Nerd Out: Fibromyalgia Syndrome

My latest assignment for my Master’s in Holistic Nutrition was to write a paper about a disorder of the nervous system. I chose Fibromyalgia as it affects someone close to me and I wanted to find out the various therapeutic modalities and treatment options available.

If you’d like to nerd out with me, continue reading:

Fibromyalgia syndrome (FMS) is characterized by widespread, generalized pain of at least a 3-month duration, affecting an estimated 6-12 million Americans, 80% of whom are women (Kohlstadt, 2012, p. 637; Pizzorno & Murray, 2013, p. 1374; Rakel, 2018, p. 475). Patients with FMS typically experience pain at certain anatomical points on the body, along with extreme fatigue, joint stiffness, headaches, sleep disturbances, irritable bowel, cognitive dysfunction, anxiety, depression, and exercise intolerance, among other symptoms (Pizzorno & Murray, 2013, p. 1375). Although not considered an autoimmune disorder, FMS can coexist and imitate such conditions as Lyme disease, hypothyroidism, and hepatitis C (Rakel, 2018, p. 475). Once considered a result of serotonin deficiency, FMS is now thought to be a disorder of the central nervous system (CNS), specifically neuronal dysregulation (Gota, 2018; Kohlstadt, 2012, p. 637) and a dampening of hypothalamus–pituitary–adrenal reactivity (Gota, 2018). 

There is a strong psychosomatic component to FMS. Symptoms seem to begin with a precipitating stress occurrence or trigger, such as an accident, illness, emotional stress, or trauma (Galvez-Sánchez, Duschek, & Reyes Del Paso, 2019; Rakel, 2018, p. 475). Patients may present with a sensitive personality temperament, inappropriate cortisol response to stress, heightened pain perception (hyperalgesia), and/or a concurrent mood disorder such as anxiety or depression (Bellato et al., 2012; Gota, 2018; Rakel, 2018, p. 475).  

The etiology of FMS isn’t fully understood, though there may be genetic, hormonal, psychiatric, external stressor, neurotransmitter, immune system, and other contributing dysfunctions (Bellato et al., 2012). Obesity, reduced physical activity, hypothyroidism, adrenal dysfunction, irritable bowel syndrome, post-traumatic stress disorder (PTSD), and nonrestorative sleep all are recognized as possible underlying causes (Coppens et al., 2017; Kohlstadt, 2012, p. 642).

Diagnosis of FM can be challenging, as each patient presents with a unique combination of symptoms (Bellato et al., 2012). A thorough patient history including sleep quality, physical activity level, bowel habits, pain perception, fatigue level, menstruation, and cognitive function are key (Pizzorno & Murray, 2013). The ACR Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity, the Pain Distribution Body Form, the FibroQuest Symptoms Survey, and/or the Fibromyalgia Impact Questionnaire may be used to measure the patient’s pain, symptoms, and functional status (Pizzorno & Murray, 2013, p. 1381). 

A physical examination finding abnormal tenderness at 11or more of 18 specific anatomic tender points indicates FMS (Pizzorno & Murray, 2013, p. 1375). The Widespread Pain Index and Symptom Severity Scale also help define the patient’s pain experience (Gota, 2018). A mental health screening, including Zung’s Self-Rating Depression Scale, may provide insight to depression, anxiety, trauma, and PTSD and provide opportunities for referral to mental health specialists (Coppens et al., 2017; Pizzorno & Murray, 2013, p. 1381). 

Laboratory tests include a complete blood count, erythrocyte sedimentation rate, cyclic citrullinated peptide test, rheumatoid factor, antinuclear antibody, Celiac serology, and vitamin D levels, to rule out infection, autoimmune disorders, etc. (Fibromyalgia, 2020). In addition, a thyroid function test and thyroid antibodies test may be ordered to rule out concurrent hypothyroidism (Pizzorno & Murray, 2013, p. 1377). Adrenocorticotropic Hormone test (ACTH), salivary cortisol, Dehydroepiandrosterone Sulfate (DHEA-S), 24-hour urine cortisol, and urinary organic acids (OAT) testing help uncover other possible metabolic, toxic, and infectious contributors to FMS (Kohlstadt, 2012, p. 642). Finally, a colonoscopy and/or stool culture may be ordered to rule out other sources of gastrointestinal discomfort (Kohlstadt, 2012, p. 642).  

Pain relievers, antidepressants, muscle relaxants, and anti-seizure drugs are prescribed most often for FMS. Over the counter non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen (Advil, Motrin IB) and naproxen sodium (Aleve), are preferred to allay the discomforts associated with FMS (Fibromyalgia, 2020). Acetaminophen (Tylenol) is another widely-used option (Fibromyalgia, 2020). In addition, the analgesic, tramadol, is approved by the FDA specifically to treat pain in FMS (Bellato et al., 2012). Opioids are not recommended due to their significant side effects and dependence (Bellato et al. 2012; Fibromyalgia, 2020). In addition, they have not proven effective in long-term relief, possibly worsening the pain experience over time (Fibromyalgia, 2020). 

Serotonin-norepinephrine reuptake inhibitors (SARIs) such as duloxetine (Cymbalta), milnacipran (Savella), and trazodone (Desyrel), as well as the tricyclic antidepressant/sedative (TCA) amitriptyline (Elavil), are commonly prescribed to help with anxiety and depression associated with FMS (Bilodeau, 2020; Fibromyalgia, 2020; Gota, 2018). Other medications such as the muscle relaxant cyclobenzaprine (Flexeril), the anticonvulsant pregabalin (Lyrica), gabapentin (Neurontin), and/or melatonin are also often prescribed to help with sleep (Bilodeau, 2020; Gota, 2018). Referral to support groups, counseling, and/or therapy may also be part of a traditional FMS treatment plan (National Fibromyalgia Association, 2020).

An integrative approach to FMS includes a focus on nutrition, movement, detoxification, mental health support, and sleep hygiene, minimizing long-term pharmaceutical use (Myers, 2020).  Digestive issues including food intolerances, candida albicans overgrowth, small intestinal bacterial overgrowth (SIBO), leaky gut, irritable bowel syndrome (IBS), and gut dysbiosis are all addressed in a functional treatment plan (Kresser 2019; Myers, 2020). Healing the gut and restoring a healthy gut microbiome is the foundation for healing FMS (Kresser, 2019). 

Removing inflammatory foods, ingredients, and medications such as gluten, sugar, industrial seed oils, dairy, MSG, aspartame, coffee, and when possible, antibiotics, and replacing them with an antiinflammatory diet rich in leafy greens (kale, salad greens, chard, arugula, etc.), cruciferous vegetables (broccoli, cauliflower, Brussels sprouts, etc.), omega-3 fats (salmon, sardines, anchovies, etc.), fermented foods (unsweetened, full-fat yogurt, sauerkraut, kombucha, etc.), fermented fibers (sweet potato, yams, etc.), and bone broth (Kresser, 2019; Rakel, 2018, p. 483) heals the gut and begins restoration of the microbiome. Integration of adaptogenic herbs into the diet such as turmeric, ashwagandha, schisandra, rhodiola, and ginseng aid in balancing the immune system and help to decrease inflammation (Myers, 2020). Finally, nutritional support of the thyroid may be encouraged with consumption of sea vegetables and dulse (Higdon & Drake, 2012, p. 153).

FMS patients often present with deficiencies in magnesium and vitamin D (Myers, 2020). A balance of calcium, magnesium, vitamin D, and vitamin K is crucial to support optimal uptake of all four nutrients (Mercola, 2018). Food sources of magnesium are oats, spinach, beans, nuts, seeds, blackstrap molasses, banana, and avocado (Higdon & Drake, 2012, p. 175; Mercola, 2018). Vitamin D sources are salmon, sardines, and mackerel (Higdon & Drake, 2012, p. 91).  Balanced supplementation is an option when quality food sources aren’t available or tolerated (Higdon & Drake, 2012, p. 175; Mercola, 2018). 

B12 deficiency is also common in FMS patients, and may be the result of age, poor digestion and/or absorption of nutrients, poor diet, or mutation of the MTHFR gene (Kohlstadt, 2012, p. 652; Myers, 2020). Genetic testing may be prescribed by an integrative practitioner. If a mutation is found, supplementation with methylfolate in addition to dietary means (salmon, beef, eggs, chicken, turkey, and nutritional yeast) helps optimize B12 levels (Higdon & Drake, 2012, p. 67-68; Procyk, 2018, p. 101). Healing the gut as mentioned earlier is key to B12 digestions and absorption (Myers, 2020).

Other supplements for FMS may include a high-quality multivitamin, iron, coenzyme Q10, acetyl-L-carnitine, D-ribose, S-adenosylmethionine, boswellia, N-acetyl choline, milk thistle, alpha lipoic acid, and/or St. John’s wort (Kohlsdadt, 2012, p. 652; Myers, 2020; Rakel, 2018, p. 479).

In addition to the laboratory tests mentioned above, functional medicine practitioners may also order an intestinal barrier function test to evaluate the mucosal lining of the intestines, and/or a comprehensive stool assessment to check for parasites and bacterial infections (Grisanti, 2015). Heavy metals testing with a pre- and post- DMPS urine challenge reveals heavy metal burden and indicates any need for chelation therapy (Myers, 2020). Celiac serology confirms sensitivity or allergy to gluten (Fibromyalgia, 2020).

