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Strategic Approach to Andropause, by Dr. Zina Kroner
I would like to bring to your attention an important article I wrote that features treatment strategies for andropause. (This article was originally published on www.drhoffman.com/page.cfm/531)
Menopause has been grabbing all the headlines lately, but half the world faces a comparable syndrome that is more insidious and less predictable. This disease entity is andropause.
Unlike menopause which usually occurs at a predictable time, men's testosterone levels decline at different ages and different rates, sometimes slowly, and sometimes precipitously. Testosterone production by the testes reaches adult levels by age 17 (300-1000 ng/dL). The testosterone level remains constant until the fifth decade at which point it declines at a rate of 1.2 percent per year. But in some men, testosterone can drop prematurely and precipitously.
In the Baltimore Longitudinal Study of Aging (2001), it was demonstrated that free testosterone decreased at a constant rate with age and this decline was not related to other causes. Another study demonstrated that poor health may accelerate the natural age-associated decline in testosterone concentrations. One interesting finding is that studies that measured testosterone in the morning were more likely to show a decline in testosterone when compared to studies that measured testosterone in the afternoon. The logic behind this is that older men have little variation in their levels of testosterone throughout the day, unlike young men, who have peaks in their testosterone levels in the morning and troughs in the evenings.
As one ages, there is an increase in fat cells, which in turn causes an elevation in an enzyme called aromatase. This enzyme transforms testosterone to estrogen in the body. Secondarily, estrogen can indirectly cause an increase in a protein called sex-hormone-binding-globulin (SHBG), which binds to free testosterone and prevents its action. This protein will ultimately cause a decrease in testosterone.
At this point you should be asking "Does this apply to me or to my spouse/partner?"
There are theories that demonstrate that a decline in testosterone can cause a decline in mental function. In a study published in the Journal Of Clinical Endocrinological Metabolism in 2002, 407 men were studied ages 50-91 and subsequently demonstrated that those classified as having a low testosterone had lower scores on memory and visuo-spacial performance. The results of several pilot studies have tied low testosterone levels to Alzheimer's disease, in which there is a build-up of a toxic peptide called beta-amyloid. These studies showed that the toxic effects of this peptide are reduced by testosterone. Interestingly, testosterone levels were lower in Alzheimer's patients as compared to controls. It is unknown if these low levels cause or are caused by Alzheimer's disease. According to Dr. Jonathan Wright (co-author of Maximize Your Vitality and Potency), low testosterone levels are associated with moodiness, feeling weak, passivity, and reduced interest in one's surroundings.
In addition to having an effect on cognitive function, studies have shown correlations between a declining testosterone level and a decline in sexual function as measured by frequency of orgasm or intercourse or by sexual satisfaction (Journal of Clinical Endoclinology 1983). Studies also show that muscle mass, muscle strength and bone mineral density decline with age.
The first step in diagnosing andropause starts with a thorough evaluation at your physician's office. First, your doctor will obtain a complete medical history from you and perform a series of blood tests to see if you have testosterone deficiency and what may be causing it. Before starting any treatment, however, it is imperative to rule out underlying prostate cancer, just as we would rule out breast cancer in a woman contemplating estrogen therapy. The following are some examples of causes of low testosterone and approaches to them.
First, as discussed, in obese patients, there is excess aromatase enzyme activity causing the testosterone to convert to estradiol causing estrogen overload and testosterone deficiency. Poor liver function is another entity that causes excess estrogen because the liver then cannot detoxify the small amounts of estrogen that even men have. In this case, total testosterone levels would be normal and estrogen levels would be high as much of the testosterone is being changed into estradiol, and the free or usable testosterone levels would be low. This often occurs with excess alcohol consumption.
If you fall into the above category, you should maintain an appropriately high level of aromatase inhibitors in your diet. The recommendation is zinc 80mg daily. A supplement call chrysin, a flavonoid, together with piperine for enhance absorption into the bloodstream, functions as a mild aromatase inhibitor as well. There is a more potent aromatase- inhibiting drug called Arimidex (anastrozole), which can only be prescribed by your doctor. Arimidex is prescribed to estrogen receptor positive breast cancer patients to prevent hormones in the body from aromatizing into estrogen. It has not yet been FDA approved for other indications.
A diet that does not adversely affect liver function should be adhered to. This will of course include an alcohol-free diet, since even small amounts of alcohol are shown to augment estrogen in both men and women. Special attention should be paid to medications affecting the liver and should be reviewed with your doctor in detail. As estrogen excess may be a problem in the setting of liver dysfunction, a substance called indole-3-carbinol (or diindole methane or DIM)) found in special supplements or cruciferous vegetables can help to neutralize the excess estrogen. Most importantly, it is essential that you lose weight as it is the excess aromatase enzyme that is produced by the fat cells that convert the testosterone into the estrogen.
Second, an excess of sex-hormone-binding-globulin can bind much of the free- testosterone and therefore inactivates it. In this case, one will have low free testosterone, normal or even high total testosterone and normal estradiol levels. In addition to following the protocol that inhibits aromatase activity, take saw palmetto which can block the estrogen receptor sites in the prostate cells and therefore reduce the effects of excess estrogen. Saw palmetto also blocks the conversion of testosterone into a hormone, DHT, which has been directly linked to the development of prostate disease.
Methanolic extract of nettle can also inhibit SHBG. It binds to SHBG and therefore blocks its testosterone binding effects, thus allowing more testosterone to be in its natural free state. This root has also been used for benign prostatic hyperplasia. It inhibits the binding of dihydrotestosterone ( DHT), a prostate growth stimulator, to the prostate.
A third cause of low testosterone is failure of the pituitary gland to produce a hormone called leutenizing hormone (LH). One of the functions of LH is to stimulate testosterone production by the testes. In this case, the levels of total testosterone would be low as there is a problem with production.
