Category Archives for "Wellness"

0 Are you missing a key mineral in your diet?

I hope your summer is off to a great start. It’s definitely going to be a different kind of summer given the landscape of the pandemic. A good reason to make sure our bodies are fueled with proper nutritious foods and that we correct any nutrient depletions we may be experiencing. I get a lot of questions about magnesium, it’s such a powerful mineral in the body and one that unfortunately is depleted in our soil with modern farming practices. This post was written by Dr. Kristina Burban, PharmD who was an intern with us in April. We will be sharing part 2 later this week where we will discuss various forms of magnesium.

Magnesium is an essential mineral that plays a role in healthy cell function and bone structure. Sources of dietary magnesium include legumes, whole grains, vegetables, nuts, dark chocolate, fish, and beef.¹ Magnesium deficiency is common in the United States; one study found that 68% of Americans do not consume the recommended amount (310-420 mg) of magnesium daily.² Signs and symptoms of magnesium deficiency include muscle cramps, headaches, fatigue, mood changes, and irregular heartbeat¹. Your provider can test blood magnesium level through a simple blood draw. Problems with absorbing magnesium or not enough intake of magnesium have been associated with developing osteoporosis, high blood pressure, diabetes, and heart disease.¹ People commonly use magnesium for constipation or heartburn, but it can be useful for other reasons as well.

Benefits of Magnesium:

Heart health:

• Having enough magnesium is important for heart health. Studies have shown various cardiac benefits with either dietary or supplemental magnesium. Magnesium intake has been shown to decrease stroke risk. Most of these studies looked at magnesium from dietary sources.^3-8  In heart disease patients with low magnesium levels, taking magnesium supplements reduced heart pain. Also, heart disease patients with low magnesium levels had worse outcomes than heart disease patients with normal magnesium levels.⁹  Supplementing magnesium in coronary artery disease may help reduce blood clots.¹⁰  Patients who took 800-1200 mg magnesium oxide daily for 3 months had 35% less clots than patients who did not take magnesium.

 Diabetes:

• Multiple studies show that increasing dietary magnesium reduces the risk of developing type 2 diabetes.^11-14  A review combined and analyzed existing data about type 2 diabetes and magnesium in 2016. It found that more magnesium intake corresponded to less risk for developing type 2 diabetes. This study also found that increasing dietary magnesium by 100mg/day reduced the risk of developing type 2 diabetes by 8-13%.¹⁵ In people who have diabetes, there is evidence that taking magnesium can increase insulin sensitivity.¹⁶ 

Metabolism:

• Magnesium helps support a healthy metabolism. There is evidence that supplementing magnesium can reduce the risk of developing metabolic syndrome¹⁷, a combination of conditions including high blood pressure, blood sugar, body fat, and cholesterol. People with metabolic syndrome are more likely to have low magnesium levels.¹⁸  Studies have shown that taking supplementing magnesium can have slight benefits on blood pressure and cholesterol.^19-23 A study of adults in the United States found that 68% consumed less than the recommended daily amount of 310-420 mg magnesium daily. Also, it found that people who didn’t consume enough magnesium were more likely to have inflammation. C-reactive protein, a marker of the body’s inflammation, was more likely to be elevated in those patients.²

Mental Health:

• Through what we know about brain function, magnesium has a potential role in altering mood. GABA, a calming neurotransmitter, needs magnesium to be able to function properly in the brain. Magnesium can also change how glutamate, a neurotransmitter that excites, functions in the brain. Therefore, it must be important to have enough magnesium. 
• Research suggests that magnesium could have benefits in anxiety.  One study tested a preparation of 300mg magnesium with hawthorn and poppy plant extracts in patients with anxiety disorders.  The group that took the magnesium preparation showed clinical improvement. ²⁴ In a 2017 review of existing data, researchers found that 4 out of the 8 total clinical studies about magnesium and anxiety reported positive effects on anxiety outcomes.²⁵ However, all of the studies tested a combination of ingredients, not magnesium by itself. More research is needed to establish the effectiveness of magnesium on reducing anxiety.
• Clinical research about magnesium’s effects on depression are also promising, but limited. In animal studies, magnesium seems to have an antidepressant effect, but there is less evidence in humans. One study tested 2,000 mg magnesium daily for 6 weeks in patients with symptoms of depression. The study showed improvement in depression symptoms, but there was no placebo group and the patients knew they were taking magnesium, which could have affected the results.²⁶  Another study tested supplementing 500 mg magnesium versus placebo in patients with depression and low magnesium levels. After 8 weeks, the patients taking magnesium showed improvement in depression status.²⁷ Again, more research is needed to see how effective magnesium is in improving depression.
• A national health and nutrition survey showed that people who report under 7 hours of sleep have lower intake of calcium, magnesium, and vitamin D.²⁸ This reinforces how important it is to have enough mineral and vitamin intake, whether through dietary sources or supplementation. Overall, having enough magnesium is likely to help improve rest, relaxation, and mood. 
• Magnesium is also helpful for sleep. In one particular study of insomnia in the elderly statistically significant increases in sleep time, sleep efficiency, and melatonin, and also resulted in significant decrease in time to sleep onset and serum cortisol concentration.²⁹

References:

