1 Probiotic FAQ: Part 1

Hope you all had a great weekend! Our family was visiting my husband’s parents. On Friday my daughter and I had appointments for acupressure allergy treatments which went very well. I’ve been struggling with a lot of sinus headaches recently and I’m hopefully that these will help those calm down. One of the foods I was reacting to was chocolate 😔, but thankfully the treatment should allow me to put it back in my diet occasionally. 😊 I think I’m going to try to abstain for a little while before re-introducing. Our daughter is doing so well from where she was as a baby, hopefully these will help her be able to continue to expand her food choices. We had a lot of success with them in the past and calming down her eczema.

We enjoyed a relaxing Saturday with his family and today are celebrating his mom’s birthday before we head home. Hopefully this week we also get to meet our newest nephew who is due to arrive any day now!

Probiotics are a hot topic, and I don’t have all the answers but this post and my post next week will help address some of the most common questions I receive about them. We aren’t at a place yet where we can say you have this issue and you need this particular product 100%, but we have good data and is helping us guide recommendations. The microbiome is complex and everyone’s is different which makes it challenging. A lot of probiotic treatment is trial and error but sometimes what we try the first few times works! If you missed the first post Probiotic 101, make sure to check it out. As with the last post, two of my interns Vineeta Rao and Ruth Gunti worked hard on this! Thank you!

Hope you enjoy this first FAQ and stay tuned for more next week.

Dr. Hartzler

If I have a milk or other food allergy, can I take probiotics?

Yes. A  randomized controlled-trial found that supplementation with a probiotic helped infants allergic to cow’s milk develop a tolerance at a higher rate.1  Severe milk allergy patients should avoid probiotics made from milk. Dairy free probiotics are recommended for those with severe intolerance or allergy, where as dairy free would not be necessary for lactose intolerant patients. Additionally, a recent study that followed peanut allergic children found that a combination of probiotics (Lactobacillus rhamnosus) and peanut oral immunotherapy produced a sustained non-allergic response in children even four years after initial treatment indicating potential future use of probiotics in immunotherapy for the treatment of food allergies.2

If I have lactose intolerance, can I take probiotics?

Yes. In fact, probiotics are being used to help those with lactose intolerance. In a review article examining the relationship between probiotics and their use in those with lactose intolerance it was found that there was an overall positive relationship. The species of bacteria that were most common among the reviews studied were lactobacillus acidophilus, lactobacillus bulgaricus, and streptococcus thermophilus all of which demonstrated some level activity. 3

The World Gastroenterology Organisation Global Guidelines on probiotics states that “Streptococcus thermophilus and Lactobacillus delbrueckii subsp. bulgaricus improve lactose digestion and reduce symptoms related to lactose intolerance.”3

Should I take my probiotic with or without food?

A study looking at four species of bacteria found that survival through the GI tract was most preserved when given with a meal or 30 minutes before the meal.4   This may be due to the changes in acidity of the stomach during the fed and fasting states. During the fasting state, the stomach environment is more acidic, making it is more difficult for the bacteria to survive. Upon eating, however, the stomach environment becomes less acidic, thus providing a more favorable environment for bacteria to thrive. 4,5 In this study, probiotic survival was greater when taken with foods high fat content than with carbohydrates, apple juice, or water alone. Fat content appears to help “coat” the bacteria to protect against stomach acid. Thus, it is best to take your probiotic with a higher fat meal or snack to help the bacteria survive transit through the acidic stomach environment.4

What is the safety profile of probiotics?

Studies have found that probiotics have minimal to no side effects. Side effects that are observed are most commonly bloating and flatulence, but the symptoms are mild and subside with continued use of the probiotic. Constipation and increased thirst have also been rarely associated with the species S. boulardii.6 The extreme side effects that have been found are in patients whose immune system have already been compromised.

Why might my probiotic cause diarrhea or constipation?

Diarrhea or constipation can occur with probiotics especially at the start of therapy due to multiple factors. Likely, it depends on the degree to which the gut is imbalanced to begin with, and as the gut is being rebalanced, bacteria can release by-products through fermentation that influence how fast the bowels move. Also, since the brain and gut appear to influence each other, lifestyle factors such as stress may influence the gut’s movement. While we do not know how each of these factors specifically affect the gut, there are multiple neurological influences by different types of bacteria which may contribute to the speed in which transit happens.7

That is a wrap for today’s FAQ.. more to come next week! Next week I will address probiotics with antibiotics, histamine intolerance, and Small Intestinal Bacterial Overgrowth (SIBO). Don’t miss it! If you are looking for a quality probiotic feel free to check out my FullScript Store or send me an email if you need help!

References:

  1. Probiotic formula reverses cow’s milk allergies by changing gut bacteria of infants. The University of Chicago Medicine. https://www.uchicagomedicine.org/biological-sciences-articles/probiotic-formula-reverses-cows-milk-allergies-by-changing-gut-bacteria-of-infants. Updated September 22, 2015. Accessed February 9, 2019.
  2. Hsiao KC, Ponsonby AL, Axelrad C, Pitkin S, Tang MLK. Long-term clinical and immunological effects of probiotic and peanut oral immunotherapy after treatment cessation: 4-year follow-up of a randomised, double-blind, placebo-controlled trial. Lancet Child Adolesc Health. 2017;1(2):97-105.
  3. Oak SJ, Jha R. The effects of probiotics in lactose intolerance: A systematic review. Crit Rev Food Sci Nutr. 2018;9:1-9.
  4. Tompkins TA, Mainville I, Arcand Y. The impact of meals on a probiotic during transit through a model of the human upper gastrointestinal tract. Benef Microbes. 2011;2(4):295-303.
  5. Zembroski R. Why taking probiotics on an empty stomach is a bad idea. REBUILD. https://www.drzembroski.com/why-taking-probiotics-on-an-empty-stomach-is-a-bad-idea/. Accessed February 9, 2019.
  6. Williams NT. Probiotics. Am J Health Syst Pharm. 2010;67(6):449-58.
  7. Conlon MA, Bird AR. The impact of diet and lifestyle on gut microbiota and human health. Nutrients. 2014;7(1):17-44.

