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Dr. Kroner Featured in Renew Magazine

Zina Kroner — 2012-02-27T21:58:35Z

Dr. Kroner was featured in Renew Magazine for her expertise in sublingual immunotherapy as a form of non-invasive allergy treatment. Check out the article: http://www.janicearenofsky.com/2-19-2012_11_14_01_AM.PDF

Learning point: Mechanism of Sublingual Immunotherapy

Sublingual immunotherapy, or allergy drops, work similar to allergy shots by slowly helping you build tolerance to the substance(s) that cause your allergic reactions. The difference is that the antigen is placed under your tongue in a liquid form, as opposed to injected into body with a needle.

This area under the tongue is referred to as the sublingual mucosa, and it has the highest concentration of antigen/allergen presenting cells found anywhere within the body. This cell, called the dendritic cell, is responsible for either determining allergen tolerance or a state of allergy. By manipulating this cell with daily allergy drops, the body begins to develop a tolerance to the things that cause allergic reactions.

Much like allergy shots, allergy drops help build the body's tolerance to an allergy. Over time, this tolerance to the offending allergen results in fewer symptoms and medication needs, and can change the underlying allergic disease. This is a great option for chronic allergy sufferers who do not want the hassle of getting weekly allergy shots. They are able to do this at the comfort of their homes but under the supervision of a physician. I test my patients for allergies via blood test and formulate the SLIT based on that.

Dr. K

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Diet Soda Intake Linked with Adverse Vascular Events

Zina Kroner — 2012-02-03T00:47:04Z

"Vascular events" have now been added to the widely known laundry list of ill-effects of diet sodas. An eye-opening study published in the Journal of General Internal Medicine shows that individuals who drink diet soft drinks on a daily basis may be at increased risk of suffering vascular events such as stroke, heart attack, and vascular death.

Researchers from the University of Miami Miller School of Medicine and the Columbia University Medical Center studied the soda-drinking habits of 2,564 people in a multi-ethnic, urban population over a 10-year period, and discovered that daily drinkers had a 43 percent higher risk of having a vascular event than non-drinkers.

In today's fast paced climate, where zero calorie sodas find their way in many people's daily lives as an assumed healthier alternative to sugary drinks, many are disregarding much solid evidence showing that diet sodas are associated with multiple side effects.

The Ingredients:

Caffeine is quite dehydrating. For every ounce of soda, one needs 2 ounces of water to handle the toxin level. Caffeine causes irritability and palpitations in some. Caffeine elevates cortisol levels which contributes to weight gain, metabolic syndrome and diabetes. It is addictive in nature and depletes B-vitamins, especially B1 (thiamine). Fatigue, nervousness, general aches and pains, and headaches are all symptoms of a low B1 level. This level can be assessed by your physician. It contributes to a general malabsorptive state, and therefore depletes a variety of minerals as well, leading to fatigue and muscle cramps.

The FDA granted aspartame, which is 200 times sweeter than sugar, a "generally recognized as safe" status, or GRAS. It is composed of two amino acids Â– phenylalanine and aspartic acid, and contains 10% methyl alcohol, a light volatile flammable liquid alcohol used as a solvent and anti-freeze. It is a known neurotoxin.

Saccharin is quite dangerous as well. It is a non-caloric petroleum derivative and is 300 times sweeter than sugar. It is excreted unchanged in the urine being that is is not modified by the body.

Phosphoric acid's acidic nature dissolves calcium out of the bones. Caucasian women in particular have been shown to suffer from osteoporosis in the setting of high phosphoric acid intake (soda & coffee).

In spite of this study and prior research on the ill-effects of diet drinks, the diet soda industry is not going downhill after this study, especially being that soft drinks in general account for more than a quarter of all drinks consumed in the United States.

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Latest Fish Facts

Zina Kroner — 2012-01-30T23:39:17Z

Two "oMEGA" important studies hit the big medical scene this week. The stage is dementia and cholesterol.

The first one was a 20 year long study of 260 subjects which showed that those who ate baked or broiled fish once a week had a significant reduction in the risk of cognitive decline, as compared to non fish eaters. The study showed that the fish eaters had an improvement in their brain volume in areas responsible for learning and memory. It is important to note that about 65% of brain chemistry of composed of fat. Those on statin drugs may potentially have the negative effect of memory decline if on a long-standing high dose. Those with the larger brain volumes had a lower incidence of Alzeimer's Dementia, according to the study. (Source: Annual meeting of the Radiologic Society of North America). So, please indulge in mercury-free wild caught baked or broiled fish regularly to help prevent cognitive decline.

The second was a 12 week study, which included 700 patients on statin drugs with high cardiovascular risk, and showed that there was a 20% reduction in triglycerides in patients taking 4 grams of pure fish oil ( EPA), in addition to other favorable lipid changes. (Source: Annual Scientic SEssions of the American Heart Association)

This study is not exactly shocking to the medical community. The first study to show this effect was the JELIS study. The Japan EPA Lipid Intervention Study followed almost 19,000 people with elevated cholesterol over approximately 5 years. One group was given statin therapy (prescription medication to lower cholesterol), the other statin plus 1800 milligrams of EPA a day. The EPA group had a statistically significant decrease in major coronary events, including non-fatal events. A follow-up study on secondary prevention showed a significant decrease in major coronary events in patients with pre-existing coronary heart disease who took 1800 milligrams EPA in addition to statins. ( Yokoyama, M, Origasa, H, Matsuzaki, M, et al. Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis. Japan EPA lipid intervention study (JELIS) Investigators. Lancet. 2007;369(9567):1090-8.)

So, fish is good for your brain and heart. Surprise, surprise.

(Check out: www.gotmercury.org, www.vitalchoice.com, Orthomega brand fish oil from orthomolecular)

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THE SPECIFIC CARBOHYDRATE DIET, by Dr. Zina Kroner

Zina Kroner — 2010-09-13T18:16:00Z

Patients with inflammatory bowel disease (IBD) suffer from diarrhea and abdominal pain; this is often accompanied by difficulty in absorbing nutrients which results in weight loss. With ulcerative colitis, the large bowel (colon) is involved; Crohn’s disease can affect everything from the mouth to the anus, although usually small and/or large bowel disease usually predominates. Medical treatment of IBD is aimed at reducing the intestinal inflammation.

Medications including sulfasalazine and related drugs and corticosteroids, taken orally or topically may be able to cause improvement in many patients. Stronger medication are frequently needed, with more side effects, including azathioprine, 6-mercaptopurine, methotrexate, and injectable anti-tumor necrosis antibody preparations.

Surgery may be needed if medical treatment fails. In the case of ulcerative colitis, surgical procedures can be as drastic as removal of the entire colon with a permanent stoma (ostomy). Patients with Crohn’s disease may require surgery after surgery removing affected parts of the bowel.

For many patients, medical interventions are not enough, and surgery may undesirable. There is another approach to treating IBD on a more basic level. This involves a significant change in diet for most people, to what is called the “Specific Carbohydrate Diet.” This diet can be undertaken along with any medical treatment.

This diet is available to anyone wanting to try it because of the late Elaine Gottschall (d. 2005). Gottschall was both a mother and a scientist who was able to find a way to help her own child, and decided to share her knowledge. In 1958, her eight-year-old daughter was suffering from ulcerative colitis that failed to respond to medical treatment. Looking for an alternative to surgery, Gottschall took her daughter to Dr. Sidney Haas, a 92-year-old physician who had published a textbook outlining his nutritional approach to healing the intestines.

Dr. Haas quickly started the young girl on his specific carbohydrate diet. After a few months on the diet, her intestinal symptoms started to improve and she began to gain weight. After two years, she was well and free of symptoms of the disease. However, Dr. Haas had died in the interim and could no longer provide guidance.