1. Magnesium. In: Natural Medicines Comprehensive Database. Stockton, CA: Therapeutic Research Faculty. [Updated January 23, 2020]. 
2. King DE, Mainous AG 3rd, Geesey ME, Woolson RF. Dietary magnesium and C-reactive protein levels. J Am Coll Nutr 2005;24:166-71.
3. Adebamowo SN, Spiegelman D, Willett WC, Rexrode KM. Association between intakes of magnesium, potassium, and calcium and risk of stroke: 2 cohorts of US women and updated meta-analysis. Am J Clin Nutr. 2015;101(6):1269-77. 
4. Suter PM. The effects of potassium, magnesium, calcium, and fiber on risk of stroke. Nutr Rev 1999;57:84-8.
5. Ascherio A, Rimm EB, Hernan MA, et al. Intake of potassium, magnesium, calcium, and fiber and risk of stroke among US men. Circulation 1998;98:1198-204.
6. Nie ZL, Wang ZM, Zhou B, Tang ZP, Wang SK. Magnesium intake and incidence of stroke: meta-analysis of cohort studies. Nutr Metab Cardiovasc Dis 2013;23(3):169-76.
7. Xu T, Sun Y, Xu T, Zhang Y. Magnesium intake and cardiovascular disease mortality: a meta-analysis of prospective cohort studies. Int J Cardiol 2013;167(6):3044-7. 
8. Zhang W, Iso H, Ohira T, Date C, Tamakoshi A; JACC Study Group. Associations of dietary magnesium intake with mortality from cardiovascular disease: the JACC study. Atherosclerosis 2012;221(2):587-95.
9. Lasserre B, Spoerri M, Moullet V, et al. Should magnesium therapy be considered for the treatment of coronary heart disease? II. Epidemiological evidence in outpatients with and without coronary heart disease. Magnes Res 1994;7:145-53. 
10. Shechter, M., Merz, C. N., Paul-Labrador, M., Meisel, S. R., Rude, R. K., Molloy, M. D., Dwyer, J. H., Shah, P. K., and Kaul, S. Beneficial antithrombotic effects of the association of pharmacological oral magnesium therapy with aspirin in coronary heart disease patients. Magnes.Res. 2000;13(4):275-284.
11. Meyer KA, Kushi LH, Jacobs DR, et al. Carbohydrates, dietary fiber, and incident type 2 diabetes in older women. Am J Clin Nutr 2000;71:921-30.
12. Song Y, Manson JE, Buring JE, Liu S. Dietary magnesium intake in relation to plasma insulin levels and risk of type 2 diabetes in women. Diabetes Care 2004;27:59-65.
13. Fung TT, Manson JE, Solomon CG, et al. The association between magnesium intake and fasting insulin concentration in healthy middle-aged women. J Am Coll Nutr 2003;22:533-8. 
14. Lopez-Ridaura R, Willett WC, Rimm EB, et al. Magnesium intake and risk of type 2 diabetes in men and women. Diabetes Care 2004;27:134-40.
15. Fang X, Han H, Li M, et al. Dose-Response Relationship between Dietary Magnesium Intake and Risk of Type 2 Diabetes Mellitus: A Systematic Review and Meta-Regression Analysis of Prospective Cohort Studies. Nutrients. 2016;8(11)
16. Barbagallo M, Dominguez LJ. Magnesium and type 2 diabetes. World J Diabetes. 2015;6(10):1152‐1157. doi:10.4239/wjd.v6.i10.1152
17. He K, Liu K, Daviglus ML, et al. Magnesium intake and incidence of metabolic syndrome among young adults. Circulation 2006;113:1675-82.
18. Guerrero-Romero F, Rodriguez-Moran M. Low serum magnesium levels and metabolic syndrome. Acta Diabetol 2002;39:209-13. 
19. Hoogerbrugge N, Cobbaert C, de Heide L, et al. Oral physiological magnesium supplementation for 6 weeks with 1 g/d magnesium oxide does not affect increased Lp(a) levels in hypercholesterolaemic subjects. Magnes Res 1996;9:129-32.
20. Jee SH, Miller ER 3rd, Guallar E, et al. The effect of magnesium supplementation on blood pressure: a meta-analysis of randomized clinical trials. Am J Hypertens 2002;15:691-6.
21. Dickinson HO, Nicolson DJ, Campbell F, et al. Magnesium supplementation for the management of essential hypertension in adults. Cochrane Database Syst Rev 2006;3:CD004640.
22. Kass L, Weekes J, Carpenter L. Effect of magnesium supplementation on blood pressure: a meta-analysis. Eur J Clin Nutr 2012;66:411-8.
23. Zhang X, Li Y, Del Gobbo LC, et al. Effects of magnesium supplementation on blood pressure: a meta-analysis of randomized double-blind placebo-controlled trials. Hypertension. 2016 Aug;68(2):324-33. 
24. Hanus M, Lafon J, Mathieu M. Double-blind, randomised, placebo-controlled study to evaluate the efficacy and safety of a fixed combination containing two plant extracts (Crataegus oxyacantha and Eschscholtzia californica) and magnesium in mild-to-moderate anxiety disorders. Curr Med Res Opin 2004;20:63-71.
25. Boyle NB, Lawton C, Dye L. The Effects of Magnesium Supplementation on Subjective Anxiety and Stress-A Systematic Review. Nutrients. 2017;9(5):429. Published 2017 Apr 26. doi:10.3390/nu9050429
26. Tarleton EK, Littenberg B, MacLean CD, Kennedy AG, Daley C. Role of magnesium supplementation in the treatment of depression: a randomized clinical trial. PLoS One. 2017 Jun 27;12(6):e0180067. 
27. Rajizadeh A, Mozaffari-Khosravi H, Yassini-Ardakani M, Dehghani A. Effect of magnesium supplementation on depression status in depressed patients with magnesium deficiency: A randomized, double-blind, placebo-controlled trial. Nutrition. 2017 Mar;35:56-60. doi: 10.1016/j.nut.2016.10.014. Epub 2016 Nov 9.
28. Ikonte CJ, Mun JG, Reider CA, Grant RW, Mitmesser SH. Micronutrient Inadequacy in Short Sleep: Analysis of the NHANES 2005-2016. Nutrients. 2019 Oct 1;11(10). pii: E2335. doi: 10.3390/nu11102335. 
29. Abbasi, et al. J Res Med Sci. 2012 Dec; 17(12): 1161–1169.

0 One Option for Stress & Anxiousness

I know with recent events, the anxiousness and stress level, especially among many of our front-line healthcare workers is high. I also know friends and family that are struggling with anxiousness as they continue to see the impact of this pandemic on our world. My pharmacy intern Sydney Schultz, wrote this post for you. I don’t think we knew how relevant it would be in this time. I hope you find it valuable and reach out if you have questions.

Anxiety disorders are one of the most common mental illnesses in the United States, affecting 40 million adults in the United States age 18 and older, or 18.1% of the population. Anxiety is an extremely prevalent condition worldwide that is associated with a high degree of morbidity and impairment of quality of life. Generalized anxiety disorder (GAD), according to the DSM 5 criteria, is characterized by excessive anxiety and worry occurring more days than not for at least six months.