Fourth, if the testes themselves lose their ability to produce testosetrone, there would be an elevated LH, which would act as a stimulant to produce testosterone. Total testosterone would be low. Patients like these are candidates for testosterone replacement.
Lastly, DHEA, a precursor hormone to testosterone and estrogen, may be low and worsen the consequences of borderline testosterone. The solution here is to supplement DHEA under a doctor's supervision.
Physicians have prescribed testosterone administered via creams, tablets, patches, lozenges and injections. Such preparations can lead to normalization of testosterone and improvements in muscle strength, libido, mood and bone density. They may also be associated with side effects, so care must be taken to use the right form of replacement and dosage. There is no "one size fits all" approach.
After initiating testosterone, during the first few months, some men may note effects seen in normal puberty, such as acne and gynecomastia. In men over the age of 50, worsening of prostate symptoms may occur, although sometimes they improve. If, however, the testosterone is not taken in excess and used to maintain a normal serum testosterone, there is no reason to believe that these men are more likely to develop these conditions than men who produce their own natural testosterone. Nevertheless, a PSA and a digital rectal exam and close monitoring of hormone levels must be adhered to.
Living Smarter, Living Longer
Dr. K
How Carbohydrates Elevate Cholesterol
Yes, carbs can indeed elevate cholesterol. This sentence is not a typo.
The Scenario
Assume that you have an unfavorable cholesterol profile (low HDL, high triglycerides and low LDL). The typical scenario is as follows: You have high cholesterol, you pursue a million dollar workup with your cardiologist, including a stress test, EKG, blood work, etc, and the ultimate recommendation is to follow the Dean Ornish Diet. This diet was based on a five year intervention study called the Lifestyle Heart Trial which followed 48 men with heart disease and told them to exercise, manage stress, stop smoking, get psychological help, and go on a high fiber low fat and low calorie diet. Of the 48 men, 20 actually completed the study, where all the recommendations were adhered to.
The results showed that there was actually some reversal of heart disease! The bottom line that was extracted from this study was that a low fat diet helps to reverse heart disease. Seldom were the other factors addressed. Since then, most patients have been advised by their cardiologists and internists to stay on a diet of this nature.
Thereafter, many have tried to comply with the low fat diet and noticed that cholesterol was not dropping. Hmmm… Let’s look at the science to figure this out.
I am going to break this one down to the nitty gritty details, so beware.
How Carbs Actually Elevate Cholesterol
You are eating your whole grain toast or dairy item in the morning with fruits, pasta for lunch and a rice dish with a protein for dinner. Your desserts are always fresh or dried fruits. You are drinking juices with your meals. Once the digestive juices are appropriately secreted and the food is churned, the necessary nutrients are absorbed through the intestinal walls. Glucose (derived from carbs), amino acids (derived from proteins), and fatty acids ( derived from fats) are passed through a corridor (the portal vein) and enter the liver.
The pancreas is paying very close attention to the molecules passing through this corridor into the liver. It gets quite excited when it sees glucose and quickly shows its affection by secreting insulin. Insulin does several things:
It stimulates the production of cholesterol. Many of you have heard of statin drugs. They work by inhibiting an enzyme called HMGcoA reductase. Insulin stimulates this enzyme! How can it be possible for your cholesterol to go down if the foods that you are eating stimulate the very enzyme that cholesterol reducing drugs are trying to decrease?
Insulin slows down an amino acid called carnitine. Carnitine is important because it functions to shepherd the fatty acids into the part of the cell where they will be converted into usable energy. Insulin can therefore harbor weight gain by not allowing the fatty acids to be converted into energy effectively, via the mechanism of carnitine.
Insulin causes cells in the liver, muscles and fat to take up glucose. In the liver, the glucose is stored as glycogen. Here is the interesting part… There is not that much glycogen in the liver, so whatever sugar the liver is unable to hold is spilled over to another processing system. The glucose is packaged neatly into triglycerides. Yes, the ones associated directly with cardiovascular disease. This was the bottom line, ladies and gents. VLDL (very low density lipoprotein ) is then stimulated by the liver and LDL, the bad cholesterol) is made. Whew!
When there is not much glucose in he body, as in the case in a lower-carb diet, there is no signal to release the insulin . Insulin is absent (or low), glucose is not taken up by the cells and triglycerides are not manufactured from the spillover of glucose. Therefore, the above process is not as robust. With low insulin levels, the body begins to use fat as an energy source since it does not have the glucose. Using fat as an energy source is one of the mechanisms of weight loss. Let’s pause for the “ahaa” moment.
So there it is, eat low carb and see the weight come off and cholesterol decrease. A common mistake is that patients eat BOTH low and high carb simultaneously. They also focus on meats that are not lean. They come into my office telling me about all the healthy proteins they have been eating. Only problem is that they are having tons or rice or pasta along with a small amount of fatty protein. Taking the above mechanism of action into consideration, this is truly counterintuitive,.
Please reread the mechanism several times. Once you understand it, you will be able to intelligently change your diet. Being informed is crucial.
I look forward to hearing about your dietary changes and how they improved or worsened your cholesterol.
Living smarter, living longer,
Dr. K
Genotyping Helps Docs Decide on Whether to Give Quercetin
Genetic typing has come a long way. In very select cases, we are able to know that certain patients may do better with a certain drug or chemotherapeutic agent depending on their genetic makeup. It is surprising to see a study that studies genetics and supplements.
