The B Vitamins and Their Multilayered Importance In Human Physiology

The B Vitamins and Their Multilayered Importance In Human Physiology

Folate, Vitamin B12, Vitamin B6, Choline

B vitamins are a class of water-soluble vitamins that are essential to maintain health and to carry out a host of metabolic functions.   There are 8 different B vitamins that are necessary for several organs and systems to function optimally.  B vitamins are utilized for cellular functioning, carbohydrate metabolism and the production of red blood cells.  They are also needed for healthy skin and neurotransmitter formation.  Symptoms of B vitamin deficiency vary from fatigue to anemia, nervous system dysfunction, compromised immunity and skin issues.  While over consumption of B vitamins from food sources is quite rare and generally not worrisome, dangerously high intake of B vitamin through supplementation leads to hypervitaminosis B.  This condition comes with side effects that include liver problems, blurry vision, high blood sugar, and numbness. 

What Is Folate?

Folate is needed to produce healthy red blood cells; it reduces the risk of neural tube defects such as spina bifida and, together with vitamin B12 and vitamin C, is an important coenzyme in the synthesis of nucleic acids and the metabolism of amino acids.  Optimal folate intake helps in the prevention of folate deficiency anemia.

The Importance of B12

Vitamin B12 is an important factor for the formation of red blood cells, and it is essential in preventing megaloblastic anemia.  Vitamin B12 is important for DNA synthesis.  Cellular metabolism is dependent on this vitamin, which has a role in the metabolism of fatty acids as well as amino acid synthesis.  Vitamin B12 is also necessary for the absorption of folate, and it is necessary for conversion of carbohydrates into glucose.  Vitamin B12 also plays a role in white blood cell formation, affecting immune system function. 

What To Know About Vitamin B 6

Vitamin B6 (Pyridoxine) exists in various coenzyme forms (pyridoxal 5 phosphate (PLP) and Pyridoxamine 5 phosphate (PMP)).  It plays a role in over 100 enzyme reactions, and it is involved in the metabolism of protein, carbohydrates, and lipids.  Vitamin B6 is essential for brain development and for immune function.  It is vital to synthesize neurotransmitters and to ensure adequate levels of homocysteine.  It is also essential for gluconeogenesis, glycogenolysis, and hemoglobin formation.  Vitamin B6 works synergistically with folate and vitamin B12 to reduce homocysteine levels.  High level of homocysteine is a risk factor in heart disease.  While the mechanisms aren’t fully understood, it appears that high homocysteine levels can damage arteries, leading to atherosclerosis and blood clots. 

What You Need To Know About Choline

Choline is an organic, water-soluble compound similar to B vitamins.  It is manufactured in the liver, and it is also found in foods such as liver, muscle meat, fish, eggs, beans, wheat germs, and nuts.  Choline is essential in metabolism, and it is needed for cell membrane integrity.  It is important for DNA synthesis, cell signaling, fat transport and metabolism.  Choline is necessary to make acetylcholine, an important neurotransmitter; therefore, it is crucial for the nervous system.  Choline is a source of methyl groups and is needed to produce two major phospholipids (phosphatidylcholine and sphingomyelin) crucial to cell membranes. 

What is the RDA level for each of the vitamins? What is the upper limit for each of the vitamins and What are the signs or symptoms of deficiency and toxicity for each of the vitamins? 

The RDA for vitamin B6 varies depending on age, sex, and for women RDA changes also during pregnancy and breastfeeding.  RDA for babies from birth to six months is 0.1mg; it is 0.3mg for babies from 7 months to 1 year of age. From 1 to 3 years it is 0.5 mg, 4 to 8 years is 0.6 mg while 4 to 8 years 0.6 mg, 9-13 years is 1.0 mg.  RDA for males and females between 19 to 50 years is 1.3 mg.  RDA of vitamin B6 for males above 51 years is 1.7 mg and for females it is 1.4 mg. 

The RDA for vitamin B12 is dependent on age. The RDA for breastfeeding mothers is 2.8 mcg, while for pregnant teens and women it is 2.6 mcg.  Teens and adults are recommended to take 2.4 mg per day of vitamin B12.  The RDA for children is 1.2 mcg for the age group 4-8 years, and 1.8 mcg for 9 to 13 years.  Infants up to 6 months need 0.4 mcg of vitamin B12 per day; the recommendation for infants 7 to 12 months is 0.5 micrograms per day, and children between 1-3 years require 0.9 mcg per day.

The RDA for folate is also dependent on age.  Women and men above 19 years should take 400 mcg of dietary folate equivalents (DFE) per day.  The RDA for pregnant women is 600 mcg per day, while RDA for lactating women is 500 mcg.  The RDA for people who habitually consume alcohol is at 600 mcg. 

The Office of Dietary Supplements states that there is insufficient data to establish the RDA for choline; however, adequate intakes (AI) are available.  AI is defined as the “recommended average daily nutrient intake level based on approximations of observed mean nutrient intake by a group (or groups) of apparently healthy people that are assumed to be adequate” (Dietary Reference Intakes: applications in dietary assessment).  The AI for individuals above 19 years is 550 mg/day for males and 425 mg/day for females.  The AI for pregnant women is 450 mg/day, and for lactating women it is 550mg/day.  AI is used as a reference levels when there is not enough evidence to develop an RDA.  

Choline deficiency can damage the muscles, liver, and it is linked to the development of nonalcoholic fatty liver disease (NAFLD).  Most people in the US consume less than the daily requirement of choline; however, thanks to endogenous production of choline by the liver, deficiency in healthy and non pregnant individuals is rare.  High doses of choline can cause dizziness and can lower blood pressure.  Choline toxicity can also cause also vomiting, increased sweating, salivation, and it can cause fishy body odor.  