3 Probiotics 101

It’s been a whirlwind the last few months. I’m teaching my last lecture in Endocrine tomorrow.. I’m excited it’s on functional medicine approach to pre-diabetes and obesity! The best part about teaching part-time is getting to teach what I’m passionate about. After this, I just have lots of grading and course coordination items. But the course ends next week then I’m off to Seattle, WA to speak on diabetes cardiovascular outcomes trials. It’s the same presentation from December in Anaheim showcased at a different meeting. It’s nice when you spend a lot of time on something, to be able to do it twice! For this blog post, I had a lot of help from two students working on this probiotic series, so thank you to Vineeta Rao and Ruth Gunti for your hard work. Soon they will be my colleagues! Enjoy!

Dr. Hartzler


Welcome to probiotics 101, a guide to all your FAQs!

What are probiotics?

‘Probiotics are defined as live microorganisms, which when administered in adequate amounts, confer a health benefit on the host.’ 1 The microorganisms are bacteria of different strains that process our food into nutrients that benefit our health. Probiotics come from the Latin preposition pro (“for”) and the Greek adjective (biōtikos) meaning “fit for life, lively.” Put together this means that probiotics are for life.

Why use probiotics?

Using probiotics enhances the gut microbiota to better do its job.  The gut microbiota/microbiome is the conglomerate of bacteria that live in your gut and work together to bolster the immune system, to fight against potential infections, and to make nutrients such as vitamins, fats and other molecules that are needed by the body to function. 1  Furthermore facets of our modern day western lifestyle, such as diet, stress, geography, as well as sleep and travel patterns can negatively affect our gut microbiome meaning we don’t have a healthy gut to begin with. 2 In addition to the poor lifestyle factors, the increasingly prevalent use proton pump inhibitors is correlated with and probably contributes to “decreased bacterial richness” of  gut microbiome, an increased amount of oral bacteria that is potentially pathogenic present in the gut, and an overall greater “microbial alterations” in the gut than those on antibiotics. 3

How do probiotics work?

While probiotics are most commonly associated with replacing flora or colonizing the gut, modifications made to the gut microbiota are not likely permanent and reflect only one of many actions that probiotics have in the body. Among these actions are immune modulation, anti-inflammatory activity, pathogen antagonism, production of short chain fatty acids, repairing and strengthening of the intestinal barrier, metabolism of gut cholesterol, and enhanced antibody secretion.4 While not all probiotics encompass all of these features, depending on the strain, a given probiotic may provide one or several of these protective benefits.5

What is genus, species, and strain?

Bacteria are usually classified to the public by three names much like people who have first, middle and last names. Therefore the first name is a broad name termed genus, followed by a more specific name called a species finally followed by a strain number that is further specifies the exact kind of bacteria.  A labeled example is below!

What is the evidence for probiotic use?

Numerous review studies indicate that probiotics are beneficial overall, especially for gut health.6 However, evidence for treating or preventing specific conditions through probiotics is best established through clinical trials that demonstrate how probiotics produce a specific effect. While the number of controlled trials demonstrating specific effects in humans is still growing, probiotics have also been evaluated in animal experiments and or other in vitro studies that demonstrate efficacy and safety in terms of their use. 1  Fermented foods with probiotics in them have been consumed for centuries for health benefits. Additionally, the modern diet lacks prebiotic fiber that contributes to a diverse gut microbiome.7

What is the difference between Bifidobacterium and Lactobacillus genus of bacteria?

Lactobacillus bacteria is a type of bacteria that produces lactic acid as an end-product of its metabolism. Bifidobacterium bacteria on the other hand produce lactic acid and acetic acid; both these substances are important for the maintenance of the gut microbiome. 8,9

Here are some of the bacteria in each genus considered to be probiotics.8

Microorganisms
 considered as probiotics
Lactobacillus speciesBifidobacterium species
L. acidophilus
L. casei
L. crispatus
L. gallinarum
 L. gasseri
L. johnsonii
L. paracasei
L. plantarum
L. reuteri
L. rhamnosus
B. adolescentis
B. animalis
B. bifidum
B. breve
B. infantis
B. lactis
 B. longum

How to know you are getting a good product?

There are many overarching reviews that conclude that probiotics as a whole class are effective, suggesting that many strains share the similar levels of effectiveness. Additionally, there are number of factors that contribute to how probiotics act in our bodies such as genetics, diet and host microbiome that makes it difficult to isolate the effects of one strain over another. However, it is important that the product contains the live bacteria in large doses that will survive the harsh environments of the stomach.6

How much does the specific strain matter when ensuring that you have a good product? As more studies for probiotic use emerge, there is an ongoing controversy about the importance of the strain. On one side of the debate, larger studies that examine multiple clinical trials suggest that probiotics have benefit even when grouping similar strains together in one class. The theory behind this position is that similar strains of probiotics will have actions causing similar effects in the body.6 One the other side of the debate, some clinicians compare strain selection to choosing a particular antibiotic to attack a specific disease-causing microbe.4 Advocates of this position point to the fact that Lactobacillus plantarum DSM 9843 reduces irritable bowel syndrome while Lactobacillus plantarum MF 1298 aggravates the condition and thus conclude that when supporting a specific condition, one should only use a strain that has demonstrated efficacy for that specific condition.10-12

In summary, data for use of probiotics is exploding on a daily basis. Probiotics are useful to promote healthy gut transit and repair and for a myriad of immune benefits.  In addition, data suggests significant changes to the gut microbiome is most easily stimulated by ingestion of prebiotics, which are non-digestible foods that promote and stimulate the growth of bacteria in the gut.13 Prebiotics are often combined with probiotic supplements.  Sometimes they may not be well tolerated by certain individuals especially those that have an imbalance in bacteria. Certain non-gas producing prebiotics may be helpful for some patients. We will talk more about these situations in my next post!

If you are looking for quality probiotics. Please check out my Fullscript store and click on the probiotics category! I’m happy to help with simple questions on products via email or if you are interested in a 1:1 personal GI health consults with my team, please let me know. We are launching tele-health services soon!