A recent well-designed study showed that genetic testing can help nutritionally oriented physicians decide whether or not quercetin is beneficial to patients with metabolic syndrome. Remember that those with metabolic syndrome are at increased risk for cardiovascular disease as well as diabetes. According to the American Heart Association, metabolic syndrome is characterized by a group of metabolic risk factors in which include
- Abdominal obesity (excessive fat tissue in and around the abdomen)
- Atherogenic dyslipidemia (blood fat disorders — high triglycerides, low HDL cholesterol and high LDL cholesterol — that foster plaque buildups in artery walls)
- Elevated blood pressure
- Insulin resistance or glucose intolerance (the body can’t properly use insulin or blood sugar)
- Prothrombotic state (e.g., high fibrinogen or plasminogen activator inhibitor–1 in the blood)
- Proinflammatory state (e.g., elevated C-reactive protein in the blood)
In a randomized, double-blind, placebo-controlled, 93 patients who took 150mg of quercetin were studied. Different results were found depending on their genetic profile. Those who were Apo E 3 + were found to have a decrease in systolic blood pressure by 3.4 mm Hg. This was not found in subjects with the apolipoprotein (apo) E4 allele.
There was a decrease in the good (HDL) cholesterol and an increase in the LDL:HDL ratio in the apo E4 subgroup. This is certainly not an effect that we are striving for with supplementation. Fortunately, no such change was found in the apo E3 subgroup.
In both the apo E3 and E4 groups, quercetin significantly decreased plasma oxidized LDL and tumor necrosis factor-alpha, a marker of inflammation.
This study was too small for us to draw broad conclusions of the use of quercetin. It does, however, demonstrate that genotyping may have a role in the routine prescribing of supplements.
Note that quercetin may not be used with antibiotics that are in the category called flouroquinolones. Quercetin binds to bacterial DNA gyrase, the sight where floroquinolones work. Quercetin may also slow down the rate at which certain medications leave the system... allowing the medication to linger in the body.
I look forward to hearing about your experiences with genetic testing.
Sources:
"Serum lipid and blood pressure responses to quercetin vary in overweight patients by apolipoprotein E genotype," Egert S, Boesch-Saadatmandi C, et al, J Nutr, 2010, 140(12): 278-84.
Maximizing Health and Well-Being While Flying: Introducing the Flight Pack, Dr. Kroner
As a nutritionally-oriented internist, I have seen air travel take quite a toll on the health and well-being of many of my friends and patients. With the excitement of traveling to a new destination, the new food, the change in schedule, the stress, the hassle; it is easy to neglect one’s health. My patients are frequently asking me for health travel advice. While practicing in a city where both business and leisure travel are staples in the lives of many of my patients, I have developed a nutritional and lifestyle plan to help optimize health while traveling.
Drink 2 large glasses of water on an empty stomach in the morning of travel. This will hydrate you effectively. Have a high protein breakfast.
Stress plays a significant role in air travel. Aside from a healthy diet, restorative sleep, regular exercise, and the addition of key nutritional supplements to the regime are helpful. One mineral that helps to combat stress is magnesium. It is one of the first nutrients to be depleted in the setting of stress. Your adrenal glands depend on magnesium, as do over 300 different enzyme reactions in the body. I recommend my patients take 100mg of magnesium-taurate the morning of the flight, and then another 100mg just before the flight.
It is not uncommon for travelers to contract a respiratory infection, the flu, or other infection while flying. The poor air circulation in the cabin compounded by the proximity to other passengers who may potentially be sick poses a double threat. Those with weak sinuses are at a heightened risk, as well, due to the periodic changes in air pressure. Washing hands and using hand sanitizers in the plane may be of benefit. Hydration and optimal nutrition are integral components, as well. I recommend my patients take several key nutrients to help boost the immune system in the setting of travel. I recommend taking oleuropin before the flight, which is the active ingredient in the olive leaf that has potent antibacterial, antifungal, and antiviral properties. In addition, beta 1,3 glucans and the prickly pear are cutting edge nutrients that I recommend that have been studied for their anti-microbial effects. Vitamin C and a combination of immune boosting mushrooms, such as cordyceps, reishi, and maitake, may help to prevent colds and other respiratory ailments in flight.
Boosting the immune system by addressing the gut is essential. It is an established fact that over sixty percent of the immune system is in the gut, referred to as the gut associated lymphoid tissue (GALT). In addition to a healthy diet, intake of a probiotic (beneficial gastrointestinal flora) is imperative to optimizing function. I strongly recommend taking a probiotic a week before the date of travel and to continue for a week thereafter.
Constipation is common in the setting of travel. The change in food, regime, stress level, and diet are contributors to this phenomenon. Probiotics can help deal with this. Magnesium plays a crucial role as well, being that it is a muscle relaxor that can relax the muscles of the colon wall and therefore improve regularity. Hydration, exercise and healthy fiber intake are important as well.
It is not uncommon to get a muscle cramp during the flight. Magnesium, a natural muscle relaxer, can help to prevent this. Be careful, because what feels like a cramp may actually be a blood clot. I highly recommend taking natural supplements that improve circulation before the flight. Natural vitamin E and omega-3 fish oil have been shown to optimize the cardiovascular system. Their mild blood thinning effect may help to prevent a clot. I also recommend the use of nattokinase for clot prevention. There is a lot of research supporting nattokinase’s role as an anti-clotting agent. It is an enzyme extracted from natto, which is derived from fermented soybeans.
To make it more user-friendly, I have put together all the supplements described above into prearranged packets. I have blended the highest quality nutrients into the “Flight Pack,” the only physician-grade supplement pack on the market used to optimize health and well-being while flying. I hope you find them helpful. Take one packet with a meal before your flight. Each Flight Pack contains 8 supplements. If it is okay with your physician, you can take this packet daily while traveling. Do not take if you are pregnant, are taking a blood thinner, have kidney or liver disease, or a bleeding disorder. Living smarter, living longer… (The product can be ordered online at www.advanced-medicine.com/our_products.html)
Enjoy your journey.
Dr. K
Winter Update
I hope this Winter Update finds you in good health. There are a few key updates I wanted to bring to your attention.
