Doctor's Corner

HEALTH SCREENING UPDATES

2012-01-27T10:13:00.000-08:00

Over the past several years there have been a number of changes in the recommendations for cancer screening tests. Cervical, breast and prostate are just a few of the cancers where recommendations for screening tests have been modified, although not without controversy.
The governmental agency involved in developing recommendations for disease prevention is the U.S. Preventive Services Task Force (USPSTF). Comprised of an independent panel of experts in primary care and prevention, this agency reviews the evidence of effectiveness for existing screening tests. Based on the current data, a decision is made to keep the present recommendation or to suggest changes. Some of the more common screenings performed that have had changes made are the PAP, mammogram and PSA tests.

The PAP test screens for cervical cancer and was performed on an annual basis for all women. Current clinical guidelines still strongly recommend routine screening for high risk individuals. However, for women who are not high risk, testing is now suggested every two years for ages 21-30 and for over 30, every three years, with the provision of three consecutive, negative results. Research suggests women above the age of 70 can discontinue cervical cancer screening altogether.

Similarly, there have been some changes in recommendations for breast cancer screening with mammography. Previous guidelines were annual mammograms. Evidence shows current modifications from annual to biennial mammograms for women aged 40-59 are enough to reduce the harm and still provide benefit. And, the age group that may benefit the most is 60-69. The harm encountered includes false-positive test results leading to unwarranted biopsies, repeated imaging and doctor’s visits, not to mention causing worry and anxiety for many women. Even though breast cancer is more prevalent in women as they age, according to the task force, there is uncertain benefit for screening mammograms in women 75 years or older. And the breast self-exam (BSE) is being discouraged where previously it was thought monthly exams were crucial.

Additionally, the benefit of measuring PSA (prostatic specific antigen) to screen for prostate cancer has come into question. Initially, annual PSA testing was thought to help detect prostate cancer in the earlier stages, therefore providing a better chance for successful treatment. However, there are reasons for high PSA levels other than cancer, which can cause the patient anxiety. Prostatitis, benign prostatic hyperplasia (BPH) and recent ejaculation are just a few. Moreover, the research is inconclusive showing that a decline in deaths can be attributed to PSA screening. With positive PSA tests comes the decision of ‘watchful waiting,’ or active surveillance. More invasive procedures may be considered such as biopsy, radical prostatectomy or radiation therapy. So, according to the USPSTF, screening for prostate cancer in men younger than 75 years may not offer any better outcome than not screening. And for men 75 years and older PSA testing is not recommended, as the harm seems to outweigh the benefit. If PSA testing in men younger than age 70 is continued, the suggestion is for every 4 years, along with a discussion of the ambiguity of the benefits and drawbacks.

Sherry LaBeck, ND

Environmental Toxins and Hormone Health

2011-11-01T12:54:00.000-07:00

You may not be aware of the effects some chemicals commonly found in our homes and our environment have on our health and wellbeing, but these so-called endocrine disruptors are all around us and can interfere with hormone balance and the immune system. While it’s becoming common knowledge that the chemicals in our foods can affect our health, the lesser known environmental exposures may be even more ubiquitous.

Here are some examples:
• Pthalates- found in beauty products, plastics and also in new shower curtains. You know that “icky” smell of a new shower curtain? That’s the airborne phthalates. Tip: To disperse the chemical, Air the curtain outside for 24 hours prior to hanging in your bathroom to disperse the chemical.
• Bisphenol A (BPA)- found in plastic drinking bottles, baby bottles, and cash register receipts
• Dioxins- found in all bleached paper products: toilet paper and tampons are particularly problematic as they come in contact with our skin (mucous membranes)
• Chemicals used in dry cleaning will off-gas from the clothing for days after we bring them home.
• Cleaning supplies that we use to wash our kitchen counters, floors and ovens put endocrine disrupting chemicals into the air and can remain on these surfaces
• Many pesticides that are used for repelling ants, roaches and other insects can be also harmful to humans

This is a short list; the ways we are exposed are many. To read more see Dr Marianne Marchese’s book 8 Weeks to Women’s Wellness. Her book outlines the environmental links to 10 common women’s health conditions, the various ways we are exposed to these chemicals on a daily basis and provides an 8 week detoxification program that is both informative for the doctor and useful for patients.

OR log in to our provider website and listen to my interview with her on Let’s Talk, ZRT’s teleconference series where we discuss how hormone health is affected by environmental toxins.

And check out the environmental working group which has a great cosmetic database and other great info on toxins in the home and elsewhere

Elise Schroeder ND

Vitamin D and Pregnancy

2011-09-08T09:56:00.000-07:00

Before you get pregnant, or right when you get pregnant, blood tests are done to check for anemia, certain viruses, blood type and others. Increasingly, doctors are now also testing a woman’s vitamin D level. Vitamin D has been a hot topic in the medical world for a few years, but why and how is it affecting conception, pregnancy and the health of the newborn? That's the question scientists have been working on for almost a decade now. Let’s start by understanding what vitamin D is.

Viatmin D is a misnomer. This so- called vitamin is actually a hormone. For those of you chemically inclined- the 4 carbon ring backbone of this molecule makes it more of a steroid hormone than a vitamin. It is structurally similar to estrogen, testosterone, progesterone and all the steroid hormones. Technically speaking- for those more word inclined- a vitamin is a catalyst to a reaction in body, and a hormone is a chemical messenger that actually sends messages to cells that causes them to change. There is a distinct difference between the two, and vitamin D falls into the hormone category.

Because of its steroid structure and function, vitamin D plays an important role in priming cells for other hormones to do their job properly. This is why being sufficient in Vitamin D is so important for conception. Its not just the most well known hormones estrogen or progesterone that need to be balanced and functioning optimally, but the second string players as well- thyroid hormone, cortisol, dheas, testosterone and VITAMIN D too. These all need to be well balanced with each other in order for the miracle of ovulation and conception to occur.

Having enough vitamin D circulating through your system can increase your chances of fertility whether you’re struggling with poly cystic ovarian syndrome (PCOS), lack of ovulation or general fertility problems. This “hormone” also plays a role in male reproduction. Both sperm motility and production are increased when levels of vitamin D are normal. SO get your men tested too- as we all know it takes two to tango (so to speak).

Once pregnant, the focus shifts to the developing fetus who is dependent on maternal vitamin D levels. The placenta- which provides nutrition and oxygen to the growing fetus, requires vitamin D to function. In this study , the authors indicate that vitamin D may play a role in implantation of the pregnancy, normal placental development and the development and prevention of eclampsia. All imperative to a healthy full term pregnancy

Some studies have also looked at childhood health as related vitamin D levels in utero. Healthy maternal levels of vitamin D have been shown to decrease the likelihood of wheezing in their children. It is also implicated in the prevention of respiratory infections, type one diabetes and MS (multiple sclerosis).

With all this information stacking up, it makes sense that vitamin D levels should be monitored pre conception and during the pregnancy. It’s a simple test that your doctor can order or you can get an at-home finger stick test through the Vitamin D council or ZRT Lab.

Elise Schroeder ND

Precocious Puberty

2011-08-11T12:23:00.000-07:00

Anyone else concerned that young girls are entering puberty earlier that a generation or two ago? It's made the news lately and seems to be getting more attention although attentive physicians have been concerned for a long time.

In 1999, the American Academy of Pediatrics published guidelines revising what defined precocious puberty based on a study looking at 6-8 year olds in 1997. This guideline did 2 things. It separated out African-American and Caucasian girls and lowered the "OK" range of what 'normal' puberty ages were to as young as age 6. Interestingly, they did not find a change in boys puberty ages. According to these guidelines, it is considered "OK" for girls to develop breasts or pubic hair as young as 7 for Caucasian girls and as young as 6 for African-American girls. It is only considered precocious puberty if there are 2 signs under the age of 8 in girls.

Fairly recently, Dr Biro repeated this study, comparing the results to those found in the 1997 study. What he found was startling. Link to abstract of the article here.
• 10.4% of Caucasian girls had breast development - double the 1997 study.
• 23.4% of African-American girls had breast development vs. 15.4% in 1997. That is almost 1/4 of all African-American little girls.
These are 6-8 year olds!

So, what are a few of the causes behind this situation and more importantly what can we do right now for our children and our young patients?

1. There is no doubt that the increasing obesity numbers in young children is dramatically increasing. Children today are heavier. Even the non-obese children are heavier than they were one to two generations ago. If you look back at your elementary school photos, there probably were one or two children that were heavier. Now, start watching children today walking around. The thinner children often stand out because they are the more unusual in the community. There are many reasons for this situation of course, changing social structures, changing food quality and quantity and social acceptance. A growing proportion of our children are sadly also becoming insulin resistant; crossing that line between "baby fat" and into obesity. Obesity and the associated hyperinsulinemia, increases the stimulation on DHEAS production from the adrenal glands. As a result, the zona reticularis, becomes hypertrophied setting up an anatomical problem leading to higher androgens life-long. Higher androgens lead to development of early pubic hair and breast development, but long term contribute to hirsutism, acne and infertility. Yikes.

2. Bisphenol A or BPA is a recognized environmental estrogen receptor agonist. In fact, BPA was discovered when researching hormone replacement, but instead, they stumbled upon the wonders of DES instead. BPA is found in can linings (including powdered baby formula) and plastic containers (unless noted BPA free: 2, 4, and 5 plastics are considered “safe”). BPA has been found by major university studies to contribute to health problems both at low doses and at high doses, but different problems at each titration. And if that wasn't bad enough, BPA has been found to cause problems in-utero for the reproductive tract of the offspring. BPA is bad; try to avoid it.

3. Other environmental estrogens have been found in normal household products. One that has been identified as more commonly used in the African-American population is protein enriched shampoo - enriched with placenta. Since the placenta makes hormones, the hormones get into the shampoo and cause precocious puberty. Cases have been reported of infants being washed with placenta containing shampoos and developing pubic hair. Of course, family members using topical hormones may also contribute to environmental exposure.

4. Pituitary tumors may also cause early sexual development. These are always considered, but generally found with rapid and extreme precocious puberty and are more common in boys.

Testing recommended for precocious puberty: MORNING levels (bloodspot works great)
o Testosterone
o Estradiol
o DHEAS
o LH
o FSH
o Thyroid - especially with additional symptoms

o Additional testing that may be recommended afterwards includes MRI and/or ultrasound.

So what to do if you suspect that your patient/daughter/son has precocious puberty?
First, assess whether they fit the guidelines, then, follow-up with a pediatrician who can examine them thoroughly. For instance, don't assume that it's the drinking from the BPA-filled water bottle is the cause until a pituitary tumor has been ruled out. Certainly avoid environmental estrogens, eat organic, don't shampoo with estrogen, but make sure you are doing that while waiting for your appointment. That way, when you are told it's idiopathic (i.e. “unknown cause”) you'll be well on your way to helping the situation.

Treatment for precocious puberty depends on finding the cause. If a cause is not found, depending on the age, no treatment may be suggested. However, it is common that children who are young will be offered Lupron or another medication to cause the LH and FSH to shut down the testicles and ovaries until the appropriate time for development. Since they shouldn't have hormones already, this does not cause the problems and side effects that you see with adults. Using hormone blockade allows for a normal childhood and attainment of full height which may be blunted by high hormone levels.

Some children will always be the early bloomers and some children will always be late. But if we can watch for those that are negatively been affected by the world around us and rather than just accept this new baseline and instead take action to educate others and change what we can, perhaps our children have a better chance of reaching their full potential.

Best Wishes

Dr Alison McAllister

For more information on precocious puberty see http://emedicine.medscape.com/article/924002-overview OR http://www.nichd.nih.gov/health/topics/precocious_puberty.cfm

Barriers to Hormone Absorption

2011-06-09T12:13:00.000-07:00

Lower than expected lab results with supplementaion is something that almost everyone will see. There are several reasons for this:

Not using the full dose prescribed

Skipping a dose before collection

Showering too soon after hormone application

Applying moisturizers, creams or lotions prior to dosing with topical hormones. Moisturizers and body lotions can act as a physical barrier that delays or prevents transdermal hormone absorption.

In discussing a patient’s low hormone levels with one practitioner, we went over the common reasons as described above. None seemed to apply as the practitioner was diligent with her instructions before giving out the test kit. However, these are very common mistakes, so i suggested re-checking with the patient. With further investigation the practitioner called back to report that the patient had been using a moisturizing body wash (aka shower gel).

Now, you would think that body wash should not pose a problem. After all, like soap it's supposed to "wash" the body, right? Yet, the product's website claims that it contains special moisturizers that don't just sit on top of the skin. New technology enables the moisturizers to be absorbed deeper into the skin. It seems likely that the deeper absorption would create a barrier which could interfere with hormone absorption. The patient will discontinue the body wash for several days, continue to apply her topical hormones as prescribed and then recollect for a retest. The new results should be interesting!

For more information on how to collect the best sample and best the most accurate test result, see ZRT's handout on the web: ZRT handouts
OR watch a video on saliva or blood spot collection

Sherry LaBeck ND

GOT IODINE? How to get enough Iodine through your diet

2011-05-17T10:11:00.000-07:00

Iodine is an essential component of thyroid hormone (T3 & T4) and important for normal thyroid functioning. It also functions as an antioxidant, an anti infective agent and is protective in certain cystic conditions like fibrocystic breast disease and ovarian cysts. Iodine is found in the soil and the oceans, however the iodine content in soil varies from region to region. Subsequently, foods grown in different regions vary in iodine content as well.

