yoga teacher at the time and described her lifestyle as very relaxed and health focused. Her diet consisted of a gluten-free, dairy-free, whole food, plant-heavy diet with occasional homemade gluten-free treats. For the last three years, she has been following the Blue Zone diet, with her weekly diet intake consisting of 80% plant-based food and 20% animal-based food, consuming occasional fish or chicken. She exercised 4-6 times a week and drank 100 oz of Brita filtered water daily while weighing around 110 pounds.
Initial Lab Work:
Comprehensive Stool Test Results:
- Low Commensal Bacteria: Akkermansia spp., Lactobacillus spp., Collinsella spp., Ruminococcus spp., Bifidobacterium spp.
- Digestive Enzyme production: within normal limits
- Elevated Fecal Secretory IgA: 3,185 mcg/mL (<=2,040 mcg/mL)
- Beta-glucuronidase <DL
- Low SCFA overall
Micronutrient Test Results:
- Mild deficiencies: Vitamin C, B2, B9, B12, Omega 3
- Strongly deficient: B6, Magnesium
Lab Analysis
Alison's lab work points to multiple processes contributing to her symptoms:
- Her low iron and ferritin were paired with low MCV and MCH found on her CBC, indicating current and past iron deficiency anemia. This likely contributed to her current fatigue and her ongoing Restless Leg Syndrome.
- There was a low level of beneficial commensal bacteria and a high level of gastrointestinal inflammation. The synergistic relationship between the commensal microflora and intestinal lining is pivotal to maintaining the proper integrity of the tissue and the protective mucous membrane lining it. When bacterial microflora levels are low and inflammation is high, digestion and absorption begin to suffer. They can result in frank nutrient deficiencies, including iron deficiency, due to the difficult nature of their absorption at the brush border of the gut lining.
- Low commensal bacteria also contribute to low SCFA levels, as microflora consume the fiber and complex carbohydrates in our intestines to produce these gut-healing short chain fatty acids (SCFA).
- B-glucuronidase is an indicator of abnormal metabolic activity among the intestinal microbiota that can be caused by diminished abundance and diversity of the intestinal microbiota. This low level is concerning as B-glucuronidase is essential to the detoxification process that inactivates and detoxifies hormones, neurotransmitters, drugs, mold toxins, and other toxins, leading the patient to accumulate high levels of toxins.
- The patient's specific B Vitamin deficiencies further hinder her ability to absorb and convert iron since Vitamin B6, B9, and B12 are essential for these mechanisms to occur.
- The patient's other nutrient deficiencies (magnesium and omega-3 fatty acids) potentially contribute to sleep issues and restless legs.
Interventions
- Gut healing support was the priority for this initial treatment as this was likely the root cause of many of the patient's issues. We started a high dose of L glutamine powder, 5g 2x daily (away from food), to support gut lining integrity. Fish oil was also started at 2g daily (liquid form) to support nutrient repletion and reduce gastrointestinal inflammation.
- To support microbiome diversity, a powdered prebiotic supplement consisting of plant-based polyphenols was paired with a spore-based probiotic while instructing her to increase her intake of prebiotic and probiotic foods such as chicory root, acacia, and fermented foods.
- A powdered multivitamin and liquid iron supplement were recommended each 2x per day for nutrient restoration. We also reviewed food sources of iron and the correct nutrient pairing for absorption, such as eating leafy greens with a dressing that included lemon (for Vitamin C) and black pepper (for absorption support).
- A gentle liver cleanse was discussed with a slow increase of a liver-supportive supplement containing milk thistle, burdock root, and chicory root to support liver function and detoxification.
- Diet changes included increasing red meat intake to 1x weekly, decreasing water intake to 70 oz with electrolyte support, taking additional magnesium to replenish her low level, and reducing coffee intake to 2 cups daily.
4 Months Follow Up:
One month into treatment at the initial follow up, Alison needed support sticking with the plan as she had cut down on coffee but was still suffering from restless leg induced sleepless nights and high level of fatigue during the day.
Six weeks into treatment, she began noticing improvement.
Four month follow-up for labs: Allison’s labs were normalizing so we reduced iron supplement and multivitamin to 1x daily. At this point in the treatment process Allison was a different person. Her energy has improved remarkably, and she has replaced coffee entirely with a chicory root based alternative. Her digestion was back to a stable place, and she slept effectively through the night. She was instructed to continue with the ongoing diet work for optimal iron and probiotic intake.
Summary
This case is unique in how quickly the patient progressed; however, her dedication to healthy living and compliance with the recommended treatment helped her see sustainable results quickly. Her low-level commensal microbiota and gastrointestinal inflammation promote nutrient malabsorption, including iron, leading to decreased iron storage, which sets the stage for RLS. This demonstrates that when treating patients with chronic restless leg syndrome, consider the role of suboptimal digestion as a contributing cause of symptoms and underlying nutrient deficiencies.
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