To start off... on a humble note, I was published in a peer-reviewed journal called Alternative Medicine Review. The article is entitled "The Relationship between Alzheimer's Disease and Diabetes; Type 3 Diabetes?" The PDF will be on my website soon. This information is quite revolutionary.
Advanced Medicine now has the capability to test patients for hereditary cancer risk. Genetic mutations dramatically increase the risk of developing cancer. Fortunately, it is possible to test for certain genetic markers in order to establish if you are at heightened risk. Knowing what your genetic predisposition is allows you to take steps early on to help with prevention planning. Check out my detailed blog on this.
I wanted to thank many of you for the excellent feedback you have given us regarding the automatic submissions of the paid medical bills to your insurance companies. We recognize that it makes life easy for you and we are happy to provide this free service. For the most part, it has been working quite efficiently. We are still ironing out some glitches in a few select cases. Hang in there!
The newly revised batch of "Living Smarter" and the popular "Seasonal Support" has arrived. Many of my patients have benefited immensely from the physician's grade packs. I take them daily myself. Check out my website www.advanced-medicine.com/our_products.html for a detailed overview if you are not yet familiar with the products.
Many of my previously labeled "chronic fatigue" and "fibromyalgia" patients have been free of this label since initiating their treatment protocols. This shows how important it is to unearth the etiologies of diseases and stay away from labels. These patients no longer have to be suffering with fatigue and are totally free of pain meds.
Living Smarter... Living Longer...
Stay Well, Dr. Zina Kroner
Hereditary Cancer Screening Has Evolved into Preventive Care
Advanced Medicine now has the capability to test patients for hereditary cancer risk. Genetic mutations dramatically increase the risk of developing cancer. Fortunately it is possible to test for certain genetic markers in order to establish if you are at heightened risk. Knowing what your genetic predisposition is allows you to take steps early on to help with prevention planning.
There are several genetic tests that can be assessed for in my office using the technology of a testing company called Myriad (www.myriadtests.com). I am now able to assess your risk profile for the following genetic predispositions:
1. Colorectal Cancer
- Lynch Syndrome: If you have a personal or family history of colorectal and/or endometrial (uterine) cancer, the disease may come from an inherited genetic condition known as Lynch syndrome. Lynch syndrome is an inherited tendency to develop certain cancers, making your risk of cancer much higher than average. Families with Lynch syndrome usually have 2 or more members who develop colorectal, endometrial, ovarian, or other cancers often before age 50. COLARIS® is a test to find out if you have Lynch syndrome. Lynch syndrome is also alled Hereditary Nonpolyposis Colorectal Cancer syndrome (HNPCC).
- FAMILIAL ADENOMATOUS POLYPOSIS (FAP): This is a hereditary syndrome that is caused by mutations in the adenomatous polyposis coli (APC) gene and characterized by hundreds to thousands of adenomatous polyps throughout the colon. Polyps are almost inevitable and tend to occur at an early age. Without intervention, nearly all patients with FAP will be diagnosed with colorectal cancer by age 50. Most of these patients are also at risk for developing adenomatous polyps and cancer in the upper GI tract.
- ATTENUATED FAMILIAL ADENOMATOUS POLYPOSIS (AFAP). This is a hereditary syndrome caused by mutations in the adenomatous polyposis coli (APC) gene that is associated with much lower numbers of polyps than classical FAP (usually 10-99 cumulative adenomas). Polyps are often found in the proximal colon (right side), with average age of onset later than classical FAP. Polyps are common in upper GI tract (stomach and duodenum), with an increased cancer risk in these areas.
- MYH-ASSOCIATED POLYPOSIS (MAP). This is a hereditary syndrome characterized by multiple polyps, ranging from a few thundreds and has an autosomal recessive pattern of inheritance.
2. Breast/Ovarian Cancer
- BRCA1 or BRCA2 genes: Approximately 7% of breast cancer and 11 - 15% of ovarian cancer cases are thought to be associated with an autosomal dominant pattern of inheritance ofBRCA1 and BRCA2 gene mutations.
- Normally, the proteins encoded by BRCA1 and BRCA2 genes prevent cells from becoming malignant by helping to repair mutations that occur in other genes—making them tumor suppressor genes. But an inherited mutation within either of these genes greatly increases the probability of malignant transformation and cancer.
- The association of BRCA1 and BRCA2 mutations primarily with breast andovarian cancer is not yet fully understood, but is thought to be related to estrogen receptor expression in these tissues.
2. Skin Cancer / Pancreatic Cancer
- MELARIS® testing may help you understand the cause of the melanoma and/or pancreatic cancer that runs in your family. Knowing you carry a gene mutation related to hereditary melanoma and/or pancreatic cancer guides decisions and actions that may reduce cancer or detect it in an earlier, more treatable stage.
- Melanoma: There are about 62,000 new cases of melanoma in the United States each year—and the incidence is increasing. Approximately 10% of cases are hereditary, and may have a strong link to the development of pancreatic cancer.
- Family linkage studies identified an autosomal dominant melanoma gene located on chromosome 9p21.
- This gene, called p16 (also known as CDKN2A, INK4A, or MTS1), accounts for up to 40% of hereditary melanoma cases. p16 is a tumor suppressor gene involved in regulating cell growth. Mutations in p16 that disrupt its function lead to unregulated cell growth. In the United States, p16 mutations are likely responsible for 1000-2000 new melanoma cases each year. p16 mutations account for the majority of known genetic causes of inherited melanoma cases.
Limitations of Testing
- Testing does not detect all causes of hereditary cancer
- A negative result is most helpful when there is a known mutation in the family
- Some variants are of unknown clinical significance
Once you know…
- A positive result allows you to immediately help reduce your risk of a first or second cancer by earlier and more frequent screening and other preventive strategies.