How much Iodine is needed each day?

The Recommended Daily Allowance (RDA) for iodine is 150 ug/day for proper thyroid functioning. It is important to note that many other tissues of the body need iodine for good health as well.

• Adults 150 ug day
• Children 90-120 ug /day
• Pregnancy 220 ug/day
• Breastfeeding 290 ug/day

Higher levels of iodine intake have been shown to be protective against benign breast changes such as fibrocystic breast disease. Studies show a daily intake of 3000- 6000 ug/day to be helpful and tolerable for this condition. These higher levels are similar to the typical daily intake seen in Japan.

To be certain our bodies are sufficient in iodine, we can eat foods high in iodine and/or take an iodine supplement. Below is a list of the amount of iodine found in foods. Many people assume that all seaweeds have a lot of iodine. But if you look closely at the table, you will notice a great deal of variability in the amount of iodine found in different types of seaweed. Kelp has the most and nori has the least. This means that your weekly nori roll at the sushi restaurant may not be giving you enough iodine to be sufficient!

Dietary sources of Iodine in ug

SEAWEEDS
Kelp 3400 1 tsp
Arame 730 1 Tbs
Wakame 80 1 Tbs
Nori 32 1 sheet

FISH
Cod 341 3 ounces
Shrimp 79 3 ounces
Halibut 56 3 ounces
Herring 56 3 ounces
Sardines 30 3 ounces
Tuna 17 3 ounces

SALT
Iodized salt 76 1 tsp

DAIRY
Cow’s milk (US) 56 1 cup
Mozzarella cheese 10 1 ounce
Yogurt 87 1 cup

OTHER FOODS
Turkey breast 34 3 ounces
Strawberries 12 1 cup
Egg 23 1egg

SUPPLEMENTS
Iodoral TM 12,000 1 tab
Lugol’s TM 5% 6250 Per drop
Typical multi vitamin 150 Per serving

References
Medical Nutrition from Marz 2nd edition. Russell Marz ND MAcOP C 1999 Omni Pennington JAT, Schoen SA, Salmon GD, Young B, Johnson RD, Marts RW. Composition of core foods of the U.S. food supply, 1982-1991. III. Copper, manganese, selenium, iodine. J Food Comp Anal. 1995;8:171-217.

http://www.whfoods.com/genpage.php?tname=nutrient&dbid=69#references

Teas, J., Pino, S., Critchley, A., Braverman, L.E., 2004. Variability of iodine content in common commercially available edible seaweeds. Thyroid 14, 836–841.

We do research so you don't have to! ZRT docs on staying up-to-date with hormone research

2011-03-02T15:40:00.000-08:00

I'm often asked where I find out all the hormone information that we are able to share with you. The truth is that the docs here at ZRT are voracious readers. On a routine basis, I scour a variety of resources to try to stay on top of all things hormones, herbs, and medicine. For this blog, I thought I might share a few of the articles that have caught my attention - a review of the reviews so to speak. I hope that one of these peaks your interest.

Osteoporosis docs urge screening for more women.
The current recommendation is to screen women older than 65 or younger women at higher risk. Men were considered to have insufficient evidence to promote screening.

Alison's comments. By the time you are screening a 65 year old, your ability to change their course of osteoporosis is severely hampered by the 10+ (average) onset of menopause and postmenopausal bone loss. Instead, consider at the onset of menopause or at least age 50 to see if hormone supplementation benefits outweighs risk for bone health. In men, consider routine screening as well. As the population of men have a drop in testosterone, an increase in cardiometabolic syndrome, a decrease in exercise and nutritional status; then all men become at higher risk for osteoporosis. Certain individuals with family history in osteoporosis may also benefit from screening much earlier. Also, consider testing vitamin D to prevent future problems.

Increased pregnancy loss rate in thyroid antibody negative women with TSH levels between 2.5 and 5.0 in the first trimester of pregnancy.
Women with autoimmune antibodies have higher miscarriage rate, but this is one of the few studies to look at autoimmune negative women. Women with autoimmunity have twice the rate of pregnancy loss. Women with TSH levels < n="4123).">

Alison's comments. Sarcasm is tempting here, but there is a point when you have to step back and really look at the situation. If I was pregnant and I could cut my risk of miscarrying a wanted baby by half without any detriment to my health or the baby's I think we have to question how criminal it is to NOT screen all women and treat them. Many women aren't tested for thyroid early in the first trimester and most are not screened preconception, and I wonder if we did more screenings could we change the now standard miscarriage rate. Take home: encourage preconception thyroid screening and EARLY pregnancy screening of thyroid; maintaining TSH levels.

Sexy thoughts: effects of sexual cognitions on testosterone, cortisol and arousal in women.
Abstract states that thinking sexy thoughts increased testosterone, but didn't change cortisol. They also found that baseline testosterone and use of hormonal contraceptives may blunt this.

Alison's Comments. I find this intriguing because we don't usually think of hormones outside of cortisol to be under our control. This sexy thought workshop only lasted 15 min. It's a good article to back up mindful fantasy for men and women experiencing low libido.

Adaptogens exert a stress-protective effect by modulation of expression of molecular chaperones.
First rule of researching herbs in pubmed is to know the botanical (latin) name of the herb. Many, many pages of articles exist in the medical literature about herbs. This article is about a product (no endorsement) which is a combination of Schisandra chinensis, Rhodiola rosea and Eleutherococcus senticocus (i.e. siberian ginseng). What they found was when they tortured mice (sorry, but that's what they do) by making them swim to exhaustion, they were able to swim with less emotional trauma after adrenal support. This theory is that the use of the herbs increased the expression of heat shock proteins (Hsp 72) which mediated the stress response. To learn more about heat shock proteins check out wikipedia

Alison's Comments. I absolutely love when science backs up and supports the use of herbal remedies that have been used for generations based on folklore, kitchen wisdom, herbal heritage, and old fashioned remedy. My ultimate favorite is finding out how something works from my old merck manual 1895 edition (which I and the other docs here actually know how to read). So, I love learning about Eleutherococcus. However, it did make me wonder about it's use in people with Melanoma after brushing up ala wikipedia and seeing that heat shock protein 72 is already highly upregulated in that disease.

Ah… I think I feel another literature search coming on…

Dr Alison McAllister

ZRT participates in research around the world. Click here for the latest in our collaborations.

Too Much Of A Good Thing

2011-01-26T10:55:00.000-08:00

Not too long ago a provider questioned me about the adverse effects of testosterone supplementation. He was concerned as one of his clients, a physician, was admitted to the hospital for complications related to an increase in red blood cells (polycythemia). The client had been using 100 mg of topical testosterone for several months and the provider wondered if this could be a contributing factor. Our conversation started a lively discussion with the other doctors on staff at ZRT and I decided it was worth sharing with the community

With several articles on hypogonadism in aging males coming out in the last few years, testosterone replacement has become commonplace. And while it’s easy to see the benefits of testosterone therapy, we need to know the risks as well. Most of the adverse effects are not often seen with physiological testosterone levels and it’s usually the supra-physiological levels we see with high testosterone dosages that are problematic.

One adverse effect of elevated testosterone that occurs most frequently is secondary polycythemia. Secondary polycythemia is a condition in which an abnormal increase of red blood cells (RBCs) is generated in response to a medication/hormone or underlying condition. Erythropoietin, from the kidney and liver, is the primary hormone that stimulates production of RBCs. Testosterone works synergistically with erythropoietin which can lead to an elevated hematocrit (number of RBCs). Several studies have documented an association between testosterone supplementation (injection and transdermal) and an increase in hematocrit (i.e. polycythemia), sometimes twice as high as with placebo.

Symptoms of polycythemia may include headache, lethargy and hypertension. Complications are related to changes in the blood. An increase in blood viscosity and a decrease in circulation set the stage for blood clots, which can lead to a stroke, heart attack, pulmonary embolism or deep vein thrombosis. Polycythemia, secondary to testosterone administration, is usually reversible with dosage adjustment or discontinuation of supplementation. Blood donation is another means of ridding the body of too many red cells.

Accordingly, men receiving testosterone replacement should have their hematocrit checked before initiating therapy, six months after and then annually. And to avoid any adverse consequences, adhering to physiological dosing practices is important. Deficiency symptoms may take slightly longer to resolve with lower testosterone levels, but down-regulation of the receptors does not occur as it can with supra-physiological dosing. While not everyone using testosterone therapy will experience the complications indicated above, monitoring the RBC count can identify those men with the predisposition.

Sherry LaBeck, ND

When Things Don't Go As Planned

2010-10-20T15:26:00.000-07:00

As a clinician you want the answers and certainly your patient wants you to have them. There is total satisfaction when someone comes in and says "I have this" and you know exactly what to do. I imagine it's what makes doctors go into orthopedics and surgery. "That hurts?", I'd say. "I'll add some plates, screws, or just remove that little bit and EVERYTHING will be better".
Sadly, hormone balance can be a bit trickier.

So, when a patient is frustrated with not getting better, it seems that I am almost as frustrated at not being able to help them get better.

Sometimes, I'm frustrated at the patient, since commonly the patient forgets that they didn't do the steps that you wanted them to because of time or money or willingness.

Other times, I'm frustrated because I too, don't know why they haven't improved. It worked for other patients and should have worked for them. It makes me start to look outside of myself to see who might have a different take on this patient. Who might be able to do or see what I couldn't?

And then there are the unique patients. The ones I desperately want to help, have no idea what's wrong and don't know where in the world to send them. Any one with a cure for closed head trauma brain dysfunction in the NW, please contact me.

But, these patients that you want to help the most and who don't react the way you expected can teach you new tricks.

One of my favorite stories is about a woman who came to me trying to get pregnant.
She had tried for several years without success, was young, and didn’t have any "classic" reason to be facing infertility. BUT, she had menstrual spotting from ovulation until her period. Multiple OBGYNs had told her that that wouldn't make a difference, but physiologically, that didn't make sense to me. So, we set upon giving her progesterone. So me in my cocky way, started her on progesterone. After all, how hard could it be? We see this every day.
Well…
It did nothing.
Still spotting.
...Great! (read sarcasm here)

Next cycle - we upped the dosage and when she started to spot I doubled it! Then doubled it again!
Yup - spotting away.

Hmmm… Ok, lets try oral. (Clinically, I find that the oral progesterone may stop dysfunctional bleeding better than topical; perhaps because of the action of progesterone metabolites).
Anyone guess?
Yup, continued to spot.

Thankfully this woman was very patient with me and a few other symptoms that she had were getting better. So I changed her dosage for the next month and started her a couple of days earlier than ovulation.

SHE STILL SPOTTED.

In utter frustration for both of us, I suggested that she use one of those oral capsules and just insert it vaginally.

AND IT STOPPED!

And it continued to stay stopped at much less than 1/2 the dosage I had been using orally (200mg vaginally if you care to know).

The next month she got pregnant doing vaginal progesterone from ovulation to day 28. I kept her on it the entire first trimester. A very happy ending.

Needless to say, now I consider vaginal progesterone even when oral and topical have failed.

Anyone else care to share a success born out of failure?

Dr Alison McAllister

Better Patient Care With Lab Testing

2010-09-30T11:54:00.000-07:00

You can tell a lot about someone’s health from their symptoms, physical appearance and a simple physical exam. But sometimes getting more data is critical to unearthing the right diagnosis. Luckily, we live in an era in history where the technology exists to delve deeper into a situation. We can make a phone call from a small wallet-sized phone from almost anywhere; we can send a letter in a few seconds to a person who lives on the other side of the world; and we can test our blood, saliva or even our urine for hints to our health.

I see a lot of patients who have ongoing health issues that somewhat improve with simple lifestyle adjustments, but don’t completely go away. It’s these cases where I find laboratory testing most useful. Obtaining more information as to what is going on inside the body can be so helpful in guiding diagnosis and treatment.

Let’s take the case of hormone balance. Hormones are important for so many things- fertility, feelings of wellbeing, energy, memory, sex drive, muscle function, etc..., the list goes on. Symptoms alone can often tell the doctor what needs to happen in order to reinstate hormone balance - but sometimes testing a woman’s hormone level at a particular time in her cycle is critical for making the right changes to her hormonal milieu to achieve balance. One symptom might look like estrogen deficiency, but really be related to adrenal fatigue or thyroid imbalance. For example, some women experience hot flashes when they are low in cortisol, while others are simply low in estrogen. Let’s take another symptom- hair loss in a woman. Initially you might think thyroid. But when you test you find her thyroid is normal, it’s her high testosterone that is causing the hair loss.

Hormones work together in a symphony of sorts, playing off of and complementing one another for health and harmony. But when one hormone suffers, the others do, too. The data and information we gather from testing, is invaluable in creating wellness and vitality in individuals. Fortunately, we have the technology!

Elise Schroeder, ND

Pearls From a Summer Conference

2010-08-24T17:09:00.000-07:00

The American Association of Naturopathic Physicians (AANP) held their 2010 convention last week in my neck-of-the-woods. In attending each day, I realized there are pros and cons to having a conference in the area where you live. One of the advantages of having it close to home is that you don’t have the hassles that go along with traveling, such as flying, booking hotels, eating out, etc. Another plus is that your normal routine is not interrupted to a great degree since you’re able to go home after attending the lectures. However, I found that this aspect can also be a disadvantage. Returning home at the end of the day means that you still have to do chores, water the garden, cook evening meals and do dishes afterward, instead of relaxing in your room or at the pool. However, with reflection, the pluses outweighed the minuses and there were some pretty interesting “pearls” of information I gleaned from the lectures I attended.