Finally, positive lifestyle habits are encouraged in the integrative treatment of FMS. Exercise has been shown to ease the pain of FMS patients (Bellato et al., 2020; Mercola, 2010). Starting with just a few minutes a day working up to at least 30, a combination of weight-bearing, aerobic, and strength training activities bring the best benefit (Pizzorno & Murray, 2013, p. 1382; Rakel, 2018, p. 483). Sleep hygiene is addressed, optimizing the sleep environment, quality, and duration (Chetlin & Landis, 2020). Stress, anxiety, and/or depression are managed through psychotherapy, cognitive behavioral therapy, emotional freedom technique tapping (EFT), meditation, journaling, art, etc. (Michalsen et al., 2013; Rakel, 2018, p. 482). Lastly, various forms of fasting have been shown to help with inflammation and pain management (Michalsen et al., 2013).







References

Bilodeau, K. (2020, September 15). Getting the best treatment for your fibromyalgia. Retrieved November 16, 2020, from https://www.health.harvard.edu/blog/getting-the-best-treatment-for-your-fibromyalgia-2020091020905

Bellato, E., Marini, E., Castoldi, F., Barbasetti, N., Mattei, L., Bonasia, D., & Blonna, D. (2012). Fibromyalgia syndrome: Etiology, pathogenesis, diagnosis, and treatment. Retrieved November 03, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3503476/

Chetlin, S. M., & Landis, C. (Eds.). (2020, September 28). Fibromyalgia & Sleep. Retrieved November 19, 2020, from https://www.sleepfoundation.org/articles/fibromyalgia-and-sleep

Coppens, E., Van Wambeke, P., Morlion, B., Weltens, N., Giao Ly, H., Tack, J., . . . Van Oudenhove, L. (2017, May 24). Prevalence and impact of childhood adversities and post‐traumatic stress disorder in women with fibromyalgia and chronic widespread pain. Retrieved November 09, 2020, from https://onlinelibrary.wiley.com/doi/full/10.1002/ejp.1059

Fibromyalgia. (2020, October 07). Retrieved November 09, 2020, from https://www.mayoclinic.org/diseases-conditions/fibromyalgia/diagnosis-treatment/drc-20354785

Galvez-Sánchez, C., Duschek, S., & Reyes Del Paso, G. (2019, February 13). Psychological impact of fibromyalgia: Current perspectives. Retrieved November 03, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6386210/

Grisanti, R. (2015, January 31). Fibromyalgia Who Told You There Wasn't A Cure? Retrieved November 18, 2020, from https://www.functionalmedicineuniversity.com/public/986.cfm

Gota, C. (2018, May 01). What you can do for your fibromyalgia patient. Retrieved November 03, 2020, from https://www.ccjm.org/content/85/5/367

Higdon, J., & Drake, V. J. (2012). An evidence-based approach to vitamins and minerals health benefits and intake recommendations (2nd ed.). Stuttgart, Germany: Thieme.

Kohlstadt, I. (2012). Advancing medicine with food and nutrients. Boca Raton, FL: CRC Press, Taylor & Francis Group.

Kresser, C. (2019, June 18). Is Fibromyalgia Caused By SIBO and Leaky Gut? Retrieved November 16, 2020, from https://chriskresser.com/is-fibromyalgia-caused-by-sibo-and-leaky-gut/

Mercola, J. (2010, January 19). Foods to Avoid by Patients Dealing with Chronic Pain. Retrieved November 18, 2020, from https://articles.mercola.com/sites/articles/archive/2010/01/19/foods-that-chronic-pain-sufferers-need-to-avoid.aspx

Mercola, J. (2018, March 21). Magnesium: An Invisible Deficiency That Could Be Harming Your Health. Retrieved November 16, 2020, from https://www.prohealth.com/library/magnesium-an-invisible-deficiency-that-could-be-harming-your-health-34192

Michalsen, A., Li, C., Kaiser, K., Lüdtke, R., Meier, L., Stange, R., & Kessler, C. (2013, January 23). In-Patient Treatment of Fibromyalgia: A Controlled Nonrandomized Comparison of Conventional Medicine versus Integrative Medicine including Fasting Therapy. Retrieved November 18, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3566607/

Myers, A. (2020, September 15). Fibromyalgia - A Functional Medicine Approach. Retrieved November 03, 2020, from https://www.amymyersmd.com/article/fibromyalgia-functional-medicine/

National Fibromyalgia Association. (2020, November 10). Retrieved November 16, 2020, from https://fmaware.net/

Pizzorno, J. E., & Murray, M. T. (2013). Textbook of natural medicine. St. Louis, MO: Elsevier.

Procyk, A. (2018). Nutritional treatments to improve mental health disorders: Non-pharmaceutical intervention for depression, anxiety, bipolar & ADHD. Eau Claire, WI: Pesi Publishing & Media.

Rakel, D. (2018). Integrative Medicine. Philadelphia, PA: Elsevier Health Science.

Nerd Out: Deep Vein Thrombisis

My latest assignment for my Master’s in Holistic Nutrition was to write a paper about a disorder of the cardiovascular system. I chose Deep Vein Thrombosis, a common and potentially lethal syndrome that can happen to anyone, no matter your health or fitness status. If you’d like to nerd out with me, continue reading:

Deep Vein Thrombosis (DVT), also known as thromboembolism, post-thrombotic syndrome, venous thromboembolic disease, or postphlebitic syndrome (Delgado & Holland, 2018; Tovey & Wyatt, 2003) is defined as a clot formation deep inside a vein. A serious condition representing the third most common cardiovascular disease, DVT is commonly underdiagnosed though preventable (Sista, Vedantham, Kaufman, & Madoff, 2015; What is Venous Thromboembolism, 2020). Most often affecting the lower extremities, including lower leg, thigh, or pelvis, it can also manifest in the arms (What is Venous Thromboembolism, 2020). Complications arising from DVT can be life-threatening, as the clot may break free and travel to the lungs, causing a blockage known as a pulmonary embolism (PE) (What is Venous Thromboembolism, 2020). The risk of DVT recurrence is approximately 7% despite anticoagulant therapies, and may lead to a persistent, chronic condition known as post-thrombotic syndrome (PST), due to the valves of the affected vein remaining scarred, inflamed, weakened, and dysfunctional (Behravesh, Hoang, Nanda, Wallace, Sheth, Deipolyi, Memic, Naidu, & Oklu, 2017; Sista, et al., 2015; Tovey & Wyatt, 2003).

Risk factors for DVT are varied and fall under the umbrella of the following conditions: injury to a vein, as in fractures, muscle injuries, or major surgery; slowed blood flow, as in confinement to bed, immobilization, excessive sitting, and paralysis; increased estrogen due to hormone replacement, especially estrogen, hormonal birth control, pregnancy, and immediate postpartum; certain chronic illnesses, such as cancer, cardiovascular disease, and inflammatory bowel disease; and other factors including advancing age, previous DVT or PE, family history of DVT or PE, obesity, and inherited clotting disorders (Galson, 2008; What is Venous Thromboembolism, 2020). 

Signs and symptoms of DVT include swelling, pain, tenderness, stiffness, and redness of an affected extremity, although half of those with DVT have no symptoms at all (What is Venous Thromboembolism, 2020). More specifically, unilateral swelling on the foot, ankle, or leg; cramping in leg or calf; severe, unexplained pain in the foot or calf; warmth of skin compared to surrounding areas; and changes such as paleness, redness, or bluish coloration of skin all point to DVT of the lower extremity (Delgado & Holland, 2019). Upper extremity symptoms include neck pain, shoulder pain, swelling in the arm or hand, weakness, blue coloration of arm or hand, and pain radiating from the arm to forearm (Delgado & Holland, 2019).

It is important to know the symptomatology of PE in addition to DVT, as it can occur before a diagnosis of DVT is made (Delgado & Holland, 2019). Labored breathing, rapid or irregular heart beat, coughing up blood, hypotension, and lightheadedness are all symptoms of pulmonary embolism (What is Venous Thromboembolism, 2020). 

In low-risk patients, the Pulmonary Embolism Rule-out Criteria (PERC) can be used to rule out PE and determine need for further testing (Behravesh et al., 2017; Kline, 2020). Further screening is indicated when a patient presents a PERC score of 1 or higher (Kline, 2020), in which case the next step is a D-dimer assay, a blood test which can rule out venous thromboembolism (VTE) in 30-50% of patients (Behravesh et al., 2017; Delgado & Holland, 2019; Strandberg, 2017). A positive D-dimer assay leads to computed tomography angiogram, or CT angiography, imaging which can show narrow or blocked blood vessels, or a VQ scan, to examine airflow (ventilation) and blood flow (perfusion) in the lungs (Behravesh et al., 2017; Jong, 2018). Moderate-risk patients skip the PERC and go straight to the D-dimer, while high-risk patients are promptly assessed with imaging, such as a QT scan (Behravesh et al., 2017). At any point in the diagnostic process a clinician may also order plethysmography, which records changes in size of the limb, or Doppler or duplex ultrasonography, which use high frequency sound waves to detect clots (Behravesh et al., 2017; Cheung & Firstenberg, 2020; Tortora & Derrickson, 2015, p. 387).