Current standard of care for anxiety typically includes selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline and paroxetine as first line therapy, and benzodiazepines such as clonazepam, alprazolam and lorazepam for breakthrough anxiety. These medications are often times habit forming and associated with undesirable side effects such as sedation, impaired concentration and depression. Not to mention, it can be quite difficult to taper off these medications due to withdrawal effects. 

Lavandula angustifolia, on the other hand, is a non-habit forming, well-tolerated, natural supplement that has shown to be effective in relieving symptoms of anxiety, promoting quality of sleep and calming nerves.  Lavender has been used for centuries for its relaxing, calming and mood alleviating effects. In Germany, a monograph issued by the Federal Health Agency in 1978 approved lavender flowers, under the trademark name Silexan, for the treatment of restlessness. Whereas lavender products have historically been used as aromatherapy, Silexan™ is a novel preparation created through steam distillation from Lavandula angustifolia for oral use.

Silexan™ has been shown to be more effective than placebo and as effective as paroxetine and lorazepam (see table below). These trials utilized the Hamilton anxiety rating scale (HAM-A) to assess symptom relief. The HAM-A is a clinician rated scale that assesses symptoms of anxiety. Patients are rated based on the extent of their symptoms and physical manifestations of anxiety such as gastrointestinal and insomnia. 

Trial	Inclusion diagnosis	Design	Intervention	Results: Mean decrease in HAM-A
Kasper et al. (2010)	Anxiety disorder, not otherwise specified	Double-blind, randomized, placebo-controlled	80 mg/day Silexan™ (n=104) or placebo (n=108) for 10 weeks	16.0 ±  8.3 (Silexan)  9.5 ± 9.1 (Placebo)
Woelk and Schlaefke (2010)	Generalized anxiety disorder	Double blind, double dummy, randomized, reference-controlled	80 mg/day Silexan™ (n=40) or 0.5 mg/day Lorazepam (n=37) for 6 weeks	11.3 ± 6.7 (Silexan)  11.6 ± 6.6 (Lorazepam)
Kasper et al. (2014)	Generalized anxiety disorder	Double blind, randomized, reference-controlled, placebo-controlled	160 mg/day Silexan™ (n=121), 80 mg/day Silexan™ (n=135), 20 mg/day paroxetine (n=132) or placebo (n=135) for 10 weeks	14.1 ± 9.3 (Silexan 160) 12.8 ± 8.7 (Silexan 80) 11.3 ± 8.0 (paroxetine)  9.5 ± 9.0 (placebo)
Kasper et al.  (2016)	Mixed anxiety/depressive disorder	Double-blind, randomized, placebo-controlled	80 mg Silexan™ (n=159) or placebo (n=156) for 10 weeks	10.8 ± 9.6 (Silexan) 8.4 ± 8.9 (placebo)

In the Kasper (2010) study, the HAM-A score decrease was significant as of week 2 in the Silexan™ group (p<0.001). In the Woelke (2010) study, Silexan™ was as efficacious as low dose lorazepam 0.5 mg in adults with GAD without causing sedation or potential for abuse. In the Kasper (2014) trial, Silexan™ 160 and 80 mg daily were both superior to placebo in reducing the HAM-A total score (p<0.01). In Kasper (2015), Silexan™ 80 mg was once again superior to placebo (p<0.001). There was also a significant decrease in the Montgomery Asberg Depression Rating Scale (p<0.001) seen in this study when comparing Silexan to placebo.

Beyond being effective for reducing symptoms, Silexan™ is also extremely well tolerated. Adverse effects seen in clinical trials were uncommon and included nausea (5.2%), burping (3.9%) and dyspepsia (2.6%). It was shown to improve quality and duration of sleep by calming nervousness and increasing relaxation without causing sedation. 

The commercially available product in the US is called Lavela WS1265, which is a brand name for the Silexan™ formulation. You can find it on our fullscript store. It contains 80 mg of active ingredient, Lavandula angustifolia, and is taken as one softgel by mouth once or twice daily with a full glass of water. Lavela WS1265 has not been studied during pregnancy, lactation or in patients less than 12 years of age. This is not an FDA approved treatment for anxiety or other mood disorders, however it could be an option to discuss with you healthcare provider, to determine if it could be used for support and symptom relief.

References: 

1. Baldwin DS, Montgomery SA, Nil R, Lader M. 2007. Discontinuation symptoms in depression and anxiety disorders. Int J Neuropsychopharmacol. 10:73–84.
2. Haller H, Cramer H, Lauche R, Gass F, Dobos GJ. 2014. The prevalence and burden of subthreshold generalized anxiety disorder: a systematic review. BMC Psychiatry. 14:128–140. 
3. Kasper S, Gastpar M, Müller WE, Volz HP, Möller HJ, Schläfke S. 2014. Lavender oil preparation Silexan is effective in generalized anxiety disorder: a randomized, double-blind comparison to placebo and paroxetine. Int J Neuropsychopharmacol. 17:859–869.
4. Kasper S, Volz HP, Dienel A, Schläfke S. 2016. Efficacy of Silexan in mixed anxiety-depression: a randomized, placebo-controlled trial. Eur Neuropsychopharmacol. 26:331–340.
5. Kessler RC, Demler O, Frank RG. 2005. Prevalence and treatment of mental disorders, 1990 to 2003. N Engl J Med. 352:2515–2523.
6. Longo LP, Johnson B. 2000. Addiction: part I. Benzodiazepines-side effects, abuse risk and alternatives. Am Fam Physician. 61:2121–2128.
7. Müller WE, Schuwald A, Nöldner M, Kasper S, Friedland K. 2015. Pharmacological basis of the therapeutic use of Silexan (Lasea). Psychopharmakotherapie. 22:3–14.
8. Musazzi L, Racagni G, Popoli M. 2011. Stress, glucocorticoids and glutamate release: effects of antidepressant drugs. Neurochem Int. 59:138–149. 
9. Kasper S, Gastpar M, Müller WE, Volz HP. 2010. Silexan, an orally administered Lavandula oil preparation, is effective in the treatment of ‘subsyndromal’ anxiety disorder: a randomized, double-blind, placebo controlled trial. Int Clin Psychopharmacol. 25:277–287.
10. Woelk H, Schläfke S. 2010. A multi-center, double-blind, randomized study of the Lavender oil preparation Silexan in comparison to Lorazepam for generalized anxiety disorder. Phytomedicine. 17:94–99.