Gottschall decided to learn more about science behind the diet. She studied biology, cellular biology and nutritional biochemistry, earning a master’s degree and doing research on carbohydrate metabolism in the intestine. She published the Specific Carbohydrate Diet in a book first entitled Food and the Gut Reaction. It is now in its 13th printing, and called Breaking the Vicious Cycle: Intestinal Healing Through Diet. Over a million copies have been sold, and the book has been translated into seven other languages.

The Specific Carbohydrate Diet is based on the way carbohydrates are digested in the intestine, and what may be going wrong with the digestion in people with IBS and other intestinal disorders. Single sugars, including glucose, fructose and galactose can be transported from the intestine into the bloodstream without requiring digestion, in this case, splitting of molecules by enzymes. The cells of the small intestine must work harder to digest carbohydrates, as well as two-sugar molecules.

Carbohydrates are broken down into disaccharides by salivary enzymes and pancreatic enzymes as they pass through the digestive tract. Disaccharides, comprised of two sugars, must be split into their component parts by enzymes located in the outer membrane of the cells in the small intestine. The cell membranes have small finger-like projections called microvilli that line the intestinal walls. The enzymes are located in the microvilli. There are four key disaccharide/enzyme pairs.

• Lactose, found in milk and milk products, must be broken down into glucose and galactose by the enzyme lactase.

• Sucrose, or table sugar, must be metabolized into glucose and fructose. Sucrose is fruit derived (cane sugar, beet sugar). As fruits ripen, sucrose can be broken down into glucose and fructose, so that ripe fruits may have less sucrose.

• Isomaltose is broken down into two molecules of glucose by isomaltase.

• Maltose is similarly metabolized into two glucose molecules by maltase.

A deficiency of any of these enzymes prevents the final digestion of disaccharides. They stay in the intestine where they can cause physical symptoms. For example, sugars can ferment and cause gas.

Many people are affected by a lack of lactase, leading to the inability to fully digest the lactose in milk. This is called “lactose intolerance” which causes symptoms of gas, pain and diarrhea. The incidence of lactase deficiency varies between different ethnic groups, and is also more prevalent in older people than children. People with simple lactose intolerance can take a tablet containing lactase, or they can consume milk products which have lactase added. They can also usually tolerate milk products in which the lactose has been digested already. For example, in properly prepared yoghurt, the right kind of bacteria have already split and digested the lactose.

It has been postulated that in IBS, all of the disaccharidases are not functioning. Consequently, carbohydrate residues and disaccharides cannot be digested. These comprise so much of an average diet that the undigested material is a very significant amount. The symptoms of pain, gas and diarrhea are severe.

The undigested disaccharides can feed the bacteria living in the intestine, causing an overgrowth of bacteria. Many kinds of bacteria normally live in the large intestine, and to a lesser degree, in the terminal ileum that connects to the large intestine. These can multiply and migrate up into the small intestine where they do not belong.

Bacteria in the wrong place can cause damage to the lining of the small intestine, to the microvilli lining the small intestinal walls. This further reduces the amount of functional enzymes and perpetuates the cycle. Decreased digestion of carbohydrates and disaccharides allow bacteria to grow that damage the intestine and decrease the digestion of disaccharides even more. Additionally, the bacteria can release toxic byproducts that cause some of the symptoms of IBS.

Whatever begins the cycle of the intestinal damage, the decreased ability to digest carbohydrates and disaccharides leads to further damage, with more symptoms and even less digestive ability. The Specific Carbohydrate Diet interrupts the cycle.

The main principle of the Specific Carbohydrate Diet is that only so-called “legal” carbohydrates are permitted. These are found in fruits, honey, properly-prepared yoghurt, and certain vegetables and nuts, and are to be used as follows:

• Fruits: Not introduced during the first one to two weeks. Then ripe, peeled and cooked.

No raw fruits until diarrhea under control. First raw fruit should be ripe mashed banana. No canned fruits with added sugar.

• Vegetables: No raw vegetables (such as salad greens and cucumbers) until diarrhea is under control. Only frozen or fresh vegetables are allowed, not canned.

• Dairy products: No fluid milk. Specific cheeses are allowed. Homemade yoghurt is a large part of the diet. Dry curd cottage cheese is also important.

The following foods can also be eaten:

• Eggs: Added when diarrhea is less severe.

• Meats

• Fats: Well tolerated in association with meat, butter, and allowed cheese and yoghurt. Use of low-fat milk is not advised unless there is another reason.

Forbidden “illegal” carbohydrates:

• All cereal grains, including but not limited to corn, oats, wheat, rye, rice, millet, buckwheat, triticale or any other “new” grains such as quinoa. No products made from these grains are allowed, which means no bread, pasta, cakes, or other baked goods. Ground nut flours replace grains for baking.

• No table sugar is allowed as a sweetener or in candy. It is sucrose, a disaccharide. Honey is the allowed sweetener. It contains glucose and fructose separately.

• No processed food, as starch (or disaccharides) are often added.

• No starchy vegetables, including potatoes and yams.

The diet should be as varied as possible. It is very difficult to follow the diet if you are a vegetarian, but not impossible. Consultation with a dietitian would probably be best if you want to follow the diet without any animal products. Anyone with a severe nut allergy will also have a very difficult time with the diet, since nut flour replaces all other carbohydrate flours.

Beginning the Diet

There are recipes in the SCD book, and specific foods you must buy and make before you can start the diet. There are suggestions for where to obtain needed products, and guidelines as to which brands are best. Beyond the information in the book, there are also cookbooks available as well as information on the SCD website. Whoever is going to prepare the food must be able to follow the recipes. In Gottschall’s words, the diet must be followed with “fanatical adherence” in order to work. Instructions on how to make the food for the beginning diet are on the website

(http://www.breakingtheviciouscycle.info/index.htm).

Sample menu for beginning the diet

• Breakfast:

o Dry curd cottage cheese (moisten with homemade yogurt)

o Eggs (boiled, poached, or scrambled) – not if diarrhea is very severe

o Pressed apple cider or grape juice mixed 1/2 and 1/2 with water.

o Homemade gelatin made with juice, unflavored gelatin, and sweetener (honey)

• Lunch:

o Homemade chicken soup

o Broiled beef patty or broiled fish

o Homemade Cheesecake

• Dinner:

o Variations of the above

The above diet needs to be followed strictly. If you have a lot of diarrhea and cramping, you may need five days before you can add other foods. Some people only need a couple of days.

After diarrhea and cramps have stopped, you can add cooked fruit, ripe banana, and other vegetables, as well as egg if you did not start it earlier. You still need to avoid vegetables in the cabbage family. As you add a food, do it slowly, starting with a small portion and increasing it over a week.

Many people decide to try the diet for a month. Gottschall says that it usually takes three weeks to see an improvement, so if you feel absolutely no better after a month, you might want to reconsider whether or not you want to stay on the diet. Keeping a food journal may be the best way to document your symptoms and see if there is a trend toward improvement.

There is also a chance of a relapse of symptoms around the second or third month, which may occur because of a viral infection. Even if there is no specific cause, the symptoms will go away, so you should not be discouraged.

The Specific Carbohydrate Diet

The best way to collect all the information about the diet is from Gottschall’s book, other recommended cookbooks, recipes and tips, as well as places to buy the cookware and other items needed to make the foods, on the website (http://www.breakingtheviciouscycle.info/index.htm).

You do not have to buy anything beyond the book if you are used to cooking and understand some of the more unusual foods you have to make, such as homemade yoghurt. There are no controls on portion size in general. You can eat as much of “legal” foods as you want.

Here are some general instructions.