One of the first pearls came in a lecture about small intestine bacterial overgrowth (SIBO). Most discussions about normalizing gut bacteria are about the large intestine, so focusing on the small intestine was somewhat new to me. An important pearl the lecture provided was four key indicators to consider SIBO. The indicators to be alerted to: are when patients report an improvement in GI symptoms with antibiotic use, report worsening of GI symptoms from probiotics, report worsening of constipation with use of fiber and when Celiac patients report little improvement from gluten-free diets.

Another lecture shared the history of Gelotology, the study of laughter. Several studies presented showed that humor/laughter, from watching comic videos, had a discernable positive effect on allergy induced skin problems. The pearl here was the presenters reminding us of how, in general, laughter can be good medicine and then they proceeded to tell jokes for a good part of the hour. I’d relate a couple of the jokes, some of them were really funny, but I can’t remember them.

Cosmetics and personal care products were the subject of great interest to many conference attendees. I also found the information interesting although it made me a little fearful of what’s in my bathroom cabinet. I wanted to trash all my current face, hair and body cleansing products and go shopping for new products, armed with the best information I now had. There has been a lot of media coverage about the health effects of Bisphenol A, found in plastic bottles, IV tubes, etc. But other chemicals, such as hydroquinone and phthalates (pronounced thalates), has not had as much press.
Phthalates are found in a variety of products mainly acting as a “plasticizer” making plastics more flexible, but also used as a solvent. Many medications and any product that has a synthetic fragrance contain phthalates. One primary problem with phthalates is that they disrupt the endocrine system, altering reproductive hormone levels in both men and women. This chemical is also linked to liver cancer. Hydroquinone is found in skin lightening creams, moisturizers, sunscreen, hair coloring products and cigarettes. This chemical has been found to cause skin irritation and contact dermatitis, but is also associated with skin tumors and cancer. The following link will provide more information about these and other chemicals EWG

Two of the most inspiring lectures were the opening and closing sessions, which featured “elders” of the naturopathic profession, Dr. Jared Zeff and Dr. Joseph Pizzorno. The first day, Dr. Zeff led us through the evolution, history and current status of naturopathic medicine, some of which I had never known. Then the last day, Dr. Pizzorno discussed how naturopathic medicine has integrated with conventional medicine and talked about the future of the profession. There was such a variety of lectures and so many more information pearls I could share. All in all, I feel pretty blessed that the AANP conference was held in Portland and that I had the chance to attend.

Sherry LaBeck, N.D.

DHEA as Vaginal Treatment

2010-07-21T08:27:00.001-07:00

Dr. Alison McAlister, ZRT Laboratory Clinical Consultant, talks about the importance of DHEA to women's health and possible treatment options in case of deficiency.

Low Dose Naltrexone

2010-07-20T13:30:00.000-07:00

Naltrexone, traditionally used in higher doses to manage alcohol and opioid dependence, is now being used in low doses in conditions of immune dysregulation. This treatment is referred to as “Low Dose Naltrexone” or LDN for short, and it was the topic for this month’s “Let’s talk Teleconference”, which I host. I was very lucky to have Natalie Gustafson, pharmacist and owner of Pacific Compounds in Hillsboro Oregon, as my guest. She was very excited about the interview because of the amazing results she has seen using this medication.

As an opioid antagonist, naltrexone literally blocks opioids from hitting their receptors. At high doses (50 mg), naltrexone continuously blocks (all day long) the opioid receptors in the brain, blocking the pleasure that one might experience from alcohol or drugs. In low doses (1-4.5 mg /day), Naltrexone blocks the receptors for only a few hours, just enough time to stimulate the body to produce more endorphins and enkephalins. It’s thought that LDN boosts the immune system via this transient surge of endorphins.

Practitioners who have used LDN (like Natalie) have seen it improve symptoms in conditions that are otherwise very tough to treat- like multiple sclerosis, fibromyalgia, rheumatoid arthritis, Crohn’s disease, and psoriasis. Typical doses range from 1.5 mg /day to 4.5 mg /day and practitioners are advised to start low and increase the dose slowly. Vivid dreaming and insomnia are the most common side effects when the dose is started to high.

To listen to my interview with Natalie, go the medial vault on the ZRT website and click on the LDN teleconference. To learn more about LDN and its uses you might consider the following website: Lowdosenaltrexone.org

As a new and upcoming treatment for some very difficult to treat conditions, LDN seems promising. Hopefully we will see some studies coming down the pike to help us discern the effectiveness and the exact mechanism of action. In the meantime, we can rely on those providers out there on the clinical frontline, using it every day and getting results.

Elise Schroeder ND

Skin Tags and Metabolic Syndrome

2010-07-06T09:42:00.000-07:00

Dr. Deborah McKay, ZRT Laboratory Clinical Consultant, talks about recent studies indicating that skin tags might be indicative of metabolic syndrome.

For the original video, click here.

Progesterone vs. Progestins

2010-06-23T14:35:00.000-07:00

Dr. Elise Schroeder, ZRT Laboratory Clinical Consultant, talks about the difference between progesterone and progestins, terms which are often used interchangeably by mistake.

For the original video, click here.

Hypertension, Hepatocytes, and Fructose

2010-06-17T11:33:00.000-07:00

Frequently I tell my patients that fructose is a liver toxin. Their most common response is, “Fructose? You mean corn syrup, don’t you? Surely you can’t mean natural fruit sugar from apples and pears?” Yes, I do mean to include natural fruit sugar – regardless of the source, excess fructose is a liver toxin. The dose of fructose is much higher in soda pop than in whole fruit or carrots, but biochemically speaking, it’s the same molecule, whether it arrives in the sugar bowl, a glass of juice, a can of pop, or in a health food snack bar.

Fructose targets the liver, because that’s pretty much the only part of the body capable of metabolizing it. In the liver, fructose wreaks havoc in several ways: it damages hepatocytes, stimulates production of uric acid, and is metabolized into circulating lipids (triglycerides and low-density lipoprotein, the so-called “bad cholesterol.”) A liver that has been damaged by excessive fructose looks almost exactly the same as a liver that has been damaged by excessive alcohol.

Fructose also causes high blood pressure: Uric acid is one of the bigger culprits behind hypertension. Uric acid constricts blood vessels and causes oxidative damage, in addition to its notoriety in causing gout (painful inflamed joints in the feet). Uric acid is so reliable in this regard, that laboratories testing new blood pressure drugs use fructose to induce hypertension in their laboratory animals. That’s right; a healthy mammal that is overfed on fructose will reliably develop hypertension.

Fructose’s effects in the liver don’t stop at uric acid and hypertension; it also induces fibrosis (formation of scar tissue) in people who have fatty liver disease – which is a surprisingly common condition: about one in five seemingly healthy American has NAFLD, non-alcoholic fatty liver disease. Due to the lack of troubling symptoms, most cases are undiagnosed (and therefore untreated). A new study published in the journal Hepatology in January 2010 points out that heavy intake of fructose is defined as one or more servings of fruit juice (!) or soda pop per day, and is associated with fibrosis of the liver. Heavy fructose consumption is also associated with increased liver inflammation in older adults. How many people are drinking fruit juices every day, believing that it’s good for their health, when in fact it is damaging their livers?
One current fad food (or rather, “foodlike substance,” as journalist Michael Pollan says), is agave syrup, also called agave nectar. Commercial agave syrup is even more nefarious than high fructose corn syrup in terms of its fructose content: HFCS is commonly about 55% fructose, while agave syrup can be as high as 90% fructose in some cases. By comparison, ordinary corn syrup, for example Karo Syrup, has no fructose whatsoever; it is plain dextrose, also known as glucose. I find it stunning that a known liver toxin would be marketed as if it were a health food, but the rules of the game in marketing and advertising are not the same as the rules of biochemistry.

High-fructose anything is not good nutrition, nor is it good for human health; however, it is great for sales – fructose tastes about twice as sweet as glucose, and it has a stronger browning reaction in prepared foods. Sweet, crispy, caramelized, well-browned crusts are selling points when it comes to industrially-prepared “foodlike substances.” If only it were as good for our bodies as it is for the manufacturers’ sales quotas. Just some food for thought! Love your liver if you want to live long and prosper.

To your good health,
Deborah McKay ND

Vitamin D

2010-06-07T13:40:00.000-07:00

Dr. Elise Schroeder, ZRT Laboratory Clinical Consultant, talks about the prevalent Vitamin D deficiency, how important Vitamin D is to our health, how to determine if your Vitamin D levels are normal, and if low, how to supplement.

For the original video, click here.

Adrenal Dysfunction

2010-05-27T08:41:00.000-07:00

Dr. Alison McAllister, ZRT Laboratory Clinical Consultant, talks about the symptoms, physiology and treatment of adrenal dysfunction.

For the original video, click here.

Topical Hormones - How Is Your Skin?

2010-05-18T07:44:00.000-07:00

Dr. Deborah McKay, Naturopathic Physician at ZRT Laboratory, talks about occasional low hormone levels in patients on bioidentical hormone replacement therapy (BHRT).

For the original video, click here.

DHEA as a Vaginal Treatment

2010-05-14T15:33:00.000-07:00

We think about DHEA for help with adrenal function, help with energy and immunity, but how many people have been thinking about DHEA for vaginal health?

Well if you haven’t, now may be the time.

Using DHEA vaginally has been in the research since about 2005, but only recently has it been getting more press with 2 studies this year alone. Studies have found that DHEA supplementation had both an estrogen and androgenic effect on vaginal tissue, perhaps creating a best of both world situations. Research showed that the mucus layer of the epithelial tissues the collagen layer, and muscle layer all improved with DHEA vaginal treatment. Interestingly though, more has not been found to be better; lower dosages perform just as well as the higher dosage.

How could this be working?

DHEA is the precursor to androstenedione which is a precursor to both testosterone as well as estradiol. Oral DHEA supplementation appears to have different effects in women as compared to me. Men appear to take any excessive DHEA and convert it to estradiol while women appear to take excessive DHEA and convert it to testosterone in their tissues. It appears that vaginal tissue has the ability to use both pathways depending on what the woman’s tissue needs.

Prasterone™/Prestara™ /Aslera™ /GL701 / DHEA) was originally given a NDA for the treatment of Systemic Lupus. Since the drug form of DHEA is likely reaching the end of its patent, there is renewed interest in creating new indications. There are currently about 45 studies that have been initiated, active, or already discontinued looking at DHEA treatments. Perhaps we can expect a new vaginal medication in a couple of years? Some studies are already in phase III clinical trials.

Until then, what can you do if you want to try it out? DHEA is an OTC supplement and any compounding pharmacy should be able to create a vaginal suppository or vaginal cream similar to those used in the studies. The studies have used dosages of 3.25mg to 13mg. Since the 3.25 mg dosage worked as well as the 13 mg I would not see any reason for using the higher dosage. In fact, since you are going for a localized effect, my educated guess is that even ½ that dosage – 1.5 would work well for many women. Using DHEA may also have a higher safety rating than using vaginal testosterone since you are unlikely to trigger irreversible clitoral hypertrophy which maybe caused rarely by testosterone especially at higher dosages.

If you’ve used it in patients and want to let us know how it worked, please leave a comment and tell us about the experience. We would love to hear if there are any tricks in dosing or in compounding that can help other healthcare professionals.

Until then – go DHEA!
Dr Alison McAllister

Labrie F et al. 2010. High internal consistency and efficacy of intravaginal DHEA for vaginal atrophy. Gynecol Endocrinol. May 12. (Epub ahead of print).

Berger, L et al. 2005. Effects of dehydroepiandrosterone, Premarin and Acolbifene on histomorphology and sex steroids receptors in the rat vagina. J Steroid Biochem Ml Biol. Jul;96(2): 201-215.

BIO RYTHMS

2010-04-21T12:03:00.000-07:00

Every day I discuss adrenal health with practitioners and the importance of assessing a patient’s circadian rhythm. But last week someone asked me “what is the circadian rhythm?” Although I was able to explain the concept in simple terms, I started thinking – this is anything but simple…what is a circadian rhythm really?

The term circadian is derived from the Latin words “circa” meaning around and “diem” meaning day, translated 24 hours. Wikipedia defines the circadian rhythm as a 24-hour cycle in the biochemical, physiological or behavioural processes of living entities. Science has set specific criteria to identify a true endogenous circadian pattern:

1) The rhythm persists in constant conditions in a 24 hr period.
2) The rhythm persists over a range of temperatures.
3) The rhythms can be reset by exposure to an external stimulus.

My tendency was to think of the body’s circadian rhythm as primarily pertaining to the adrenal glands and cortisol synthesis. However, this does not seem to be the case. There are many autonomic, endogenous processes, besides cortisol secretion, that have a 24 hour circadian rhythm, including control of body temperature, cardiovascular function (heart rate and blood pressure), melatonin secretion, metabolism and sleep. Many of these are interrelated, affecting each other. For example, melatonin levels usually run opposite those of cortisol, but both have a 24 hour cycle. High night time cortisol levels may delay the normal rise of melatonin affecting sleep patterns.