0 Probiotic FAQ: Part 2

It’s finally Spring in Ohio! Trees are blooming, and it’s warm enough for walking and playing outside. Our daughter learned to ride a bike without training wheels this week and she’s been non-stop asking to go outside. Balance bikes are amazing, she literally tried the real bike for 1 day before she got it after using the balance bike the last few years.

This is the final post in my Probiotic Series at least for now! If you haven’t checked out the other post, please do, it starts with Probiotics 101, then Probiotic FAQ: Part 1 . And now on to Part 2! I also have a post over on my friend Lindsey Elmore’s site you should read as well. Thanks again to my interns Vineeta Rao and Ruth Gunti who worked on this series with me.

I hope these post help explain some of the basics about probiotics and the answer your questions, if you have further questions. Don’t hesitate to reach out.

If I have histamine intolerance, should I avoid certain strains? If so which ones?

Histamine intolerance is a condition in which the body has imbalanced levels of histamine. In this state, through the body’s own metabolic processes or consumption of histamine-rich foods, the body has too much histamine and may react to certain food with allergic-like symptoms such as hives, skin rashes, and other digestive symptoms.¹ Gut bacteria are involved in both producing and degrading histamine, and having too many histamine-producing bacteria or too little histamine-degrading bacteria may cause elevated histamine levels.^2,3 Therefore, it is crucial to select a probiotic that contributes to the proper balance of histamine in the body.

If you have histamine intolerance, it is important to avoid certain species of histamine-producing bacteria when selecting a probiotic. Those that should be avoided are Lactobacillus casei, Lactobacillus Bulgaricus, Streptococcus thermophilus, Lactobacillus delbrueckii, Lactobacillus helveticus.³
In contrast, certain probiotics appear to aid in relieving the imbalances found with histamine intolerance. Lactobacillus rhamnosus strains GG and c705 have been observed to inhibit the effect of histamine in the body.⁴ Additionally, in vitro studies suggest that bifidobacterium lactis and lactobacillus plantarum species promote histamine breakdown. ^5,6

Should I take a probiotic while also taking an antibiotic? If so which one, and for how long?

Although clinicians have generally supported using probiotics with an antibiotic course, this is an area of controversy as new studies suggest that probiotics may interrupt the body’s natural process of restoring the bacterial balance in the gut. There are many studies that support using probiotics to prevent antibiotic-associated diarrhea, and among the tested species S. boulardii has specifically been shown to be effective.⁷ Studies have also shown that Lactobacillus rhamnosus GG, the strain contained in the Culturelle probiotic, appears and effective to prevent antibiotic associated diarrhea (AAD) in an outpatient setting.⁸ The recommended  dose is 10⁷ to 10¹⁰ colony-forming units (CFU) per capsule (taken one to 3 times daily) as that is what has been studied; duration of therapy can be 1-3 weeks or the entire length of time that the patient is on antibiotics.⁹ For reference, Metagenics “UltraFlora LGG” and Culturelle “Digestive Health” products contains 10¹⁰ CFU per dose, and Culturelle “Kids” product contains 10⁹ CFU per dose, making these products good choices for AAD.¹⁰ It is generally recommended to take probiotics for a couple months after therapy and consuming fermented foods. Overall it is said that “probiotics appear to be effective in preventing and treating AAD in children and adults receiving a wide variety of antibiotics.” ^8-10

However, there is emerging research that suggests that probiotics may actually delay spontaneous recovery of the microorganisms in the gut, or the “gut microbiome.” A recent study compared spontaneous gut recovery to probiotic use in humans receiving a broad-spectrum antibiotic course. By performing endoscopies and examining the stool from the patients before and after receiving antibiotics, normal genetic expression of bacteria in the gut was delayed by up to 5 months in the probiotic group versus a matter of weeks in the group allowed to spontaneously recover.^11,12 The in vitro portion of the study suggested that Lactobacillus acidophilus may inhibit the native gut microbiome.¹¹ While this study cautions against the preventative use of probiotics with an antibiotic course, further studies to shed light on the benefit or harm of probiotics are needed to come to a clear conclusion.¹²

In the meantime, it may be wise to avoid probiotics with Lactobacillus acidophilus when taking an antibiotic course. One of the challenges as a provider recommending probiotics is that this was just 1-2 studies in the midst of all the literature and didn’t not look at saccharomyces boulardii and its effect, therefore it really just raises questions for future research and gives us a pause to our practice of using blanket probiotics for everyone on antibiotics habit.

If I have dysbiosis or Small intestinal bacterial Overgrowth, should I avoid pre-biotics or certain probiotic strains?

Small Intestinal Bacterial Overgrowth (SIBO) typically refers to a form of dysbiosis (imbalance of bacteria on the body) attributed to an excessive overgrowth or changes in types of bacteria in the small-intestine.^13,,14 While the small intestine is not sterile, it has far fewer bacteria than the large intestine. Thus, SIBO may result from the specific bacteria that normally grows in the large intestine growing inappropriately in the small intestine.^13,14 Other causes of SIBO include multiple courses of antibiotics and impaired defense mechanisms such as low stomach acid, which may be caused by use of Proton Pump Inhibitors (PPIs). While the definition is constantly changing and expanding to include other forms of dysbiosis, SIBO is typically characterized by non-specific gastrointestinal symptoms such as bloating, abdominal discomfort, diarrhea, fatigue, and weakness and might be treated with an antibiotic course.^13,14

There are several studies that actually support the use of probiotics for this disorder.¹⁵  However, at the moment there is little consensus across the studies as to which probiotics species and strains will provide benefit for SIBO. Regardless of the species, the theoretical concern with using probiotics in SIBO even if the bacteria added to the gut is “good” bacteria, too much bacteria often produces symptoms of bloating and gas, which would worsen symptoms. In SIBO, patients often have an overgrowth of D-lactate-producing bacteria, so it may be best to avoid probiotics that also produce D-lactate such as Lactobacillus acidophilus.¹⁶

In the past it has also been generally recommended that one avoid the use of prebiotics until SIBO symptoms under control. Currently, studies that challenge this notion are frequently emerging, and in time, we may see a demonstrable benefit of certain probiotics and prebiotics in SIBO.¹⁶ However, until studies show which species and strains relieve rather than aggravate SIBO symptoms, it is likely best to avoid prebiotics and probiotics that produce D-lactate. In general, I recommend treating the overgrowth before working on replacing the flora with probiotics. Once those probiotics are tolerated, consider adding prebiotics to support healthy growth of gut flora along with other measures to prevent SIBO recurrence. Specifically, Partially Hydrolyzed Guar Gum (PHGG) is a prebiotic that has been shown to treat SIBO when administered alongside the antibiotic rifaximin better than rifaximin alone.¹⁷ Thus, this product could be a good option for encouraging healthy gut flora growth.