Allowable proteins

Essentially all fresh or frozen beef, lamb, pork, poultry, fish, eggs, specified cheeses, homemade yoghurt and dry curd cottage cheese, as well as fish canned in oil or water are allowed. No processed meats are allowed because they may container filler carbohydrates (like in hot dogs) or they may have had added sugars. No canned meats.

Allowable vegetables

Fresh or frozen, no canned vegetables or vegetables in jars. Dried peas and certain beans can be introduced after special preparation and when symptoms are better. No grains, no starchy root vegetables. Soybeans and soy products are not allowed

Allowable fruits

Fresh, raw or cooked, frozen or dried. Canned “in its own juice” with no added sugar is acceptable. Just about all fruits are allowed.

Allowable nuts

Just about all nuts in shells. Shelled nuts are acceptable if they have not been coated with starch when salted, which is usually the case with peanuts.

Nuts should only be used as nut flour until diarrhea has stopped. Then they can be eaten whole.

Beverages

Tomato juice is allowed, as is grapefruit juice, freshly squeezed. Orange juice should not be used in the morning when diarrhea is still active. If buying juice, avoid brands with added sugar. Many companies do not state this on the label. Bottled grape juice is usually without added sugar. Apple cider can be used, but not apple juice because sugar has been added. Juice boxes should be avoided.

You may also drink weak tea or coffee, and peppermint or spearmint herb tea. Other herb teas can worsen diarrhea. Only sweeteners allowed are honey or saccharin. Soft drinks with aspartame or NutraSweet may contain lactose and should be avoided. Instant coffee, tea and Postum are not permitted.

No liquid milk is allowed; no soy milk is allowed.

General

You can use oils made from “illegal” foods for cooking, because the carbohydrates have been removed. Unflavored gelatin is used in dessert recipes. Sweets are allowed, made from honey nuts and dates.

Some alcohol is allowed, including very dry wine, gin, Scotch, vodka and other similar. No cordials or liqueurs.

Once symptoms are under control and you are on the diet with all allowed foods, there is a great amount of variety allowed. There is generally no limit on portion sizes; you can eat as much as you want of allowed foods. There are sweets and treats, baked goods made with nut flour, substitutes suggested for pasta, and many clever ways to prepare food.

Gottschall recommends that you stay on the diet for one year after your illness is gone. She then suggests that you start “illegal” foods slowly, one at a time

While the diet is restrictive, it is balanced and able to provide a good source of most nutrients. Vitamin supplements are usually necessary, and you should discuss this with your physician. Many people begin this diet underweight because of their illness, and are able to gain weight.

Does this diet work?

Thousands of people have used this diet successfully. Their stories have been documented on the website, in the form of testimonials as well as surveys.

One article was published in the journal Tennessee Medicine using data from the SCD site as well as follow-up conducted by two doctors. Two case studies were reported, one of a patient with Crohn’s disease and one patient with ulcerative colitis. Both were inadequately controlled on medication and had symptoms resolve on the diet. In these two cases, a physician reviewed colonoscopy reports and biopsies before and after the diet. In these two cases, the patients had demonstrable abnormalities which resolved.

In addition, survey material from the SCD website was used. 51 patients responded, 31 with Crohn’s disease and 20 with ulcerative colitis, Most of them were either in remission or much improved on the diet. Many of these individuals did not follow up with their physicians. 16 patients did have repeat colonoscopies, 12 of which were normal. This article ends with the following statement, “Proper randomized clinical trials are warranted to investigate the merits of this treatment (Nieves and Jackson, 2004).”

Large-scale randomized trials may never be done. Without a medication to study, there is no financial incentive to doing such a trial, and no source of funding. Many physicians will not accept treatments that have not been studied in such trials, and will not accept the Specific Carbohydrate Diet. However, other physicians will, and many patients have done very well on it.

Should you decide to try the Specific Carbohydrate diet, you should actively discuss your progress with your doctor. As noted, you may need specific vitamins. You may also be able to lower medications, which you should do under a doctor’s care.

Resources:

The Specific Carbohydrate Diet website:

http://www.breakingtheviciouscycle.info/index.htm

Breaking the Vicious Cycle: Intestinal Health Through Diet by Elaine Gloria Gottschall. Kirkton Press; Revised edition (August 1994). 13th printing, May 2010. (Available on Amazon.com, from Barnes and Noble, and elsewhere.)

Nieves R, Jackson RT. Specific Carbohydrate Diet in Treatment of Inflammatory Bowel Disease. Tennessee Medicine. 2004 Sep; 97(9):407. (This article can be viewed on the website).

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COenzyme Q 10 and the Heart

Zina Kroner — 2010-06-21T20:01:00Z

CoQ10 has been considered for prevention and treatment of cardiovascular disease related to atherosclerosis, hypertension, diabetes and other common risk factors. LDL (“bad cholesterol”) in the walls of arteries can be oxidatively damaged and that may be an initiating event leading to atherosclerosis. In these cases, the antioxidant function of CoQ10 might be beneficial. There are other properties of CoQ10 that are of interest, such as its ability to decrease the amount of a specific substance on the surface of cells that can collect on the blood vessel walls (1).

An analysis of available research in 2003 found conflicting results. Some improvement in cardiac function was observed in some studies, but not confirmed in others (4).

CoQ10 is considered as a possible treatment for cardiomyopathy, which is an abnormality or disease of the cardiac muscle. Improvements in cardiac output have been found in some small studies. It has also been shown to help congestive heart failure as the result of coronary heart disease in other small studies. Again, there is a need for more large-scale clinical trials (1, 3).

Levels of CoQ10 have been considered as an independent predictor for outcome in patients with chronic heart failure. Those with lower levels have a higher risk of death. In one recent study, the correlation was strong enough for investigators to call for more interventional studies using CoQ10 to treat heart failure (4).

This same pattern repeats for almost all types of cardiovascular disease and treatment. From the treatment of angina (lack of blood supply to the heart muscle), to high blood pressure and damage of the lining of the blood vessels, there is some evidence of benefit from CoQ10 and a need for more studies (1).

I make sure that my patients' coq10 levels are assessed and they are treated accordingly.

Citations:

1. Higdon, J. Coenzyme Q10. Micronutrient Information Center. Linus Pauling Institute. 2/2003. Updated 2/2007. lpi.oregonstate.edu/infocenter/othernuts/coq10/#deficiency />

Accessed 5/27/2010)

2. Shekelle P, Morton S, Hardy M. Effect of Supplemental Antioxidants Vitamin C, Vitamin E, and Coenzyme Q10 for the Prevention and Treatment of Cardiovascular Disease. Summary, Evidence Report/Technology Assessment: Number 83. AHRQ Publication Number 03-E042, June 2003. Agency for Healthcare Research and Quality, Rockville, MD. www.ahrq.gov/clinic/epcsums/antioxsum.htm. />

3. Dallner, G, Stocker, R. Coenzyme Q10. Encyclopedia of dietary supplements, ed Paul M. Coates. Marcel Dekker, New York. 2005.

4. Molyneux, SL, Florkowski, CM, George, PM, et al. Coenzyme Q10: An Independent Predictor of Mortality in Chronic Heart Failure. J. Am. Coll. Cardiol. 2008;52;1435-1441.

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Adding Nuts to Your Diet Lowers Cholesterol

Zina Kroner — 2010-06-10T15:41:00Z

Nuts are considered to be good fats. It has been shown that regular consumption of nuts may decrease the likelihood of heart disease. It is believed that nuts’ omega 3 fatty acid content is at least in part responsible for the beneficial effect on one’s cholesterol profile, thereby heart health. Prior studies have shown that nuts lower lipoprotein(a) levels, an advanced marker for cardiovascular disease.