Circadian patterns in mammals are controlled by the suprachiasmatic nucleus (SCN), a small group of cells located in the anterior hypothalamus of the brain acting as a pacemaker. Neuronal pathways into the SCN from other parts of the brain, along with fibers from the SCN to target tissues, result in a stable system of circadian rhythms. However, alterations to this system can occur. The environmental factor of the light/dark cycle of day and night is important for keeping circadian rhythms synchronized. Visual signals of light from the retina are sent to the SCN through the retinohypothalamic tract (RHT). These signals are then used to “set” our internal clocks and endogenous circadian rhythms. In contrast, research has shown that blindness or even constant darkness can alter the “settings” and lead to variations of the diurnal rhythm and secretion of several hormones, including melatonin, cortisol, growth hormone and gonadotropin hormones (FSH & LH). http://www.ncbi.nlm.nih.gov/sites/entrez

Although my search started with what I thought was a straightforward question about adrenal health and cortisol, it unexpectedly uncovered a larger field of study specializing in biological and circadian rhythms. I should have realized that anything to do with hormones is complicated, one piece of a puzzle leading to another. Yet, the normal, physiological pattern of cortisol, morning elevation and evening decline, is important for a healthy life, if only as a single part of the whole.

Sherry LaBeck, ND

Progesterone vs Progestin: The curious case of a mistaken molecule

2010-04-07T12:20:00.000-07:00

Progesterone is a steroid hormone produced by the adrenal gland in both men and women, the testes in men and the ovary in women. It plays a role in the female menstrual cycle and pregnancy and circulates throughout the body binding to receptors in the brain, the cardiovascular tissue, breast tissue and more. Progesterone is also a precursor to other important hormones in our body- cortisol, aldosterone, testosterone and estradiol.

Progestins are a synthetic progestogens that bind some progesterone receptors in the body, but not all. They were produced first in 1938 in hopes of finding a patentable drug that could work like progesterone in the body. While chemically similar to progesterone, they are not identical, and this makes them patentable.

Since Progestins and Progesterone are different molecules they have different effects on the body. As a general rule, synthetic progestins are more potent that bio-identical progesterone. They have a longer half life than progesterone, have greater relative binding affinities and have been found to have a stronger affect on the endometrium at lower doses than progesterone. Thus -more potent. Progestins also can have androgenic qualities like increased facial hair growth while progesterone can be used as a treatment to reduce this symptom.

The metabolism of these two hormones differs quite a bit. Metabolites of progesterone are well known and include dihydroprogesterone, pregnenolone, pregnanediol and their isomers. Progesterone metabolites can be found in feces, urine, saliva and blood. Less is known, however, about the metabolism of progestins. One thing we do know is that progestin metabolites while fewer in number, have biologic activity themselves. Norethindrone in fact metabolizes to ethinyl estradiol increasing that total amount of ee that an individual is exposed to in combined HRT.

It’s a very common mistake among health care professionals to use the terms progesterone and progestin interchangeably. But this mistake can be deadly. We know now that progestins have an unfavorable effect on the cardiovascular system while progesterone can be used to treat and prevent cardiovascular disease. A great review of this can be found in the Hermsemeyer et al article “cardiovascular effects of medroxyprogesterone acetate and progesterone: a case of mistaken identity?”

Progesterone protects against estrogen-induced breast cancer, as seen in the following study in the http://aje.oxfordjournals.org/cgi/content/short/114/2/209 and as outlined in Dr John Lee, David Zava and Virginia Hopkins book “what your doctor may not tell you about breast cancer”. Synthetic progestins when combined with estrogen increase a woman’s risk of breast cancer. Recent studies can be seen at these links http://content.nejm.org/cgi/content/abstract/332/24/1589 http://jama.ama-assn.org/cgi/content/abstract/283/4/485

So if progestins can increase our risk for cardiovascular disease and breast cancer, while progesterone prevents them, if they each have their own distinct chemical structure, if they are metabolized differently and affect our other hormones in two different ways- how can we refer to them interchangeably? They are clearly affecting our health and our bodies in different ways. They are different!

We certainly don’t know everything there is to know about these two hormones yet. There is always more to learn. Current evidence suggests that using progesterone is a safer and more beneficial choice than progestins and naturally, it make sense that we might want to use a molecule that our own body makes. But what’s most important as health care providers, as researchers and health educators is that we come to understand that there is a distinct difference between Progesterone and Progestins and call it like it is!

Elise Schroeder ND

Armour’s Back- a return of an old or maybe a new friend?

2010-03-30T12:14:00.000-07:00

Hurray, Hurrah Armour thyroid is available again!
For those like me that prescribe Armour™, this puts an end to the pain of having to change people from Armour to one of the various types of thyroid supplementation available. In the past 6 months, I've changed people from Armour to Synthroid™, generic T4, Cytomel™, generic T3 (now available hurrah again), Nature-throid™, Westhroid™, compounded desiccated thyroid, T4 and T3, and every combination possible. We've dealt with dosages that were too much and too little from people who were perfectly controlled on their Armour prior to it not being available on the marketplace. But happily, we now seem to have a steady supply of our medications.

Of course, it's important to know that Armour isn't quite the same as it was, say 2 years ago. The company made some changes to the fillers in Armour. They decreased the dextrose (a sugar) and replaced it with cellulose (a fiber) and added cornstarch (fiber). They did this to try to increase the absorbability of the tablet by improving its properties of disintegration. Unfortunately, thyroid is very picky. When you change the fillers or binders in thyroid supplementation it will change absorption by 20%. Up or down. We know this because even going from brand name Synthroid to generic T4 (same dosage) may change absorption for patients. This was quite the nightmare before it was discovered. Patients were getting generics by different companies every month or were regularly changed from Synthroid to generic to Synthroid again. Symptoms would be great, then worsen (which led to lab testing showing inadequate or excessive dosing), which then would be altered, only to be completely problematic when they next filled their prescription. With generic brands being made by multiple companies, the label would stay the same - T4, but the colors of the pills would give it away - pink, then green, then pink again. Thankfully, someone finally realized that the fillers and binders in thyroid make all the difference - approximately 20% in fact.

So, Armour changed their fillers and what happened? Search for Armour reformulation and you can read the horrors. Patients who were stable on 60mg all of a sudden were hypothyroid again. Now, they needed 90mg or more; rarely they needed less. Basically, it was like changing to a completely different thyroid medication. Some patients have actually had such a hard time metabolizing their tablets that even increasing the dosage didn't help. This should not have been a surprise to Forest Pharmaceuticals the manufacturers of Armour. Individuals with thyroid dysfunction often have problems with digestion. Most triggers for Hashimoto’s (the most common reason for becoming hypothyroid) are gastrointestinal triggers and 50% of patients with Hashimoto’s have antibodies to their own gastric cells (http://www.thyroidmanager.org/Chapter10/chapter10.html) which means that digestion is compromised. For those people, changes in fillers and binders make huge differences. For many this meant a return of old symptoms, but for people on multiple medications this may have had severe consequences as other medication potency increased from a severely decreased metabolic clearance. How many problems due to this is unknown.

This formulation change took place in the spring of 2009 and was unpublished at the time. No doctors or pharmacies were notified. Then, while I was still trying to figure this out, Armour disappeared. I personally wondered if it was due to the change in formulation. The rumors started flowing; implicating the FDA, new drug applications, permanent stop in manufacturing, stop in all desiccated thyroid products etc. However, it soon became clear that the raw materials were unavailable, but why? Good question. The fact that Armour is from pigs and H1N1 (swine flu) was rampant at the time seems a bit suspicious, but unconfirmed. But the sad result was this thyroid supplementation was gone and soon all other desiccated thyroid products followed. For patients who have doctors who love the thyroid, this was an inconvenience, but generally easily switched to some combination of T4 and T3. Since any change requires some fiddling, it commonly took another 1-2 months before we were both sure that this was the right dosage. But, since once again we were changing fillers, the likelihood of increasing or decreasing dosages was common. For patients who don't have healthcare providers that understand thyroid, they have had to put up with T4 only therapy being told it will do the same thing (which it isn't) and is better (debatable). For those individuals who don’t convert well between T4 and T3, they have suffered. So, I'm thrilled that Armour and Naturethroid and Westhroid (same product with two names) are back. Although I think that there is no such thing as the right way to treat hypothyroidism, I personally find these forms to be well tolerated, inexpensive, very effective, and convenient for many patients.

I believe that this fiasco has brought to clear attention how delicate and dependant we all are on the flow of medications. I think that it also brings to clear attention the "inactive" ingredients so commonly ignored by myself and other prescribers. They are the reasons that generics and brand names may be very different. I would also like to see Forest Laboratories and others make a policy of notifying pharmacies in the future that their product fillers have changed and therefore dosages may need adjustment. It also brings to light the helpfulness in the internet in linking people with common complaints. It is of course, how I,a physician, found out what was going on. I know that the researchers at Forest thought that this would be a small change, not noticed and of no significance, and I'm sure that some didn't. But for those that did - Hurrah, Hurrah your Armour is back, it just might need some dose adjustments.

Now, what happened to Thyrolar™?
Alison McAllister, ND
PS. Please note this is not about which is the right thyroid or why one is better than another or all the options available. This is about fillers and the impacts they have on what should essentially be the same medication.

http://www.armourthyroid.com/ - Forest Laboratories; has a handy calculator if you are switching from T4 to Armour. Fun fact, Armour got its name from the animal processing plant that harvested the thyroid glands.

Westhroid- a look at inactive ingredients put into supplements. A nice review from Westhroid a T4/T3 combination medication

http://thyroid.about.com/ - I highly recommend this site to my patients as well as other healthcare professionals. As a blog about thyroid, Ms Shomon has provided invaluable information about the changes to Armour. She continues to watch the situation closely.

http://www.thyroidmanager.org/ - for those that love the deep gory biochemical details. Fabulous. Dr DeGroot and her team have done an amazing job in putting together the best thyroid textbook I've seen yet (If you know of a better let me know!).

Proof that stability is a big issue in ALL THYROID BRANDS.

Thyroid. 2009 Feb;19(2):103-10.
TSH-based protocol, tablet instability, and absorption effects on L-T4 bioequivalence.
Eisenberg M, Distefano JJ.
Biocybernetics Laboratory, Departments of Computer Science , Medicine and Biomedical Engineering, UCLA, Los Angeles, California.

BACKGROUND: FDA Guidance for pharmacokinetic (PK) testing of levothyroxine (L-T(4)) for interbrand bioequivalence has evolved recently. Concerns remain about efficacy and safety of the current protocol, based on PK analysis following supraphysiological L-T(4) dosing in euthyroid volunteers, and recent recalls due to intrabrand manufacturing problems also suggest need for further refinement. We examine these interrelated issues quantitatively, using simulated what-if scenarios testing efficacy of a TSH-based protocol and tablet stability and absorption, to enhance precision of L-T(4) bioequivalence methods. METHODS: We use an updated simulation model of human thyroid hormone regulation quantified and validated from data that span a wide range of normal and abnormal thyroid system function. Bioequivalence: We explored a TSH-based protocol, using normal replacement dosing in simulated thyroidectomized patients, switching brands after 8 weeks of full replacement dosing. We simulated effects of tablet potency differences and intestinal absorption differences on predicted plasma TSH, T(4), and triiodothyronine (T(3)) dynamics. Stability: We simulated effects of potency decay and lot-by-lot differences in realistic scenarios, using actual tablet potency data spanning 2 years, comparing the recently reduced 95-105% FDA-approved potency range with the original 90-110% range. RESULTS: A simulated decrease as small as 10-15% in L-T(4) or its absorption generated TSH concentrations outside the bioequivalence target range (0.5-2.5 mU/L TSH), whereas T(3) and T(4) plasma levels were maintained normal. For a 25% reduction, steady-state TSH changed 300% (from 1.5 to 6 mU/L) compared with but tablets of the same dose strength and brand were not bioequivalent between lots and between fresh and near-expired tablets. CONCLUSIONS: A pharmacodynamic TSH-measurement bioequivalence protocol, using normal L-T(4) replacement dosing in athyreotic volunteers, is likely to be more sensitive and safer than current FDA Guidance based on T(4) PK. The tightened 95-105% allowable potency range for L-T(4) tablets is a significant improvement, but otherwise acceptable potency differences (whether due to potency decay or lot-by-lot inconsistencies) may be problematic for some patients, for example, those undergoing high-dose L-T(4) therapy for cancer. PMID: 19191742 [PubMed - indexed for MEDLINE]Pasted from

Skin Tags and Metabolic Syndrome

2010-03-18T10:34:00.000-07:00

Skin tags are common, benign, unremarkable, and best left alone – but like the Rodney Dangerfield of clinical observations, I think they deserve some respect.

I have come to view skin tags as markers for metabolic syndrome, basically a visible warning system. Also called acrochordons or pedunculated fibromas, these small forgettable protuberances most commonly appear on the upper body in areas subject to friction and moisture (axillary, under the collar, at the bra line), so it’s easy to dismiss them as the body’s response to repeated irritation, and let it go at that.

For example, one case study from Spain entered the medical literature when a woman developed dozens of skin tags, linearly arranged beneath her bra line, after she started a new job that required her to move her arms up and down hundreds of times each day. In that case, the doctors excised the skin tags and sent her on her way, pausing briefly to document the striking visual pattern and the coincidence with her new job. But they had the good sense to raise an important question: “Our patient did not have overt diabetes mellitus, but we cannot exclude impaired carbohydrate metabolism, because we did not perform a glucose tolerance test or insulin level” [emphasis mine]. So there were two red flags in this case: not only was the woman obese, but there is a documented correlation between skin tags and metabolic syndrome or carbohydrate dysmetabolism. She should have been tested when all those skin tags showed up.