SOURCES:

  1. Fijan S. Microorganisms with claimed probiotic properties: an overview of recent literature. Int J Environ Res Public Health. 2014;11(5):4745-67.
  2. Conlon MA, Bird AR. The impact of diet and lifestyle on gut microbiota and human health. Nutrients. 2014;7(1):17-44.
  3. Imhann F, Bonder MJ, Vich vila A, et al. Proton pump inhibitors affect the gut microbiome. Gut. 2016;65(5):740-8.
  4. Probiotic Advisor. The Importance of Strain. https://www.probioticadvisor.com/probiotic-essentials-1/the-importance-of-strain/#.XC-EEPZFxPZ. Accessed January 21, 2019.
  5. Hill, C., et al., Expert consensus document: The International Scientific Association for Probiotics and Prebiotics consensus statement on the scope and appropriate use of the term probiotic. Nat Rev Gastroenterol Hepatol, 2014. 11(8): p. 506-514.
  6. California Dairy Research Foundation. Is it time to consider generic probiotic effects? http://cdrf.org/2013/03/01/is-it-time-to-consider-generic-probiotic-effects/. Updated March 1, 2013. Accessed August 20, 2018.
  7. Holscher HD. Dietary fiber and prebiotics and the gastrointestinal microbiota. Gut Microbes. 2017;8(2):172-184.
  8. Kechagia M, Basoulis D, Konstantopoulou S, et al. Health benefits of probiotics: a review. ISRN Nutr. 2013;2013:481651.
  9. Bifidobacteria Institute. Difference between bifidobacteria and lactobacillus. http://bb536.jp/english/basic/basic03.html. Accessed August 20, 2018.
  10. Ducrotte, P., P. Sawant, and V. Jayanthi, Clinical trial: Lactobacillus plantarum 299v (DSM 9843) improves symptoms of irritable bowel syndrome. World J Gastroenterol, 2012. 18(30): p. 4012-8.
  11. Niedzielin, K., H. Kordecki, and B. Birkenfeld, A controlled, double-blind, randomized study on the efficacy of Lactobacillus plantarum 299V in patients with irritable bowel syndrome. Eur J Gastroenterol Hepatol, 2001. 13: p. 1143-1147.
  12. Ligaarden, S.C., et al., A candidate probiotic with unfavourable effects in subjects with irritable bowel syndrome: a randomised controlled trial. BMC Gastroenterol, 2010. 10: p. 16.
  13. Cashman K. Prebiotics and calcium bioavailability. Curr Issues Intest
    Microbiol. 2003 Mar;4(1):21-32. Review.

Love Your Skin: My Top 3 Supplements for Skin Health

Valentine’s Day is approaching, and love is in the air! At this time of year, we (especially women!)  often start to look at our skin and wonder how we can help our skin be healthier.  While there are a whole host of topical products aimed at healthy skin, supporting skin cells from the inside out is equally, if not more important.  This post is going to be quick but if you have questions, don’t hesitate to reach out. I have quite the to-do list with my upcoming teaching at Cedarville, and I wanted to get this to you while it is on my mind. Also, I finally feel like my probiotic post series is at a good place and I will be starting to put out that content in the next few weeks during my busy season of the year.  I am very thankful for awesome pharmacy student researchers that have helped me prep those. The data on probiotics is massive! In the midst of my busy teaching season comes 2 work-trips and 3 birthdays in this house to celebrate in March! It’s pretty much Christmas Round 2 here! Stay warm wherever you are, in Ohio we are dreaming of spring!

Dr. Hartzler

Here we go.. My top 3 supplements for glowing skin!

  1. Collagen: Collagen peptides (CPs) are the broken down product of collagen or gelatin and they are used as important active components because of their various biological activities, good absorption, and low side effects.1
    1. One study of women aged 40-60 found 1,000 mg (1 Gram) of collagen peptides to improve hydration, elasticity and appearance of wrinkles in 12 weeks. Hydration differences were seen after just six weeks.2
    2. Another study of women aged 35-55 found 2.5 to 5 grams of collagen daily significantly improved skin elasticity compared to placebo. There was improved skin moisture and skin evaporation, however those did not reach statistical significance.3
    3. Bonus: Collagen has also been shown to improve Brittle Nails4 and shown improvement in bone building!5

My favorite Collagen Product is Vital Proteins.  There have options for marine based products as well as products from animal sources. In addition there are other various options you can find in my FullScript Store.

  1. Lyciumbarbarum (also known as Goji Berry and wolfberries): This fruit has long been recognized in traditional Chinese medicine for various therapeutic properties based on its antioxidant and immune-modulating effects. Lycium barbarum polysaccharide (LBP), the most biologically active fraction of wolfberry, possesses significant antioxidative and anti-inflammatory effects on multiple tissues.6
    1. A study on human cells showed that the antioxidant LBP could partially protect against UVB irradiation-induced photodamage through activation of specific pathways and reducing DNA damage.6
    2. In a study in mice, antioxidant activity in the skin was demonstrated by the significant protection of 5% goji juice against lipid peroxidation (AKA damage) induced by UVA radiation.
    3. Bonus: the antioxidant properties of this plant extend way beyond the skin.8

Many of you know one of my favorite places to get Wolfberries.  You can find products with this compound over at Young Living in various products.  If you haven’t started your journey with YL yet, I’d love to help you get started. My team has a host of resources to set your wellness journey up for success.

  1. Vitamin C: Last but not least is Vitamin C. Who doesn’t love Vitamin C. For one it’s cheap! Secondly, it is a powerhouse antioxidant. Normal skin contains high concentrations of vitamin C, which supports important and well-known functions, stimulating collagen synthesis and assisting in antioxidant protection against UV-induced photo damage.9
    1. Vitamin C promotes collagen formation, and we already know how good collagen is!9
    2. “Vitamin C is a potent antioxidant that can neutralize and remove oxidants, such as those found in environmental pollutants and after exposure to ultraviolet radiation. This activity appears to be of particular importance in the epidermis, where vitamin C is concentrated in the skin.”9
    3. One study with men aged 30–45 given oral supplement of 54 mg or 22 mg of vit. C, 28 mg tomato extract, 27 mg grape seed extract, 210 mg of marine complex, 4 mg zinc gluconate for 180 days showed improvement in redness, hydration, radiance, and overall appearance. The treatment group decreased intensity of general skin spots, UV spots, and brown spots, improved skin texture and appearance of pores. Biopsies showed increased collagen (43%–57%) and elastin (20%–31%). This study was a mix of antioxidants, unfortunately there haven’t been a large # of human clinical trials with vitamin C alone. So mix it in with your regimen! 10

That’s a wrap.. treat yourself to good-nutrition to support your skin this valentine’s day, I would love to help you find products that fit not only your skin needs but optimize your health and wellbeing too! If you are shopping for these or any supplements please check out my limks on the blog and know that 10% of revenue on this blog goes to support amazing ministries! You know where to find me on Facebook and Instagram if you have questions.