A recent study in the Archives of Internal Medicine analyzed 25 trials with 583 participants in seven countries, and found that when people ate a mean of 2.4 ounces of nuts (most commonly, walnuts and almonds), the result was an estimated reduction of total cholesterol by 10.9 mg/dL, LDL reduction of 10.2 mg/dL, and a triglyceride decline of 20.6 mg/dL. This was observed regardless of the type of nut one had on a regular basis.

So enjoy your delicious high protein snacks as they are heart healthy and may lower your cholesterol as well.

Source:

Sabaté J et al. Nut consumption and blood lipid levels: A pooled analysis of 25 intervention trials. Arch Intern Med 2010 May 10; 170:821.

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Glutathione and Parkinson's Disease

Zina Kroner — 2010-06-02T13:56:00Z

Glutathione has been used to help alleviate some of the symptoms of Parkinson's disease. Glutathione is a small peptide made up of three amino acids – glutamic acid, cysteine and glycine. The active group of this peptide is the sulfhydryl or thiol (SH) group, a bond formed between the amine (NH2) group of cysteine and carboxyl group (COOH) of glutamic acid.

In the human body, glutathione occurs in two forms:

1. the majority of glutathione is present in the reduced form (GSH)

2. and a small percentage of it is present in the oxidized form (GSSG or glutathione disulphide).

The reduced form of glutathione is the active form, and it donates its electrons to highly reactive molecules like free radicals, peroxides and superoxides to stabilize them. The process is called neutralizing the free radicals. During this process, glutathione is oxidized and the harmful free radicals are reduced and neutralized.

The free radicals, peroxides and superoxides are unstable and highly reactive molecules formed as part of normal metabolic processes. These can literally snatch electrons from the surrounding molecules (like DNA, cell membrane and other cell organelles) to stabilize themselves, making the other molecules unstable, that repeats the process, setting off a chain reaction producing more unstable molecules, which can easily result in the collapse of the cell membrane and the membranes of other cell organelles.

Glutathione is synthesized internally in the liver and does not need to be supplied in the diet. A balanced diet has all the necessary precursors for the internal synthesis of glutathione. The ability of glutathione to neutralize these harmful free radicals makes it a major powerful intracellular antioxidant. For glutathione to be active, it needs to be kept in the reduced form in the blood. The oxidized glutathione is immediately recycled back to its reduced form by an enzyme called glutathione reductase, and glutathione is again ready to donate electrons to free radicals. The reduced and oxidized forms of glutathione together are called a redox couple.

Glutathione preserves the integrity and fluidity of the cell membrane. It is available in the cells in relatively high concentrations in the reduced form. Depletion of glutathione levels in the cells leads to excessive formation of reactive oxygen species which puts more stress on the cells. This is called oxidative stress. This increased oxidative stress causes the cell organelles to burn out gradually and lead to eventual cell death. Increased oxidative stress plays a major role in increasing the risk for a variety of cancers, inflammatory and degenerative diseases.

Glutathione and Parkinson’s disease

Glutathione has been extensively studied for its role as an antioxidant in Parkinson’s disease, an adult-onset progressive neurodegenerative disorder. In Parkinson’s disease, there is a selective degeneration of dopaminergic neurons in the substantia nigra of midbrain. Substantia nigra is the part of the brain responsible for physical movement (like walking, moving hands and legs, etc). Hence, degeneration of dopaminergic neurons in substantia nigra causes physical symptoms like tremors, bradykinesia (slow movements), muscle stiffness and loss of automatic movements in Parkinson’s disease.

Progressive degeneration of dopaminergic neurons in substantia nigra is caused by:

1. Excessive formation of reactive oxygen species (ROS)

2. Increased oxidative stress accumulation of abnormal proteins in the cells

3. Drastic depletion of glutathione (GSH) levels

Dopaminergic neurons are more prone to oxidation due to a combination of factors like the metabolism of dopamines, auto-oxidation, increase in iron levels, decrease in glutathione levels and excessive formation of ROS. Oxidative stress needs to be reduced to slow down the progression of symptoms of Parkinson’s disease. Research suggests that oxidative stress can be effectively reduced by increasing the glutathione levels or slowing its degradation in the substantia nigra.

In the body, glutathione is synthesized from 3 amino acids – glutamic acid, cysteine and glycine. The availability of cysteine is the deciding factor (or rate limiting factor) in the synthesis of glutathione.

Dr. Perlmutter’s Research

Dr. David Perlmutter, a board certified neurologist from Naples, Florida, started using intravenous glutathione in 1998 for his Parkinson's patients after did extensive research on Parkinson’s disease and effects of supplemental glutathione on improving the symptoms of Parkinson’s disease. He is the pioneer in using intravenous glutathione in the treatment of Parkinson’s disease. His research opened new doors in the treatment of Parkinson’s disease and other neurodegenerative diseases. Dr. Perlmutter has successfully used intravenous glutathione in patients with significant improvement in the symptoms. Although glutathione treatment cannot prevent the occurrence of symptoms, it significantly slows down the occurrence of symptoms with improvement in the existing symptoms.

Glutathione supplements do not directly raise the dopamine levels in the brain, instead they improve the efficiency of dopamine in the brain and also increase the sensitivity to dopamine and serotonin.

Glutathione Treatment

Glutathione supplements are available in oral, intramuscular, and intravenous forms.

Oral – Glutathione is available in capsule form and also precursors of glutathione are available in powder form to be used as oral supplements. However, recent research suggests that glutathione is digested in the gastrointestinal tract and broken down to its constituents even before it enters the blood. So, oral glutathione supplements are not effective. I prefer to give the natural precursors to glutathione to my patients.

Intramuscular – Glutathione injections are also given intramuscularly. These are mildly effective according to anectodal data.

Intravenous – Glutathione injections given intravenously are the best and most effective form of supplementation. Not only does it reach the brain and potentially improves Parkinson’s symptoms, it also reaches the liver and help in a variety of functions like neutralization of free radicals via detox pathways. Standard dosage for glutathione supplements is 1400 milligrams mixed with saline, given intravenously for ten minutes three times a week.

Contraindications and Safety:

Glutathione is in the GRAS (generally regarded as safe) category, according to the FDA. However, if you are taking other prescription medicines, glutathione supplements may reduce the efficacy of these medicines. This is because glutathione plays a role in the detoxification function in the liver, removing foreign substances from the body. Prescription medicines may therefore be removed from the system, thus reducing their efficacy

Sources:

1. Hauser, RA, Lyons, KE, McClain, T, et al. Randomized, Double-Blind, Pilot Evaluation of Intravenous Glutathione in Parkinson’s Disease. Movement Disorders. 2009;24(7): 979–983.

2. Sechi, G, Deledda, MG, Bua, G, et al. Reduced intravenous glutathione in the treatment of early Parkinson's disease. Prog Neuropsychopharmacol Biol Psychiatry. 1996;20(7):1159-70.

3. Perlmutter, D. “New Advances in Parkinson’s Disease.” From BrainRecovery.com. Last updated 2004, currently unavailable. Chapter found at www.inutritionals.com/healthy-living/neurodegenerative-conditions/parkinsons disease/glutathione/glutathione-8

4. Bharath S, Hsu M, Kaur D, Rajagopalan S, Andersen JK, Glutathione, iron and Parkinson's disease. Biochem Pharmacol. 2002 Sep;64(5-6):1037-48.

5. Martin HL, Teismann P. Glutathione--a review on its role and significance in Parkinson's disease. FASEB J. 2009 Oct;23(10):3263-72. Epub 2009 Jun 19.

6. Chinta SJ, Andersen JK. Redox imbalance in Parkinson's disease. Biochim Biophys Acta. 2008 Nov;1780(11):1362-7. Epub 2008 Mar 4.