Vitamin B 12 deficiency causes fatigue, weakness, constipation, loss of appetite, weight loss, and megaloblastic anemia.  It also leads to numbness, balance problems, depression, dementia, and confusion.  Vitamin B12 toxicity is rare, and it generally manifests with diarrhea, itching, blood clots, numbness of the extremities, and allergic reactions.   

Excessive folate intake masks the symptoms of vitamin B 12 deficiency and can cause damage to the nervous system. Its deficiency mainly leads to folate deficiency anemia, diarrhea, gray hair, peptic ulcer, poor growth, glossitis, and ulcers in the mouth.

It is rare to have an isolated deficiency of vitamin B6.  While uncommon, vitamin B6 deficiency is associated with microcytic anemia, cheilosis, dermatitis, glossitis, depression, confusion, and a weakened immune system.  An excess of the vitamin B6 leads to sensory neuropathy, ataxia, skin lesions, photosensitivity, nausea, and heartburn. These signs and symptoms are dose-specific.

Where are these vitamins found in the diet and what may impede availability and absorption? How does the concept of food poverty impact a client’s ability to obtain these vitamins?

Vitamin B6 is found in a variety of foods, including salmon, beef, liver, pork, potatoes, bananas, and avocado.  Other sources include fortified cereals, poultry, pistachio nuts, and non-citrus fruits.

Beef liver is a great source of folate, and boiled spinach comes right behind.  Other good sources include broccoli, leafy green vegetables, peas, kidney beans, chickpeas, and fortified cereals.  Pregnant women should take folate supplements and consume foods high in folate to prevent neural tube defects.

The best sources of vitamin B12 are liver and clams.  Other good sources are meat, fish, milk, cheese, eggs, dairy, and fortified cereals. 

Dietary sources of choline include meat, poultry, fish, milk, eggs, gravies, salads, nuts and seeds, and wheat germ.

Several factors can hinder the absorption and availability of vitamins.  Various medications can affect the absorption of various vitamins like vitamin B6.  These medications include anti-seizure drugs, the bronchodilator theophylline, and antibiotics like cycloserine.  The mechanisms for drug-nutrient interactions vary as well.  For instance, cycloserine increases the urinary loss of pyridoxine.  Availability and absorption of vitamin B12 are also affected by various gastrointestinal conditions like ulcers, inflammatory bowel disease and other digestive disorders, surgical conditions like gastrostomy, and, of course, medications.  The medications include chloramphenicol, omeprazole, cimetidine, and metformin.  It is worth noting B vitamins are also best absorbed from food sources; however, folate supplementation is needed in pregnancy and some studies show that supplemental folate is better absorbed than dietary folate (85% bioavailability of supplemental compared to 50% from food sources).   It is important to identify factors that can affect the vitamins’ availability and to develop proper strategies that will ensure that our clients have optimal intake and absorption.  

What Happens When Food Poverty Is A Significant Component In Mal-nutrition?

Food poverty is the inability to access or purchase foods that make up a healthy diet.  In other words, food poverty reduces access to the healthy foods that provide an abundance of vitamins and minerals.  Food poverty is linked to malnutrition, obesity, vitamin deficiencies, weakened immune system and other diseases, and disordered eating (people living in food insecurity tend to eat even when not hungry, as a guard against food uncertainty).  Since food poverty translates to limited access to healthy foods, people affected by food poverty do not meet RDAs and AI of vitamins and minerals. 

References:

Stipanuk MH, Caudill MA, editors. Biochemical, physiological, and molecular aspects of human nutrition. 4th ed. St. Louis, Mo: Elsevier; 2019. 959 p.

Bjørndal B, Bruheim I, Lysne V, Ramsvik MS, Ueland PM, Nordrehaug JE, et al. Plasma choline, homocysteine and vitamin status in healthy adults supplemented with krill oil: a pilot study. Scandinavian Journal of Clinical and Laboratory Investigation. 2018 Nov 17;78(7–8):527–32.

Kennedy DO. B vitamins and the brain: mechanisms, dose and efficacy—a review. Nutrients. 2016 Feb;8(2):68.

Office of dietary supplements – choline [Internet]. [cited 2020 Nov 15]. Available from: https://ods.od.nih.gov/factsheets/Choline-HealthProfessional/

Office of dietary supplements – vitamin b6 [Internet]. [cited 2020 Nov 15]. Available from: https://ods.od.nih.gov/factsheets/VitaminB6-HealthProfessional/

Office of dietary supplements – vitamin b12 [Internet]. [cited 2020 Nov 15]. Available from: https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/

Vitamins and minerals – B vitamins and folic acid [Internet]. nhs.uk. 2017 [cited 2020 Nov 15]. Available from: https://www.nhs.uk/conditions/vitamins-and-minerals/vitamin-b/


Sobczyńska-Malefora A, Harrington DJ. Laboratory assessment of folate (Vitamin b9) status. Journal of Clinical Pathology. 2018 Nov 1;71(11):949–56.

Siddiqui F, Salam RA, Lassi ZS, Das JK. The intertwined relationship between malnutrition and poverty. Front Public Health [Internet]. 2020 [cited 2020 Nov 15];8. Available from: https://www.frontiersin.org/articles/10.3389/fpubh.2020.00453/full

Nutrition For Female Marathon Runners

Nutrition For Female Marathon Runners

There is no one-size-fits-all in nutrition, and nutrient requirements vary based on age, sex, physical activity, and even illness.  As nutritionists, we need to ensure that our plans meet our client’s unique individuality, as well as their goals. 