- In some cases risk may be eliminated through preventive surgery.
- Healthcare professionals can use the information to guide their plan for medical or surgical treatment.
- Results for one family member can give other members important information about their own level of risk.
I look forward to your queries. Also, check out www.myriadtesting.com.
Stay Well,
Dr. Kroner
P.S. The newly revised "Living Smarter" Packs are now in... We also just received a new batch of "Seasonal Defense."
Living Smarter... Living Longer.
Finally, Acceptance of Modern Day Allergy Treatment - Sublingual Immunotherapy Revisited
Sublingual Immunotherapy(SLIT) has been used successfully for many years, but has often been shunned by ultra-conservative allergists and immunologists who state that the treatment is not as precise as allergy shots. Allergy shots require multiple office visits and are therefore a substantial source of income for allergists.
SLIT is more user-friendly for the patient as it is administered painlessly at home by the patient via drops, thereby foregoing the needs for injection therapy. Finally, however, SLIT may now be embraced by the more traditional allergist being that the World Allergy Organization issued a “Position Paper”, reported in the November issue of the World Allergy Organization Journal, which was co-published as a supplement to the December 2009 issue of Allergy.
Being that large well run clinical trials have confirmed the efficacy and safety of SLIT, the World Allergy Organization has decided to offer a consensus statement on its use based on currently available evidence and expert opinion. After evaluating many well designed studies, it has been suggested that high-dose, sublingual, specific immunotherapy is effective. Some of the patients who qualify for SLIT include those with: allergic rhinitis, conjunctivitis, and/or asthma caused by pollen and/or house dust mite allergy. It is important to note that, SLIT may now be considered an initial treatment strategy for many. In addition, failure of pharmacologic treatment is not required before starting therapy.
The following are the recommendation by the World Allergy Organization for starting immunotherapy (source: medscape & World Allergy Organization J. 2009;2:233-281.)
- There should be the presence of a demonstrated immunoglobulin E (IgE)–mediated disease, with positive skin test results and serum-specific IgE to an allergen concordant with clinical symptoms.
- There should be documentation that the symptoms can be explained by specific sensitivity, based on appearance of symptoms related to exposure to the allergen(s) identified by allergy testing. Optional confirmation may include allergen challenge with the relevant allergen(s).
- Severity and duration of symptoms should warrant use of SLIT, with confirmation from objective parameters such as missing time from work or school. For rhinoconjunctivitis, patients should have subjective symptoms of sufficient severity and duration. For asthma, the control questionnaire should not show uncontrolled asthma, and pulmonary function testing is required to exclude patients with severe asthma. Pulmonary function should be monitored during therapy.
- SLIT therapy should only be started in settings where standardized or high-quality vaccines are available. Only specialists should prescribe specific immunotherapy. Subcutaneous immunotherapy should be administered only by physicians trained to manage systemic reactions if anaphylaxis occurs.
- Although SLIT is administered at home, patients should be educated regarding possible risks and how to control adverse effects that may develop.
- Patients with single allergen sensitivity are more likely to benefit from specific immunotherapy vs. patients sensitive to multiple allergens, but more data are needed in this area.
- Specific immunotherapy will not benefit patients with nonallergic triggers.
- For safety reasons, asthmatic patients must be asymptomatic when receiving SLIT injections. Asthmatic patients with severe airways obstruction are more likely to have lethal adverse reactions.
- To maximize the efficacy and safety of SLIT in asthmatic patients, forced expiratory volume in 1 second with pharmacologic treatment should reach at least 70% of predicted values.
With the above in mind, getting ready for the spring and summer allergy seasons could be an easier endeavor with SLIT as opposed to weekly injections. I use Allergy Choices (www.allergychoices.com) as a source of well calibrated immunotherapy drops. I prefer to outsource this as they are superb at what they do. When doctors who are not allergists and their staff, mix allergy drops themselves in the office, there may be too much room for error, as they are not regulated. Having experienced both systems, I personally found that the mixtures are more reliable when they come from a well established allergy company.
Feel free to submit a comment about your experiences with either SLIT or injection therapy.
Don’t Delay Use of CoenzymeQ10 in Parkinson’s Disease
The National Institute of Health is currently conducting a study to evaluate the safety and effectiveness of high dosages of Coenzyme Q10 in slowing clinical decline in people who have early Parkinson disease (PD). The researchers intend to test 1,200 and 2,400 milligrams coq10 in the form of a chewable wafer containing vitamin E, to be administered for 16 months to PD patients at 60 centers in the United States and Canada. Participants will be evaluated for tremor, stiffness of the limbs and trunk, balance and coordination, speed of movements, ability to perform daily activities, quality of life, and the need to take medication. Many PD patients are hoping that this study pans out in their favor being that coq10 is a safe product they could use without it interfering with their other PD medications.
Adding Weight to an Excellent Prior Study
This study is intended to add weight to a study, published in 2002 in the Archives of Neurology, showing that 1,200mg of coq10 given to PD patients for 16 months had a 44 percent less decline in mental function, motor (movement) function, and ability to carry out activities of daily living, such as feeding or dressing themselves. Those were astounding results which would have received more press if the compound used was a medication. Since this study, many neurologists have embraced the utilization of high dose coq10. Some, however, are waiting for confirmatory research. Hopefully this confirmatory research is around the corner with this new trial.
The Rationale behind why Coq10 May Help PD
It has been shown that patients with PD have a deficiency of a neurotransmitter called dopamine. There is also evidence of a reduction in mitochondrial activity in the dopaminergic neurons. It has been shown that coq10 improves energy production via the mitochondria, which are the energy-producing organelles of the cells. Studies have shown that PD patients have reduced levels of coQ10 and coq10 may have a protective effect in the area of the brain that is damaged by the disease. Coq10 is imperative for the proper functioning of mitochondria which are reduced in the neurons important for dopamine signaling.