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Physician Grade Supplement Pack for the Busy New Yorker

Zina Kroner — 2010-06-02T13:17:00Z

As you know, there are hundreds of supplements of varying degrees of purity and efficacy out on the market today. I recommend an array of supplements to many of my patients customized to suit their needs. One of the complaints that I hear daily is what a nuisance it is to open scores of bottles on a daily basis. This feedback that I have received prompted me to focus on making the day to day lives of my patients easier by creating a line of supplements that are in ready-made packs.

The first in this series of packs is called “Living Smarter.” My patients often ask me what I take on a regular basis. I would run down the supplements du jour depending on the time of year and what I was trying to focus on. What I noticed was that certain supplements were always in the mix. “Living Smarter” was conceived on this basis. I conceived this pack based on what I thought an active busy person, such as myself, would benefit from most from the bountiful supplement world.

Living Smarter, thereby Living Longer is the philosophy engrained in this pack. Living Smarter is ideal for the active person multi-tasking through life. The cutting-edge composition is high in anti-oxidants like alpha-lipoic acid, lycopene, white tea polyphenols, wild blueberry extract, and pomegranate. The coenzyme Q 10 is the rate limiting step in energy production and will help to combat lethargy.

The pack is rich in nutrients from the Mediterranean that have been shown to support longevity, such as organic Tunesian olive oil, omega 3-fatty acids, and muscadine grapes. The research on vitamin D in the fields of cancer, cardiology, and endocrinology in the past decade is brought to light via the inclusion of vitamin D3 in the pack. Natural mixed tocopherols and a vitamin B complex are both indispensable for an active you. Living Smarter...Living Longer.

Do not take if you are pregnant, have a bleeding disorder or if you are on blood thinners. Take one pack a day in the middle of breakfast or lunch. Feel free to check it our on the "Our Products" page.

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At the Mercy of Allergies?

Zina Kroner — 2010-04-30T14:17:00Z

Many people unnecessarily suffer from allergies. They rely onantihistamines, steroids, and other heavy duty prescription medicationsto cover up the symptoms. Allergies can take a toll on one’s immunesystem, energy levels, general well-being, and even mood. Allergies maypredispose one to chronic sinusitis, daily headaches, inability toconcentrate, insomnia, eye pressure, etc. Allergy sufferers are oftentold to avoid the allergen or undergo weekly intramuscular injections to“desensitize” them. Neither of those options is feasible for mostpeople. Avoidance is often impossible and very few allergy suffererswant to visit the allergist for an injection once a week for severalyears.

Many allergy sufferers who do not want to rely on weeklyantigen injections, and who are not satisfied with medicating themselvesto cover up the symptoms of allergies, have chosen to undergosublingual immunotherapy (SLIT). SLIT is very popular and used widelyin Europe. It is emerging as an effective treatment strategy in theUnited States as well, with new research being generated regularly tosupport it. More than 300 scientific articles in peer-reviewed journalsprove that sublingual treatment is both safe and effective. Thepublication of the ARIA (Allergy Rhinitis and its Impact on Asthma)guidelines, by an international workgroup, indicated that SLIT is aviable treatment approach. A Cochrane Review, the most trustedindependent, evidence-based, meta-analysis organization in the world,released their analysis in 2003 and determined SLIT both safe andeffective.

SLIT, or allergy drops, can be formulated based oneither skin or blood testing. Once formulated, the drops are placedunder the tongue where absorption is ideal. The drops then deliver aslowly increasing dose of physician prescribed antigen. An antigen iswhat the person is allergic to, such as dust, ragweed, etc. The dose iscalculated based on the degree of allergenicity on either the skin orblood testing. The allergy drops are used in gradually increasingdosages affecting the immune system such that there is a development oftolerance to the antigen, the allergy-causing substance. Over time,tolerance to the antigen means that allergy sufferers are no longerexhibiting signs and symptoms of an allergic response. They are able tolead an allergy-free life over time. This is one of the mostgratifying things that I see in my medical practice.

Allergydrops are painless and easy to use. There is no need to go to theallergist’s office to obtain painful weekly or monthly injections.Allergy drops are also more cost-efficient than allergy shots. Thetreatment usually requires approximately 2 office visits a year tooptimize the dose and recheck response. Over time, allergy drop userswill notice that they are able to breathe easier and therefore will beable to wean off the allergy medications that were giving themside-effects of their own.

There are two possible treatmentregimens. The first is a “pre-seasonal treatment,” in which the dropsare more concentrated. This is a quick build up of antigen severalweeks prior to an allergy season. There drops are continued at a lesserconcentration for the duration of the allergy season. Treatment is thenstopped thereafter. The second, and more common, approach is more“regular dosing” for patients with chronic allergies to things likemolds, foods, dust, etc. The treatment can last from one to two years.

Advanced Medicine of New York is pleased to announce that it is now accepting new allergy patients. The approach will becomprehensive; including recommendations in diet as it reflects thepatient’s particular allergy, a focus on natural supplements thatsupport the immune system and fight off an allergic response,medications and/or intravenous treatments as needed, and with SublingualImmunotherapy or allergy drops.

Living Smarter, Living Longer,
Dr. Kroner

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Curbing Inflammation May Reduce Heart Disease Risk

Zina Kroner — 2010-04-28T01:46:00Z

It has been established in prior studies that if one has an inflammatory condition such as psoriasis, for example, the risk of heart disease increases substantially. A pro-inflammatory agent called tumor necrosis factor (TNF) tends to be elevated in patients with many inflammatory conditions such as psoriasis and rheumatoid arthritis. Prior studies have shown us that when patients took medication that act again TNF, the risk of heart disease decreased (J Am Acad Dermatol 2005; 52:262).

A recent study in Norway looked at patients with 3 different inflammatory conditions: rheumatoid arthritis, ankylosing spondylitis, and psoriatic arthritis. Patients were treated with TNF antagonists and aortic stiffness was assessed as a marker of heart disease. It was found that those receiving anti-TNF agents as compared to placebo had statistically significant decreases in aortic stiffness and C-reactive protein levels (a marker for heart diseaes). Although the study was of small sample size and of short duration, it can be concluded that TNF-antagonists may potentially decrease heart disease risk.

Medications that are TNF antagonists have a wide and potentially detrimental side effect profile and need to be prescribed judiciously. There are an array of natural treatments that can be catered to one's condition that can potentially lower TNF and cardio-CRP levels as well.

This is an important study in that it substantiates the fact that decreasing inflammation in our bodies will help reduce cardiovascular risk. This can be done via a number of fronts depending on one's unique inflammatory condition.

source: Angel K et al. Tumor necrosis factor-{alpha} antagonists improve aortic stiffness in patient with inflammatory arthropathies: A controlled study. Hypertension 2010 Feb; 55:333.

Time exhibited a wonderful and potentially life saving article on inflammation and its ties to heart disease in 2005. I highly recommend this read. www.time.com/time/magazine/article/0,9171,993419,00.html

Living Smarter, Living Longer,

Dr. Kroner

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What is already Know is Now Confirmed: Study Highlights that Sugars Cause Dyslipidemia

Zina Kroner — 2010-04-22T16:37:00Z

Many of my patients are so surprised when their triglyceride levels come back high after the spring and summer months. They say they have been just as active as before and maintaining a relatively low fat diet. Well, the diet part may be the snag. For those of you new to this blog, it is the carbs and sugars that can affect one’s cholesterol profile adversely. This has been scientifically proven for quite some time now.

Study Confirms that Sugars Cause Dyslipidemia:

This has been confirmed in a recent study in JAMA. This 6000 person study demonstrated that a high intake of added sugars is associated with increased risk for low HDL cholesterol (the good cholesterol) and high triglycerides. Yes, it is now official.