Case Example Of a Young Female Marathon Runner

In this case, my 25-year-old marathon runner’s goal is to improve performance and feel her best during each race.  She needs recommendations for what to consumer before, during, and after her races to ensure performance as well as recovery.  A female athlete’s nutritional needs are quite different from those of male athletes: factors that come into play include bone density, as well as differences in caloric consumption and expenditure.  While both male and female athlete require more dietary protein than the average couch potato, the maximal increase is about 100% for male athletes and 50-60% for female athletes.  Proteins are essential for the marathon runner. 

Foods For Faster Recovery

They promote faster recovery after training and race, facilitating muscle growth and repair.  Protein also are needed in the synthesis of new structures, red blood cell development, and antibody production. When glycogen stores are low, the protein stores provide about 15% of the needed energy during muscle activity.  Those who lack protein are at an increased risk of injury, fatigue, and decreased muscle mass, all factors that hinder performance.  My client’s diet plan will include: organic eggs, wild-caught fish, pastured chicken and grass-fed meat, peanut butter and other nuts, if tolerated. 

Carbohydrates and Fats For High Performance Runners

Fats should also be a vital inclusion in marathon runners’ nutritional plan.  Fats are more calorie-dense, providing 9 calories per gram compared to the 4 calories per gram provided by protein and carbohydrates.  Additionally, fats are essential for the transportation of fat-soluble vitamins, for hormone production, brain function, and satiety.  A low-fat diet in athletes can limit athletic performance causing earlier onset fatigue during a race. Sources of fats include coconut oil, extra virgin olive oil and olives, butter and ghee, dairy, avocado, and if tolerated dairy.  

Carbohydrates are important for providing energy during the races.  The runner should be able to consume and maintain optimum carbohydrate intake.  This will help prevent hypoglycemia during the races, maintain the intensity of training, strengthen the immune system, and facilitate post-recovery.  If this client does not consume enough carbohydrates, she will not be able to endure and perform effectively due to increased glucose depletion.  Before a marathon, the total caloric intake should also be increased, including the carbohydrate calories, to achieve an effective carbohydrate-caloric loading effect. 

What Is The General Nutritional Advice Given To Marathon Runners?

The general advice given to marathon runners is to consume fruit juice, honey, molasses, whole-grains, cereals, rice and pasta, starchy carbohydrates and legumes, as well as fruit and high-carbohydrate dairy products such as yogurt.  About 60 to 70% of the calories should be from carbs. Before the race, only quick sources of energy should be consumed because they are absorbed faster.  During the race, she should increase the rate of carbohydrate intake by one gram per minute by consuming carbohydrate-containing drinks.  These drinks should be consumed at regular intervals during the race, and oftentimes an alarm can help keep track.  Additionally, consumption of carbohydrates with high glycemic index such as honey can help during the marathons.  After the races, the goal is to replace the depleted energy stores and fluids.  Attention should also be directed to muscle repair and recovery; hence, micronutrients and proteins will be essential.  Fast recovery is important so that the body can be ready to get back to training.  Carbohydrates will help restore glycogen stores; protein will help with muscle repair and recovery, and electrolytes will help in re-hydrating.  

Every Athlete Has Unique Nutritional Requirements

While the general advice has been used in sports nutrition for decades, I like to use a more individual approach with my athletes.  In my work, I have found that using a continuous glucose monitor is paramount to study each individual athlete’s response to carbohydrates and glucose.  Too much or too little glucose can be detrimental to athletic performance leading up to and during an event. Glucose levels are complex and many factors can influence them.  Plus, every athlete has unique fueling requirements. A continuous glucose monitor is my preferred tool when working with athletes.  For this reason, I will recommend that this client use this tool to learn how her body responds to different carbohydrates.  This will help us find the perfect nutrition for performance.  Athletes usually begin glucose loading 3 days before a race.  Knowing how her body responds to different foods will allow this client to eat meals that provide a stable and sustainable glucose rise and that will keep her in optimal fuel range. 

Hydration is extremely important. Before and during a marathon, my client will make sure to keep well hydrated.  I recommend electrolyte supplements, mineral-rich water, and coconut water.  

Other factors to consider are vitamins and minerals.  Calcium, for example, is an essential mineral needed for bone growth, density, and prevention of bone loss and fractures.  Consumption of calcium-rich foods help maintain strong bones that can endure the intensity of the races.  Therefore, this client should consume foods rich in calcium like dairy products, green leafy vegetables, spinach, and broccoli. 

B Vitamins And The Health Of Female Athletes

Vitamins are essential nutritional components for the marathon runner.  The most important vitamins are vitamin D and B complex vitamins.  The body needs vitamin D to metabolize calcium.  Vitamin D is necessary for a healthy immune system and hormone production. Therefore, I will advise my client to include fatty fish in her diet and supplement with vitamin D3 if needed.  Vitamin B6, B12, and Folate are also important.  For example, vitamin B12 and folate are essential for red blood cell development, protein synthesis, and tissue repair.  These are important in improving the oxygen-carrying capacity and building endurance during long races. 

My client will begin adopting her new dietary plan during training so that she can get used to the changes and, if needed, we can modify the plan according to her needs well before the race.  

References


Tarnopolsky MA. Gender differences in metabolism; nutrition and supplements. J Sci Med Sport. 2000 Sep;3(3):287–98.

Burke, L. M., Jeukendrup, A. E., Jones, A. M., & Mooses, M. (2019). Contemporary Nutrition Strategies to Optimize Performance in Distance Runners and Race Walkers. International journal of sport nutrition and exercise metabolism, 29(2), 117–129. 

Costa, R., Knechtle, B., Tarnopolsky, M., & Hoffman, M. D. (2019). Nutrition for Ultramarathon Running: Trail, Track, and Road. International journal of sport nutrition and exercise metabolism, 29(2), 130–140. 