In study after study, mostly from Europe and Middle East, skin tags have been shown to be markers for various aspects of the metabolic syndrome: elevated cholesterol and LDL, basal hyperinsulinemia, reactive hypoglycemia, elevated fasting plasma glucose, postprandial hyperglycemia, and overt diabetes mellitus type 2. One study from Turkey was especially striking: 88 of 120 patients with skin tags were found to have diabetes mellitus, and another 10 patients were on their way to diabetes with reactive hypoglycemia or glucose intolerance – an impressive 98 out of 120 patients, all told. Conversely, another study from the Netherlands pointed out that, of the subjects with abnormal lab results, only 15% of them failed to exhibit cutaneous markers (skin tags, acanthosis nigricans, and enlarged waistline). So it’s possible we might be looking at as many as 80% of patients with visible skin tags who also have some degree of metabolic syndrome, up to and including diabetes.

Just to clinch the observation, it seems the number of skin tags is correlated with the severity of the carbohydrate dysmetabolism – the greater the number of skin tags, the greater the probability of abnormal labs and the greater the severity of findings upon deeper investigation. A study from Iran noted that more than 30 skin tags was a marker for full-blown diabetes (52%).

And I saved the worst for last: In a study from the UK, three out of four patients with skin tags plus abnormal lipid profiles turned out to have coronary artery disease. Yikes, now we’ve got skin tags as predictors of heart disease. I’ll say it again; I think that skin tags deserve more respect!

-Dr. Deborah McKay
Naturopathic Physician

http://jcp.bmjjournals.com/cgi/content/abstract/53/11/873
http://www.ncbi.nlm.nih.gov/pubmed/18397315
http://www.e-ijd.org/article.asp?issn=0019-5154;year=2009;volume=54;issue=1;spage=20;epage=22;aulast=Gorpelioglu
http://dermatology.cdlib.org/143/case_presentations/skintags/allegue.html
http://www.ncbi.nlm.nih.gov/pubmed/17988334?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=1&log$=relatedarticles&logdbfrom=pubmed
http://www.ncbi.nlm.nih.gov/pubmed/12120914

Stress Relief Made Simple

2010-03-02T13:57:00.000-08:00

In the world of botanical medicine there are many wonderful plants that have marvelous effects on the body. For me, one of the most amazing herbs is ashwagandha, (Withania somnifera). Also called winter cherry or Indian ginseng, aswagandha is an herb from the Ayurvedic system of medicine.

Native to the drier subtropical regions of India, Pakistan, Sri Lanka and Africa, the ashwagandha’s root is the part of the plant that is most valued medicinally. The fresh root is applied as a poultice for skin ulcers and swellings, but it is often dried and used whole or crushed into a powder. Traditionally healers employ ashwagandha to treat a variety of illness such as rheumatism, asthma, nervous exhaustion, impaired cognitive function, infertility, gastric ulcers and premature ageing. Due to its high iron content, ashwagandha is also beneficial for anemia. Some of the herb’s properties include anti-inflammatory, adaptogen, antioxidant, immune amphoteric and nervine. However, I have prescribed the herb most often for its adaptogen quality

As the term implies, an herb’s adaptogen action helps the body adapt to stress, promoting normal physiological functioning and restoring metabolic balance. Herbalists note that it aids “the building of ‘adaptive energy’ to keep the body balanced when affected by multiple stressors or harmful influences.”* In other words, the adaptogenic herbs are trying to conserve energy used by the cells during stress, and also restore the cellular energy that has been depleted from a prolonged stress response. Most of these herbs exhibit both stimulating and normalizing actions on the body, thus maintaining homeostasis.

Although the active constituents of ashwagandha have been identified as alkaloids, steroidal lactones (withanolides) and saponins, my preference is to work with the whole root of the plant. Two animal studies demonstrated ashwagandha’s countering effects on elevations of blood sugar, lactic acid, urea, creatinine, glucose intolerance, corticosteroid levels, immunosuppresion and mental depression when rats were subjected to cold and immobilization stress and random foot-shock. Another rat study showed protection against stress-induced stomach ulcers with pretreatment of oral ashwagandha. Clinical trials have exhibited restorative effects such as increasing body weight (when needed), increasing hemoglobin, red cell count and serum albumin.

More recent research has focused on other aspects of ashwagandha’s properties. Its antioxidant effect has been studied in the prevention of Alzheimer’s disease, protection for drug-related kidney toxicity and improvement of physiological abnormalities in Parkinsons’s disease. Further, research has shown evidence for ashwagandha’s immunomodulating and antitumour activity.

Not only has my experience with ashwagandha been professional but also personal. For me, ashwagandha works on the core of the nervous system, quieting the internal chaos and smoothing the currents of stress that reverberate through the body. By itself or acting synergistically with other herbs, ashwagandha restores a sense of balance.

Sherry LaBeck, ND

*Adaptogens Herbs for Strength, Stamina, and Stress Relief, David Winston and Steven Maimes. Healing Arts Press, Rochester, VT; 2007.

Principles and Practice of Phytotherapy Modern Herbal Medicine, Simon Mills and Kerry Bone. Churchill Livingstone, Harcourt Publishers Limited, United Kingdom; 2000.

Clinical Applications of Ayurvedic and Chinese Herbs Monographs for the Western Herbal Practitioner, Kerry Bone. Phytotherapy Press, Queensland, Australia; 1996.

Dadkar, VN et al: Ind J Clin Biochem 2 101 (1987).

Ghosal s, Lah J, Srivastava R et al. Phytother Res 1989; 3 (5): 201-206.

Being 2 - Why???

2010-02-26T20:24:00.000-08:00

I once had the privilege of working with a hospitalist who was an internist. During my rotations with him, it wasn't enough to know the treatment for the condition or the name of it, but he would grill me on the mechanism of what was happening in the body (I studied every night by the way). It's often so easy to jump to the answer and treatment. Your patient comes in with this - do this - is a common scenario. But when you start to ask "why?", you start to put together the biochemical puzzle of health, anatomy and disease. And since I don't like to memorize things, asking "why?" helps me to backtrack to the cause of conditions and therefore, configure hopefully smart treatment plans. And since memorizing conditions is also not fun, I prefer to try to delve into the normal physiology of the body. After all, if I know how it should work and "why", then I can usually figure out what happens when it stops.

It is also a huge help in understanding the traditional roles of herbs in medicine. We have a long history of traditional herbal treatments, but our clinical studies lag far behind. As new understanding of how different diseases come to be, and our understanding of the mechanisms of actions of herbs increases, we gain an insight into the wisdom of our ancestors. These people used herbs without double blind placebo controlled studies because they worked. Finding out the why of how they work is hugely satisfying to me. Of course, along the way, there were and continue to be many medications and herbs that have been found not to work and I try to embrace that as well (Coca cola for hair loss is a great example). But over time, the strong traditional herbs are starting to be understood in their mechanisms and gain respectability as "true" medicine in the world of hard science. As science keeps finding out how different systems work and interact, the possibilities of treatments grow and our understanding of what may be going wrong deepens. Although, I personally think that every discovery reminds us how little we actually know about the body and consequently leads to the next question "But why?"

You really need to love puzzle; it's part of the "why" I decided to be a physician.
Alison McAllister, ND

Coming up on this blog and in a webinar are 2 pieces by ZRT doctors looking at the why of traditional herbs used in adrenal health.

Lighting up the winter blues

2010-02-11T10:54:00.000-08:00

Seasonal affective disorder is a recurrent melancholy mood that tends to come on in the fall and winter, and subside in the spring and summer months.

Symptoms include:
• Depressed mood
• Weight gain
• Hypersomnia or insomnia
• Fatigue
• Social withdrawal
• Carbohydrate cravings
• Anxiety or irritability
• Difficulty concentrating

According to the National Mental Health association an estimated 10 million people are affected by SAD each year. Among the causes are less daylight during the fall and winter, increased melatonin, low vitamin D, genetics and age.

The most popular and least invasive treatment for SAD is phototherapy. The idea of using light therapeutically for winter blues is credited to a study from 1984 by Norman Rosenthal et al in which the SAD was first defined. Phototherapy requires a light source of 10,000 lux.

For a frame of reference:
• On a bright sunny day, daylight provides about 20,000 lux
• On a cloudy day daylight provides 5,000 lux.
• Office fluorescent lighting provides 300-500 lux
• Typical lighting in a living room 100 lux.

At 10,000 lux the total time of exposure should be around 30 minutes. If your light source is 5,000 lux then you need 60 minutes of exposure. SAD lights do not emit UV rays and are considered safer than tanning beds for this reason. The therapy works best if your eyes are open and you are actually doing something productive, like reading or sewing, or working on a puzzle. Most lights require that the distance you sit from the light is 12-20 inches in order to get the full dose of light exposure.

One might consider using a tanning bed to treat SAD, and in northern climates, tanning is very popular in the winter. Evidently, tanning and UV exposure improves mood and sense of well being. It can make you feel so good in fact, that there is an addictive quality to it. Some scientists postulate that UV light increases endorphin levels. In one study Naltrexone, a drug that blocks the release of endorphins, was administered to frequent tanners and resulted in typical withdrawal like symptoms. This suggests that UV light exposure can cause an increase in endorphins. Since endorphins can be addicting we have a double edged sword here- UV light makes you feel good, but can be addicting! It seems safer when treating SAD to use an SAD light that does not emit UV rays.

Low vitamin D levels are correlated with SAD but whether there is a causal relationship is still being studied. Vitamin D levels have been associated with depression and vitamin D levels are typically lowest in the winter. Thus the connection between the winter blues and low Vitamin D. A pilot study from the journal Applied Nursing Research by Shipowick et al. suggests that supplementing with Vitamin D in the winter months reduces symptoms of depression. While scientific proof is pending, why not make sure levels of vitamin D are within normal range? Vitamin D deficiency is easy to test and treat and has far reaching benefits beyond depression and fatigue.

Melatonin, a hormone produced by the pineal gland helps in regulating the circadian rhythm. Its production is decreased by light and increased by darkness. In SAD, melatonin levels are often found to be higher in the winter than in the summer. Blue colored light is primarily what suppresses melatonin and many light boxes made for SAD phototherapy are blue light. Here is a link to one blue light.

Medications are also used to treat SAD, especially in patients for whom light therapy is contraindicated (eg. macular degeneration). Antidepressants like serotonin reuptake inhibitors are the most commonly used. Buproprion, which is not an SSRI, is the first drug to receive FDA approval for treating SAD.

If you or your patients are feeling the winter blues, remember there are simple and effective ways to help.

Helpful links:
SADA

Lights: Sunbox and Philips lighting (formerly apollo lighting)

- Dr. Elise Schroeder

Environmental Endocrine Disruptors and Bisphenol A

2010-01-25T18:22:00.001-08:00

I am often asked about environmental toxins at my work here at ZRT and in my private practice. People find the topic confusing for multiple reasons - how is it that chemicals which are in everything and everywhere could be dangerous? Why would the FDA and EPA allow them to be there? And what happens if you get exposed to these levels?

I find environmental endocrine disrupters (EEDs) biochemically fascinating; personally, I find them terrifying. In a very short time frame of human history, we have created chemicals which can latch on to our own hormone receptors and create DNA and genetic changes. We then have put them in multiple places so that we are exposed to them all the time. We have no idea how to get rid of them, neither from our own bodies nor from our environment. Industry and society are wedded to EEDs which means safety issues maybe secondary to financial implications. Our government's politicians receive monies from chemical industries at the same time complaining about the monies spent on healthcare of individuals who may be ill secondary to exposures. In addition, the US government's general perspective is that most chemicals are safe until proven dangerous. Altogether, the whole thing is a truly mind-bending mess. But since this blog isn't about how to become active in government and public policy, I'll just share what I know and am concerned about with these endocrine disrupters.

One of the first things to understand about these disruptors is that we can't continue to think of them as poisons. Human history is filled with people using poisons for healthcare and beauty. Anyone for lead makeup to create pale youthful skin? Perhaps with some nice belladonna eye drops to dilate your pupils to mimic sexual interest? What we do to be beautiful. Poisons are generally safe at small dosages with mild symptoms, that get worse as you increase the dosages, until eventually you die. Classic poisons like arsenic, medications, and certain mushrooms all work on this principle. In science this is referred to as a monotonal curve -

However with environmental endocrine disruptors (EEDs) the curve does not appear to work this way. Rather, EEDs show a pattern logically called a non-monotonal curve. It is thought to look like this… In this diagram, symptoms are present at both low and high dosages rather than increasing with the dosage. EEDs are also tricky, showing us certain symptoms at low levels and then completely different and occasionally opposite symptoms at high levels. As if that were not hard enough to research, because they are hormones, the duration of exposure, and your age at the time of the exposure to these chemicals, also can change your symptoms and their toxicity. GREAT! (read sarcastically). Sandra Steingraber PhD names this beautifully as the "window of vulnerability." In summary - the amount of the EED, the dose of the EED, how long you were exposed to the EED, and the your age at the exposure may all influence your symptoms and the consequences of your exposure. This is why research on these chemicals is so difficult.