On the Bandwagon:

Even the American Heart Association is on the bandwagon as well. They made a statement recognizing this fact and finally recommended against high intake of calories from sweets. According to a statement published the journal Circulation ( April 2010), “A prudent upper limit of intake is half of the discretionary calorie allowance, which for most American women is no more than 100 calories per day and for most American men is no more than 150 calories per day from added sugars.

http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.109.192627

Still Confused?

My vegetarian patients are often confused how their seemingly healthy diet often results in an unhealthy cholesterol profile. Here is how it works:

To review how carbs cause a dyslipidemic state:

1. glucose (sugar derived from carbs) is passed through a corridor (the portal vein) and enters the liver.

2. The pancreas is paying very close attention to the molecules passing through this corridor into the liver and secretes insulin

3. Insulin stimulates the production of cholesterol by stimulating an enzyme called HMGcoA reductase ( the very enzyme that statin drugs try to inhibit!)

4. Insulin also 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.

5. In the liver, the glucose is stored as glycogen. Because there is not that much glycogen in the liver, whatever sugar that it is can’t hold is spilled over to another processing system.

6. The glucose is then packaged neatly into triglycerides.

7. VLDL (very low density lipoprotein ) is then stimulated by the liver and LDL, the bad cholesterol) is made.

When there is not much glucose in the 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.

So there it is, eat low-carb and see cholesterol profiles improve.

Stay Informed. Living Smarter, Living Longer

Dr. Kroner

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Statins' Laundry List

Zina Kroner — 2010-04-13T20:23:00Z

According to a recent study not funded by a pharmaceutical company, in the journal Lancet, use of statins (Lipitor, zocor, etc) is associated with a small risk of developing diabetes. When looking at 90,000 subjects in this meta-analysis, it was found that there was a 9% increase in diabetes risk as compared to controls. This association was of greater significance with increasing age.

How does this affect you, statistically speaking?

Well, for every 255 patients treated with a statin medication for four years, there is the potential, according to the authors of this study, to produce one additional case of diabetes.

Add it to the Laundry List

This is yet another adverse effect added to statins’ already long list of side-effects. It means that physicians as well as patients have to be cognizant of this fact and monitor for signs and symptoms of glucose imbalance on a regular basis.

Remember that statin drugs are effective at reducing overall cardiovascular risk, so cardiologists will argue that the benefits of statins far outweigh the risks. From a conventional standpoint, it is, therefore, not recommended to change the existing indications for statin therapy in the setting of cardiovascular risk prevention.

Stay well and keep informed, Dr. K

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Staying Ahead of the Curve on Parkinson’s Disease: Dementia and Green Tea

Zina Kroner — 2010-03-22T20:14:00Z

More recently, doctors are being urgedto treat dementia more aggressively inParkinson’s patients, as it would optimize quality of life for the patients andtheir caregivers. It is established that one third of patientswith Parkinson’s disease experience dementia. Cognitive impairments are the hallmark features, including decreasedattention span, executive functioning and memory deficits. Obtaining a legitimate diagnosis of dementiacan be quite tricky in that symptoms may widely fluctuate and therefore thediagnostic instruments that physicians use the diagnose Parkinson’s dementia maynot always give reliable results. Researchis conflicting at this point as to which is the best medical agent to use inthis population.

Optimize Diet

Thereare multiple safe nutritionally oriented treatments that patients may engage into help prevent early onset dementia as it related to Parkinson’s disease. First and foremost, optimization of diet iscritical. There is much research tosuggest that a diet that is high on the glycemic index scale can exacerbatedementia. Insulin resistance, associatedwith a diet that is chronically high on the glycemic index, has been associatedwith Alzheimer’s disease. The connectionhas been labeled type 3 diabetes by some. (See my published article under the References section of my websiteonthis topic).

Low Glycemic Index, No Pesticides, No MSG

Eatingorganic, MSG and pesticide free foods that can exacerbate both Parkinson’s aswell as dementia is important. Remember thatMSG can trigger glutamate receptors in Parkinson’s and non-Parkinson’s patientsalike. Followinga Mediterranean style diet that is high in unheated extra virgin olive oil,fish and poultry, nuts, vegetables, low glycemic index fruits, whole grainsthat are gluten free and unprocessed foods in key.

Just Do It

Addinga daily exercise component is imperative. Exercise can trigger dopamine levels to rise, help with coordination,drive down cortisol, improve insulin resistance, and help with mental acuity. These are all essential when hoping to helpprevent dementia and improve Parkinson’s symptoms. Exercise should include weight bearingexercise as well as core bodywork.

DHEA

Theadrenal hormone DHEA has been shown to boost dopamine levels. There is also a significant amount ofresearch pointing to DHEA helping with improvement in memory in dementiapatients. DHEA is ever present in braintissue and helps to offset the negative effects of cortisol. It is, however, a precursor to many of theother hormones and needs to be used judiciously and under medicalsupervision.

Follow an Anti-Inflammatory Program

Low grade chronicinflammation may be a precursor to neurodegenerative disease. An excellent anti-inflammatory program,including diet and supplements may help to quite the inflammation down.

Polyphenols, excellentantioxidants found in green tea, have recently been studied to see if theymodify the course of Parkinson’s. TheChinese study enrolled 410 untreated people with Parkinson’s disease and wererandomized to receive 0.4g, 0.8g, or 1.2 g of green tea polyphenols daily. As a reference, 2 cups of green tea containapproximately 300mg of polyphenols. At 6months a significant improvement was noted in each dosage category based on theUnified Parkinson Disease Rating Scale. At 12 months, however, unexplainably, the scores did not differ fromplacebo. Improvements were more profoundfor those with a greater severity of disease. There were no notable side effects except for insomnia for those notaccustomed to green tea intake.

The reduction ofoxidative stress on neurologic tissue in Parkinson’s as well as dementiapatients is important. Utilization ofpolyphenols. vitamin C, tocotrienols, bioflavanoids, proanthocyandinsfrom grape seed extract, coenzymeQ10, and curcumin may have a beneficialeffect.

Stay Tuned...

Stay tuned for anarticle on coenzyme Q 10 and glutathione treatment in Parkinson's Disease.

Living Smarter, Living Longer,

Dr. Kroner

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Biggest Study Yet on Vitamin D and Colorectal Cancer Prevention

Zina Kroner — 2010-03-11T23:06:00Z

It seems like vitamin D is all we hear about lately. A flurry of well designed studies have been brought to light in the past decade. The largest study to date on vitamin D and cancer prevention confirmed several smaller studies which have suggested that higher blood levels of vitamin D are associated with lower risk for colorectal cancer.

Spanning 10 European countries and 520,000 subjects, vitamin D levels were measured and subjects were followed for 4 years after enrollment. 1248 of the subjects were then diagnosed with colorectal cancer. It was found that those with lower vitamin D 25 hydroxy concentrations (25-50 nmol/L) were associated with higher colorectal cancer risk and those with higher concentrations (75-100 nmol/L) had lower risk. Patients in the highest quintile had a 40% lower risk for CRC than those in the lowest quintile.

At this point I strongly believe that patients should be advised to take vitamin D in order to help prevent colorectal cancer. Such advice should be routine and definitely not considered "alternative."

CITATION(S):

Jenab M et al. Association between pre-diagnostic circulating vitamin D concentration and risk of colorectal cancer in European populations: A nested case-control study. BMJ 2010 Jan 21; 340:b5500.

Living Smarter, Living Longer
Dr. Kroner

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Chocolate linked with Stroke Risk Reduction

Zina Kroner — 2010-03-08T18:03:00Z

No wonder everyone loves Canadians (and chocolate!). A literature review by Canadian researchers shows that higher chocolate consumption may be associated with a lower risk of stroke. This information will be presented in April 2010 at the American Academy of Neurology’s 62nd meeting.