That’s a wrap. As always you can find great probiotic options on my FullScript Store or at YoungLiving. Feel free to message me if you have specific questions. We have so much science but we are still not quite a place were we absolutely know which probiotic product is going to work for each person. We are moving closer to that each day.

References:

1. Maintz L,  Novak N.Histamine and histamine intolerance.Am J Clin Nutr. 2007;85(5):1185-96.
2. Pugin B, Barcik W, Westermann P, et al. A wide diversity of bacteria from the human gut produces and degrades biogenic amines. Microb Ecol Health Dis. 2017;28(1):1353881.
3. What causes Histamine Intolerance. Facts vs Fitness. https://factvsfitness.com/probiotics-histamine-intolerance/. Updated July 27, 2017. Accessed January 23, 2019.
4. Oksaharju A, Kankainen M, Kekkonen RA, et al. Probiotic Lactobacillus rhamnosus downregulates FCER1 and HRH4 expression in human mast cells. World J Gastroenterol. 2011;17(6):750-9.
5. Mokhtar S., Mostafa G, Taha R. et al. Effect of different starter cultures on the biogenic amines production as a critical control point in fresh fermented sausages. Eur Food Res Technol. 2012;235(3): 527-535.
6. Capozzi V, Russo P, Ladero V, et al. Biogenic Amines Degradation by Lactobacillus plantarum: Toward a Potential Application in Wine. Front Microbiol. 2012; 3: 122.
7. Mcfarland LV. Systematic review and meta-analysis of Saccharomyces boulardii in adult patients. World J Gastroenterol. 2010;16(18):2202-22.
8. Blaabjerg S, Artzi DM, Aabenhus R. Probiotics for the Prevention of
   Antibiotic-Associated Diarrhea in Outpatients-A Systematic Review and Meta-Analysis. Antibiotics (Basel). 2017 Oct 12;6(4).
9. Rodgers B, Kirley K, Mounsey A. PURLs: prescribing an antibiotic? Pair it with probiotics. J Fam Pract. 2013;62(3):148-50.
10. Antibiotic Use & Associated Diarrhoea Prevention. Probiotic Advisor. https://www.probioticadvisor.com/ Accessed February 9, 2019.
11. Suez J, Zmora N, Zilberman-Schapira G, et al. Post-Antibiotic Gut Mucosal Microbiome Reconstitution Is Impaired by Probiotics and Improved by Autologous FMT. Cell. 2018;174(6):1406-1423.
12. Kresser C. RHR: What the Latest Research Says about Probiotics, with Lucy Mailing. https://chriskresser.com/what-the-latest-research-says-about-probiotics-with-lucy-mailing/ Updated November 4, 2018. Accessed February 9, 2019.
13. Drake LE, Guilliams TG. Small intestinal bacterial overgrowth (SIBO): diagnostic challenges and functional solutions. Point Institute. 2018;14(2)1-15.
14. Kresser C. What Causes SIBO (Small Intestinal Bacterial Overgrowth) and Why It’s So Hard To Treat. https://chriskresser.com/sibo-what-causes-it-and-why-its-so-hard-to-treat/ Updated November 4, 2014. Accessed February 9, 2019.
15. Chen WC, Quigley EM. Probiotics, prebiotics & synbiotics in small intestinal bacterial overgrowth: opening up a new therapeutic horizon!. Indian J Med Res. 2014;140(5):582-4.
16. Kresser C. RHR: Treating SIBO, Cold Thermogenesis, and When to Take Probiotics. https://chriskresser.com/treating-sibo-cold-thermogenisis-and-when-to-take-probiotics/. Updated March 12, 2013. Accessed February 9, 2019.
17. Furnari M, Parodi A, Gemignani L, et al. Clinical trial: the combination
    of rifaximin with partially hydrolysed guar gum is more effective than rifaximin alone in eradicating small intestinal bacterial overgrowth. Aliment Pharmacy Ther. 2010;32(8):1000-6.

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.

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.

0 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!

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.

2. 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 photo–damage 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.⁷ 
   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.

3. 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.

 

0 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!

 

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 migraines^16,17.  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 prevention^16,17

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.

 

 

0 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. 

0 The NEW Nutrient Duo – Vitamins D and K2

I’ve been meaning to get a post up on this topic for awhile now, my fabulous former student and intern who just graduated with her PharmD, Dr. Kara Lish wrote this for you.  It has a lot of content, so hopefully the length won’t overwhelm you but help you see how Vitamin K2 is an essential nutrient that many of us are lacking in our diets. I will be doing a facebook live on this topic this on Thursday June 14th at 8 pm EST to answer questions!

 

For years, vitamin K has really only been known for its role as a cofactor to assist calcium in the regulation of blood clotting. Likewise, vitamin D was thought to aid calcium absorption to promote strong bones. It was not until recently that we learned it is vitamin K, particularly vitamin K2, that actually assists vitamin D to get calcium into the bones and to keep calcium out of the arteries, organs, and joints. In fact, various studies have shown that the supplementation with vitamin K2 actually strengthens the bone and reduces the risk for osteoporosis, and bone fractures. Additionally, vitamin K has been shown to promote cardiovascular health and arterial elasticity and to boost immune function as well. Read below for a complete guide in understanding how vitamin K works and what types exist and their specific benefits.

What is vitamin K? What types are beneficial and what dietary sources include those types?