Also know that you are Loved by your Creator this Valentines Day.. if you want to know about this more too.. I’d love to chat over coffee or virtual coffee. 🙂

As always, the information provided on this site is intended for your general knowledge and education only and is not a substitute for professional medical advice or treatment for specific medical conditions. Head over to this page if you have further questions about that.

References

  1. Song H, Zhang S, Zhang L, Li B. Effect of Orally Administered Collagen Peptides from Bovine Bone on Skin Aging in Chronologically Aged Mice.Nutrients. 2017;9(11). doi:10.3390/nu9111209.
  2. Kim D-U, Chung H-C, Choi J, Sakai Y, Lee B-Y. Oral Intake of Low-Molecular-Weight Collagen Peptide Improves Hydration, Elasticity, and Wrinkling in Human Skin: A Randomized, Double-Blind, Placebo-Controlled Study. Nutrients. 2018;10(7). doi:10.3390/nu10070826.
  3. Proksch E, Segger D, Degwert J, Schunck M, Zague V, Oesser S. Oral supplementation of specific collagen peptides has beneficial effects on human skin physiology: a double-blind, placebo-controlled study. Skin Pharmacology And Physiology. 2014;27(1):47-55. doi:10.1159/000351376.
  4. Hexsel D, Zague V, Schunck M, Siega C, Camozzato FO, Oesser S. Oral supplementation with specific bioactive collagen peptides improves nail growth and reduces symptoms of brittle nails.Journal Of Cosmetic Dermatology. 2017;16(4):520-526. doi:10.1111/jocd.12393.
  5. König D, Oesser S, Scharla S, Zdzieblik D, Gollhofer A. Specific Collagen Peptides Improve Bone Mineral Density and Bone Markers in Postmenopausal Women-A Randomized Controlled Study.Nutrients. 2018;10(1). doi:10.3390/nu10010097.
  6. Li H, Li Z, Peng L, et al. Lycium barbarum polysaccharide protects human keratinocytes against UVB-induced photo-damage.Free Radical Research. 2017;51(2):200-210. doi:10.1080/10715762.2017.1294755.
  7. Reeve VE, Allanson M, Arun SJ, Domanski D, Painter N. Mice drinking goji berry juice (Lycium barbarum) are protected from UV radiation-induced skin damage via antioxidant pathways.Photochemical & Photobiological Sciences: Official Journal Of The European Photochemistry Association And The European Society For Photobiology. 2010;9(4):601-607. doi:10.1039/b9pp00177h.
  8. Gao Y, Wei Y, Wang Y, Gao F, Chen Z. Lycium Barbarum: A Traditional Chinese Herb and A Promising Anti-Aging Agent.Aging And Disease. 2017;8(6):778-791. doi:10.14336/AD.2017.0725.
  9. Pullar JM, Carr AC, Vissers MCM. The Roles of Vitamin C in Skin Health.Nutrients. 2017;9(8). doi:10.3390/nu9080866
  10. Costa A, Pegas Pereira ES, Assumpção EC, Calixto Dos Santos FB, Ota FS, de Oliveira Pereira M, Fidelis MC, Fávaro R, Barros Langen SS, Favaro de Arruda LH, Abildgaard EN. Clin Cosmet Investig Dermatol. 2015; 8():319-28.

 

Cincinnati-Style Chili

Growing up in the Cincinnati area meant I had my fair share of coneys and 3-ways.  Cincinnati-Style Chili dates back to the 1920’s  when an immigrant from Macedonia started serving it in his Greek restaurant. It is a Mediterranean spiced meat sauce that definitely isn’t your typical chili. For the full history, check out this page.  Most of my life, my hometown, about 20 minutes west of Cincinnati, had a Skyline chili.  GoldStar came to compete several years later, and I think in the early days there was even an independent chili restaurant too.  We spent lots of Friday nights at Skyline after football or basketball games. We also held fundraisers there for various sports and cheerleading. It was pretty much a staple in our diet.

I’m not sure why but for some reason they always served oyster crackers alongside all the other carbs too, which as a kid was a great snack while you awaited your meal. Fast forward to now, times have changed a bit for us and our diet, but when I think of comfort food, this is it for me. The best part about this meat sauce is I can still enjoy the comfort of childhood without the high carbs by serving it over Spaghetti Squash topped with cheddar cheese. And just for the experience, I gave the kids some Simple Mills Crackers on the side. A little bit to my surprise, my kids love this dish too. My daughter said it tastes better than cake! This week I’m making it for a potato bar at the Victory Project, which should be yummy too!

To all my fellow Cincinnatians or those ready to try a new dish.. enjoy! It’s perfect to try for any Super Bowl festivity.

Dr. Hartzler


Print Recipe


Cincinnati-Style Chili

For a taste of what everyone in Cincinnati is eating, check out this recipe. It's easy to make-ahead and warm up during the week on top of squash or any veggie. If low carb isn't needed try it over gluten free pasta or potatoes.

Course Main Dish
Cuisine Low-carb

Prep Time 20 minutes
Cook Time 2 hours

Servings


Ingredients

Course Main Dish
Cuisine Low-carb

Prep Time 20 minutes
Cook Time 2 hours

Servings


Ingredients


Instructions
  1. Place the ground beef in a large pan, cover with about 1 quart of cold water, and bring to a boil, stirring and breaking up the beef with a fork to a fine texture. Slowly boil until the meat is thoroughly cooked, about 30 minutes, then remove from heat and refrigerate in the pan overnight.

  2. The next day, skim the solid fat from the top of the pan, and discard the fat. Place the beef mixture over medium heat, and stir in tomato sauce, vinegar, Worcestershire sauce, garlic, chocolate, chili powder, salt, cumin, cinnamon, ground, cloves, allspice, crushed red pepper, and bay leaf. Bring to a boil, reduce heat to a simmer, and cook, stirring occasionally, for 1.5 hours. Add water if necessary to prevent the chili from burning. Remove Bay leaf before serving. Best if refrigerated overnight.

  3. One hour prior to eating, heat oven to 400 F. Slice squash in half lengthwise and scoop out seeds. Place squash cut side down on baking sheet and roast until tender, 45-50 minutes. Use a fork to scrape out “spaghetti.” I generally add a bit of water to the pan.

  4. Lastly to make a true "3-way" top with cheddar cheese, we like white cheddar, but any cheddar will do. For dairy free try topping with onions or beans, or add those to your cheese for a 4-way or 5-way!