Although the studies the researchers examined were small and the type of chocolate and its flavonoid content not clearly defined, this review warrants some attention. There has been prior research on chocolate consumption decreasing the risk of cardiovascular disease. Flavonoids are a category of antioxidants that have been associated with lower cardiovascular risk. Cocoa contains epicatechin, a type of flavonoid, which harbors a significant amount of antioxidant activity.

Antioxidants such as flavonoids protect the heart in a variety of ways:

Prevents the oxidation of LDL – a process that occurs prior to plaque formation

May mildly reduce blood pressure via the mechanism of arterial dilation and inproved blood flow

Can Mood Elevation Post Chocolate Intake Explain Decreased Risk?

The Journal of Internal Medicine in September 2009, published a study stating that survivors of heart attacks who ate chocolate at least two or three times a week reduced their risk of death by a factor of up to three times compared to survivors who did not eat chocolate. It is quite possible that this link is associated with chocolate consumption elevating serotonin levels. Elevated serotonin levels are associated with improved mood, which has been associated with better outcome after a cardiovascular event. Depression is a risk factor for cardiovascular disease. Can this very mood elevation prevent stroke as well? Are elevated brain serotonin levels at least part of the cause of chocolate contributing to stroke prevention? It is possible.

Do I Recommend a life of Chocolate Indulgence in Hopes of Stroke Prevention?

Hmmm. Remember to evaluate the risk vs. benefit ratio of this decision. Unless you are eating a small amount of pure dark chocolate that is not heavily sweetened, the amount of sugar in the average chocolate bar can put you at great risk for heart disease. The link between elevated blood sugar levels and heart disease is well established. Be careful to not fall into the trendy research trap. If we followed the research without judiciously weighing the risks, we would be swimming in wine, hot chocolate and caffeine. Sounds great for a day or two, until the consequences hit.

Living Smarter, Living Longer,

Dr. Kroner

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HgA1C Better than Fasting Glucose at Predicting Risk for Heart Disease and Stroke

Zina Kroner — 2010-03-08T16:33:00Z

Many of you may have already been tested for pre-diabetes or diabetes using a marker called hemoglobin A1C (HgA1C). This test basically allows you to know how well your blood sugars have been controlled in the last three months. More recently, however, this test is becoming quite integral in predicting your risk of heart disease. According to the New England Journal of Medicine, levels above 6.0%, are better than fasting glucose for predicting long-term heart disease and stroke risk.

Scientists have known for years now that insulin resistance and diabetes have been tightly linked to cardiovascular disease, as the information is omnipresent. This is the one of the first studies comparing fasting glucose and HgA1C as they compare to assessing heart disease risk.

Why this May be

This may be so because fasting glucose is not as consistent a test. It will vary depending on what the patient ate the night before. It is not uncommon for patients to alter their diets slightly the night before the test in order to obtain a more favorable blood result. They may not have that glass of wine or extra helping of dessert. Therefore, unless they already have full blown out diabetes, their morning blood sugars may come back as normal.

A Hemoglobin A1c, however, is a more stable marker of one’s blood sugar control. The red blood cell has a life span of 120 days, during which glucose molecules react with hemoglobin. This forms a “glycated hemoglobin”, another term used for HgA1C. Those with poorer blood sugar control have a higher glycatred hemoglobin. A normal level is below 6.0%.

A standard American Diet will often cause spikes in blood sugar and therefore elevated the HgA1C. This, in turn, will increase the risk for multiple complications associated with both diabetes and insulin resistance; including coronary disease, vascular disease, heart attack, stroke, heart failure, kidney failure, blindness, erectile dysfunction, neuropathy (loss of sensation, especially in the feet), gangrene, and gastroparesis (slowed emptying of the stomach).

Now that a major journal is embracing the test for HgA1C, as opposed to a fasting glucose, as a measure of heart disease risk, I strongly believe that aside from routinely assessing its value, it is imperative to stay ahead of the curve and be proactive. Prevent heart disease and stroke by maintaining good control of your blood sugar. Keep the HgA1C low.

Living Smarter, Living Longer,

Dr. K

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Question from Patient Suffering from Statin Side Effects

Zina Kroner — 2010-02-25T15:27:00Z

Dear Dr. Kroner,

Thank you for this (Statin Side Effects) article. I was started on Pravachol 20 mg po q day approx. 6 weeks ago. After taking it for just 2 weeks, I stopped due to severe, activity-limiting muscle aches ( arms, thighs) and arthralgias (particularly in forearms, elbows, wrists and hands) accompanied by fatigue. These sx have persisted for 4 weeks now with a little improvement, but I'm still not able to do my usual moderate, regular exercise routine and feel exhausted. How long do these sx take to resolve? Are the arthralgias typical? Should I try CoQ10?

I'm an active, healthy 51yo female. My doctor doesn't think my sx are statin-related, wants me to try a lower dose or another statin, which I won't attempt until these sx resolve completely and I've investigated this further. Thank you for your thoughts. -

- Female (Anonymous) from Maryland

Hi,

Thank you for your note.

I am sorry to hear about your side effects. I see the side effects of myalgias and fatigue related to statin use regularly. On one occasion, I have witnessed arthralgia as a side effect. It may take up to 3 months for symptoms to resolve.

The most important thing to understand is whether or not you need the statin in the first place.

What is your risk of heart disease? Did your doctor recommend a coronary calcium score in order to figure out whether or not you have plaque in your arteries? One of the indications for statin use, according to the American Heart Association is coronary artery disease. I would also want to know what your other risk factors are: such as diabetes, smoking history, obesity, insulin resistance, sedentary lifestyle, family history of early onset coronary artery disease, etc.

I would want to perform blood tests that further risk stratify you: I would check a VAP cholesterol panel to assess your LDL particle size (the larger the LDL particle size, the less the chance that it will cause plaque formation), homocysteine, cardio-CRP, Lipoprotein (a), uric acid, HgA1C, fasting glucose, fibrinogen, fructosamine, etc. This will help to determine the degree to which you need the statin. I would definitely assess your baseline coenzyme Q 10 levels via a blood test. An average amount to take in the setting of statin use would be 100 - 200 mg of ubiquinol - the more bioactive form of coq10 daily with breakfast.

Hope this helps. Stay well.

Best,

Dr. Zina Kroner

Internist

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The Second Brain: The Gut

Zina Kroner — 2010-02-15T22:49:00Z

This is not the “shock and awe” study of the year, but it elucidates an excellent medical phenomenon. A recent study in the American Journal of Gastroenterology showed that St. John’s Wort, an herb used to treat mild depression, was less effective than placebo at treating irritable bowel syndrome (IBS). Improvements in quality of life were similar in both placebo and the herb treated groups. Gastroenterologists have been treating IBS with anti-depressants for quite some time. I would like to bring to light the theory behind it, as this may have clinical implications beyond the use of medication.

The gut, often referred to as the second brain due to the powerful enteric nervous system that it houses, is tightly connected to serotonin, the feel good neurotransmitter. Dr. Michael D. Gershon, the chairman of the department of anatomy and cell biology at Columbia has brought this to light in his book entitled “The Second Brain.”

We have all felt a twinge in the stomach prior to a major exam or a public speaking event. It is quite common for my patients with a psychiatric disorder to have a concomitant gastrointestinal issue.

The Fight or Flight response and IBS

There are several reasons why stress or anxiety can cause irritable bowel syndrome. First, with any fight or flight response, cortisol, a stress hormone, is released. Cortisol fires up the sympathetic nervous system and makes the parasympathetic nervous system less efficient. It is the parasympathetic nervous system that we need in order to maintain bodily homeostasis, such as breathing, digestion,etc. Therefore, with a cortisol surge, digestion becomes ineffective and irritable bowel syndrome can kick in.