Smith-Ryan, A. E., Hirsch, K. R., Saylor, H. E., Gould, L. M., & Blue, M. (2020). Nutritional Considerations and Strategies to Facilitate Injury Recovery and Rehabilitation. Journal of athletic training, 55(9), 918–930. 

Thomas, D. T., Erdman, K. A., & Burke, L. M. (2016). American College of Sports Medicine Joint Position Statement. Nutrition and Athletic Performance. Medicine and science in sports and exercise, 48(3), 543–568. 

Attention Deficit Hyperactivity Disorder (ADHD)

Attention Deficit Hyperactivity Disorder (ADHD)

What Is ADHD & Who Does It Affect?

Attention deficit hyperactivity disorder (ADHD) is the most prevalent neurodevelopmental disorder that affects children, and, additionally, it often continues into adulthood. It is estimated that in the United States 9.4% of children and 4.4% of adults suffer from ADHD (Data and Statistics About ADHD | CDC, 2020). The disorder affects boys six times more than girls (Kohlstadt, 2012). 

What Causes ADHD?

We still don’t know the exact causes of ADHD, and scientists believe that there are interplaying biological, genetic, epigenetic, and environmental factors contributing to the development of the disorder. Additionally, no one case is identical to another, and ADHD presents with several manifestations such as hyperactivity, difficulty concentrating and controlling impulsive behaviors.

What Are The Symptoms Of ADHD?

The child is unable to focus or sit still; he may fidget, talk too much, and he may be unable to take turns. ADHD is also generally accompanied by a series of comorbidities which can include anxiety, mood disorders, learning disabilities, conduct disorder, and oppositional defiant disorder (Kohlstadt, 2012). There seem to be a dysfunction in the neurotransmitter and in the adrenergic nervous systems, as well as exposure to certain environmental pollutants such as lead as well as exposure in utero to cigarette smoking and alcohol consumption. Thyroid hyperfunction is also more prevalent in children with ADHD, though a clear connection between the two conditions has yet to be established (Kohlstadt, 2012).

What Pharmaceutical Approaches Are Available Today?

Several medications are available for the treatment of ADHD: there are stimulant medications that affect the dopaminergic anterior system related to executive functioning and behavioral inhibition; other stimulant medications affect the noradrenergic systems which plays a role in selective attention. Lastly, norepinephrine transport inhibitors and anti-depressants can be used though they do not seem to be as effective as the stimulants described above. About 70% of patients respond to medication, but the rest do not respond to treatment. The side effects are not insubstantial and range from sleep disorders to loss of appetite, headaches, and irritability (Herndon, 2021). 

What Is The Correlation Between Diet & ADHD?

Scientific research has found several dietary triggers that seem to play a role in the manifestation of the disorder: sugar, food additives and coloring, as well as foods that cause allergies and sensitivities seem to aggravate the condition (Kohlstadt, 2012). A review from Millichap & Yee (2012) also shows that the high-fat, high-sugar Western diet is associated with a higher incidence of ADHD and that dietary intervention can greatly mitigate ADHD symptoms. Several studies have shown that the elimination of processed foods laden with artificial coloring and preservatives has yielded positive results in the management of ADHD symptoms. A reduction in salicylates can give positive results; a low-glycemic diet can as well (Konikowska et al., 2012). According to Konikowska et al. (2012), the mother’s diet during gestation and lactation affects the fetus’s brain development; therefore, a suboptimal maternal diet has an impact on the development and severity of attention deficit disorder. A deficiency of essential fatty acids, especially DHA, and minerals such as zinc, iodine, magnesium, and iron can negatively affect brain development. 

 While it is known that sugar can negatively impact behavioral issues, it was very interesting to learn that the quantity of sugar ingested compared to to other dietary components also plays a role. For example, a diet high in sugar and void of protein causes glucose crashes that are associated with worsening behavior. Therefore, manipulating the carbohydrate/protein ratio of meals could prevent this phenomenon regardless of sugar consumption (Kohlstadt, 2012). 

How Can Nutritional Therapy Help In The Treatment of ADHD?

Nutritional therapy is a foundational piece in the management of ADHD. It is necessary to provide the patient with the right amount and quality of essential fatty acids (EFA). EFAs are necessary for the structural and functional integrity of neuronal membranes and for neurotransmitter receptor sites (Kohlstadt, 2012). EFAs are also necessary to reduce neuroinflammation (Austin et al., 2014). A review from Raz & Gabis (2009) shows that children affected by ADHD have lower than normal serum levels of EFAs. Children 4 to 6 years old should supplement with 500 mg to 1 g omega-3 per day. Older children can take 1 to 2 g per day. 

 L-carnitine is an amino acid that has neurotrophic, neuroprotective, and neuromodulatory properties. It also has beneficial effects on memory and learning (Kohlstadt, 2012). L-carnitine is also important for fatty acid metabolism, and it is an important component of the cell membranes of the brain (Choi et al., 2018). Research on the use of L-carnitine in ADHD children has been inconclusive so far, but supplementation is free of side effects and can be worth trying. 

 Children affected by ADHD show lower than normal iron levels. This micromineral is important for regulating the brain’s dopamine-related activity. While more research is needed, a few small trials show “improvement on parent- but not teacher-rated ADHD behavior on iron versus placebo” (Kohlstadt, 2012).

 Another mineral important for neurotransmitter function is zinc. Zinc also plays a role in EFA’s synthesis, and zinc deficiency could diminish the treatment response to stimulant medications. Additionally, studies show that children with ADHD have lower zinc levels than children without ADHD.  A small study showed that supplementation with zinc was found to be beneficial in both parent- and teacher-rated behaviors (Kohlstadt, 2012). Zinc is found in organ meats, seafood, oysters, red meat, whole grains, and legumes (Office of Dietary Supplements – Zinc, 2021). 