Recipe Notes
  1. If you don't have time to cook the meat overnight, you can still boil the meat and drain it, or you can just sauté in a pain and rinse afterward. The boiling process gets the meat a bit finer than cooking in a pan.
  2. Slow Cooker- Cook the meat in advance with one of the options above, then mix all the other ingredients in the crockpot, then add the meat and stir well.  I put it on low for 3-4 hours then turn it down to keep warm until ready to serve! (Remove bay leaf prior to serving & make sure to stir again so the chocolate gets mixed in after it melts!) I doubled the recipe to fill a crockpot.
  3. Thrive Market Tomato Sauce link. , if you aren't saving money using Thrive Market now, you should be. Use this link for a 30 day free trial.


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Coenzyme Q10

It’s been awhile since I got a post up here on the blog.  December was a whirlwind with a trip to ASHP Midyear and Disneyland, closing on our house and moving 2 days before vacation with my family. We threw our boxes in, then headed to warm weather for a week in Key Largo.  You can find pictures about our adventures on Instagram. We celebrated Christmas with my family on Christmas Day at my sister’s new home in Lexington, KY,  and later in the week with Dustin’s family in Northeast Ohio.  We celebrated New Years Eve with our local friends and church family in our new home, and visited our college friends on New Years Day in Findlay, Ohio.  We have had our New Years Day gathering tradition for over a decade now!  So far January has been stay home and work on getting our house together and of course fight off viral gunk 🙂 Back in November,  Marina Reid, who is a DO student, rotated with me and we worked on this post together. She will be Dr. Reid in the spring and someday an anesthesiologist!  I love getting to spend a few weeks with medical students sharing my passions for diabetes care and functional medicine. CoQ10 is an amazing compound with lots of potential.  Make sure to read this post to the end!

Dr. Hartzler

 

One of the most widely sold supplements on the market is the compound with the mysterious – sounding name, CoQ101. As it turns out, this is an abbreviation for an enzyme that is found in every cell in the human body2. Logically, an enzyme so widely prevalent was given a name ‘ubiquinone’. CoQ10 describes the chemical structure of ubiquinone molecule, that is actually similar to vitamin K in structure3. ‘Co’ is short for ‘coenzyme’, ‘Q’ is for ‘quinone’ chemical group, and ‘10’ refers to the number of isoprenyl chemical subunits in the molecule4. CoQ10 is an essential molecule that participates in the rate limiting transfer from step II to step III of the electron transport chain in mitochondrial membrane to produce ATP molecules. In basic terms this means that CoQ10 is a vital part of energy production in our cells.

You may remember from high school biology class that the mitochondria are considered the powerhouse of the cell.  Organs such as the heart, liver, and kidneys are packed with mitochondria. Unfortunately, with age5 or certain disease states,6 our bodies get depleted of this essential enzyme and those vital organs suffer the most.

The role of CoQ10 in treatment of ischemia (inadequate blood supply to the heart) and congestive heart failure has been widely supported by the research. Q-SYMBIO was a prospective, randomized, double-blind, placebo controlled multicenter study that showed that patients treated with CoQ10 supplementation had significant reduction in cardiovascular death, all-cause mortality and heart failure hospitalizations7. There are reports that also show the improvement of cardiac function in transplant patients with CoQ10 supplementation8. CoQ10 supplementation can be especially beneficial for pediatric9 and postpartum patients10 with dilated cardiomyopathies (enlarged hearts). The exact mechanism of this cardio-protective function is still to be determined. Suggested mechanisms include stabilization of mitochondrial membranes and prevention of cell death,11 and prevention of damage to the lining of the blood vessels12 which may be contributing to restoring delicate balance in heart failure patients.

Another widely accepted use for CoQ10 supplementation is the prevention of muscle pain associated with a common prescription medication class called “statins” that are used for cholesterol reduction and secondary prevention of heart attacks. Both CoQ10 and cholesterol production share a common pathway, this pathway gets inhibited by statin drugs4, so not only do statin drugs slow cholesterol production, they also deplete CoQ10.

Since CoQ10 is an essential molecule for energy production, it’s depletion may contribute to one of the most common side effects of statin medications, muscle pain, also known as myopathy. Hence, taking CoQ10 supplements while taking statins may prevent the negative side effects.14 In addition, CoQ10 has been shown to lower blood pressure in several controlled studies. One study reduced Systolic Blood Pressure (SBP, the top number) by 17 mmHG!15. 

As a potent anti-oxidant, CoQ10 has been also shown to decrease the frequency and severity of migraines16,17.  This is a really exciting area of exploration, considering how debilitating migraines can be.  There are also several other uses that are being currently investigated: fibromyalgia pain18, depression in patients with bipolar19, skin texture improvement20, and Parkinson’s disease21.

Since CoQ10 is an endogenous molecule produced by our bodies, getting too much is highly unlikely even in high doses.21 Mild side effects reported include nausea, vomiting, and diarrhea12. It has to be administered with caution in patients on warfarin or chemotherapy due to the risk of drug interactions12. Always disclose supplements to your healthcare providers so they can work with you to make the best decisions for your health! 

Based on this review of the literature, the current recommended doses are listed below.

  • 100-300 mg daily for Congestive Heart Failure (CHF)12
  • 100 mg per day for high blood pressure15 statin induced myopathy14 and migraine prevention16,17

Lastly, as always, if you are going to add any supplement to your regimen for you or a patient, make sure it’s from a high-quality source.  Here are a couple of my favorite CoQ10 products. FullScript is an amazing resource with all kinds of reputable supplement manufacturers.

 