A positive diagnosis of DVT indicates anticoagulation therapy, most likely intravenous heparin or low molecular weight heparin (LMWH), or fondaparinux, a factor Xa inhibitor, both for acute cases (Behravesh et al., 2017; Galson, 2008; Tovey & Wyatt, 2003). Compression socks or stockings are also encouraged to relieve pain and swelling (What is Venous Thromboembolism, 2020). In the case of PE, immediate administration of intravenous thrombolytics, such as bivalirudin, argatroban, dabigatran, or antithrombin III, is necessary (Delgado & Holland, 2019; Omudhome, 2019; What is Venous Thromboembolism, 2020). Many patients are given warfarin, a vitamin K antagonist, in tablet form for long-term therapy (Behravesh et al., 2017).

Other treatments include inferior vena cava filters to prevent clots from entering lungs; thrombectomy surgery to remove large clots; catheter-directed thrombolysis (CDT) to dissolve clots; percutaneous mechanical thrombectomy (PMT) to macerate and aspirate clots; pharmacomechanical catheter-directed thrombolysis (PCDT) to simultaneously macerate and infuse a lytic drug; and stent placement to encourage and maintain vascular integrity (Behravesh et al., 2017; Delgado & Holland, 2019; Sista et al, 2015).

Lifestyle modifications are encouraged, such as increasing movement through exercise and frequent breaks from sitting, wearing elastic compression stockings to provide support and to increase circulation, stretches and foot exercises to improve blood flow, and wearing loose-fitting clothing to encourage venous flow (Delgado & Holland, 2019; What is Venous Thromboembolism, 2020). Smoking cessation, a detailed family health history to determine genetic predispositions, weight loss, adjustment or cessation of hormone-replacements, and use of non-hormonal birth control may also be encouraged in an allopathic setting (Galson, 2008). Follow-up appointments are necessary to check progress and to ensure integrity of vein post-diagnosis. 

Integrative and holistic approaches to healing DVT support the above-mentioned therapies but it is important to note they do not replace them. Moving away from the standard American diet (SAD), increasing movement through regular exercise, a focus on sleep, hydration, and chronic stress reduction, in addition to allopathic measures encourage optimal blood circulation and overall cardiovascular health.

An anti-inflammatory and antioxidant-rich diet supports a healthy cardiovascular and immune system. Cold-water fish, such as salmon, mackerel, sardines, and low-mercury tuna, are rich in Omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) and are potent anti-inflammatory foods (Weil, 2020). Red, yellow, orange, and deeply-colored fruits and vegetables, such as cherries, blueberries, raspberries, blackberries, pumpkins, sweet potatoes, etc., are rich in flavonoids, carotenoids, and polyphenols, with both antioxidant and anti-inflammatory properties (Pandey & Rizvi, 2009; Weil, 2020). Red wine, black and green tea, legumes, mushrooms, onions, garlic, dark chocolate and herbs and spices such as turmeric, curry powder, chili peppers, ginger, basil, cinnamon, rosemary, and thyme all offer antioxidant benefits  (Pandey & Rizvi, 2009; Weil, 2020). Dark, leafy salad greens, cruciferous vegetables such as broccoli and Brussels sprouts, avocado, and bananas are all high in vitamin K, potassium, and magnesium, which support optimal blood flow (Levy, 2019). These foods may enhance blood thinners and anticoagulants, so regular follow-up checks are important to monitor medication dosages (Levy, 2019). 

Moving away from trans fats and industrial seed oils towards healthier oils such as olive oil, walnut oil, coconut oil, avocado oil, decreasing sugar and over-processed foods, and limiting alcohol and caffeine all round out a diet supportive of cardiovascular health (Levy, 2019; Weil, 2020).

Supplementation of diet might be necessary, depending on dietary tastes, preferences, and access to whole foods. Vitamins A, C, E, beta carotene, selenium, copper, zinc, magnesium, coenzyme Q10 (Ubiquinone), alpha-lipoic acid (ALA), n-acetylcysteine (NAC), glutathione, quercetin, pine bark extract (PBE), grape seed extract (GSE), silymarin, resveratrol, and ginkgo biloba are among the most recommended antioxidant supplements (Pizzorno & Murray, 2013, p. 894-902). 

A program to increase movement is imperative for prevention of DVT and its recurrence. Setting a timer when sitting for long periods serves as a reminder to get up, stretch, and walk around to stimulate blood circulation in the legs (Levy, 2019). Incorporating walking into a daily routine is recommended, with shorter, more frequent walks a priority over longer walks (Delgado & Holland, 2018). Movements that focus on the legs, such as cycling, running, squats, lunges, etc., are also beneficial for blood flow (Levy, 2019). 

Both quality and quantity of sleep affect adiposity, in that it is more difficult to lose body fat when sleep deprived (Nedeltcheva, Kilkus, Imperial, Schoeller, & Penev, 2010). Fat cells store hormones, including estrogen and testosterone, and thus a weight-loss program ultimately decreases the body’s exposure to hormones that might trigger a DVT (Chodosh, 2018).

Hydration is important to maintain optimal blood viscosity and venous integrity (Simmons, 2011). Current recommendations are to drink twenty-five to fifty percent of one’s weight in ounces of water each day (Axe, 2020), or to drink according to thirst (LaFee, 2014). Sipping water throughout the day and replacing non-nutritive drinks with water will enhance hydration as well. 

Finally, chronic oxidative stress is known to negatively affect cardiovascular health. By taking measures to reduce lifestyle stressors it may be possible to lessen this sympathetic response and help prevent DVT and its recurrence (Dong, Cheng, Yang, Sun, Zhu, Zhu, & Zhang, 2015). Meditation, deep breathing, yoga, journaling, and Tai-Chi, are examples of proven relaxation methods that help calm the nervous system and thus discourage the cascade of negative effects related to chronic stress. Combined with an anti-inflammatory diet, regular exercise, deep, restful sleep, and hydration, these holistic practices fully support the allopathic approaches to manage and prevent DVT and its recurrence (Dong et al., 2015; Galson, 2015; Levy, 2019). 




References

Axe, J. (2020, February 13). How to Stay Hydrated in 4 Steps. Retrieved May 6, 2020, from https://draxe.com/nutrition/how-to-stay-hydrated/

Behravesh, S., Hoang, P., Nanda, A., Wallace, A., Sheth, R. A., Deipolyi, A. R., … Oklu, R. (2017, January 5). Pathogenesis of Thromboembolism and Endovascular Management. Retrieved May 2, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5244017/

Cheung, M. E. (2020, January 20). Duplex Ultrasound. Retrieved May 2, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK459266/

Chodosh, S. (2018, January 11). When you lose weight, your fat cells don't just let go of fat. Retrieved May 5, 2020, from https://www.popsci.com/when-you-lose-weight-your-fat-cells-release-more-than-just-fat/

Delgado, A., & Holland, K. (2019, November 13). Deep Vein Thrombosis (DVT): Symptoms, Treatments, and Prevention. Retrieved May 2, 2020, from https://www.healthline.com/health/deep-venous-thrombosis

Dong, T., Cheng, Y.-W., Yang, F., Sun, P.-W., Zhu, C.-J., Zhu, L., & Zhang, G.-X. (2015, October 20). Chronic Stress Facilitates the Development of Deep Venous Thrombosis. Retrieved May 6, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4630420/

Galson, S. K. (2008). Prevention of deep vein thrombosis and pulmonary embolism. Retrieved May 6, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2430635/

Jong, I. (2018, August 24). VQ Scan. Retrieved May 3, 2020, from https://www.insideradiology.com.au/vq-scan/

Kline, J. (2020). PERC Rule for Pulmonary Embolism. Retrieved May 2, 2020, from https://www.mdcalc.com/perc-rule-pulmonary-embolism

LaFee, S. (2014, April 21). 10 Colors That Suggest Urine Trouble. Retrieved May 6, 2020, from https://health.ucsd.edu/news/features/Pages/2014-04-21-colors-that-suggest-urine-trouble.aspx

Levy, J. (2019, February 18). What You Need to Know About Deep Vein Thrombosis. Retrieved May 3, 2020, from https://draxe.com/health/deep-vein-thrombosis/

Nedeltcheva, A. V., Kilkus, J. M., Imperial, J., Schoeller, D. A., & Penev, P. D. (2010, October 5). Insufficient sleep undermines dietary efforts to reduce adiposity. Retrieved May 5, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2951287/

Omudhome Ogbru, P. D. (2019, November 25). Anticoagulant Drug List: Blood Thinner Side Effects & Types. Retrieved May 2, 2020, from https://www.medicinenet.com/anticoagulants_drug_class_of_blood_thinners/article.htm#what_are_anticoagulants

Pandey, K. B., & Rizvi, S. I. (2009). Plant polyphenols as dietary antioxidants in human health and disease. Retrieved May 3, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2835915/

Pizzorno, J. E., & Murray, M. T. (2013). Textbook of Natural Medicine. Churchill Livingstone.