Vitamin K is a fat-soluble vitamin that occurs naturally as either vitamin K1 (phylloquinone) or vitamin K2 (menaquinones). Vitamin K1 is found in green vegetables, like spinach, whereas vitamin K2 is found mostly in grass-fed dairy products, such as fermented milk or kefir. To a lesser extent, vitamin K2 can also be produced by bacteria in the digestive tract of animals, like chickens or cows. Unlike K1 where most goes directly to the liver where it stays to regulate normal blood clotting, vitamin K2 quickly passes through the liver before being redistributed throughout the entire body to be absorbed to help aide in various functions. For example, vitamin K2 is redistributed to the bones and blood vessels to support bone and cardiovascular health. Deficiencies of vitamin K1 have been linked to an increased risk of bleeding and less vitamin K2 available to the rest of body since the liver will then hold onto it to clot blood properly. Deficiencies of vitamin K2 have been associated with osteoarthritis, osteoporosis, and vascular calcification among other things, like a decline in cognitive function.^1,2 Because of their vital roles in overall health; men and women, including expecting and lactating mothers, should obtain 120 and 90 μg per day of vitamin K1 and 45-185 μg per day of vitamin K2.^3,4

Where does vitamin D come into play?

Focusing on vitamin K2 and bone health, there are three vitamin K2 dependent non-clotting proteins regulated by vitamin D3 that have been shown to prevent osteoarthritis, osteoporosis, and vascular calcification (strengthening) of bone. Vitamin D controls how much calcium is absorbed from the diet. Vitamin K2 directs the absorbed calcium to the bones where its new role is to promote bone building and prevent its breakdown.

 

Vitamin D3 regulates the amount of calcium and production of a certain protein, osteocalcin, which plays a vital role in bone health once vitamin K2 activates it. Once activated, vitamin K2 then helps bind osteocalcin to calcium before directing the absorbed calcium to the bones, where it binds to the bone matrix to build bone and prevent its breakdown. Without vitamin K2, osteocalcin would remain inactivated and calcium would neither be able to bind to it nor reach its destination in the bones. As a result, it would be impossible for the body to build or strengthen bone to prevent against fractures or breaks.^1,2,5,6

In fact, studies have demonstrated an increase in activated osteoclacin after the administration of vitamin K2, and thus, correlated inactivated osteocalcin with the risk for clinical fractures.⁵ Vitamin K has also even been shown to help maintain bone mineral density or bone strength. It does this by decreasing the breakdown of bone.⁷ Thus, vitamin K2 stimulates cells that promote bone building, while inhibiting cells that break down bone, resulting in greater calcification or bone strength.

Evidence showed that vitamin K2 helps to strong bones and to reduce bone fractures.⁸ Gajic-Veljanoski and group found that the daily use of 800 IU vitamin D, 45 μg vitamin K2, and 1200 mg calcium reduced the lifetime risk of a fracture by 25%.⁹ Similarly, Cockayne and colleagues demonstrated that vitamin K2 supplementation reduced bone loss and prevented hip, nonvertebral, and vertebral fractures by 77%, 81%, and 60%, respectively.¹⁰ Comparing osteoporotic patients who received 150 mg calcium with or without 45 μg vitamin K2, those who received only calcium lost 2.5% of their bone strength and experienced 45% more fractures versus those who received both, calcium and vitamin K2.¹¹ More so, other studies have proven that vitamin K2 can even reduce bone fractures induced by certain medications, like glucocorticoids, as well as to maintain and increase bone strength in liver-dysfunction-induced osteoporosis and paralytic patients with cerebrovascular disease.⁸

Not only are adequate levels of vitamin K2 desired in adults, particularly in the elderly population and pregnant women, but also in children.⁶ Recent studies have shown that even most healthy, prepubertal and pubertal children have high levels of inactive osteocalcin, which in turn signifies inadequate levels of vitamin K2, when compared to adults. Long-term, this could prevent the nonessential vitamin-K proteins from functioning, prohibiting optimal bone development to cause early onset osteoporosis. Karpinski and group’s study actually identified children as being the most deficient in vitamin K2 due to only 10% of it being found in the typical Western diet. Like the previous studies, they too recommend at least 45 μg vitamin K2 daily to increase levels to then increase osteocalcin activation, which to reiterate is the vitamin K dependent protein that helps bind calcium to promote bone mineralization, and thus, bone health.² On the other hand, other studies found that the relationship between the administration of supplemental vitamin K2 and the improvement in osteocalcin carboxylation is dose dependent, so Inaba and group recommend ≥100 μg vitamin K2 per day.¹²

How do I get more vitamin K2 in my daily diet?

To obtain more, you can either eat foods high in vitamin K2 (see below) or choose an appropriate supplement for you. When choosing a supplement, it is important to keep these 5 things in mind:

• Choose the right vitamin K2: MK-7 is best due to it’s longer half-life, but a mixture of MK-4/MK-7 is fine.

• Pick an appropriate dose: Adults opt for at least 100 μg (MK-7) daily.

• Eat with fat: It is fat-soluble; intake with fat sources maximizes absorption.
• Remember its companion: Vitamin D and K work synergistically. Other supplements, like magnesium and zinc, can further increase bone mineralization.

Adults and children require adequate amounts of both, vitamin D and vitamin K to create the ultimate duo for bone health!

• Consider current medications/dietary needs: If you are on a blood thinner, like warfarin, then talk to your doctor or pharmacist before supplementing with vitamin K2. If you have an allergy, intolerance, or dietary preference, then rest assured knowing there are options to meet these needs as well!

Take a look at these different products as well as the dietary options below, and talk to your doctor and pharmacist to see which may work best for you, but remember… Adults and children require adequate amounts of both, vitamin D and vitamin K to create the ultimate duo for bone health! If you don’t need additional Vitamin D, Orthomolecular also as a K2 only product. Dr. Hartzler recommends the liquid D3/K2 frequently because when it is in the MCT oil drops, the oil helps the nutrients absorb since they are fat soluble.

Dr. Hartzler will be on Facebook live this Tuesday evening June 12th at 8 pm EST to answer any questions you have about Vitamin D/K2. There some additional benefits to K2 as well that we will discuss beyond bone building!

Other Dietary Foods High in Vitamin K2, specifically MK-4/MK-7.