References

  1. Bronzato S, Durante A. Dietary Supplements and Cardiovascular Diseases. Int J Prev Med. 2018;9:80. Published 2018 Sep 17. doi:10.4103/ijpvm.IJPVM_179_17
  2. Tran UC, Clarke CF. Endogenous synthesis of coenzyme Q in eukaryotes. Mitochondrion. 2007;7 Suppl(Suppl):S62-71
  3. Hemmi N. Bhagavan & Raj K. Chopra (2006) Coenzyme Q10: Absorption, tissue uptake, metabolism and pharmacokinetics, Free Radical Research, 40:5, 445-453, DOI: 10.1080/10715760600617843
  4. Mikael Turunen, Jerker Olsson, Gustav Dallner, Metabolism and function of coenzyme Q, Biochimica et Biophysica Acta (BBA) – Biomembranes, Volume 1660, Issues 1–2, 2004,Pages 171-199, ISSN 0005-2736, https://doi.org/10.1016/j.bbamem.2003.11.012. (http://www.sciencedirect.com/science/article/pii/S0005273603003717)
  5. Del Pozo-Cruz, Jesús & Rodriguez Bies, Elizabeth & Ballesteros, Manuel & Enamorado, Ignacio & Bui Thanh, Tung & Navas, Placido & Lopez-Lluch, Guillermo. (2014). Physical activity affects plasma coenzyme Q10 levels differently in young and old humans. Biogerontology. 15. 10.1007/s10522-013-9491-y.
  6. Chase M, Cocchi MN, Liu X, Andersen LW, Holmberg MJ, Donnino MW. Coenzyme Q10 in acute influenza. Influenza Other Respi Viruses. 2018;00:1-7 https://doi.org/10.1111/irv.12608
  7. Mortensen SA, Rosenfeldt F, Kumar A, Dolliner P, Filipiak KJ, Pella D, et al. The effect of coenzyme Q10 on morbidity and mortality in chronic heart failure: results from Q-SYMBIO: a randomized double-blind trial. JACC Heart Fail. 2014;2(6):641–9. https://doi.org/10.1016/j.jchf.2014.06.008.
  8. Karl Folkers, Peter Langsjoen, Per H. Langsjoen,Therapy with coenzyme Q10 of patients in heart failure who are eligible or ineligible for a transplant, Biochemical and Biophysical Research Communications, Volume 182, Issue 1, 1992, Pages 247-253,ISSN 0006-291X,https://doi.org/10.1016/S0006-291X(05)80137-8.
  9. Chen, F.-L.; Chang, P.-S.; Lin, Y.-C.; Lin, P.-T. A Pilot Clinical Study of Liquid Ubiquinol Supplementation on Cardiac Function in Pediatric Dilated Cardiomyopathy. Nutrients2018, 10, 1697
  10. https://www.drkarafitzgerald.com/2018/09/04/dr-stephen-sinatra-past-present-future-integrative-cardiology/
  11. Haas RH. The evidence basis for coenzyme Q therapy in oxidative phosphorylation disease. Mitochondrion 2007;7 Suppl:S136–45. https://doi.org/10.1016/j.mito.2007.03.008
  12. Sharma A, Fonarow GC, Butler J, Ezekowitz JA, Felker GM. Coenzyme Q10 and heart failure: a state-of-the-art review. Circ Heart Fail. 2016;9(4):e002639. https://doi.org/10.1161/ CIRCHEARTFAILURE.115.002639.
  13. https://www.lifeextension.com/magazine/2008/2/Alleviating-Congestive-Heart-Failure-With-Coenzyme-Q10/Page-01
  14. Caso G, Kelly P, McNurlan MA, Lawson WE. Effect of coenzyme Q10 on myopathic symptoms in patients treated with statins. Am J Cardiol. 2007;99:1409–1412.
  15. Yang Y-K, Wang L-P, Chen L, et al. Coenzyme Q10 treatment of cardiovascular disorders of ageing including heart failure, hypertension and endothelial dysfunction. Clinica Chimica Acta; International Journal Of Clinical Chemistry. 2015;450:83-89. doi:10.1016/j.cca.2015.08.002.
  16. Shoeibi A, Olfati N, Soltani Sabi M, Salehi M, Mali S, Akbari Oryani M. Effectiveness of coenzyme Q10 in prophylactic treatment of migraine headache: an open-label, add-on, controlled trial. Acta Neurologica Belgica. 2017;117(1):103-109. doi:10.1007/s13760-016-0697-z.
  17. Elyas Nattagh-Eshtivani et al. The role of nutrients in the pathogenesis and treatment of migraine headaches: Review, Biomedicine & Pharmacotherapy, Volume 102, 2018, Pages 317-325, ISSN 0753-3322, https://doi.org/10.1016/j.biopha.2018.03.059.
  18. Cordero MD, Santos-García R, Bermejo-Jover D, Sánchez-Domínguez B, Jaramillo-Santos MR, Bullón P. Coenzyme Q10 in salivary cells correlate with blood cells in Fibromyalgia: improvement in clinical and biochemical parameter after oral treatment. Clin. Biochem. 2012 Apr;45(6):509-11 https://doi.org/10.1016/j.clinbiochem.2012.02.001.
  19. Mehrpooya M, Yasrebifar F, Haghighi M, Mohammadi Y, Jahangard L, Elevating the Effect of Coenzyme Q10 Augmentation on Treatment of Bipolar Depression: A double-blind controlled clinical trial. Journal of Clinical Psychopharmacology 2018 Oct;38(5):460-466
  20. Knott,A.;Achterberg,V.;Mielke,H.;Sperling,G.;Dunckelman,K.;Vogelsang,A.;Kruger,A.;Schwengler,H.; Behtash, M.; Kristof, S.; et al. Topical treatment with coenzyme Q10-containing formulas improves skin’s Q10 levels and provides antioxidative effects. Biofactors 2015, 41, 383–390. https://doi.org/10.1002/biof.1239
  21. Mischley L, Lau R, Bennet R, Role of diet and Nutritional Supplements in Parkinson’s Disease Oxidative Medicine and Cellular Longevity, Volume 2017, Article ID 6405278, 9 pages https://doi.org/10.1155/2017/6405278
  22. K.Ferrante, et al, Tolerance of high-dose (3,000 mg/day) coenzyme Q10 in ALS. Neurology Dec 2005, 65 (11) 1834-1836; DOI:10.1212/01.wnl.0000187070.35365.d7.

 

 

Instant Pot Favorites

Happy Thanksgiving!  Hope all of those celebrating today enjoyed some wonderful food with a table of family and friends surrounding you.  For many of you, this kicks off the shopping season!  There are deals all over the place for the Instant Pot. I just purchased one for the couple that we’ve been living with the last 5 weeks as a thank you and Christmas present! It inspired me to post some of my favorite recipes.  Friends are always asking what are your go-to instant pot uses, and here are my top 10!

Dr. Hartzler


  1. White Sweet Potato Turkey Soup, inspired by Castaway Kitchen
  2. Arroz Con Pollo, Castaway Kitchen
  3. Pressure Cooker Kalua Pig Nom Nom Paleo
  4. Paleo Mongolian Beef Once a Month Meals
  5. Paleo Thai Red Curry Soup Balanced Bites
  6. Curried Cream of Broccoli Soup Nom Nom Paleo
  7. One-Pot Spaghetti Squash and Meat Sauce Skinny Taste
  8. Pressure Cooker Pot Roast Domestic Man
  9. Mushroom and Roasted Butternut Squash Risotto My Recipes
  10. Bone Broth The Kitchn
Other things that I love the Instant Pot for are making rice or quinoa! The 6 QT 7-in-1 Programmable Pressure Cooker is on sale on Amazon! Happy shopping and cooking!