Simmons, S. (2011, August). Deep vein thrombosis : Nursing2020. Retrieved May 6, 2020, from https://journals.lww.com/nursing/Fulltext/2011/08000/Deep_vein_thrombosis.12.aspx

Sista, A. K., Vedantham, S., Kaufman, J. A., & Madoff, D. C. (2015, July). Endovascular Interventions for Acute and Chronic Lower Extremity Deep Venous Disease: State of the Art. Retrieved May 2, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4787709/

Strandberg, K. (2017, June). The clinical use of a D-dimer assay. Retrieved from https://acutecaretesting.org/en/articles/the-clinical-use-of-a-d-dimer-assay

Tortora, G. J., & Derrickson, B. (2015). Introduction to the human body: the essentials of anatomy and physiology. Hoboken, NJ: John Wiley & Sons.

Tovey, C., & Wyatt, S. (2003, May 31). Diagnosis, investigation, and management of deep vein thrombosis. Retrieved May 2, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1126050/

Weil, A. (2020, April 28). Anti-Inflammatory Food Pyramid: Anti-Inflammatory Diet: Andrew Weil, M.D. Retrieved May 3, 2020, from https://www.drweil.com/diet-nutrition/anti-inflammatory-diet-pyramid/dr-weils-anti-inflammatory-food-pyramid/

What is Venous Thromboembolism? (2020, February 7). Retrieved April 30, 2020, from https://www.cdc.gov/ncbddd/dvt/facts.html

Nerd Out: Plantar Fasciitis

My latest assignment for my Master’s in Holistic Nutrition was to write a paper about a disorder of the musculo-skeletal system. I chose Plantar Fasciitis, as many of the active people I know experience it. If you’d like to nerd out with me, continue reading:

Plantar Fasciitis is a chronic foot condition, described by some experts as inflammation of the fascia or connective tissue supporting the arch of the foot (Wheeler, 2019), and by others as chronic degeneration and irritation at the insertion of the fascia to the calcaneus, or heel bone (Young, 2019). Affecting an estimated 2 million people a year in the United States (Searing, 2019) the cost of treatment of plantar fasciitis is estimated at between $192 and $376 million dollars annually (Young, 2019).  Pain ranges from mild to extreme, intermittent to constant, and may affect one or both feet. Risk factors include obesity, age, overuse of feet via running, jumping, or standing for long periods of time, tight calf muscles, menopause, flat feet or high arches, and wearing unsupportive footwear (Ingraham, 2019; Wheeler, 2019). Symptoms include sharp, stabbing, burning pain in the heel or arch of the foot, or both. Pain is often most intense with the first steps in the morning, with symptoms sometimes subsiding with increased blood flow to the calves, heel, arch, and fascia as the day progresses. However, it is common for symptoms to be severe, lasting months or even years, affecting work, recreation, and activity level for its sufferers. 

Etiology is multifactorial but overuse is most often to blame (Young, 2019). Because of its high incidence in runners and other athletes such as football, basketball, and baseball players, it is supposed that repeated microtraumas through jumping and running contribute to plantar fasciitis (Young, 2019). Heel spurs may encourage or magnify symptoms, and are thought to be a result of plantar fasciitis rather than the cause (Wheeler, 2019; Young, 2019). Plantar fasciitis often presents in conjunction with an uptake in activity or training: increased miles, increased duration, or the addition of higher-intensity drills are examples (Young 2019). This condition is not limited to athletes, however, as overweight may be a contributing factor (Young, 2019). Standing for long periods of time, wearing footwear with insufficient arch support, age, and gender play a role as well (Young, 2019). Women experience plantar fasciitis twice as often as men, with peak incidence occurring between the ages of 40-60 (Young, 2019), coincidentally during the time of perimenopause and menopause (Wheeler, 2019). Any hormonal connection is yet to be explained.

Structural risk factors include a low arch (pes planus) or high arch (pes cavus), as each is associated with increased stress on the connective fascia (Young, 2019). Other sources of fascia stress include leg-length discrepancy, overpronation, excessive lateral tibial torsion, and excessive femoral anteversion (Young, 2019). Tight muscles, specifically the hamstrings, gastrocnemius, and soleus, as well as tight Achilles tendon may play a role as well (Young, 2019).

Plantar fasciitis is diagnosed by ultrasound, MRI, or x-ray (Wheeler, 2019), by ruling out other causes of pain, such as heel bruising, fractures, achilles tendonitis, infection, arthritis, and other foot syndromes (Ingraham, 2019; Wheeler, 2019). 

Once a diagnosis is made, Allopathic approaches indicate rest, ice, stretching, massage, and non-steroidal anti-inflammatories (NSAIDs) for relief of symptoms (Wheeler, 2019). Despite these options, this chronic inflammatory condition may last many months. At the 12-month mark, 80% of cases will experience relief, with 5% of cases progressing to more invasive options (Young, 2019). Treatment for persistent or severe cases includes physical therapy, extracorporeal shock-wave therapy, shoe inserts or orthotics, corticosteroid injections to the affected area, and/or surgery for plantar fascia release (Buchbinder, 2004; Wheeler, 2019; Young, 2019). Because each case is unique,combinations of treatments are recommended for optimal healing (Buchbinder, 2004).

Integrative approaches to treatment of plantar fasciitis utilize the above-mentioned allopathic treatments in addition to other holistic measures. An integrative practitioner will take into consideration stress levels of patients as well as quality of sleep, hormone levels, and nutritional status. Complementary treatment practices include chiropractic, massage and body work, dry needling, acupuncture, cupping, etc., with the intention of decreasing inflammation and restoring blood flow (Al-Boloushi, Gómez-Trullén, Bellosta-López, López-Royo, Fernández, & Herrero, 2019).

Assessments utilized may include meal-tracking with subsequent data on nutrient excesses and deficiencies. A detailed health history including sleep tracking and stress-level questionnaires provide important background information related to inflammation and lifestyle patterns that may contribute to chronic pain. Lab tests, including insulin and glucose levels assess inflammatory markers, while a gut microbiome test or comprehensive stool analysis can assess gut integrity (Rakel, 2018, p.869). 

An anti-inflammatory diet may be recommended. Eating foods high in healthy fats including omega-3s (found in cold water fish, such as salmon, mackerel, anchovies, and herring), oleic acid (found in olive oil), a variety of nuts, and coconut oil, lead to the formulation of less-inflammatory or antiinflammatory prostaglandins and leukotrienes (Rakel, 2018, p.870-872). Organic vegetables and fruits provide protective phytochemicals (Rakel, 2018, p.873). Avoiding gluten may reduce inflammatory markers, while decreasing intake of  over-processed, packaged foods and focusing on whole-food, nutrient-dense sources of low-glycemic carbohydrates favor an optimal gut microbiome composition and balanced insulin response (Rakel, 2018, p. 872-873). Cultured or fermented vegetables such as kimchee or sauerkraut also optimize gut microflora while sea vegetables such as kombu, arame, dulse, wakame, and nori provide essential micronutrients and trace nutrients (Lipski, 2012, p.148). Finally, bone broth is touted for its collagen-enhancing properties (Kresser, 2019), while certain spices (turmeric, ginger, rosemary, oregano and cayenne), garlic, green tea, wild mushrooms, organic red wine, and cacao or dark chocolate all provide improvements in inflammatory markers (Rakel, 2018, p.874; The Anti-Inflammatory Diet & Food Pyramid: Andrew Weil, M.D., 2019; Turmeric, 2018). 

Integrative approaches may also call for supplementation. Common anti-inflammatory supplements include glucosamine chondroitin, s-adenosyl methionine (SAMe), EPA/DHA fish oils, Hawaiian astaxanthin, vitamins C and D, medium chain triglyceride oil (MCT oil), Co-enzyme Q-10 (CoQ10), N-acetyl-cysteine (NAC), methylsulfonylmethane (MSM), and trace mineral drops (Bode & Dong, 1970; Kohlstadt, 2012, p.684-689; Wilson, 2018). 

Lifestyle changes are encouraged in holistic practice to decrease stress and support healing. Positive sleep hygiene promotes deep, restful sleep, allowing the body to heal and restore (Seaward, 2014, p.13). Meditative practices, including breathwork and moving meditations like yoga and tai chi, provide opportunity to release emotional and physical stress (Krohn & Taylor, 2000, p.342-344). Hyperbaric oxygen therapy helps oxygenate tissue to promote healing (Krohn & Taylor, 2000, p. 348-349). Cold therapy, including cryotherapy, increases microcirculation and synthesis of collagen, while heat therapy, including epsom salts soaks, steam rooms, and saunas provide pain relief and help to improve circulation (Krohn & Taylor, 2000, p. 262-265). Magnets are thought to encourage healing (Krohn & Taylor, 2000, p. 437-438). Finally, body work, touch therapy, and energy work such as chiropractic adjustments, Swedish massage, shiatsu, Rolfing, sports massage, Thai massage, reflexology, acupuncture, therapeutic touch, Reiki, and qi gong provide relaxation and reduction in chronic pain  (Al-Boloushi et al, 2019; Krohn & Taylor, 2000, p. 258-261).

Both allopathic and integrative experts agree that plantar fasciitis is persistent and often challenging to treat. With multiple options and different approaches, the consensus is that a combination of treatments bring the most favorable results (Fink, 2012).