But wait, it gets even more fun. NOW think IN-UTERO & MULTIGENERATIONALLY! Ok, here's where things get even crazier. Now we have the dose/exposure/timing etc, but we now have to also think of your age as the age of your DNA when that DNA was being exposed to these EEDs. So, now we have you as a baby inside your mother and to get even crazier, now we have you as an egg inside your mother when she was a baby inside your grandmother! Yikes, don't you want off of this train? Women are born with all the eggs that they will ever have, so when a woman is pregnant with a girl, that girl is also forming her eggs - or in other words, the grandmother is pregnant with the eggs of her grandchildren, and their DNA may be influenced by the EEDs. Therefore, the exposure isn't just you being exposed, it's also your mom being exposed and possibly even your grandmother being exposed to EEDs (thankfully, that seems to be where we stop with the generations). With EEDs however, it means that the exposure may have different effects on each generation. Since research always tries to be as straightforward as possible, you can see the trouble. This also makes things more difficult because ongoing research suggests that you may react differently if you are exposed to an EED in adulthood, that you were already exposed to in-utero.

This past week one of the most concerning EEDs is once again making news - Bisphenol A (BPA). Bisphenol A is a chemical that was created approximately 120 years ago. In the 1930s it was being looked at as a synthetic estrogen replacement, but upon the discovery of DES (Di-ethyl-stilbestrol) it was abandoned. (DES has its own traumatic history as well). Meanwhile BPA was found to have properties that were helpful in making plastics flexible and clear. With BPA containing products we were able to line cans so that the metal taste didn't contaminate the food, as well as make polycarbonate plastics. The realization that BPA in plastics could be an issue occurred when a doctor who was doing breast cancer research found that cells that were supposedly estrogen-free were growing as if exposed to estrogens. This led to the realization that our plastics are not inert as we had thought. Unfortunately, the safety standards for BPA were established when we did not yet recognize the non-monotonal curve. This has led to a number of the arguments in industry and scientific journals about the safety levels maintained by the EPA for BPA. At this time, it is thought that the safety dosages set by the EPA for BPA is approximately 25 times higher than the dose shown to produce harm. It is thought that almost everyone has exposure to BPA at concentration levels shown to cause problems in rats.

Well, you might ask, why is everyone not sick if this BPA is such a big deal? The answer to this lies in what symptoms have been linked to BPA, and all the other things we know about EEDs - timing of exposure, dosage etc. However, the truth today is that in general, we are not very healthy. BPA has been linked to cardiovascular disease, brain changes, low testosterone and testicular size in males, sperm deficiency, and cancer risks. BPA is thought to show beautifully in some studies this non-monotonal curve, for example contributing to obesity at low concentrations and weight loss at high concentrations - 2 different symptoms for different dosages. Research has also suggested that exposure to BPA in-utero means that you only have to be exposed to a lower dosage during the adult years to trigger cancer. Exposure to very low levels on a daily basis for many years may create different symptoms than the higher bolus dosages. The research for BPA is vast - search bisphenol-a at pubmed.gov for 5,000+ articles. The website Ourstolenfuture.org is an environmental website based on the book by the same name, their site has a ton of research and explanations about BPA. The Environmental Health Perspectives is a peer reviewed journal looking at environmental health concerns including bisphenol-a. Or check out the 2000 report from the World Wildlife Fund for a European analysis of BPA. The National Toxicology program and the Environmental Working Group also have more information about bisphenol-a. To read the plastic industries response to this research click here.

So what things do you find BPA in? Lots! If you want to err on the safe side, think 2, 4, and 5 as your "safe plastics" since they don't contain BPA. Avoid polycarbonate plastics (the hard and glass-like plastics) found in plastic drinking bottles (non-disposables), baby bottles, and bowls. If you have the option, choose glass which does not leach any chemicals. When eating canned foods, choose canned products that do not use a BPA liner (Eden foods is one example) or better yet, choose frozen or fresh. Many companies are making the switch to BPA free since some countries are banning its use. If you do have to use a BPA container - don't heat it, especially in the microwave, and try to avoid putting acidic foods like tomato paste in contact with the plastics. For more information as to products containing BPA see thedailygreen.com.

So how big is the challenge of BPA? Think 6 billion tons per year. Knowing that we make this much, use this much and in all the products that BPA is in and you start to see the enormity of the research and industry challenge. This month, the FDA is reviewing again the research into BPA. Research suggesting the potential problems of BPA has been available since the 80's but the US government is being put in the difficult situation of reviewing the status while other countries including Canada are banning the chemical. We only have to think of the lawsuits to understand why. Follow the FDA's debate in the next couple of months here.

Really, it's enough to make you want to crawl into your glass bubble (definitely not plastic) to hide.

Alison McAllister, ND

Obesity: Thinking Outside the Box

2010-01-13T12:30:00.000-08:00

The following story was brought to my attention by science journalist Gary Taubes, author of Good Calories, Bad Calories: Challenging the Conventional Wisdom on Diet, Weight Control, and Disease, which is my favorite book of the year. Here’s the story:

A fashionable and prosperous London businessman suffered for many years with obesity so extreme that he could not tie his own shoes, and he had to walk down stairs backwards to avoid jarring his knees. He visited doctor after doctor, tried every fad diet he could find, and exercised like a professional athlete, but still the excess fat clung to his body.

He grew hard of hearing, suffered indigestion, and had constant aches and pains. Then by chance he saw an ear doctor who had recently attended a diabetes conference in France; this ear doctor told our beleaguered businessman that the cause of his corpulence was carbohydrates – starches and sugars. He suggested some very basic dietary guidelines. And it worked. It worked like a charm.

William Banting, the London businessman afflicted with the discomforts of obesity, simply stopped eating starchy and sweet foods, enjoyed four meals per day, did not count calories, did not go out of his way to exercise -- and swiftly corrected his body’s imbalance. Within weeks he felt remarkably better. Within one year he was at a comfortable weight, without pains or indigestion, and he was thrilled.

He was so delighted that he self-published a book giving all the details. It sold out immediately. He had it reprinted. It sold out again. He reprinted it at least three times in the first year alone. A year later, he published a revised edition which included excerpts from the thousands of letters he had received from delighted and grateful readers. He gave away profits from the book to local charities.

His name entered the English language as a verb: when a person was “banting,” they were overcoming obesity by following a low-carbohydrate, moderate-fat diet.

The most amazing part is that this enlightening event occurred in 1864-65, over 140 years ago.

To see or download the 1864 book “A Letter on Corpulence” by William Banting, which is now copyright-free, click here (thanks to the University of Illinois Urbana-Champaign). To see or download the 1865 version of the book, with additional material from grateful readers -- as well as critical reviews from Harper’s Weekly and Blackwood’s Magazine, click here (thanks to Google books).

One contemporaneous book review, included in the 1865 book, was critical of Banting’s point of view: “Orthodoxy is allied to plumpness, and a certain breadth of beam is most becoming to a high dignitary of the church. In the man of portly presence… we can repose implicit trust…” This same review later concludes, “We rise from the perusal of Mr. Banting’s pamphlet with our belief quite unshaken in the value of bread and potatoes as ordinary and universal articles of diet… Starch and sugar are eminently nutritious…”

The concept of strict carbohydrate restriction as a cure for obesity raised disbelieving, mocking opposition. “I just don’t believe it” was then (and still is) the most common criticism. This response is based upon comfortable familiarity with the status quo rather than on unbiased observation and research. Thinking outside the box entails challenging conventional wisdom, while the cure for obesity may require banting outside the box.

-Dr. Deborah McKay, Naturopathic Physician

Resolutions Anyone?

2009-12-31T14:56:00.000-08:00

Good news for the New Year and all those exercise resolutions! Chronic shoulder and neck pain can be helped with exercise. This is not new information since many studies have shown that exercise helps to reduce pain and improve general well being. However, this study’s findings target specific Repetitive Strain Injury (RSI) that is becoming commonplace, affecting millions of office workers.

RSI (aka overuse syndrome) is the repetition of hand, arm and upper body movements in many ordinary tasks in the workplace. With these activities, shoulder and neck muscles can become chronically tight and painful. The trapezius is one of the muscles especially affected by RSI. Its three sections extend from the base of the skull, laterally to the shoulder blade and down the back to the lower thoracic vertebrae. The function of the trapezius involves supporting arm and shoulder movements. Chronic muscle tension in the trapezius can contribute to muscle tenderness and pain that can radiate down the arm or up into the neck and head resulting in headaches.

In the 2009 study, from the Journal of Applied Physiology, investigations showed that specific strength exercises using weights can decrease neck pain and improve muscle response to neural stimulation. Significant improvement was measured after 10 weeks of performing five simple exercises.

The exercise routine includes shoulder shrugs, one-arm rows, bent rows, reverse flyes and shoulder abduction. Three sets of each exercise were done for 8-12 repetitions using varying weights, three times a week. The movements focused primarily on the actions of the trapezius in relation to shoulder motion and to strengthening the three individual sections of the muscle.

It’s amazing that such a simple practice and small amount of time can yield such positive results. Physical movement in general is a great way to positively affect your health. But when more specific movements, that don’t take a lot of time, can make such a difference…well that’s the resolution I’m going to make.

Happy New Year!
Sherry LaBeck, ND

Business building through teamwork

2009-12-17T14:31:00.000-08:00

Here at ZRT I get the opportunity to interview doctors, pharmacists, business manages and the like for our monthly teleconference series “Let’sTalk”. This past month I interviewed Natalie and Adam Gustafson of Pacific Compounds . They talked about how they went about starting and building their practice. I learned something from them about the value of networking within and across professions. As a clinician, I’ve always understood the importance of creating and maintaining relationships with other clinicians. It was a great reminder however, to think about networking with people outside my profession. Pharmacists aren’t the only health care professionals, who might send patients our way, there are all sorts;massage therapists, chiropractors, acupuncturists, how about the folks that help us run our clinics- the insurance billers, receptionists and office workers. That’s to name just a few.

What really impacted me was hearing the Gustafson’s perspective on networking. As a pharmacy- their business builds when the doctors (who are their clients) businesses build. To foster that relationship they do things like host continuing education meetings for doctors in the area. This brings the docs in to hear about topics like hormone replacement therapy, and which in turn gets more of these docs prescribing HRT. As the Doctors become experts in the field, their business grows and in turn so does the pharmacy’s. It’s a symbiotic relationship. Most of practice building is like that. Remembering that we as individual clinicians or pharmacists or business owners are connected to a network of others is very important. We don’t live in a bubble! Our business thrive when other businesses thrive.

Celiac, Hypothyroidism, and Adrenal dysfunction oh my!

2009-12-09T16:50:00.000-08:00

I'm continuing my discussion on Gluten - see blog part 1 on diagnosis and symptoms. But I wanted to discuss the reason why this all ties into hormone function; in particular Cortisol and Thyroid. As many may know, Adrenal and Thyroid dysfunction and diseases are commonly linked to autoimmune diseases - Addisons, Hashimotos, & Graves for example. There is a strong association between having one autoimmune disease and having additional subsequent autoimmune diseases. Well, it does appear that we can count Celiac disease as a form of autoimmune disease. Many studies have looked at the representation of other autoimmune diseases if a patient has celiac disease; finding a higher rate than expected of thyroid, adrenal, and pancreatic dysfunction; for example - about 10-26% depending on the study and the autoimmune disease. More recent studies however, have reversed this search- looking instead for the presence of celiac disease in individuals who have thyroid or adrenal dysfunction. Not surprisingly, there has been an amazing frequency of celiac in these populations - about 3-5% for Autoimmune thyroid, 12% for Addisons, and 1/20 of patients with type 1 diabetes. So, a patient comes into the office and has multiple autoimmune diseases, think about adding a test for celiac as well and vice versa.

But what about the patient who comes in with hormonal problems, fatigue, headaches, and weight gain? Consider celiac as well. Untreated and undiagnosed celiac disease patients, which is about 90+% of celiac disease sufferers, have hormonal disruption that may not have yet been diagnosed OR as of yet, a disease. Celiac creates at number of inflammatory cytokines which may mimic multiple conditions. Cortisol levels may be high or low depending on the amount of adrenal autoimmunity, inflammatory cytokines, and overall stress of the individuals physiology due to eating gluten. As an example, individuals with profound skin itchiness due to celiacs, sleep maybe disrupted routinely due to discomfort. Plus, the changes to cortisol levels may also increase the inflammation when the adrenals are unable to produce enough cortisol to inhibit autoimmunity (TH1 and TH2 balance) and inflammation (relative adrenal insufficiency).

I routinely get asked what to do about individuals who have high levels of antibodies to their thyroid glands (TPOab and TGab) and going gluten-free is one of the tricks that you can try. I have seen that successfully lower antibody levels very quickly for some individuals. Remember however, that if you need to diagnose someone with celiac, you need to do that before they go gluten free.
The thyroid gland embryologically begins at the back of the tongue and migrates down into the neck by week 7 of fetal life. A process that to me epitomizes the magic of embryology. As a refugee of the GI tract however, thyroid tissue appears to share the same tendency to react to the same irritants as GI tissue does. Thus, we see many of the thyroid autoimmune diseases actually being GI infections; for example: H. pylori, giardia, and entamoeba histolytica.

I am constantly amazed at the many ways our body system interacts. It's truly amazing that any of us are able to be ok. But, if you haven't looked at Celiac disease as a contributor to endocrine disorders it's worth your time to consider it. Since most patients are undiagnosed, and family inheritance is high, you might cure and prevent a large amount of suffering and hormonal dysfunction.

Happy Holidays
Dr Alison McAllister

Gratitude for Setbacks: Maybe Pollyanna was Right

2009-12-03T09:16:00.000-08:00

Loomis Dean/Time Life Pictures/Getty Images. Hayley Mills starred in the 1960 film, Pollyanna.