Therefore, I urge all my PD patients to have their coq levels checked and to initiate coq10 use.
Waiting for Confirmatory Research?
Parkinson’s patients do not have time to wait for confirmatory research of a product that has already proven itself to be quite safe. This treatment strategy can potentially slow down the degenerative process of PD, as opposed to simply covering up the symptoms. Most PD patients are managed with medications and watch themselves slowly spiral down and deteriorate neurologically. Waiting for confirmatory research on a product that they probably should have already been advised to use by their neurologist may not be medically sound. Coq10 is safely being used in patients with the neurodegenerative disorder called Huntington’s Disease with some success as well.
Drawbacks
Coq10 has some drawbacks. First, patients on coumadin (warfarin) may need to have their dose readjusted as it may make the coumadin somewhat less effective. Second, patients have to be wary of the suppliers of coq10 as the quality can vary considerable from company to company. I usually recommend a more bioavailable version of to my patients, called ubiquinol and urge the use of physician’s grade supplement companies. Third, coq10 is quite expensive. Fourth, the study results do not extend to people in later stages of PD or to those who are at risk but have not been diagnosed with the disorder.
** Let’s hope that his new study brings forth sound medicine. Let’s not lose sight of the fact that there are currently many other safe natural treatment strategies being employed in PD patients; such as intravenous glutathione. Please discuss how to employ them together with your medications with your nutritionally oriented physician
Citations:
Shults CW et al. Effects of coenzyme Q10 in early Parkinson disease: Evidence of slowing of the functional decline. Arch Neurol 2002 Oct; 59:1541-50.
http://clinicaltrials.gov/ct2/show/NCT00740714?term=coenzyme+q+10&rank=1
An Experienced Doula’s Tips for a Holistic Pregnancy and Birth
I wanted to share the tips of an experienced NYC doula with you. Please pass it along to expecting mothers.
Andrea Crossman, founder of Holistic Doula NYC, is a holistic RN, doula, and former labor and delivery nurse in NYC. Below, she shares her pregnancy and birthing tips for our glorious Mommazons-to-be:
"We have a secret in our culture, and it’s not that birth is painful. It’s that women are strong. -Laura Stavoe Harm
Last night I supported one of my doula clients through a natural birth and I’m still buzzing with post-birth energy. This Mama took an evening prenatal yoga class from 6:30 - 8:00, and was apparently in labor the whole time without fully realizing it. Four hours and fifteen minutes after rolling out of Savasana, she gave birth to her first baby. During her pregnancy, she was a regular at her yoga class and took the right supplements. During her labor, she sipped on coconut water and used hydrotherapy, multiple positions, and focused breathing to manage her pain. All of these holistic practices played a role in her healthy transition into motherhood. In an effort to share the tips and resources I give my doula clients with even more holistic mamas-to-be, I’m teaching a Truly Holistic Pregnancy and Childbirth Series at the New York Open Center in January. When I learned that Girlie Girl Army’s Chloé Jo is sporting her own beautiful baby bump, I wanted to give her and the rest of Girlie Girl’s hot mamas a sneak peek at some of my best and perhaps less well known tips for a holistic pregnancy and birth. Because everyone already knows to lay off the bad habits, get enough sleep, and take prenatal vitamins with folic acid, right? Onward!
CHOOSE YOUR TEAM WISELY
Find a provider who shares your philosophy about health, wellness, pregnancy, and birth. In New York City, it is typical to choose a homebirth midwife, a midwife practicing in a hospital, or an obstetrician (Ob/Gyn) to provide your prenatal care and attend your birth. My perspective from working with hundreds of laboring women is that your choice for Team Birth is far and away the most important factor in having an experience you feel good about. You also need to know that if your midwife or obstetrician is part of a group practice, it may be one of her/his partners who is actually on call when you deliver. So make sure you research, meet, and feel good about everyone in your chosen provider’s practice.
GET A DOULA
And I’m not just saying that because I am one. When I was a labor and delivery nurse I was awfully doula-ish, but with all of my responsibilities-other patients, charting, sometimes setting up the OR-it was impossible for me to offer the continuous emotional, physical, and informational support a doula does. Also, as a doula I meet women and their partners in their homes for weeks before the birth. I help them pack their labor bags (or prepare for home birth), make sure the ice pack is chilling in the freezer, and may even fire up the blender and teach them how to make a glow-getting green smoothie. This kind of relationship is totally different than one with someone you meet in the midst of transition and hee-hee-who breathing. Studies show that women who have the continuous support of a labor doula have significant reduction in the rates of cesarean deliveries, epidurals, and failed inductions, and a significant increase in feelings of satisfaction with their births.
SUPPLEMENT WITH C
Vitamin C plays a critical role in the formation of collagen, the building block of tissue. Therefore, optimum levels of vitamin C may help support the skin of your growing breasts and belly. Vitamin C is good for what’s going on inside your belly too. Some studies indicate that there is a relationship between low levels of vitamin C and premature rupture of the membranes (PROM), which is medical-speak for having your water break too soon-meaning increased risk of infection and prematurity. These studies show that the amount of Vitamin C in most prenatal vitamins is sufficient to protect yourself, though it’s safe to go up to 1000 mg daily.