References

Al-Boloushi, Z., Gómez-Trullén, E. M., Bellosta-López, P., López-Royo, M. P., Fernández, D., & Herrero, P. (2019). Comparing two dry needling interventions for plantar heel pain: A protocol for a randomized controlled trial. Journal of Orthopaedic Surgery and Research, 14 doi:http://dx.doi.org/10.1186/s13018-019-1066-4

Anti-Inflammatory Food Pyramid:Andrew Weil, M.D.(2020, January 16). Retrieved January 18, 2020, from https://www.drweil.com/diet-nutrition/anti-inflammatory-diet-pyramid/dr-weils-anti-inflammatory-food-pyramid/

Bode, A. M., & Dong, Z. (1970, January 1). The Amazing and Mighty Ginger. Retrieved January 25, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK92775/

Buchbinder, Rachelle, MB,B.S., F.R.A.C.P. (2004). Plantar fasciitis. The New England Journal of Medicine, 350(21), 2159-66. Retrieved from https://search.proquest.com/docview/223938185?accountid=193085

Daniels, C. J., & Morrell, A. P. (2012, March 11). Chiropractic management of pediatric plantar fasciitis: a case report. Retrieved February 7, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3315855/#bb0070

Fink, B. R., M.D. (2012). Management of plantar fasciitis evolving. The Journal of Musculoskeletal Medicine, 29(1), 16-20. Retrieved from https://search.proquest.com/docview/922379503?accountid=193085

Ingraham, P. (2019, November 1). What Works for Plantar Fasciitis? What Doesn't? Why? Retrieved February 5, 2020, from https://www.painscience.com/tutorials/plantar-fasciitis.php

Kresser, C. (2019, September 24). Bone Broth Benefits: Everything You Need to Know. Retrieved February 7, 2020, from https://chriskresser.com/the-bountiful-benefits-of-bone-broth-a-comprehensive-guide/

Kohlstadt, I. (2012). Advancing medicine with food and nutrients. Boca Raton: CRC Press, Taylor & Francis Group.

Krohn, J., & Taylor, F. A. (2000). Natural detoxification. Point Roberts, WA: Hartley & Marks Publishers.

Levy, J. (2019, September 3). Is This Fatty Oil Actually Good for You? Retrieved January 25, 2020, from https://draxe.com/nutrition/mct-oil/

Lipski, E. (2012). Digestive wellness: strengthen the immune system and prevent disease through healthy digestion. New York: McGraw-Hill.

Rakel, D. (2018). Integrative medicine (4th ed.). Philadelphia, PA: Elsevier.

Searing, L. (2019, November 25). The Big Number: 2 million Americans get treated for heel pain caused by plantar fasciitis. Retrieved February 5, 2020, from https://www.washingtonpost.com/health/the-big-number-2-million-americans-get-treated-for-heel-pain-caused-by-plantar-fasciitis/2019/11/22/0dfe89e8-0c7a-11ea-97ac-a7ccc8dd1ebc_story.html

Seaward, B. L. (2014). Essentials of managing stress. Burlington, MA: Jones & Bartlett Learning.

The Anti-Inflammatory Diet & Food Pyramid: Andrew Weil, M.D. (2019, August 9). Retrieved January 18, 2020, from https://www.drweil.com/diet-nutrition/anti-inflammatory-diet-pyramid/what-is-dr-weils-anti-inflammatory-food-pyramid/

Turmeric. (2018, November 27). Retrieved January 25, 2020, from https://nccih.nih.gov/health/turmeric/ataglance.htm

Wheeler, T. (2019, October 7). Plantar Fasciitis: Symptoms, Causes, Diagnosis, Treatment. Retrieved February 5, 2020, from https://www.webmd.com/fitness-exercise/understanding-plantar-fasciitis-basics

Wilson, D. R. (2018, September 18). 7 Health Claims About Astaxanthin. Retrieved January 25, 2020, from https://www.healthline.com/health/health-claims-astaxanthin


Young, C. C. (2019, November 12). Plantar Fasciitis. Retrieved February 5, 2020, from https://emedicine.medscape.com/article/86143-overview#showall

Nerd Out: Hypothyroidism

My latest assignment for my Master’s in Holistic Nutrition was to write a paper about a disorder of the endocrine system. I chose Hypothyroidism, as it ranks up there as one of the most prevalent chronic disorders people experience. If you’d like to nerd out with me, continue reading:

Hypothyroidism is defined as a deficiency of thyroid hormone (Pizzorno & Murray, 2013, p.1473), and is due to one of three factors: insufficient hormone synthesis, a lack of stimulation by the pituitary gland, and/or impaired conversion of thyroxine (T4) to triiodothyronine (T3) (Pizzorno & Murray, 2013, p. 1473; Rakel, 2018, p. 347). Many factors contribute to hypothyroidism, including nutrient deficiencies, environmental toxins and endocrine disruption, estrogen dominance, infections, food intolerances and food allergies, poor liver function, and chronic stress (Kohlstadt, 2012, p. 391, 398; Myers, 2019; Rakel, 2018, p. 348-350).

In primary hypothyroidism, iodine deficiency is the most common cause due to lack of dietary iodine intake in certain regions of the world, with autoimmune destruction of the thyroid gland (Hashimoto’s Disease) most common in iodine-sufficient regions (Rakel, 2018, p. 347). Other factors contributing to primary hypothyroidism include surgery to thyroid, radioactive iodine administration, certain medications, overconsumption of goitrogens, and external beam radiation (Rakel, 2018, p. 347). Low thyroid hormone levels and high thyroid-stimulating hormone (TSH) levels from the pituitary gland indicate defective thyroid hormone synthesis (Pizzorno & Murray, 2013, p. 1473). 

Secondary hypothyroidism, on the other hand, is indicated by decreased levels of both TSH and thyroid hormones (Pizzorno & Murray, 2013, p.1473). This occurs most commonly due to pituitary tumors, pituitary surgery, or disease of the pituitary gland (Rakel, 2018, p. 347). Finally, tertiary hypothyroidism is defined by a deficit of thyroid hormone-releasing hormone (THRH) from the hypothalamus (Pizzorno & Murray, 2013, p. 1473), and may be due to infection, congenital defect, or infiltrative processes of the brain (Rakel, 2018, p. 347). Subclinical hypothyroidism is indicated by elevated TSH but normal levels of T4, and may be asymptomatic, but may lead to primary hypothyroidism over time (Rakel, 2018, p. 347). 

Hypothyroidism, regardless of its etiology, affects women more than men, and whites and Mexican-Americans more than African-Americans (Kohlstadt, 2012, p. 391; Pizzorno & Murray, 2013, p. 1473). It is estimated that the rate of hypothyroidism is somewhere near 25% of the adult population, with incidences significantly higher among the elderly (Pizzorno & Murray, 2013, p. 1473).

Symptoms of hypothyroidism can mimic other diseases making it challenging to identify and diagnose (Kohlstadt, 2012, p. 392). Mild fatigue or depression may go on for years and precede any clinical serum abnormalities, therefore a careful analysis of both symptoms and lab test results are crucial to diagnosis (Kohlstadt, 2012, p. 393; Pizzorno & Murray, 2013, p. 1474). Chronic fatigue, depression, malaise, difficulty concentrating, forgetfulness, weight gain, sensitivity to cold (especially in the hands and feet), edema, decreased libido, menstrual abnormalities, infertility, dry skin, hair loss, thinning eyebrows, thin, brittle nails, muscle weakness, joint stiffness, gastroesophageal reflux disease (GERD), shortness of breath, constipation, delayed tendon reflex, loss of hearing, and atherosclerosis are all possible presentations in hypothyroidism (Kohlstadt, 2012, p. 393; Pizzorno & Murray, 2013, p. 1474; Rakel, 2018, p. 348).  

Allopathic approaches to treatment of hypothyroidism rely primarily on serum lab testing of TSH and sometimes T4 (Mayo Clinic, 2018). Traditionally the accepted as normal range for TSH is quite broad, measuring 0.35-5.50 mIU/mL, with some conventional practitioners using levels greater than 10 mIU/mL as a basis for recommending treatment (National Academy of Hypothyroidism, 2012; Pizzorno & Murray, 2013, p. 1476). Additional labs such as cholesterol and triglyceride measures as well as clinical presentation of the patient may also be taken into account. If lab results indicate low TSH, a pharmaceutical is prescribed, most often the synthetic T4 thyroxin (levothyroxine sodium), with the most common brand names of Levoxyl (levothyroxine) and Synthroid (Lee & Hopkins, n.d.; National Academy of Hypothyroidism, 2017). It is interesting to note that thyroid hormone-replacement drugs are ranked the third most common prescribed in the United States (National Academy of Hypothyroidism, 2017). Rarely are nutrition, lifestyle, gut integrity, and stress addressed in allopathic care of hypothyroidism, with the focus almost solely on pharmaceutical intervention (National Academy of Hypothyroidism, 2012). Typically, once stabilized within normal range, TSH levels are monitored yearly and dosages adjusted as needed (Mayo Clinic, 2018). 

Integrative approaches to healing hypothyroidism are more holistic in approach, taking into account not only lab tests of thyroid hormones but also nutrition, stress levels, lifestyle choices, sex hormone levels and blood sugar regulation. A comprehensive evaluation, including labs, medical history, symptomatology, and lifestyle choices recognize that hypothyroidism is a multi-faceted disorder with often more than one overt cause (Kohlstadt, 2018, p.392). 