Vitamin C and Diabetes

Sorry for the lack of posts lately on the blog.  We are in a bit of a crazy season,  we are currently living with our gracious neighbors while we await the completion of our home. There was a lot of action today at the house! Can’t wait to share my new kitchen with all of you. Today  I saw this come across on the Designs for Health blog and thought.. I need to share this!  Vitamin C… what an easy thing to add to someone’s nutritional plan to help better control blood sugar.

Recently in my practice, I have been more proactive in evaluating my patients with diabetes for nutritional deficiencies so we can better target supplementation to address glucose control and metabolism.

While this study didn’t identify these patients as vitamin C deficient prior to treatment, it’s amazing that something as simple as Vitamin C 500 mg twice daily can make an impact on blood glucose regulation and blood pressure.  Think about the possibilities when this is combined with a healthy diet, exercise, and other key nutrients like biotin, chromium, alpha-lipoic acid, zinc, berberine and cinnamon. Stay tuned for a post on all of these amazing nutrients.

Head over to the Designs for Health Blog and read all about it at the link below! And don’t forget to order your supplements from my FullScript Store. 10% of your purchase goes to ministry!

New study demonstrates vitamin C supplementation improves glycemic control and blood pressure in patients with type II diabetes. 

Dr. Hartzler

Curcumin and Osteoarthritis

Hi everyone, sorry it’s been so long since I have put a blog post up.  Feels like August and September flew by. I had a big deadline for a presentation I’m giving at the American Society of Health-System Pharmacists Meeting and the American Pharmacists Association meeting in December and March, but the majority of that is over and I’m caught up on teaching materials for the most part!

I’m teaching a diabetes elective on-line this semester and it’s been so fun to spend part of my week on Zoom discussing diabetes with my students. I am going to be adding some new diabetes content here soon. And I promise I’m still working on my probiotics posts, it’s such an overwhelming topic when it comes to the data and making any specific recommendations but I’m getting closer! For now though, I remembered I have this awesome post put together by Dr. Timothy Unger, DO who was on a clinical rotation with me earlier this year and is now graduated and a few months into residency training. Curcumin is possibly my favorite supplement for anyone with inflammation or pain. Hope you enjoy!

Dr. Hartzler

 

I would first like to thank Dr. Hartzler for giving me the opportunity to write this post. My name is Timothy Unger and I am a 4th year medical student at Ohio University Heritage College of Osteopathic Medicine. As a young student doctor, I quickly learned that nothing in medicine is free of side effects and there is certainly no catch all medication. However, there is an age old remedy that has gained notoriety that contradicts this claim. Turmeric is a plant native to Southeastern Asia and is in the same family of plants, like ginger [1]. Turmeric has been used for centuries in these Asian countries as a herbal remedy. The active compound that can be extracted from the turmeric root is diferuloylmethane, more commonly known as curcumin [2][7]. This yellow pigmented spice was first identified in 1910 by Lampe and Milobedzka as the active compound of the turmeric root [3]. Researchers have found evidence of curcumin’s anti-oxidant, anti-inflammatory, anti-carcinogenic and anti-microbial properties [1]. This posting will focus primarily on the anti-inflammatory effects of curcumin in osteoarthritis.

Osteoarthritis (OA) is a very common condition worldwide. It is estimated that more than 20 million Americans have OA [4]. This number is projected to increase with the aging population of Baby Boomers. Osteoarthritis is commonly referred to wear and tear of cartilage in joints. There currently is not a cure for osteoarthritis, but there are treatments to treat the symptoms and slow the progression of the condition. The treatments available include pain relievers (like tylenol), steroids and non-steroidal anti-inflammatory drugs (NSAIDs, like advil, aleve, ibuprofen). These medications only manage the symptoms by reducing pain and inflammation [2]. These treatments carry with them their own set of risks. NSAIDs, for example, can cause gastric ulcers when taken long-term. Researchers are investigating novel therapies that eliminate these risks and maximize the benefits. Curcumin supplementation has caught the attention of researchers as this potentially novel agent that has anti-inflammatory properties and little to no side effects.

The chemical structure of curcumin gives it the property of not completely dissolving in water but it is stable in the acidic pH of the stomach [3]. The chemical structure also causes it to be metabolized by the body rapidly. This has led researchers to develop methods of increasing the absorption and the effect curcumin can have one the body [3][7]. Meriva is a form of curcumin developed to solve the problem of absorption [3][5][6]. With this delivery system, researchers measured levels of curcumin after patients were given Meriva and found that absorption was significantly increased compared to taking raw curcumin [3][5]. Other combination supplements are available, like the combination of curcumin and black pepper, or curcumin and sunflower lecithin [10][14]. These combinations have similar improvements on the absorption by the body.Curcumin is sold in formulations, like Meriva where the manufacturers suggests a daily dose of 1 to 2 tablets per day (1 tablet = 500mg) [11]. The manufacturer’s research found that 500mg of Meriva twice daily improved joint function and decreased achiness [12][13].

The pain and inflammation caused by OA can be very irritating and bothersome. Researchers have found that curcumin extracts are as effective as an NSAID, like ibuprofen for the treatment of pain and inflammation from OA [8][9]. These results are even more significant when you compare the side-effect profile of curcumin and NSAIDs. The side effects of curcumin are similar to NSAIDs but with fewer gastrointestinal effects [8][10]. The Food and Drug Administration (FDA) claims that curcumin is “generally regarded as safe” [10]. Several studies of curcumin on rats have shown the supplement to be safe at low to medium doses [10]. Studies have also shown, in mice, that curcumin blocks the effect of some chemotherapeutic agents, namely cyclophosphamide [10]. These reports of side effects state that curcumin is safe and further research is needed on the long-term effects in human patients.

Osteoarthritis affects millions of Americans and this amount is projected to increase over the coming years. There is no cure for this condition, only symptomatic treatment. The current treatment regimen includes NSAIDs, steroids and analgesics, which can have dangerous side effects. This has put alternatives, like Meriva (curcumin), on the main stage because taking it does not cause the dangerous side effects like conventional treatments. If suffer from osteoarthritis and are looking for a change, that can be as effective as other NSAIDS, then curcumin could be the answer. For those with Diabetes, curcumin has also been shown to decrease blood glucose levels, and increase plasma insulin levels [10].