I am glad to be alive. It’s normal to take this for granted, but it’s wonderful to really feel it. Yes, life is complicated, life can be hard, and maybe there are no easy answers. Loss is inevitable. I’ve had a rough year. But it’s good to be alive.

The 1913 children’s book “Pollyanna” has become a cultural icon (a.k.a. cliché) because of the eponymous character’s insistence upon looking on the bright side, finding the silver lining in every cloud, always looking for something to be glad about. To call someone “a Pollyanna” nowadays is considered insulting, a reference to naïvete and being out of touch with reality: http://en.wikipedia.org/wiki/Pollyanna

I understand that pessimism is fashionable and that disaster-mongering is the key to success for the news media. I get it that pessimists are comfortable with their “never wrong and rarely disappointed” attitudes. I was raised by a pessimist, famous for saying “People are no d--- good.” He found plenty of proof for this attitude. But he did not have a happy life, or a long one. If it’s true that we can’t control what happens to us, only how we respond to it, then maybe it’s worth choosing the point of view that is associated with greater happiness and better health. Not long ago, National Public Radio Weekend Edition did a special report on “The Pollyanna Effect” (you can click to read the transcript or listen to the radio interview).

Some lucky people are just born with a sunny disposition. For the rest of us, it’s something we can learn. In fact, learned optimism is just as powerful as innate optimism. Here’s a free online self-test from Stanford University, based on the work of Martin Seligman, PhD. and here is a link to Dr. Seligman’s best-seller “Learned Optimism: Change Your Mind, Change Your Life” .

Lately I’ve been told that I’m a Pollyanna. I wish this remark would be delivered with the humble gratitude that I feel in my heart. Within the past year I’ve had pain, cancer, financial setbacks, loss of loved ones – and I know I’ve had the company of thousands of other brave souls enduring similar or worse ordeals. As a result of this series of setbacks, life has more clarity for me now than before: What I love, I really love! As for the rest, I don’t have time for it any more. The kindness and unexpected generosity of oh-so-many people and circumstances has piled up to a mountain of overwhelming gratitude. While I would not wish a series of setbacks on anyone, the bottom line is this: the payback has been tremendous. Clarity of purpose, and clarity of gratitude, are precious gifts in this life. So call me a sap. I’m a happy sap who is glad to be alive.

-Dr. Deborah McKay, Naturopathic Physician, Clinical Consultant, ZRT Laboratory

Bone 101

2009-11-20T15:21:00.000-08:00

In the fall I attended a lecture on osteoporosis. The presentation was thorough, giving all the statistics and risk of fracture rates and mortality, as well as discussing conventional treatment. However, what caught my attention was the presenter’s elucidation of bone physiology and a new way of looking at osteoporosis treatment.

While the nature of bone is to be strong and firm, it also needs to be flexible. The elastic quality of bone allows it to shorten when stress is applied, but return to its original length when the stress is removed. Generally the focus of therapy is on increasing bone density, but therapy should also encourage flexibility. The following website has a fun interactive bit to illustrate this concept. http://courses.washington.edu/bonephys/Gallery/biomechanics.swf

Accordingly, the treatment plan presented at the lecture addressed the idea of maintaining bone elasticity through supporting the formation of bone collagen, as well as quality bone. Osteocalcin, a protein found in bone, undergoes a specific reaction called g-carboxylation. This chemical reaction triggers osteocalcin to bind minerals within the bone matrix and is dependent on vitamin K. Research has found an association between an increase of under-carboxylated osteocalcin (ucOC), low levels of vitamin K and an increased risk of hip fracture in older women. http://www.ncbi.nlm.nih.gov/pubmed/9062471?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=7 ;

http://www.springerlink.com/content/26hjfngbhhme8m0w/

Further, there are different forms of vitamin K, vitamin K1 and K2. In turn, vitamin K2 has two forms, menatetrenone (MK4) and menaquinone-7 (MK7). MK4 and MK7 have been researched for their activity of inhibiting osteoclast and inducing osteoblast formation resulting in an increase in normal bone modeling. The role of the different forms of vitamin K in growth of bone connective tissue is not clear. However, studies using these forms of vitamin K2 have resulted in lower fracture rates, supposing vitamin K is contributing to more elasticity to the bone architecture.

Some of my colleagues voiced concern about the amount of vitamin K presented as treatment (45 mg/d) and that there needs to be more research to determine the safety. http://www.ncbi.nlm.nih.gov/pubmed/10750566?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=126.

However, it appears that making sure vitamin K levels are optimal in the body is a key factor in bone health.

Sherry LaBeck, ND

If not the vaccine then what?

2009-11-11T15:14:00.000-08:00

With so much in the news about the flu, it’s hard to choose any other topic to write about! Every newspaper, news channel and website is talking about flu and vaccine. At this point it seems likely that not all who want it will get the vaccine. What other options might we have to prevent and treat flu? There are many out there including the herb elderberry, good hand washing, nasal lavage, getting enough sleep. But the latest (and maybe greatest) is vitamin D.

Some say that one of the best things one can do to prevent and treat the flu is maintain vitamin D levels within a range of 50-70 ng/ml. Research indicates that vitamin D plays an important role in mediating the immune response. Deaths from flu are usually a result of a so –called cytokine storm, a hyper immune response in which there is a flooding of cytokines that can ultimately lead to death. http://en.wikipedia.org/wiki/Cytokine_storm During an infection with influenza, macrophages (part of innate immunity) produce pro-inflammatory cytokines which help fight infection by producing fever, inflammation, and increasing the production of other immune cells. In a normal immune response, a feedback loop keeps the production of these cytokines in check. In the case of a cytokine storm, this immune response becomes out of control. Macrophages and other immune cells continually increase secretion of cytokines and chemokines – unchecked. This high concentration can lead to damage to respiratory tissue and fluid in the lungs that is sometimes lethal. The tissue damage presents as adult respiratory distress syndrome (ARDS), pulmonary edema, depressed ventricular function and multiple organ dysfunction syndrome (MODS) which eventually leads to death.

Research shows that vitamin D can have a modulating effect on macrophages, preventing an overproduction of cytokines. It seems that Vitamin D is converted to its active form by interferon (IFN), a cytokine produced by the macrophage, and could help mitigate the negative feedback loop which suppresses activated macrophages and further inflammation, thereby preventing a cytokine storm. http://bloodjournal.hematologylibrary.org/cgi/content/abstract/106/13/4351

Having enough vitamin D may be the key. Levels need to be maintained at 50-70 ng/ml for vitamin D to have this type of positive effect on flu prevention and treatment. Dr. Cannell, executive director of the Vitamin D Council http://www.vitamindcouncil.org/ has postulated this theory. He suggests that levels below 50 could lead to “substrate starvation”, a term he uses to describe a situation where the body uses up vitamin D as soon as it is taken or made. In the case of substrate starvation it’s possible that there would be enough vitamin to increase antimicrobial peptides, the body’s naturally produced antibiotics that fight infection directly, but not enough leftover to quell an overactive cytokine response. According to Dr Cannell, maintaining a circulating vitamin D level of 50-70 ng/ml is one way to insure that there is plenty of the vitamin to go around.

The bottom line: know your vitamin D levels. If low, supplement with vitamin D3 to get your levels between 50-70 ng/ml.

For more information about flu: http://www.cdc.gov/h1n1flu/update.htm Or listen to Let's Talk, ZRT’s teleconference series on the ZRT website http://www.zrtlab.com/ in the media vault. This week’s topic-Staying healthy in cold and flu season.

Elise Schroeder ND

Gluten Free Holidays

2009-11-04T08:03:00.000-08:00

Writing a blog at the end of October regarding health seems to almost beg me to write about insulin resistance, but instead I resist the cliché. However, as obvious by the amount of food that has begun to circulate the workplace, Halloween is the start of the holiday binges. Because my stomach was focused on food today, I thought I would write something about gluten.

Gluten is now the dominant protein in wheat, about 80% thanks to genetic grain breeding. Gluten is composed of a mix of gliadin and glutenin and is now one of our most common food allergens. Celiac disease is a genetic disorder where individuals are unable to digest the gluten protein. As a result, the small intestinal lining may become flattened; losing it's villi and it's absorptive qualities. The immune dysfunction caused by patients with celiac disease eating gluten is also profound, increasing the risk of liver disease, autoimmune diseases as well as a higher risk of cancer. The exact cause of celiac disease is unknown, but new research suggests that it requires a genetics situation combined with an environmental trigger. Two genetic phenotypes tend to have celiac - HLA DQ - 2 (95%) and HLA DQ-8 (5%). It is estimated that 1 out of every 90 individuals in the US has celiac disease and the incidence is thought to be growing significantly. It is also estimated that only about 1% of those individuals know they have the condition.

Some individuals don't have celiac, but instead have a wheat allergy or a wheat intolerance. An allergy means that you activate your immune system usually with IGG or IGE immunoglobulins. With celiac a different part of the immune system is effected and many patients will not have an IGG or IGE reaction to wheat. However, a number of people with celiac may also have an allergy to wheat as well. The third wheat problem is someone with a wheat intolerance. These people also feel better not eating wheat even though they don't have a true allergy. For them, there maybe multiple factors involved in their reactions. It's important to note that because celiac disease is a combination of genetics + environment, many people may have the genetic potential their entire lives, but not activate that potential until adulthood.

Getting diagnosed:
It is said that in the US it will take 10 years and 10 doctors in order to be diagnosed with celiac - in Europe the average time to diagnosis about 6 months. In certain countries, doctors are more aware of celiac disease and so it is diagnosed at younger ages or faster on symptom output.

So how do people escape diagnosis? I think that comes from a combination of several factors:

1. The US is a gluten-loving society - we start on wheat cereal from infancy and until recently it was on the bottom of our food pyramid. We can't imagine (either patients or doctors) that bread could be bad for us.

2. Doctors and Individuals think of gluten-free as a deprivation diet - gluten-free for celiac is LIFELONG even if symptoms resolve. But, eating poison everyday isn't good for you and if you have celiac then gluten equals poison.

3. US physicians are not well trained in celiac disease - they know what it is, but many don't acknowledge the high incidence. They think of it as a zebra diagnosis; something that they are unlikely to see in their office. It is thought to be 1/90 people according to new research.

4. Celiac mimics other things. Although it has a classic symptom picture, it actually can produce a number of low-grade symptoms or even neurological symptoms without any intestinal symptoms. You do not have to have GI symptoms to have celiac disease. Symptoms may change throughout the years and may not even show any symptoms.

5. The lab testing is commonly negative even with people with severe symptoms.

One thing to know is that you can be diagnosed several ways. Blood work may be helpful - if it's positive, it's positive. This test does have a high false negative rate. So your lab work may be negative even though you may have horrible celiac disease. You can do a screening for the HLA type: http://www.kashilab.com/. This can tell you whether you are in the 30% of the population that is at risk (you may still have a wheat allergy or intolerance). If negative, you may still have a wheat allergy or intolerance. You can do a fecal test: http://www.enterolab.com/
The gluten free diet - FOR LIFE
Being gluten free today is not the same as it was 10-15+ years ago. Today, it is easy to be just as "bad" in your diet gluten-free as gluten-filled. It is also easier as major food manufacturers also announce gluten free options. Just this week Betty Crocker announced gluten free mixes: http://www.bettycrocker.com/products/gluten-free! Our local grocery store carries a large assortment of gluten free products and flours and Bob's Red Mill http://www.bobsredmill.com/ has flours that we can make things from scratch. Almost every restaurant here in Portland has a gluten free menu as do many of the national chain restaurants (you may have to ask). The internet has also allowed us to exchange and post recipes and support for people struggling gluten free. That's not to say that being gluten-free isn't without challenges. Products commonly post wheat-free where they may not be, restaurants don't realize that their spice mix contains gluten, and friends don't realize that using their wooden cutting board to cut the gluten free bread may contaminate the sample. A 1/4 of a cracker per day may be enough to completely keep the small intestinal tract malabsorptive. Becoming truly gluten-free is an exercise in label reading, self confidence in demanding answers and perhaps a few baking disasters. BUT, the results can be absolutely miraculous. Imagine, trying new grains, avoiding gluten and not being in pain, being in GI distress, growing (children), getting stronger, not getting autoimmune disease. It's worth it! See http://www.celiac.org/lifestyle.php - I haven't tried anything of Shauna James Ahern's that hasn't worked out. Her oven is clearly better than mine leading to me having to cook longer, but fabulous. I always end up doubling the recipes. I highly recommend her biscotti: http://glutenfreegirl.blogspot.com/2009/01/lemon-pecan-biscotti-gluten-free.html - home of Gluten Free Gobsmacked. Home too of gluten free cast iron pizza - yum http://glutenfree.wordpress.com/2007/08/06/gluten-free-cast-iron-skillet-pizza-2/
http://glutenfreemommy.com/ - very nice article on the different grains and how to play with them.

My next experiment is gluten-free Fruit cake (not kidding it's a family tradition). Happy baking everyone!
Alison

For more about celiac see:
http://digestive.niddk.nih.gov/ddiseases/pubs/celiac/
http://www.blogger.com/www.celiac.org

Organic VS Commercial Foods

2009-10-22T17:09:00.000-07:00

You are what you eat… there is simply no way around it. I coach my patients on this every day. I strive to keep my family well-fed, nourished in body and soul, while keeping an eye on the bottom line. Part of that “bottom line” is long-term health… but part of it is also the daily reality of making food dollars stretch. So how much extra must we spend to get wholesome food, without too much pollution? Is it necessary to always buy certified organic foods?