Comprehensive thyroid labs test not only for TSH, but for T4, free T4, T3, free T3, and reverse T3 (rT3) (Pizzorno & Murray, 2013, p. 1474; Rakel, 2018, p. 348). Cholesterol, triglyceride, cortisol, homocysteine, and C-reactive protein (CRP) levels may also be tested, and if elevated, indicate possible hypothyroidism (Pizzorno & Murray, 2013, p. 1474). Low iron and B12 are also indicators of thyroid insufficiency (Pizzorno & Murray, 2013, p. 1474). Supplementation is recommended based on lab results, with brand name Armour Thyroid most commonly prescribed in functional medicine. Combination via dessicated pig or cow thyroid (also called USP thyroid) provides both T3 and T4 support in approximately the ratio made by the human thyroid (Lee & Hopkins, n.d.; National Academy of Hypothyroidism, 2017) as opposed to only TSH replacement. In addition to labs and to further support a hypothyroid diagnosis, a Basal Body Temperature test may be done to measure for lowered body temperature, while the Iodine patch test demonstrates iodine uptake and therefore the body’s need for iodine (Weatherby & Ferguson, 2005, p. 17-23). 

Environmental toxins play a role in thyroid health. Heavy metals compete for thyroid hormone, iodine, and selenium uptake in the thyroid, so testing for mercury, lead, and cadmium by way of urine provocation test would be indicated (Kresser, 2019; Pizzzorno & Murray, 2013, p. 194-195). The halides, including fluoride, bromide, and chloride bind with iodine receptors in the thyroid gland (Fluoride, Bromide, Chloride, and Thyroid Health, 2018). A 24-hour urine iodine test may be ordered to check for possible iodine deficiency and levels of halides (Fluoride, Bromide, Chloride, and Thyroid Health, 2018; Kohlstadt, 2012, p.396). Measures to decrease exposure to these chemicals are encouraged.

Gut dysbiosis and increased intestinal permeability both interfere with iodine, selenium, and other mineral absorption (Kohlstadt, 2012, p. 394). A Comprehensive Digestive Stool Analysis for dysbiosis, Organix test to measure protein digestion, and a lactulose-mannitol test to measure intestinal permeability may all be utilized (Rakel, 2018, p. 580). Selenium- , zinc-, and iodine-rich foods and/or supplementation may be recommended to ensure proper uptake (Kresser, 2019).

Lifestyle, and particularly stress plays an enormous role in thyroid health, as excess cortisol inhibits thyroid hormone metabolism (Kohlstadt, 2012, p. 401; National Academy of Hypothyroidism, 2017). An adrenal stress profile using salivary collection will provide clues to cortisol levels (Kohlstadt, 2012, p. 401). Meditation, low-intensity exercise, breathwork, and body work may all be recommended to support thyroid health, even if cortisol levels are within normal range (Rakel, 2018, p. 358-359). Blood glucose levels may be checked and measures taken to balance insulin levels and reduce inflammation through diet and exercise (Wentz, 2019).  Encouraging proper sleep hygiene and maintaining a healthy body weight are regarded as positive practice as well (Rakel, 2018, p. 590). 

Estrogen dominance and/or progesterone deficiency also play a big role in hypothyroidism. An imbalance of these female sex hormones not only produce symptoms mimicking hypothyroidism, but increase serum thyroid binding globulin (TBG), rendering thyroid hormones inactive (Myers, 2019). A 6- or 24-hour saliva or urine collection to measure estrogen levels may be ordered to determine a course of action.  Balancing estrogen-dominance calls for a multi-faceted approach, including decreasing stress and inflammation, minimizing exposure to xenoestrogens and hormone disruptors, reducing exposure to heavy metals, and eating organic and minimally-processed whole foods (Myers, 2019; National Academy of Hypothyroidism, 2017).  

Nutrient-rich foods are encouraged to support optimal thyroid health, regardless of lab results. Iodine-rich foods such as sea vegetables, ocean fish, and unrefined sea salt support iodine levels (Fluoride, Bromide, Chloride, and Thyroid Health, 2018; Kohlstadt, 2012, p. 394). Cooking raw goitrogens (cruciferous or Brassica vegetables, including cabbage, turnips, Brussels sprouts, broccoli, cauliflower, bok choy, etc.) before consuming or avoiding altogether is recommended (Kohlstadt, 2012, p. 394-395), as goitrogens compete for iodine uptake and block incorporation into the thyroglobulin molecule (Kohlstadt, 2012, p. 394-395. Minimizing the effect of thyroid peroxidase enzyme-inhibiting (TPO-inhibiting) soy isoflavones by consuming fermented soy is encouraged (Kohlstadt, 2012, p. 395). Increasing intake of zinc-rich foods (seafood, oysters, red meats, and organ meats), heme iron (chicken liver, oysters, beef liver, beef, turkey, and chicken), selenium (Brazil nuts, grass-fed meat, eggs, ans seafood), and copper (organ meats, eggs, yeast, beans, nuts, and seeds) are also extremely supportive to the thyroid (Kohlstadt, 2012, p. 393-398). Finally, daily exposure to sunshine or vitamin D supplementation, and vitamin A, C, E, copper, the B vitamins, and trace mineral supplementation may also be indicated to optimize thyroid hormone production and uptake (Pizzorno & Murray, 2013, p. 1479). 

Regardless of etiology, hypothyroidism can be managed through lab testing and hormone supplementation. A holistic approach provides additional support with nutritional supplementation, a nutrient-dense diet, exercise, and lifestyle modifications. 




   

References

Fluoride, Bromide, Chloride and Thyroid Health. (2018, January 2). Retrieved November 26, 2019, from https://www.naturalendocrinesolutions.com/articles/fluoride-bromide-chloride-and-thyroid-health/.

Kohlstadt, I. (2012). Advancing Medicine with Food and Nutrients, Second Edition. Hoboken: Taylor and Francis.

Kresser, C. (2019, October 10). How Environmental Toxins Harm the Thyroid. Retrieved November 25, 2019, from https://kresserinstitute.com/environmental-toxins-harm-thyroid/.

Lee, J. R., & Hopkins, V. (n.d.). What Your Dr May Not Tell You About Your Thyroid. Retrieved November 24, 2019, from https://www.virginiahopkinstestkits.com/thyroidarticle.html.

Myers, A. (2019, November 14). 9 Causes of Estrogen Dominance and What to Do About It. Retrieved November 24, 2019, from https://www.amymyersmd.com/2019/03/9-causes-estrogen-dominance/.

Mayo Clinic. (2018, December 4). Hypothyroidism (underactive thyroid). Retrieved November 24, 2019, from https://www.mayoclinic.org/diseases-conditions/hypothyroidism/diagnosis-treatment/drc-20350289.

National Academy of Hypothyroidism. (2012, January 27). Why Doesn't My Endocrinologist Know All of This? Retrieved November 24, 2019, from https://www.nahypothyroidism.org/why-doesnt-my-doctor-know-all-of-this/.

National Academy of Hypothyroidism. (2017, September 13). Estrogen Dominance and Hypothyroidism: National Academy of Hypo. Retrieved November 24, 2019, from https://www.nahypothyroidism.org/estrogen-dominance-and-hypothyroidism-is-it-hypothyroidism-or-hormone-imbalance/.

Pizzorno, J. E. (2013). Textbook of natural medicine. St. Louis, MO: Elsevier/Saunders.

Rakel, D. (2018). Integrative medicine. Philadelphia, PA: Elsevier.

Weatherby, D., & Ferguson, S. (2005). The complete practitioners guide to take-home testing: tools for gathering more valuable patient data. Ashland, OR.: Emperors Group.

Wentz, I. (2019, March 14). Why Balancing Blood Sugar is Vital for Hashimotos Help. Retrieved November 26, 2019, from https://thyroidpharmacist.com/articles/blood-sugar-imbalances-and-hashimotos/

Nerd Out: Irritable Bowel Syndrome

My latest assignment for my Master’s in Holistic Nutrition was to write a paper about a gastrointestinal disorder. I chose Irritable Bowel Syndrome, as it ranks up there as one of the most prevalent chronic disorders people experience. If you’d like to nerd out with me, continue reading:

Irritable Bowel Syndrome, or IBS, is defined as chronic inflammation of the large intestine and presents itself through a cluster of symptoms, including abdominal pain, spasms, bloating, gas, and abnormal bowel movements (Lipski, 2012, p.286). Because there is a spectrum within the symptoms (mild to severe), and because the symptoms fluctuate over time, it is often challenging to differentiate between IBS and normal variations of the gastrointestinal tract (Rakel, 2018, p.423). Stress has proven to play an integral part in the flare-up of IBS, providing a psychosocial perspective to treatment (Rakel, 2018, p.423), although some experts prefer to categorize it as a disorder of the gut-brain axis rather than as a psychiatric disorder (Kohlstadt, 2012, 261). A diagnosis is made due to its chronic nature (at least 6 months’ duration) (Kohlstadt, 2012, p.261), by excluding pathology, and including some or all of the symptoms of abdominal pain/discomfort, bloating, and diarrhea/constipation (Rakel, 2018, p.423).

Specifically, the Rome III Criteria for Irritable Bowel Syndrome defines IBS as at symptoms lasting at least three months, with onset at least six months previously of recurrent abdominal pain or discomfort associated with two or more of the following: Improvement with defecation; Onset associated with a change in frequency of stool; And/or onset associated with a change in form (appearance) of stool (Kohlstadt, 2012, p.262). This, with the absence of weight loss, anemia, and rectal bleeding, support the diagnosis of IBS (Kohlstadt, 2012, p.261).