Serotonin and GI Function

Second, it is important to note that serotonin has a profound effect on gastrointestinal function, being that 95% of the body’s serotonin is cradled in the gut. At the start of digestion, it is the enterochromaffin cells that release serotonin into the gastrointestinal tract, which houses many serotonin receptors. The receptors then initiate a process via nerve cells that starts the flow of digestive enzymes.

Serotonin then relays messages up to the brain, letting it know what is happening. Therefore, certain foods may elicit a feeling of nausea, etc. Once serotonin is released in the gastrointestinal tract and the process of digestion is stimulated, normally, it is cleared out of the way by SERT, a serotonin transporter.

These transporters are found in the gut walls. Often, those with IBS, may not have an appropriate level of functioning SERTs, and they are therefore unable to clear out the serotonin cells. This can stimulate diarrhea. Once the serotonin receptors are supersaturated, the effect is constipation, thus the infamous Irritable Bowel Syndrome. Therefore, medications as well as supplements such as St. Johns Wort which manipulate the serotonin may potentially help IBS symptoms. It is no wonder that in this recent study, placebo was quite beneficial in IBS. This shows how much mind and body are connected. Focusing on stress management is key as well.

Delayed Food Allergy and Inflammation

A third contributor to IBS as it related to the enteric nervous system is allergens. Often, the barrier of the gut becomes damaged and certain allergens, etc, may enter the bloodstream, triggering the brain to send a message to the gut to increase the production of histamines and other inflammatory cells in order to try to get rid of the allergens. This inflammatory process may trigger the neurons in the enteric nervous system (in the gut) to become hyperactive and therefore contribute to diarrhea.

The challenge now is to optimize the efficiency of the gastrointestinal tract by preventing unnecessary cortisol surges so not to disrupt the sympathetic and parasympathetic nervous system harmony, to maintain a healthy serotonin and SERT level, and to prevent unnecessary allergens from entering the GI tract so not to trigger the inflammatory process involved in diarrhea. The gut really is the Second Brain!

Citation:

Saito YA et al. A randomized, double-blind, placebo-controlled trial of St John's wort for treating irritable bowel syndrome. Am J Gastroenterol 2010 Jan; 105:170.

Stay well,

Living Smarter, Living Longer...

Dr. K

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Niacin Increases the Size of Your Cholesterol

Zina Kroner — 2010-02-04T16:02:00Z

Niacin has been more well known for its positive effects on HDL. Its effects on LDL have been more modest. Such modesty, however, deserves special attention in that it is indeed associated with an increase in LDL particle size and a shift from small LDL to the less atherogenic, large LDL subclasses. Therefore, we are looking at niacin from a standpoint of quality of LDL that it promotes, not just the quantity that it would reduce it by. This is a crucial point.

Note that a 2006 study in the American Journal of Cardiology showed that 3 months of ER niacin use in subjects w/ CAD increased large particle LDL by 82% and decreased small particle LDL by 12%.

Dr. K

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My Patient's College Essay on Overcoming Alopecia Areata

Zina Kroner — 2010-02-02T21:25:34Z

The following is a college essay from a 17 year old patient of mine, Hallie, whose medical story is quite inspiring. She has given me permission to post it online.

"I was in the familiar position, sitting on a chair, hunched over, my long thick hair hanging in front of my face. My mother prodded and poked at the spot on my scalp right above the nape of my neck, looking at the red, scaly skin that was itchy, painful and extremely annoying. I was immediately alarmed when I heard my mother utter a gasp of shock. When she informed me that a round patch of my hair was missing, I went from feeling shocked to feeling a profound sadness. My mother never would have noticed this had she not been about to apply a cortisone cream to my already unfortunate dilemma of psoriasis. Psoriasis is a serious autoimmune disease that results in red, scaly patches on the skin. I was given several topical ointments to counteract the psoriasis, but some caused terrible side effects, and regrettably none were effective. By this point, I could no longer wear my hair in a ponytail for fear that my friends would spot my red scalp. We were both terrified and unsure of what this bald patch was. Was it a side-effect of the medication? Was it a symptom of psoriasis? We immediately made an appointment with the dermatologist to discover the answers to our questions.

As the doctor entered the room, my palms became sweaty and I trembled with fear. I had had an abnormal amount of skin problems in the past prior to having psoriasis, and I was worried that this could be the worst one of all. After examining my scalp, the doctor told me that I had a condition known as alopecia areata, an autoimmune disease which causes large patches of hair loss. The doctor seemed so calm regarding the situation, which angered me. By the frightened look on my mother’s face, I could tell that she was experiencing the same feelings as I was.

After discussing the diagnosis, he explained that the only treatment that might work was steroids. Rather than pills, however, I would be injected in my scalp wherever hair was missing. The doctor warned me that he could not promise that the hair would grow back, nor was there any treatment to cure the disease.

My mother and I immediately Googled “alopecia areata”, and the search results were terrifying. I was a 16 year old girl, a sophomore in High School, and going bald was one of the worst possible scenarios for me.

We were not satisfied with the inadequate medical solution the doctor prescribed for me, so we continued our investigation. We decided to get a second opinion from a well-known, respected doctor who practiced both conventional and alternative medicine.

Our first meeting with Dr. Kroner brought back another rush of fear of the unknown. But unlike the dermatologist, she was understanding, which enabled me to relax. She explained that psoriasis and alopecia areata are related because they are both autoimmune diseases. She predicted that I had sensitivities to certain foods that were preventing the absorption of necessary nutrients into my body. She administered extensive blood tests which confirmed her suspicions. The doctor prescribed a long list of vitamins and supplements in which I was deficient.

Dr. Kroner then educated me on the diet I would now strictly follow. I could no longer eat gluten (a protein found in wheat), casein (a protein found in dairy products), chocolate, sugar, soy, or oils other than olive oil. My eyes filled with tears as I thought about my favorite foods, ice cream and pizza, which at the time, I didn’t believe I could live without.

The following day I told my friends about my new diet. They were concerned and were curious as to why I had to deal with such a terrible predicament. I was too embarrassed to tell them that my hair was falling out so I told them I was experiencing stomach problems. It was hard to think about what would happen if my hair loss became noticeable. I was worried that I would be teased or pitied. I decided that at the moment, I should simply follow my diet and hope that my hair would grow back.

A few weeks later, a new health food store opened in my neighborhood. When I walked in, I saw that there was an entire gluten-free section! They had everything from cookies to pasta. I was overjoyed and felt suddenly at ease with my diet. Now I could snack on more than just nuts.

After a month, it was time for my next doctor visit. She told me that I should get the steroid injections from the dermatologist in order to speed up the growth process. We trusted her and returned to the dermatologist.

A few months later, my mother was checking my scalp as she regularly did when she noticed that not only had the psoriasis healed, but a few small hairs were beginning to grow back. We were extremely excited. However, other patches continued to fall out.

Throughout the duration of my disease, I continued working hard in school and participating in many extracurricular activities. Despite the dire situation, I managed to ignore it and continue to live my life. Instead of constantly worrying about the future of my disease, I maintained a positive attitude as well as my usual confidence. I was never one to get stressed, and so I put my disease out of my mind, while continuing my strict diet.

Hair continued to grow back to my delight. A year and a half later, I was told that there was no more hair loss. It was the most wonderful news! It was right after final exams of my junior year and the approaching end of my disease was a huge relief.

I believe that in addition to the diet, vitamins, supplements and steroid injections, I was able to overcome this disease because of my upbeat personality. I focused on my schoolwork and on achieving my goals and I avoided thinking about the negative aspects of life. I knew that letting depressing thoughts take over my life would not benefit me mentally or physically.

Fortunately, I was able to overcome this disease due to my perseverance and positive attitude. I could have let it consume my life, but instead I held my head up high and continued on ."

Hallie K., Long Island, New York

Photo of another alopecia areata patient:

Dr. K