You can find  high-quality curcumin supplements in over in Dr. Hartzler’s FullScript store or by clicking on a image below. Don’t hesitate to reach out with questions. Specifically Dr. Hartzler recommends the ones listed below for good absorption. Both the Protocol for Life Balance and CurcumaSorb have the Meriva formulation metentioned above. Curcum-Evail has the added ingredients to help with absorption!

Meriva Formula


References

  1. Monograph: Curcuma Longa (Turmeric). Alternative Medicine Review 2001; 6: S-62 – S-65.
  2. Henrotin Y., Clutterbuck A.L., D. Allaway, et al. Biological Actions of Curcumin on Articular Chondrocytes. Osteoarthritis and Cartilage. 2010; 18: 141-149
  3. Jurenka J. S. Anti-inflammatory Properties of Curcumin, a Major Constituent of Curcuma longa: A Review of Preclenical and Clinical Research. Alternative Medicine Review 2009; 14, 2: 141 – 153.
  4. Osteoarthritis. (http://www.niams.nih.gov/). [Accessed March 16 2018]
  5. Belcaro G, Hosoi M, Pellegrini L. A Controlled Study of a Lecithinized Delivery System of Curcumin (Meriva) to Alleviate the Adverse Effects of Cancer Treatment. Phytotherapy Research 2014; 28: 444-450.
  6. Meriva: Curcumin Phytosome. Thorne Research: Clinical Research Report. 2016; 1-4; www.throne.com
  7. Henrotin Y, Priem F, Mobasheri A. Curcumin: A New Paradigm and Therapeutic Opportunity for the Treatment of Osteoarthritis: Curcumin for Osteoarthritis Management. SpringerOpen Journal. 2013; 2:56 1-9.
  8. Kuptniratsaikul V, Dajpratham P, Taechaarpornkul W. et al. Efficacy and Safety of Curcuma domestica Extracts Compared with Ibuprofen in Patients with Knee Osteoarthritis: A Multicenter Study. Dove Press Journal. 2014; 9: 451-458.
  9. Turmeric: Arthritis Foundation. https://www.arthritis.org/living-with-arthritis/treatments/natural/supplements-herbs/guide/turmeric.php [Accessed March 16 2018]
  10. Aggarwal B, and Harikumar K B. Potential Therapeutic Effects of Curcumin, the Anti-inflammatory Agent, Against Neurodegenerative, Cardiovascular, Pulmonary, Metabolic, Autoimmune and Neoplastic Diseases. International Journal Biochemistry Cellular Biology. 2009; 41: 40-59
  11. Meriva-SF. https://www.thorne.com/products/detox-support/dp/meriva-sf [Accessed March 16 2018]
  12. Meriva Scientific Support http://www.meriva.info/en/meriva-bioavailable-curcumin/scientific-support/ [Accessed March 16 2018]
  13. Belcano G, Cesarone M, Dugall M, et al. product evaluation  of registry of Meriva, a curcumin-phosphatidylcholine complex. Panminerva Med 2010;52 (suppl 1):55-62
  14. Curcum-Evail. http://catalog.designsforhealth.com/Curcum-Evail-60 [Accessed 03/20/18]

 

Superfood Smoothie

Happy Labor Day!  Did you know Labor Day was founded by Senator James Kyle who was from Cedarville, Ohio? #Randomfact of your weekend! But because of that the village celebrates with Cedarfest every year. So many other fun festivals will be happening in our area in the next few weeks as well. We are super bummed we are going to miss the weekend with the annual Greek festival and Popcorn festival!

At this point school is full swing for families across the country.  Our daughter is back to her Spanish Immersion preschool which she loves.  I can’t believe how well she understands Spanish from being there the last 2 years. She is starting to speak more as well.  This smoothie recipe is inspired by me trying to find a way for me and my kids to get another dose of veggies in the day. I don’t necessarily think it’s a great idea to “hide” veggies, but you know as parents we do what we have to do when they start getting picky! But my kids watch me make it and I tell them everything I’m putting in.  Now when they are playing kitchen they even bring us cups with lettuce in them saying it’s our smoothies!

Print Recipe
Superfood Smoothie
Really you probably don't need to measure, but I know there are people out there that want measurements! So here you go. I seriously have been loving adding frozen riced cauliflower to smoothies. There is zero cauliflower taste and all the nutrition!
Prep Time 5
Servings
Ingredients
Prep Time 5
Servings
Ingredients
Instructions
  1. The directions are pretty easy, just throw it in a blender and press go! I had to remove the lid and stir a few times. You can always add more liquid if needed!
  2. You can use fresh greens, but steamed unlocks the nutrients better!
Recipe Notes
  • You can steam your greens, let them dry, and then store them in the freezer for your next smoothie! Or just save in the fridge for the next few days.
  • Any protein powder would be fine, I prefer the simple collagen peptides for the kiddos, great for supporting gut health, You can find them at www.PharmToTable.Life/VitalProteins
  • For a chocolate or vanilla kick, add Primal Kitchen's Collagen Fuel. The best deal on this is on Thrive Market. My husband loves the chocolate and I love the Vanilla. Bonus if you get the Vanilla, you can then also make my low-carb waffles.
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To Keto or Not to Keto?

What diet is best for me?  This is question that I get a lot.  And my normal approach is very individual, but since I treat a lot of patients with diabetes, I tend to go with a lower carbohydrate approach. My general recommendations are no more than 30 grams of carbs per meal and no more than 15 grams at a snack.  If my patients with diabetes follow this, they tend to do really well as far as controlling their blood sugar.

Even more extreme carb reductions are found in the Keto diet and the Adkins diet.  Adkins focuses on higher protein content and Keto focuses on high fat, moderate protein, and low carb.  Since America is raving about the Keto diet right now, I honestly had plans to get a blog post on it up soon. But I came across this blog this week that hit a lot of my concerns with keto and keto in children (when not using for therapeutic epilepsy) that I thought it was worth sharing!

Is The Ketogenic Diet Safe For Those With Thyroid Disease?

Have you done the Keto diet? Has it worked for you? Have you maintained the Keto diet and maintained the weight loss? Or have you seen other beneficial effects?

Hope your weekend was marvelous and that you are prepping healthy foods for this week’s meals!

Dr. Hartzler

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