VITAMIN D: CHECK IT AND TREAT IT
The latest research on Vitamin D tells us that this essential nutrient is protective of just about everything. Seriously. Everything. Unfortunately, we’re almost all deficient in this wonder vitamin, a deficiency that may begin in utero. Prenatal vitamin D deficiency may play a role in increased rates of cesarean delivery, preeclampsia, gestational diabetes, and bacterial vaginitis. Risks to the child long-term relate to brain and immune system function. I talked to Dr. Zina Kroner, Medical Director of New York City’s Advanced Medicine, about vitamin D in pregnancy. She referenced a study at the University of Pittsburg that analyzed 400 pregnant women and found 63% of them to have vitamin D levels below 30 ng/mL (levels should be between 50 - 80 ng/mL) including 44% of black women with levels below 15 ng/mL. Based on this widespread deficiency and its potential harm to mother and child, Dr. Kroner told me “checking a prenatal patient’s vitamin D levels is imperative.” When I asked her about cost, she said “insurance will cover the cost if the right diagnostic code is provided. Even if the patient lacks insurance, the cost is approximately $150 at a private lab and labs will usually give a 50% discount if they know that a patient does not have any insurance.” Dr. Kroner believes that “knowing what the level is allows a nutritionally oriented physician to prescribe a more exact dose of vitamin D and decrease the likelihood of undershooting.”
Vitamin D supplementation is probably the most practical way to get your vitamin D, but heading to a tropical beach in the middle of a New York winter is a lot more fun. So if you’re thinking about taking a babymoon, tell your honey that you have to go somewhere warm (nurse’s orders). Your body will produce about 10,000 IU of vitamin D after 20 - 30 minutes of midday sun exposure. Two things to remember for this kind of medicine: don’t burn, and you must expose as much of your skin as possible. Pregnant and topless on the beach? Good and good for you.
STAY JUICY
Coconut water is the new Gatorade. It’s my number one labor beverage recommendation because it’s super hydrating and loaded with electrolytes. The fresh coconut water at New York’s Organic Avenue is hands down the tastiest I’ve ever tried, but Zico (I prefer the mango) or other brands at the grocery store are just fine too. Fresh is, of course, best. You can pick up fresh coconuts at just about any health food store or Whole Foods anytime of year. Learn how to open them easily by watching this short video. Throughout pregnancy, in addition to pure water and coconut water, I also recommend green juices and smoothies, especially those containing celery and cucumber, which may contribute to glowing skin due to their high silica content. Silica also stimulates tissue healing, which can help speed recovery from both vaginal and cesarean deliveries.
Why is hydration extra important during pregnancy? For a lot of reasons actually, let me share two of them. The first is that dehydration can cause uterine irritability. What this usually means is that you feel like you’re in labor, but you really aren’t. So you go the hospital, wait endlessly in triage to be seen, only to be put on an IV and sent home an hour later. Save yourself the trip and keep on top of your fluid intake. The second reason is that if you partake in the conventional medical tests, toward the end of your pregnancy you will likely be sent for Biophysical Profile testing. One of the things this test can indicate is low amniotic fluid levels. Critics contend that the test isn’t all that accurate in terms of measuring amniotic fluid and some believe this can lead to unnecessary inductions. There is good reason to believe some cases may simply be dehydration. Make sure you drink up an hour before your appointment to decrease the chances of this scenario.
I hope these tips help support your holistic pregnancy and birth, and I wish all of the Girlie Girl Army mamas happy, healthy, and peaceful new beginnings.
For information about Andrea’s upcoming childbirth education class, Truly Holistic Pregnancy and Childbirth Series, at the New York Open Center, visit Holistic Doula NYC (http://www.holisticdoulanyc.com). There is early bird pricing for registrations in 2009. In addition to Andrea’s work as a holistic RN and doula, she is also the co-founder of Lovemore (http://www.chooselovemore.com), a love-infused green fashion line."
Decadent Recipes that are Grain, Sugar, Starch and Dairy free
The author of the book, Cooking for Celiacs, Colitis, Crohn's and IBS, Sandra Ramacher, put together a nice newsletter of recipes for the Holiday Season. I thought you may appreciate these decadent sweets which are all grain free, sugar free, starch free and dairy free AND are actually delicious.
Pumpkin and Coconut Pie
Serves 6-8
Pie Crust
200 g (2 cups) almond meal
1 tsp baking soda
100 g (? cup) honey
1 egg
1 Tbs ground cinnamon
1 Tbs ground ginger
1 Tbs ground cloves
Preheat the oven to 150°C/300°F
Lightly oil a 27.5 cm/11 inch round pie dish
Combine the almond flour with the baking soda. In another bowl, mix the honey, egg and spices together. Then combine with the almond flour and knead into firm dough. Refrigerate covered for at least 2 hours. Take out the dough and roll out the dough between two sheets of waxed baking paper until about 2 mm thick. Invert the baking paper over the pie dish and press the dough into the dish. Bake in preheated oven for 15 minutes. Turn off oven after the 15 minutes and let the oven cool down to about 50°C/120°F. Close the oven door and let the pie crust sit in the oven for at least an hour or until it is firm to the touch. Take it out of the oven and let it cool down.
Pie Filling
500 g Pumpkin (peeled, seeded and cut into chunks)
1 egg plus 1 yolk
50 g (2 oz) honey
½ tsp ground cinnamon
¼ tsp freshly grated nutmeg
¼ tsp ground allspice
¼ tsp ground cloves
¼ tsp ground ginger
½ cup coconut cream
Bake the pumpkin in a covered dish in the oven 30 minutes, or until the pumpkin is soft. Mash the pumpkin in a food processor. Add the spices and mix. Place the coconut cream into a small pot and warm on medium. Add the egg, egg yolk and honey and stir until well blended. Do not boil. Remove from heat and combine with the pumpkin. Glaze the pie gazing thinly with honey and then pour the filling into the pie casing and bake for 45 minutes until the top feels firm to the touch.
Note: To avoid the edges of the pie-crust darkening too much cover the edges with aluminum foil, which you can remove when the pie is done. Remove from the oven and refrigerate until serving time.