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References:

1. Flore R, Ponziani FR, Di Rienzo TA, et al. Something more to say about calcium homeostasis: the role of vitamin K2 in vascular calcification and osteoporosis. Eur Rev Med Pharmacol Sci. 2013;17(18):2433-2440.
2. Villa JKD, Diaz MAN, Pizziolo VR, Martino HSD. Effect of vitamin K in bone metabolism and vascularization: A review of mechanisms of action and evidences. Crit Rev Food Sci Nutr. 2017;57(18):3959-3970. doi: 10.1080/10408398.2016.1211616.
3. Institute of Medicine. Dietary reference intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. Washington, DC: National Academy Press; 2001.
4. Mercola J. Mercola. Vitamin D and K2 work in tandem to slow arterial calcification. https://articles.mercola.com/sites/articles/archive/2013/10/19/vitamin-d-vitamin-k2.aspx. Published October 19, 2013. Accessed February 10, 2018.
5. Vergnaud P, Garnero P, Meunier PJ, et al. Undercarboxylated osteoclacin measured with a specific immunoassay predicts hip fracture in elderly women: the EPIDOS study. J Clin Endocrinol Metab. 1997;82(3):719-724. doi: 10.1210/jcem.82.3.3805.
6. Karpiński M, Popko J, Maresz K, Badmaev V, Stohs SJ. Roles of Vitamin D and K, nutrition, and lifestyle in low-energy bone fractures in children and young adults. J Am Coll Nutr. 2017;36(5):399-412. doi: 10.1080/07315724.2017.1307791.
7. Weber P. Management of osteoporosis: Is there a role for vitamin K? Int J Vitam Nutr Res. 1997;67(5):350-356.
8. Iwamoto J, Takeda T, Sato Y. Effects of vitamin K2 on osteoporosis. Curr Pharm Des. 2004;10(21):2557-2576. doi: 10.2174/1381612043383782.
9. Gajic-Veljanoski O, Bayoumi AM, Tomlinson G, Khan K, Cheung AM. Vitamin K supplementation for the primary prevention of osteoporotic fractures: Is it cost-effective and is future research warranted? Osteoporos Int. 2012;23(11):2681-2692. doi: 10.1007/s00198-012-1939-4.
10. Cockayne S, Adamson J, Lanham-New S, et al. Vitamin K and the prevention of fractures: systemic review and meta-analysis of randomized controlled trials. Arch Intern Med. 2006;166(12):1256-1261. doi: 10.1001/archinte.166.12.1256.
11. Shiraki M, Shiraki Y, Aoki C, Miura M. Vitamin K2 (Menatetrenone) effectively prevents fractures and sustains lumbar bone mineral density in osteoporosis. J Bone Miner Res. 2000;15(3):515-521. doi: 10.1359/jbmr.2000.15.3.515.
12. Inaba N, Sato T, Yamashita T. Low-dose daily intake of vitamin K(2) (Menaquinone-7) improves osteocalcin y-carboxylation: a double-blind, randomized controlled trials. J Nutr Sci Vitaminol (Tokyo). 2015;61(6):471-480. doi: 10.3177/jnsv.61.471.

0 Eczema & Probiotics

The majority of this post was written by Dr. Taylor Edwards, who was a medical student that rotated with me earlier this year, now she is a Doctor of Osteopathic Medicine off to residency!  I take medical students from Ohio University and work with the pharmacists in my area to expose them to different areas of pharmacy practice. I also talk to them a lot about functional medicine and depending on the speciality they are interested in, we look at what they could study that will impact how they treat patients in the future.  Dr. Edwards. is training to be a dermatologist so of course we talked about gut health and it’s relationship to atopic conditions such as eczema. I hope you enjoy her post!

 

Eczema, also called atopic dermatitis, is a common, chronic and relapsing skin condition characterized by extreme itching. Currently, the incidence of eczema in industrialized nations is 20%, representing a 2-3 fold increase in recent decades.^1,2 The reason for this increase remains unclear due to the complex etiology of the disease. However, it is reasonable to assume that this increase cannot be explained by genetic factors alone. Research has demonstrated that food allergy, defects in the gut mucosal barrier (ie leaky gut), and increased intestinal permeability may play a role in the development of eczema.³ Dietary manipulation remains a controversial topic in the treatment of atopic diseases, however, some studies show promise for the use of probiotics in the treatment and prevention of atopic dermatitis in young children.⁴

Probiotics are normal, healthy bacteria of the human gut that can be consumed in food or as dietary supplements.⁵ Lactobacilli and bifidobacteria are the most studied types of probiotics and are thought to assist the neonatal immune system in creating T-regulatory immune cells that are vital in preventing atopic disease.^3,6-8 One large study supports the use of probiotics as preventative care due to findings that the incidence of eczema was 20% lower in infants and children that were exposed to probiotics early in life or during gestation.⁹

Another study demonstrated that probiotics may represent a helpful adjuvant therapy in the treatment of eczema. Forty young children between the ages of 3 months and 6 years with a diagnosis of eczema were divided equally into two groups and treated with probiotics (a mixture of 7 strains including Lactobacilli and bifidobacteria gena) or placebo. At the end of 8 weeks, the children that were treated with the probiotic mixture demonstrated a significant reduction in the severity of their eczema.¹⁰ While not all studies regarding probiotics as a modality to improve eczema have demonstrated consistent results, one large meta-analysis that evaluated data from ten studies and 678 patients found that when compared to placebo, probiotics may play a role in reducing the severity of eczema.¹¹

Along with probiotics, cow’s milk is another area of interest for eczema researchers. Many parents believe the development of eczema in their child was temporally associated with the introduction of cow’s milk or cow’s milk based formula. Nearly 100 studies have examined the influence of hydrolyzed formulas versus cow’s milk based formulas in the development of eczema.  The most well-known study, the GINI study, found that infants given exclusively hydrolyzed formula were 50% less likely to develop eczema compared to infants who were fed cow’s milk based formula (hydrolyzed formula did not show benefit over breast milk).^12-16 Soy based formula is often believed to be less allergenic than cow’s milk based formula, however, research does not support this claims.¹⁷

Exclusion diets have also been studied in individuals with eczema with less promising results. However, children with eczema and suspected egg allergy may benefit from a diet excluding eggs.¹⁸ In situations where special diets are attempted, it is recommended to adhere to the diet for a limited time of 4-8 weeks and then return to a normal diet to assess the efficacy of dietary interventions.⁴

So the PharmToTable Rx for eczema definitely includes quality probiotics (find them in my fullscript store!) and addressing gut health! My favorite quality probiotics include those by OrthoMolecular, Metagenics, Klaire Labs, and Young Living. For kids omega-3’s and vitamin D are certainly another good idea to reduce inflammation and support gut healing. For breastfed babies, elimination diets for mom are also important if you can figure out the trigger. For formula fed babies, a hydrolyzed formula is a good place to start, but possibly further reducing allergens by moving to a corn-free and hydrolyzed option like Alimentum Ready Feed may be necessary. You definitely have to give it at least a month if not two months to see the full effect.