For produce, at least, there’s some trustworthy guidance available from the Environmental Working Group (EWG): The “Shopper’s Guide to Pesticides” is compiled from laboratory testing of pesticide residues in commercially available produce across the country. “EWG research has found that people who eat the 12 most contaminated fruits and vegetables consume an average of 10 pesticides a day. Those who eat the 15 least contaminated conventionally-grown fruits and vegetables ingest fewer than 2 pesticides daily. The Guide helps consumers make informed choices to lower their dietary pesticide load.” A wallet-size PDF of this guide is downloadable at: http://www.foodnews.org/EWG-shoppers-guide-download-final.pdf

And for seafood, another trustworthy guide is published by the Monterey Bay Aquarium – this one taking into account not only mercury pollution, but also environmental concerns including the state of fisheries world-wide. Printable downloads are available at: http://www.montereybayaquarium.org/cr/cr_seafoodwatch/sfw_recommendations.aspx

A few years ago, I used to be able to find “NutriClean Certified” produce at my local grocery store. I loved it – I could trust that the produce with the colorful sign had been rigorously tested and found to be free of pesticide residues. http://www.scscertified.com/docs/FDG_Cutsheet_PFNC_v5.pdf Alas, I have not seen this trusted colorful sign in years now. Anyone know where it’s gone?

Here’s to your health – and your enjoyment of all the upcoming holiday feasts!

-Deborah McKay, ND

ABC's of Hygiene

2009-10-13T15:00:00.000-07:00

Our office was just informed that a couple of employees have been diagnosed with H1N1 virus (aka swine flu). I suppose it was only a matter of time. Many areas of the country are turning up cases of this dreaded illness. A vaccine for the virus is being distributed but will it perform as expected? We all hope it does, but what can we do to take further precautions?

According to the Centers for Disease Control (CDC), hand washing is the single, best way to prevent the spread of infection and illness. Historically, this sanitary act was slow to be adopted. Even after it was proven to substantially prevent deaths from infection, hand hygiene continued to be absent. As physicians and students moved from the anatomy lab to the hospital wards they carried with them the harmful bacteria.

When I was a little girl I learned to always wash my hands before eating. I didn’t realize at the time it was to help prevent me from getting sick. I just thought my hands were always dirty. I also learned if I didn’t get my hands clean the first time, I had to do it over. As a student in medical school I was also reminded to wash my hands between patients. It was particularly important to let the patient see you wash your hands in front of them, to at least instill confidence in my hygiene if nothing else. But did I really know what I was doing with hand washing…well, sort of.

With so much concern about the H1N1 virus right now, it’s appropriate to spend some time on this very simple task. The important aspect of hand washing seems to be the time spent. The suggested time is 15-20 seconds which doesn’t seem like much until you try it. One of my colleagues sings the “alphabet song,” about 20 seconds, when washing her hands. At the CDC website you can find a step by step guide on the “right way” to wash your hands http://www.cdc.gov/Features/HandWashing/. There’s even a video!

-Sherry LaBeck ND

The Marathon

2009-10-08T08:51:00.000-07:00

The Portland Marathon was this weekend. I went to cheer on a couple of friends who were running it and felt inspired and awestruck by their determination and will to complete the race. It is quite an accomplishment to train for and participate in this type of endurance activity. Some of us have the capacity for it and some of us don’t. While it can be thrilling and motivating, this kind of extreme output of energy can also be detrimental for certain individuals.

I have heard more than one person/patient tell me “my energy has not been the same since I ran the marathon” or “my ability to work out has greatly diminished since I trained for the race” or “I don’t seem to recover like I used to from bouts of exercise”. For those individuals, the marathon might have been an exhilarating experience, but one that left them with little reserve. These are classic cases of adrenal burnout. When you are training for something like this, you are exposing your body and adrenal glands to a steady supply of stress. If you are at all adrenally fatigued, you pump out just enough cortisol to keep on going. Once the stressor (in this case training for the marathon) is taken away, the adrenal glands finally have a chance to chill out, and the individual crashes; the adrenal gland function plummets and the symptoms of adrenal fatigue emerge.

Even if you haven’t seen this in a marathon runner before, you probably have seen it in your colleague who gets sick every time he takes a vacation, or the student who gets a URI on every school break. Once the perceived stressor is eliminated the cortisol output is diminished. It is postulated that this is mediated by a decreased response from the hypothalamus in the HPA axis or perhaps a result of other hormone mediated stimuli to the HPA axis. The exact cause is still being explored. What we do know is that the way an individual responds to stress depends on many things: genetics, lifestyle, neonatal environment, previous experiences etc.

Clinically, we see these different responses in the many faces of adrenal fatigue. Some people might be pushing themselves to constantly do more and work harder, and some might be sleeping more than usual and retreating from normal activities. Individuals will have their own responses, but it’s our job as health care providers to help them when they present to us during a crash.

It’s our job to remember and remind the patient that when one is suffering from adrenal fatigue, pushing to work out more, stay up later, and work harder is not the way to get better. These people need to nourish their bodies and build their stores back up. Good sleep habits, proper nutrition for the adrenal gland, healthy diet, decrease stress and gentle exercise are what is needed to heal adrenal fatigue. That takes time and will and determination…. in fact, It’s a marathon of its own kind!

Dr Elise Schroeder

Child at Heart

2009-10-02T16:33:00.000-07:00

This week I’m feeling amazed and nostalgic. It was 7 years ago this week that the niece of my heart was born. I was there throughout the long work of her labour and when she took her first breath. And for 7 years, with rare exception, I’ve seen her every week. With fall coming and school back in session, I look at wonder at the growing girl who has transitioned into the true child – a first grader. Not in the toddler/preschool years, but not in the pre-adolescent years, she is all about learning to read, colouring in the lines, running and jumping. It’s staggering to think that 8 years ago, nothing about her existed and 7 ½ years ago she was a tiny cluster of cells in the form of a baby, putting together all that will make her unique.

Children make me feel time. You mark it yearly when the seasons change, but when you see a child grow, you watch it daily in action. Learning to sit, crawl, pull-up, stand, walk, first sounds, first words all in the first 18 months. I haven’t done anything that exciting in the last 10 years. But as a doctor, I never cease to be amazed at the complicated maze of chemicals, DNA and cells that work together to make us all so much the same and yet so different.

In children you watch it happening. When babies start walking with that stiff legged stance so easily toppled, yet so proud of themselves, they are laying down the neural pathway that very quickly becomes second nature. Research shows us that the more we use a pathway, the faster it becomes encased in the myelin sheath to protect it. Good and bad. So when we learn incorrectly, or create a poor thought pathway, it takes more and more work to change this pathway. The more years we have a habit, the harder it is to change it. It’s also harder because we are so self-conscious of what we look like doing it. Unlike our 9 month old self, we’re less willing to fall on our bottoms in the middle of the sidewalk when taking our first steps. Whether it’s starting an exercise program, stopping smoking, changing our diet, thinking more positively, we worry so much of what people will think or how much work it will take. But if we don’t start, we’ll never get to start building the pathways that will work faster and faster until they are second nature. And if we never did that, we’d never get the chance to run and jump and play with optimal health.

So, this fall I’m thinking about what pathways (i.e. habits) I’d like to grow, hoping I won’t fall on my bottom TOO much, and trying to think more like a child.

Alison

TOPICAL HORMONES – How’s Your Skin?

2009-09-24T13:57:00.000-07:00

Practitioners of BHRT (bio-identical hormone restoration therapy) generally favor topical forms of hormone therapy, because the real human sex steroid hormones are so easily absorbed through the skin. Once absorbed, these hormones circulate freely and function very well in the body.

MYSTERIOUS DISAPPEARING HORMONES:

Despite the obvious advantages of topical hormone therapy, every once in awhile, there’s a patient who seems unable to absorb hormones through the skin. They won’t experience the expected symptom relief, or will increase their dose multiple times, in an effort to gain symptom relief. Upon laboratory testing, we sometimes see that the circulating level of hormone is much lower than expected, even though we’ve calculated a physiologic dose correctly, and the patient reports following directions exactly.

When symptoms are not relieved, the culprit might be fatigue of the adrenal glands or blood sugar fluctuations. But sometimes when the lab values are actually low (not just symptoms, but actual lab values), then the problem may be with the skin itself. In my observation, skin can sometimes form a barrier that is “too good” instead of normal and semi-permeable.

Several times in the past few months, in my telephone consultations at the laboratory and in my own clinical practice, I have encountered cases of “mysterious disappearing hormones.” Sometimes topical hormones, given in a good human-size dose, fail to show up on lab testing. I say human-size dose because too often we see women given “horse-size” doses and/or actual horse hormones. The low hormone levels are accompanied by complaints of hot flashes and night sweats, PMS or peri-menopausal mood swings.

TWO SCENARIOS WHEN HORMONES SEEM TO DISAPPEAR:

More often than not in these “disappearing hormone” cases, the patient is also being treated for hypothyroidism. Of course untreated or under-treated hypothyroidism can have profound effects upon skin thickness, skin texture, and skin barrier functions. But even in cases where thyroid hormones have been titrated to restore full function, I still sometimes see dermal malabsorption.
A few months ago I spoke with a practitioner who has also had trouble with dermal malabsorption – but in her observation, the source of the skin problem might be genetic, not hypothyroid. She hypothesizes that Native American skin provides more of a barrier, and she had seen numerous cases where topical or transdermal hormone therapy had failed. Upon investigation, it turned out these patients had some fraction of Native American blood (as little as 1/8 in one case we discussed). I can’t remember her name, but I hope she gets a research grant to look into this hypothesis.

In both cases, the answer is simple: Assuming there is a good compounding pharmacist on call, just switch from skin cream to sublingual troche. The dosage is the same as you’d give topically/transdermally, because the route of administration is essentially the sameIf the patient has doubled or tripled the prescribed dose (which has happened to me), then you can ramp back down to your calculated “human physiologic” dose – because now it’s getting into the blood stream and it will work just fine!

TOPICAL/TRANSDERMAL vs. SUBLINGUAL:

I see a few downsides to using sublingual troches instead of topical creams. One is patients who are impatient: When they chew or swallow their troches, instead of allowing them to slowly dissolve, now you’ve got medication entering by the oral route of administration, with all the metabolites and liver strain that entails. And the pharmacokinetics of progesterone appear to speed up with sublingual administration as compared with topical, so there may be greater daily fluctuations in blood and tissue levels. Another problem is with follow-up testing; with sublingual troches, it is difficult to get the timing of saliva collection just right (because the saliva gets so saturated with each dose). So follow-up testing will need to be done with fingerstick bloodspot instead of saliva (please don’t waste your money on serum testing, because exogenous hormones pretty much don’t show up in serum until the poor person has been overloaded badly). And finally, there’s the problem of pronunciation. Just say “TRO-key” and you’ll sound like a pro.
I still feel much more comfortable prescribing topical BHRT, and adjusting the dose as needed. But it’s nice to have an alternative for the occasional case of “mysterious disappearing hormones.”

Blog Entry 09/22/09 by Dr. Deborah McKay, Naturopathic Physician, ZRT Lab Clinical Consultant

Back to School, Back to health: Tip the scales of health toward balance

2009-09-08T15:54:00.000-07:00

By Dr Elise Schroeder

As we say good bye to the summer, and hello to school days and autumn, we find that health care becomes a priority again. “I’m so tired in the morning as I get my kids off to school. My energy doesn’t last through the day as the hours of daylight begin to wane. I’m not sleeping through the night. I keep catching colds and flu’s. “ These are the types of complaints I see in my office in the fall. They are the types of questions that lead us back to this one very important question: are you in balance?

The scales are an image I use with patients all the time. I’ll use this idea when talking about allergies, the immune system, digestion, hormone balance and more. One side of the scale represents things that help reduce susceptibility and the other side represents things in life that increase susceptibility. It’s a concept that we all can relate to. We balance our checkbook, we balance our work and home life, we balance our time etc and when something tips the scales, we notice!

It’s the same with health. When there are enough positives to outweigh the negatives, we will find our patients are in balance and healthy. But when something extra gets added to the negative we’ll see them in our office with a cold, or an allergy attack, or digestive upset or hot flashes and night sweats. As the summer turns to fall, we have an opportunity to remind our patients to recheck their scales of health. Lifestyle changes can add something to the positive side of the scale. Like an extra hour of sleep each night, replacing sugary drinks like soda with soda water, walking or biking to work one day a week, or reducing exposure to toxins in the environment like pesticides, heavy metals like mercury in fish, or PCB’s and chlorine in drinking water.

Sometimes our patients will need help in finding their balance. As their health care provider, you can help them figure out which things might be weighing down their scales of health. Listen to your patient’s complaints. Are they experiencing symptoms of hormone imbalance like insomnia, fatigue, blood sugar imbalance, or anxiety? It could be adrenal imbalance. If it’s a sex hormone imbalance they might complain of bloating, breast tenderness, irregular cycles, hot flashes, decreased libido or excess hair growth. With your help, hormone status can be assessed and rebalanced.

The scales of health are a great teaching tool for your provider tool box. It can be applied to almost any health issue, because health is about balance. Your patients will appreciate the time you spend explaining how their actions and behaviors can affect their health. They will appreciate the benefits of understanding how stress might be affecting their hormones. Most of all they will enjoy how good they feel after you’ve helped them tip the scales of health to balance.