Also prevalent amidst the cluster of symptoms may be nausea, anorexia, hypersecretion of colonic mucus, restless leg syndrome, migraine headaches, chronic fatigue, irritable bladder, and dyspareunia (Pizzorno & Murray, 2013, p.1557). IBS is often seen in patients with a history of sexual abuse and/or sexual dysfunction, fibromyalgia, urinary frequency and urgency, poor sleep, menstrual difficulties, lower back pain, and insomnia (Pizzorno & Murray, 2013, p.1557).

IBS is cited as the most common GI disorder seen in general practice, representing 30%-50% of all referrals to gastroenterologists (Pizzorno & Murray, 2013, p.1557). Women are diagnosed twice as often as men, which might be due to men under-reporting symptoms (Pizzorno & Murray, 2013, p.1557), and is more prevalent in Caucasian persons than others. Early studies demonstrate that IBS patients tend to have an enhanced stress responsiveness that presents higher morning cortisol levels and an inability to turn off the stress response, both which have been shown to increase intestinal permeability and inflammation (Rakel, 2018, p.429).  

There are three subgroups of IBS under which patients are categorized: constipation predominant (IBS-C), diarrhea predominant (IBS-D), or mixed (IBS-M) (Kohlstadt, 2012, p.261).  Risk factors may be environmental, genetic, or both (Kohlstadt, 2012, p.262). Several conditions, including food allergies, infections, poor diet, and metabolic disorders mimic the symptoms of IBS and must be ruled out in order to make the diagnosis.

The etiology of IBS is unclear, although it frequently occurs in concert with Small Intestinal Bacterial Overgrowth (SIBO) and Leaky Gut Syndrome (Lipski, 2012, p.287). IBS can also be caused by stressors to the gut as mentioned above, leading to an over-active inflammatory response in the mucosal tissue of the large intestine (Lipski, 2012, p.288). Parasites and candida overgrowth may also play a role in IBS, and women may experience increased symptoms around their menstrual periods (Lipski, 2012, p.288). Chronic stress, dysregulated immune response, dysbiosis, overconsumption of alcoholic beverages, certain medications such as NSAIDs and birth control pills, and even lectins have been implicated in the chronic inflammation characteristic of IBS (Lipski, 2012, p. 46-47) (Rakel, 2018, p.423).

Allopathic approaches to IBS focus on three main therapies: increasing fiber in diet, probiotics, and antibiotic therapy (Rifaxamin), especially if SIBO is indicated (Lipski, 2012, p.287) (Rakel, 2018, p.430). Another pharmaceutical, oral Cromolyn (brand name Gastrocrom), is used to control the release of GI-irritating substances from mast cells in the GI tract (https://www.mayoclinic.org/drugs-supplements/cromolyn-oral-route/description/drg-20063181).  And with the mind-body connection to IBS, tricyclic antidepressants and selective serotonin reuptake inhibitors are an option for patients with IBS-D (Rakel, 2018, p.430).

For IBS-C, a diet high in fiber (25-30 grams per day, preferably insoluble fiber such as in oats and psyllium), and low in fat help with stool bulking and intestinal motility (Kohlstadt, 2012, p.272).  Pharmaceuticals such as 5-hydroxytryptophan (5-HTP), Lubiprostone, Tegaserod, and Renzapride may be indicated soften the stool and relax the gut. (Kohlstadt, 2012, p.265) (Pizzorno & Murray, 2013, p.1560).

Anticholinergic agents are used to reduce abdominal cramping and smooth muscle spasms (Kohlstadt, 2012, p.266). Peppermint oil is gaining traction in the allopathic medical community as another option for relaxation of the smooth muscle in the GI tract as well as for mediation of other symptoms (Kohlstadt, 2012, p.266) (Pizzorno & Murray, 2013, p.1560).

Broad-spectrum probiotics are recommended to repopulate the intestinal microbiome with optimal rather than pathogenic gut microflora, decrease fermentation, and stimulate proper immune function (Rakel, 2018, p.427) (Pizzorno & Murray, 2013, p.1559).

Antibiotic therapy, specifically Rifaxamin, has been found to significantly improve IBS symptoms, especially in IBS-D patients and those with comorbid SIBO (Rakel, 2018, p.430).

All types of IBS may benefit from Cognitive Behavioral Therapy and/or hypnotherapy to help with accompanying anxiety and depression (Kohlstadt, 2012, p.271).

The above-mentioned approaches are based on an extensive medical history, including frequency of abdominal pains, gas, bloating, constipation, and/or diarrhea. Lab tests may include a comprehensive stool analysis, complete blood count, erythrocyte sedimentation rate, free thyroid T3 hormone levels, and antiendomysial antibody testing for celiac disease (Pizzorno & Murray, 2013, p.1557).  The enzyme-linked immunosorbent assay (ELISA) allergen challenge test or the ELISA IgE/IgG4 test are sometimes used to detect food allergies (Pizzorno & Murray, 2013, p.1558).

IBS-D type symptoms may indicate a panendoscopy with duodena, colonic, and terminal ileal biopsies to rule out celiac disease, inflammatory bowel disease, and colitis (Pizzorno & Murray, 2013, p.1557). Additional stool testing for eosinophilic cationic proteins may be indicated if food allergy is suspected (Pizzorno & Murray, 2013, p.1557). Finally, screening for occult fecal blood, flexible sigmoidoscopy/colonoscopy are also options to rule out other causes (Pizzorno & Murray, 2013, p.1557).

Integrative approaches take a broader approach to diagnosis and treatment. Assessments such as a health history questionnaire are combined with a comprehensive discussion and/or physical assessment, and include all of the inclusions and exclusions as a diagnostic tool as listed previously. Family medical history is noted, as there may be a genetic link (Rakel, 2018, p.423). A food journal and dietary history is collected to detect possible food sensitivities, intolerances, and allergies (Lipski, 2012, p.288-289), as well as helps determine detrimental dietary choices and eating patterns.

Breath tests, including the SIBO breath test (or the Hydrogen-Methane test), the Lactose-Intolerance/Lactose Malabsorption test, the Fructose Intolerance/Fructose Malabsorption test, and/or the Sucrose Intolerance/Sucrose Malabsorption test are utilized to detect gut sensitivities to sugars, and are especially indicated if leaky gut or SIBO are suspected (What is Irritable Bowel Syndrome, 2019, https://www.commdx.com/)  (Lipski, 2012, p.289) (Kohlstadt, 2012, p.272). Organic acid testing is also a possibility, providing an evaluation of intestinal yeast and bacteria (Lipski, 2012, p.289), and an HCl challenge test can detect decreased gastric acid production (Rakel, 2018, p.430).

Permeability, or leaky gut issues can also be assessed using a lactulose-mannitol urine test or with positive IgG food antibody testing (Rakel, 2018, p.423).

A comprehensive digestive stool analysis including parasitology is recommended, as candida overgrowth and parasites are often overlooked causes of IBS (Lipski, 2012, p.288).

An elimination diet and subsequent food challenge helps identify triggering foods (Rakel, 2018, p.426). Introducing therapeutic dietary systems (FODMaPs/fermentable carbohydrates avoidance, GAPS, Paleo, low-sugar, dairy-free, gluten-free, lectin-free, caffeine-free, alcohol-free, etc.), based on individual needs often provides symptomatic relief (Pizzorno & Murray, 2013, p.1558, 1559) (Lipski, 2012, p.289) (Rakel, 2018, p.426) (Kohlstadt, 2012, p.269). It is important to note that artificial sweeteners such as sorbitol, maltitol, or xylitol may worsen bloating and diarrhea in IBS patients so should be avoided (Kohlstadt, 2012, p.270-271).

Increasing fiber with psyllium seeds, flaxseed, or hemp seed is recommended, as well as adding a broad-spectrum probiotic that includes lactobacilli and bifidobacteria (Lipski, 2012, p.290). Eliminating dairy foods, sugar, fruit, honey, and maple syrup may ease symptoms (Lipski, 2012, p.289, 290). Prebiotic-rich foods (bananas, artichokes, garlic, onions, etc.) as well as probiotic foods (sauerkraut, kimchee, and kvass, etc.) stimulate and feed healthy GI flora (Rakel, 2018, p.428) (Axe, 2018, https://draxe.com/leaky-gut-diet-treatment/).

Other dietary supplements include pancreatic enzymes, ginger, aloe, Chinese herbs such as Padma Lax and STW-5, glutamine, EPA/DHA fish oil, peppermint oil, chamomile, rosemary, Melissa (balm), valerian, betaine hydrochloride, and calcium-magnesium citrate (Rakel, 2018, p.428- 430) (Lipski, 2012, p.290-291).

Bone broth soothes the gut and provides the nutrients collagen, glycine, proline, and glutamine, as well as easily absorbable minerals and natural anti-inflammatories like chondroitin sulfate and glucosamine (Kresser, 2019, https://chriskresser.com/the-bountiful-benefits-of-bone-broth-a-comprehensive-guide/).