 Magnesium is important for fatty acid enzyme activity and the function of neurons. Studies show that children with ADHD suffer from magnesium deficiency and that supplementation of 200 mg/day for six months reduces hyperactivity. Adding pyridoxine to magnesium showed reduction in both hyperactivity and aggressive behavior while improving attention span (Kohlstadt, 2012).

Amino Acids & Nutritional Therapy When Treating ADHD

Lastly, as far as nutritional therapy is concerned, it is important to assess levels of amino acids. Amino acids are precursors for neurotransmitter synthesis. Imbalances in the dopaminergic and noradrenergic systems are involved in the manifestation of ADHD. Low serotonin levels are linked with aggressive and impulsive behavior. Although more research is needed, we know that high levels of glutamate release can exacerbate ADHD symptoms and that children affected by ADHD have lower urinary beta-phenylethylamine. While there is currently no research linking GABA abnormalities to ADHD, we know that GABA is an important neurotransmitter for reducing anxiety, and ADHD children suffering from anxiety disorder could benefit from supplementing with GABA (Kohlstadt, 2012). In my practice, I use the Organic Acid Test (OAT) to assess the amino acid status of clients affected by ADHD.

    ADHD is a complex disorder; it affects the lives of millions of children and adults worldwide, and it can be greatly helped with targeted nutrition intervention and other CAM like herbal therapy and homeopathy (Pellow et al., 2011).

References

Austin, D. W., Busija, L., & Brown, C. M. (2014). Observable essential fatty acid deficiency markers and Autism Spectrum Disorder. Breastfeeding Review, 22(2), 21–26. https://search.informit.org/doi/10.3316/ielapa.598798980959381

Choi, J., Yin, T., Shinozaki, K., Lampe, J. W., Stevens, J. F., Becker, L. B., & Kim, J. (2018). Comprehensive analysis of phospholipids in the brain, heart, kidney, and liver: brain phospholipids are least enriched with polyunsaturated fatty acids. Molecular and cellular biochemistry, 442(1-2), 187–201. https://doi.org/10.1007/s11010-017-3203-x

Data and Statistics About ADHD | CDC. (2020, November 16). Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/adhd/data.html

Herndon, M. J. S. (2021, April 13). What to Know About ADHD Medication Side Effects. Healthline. https://www.healthline.com/health/adhd/adhd-medication-side-effects

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

Konikowska, K., Regulska-Ilow, B., & Rózańska, D. (2012). The influence of components of diet on the symptoms of ADHD in children. Roczniki Panstwowego Zakladu Higieny, 63(2), 127–134. 

Millichap, J. G., & Yee, M. M. (2012). The diet factor in attention-deficit/hyperactivity disorder. Pediatrics, 129(2), 330–337. https://doi.org/10.1542/peds.2011-2199

Office of Dietary Supplements – Zinc. (2021). NIH. https://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/

Pellow, J., Solomon, E. M., & Barnard, C. N. (2011). Complementary and alternative medical therapies for children with attention-deficit/hyperactivity disorder (ADHD). Alternative medicine review : a journal of clinical therapeutic, 16(4), 323–337.

Raz, R., & Gabis, L. (2009). Essential fatty acids and attention-deficit-hyperactivity disorder: a systematic review. Developmental medicine and child neurology, 51(8), 580–592. https://doi.org/10.1111/j.1469-8749.2009.03351.x

Four Popular Diets Explored

Four Popular Diets Explored

  • THE KETOGENIC DIET
  • THE ATKINS DIET
  • THE PALEO DIET
  • THE MEDITERRANEAN DIET

The Ketogenic Diet (KD)

The ketogenic diet (KD) came in use in the 1920s as a treatment for epilepsy in children, and it prescribed 1 gram of protein per kilogram of body weight, as well as limiting carbohydrates to 10-15 grams per day. The remainder of the calories were made up by fat (Wheless, 2008). The classic ketogenic diet is still used today for the treatment of epilepsy, but less restrictive versions of the diet (carbohydrates are allowed up to 50 grams per day) are being successfully researched for the treatment of several metabolic conditions.

Research shows that this type of ketogenic diet has a positive impact on a range of diseases including polycystic ovarian syndrome, type-2 diabetes, brain injury, Parkinson’s disease, Alzheimer’s disease, and dementia (Paoli et al., 2013). The KD is also utilized as adjuvant therapy in the treatment of several types of cancers (Klement, 2017). As far as weight loss is concerned, many studies show that the ketogenic diet effectively reduces weight and improves cardiovascular risk markers (Paoli, 2014). In a study on obese patients, all 83 subjects had a significant decrease in weight, BMI, total cholesterol, triglycerides, and glucose levels after 24 weeks of treatment (Dashti, 2006). 

The Atkins Diet

The Atkins diet was introduced by Dr. Atkins in the 1970s and quickly became very popular. This diet is similar to the ketogenic diet as it prescribes low-carbohydrate, moderate-protein. The main difference is that the Atkins diet is divided into four phases. The induction phase is followed for at least two weeks, and it restricts carbohydrates to 20 grams per day. The balancing phase is still low in carbohydrates but allows the dieter to consume up to 50 grams of carbohydrates per day. This phase is followed until the person is 10 pounds shy of his goal weight. During the third phase, pre-maintenance, the dieter slowly increases carbohydrate intake to up to 80 grams per day, as long as weight loss does not stall. The dieter then stays at this phase for at least one month after achieving the goal weight before switching to the maintenance phase. The maintenance phase allows up to 100 grams of carbohydrates per day (Atkins Diet: What’s behind the Claims?, 2020).