Also check out this post by the National Eczema Association as well for further reading on this topic! There is also some interested new thoughts and emerging evidence about using probiotics topically to help heal the skin. This article discusses the topic.

References: 

1. Thestrup-Pedersen K. Treatment principles of atopic dermatitis. J Eur Acad Dermatol Venereol. 2002;16(1):1-9. http://www.ncbi.nlm.nih.gov/pubmed/11952283. Accessed February 11, 2018.
2. Eichenfield LF, Hanifin JM, Beck LA, et al. Atopic Dermatitis and Asthma: Parallels in the Evolution of Treatment. Pediatrics. 2003;111(3):608-616. doi:10.1542/peds.111.3.608.
3. Isolauri E. Intestinal involvement in atopic disease. J R Soc Med. 1997;90 Suppl 30:15-20. http://www.ncbi.nlm.nih.gov/pubmed/9176124. Accessed February 11, 2018.
4. Finch J, Munhutu MN, Whitaker-Worth DL. Atopic dermatitis and nutrition. Clin Dermatol. 2010;28(6):605-614. doi:10.1016/j.clindermatol.2010.03.032.
5. Salminen S, Bouley C, Boutron-Ruault MC, et al. Functional food science and gastrointestinal physiology and function. Br J Nutr. 1998;80 Suppl 1:S147-71. http://www.ncbi.nlm.nih.gov/pubmed/9849357. Accessed February 11, 2018.
6. Smits HH, Engering A, van der Kleij D, et al. Selective probiotic bacteria induce IL-10–producing regulatory T cells in vitro by modulating dendritic cell function through dendritic cell–specific intercellular adhesion molecule 3–grabbing nonintegrin. J Allergy Clin Immunol. 2005;115(6):1260-1267. doi:10.1016/J.JACI.2005.03.036.
7. Prescott SL, Björkstén B. Probiotics for the prevention or treatment of allergic diseases. J Allergy Clin Immunol. 2007;120(2):255-262. doi:10.1016/J.JACI.2007.04.027.
8. Pessi T, Sütas Y, Hurme M, Isolauri E. Interleukin-10 generation in atopic children following oral Lactobacillus rhamnosus GG. Clin Exp Allergy. 2000;30(12):1804-1808. http://www.ncbi.nlm.nih.gov/pubmed/11122221. Accessed February 11, 2018.
9. Pelucchi C, Chatenoud L, Turati F, et al. Probiotics Supplementation During Pregnancy or Infancy for the Prevention of Atopic Dermatitis. Epidemiology. 2012;23(3):402-414. doi:10.1097/EDE.0b013e31824d5da2.
10.   Farid R, Ahanchian H, Jabbari F, Moghiman T. Effect of a new synbiotic mixture on atopic dermatitis in children: a randomized-controlled trial. Iran J Pediatr. 2011;21(2):225-230. http://www.ncbi.nlm.nih.gov/pubmed/23056792. Accessed February 11, 2018.
11.   Michail SK, Stolfi A, Johnson T, Onady GM. Efficacy of probiotics in the treatment of pediatric atopic dermatitis: a meta-analysis of randomized controlled trials. Ann Allergy, Asthma Immunol. 2008;101(5):508-516. doi:10.1016/S1081-1206(10)60290-6.
12.   Laubereau B, Brockow I, Zirngibl A, et al. Effect of breast-feeding on the development of atopic dermatitis during the first 3 years of life—results from the GINI-birth cohort study. J Pediatr. 2004;144(5):602-607. doi:10.1016/J.JPEDS.2003.12.029.
13.   Banks JR. THE EFFECT OF HYDROLYZED COW’S MILK FORMULA FOR ALLERGY PREVENTION IN THE FIRST YEAR OF LIFE: THE GERMAN INFANT NUTRITIONAL INTERVENTION STUDY, A RANDOMIZED, DOUBLE-BLIND TRIAL. Pediatrics. 2004;114(2):521-522. doi:10.1542/peds.114.2.S1.521-b.
14.   Oldaeus G, Anjou K, Björkstén B, Moran JR, Kjellman NI. Extensively and partially hydrolysed infant formulas for allergy prophylaxis. Arch Dis Child. 1997;77(1):4-10. http://www.ncbi.nlm.nih.gov/pubmed/9279143. Accessed February 11, 2018.
15.   Halken S, Hansen KS, Jacobsen HP, et al. Comparison of a partially hydrolyzed infant formula with two extensively hydrolyzed formulas for allergy prevention: a prospective, randomized study. Pediatr Allergy Immunol. 2000;11(3):149-161. http://www.ncbi.nlm.nih.gov/pubmed/10981524. Accessed February 11, 2018.
16.   Nentwich I, Michková E, Nevoral J, Urbanek R, Szépfalusi Z. Cow’s milk-specific cellular and humoral immune responses and atopy skin symptoms in infants from atopic families fed a partially (pHF) or extensively (eHF) hydrolyzed infant formula. Allergy. 2001;56(12):1144-1156. http://www.ncbi.nlm.nih.gov/pubmed/11736743. Accessed February 11, 2018.
17.   Osborn DA, Sinn JK. Soy formula for prevention of allergy and food intolerance in infants. Cochrane Database Syst Rev. October 2006. doi:10.1002/14651858.CD003741.pub4.
18.   Lever R, MacDonald C, Waugh P, Aitchison T. Randomised controlled trial of advice on an egg exclusion diet in young children with atopic eczema and sensitivity to eggs. Pediatr Allergy Immunol. 1998;9(1):13-19. http://www.ncbi.nlm.nih.gov/pubmed/9560837. Accessed February 11, 2018.

 

0 Can Fat be Healthy?

Thanks to Danielle Baker, PharmD Intern who wrote the majority of this post while on rotation with me in the fall!