Decreasing the chemical load by eating organic produce, and pastured eggs and meat, allows for optimal healing of the gut. Other nutrient-rich foods include healthy fats like coconut oil, avocado, and the omega-3 fats in fatty fish. Sprouted seeds, fermented vegetables, and adequate hydration round out the list (Axe, 2018, https://draxe.com/leaky-gut-diet-treatment/)

Finally, lifestyle modifications that include more self-care to decrease stress, anxiety, and depression have been shown to decrease IBS symptoms. Mind-body therapies include stress management, relaxation therapy, meditation, hypnosis, journaling, biofeedback, art therapy, acupuncture, and gentle exercise such as yoga, and walking (Rakel, 2018, p.429). Often more effective than medical therapy (Rakel, 2018, p.429), stress reduction strategies tap into the mind-body and gut-brain connection that affects both sickness and wellness. An entire paper could be written on this topic as well, but suffice it to say, a holistic approach to Irritable Bowel Syndrome, including diet, supplementation, exercise, and stress reduction, offers promise to provide not just physical but emotional relief as well.   

References

Axe, J. (2018, July 30). Leaky Gut Diet and Treatment Plan, Including Top Gut Foods. Retrieved May 30, 2019, from https://draxe.com/leaky-gut-diet-treatment/

Cromolyn (Oral Route) Description and Brand Names. (2019, February 01). Retrieved May 30, 2019, from https://www.mayoclinic.org/drugs-supplements/cromolyn-oral-route/description/drg-20063181

Kohlstadt, I. (Ed.). (2012). Advancing medicine with food and nutrients. Boca Raton: CRC Press.

Kresser, C. (2019, May 28). Bone Broth Benefits: Everything You Need to Know. Retrieved May 30, 2019, from https://chriskresser.com/the-bountiful-benefits-of-bone-broth-a-comprehensive-guide/

Lipski, E. (2012). Digestive wellness: Strengthen the immune system and prevent disease through healthy digestion. New York, NY: McGraw-Hill.

Pizzorno, J., & Murray, M. T. (2013). Textbook of natural medicine. St. Louis, MO: Elsevier.

Rakel, D. (2018). Integrative medicine. Philadelphia, PA: Elsevier.

What is Irritable Bowel Syndrome? (2019). Retrieved May 31, 2019, from https://www.commdx.com/

Nerd-Out: Vitamin D Report

(For those of you who like to nerd-out on the science behind nutrition, I will be sharing portions of my writings for my Master's of Science in Holistic Nutrition.)

Here's the first one: Vitamin D

Photo by pepifoto/iStock / Getty Images

Photo by pepifoto/iStock / Getty Images

          Vitamin D is something I’d taken for granted until my breast cancer diagnosis four years ago. Growing up in San Diego, California, I mistakenly believed that my long days at the beach, poolside, and soccer fields would provide me enough of that essential vitamin. Moving to Colorado as an adult didn’t change my mindset about it. Living closer to the sun and hiking, camping, skiing, snowboarding, and simply sitting outside on my beautiful backyard deck supplied ample exposure to the sun’s vitamin D-rich rays, or so I thought. It wasn’t until my breast cancer diagnosis four years ago and the subsequent battery of labs, blood tests, and scans, that I discovered I was vitamin D deficient. Thus began this heightened interest in this “sunny” vitamin and a subsequent “dance” of treatments with my traditional oncologist and my naturopathic physician.  

            Known chemically as (cholecalciferol), vitamin D3 can be synthesized on human skin when exposed to ultraviolet B (UVB) radiation from the sun (Higdon & Drake, 2012, p.83). It can also be ingested in food or supplement form in the diet (Higdon & Drake, 2012, p.83). Although not prevalent in many foods, it can be found in liver, salmon, mackerel, sardines, cod-liver oil, and egg yolks, and vitamin D fortified cereals and milk (Smolin & Grosvenor, 2013, p382).  Vitamin D acts like a hormone in that several organs are affected in its metabolism, including the skin, intestine, bone, and kidneys (Smolin & Grosvenor, 2013, p.382).

            Activated in the liver and then dumped into the blood stream, vitamin D circulates and travels to the intestines, bones, and kidneys where it helps increase calcium levels in the blood (Smolin & Grosvenor, 2013, p.383). The maintenance of normal blood calcium levels is crucial to maintain the growth, density, and strength of bones and prevent their breakdown (Higdon & Drake, 2012, p.83). Vitamin D also helps regulate cell differentiation, immunity, insulin secretion, and blood pressure regulation (Higdon & Drake, 2012, p.84).  Proposed but yet unproven actions of this vitamin include cancer prevention, protection from certain autoimmune diseases such as type 1 diabetes and multiple sclerosis, and protection from cardiovascular disease and type 2 diabetes (Smolin & Grosvenor, 2013, p.384).

            Without proper levels of vitamin D consumption or absorption, only about 10-15% of calcium in the diet can be utilized, affecting bone mineralization, strength, and growth (Smolin & Grosvenor, 2013, p.384). And without access to dietary calcium, the body resorts to leaching existing calcium from the bones, leaving them at risk for bone pain, muscle aches, and fractures (Smolin & Grosvenor, 2013, p.385). In a child’s growing frame, this deficiency causes rickets, characterized by bowed legs, weak bones, and short stature (Smolin & Grosvenor, 2013, p.384). In adults, vitamin D deficiency results in osteomalacia, or soft bones (Higdon & Drake, 2012, p.85).

            Too much vitamin D (toxicity) raises blood calcium levels too high, which can result in deposits of calcium in blood vessels, kidneys, and the heart, hardening them, resulting in damage (Smolin & Grosvenor, 2013, p.386). Most vitamin D toxicity results from over-supplementation or consuming too much of fortified foods. Sunlight and unfortified foods do not pose a risk for overconsumption (Smolin & Grosvenor, 2013, p.386).

            Lack of sun exposure is the primary way people become vitamin D deficient. Living in big cities with tall buildings blocking the sun, wearing sunscreen, spending all daylight hours indoors, and living at latitudes greater than 40 degrees north or south, increase decrease the skin’s exposure to the sun (Smolin & Grosvenor, 2013, p.384-385). Dark skin, which prevents much of vitamin D synthesis in the skin, and concealing clothing worn by certain cultural and religious groups, are also risk factors for deficiency, even in sunny climates (Smolin & Grosvenor, 2013, p.385). Elderly people, those with fat malabsorption syndromes, kidney disease, and inflammatory bowel disease are also at risk for deficiency, as these conditions prevent optimal absorption of vitamin D (Higdon & Drake, 2012, p.86). Finally, exclusively breastfed infants may be at risk, particularly if they have dark skin and/or receive little sun exposure (Higdon & Drake, 2012, p. 85).

            Foods rich in vitamin D, as mentioned above, are fatty fish such as salmon, mackerel, and sardines. Organ meats, particularly liver, are high in this vitamin. Egg yolks are dense sources of vitamin D as well. Sunlight, although not a food source, is by far the best provider of vitamin D.

            Using the iProfile Food, Liquid, and Activity Form, I tracked my food intake for a day to take a peek at my nutritional habits and get a feel for how much vitamin D I eat on an average day (Smolin & Grosvenor, 2010, iProfile). According to the dietary analysis, the eggs I consumed for dinner provided 82% of my Dietary Reference Intake (DRI), while the cheddar cheese provided 11%, the goat cheese 4%, and the Shiitake mushrooms 4%. I nearly reached 100% of my DRI with these food items. With 8ug the goal, I reached 7.8ug.

            The Suggested Optimal Nutritional Allowances (SONA) for vitamin D are slightly different. 24ug is the goal in this case, and here, with my 7.8ug, I fall desperately short. Since it is difficult to meet the requirements for vitamin D through diet alone without consuming fortified milk, which I don’t drink, I need to get mine from other sources. It’s winter in Colorado, and so the days when I can expose my arms, hands, and face to the sun are limited. Even with spending long hours in the sun all summer, my vitamin D levels have faltered, for whatever reason. However, I can supplement with vitamin D capsules to make up for the lack in my diet and sun exposure. I currently take 10,000iu of vitamin D3 daily, which translates to 250ug, which exceeds both the RDA (300iu/7.5ug) and the SONA (960iu/24ug). I do this under the care of a qualified naturopathic physician to avoid toxicity. Because I’m a breast cancer survivor, we’re taking special care of my vitamin D levels to prevent recurrence.

            If it weren’t for my breast cancer diagnosis, I may still be in the dark to the important role vitamin D plays in the prevention and treatment of disease. Though sun exposure is the optimal route to satisfy requirements, some foods, including fortified foods, and supplementation, provide necessary levels to keep the body systems operating optimally.

**UPDATE: I have since started taking fermented cod liver oil daily to provide more whole food supplementation of vitamin D. I plan on discontinuing my vitamin D capsules and consume only the fermented cod liver oil. Blood tests will determine if this is sufficient-- I'll keep you posted. xoxo, SF

References

Higdon, J., & Drake, V. J. (2012). An evidence-based approach to vitamins and minerals: health benefits and intake recommendations. Stuttgart: Thieme.

Smolin, L. A., & Grosvenor, M. B. (2013). Nutrition: science and applications(3rd ed.). Hoboken, NJ: Wiley.

Smolin, L. A., & Grosvenor, M. B. (2010). IProfile: assessing your diet and energy balance. Hoboken, NJ: Wiley. Retrieved January 25, 2018.

The Suggested Optimal Daily Nutritional Allowances (SONA)[Online reading material for
MSHN 515, Hawthorn University]. (2017).