The Paleo Diet

 The Paleo diet refers to the diet our ancestors consumed until about 10,000 years ago, before the development of agriculture and the domestication of animals. During that time, humans ate what they could hunt and gather. The diet was made of animal flesh, naturally grown fruits and vegetables, nuts, seeds, eggs, honey, mushrooms, and tubers.

These foods are what make up the modern Paleo diet. The foods that are not allowed in this way of eating include refined sugars and artificial sweeteners, grains, corn, legumes, processed oils, dairy products, and processed foods. There is a lot of research supporting the use of the Paleo diet and showing that this diet is helpful for weight loss.  It reduces total cholesterol and LDL and improves insulin sensitivity and glucose tolerance; it also lowers blood pressure (Olivieri, 2019) (Mårtensson et al., 2021).

The Meditarranean Diet

Last but not least, there is the Mediterranean diet. Studies show that the Mediterranean diet can be beneficial for weight loss (Estruch & Ros, 2020), cancer (Mentella et al., 2019), cardiovascular disease, diabetes (Tricò et al., 2021), Parkinson’s disease, and Alzheimer’s disease (Sofi et al., 2008). Traditionally, there are several different Mediterranean diets that vary based on geographical location, regional traditions, and seasonal availability. The coastal regions have a diet higher in fish, while goat, sheep, and dairy products are more predominant in the mountains.

The French enjoy duck confit and liver pate, while the Greek feast on chickpeas, lamb, and stuffed grape leaves. I grew up in Italy, and, as a child, I had liver once a week and fish once a week. Apart from the cited regional differences, the Mediterranean diets all make sure of unprocessed, nutrient-dense foods like meat and seafood, whole grains, fruits and vegetables, pulses. The main oil used is extra virgin olive oil (Gunnars, 2021).

Comparison Of All Four Popular Diets: Benefits and Deficitiancies

When we compare these four diets, we see that they have in common avoidance of refined sugars and processed foods. While the original Atkins diet didn’t focus on nutrient density, the diet has evolved to promote the consumption of whole foods. Despite this, the Atkins brand makes over $800 million a year from the sale of their processed diet food line (Doering & Doering, 2019).

In my clinical practice, I use all four of these diets for weight loss. I also use high protein diets and macro-based diets. The choice of diet is not arbitrary and must take into consideration the client’s health (hormonal imbalances, gut dysfunction, nutrient deficiencies, etc.), his food preferences, as well as his culinary skills. Most importantly, the best dietary approach is the one that is sustainable in the long term. Working on lifestyle habits is also important: many factors contribute to weight imbalances, therefore, a good weight loss program will provide education on movement, natural light, sleep hygiene, and stress management. Addressing the factors mentioned above will not yield satisfactory weight loss if we do not create a calorie deficit.

Lastly, we need to take into consideration that as the client loses weight, energy requirements will be lower. The diet must be adjusted to meet the demands of a lower basal metabolic rate (BMR). It is also important to give clients diet breaks to avoid diet burnout, boost metabolic rate and thyroid function. For these reasons, when working with individuals that need to lose more than 20 pounds, I have them eat at a deficit for no more than 12 weeks at a time, and I have the “cutting” or weight loss phase followed by a few weeks at maintenance calories before starting a new cut (Renaissance Periodization | The Importance of Maintenance, 2016).   

References

Atkins Diet: What’s behind the claims? (2020, May 6). Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/atkins-diet/art-20048485

Dashti, H. M., Al-Zaid, N. S., Mathew, T. C., Al-Mousawi, M., Talib, H., Asfar, S. K., & Behbahani, A. I. (2006). Long Term Effects of Ketogenic Diet in Obese Subjects with High Cholesterol Level. Molecular and Cellular Biochemistry, 286(1–2), 1–9. https://doi.org/10.1007/s11010-005-9001-x

Doering, C., & Doering, C. (2019, August 22). Atkins owner to acquire protein-food maker Quest for $1B. Food Dive. https://www.fooddive.com/news/atkins-owner-to-acquire-protein-food-maker-quest-for-1b/561433/

Estruch, R., & Ros, E. (2020). The role of the Mediterranean diet on weight loss and obesity-related diseases. Reviews in endocrine & metabolic disorders, 21(3), 315–327. https://doi.org/10.1007/s11154-020-09579-0

Gunnars, K. B. (2021, October 25). Mediterranean Diet 101: A Meal Plan and Beginner’s Guide. Healthline. https://www.healthline.com/nutrition/mediterranean-diet-meal-plan#benefits

Klement, R. J. (2017). Beneficial effects of ketogenic diets for cancer patients: a realist review with focus on evidence and confirmation. Medical Oncology, 34(8). https://doi.org/10.1007/s12032-017-0991-5

Mentella, M. C., Scaldaferri, F., Ricci, C., Gasbarrini, A., & Miggiano, G. (2019). Cancer and Mediterranean Diet: A Review. Nutrients, 11(9), 2059. https://doi.org/10.3390/nu11092059 

Mårtensson, A., Stomby, A., Tellström, A., Ryberg, M., Waling, M., & Otten, J. (2021). Using a Paleo Ratio to Assess Adherence to Paleolithic Dietary Recommendations in a Randomized Controlled Trial of Individuals with Type 2 Diabetes. Nutrients, 13(3), 969. https://doi.org/10.3390/nu13030969

Olivieri C. (2019). Combating insulin resistance with the paleo diet. The Nurse practitioner, 44(2), 49–55. https://doi.org/10.1097/01.NPR.0000552683.55684.f8

Paoli A. Ketogenic diet for obesity: friend or foe? Int J Environ Res Public Health. 2014 Feb 19;11(2):2092–107.