Holiday Pudding
Serves 8 - 10
200 g (1 cup)dried dates
200 g (1 cup) dried figs
200 g (1 cup) dried prunes
120 ml (½ cup) boiling water
100 g (1 cup) pecans
100 g (1 cup) blanched almonds
250 ml (1 cup) grape juice
60 ml (¼ cup) fresh orange juice
120 ml (½ cup) bourbon
2 egg yolks
200 g (1 cup) sultanas
1 Tbs grated orange rind
200 g (2 cups) almond flour
½ tsp ground cinnamon
¼ tsp ground cloves
¼ tsp ground nutmeg
Place the dried dates, figs, prunes, hot water, pecans, almonds, grape juice, orange juice, bourbon and egg yolk into a food processor and process the mixture until chopped and well combined. Remove from the processor into a large bowl and add the sultanas, orange rind, almond flour, and spices. Mix well and then pour the dough into a 1 – 1 ½ liter/2 ½ pint pudding dish. Cover the dish well with baking paper and foil. Place into a large pot with water so the level reaches ²⁄³ of the way up the pudding dish. Cover and steam for 6 hours. Add more water as required, to maintain level. Remove from the heat and let cool for 10 minutes. Then remove pudding and either serve immediately with custard, or freeze for up to six weeks. Pudding can be reheated the next day, as well, in the oven or microwave.
Almond Milk Custard
Serves 6
500 ml (2 cups) almond milk
5 eggs - whisked
100 g (¹⁄³ cup) honey
1 tsp vanilla essence
To make the almond milk, combine 150 g (1 ½ cups) almond meal with 750 ml (3 cups) of water in a food processor and process for 3 minutes. Line a sieve with four layers of kitchen cloth and pour in the almond mixture. Let drain, squeezing out as much milk as possible.
Preheat the oven to 150?C/300?F
Combine the almond milk, eggs and vanilla essence in a medium size pot and heat, whisking constantly. Do not boil. Simmer stirring until custard thickens., then remove from heat and pour into the ramekins. Remove from the oven and place the custards into the refrigerator for at least 3 hours before serving. At serving time, mix the custard with a fork to loosen it and pour over Christmas Pudding.
Ginger Holiday Biscuits
Makes about 40
500 g (5 cups) almond flour
1 tsp baking soda
300 g
(1 cup) honey
1 egg
2 Tbs ground cinnamon
2 Tbs ground ginger
2 Tbs ground cloves
Preheat the oven to 150°C/300°F
Line a baking tray with baking paper
Combine the almond flour with the baking soda. In another bowl, mix the honey, dark honey, egg, and spices together. Then combine with the almond flour and knead into firm dough. Refrigerate covered for at least 2 hours. Take out the dough and roll out the dough until about 2 mm thick. Take a shaped biscuit cutter and dip in cold water and cut out as many shapes as possible. Gather the left over dough and refrigerate until ready to use for the second batch. Place all the biscuits onto the lined baking tray and bake for 15 minutes. Turn off oven and open the door until it has cooled down to about 50°C/120°F. Then close the oven door and let biscuit crisp up for at least 1 hour or until they are crunchy. Let biscuits cool completely before storing in an airtight jar. To decorate, simmer ? cup of honey for 8 minutes on medium. Glaze biscuits with the honey and sprinkle with desiccated coconut.
Elaine’s Vanilla and Lemon Lollipops
120 ml (½ cup) water
450 g (1 ½ cups) honey
1 tsp vinegar
1 tsp lemon zest
1 tsp vanilla essence
Heat the honey with the vinegar and lemon zest in a large pot. Simmer gently for 10 – 12 minutes, or until honey hardens when dropped onto a cold surface. Take from the heat and stir in the vanilla essence. Place the lollipop sticks onto baking paper and drop 1 ½ teaspoons of honey onto the top of the stick. Let cool and refrigerate, later covering them with cellophane. Keep refrigerated.
Candied Walnuts
450 g (1 ½ cups) honey
½ tsp ginger
1 Tbs grated orange rind
1 Tbs fresh lemon juice
400 g shelled walnuts
Heat the honey with the orange rind and the lemon juice in a large pot. Simmer gently for 10 – 12 minutes, or until honey hardens when dropped onto a cold surface. Stir in the walnuts and stir for a few minutes more. Then line a tray with baking paper and pour walnut mixture onto the paper, spreading it evenly. Let cool, then separate into small pieces. Keep refrigerated.
Sesame Snaps
400 g (1 ? cup) honey
3 cups hulled white sesame seeds
1 tsp grated lemon rind
Heat the honey with the lemon zest in a large pot. Simmer gently for 10 minutes, then add the sesame seeds and keep simmering until the seeds start to slightly turn brown. Remove from heat and pour onto a tray lined with baking paper. Spread the mixture evently, about ¼ inch high. To do this place another piece of baking paper on top and then roll evenly with a rolling pin. Then refrigerate and after 2 – 3 hours peel off the top layer of the baking paper and cut sesame snaps into small pieces. Keep refrigerated.
Pecan Caramel Toffees
Makes about 40
300 g (1 cup) honey
240 g (1 cup) nut butter*
80 g (¾ cup) pecans – chopped
*use cashew butter, peanut butter or macadamia butter. Any nut butter is fine, as long as it does not contain any additives like sugar.
Place the honey into a medium sized pot and bring to boil. The honey will froth up, turn down the heat and keep simmering for about 8 minutes. Turn off the heat, add the nut butter and chopped pecans. Remove the pot from the oven and let cool for about 10 minutes. Place 1 tsp of the toffee into candy cups and refrigerate. Eat at room temperature.
Almond Milk Eggnog
1 ltr (4 cups) almond milk
6 eggs
1 tsp cinnamon
½ tsp nutmeg
2 tsp vanilla essence
½ cup brandy (optional)
Mix all ingredients together in a mixer until frothy. Refrigerate and serve cold.
I welcome your feedback!
Happy Holidays! May this season bring you laughter and health!
Best, Dr. Zina Kroner