Paoli, A., Rubini, A., Volek, J. S., & Grimaldi, K. A. (2013). Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets. European Journal of Clinical Nutrition, 67(8), 789–796. https://doi.org/10.1038/ejcn.2013.116

Renaissance Periodization | The Importance of Maintenance. (2016). Renaissance Periodization. https://renaissanceperiodization.com/the-importance-of-maintenance/

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Fibromyalgia: Conventional Treatments & Functional Medicine

Fibromyalgia: Conventional Treatments & Functional Medicine

Differences Between Conventional Medicine and Functional Medicine 

  Fibromyalgia is a syndrome that affects between 2% and 8% of the population (Clauw D. J., 2014). It is more prevalent in women than in men, and it presents with chronic pain that affects the musculoskeletal system, fatigue, sleep problems, mood disorders, memory issues and other symptoms (Bair & Krebs, 2020). Fibromyalgia is not an illness with objective markers, and its diagnosis is usually made by studying a patient’s history and symptoms and then excluding other diseases that cause chronic widespread pain (Häuser, 2016). According to Galvez-Sánchez & Reyes Del Paso (2020) this has historically created problems in the diagnosis, management, treatment, and even social recognition of the disease. Old diagnosing guidelines called for the examination of so-called tender points: these are specific points on the body that are tested for pain and/or tenderness. In order to be diagnosed with fibromyalgia, a patient had to respond positively for tenderness to 11 out of 18 points. This was an inaccurate method, as fibromyalgia symptoms change from day to day. Current diagnostic guidelines now include widespread pain on both sides of the body for a minimum of three months (Fibromyalgia: Understand How It’s Diagnosed, 2020). After diagnosis, the patient is generally referred to a specialist in rheumatology for further treatment. 

What Does The Data Reveal?

 A study published in 2005 in The Journal of Rheumatology concluded that fibromyalgia can manifest hand in hand with neurotransmitter and neuroendocrine dysfunction, namely, higher than normal levels of excitatory neurotransmitters (catecholamines, serotonin, acetylcholine and histamine), low levels of biogenic amines as well as imbalances of the hypothalamus-pituitary-adrenal axis (HPA) (Mease P., 2005). Despite these findings, conventional medicine does not test for those biomarkers; instead, it manages fibromyalgia with the use of antidepressants (tricyclic and selective serotonin reuptake inhibitors (SSRI)), anti-seizure medications, muscle relaxants, and nonsteroidal anti-inflammatory drugs (NSAIDS).  Other drugs prescribed include sedatives, norepinephrine/serotonin reuptake inhibitors, and experimental drugs. Exercise, acupuncture and massage are complementary alternative therapies that are often recommended in conjunction with medication (Chinn et al., 2016).    

Conventional Medicine’s Approach To Treatment

Conventional medicine has a reductionist approach to illnesses such as fibromyalgia, while functional medicine uses a holistic approach in the treatment of such conditions. It is frustrating to see such disparities. It is even more frustrating when there are numerous peer-reviewed studies that share important findings demonstrating that addressing the several underlying causes of fibromyalgia can bring this syndrome into remission. These findings have been reviewed, published and shared with the medical community, but conventional medicine is not yet using this knowledge to treat the root causes of the syndrome. The conventional medicine approach uses pharmaceutical drugs to manage symptoms;

this Band-Aid approach is not only unsustainable, it is also faulty. 

Functional Medicine’s Approach To Treatment

 Functional medicine recognizes fibromyalgia as a painful neuropathic pain syndrome that can have root causes in several systems. HPA imbalances, neurotransmitters dysfunction, endocrine issues, nutrient deficiencies, autoimmunity and stress can all play a role in fibromyalgia (Martínez-Lavín M., 2020). The functional medicine approach to treating fibromyalgia aims at finding the root causes of the disease and correcting them, while continuing to support the patient holistically through the use of targeted therapies as well as with complementary alternative therapies (CAM) like massage therapy, nutrient therapy, acupuncture, etc. (Pfalzgraf et al., 2020). 

Among the factors and conditions that are taken into consideration by functional medicine doctors when working with fibromyalgia patients are celiac disease, non-celiac gluten sensitivity, candida overgrowth, hypothyroidism, nutrient deficiencies, leaky gut and small intestine bacterial overgrowth, adrenal fatigue, mercury toxicity, and glutathione deficiency. While the research is still in its early stages, preliminary findings show that people affected by celiac disease and non-celiac gluten intolerance suffer from fatigue, musculoskeletal pain, and brain fog (Isasi et al., 2016). Several studies show that many patients affected by fibromyalgia, myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) also suffer from abdominal discomfort syndrome (ADS) and irritable bowel syndrome (IBS). A study from Maes et al. (2014) shows that the ME/CFS patients also presenting with ADS have higher than normal levels of “IgA and IgM responses to LPS or commensal bacteria” (Maes et al., 2014). Small intestine bacterial overgrowth and leaky gut are also associated with fibromyalgia. Treating the bacterial imbalance has been shown to ameliorate gastrointestinal and fibromyalgia symptoms (Logan & Beaulne, 2002).

 Hypothyroidism can cause secondary fibromyalgia (Corsalini et al., 2017); therefore, failure to test and to address thyroid function will perpetuate fibromyalgia symptoms. 

A Holistic Overview Of The Treatment OF Fibromyalgia

 The functional medicine approach also looks at nutrient status and possible deficiencies: a meta-analysis of 40 observational studies show that fibromyalgia sufferers have lower levels of vitamin D, vitamin B12, magnesium and vitamin E compared to a control group (Joustra et al., 2017) (Pagliai et al., 2020). Studies also show that they have significantly lower levels of glutathione compared to control (Shukla et al., 2020).

 The adrenal glands are our stress response system. Fibromyalgia patients are shown to have either hyper-cortisol or hypo-cortisol output, as well as HPA axis imbalances (Eller-Smith et al., 2018).

 There are other factors that are assessed by functional medicine doctors who work with fibromyalgia patients. While there I was not able to find peer reviewed studies on them, I was able to find quite a bit of anecdotal evidence online. According to Dr. Amy Myers, MD, factors to consider are exposure to mold, mercury toxicity, and MTHFR gene mutations. 

 Lastly, functional medicine also focuses on the mind-body connection when treating fibromyalgia: a systematic review of the Cochrane Central Register of Controlled Trials shows that mind-body therapy is effective in improving quality of life, pain management, and mood issues in fibromyalgia sufferers. Mind-body therapy uses techniques such as biofeedback, mindfulness, relaxation and movement therapy (Theadom et al., 2015). 

References:

Bair, M. J., & Krebs, E. E. (2020). Fibromyalgia. Annals of internal medicine, 172(5), ITC33–ITC48. https://doi.org/10.7326/AITC202003030

Chinn, S., Caldwell, W., & Gritsenko, K. (2016). Fibromyalgia Pathogenesis and Treatment Options Update. Current pain and headache reports, 20(4), 25. https://doi.org/10.1007/s11916-016-0556-x

Clauw D. J. (2014). Fibromyalgia: a clinical review. JAMA, 311(15), 1547–1555. https://doi.org/10.1001/jama.2014.3266

Corsalini, M., Daniela, D. V., Biagio, R., Gianluca, S., Alessandra, L., & Francesco, P. (2017). Evidence of Signs and Symptoms of Craniomandibular Disorders in Fibromyalgia Patients. The open dentistry journal, 11, 91–98. https://doi.org/10.2174/1874210601711010091

Eller-Smith, O. C., Nicol, A. L., & Christianson, J. A. (2018). Potential Mechanisms Underlying Centralized Pain and Emerging Therapeutic Interventions. Frontiers in cellular neuroscience, 12, 35. https://doi.org/10.3389/fncel.2018.00035

Fibromyalgia: Understand how it’s diagnosed. (2020, September 18). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/fibromyalgia/in-depth/fibromyalgia-symptoms/art-20045401

Galvez-Sánchez, C. M., & Reyes Del Paso, G. A. (2020). Diagnostic Criteria for Fibromyalgia: Critical Review and Future Perspectives. Journal of clinical medicine, 9(4), 1219. https://doi.org/10.3390/jcm9041219

Häuser W. (2016). Fibromyalgiesyndrom Basiswissen, Diagnostik und Therapie [Fibromyalgia syndrome: Basic knowledge, diagnosis and treatment]. Medizinische Monatsschrift fur Pharmazeuten, 39(12), 504–511.

Isasi, C., Tejerina, E., & Morán, L. M. (2016). Non-celiac gluten sensitivity and rheumatic diseases. Reumatologia clinica, 12(1), 4–10. https://doi.org/10.1016/j.reuma.2015.03.001

Joustra, M. L., Minovic, I., Janssens, K., Bakker, S., & Rosmalen, J. (2017). Vitamin and mineral status in chronic fatigue syndrome and fibromyalgia syndrome: A systematic review and meta-analysis. PloS one, 12(4), e0176631. https://doi.org/10.1371/journal.pone.0176631

Logan, A. C., & Beaulne, T. M. (2002). The treatment of small intestinal bacterial overgrowth with enteric-coated peppermint oil: a case report. Alternative medicine review : a journal of clinical therapeutic, 7(5), 410–417. 

Lord, R.S., & Bralley J. A. (2012) Laboratory evaluations for integrative and functional medicine. 2nd edition. Metametrix.

Maes, M., Leunis, J. C., Geffard, M., & Berk, M. (2014). Evidence for the existence of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) with and without abdominal discomfort (irritable bowel) syndrome. Neuro endocrinology letters, 35(6), 445–453. 

Martínez-Lavín M. (2020). Holistic Treatment of Fibromyalgia Based on Physiopathology: An Expert Opinion. Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases, 26(5), 204–207. https://doi.org/10.1097/RHU.0000000000001455

Mease P. (2005). Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. The Journal of rheumatology. Supplement, 75, 6–21. 

Pfalzgraf, A. R., Lobo, C. P., Giannetti, V., & Jones, K. D. (2020). Use of Complementary and Alternative Medicine in Fibromyalgia: Results of an Online Survey. Pain management nursing : official journal of the American Society of Pain Management Nurses, 21(6), 516–522. https://doi.org/10.1016/j.pmn.2020.07.003

Pagliai, G., Giangrandi, I., Dinu, M., Sofi, F., & Colombini, B. (2020). Nutritional Interventions in the Management of Fibromyalgia Syndrome. Nutrients, 12(9), 2525. https://doi.org/10.3390/nu12092525

Shukla, V., Kumar, D. S., Ali, M. A., Agarwal, S., & Khandpur, S. (2020). Nitric oxide, lipid peroxidation products, and antioxidants in primary fibromyalgia and correlation with disease severity. Journal of medical biochemistry, 39(2), 165–170. https://doi.org/10.2478/jomb-2019-0033

Theadom, A., Cropley, M., Smith, H. E., Feigin, V. L., & McPherson, K. (2015). Mind and body therapy for fibromyalgia. The Cochrane database of systematic reviews, 2015(4), CD001980. https://doi.org/10.1002/14651858.CD001980.pub3

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