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Niacin, Niacinamide, Nitrates, and Nicotinamide

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green and red chili peppers

Nutrients that sound the same can be very confusing. Niacin, niacinamide, nitrates, and nicotinamide adenine dinucleotide can have differences in how they function, yet be similar in how they assist in healthy aging. So let’s start with niacin and niacinamide which are 2 forms of water soluble vitamin B3.

Niacin, also known as nicotinic acid is a vitamin essential for energy metabolism. It helps in the functioning of the digestive tract, skin and nervous system. It is also known for its benefits in reducing cholesterol, particularly people with elevated triglycerides and low HDL (good cholesterol). It is found in food sources such as fish, meat, eggs, milk, yeast, nuts, green vegetables, and beans. Niacin as a supplement can cause blood vessels to dilate which results in flushing for some people. If that’s the case, then I recommend using an extended release form that causes less flushing.

Niacinamide is the other form of B3 (Niacin) that was initially used to prevent a condition know as pellagra- a disease causing dermatitis and red lesions due to B3 deficiency. Today it is used in many skin care products to prevent acne, wrinkles and skin damage. Our body has the ability to convert niacin into niacinamide in large amounts. In high doses, niacinamide can cause skin irritation, burning, itching or redness. Topical niacinamide skin products can be as high as 10%, but studies show that there is no additional benefit compared to doses as low as 2%.

Let’s talk about nitrates. These are compounds found in beetroot and dark leafy greens like spinach and arugula. When you consume nitrates, your body converts it to nitric oxide, which allows blood vessels to dilate and lowers blood pressure. Nitric oxide is an important molecule in all aspects of aging. It increases blood perfusion and not only delivers nutrients and oxygen to tissues including the heart, but also removes waste products. It also suppresses coagulation and stops blood from getting “sticky”. Be careful because nitrates can come from processed foods, such as preservatives in bacon, cold cuts and hot dogs. You want to stay away from them due to their risk for cancer. But vegetable nitrates, such as celery, cress, lettuce, rugula and spinach are harmless and these along with other antioxidants help neutralize free radicals.

The other N-compound that assists in the aging process is Nicotinamide adenine dinucleotide (NAD+). The reduced form of NAD+ is NADH which is critical for mitochondrial production of ATP, which serves as fuel for the cells of the body. NAD+ levels decrease with age. Low levels make mitochondria more vulnerable to damage.  Low NAD+ also occurs in many neurodegenerative diseases including Alzheimer’s, Parkinson’s, cardiovascular disease and muscle atrophy. Sirtuins, which increase lifespan, need NAD+ to function properly. Sirtuins are a class of enzymes that influence aging and longevity through multiple pathways. These enzymes stop the decline in vascular endothelial function, metabolic syndrome, ischemic injury, obesity and cardiomyopathy. NAD+ can be activated with lean diets, exercise, intermittent fasting, and supplementing with NADH 5-10 mg daily. Resveratrol which is a polyphenolic compound produced in plants has been shown to activate Sirtuin. Sources are grapes and berries.

Nutrients that sound the same can be very confusing. By understanding and incorporating these nutrients in our life we can improve healthy blood flow and mitochondrial rejuvenation to help us feel healthier and more energetic as we age.

Reference: Van De Walle, G. Niacinamide: Benefits, Uses and Side effects. Healthline.com. Nov 16, 2018.

Natural Medicines Comprehensive Database: NADH. natural database.com

Meletis, C. Wilkes, K. The critical role of NAD+ and nitric oxide replenishment in anti-aging medicine. Townsendletter.com. Dec. 2021, Issue #461. p. 48-51.

The New Wave of Allergens

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With more than 60 million Americans affected, allergens are an important health issue. We are seeing a new wave of allergens that are effecting more people. Compared to 1990, pollen season occurs 20 days earlier and stays around on average 8 days longer according to a 2021 study. Not only is the season longer, but the symptoms are more severe. Plants, grasses and trees are spraying 21% more pollen than they did 30 years ago. So what gives?

The cause is our ever changing climate. As temperatures go up and the CO2 in the environment increases, plants produce more pollen. The severity depends on where you live and the plant species that proliferate there according to William Anderegg, associate professor of biology at the University of Utah and the lead author of that 2021 study. His study found that Texas and the Midwest have taken the brunt of these increasing pollen hot spots. This new wave of allergens is nothing to sneeze about (sorry.. I had to say it!) Climate change is not in the future…but is here with every breath you take.

If the current trends continue, ragweed and grass pollen concentrations will significantly rise over the next 40 years, says research analyst Hannah Jaffee of the Asthma and Allergy Foundation of America (AAFA). One spokesperson from the AAFA, Neeta Ogden MD, states that allergy symptoms usually improve as we get older because our immune systems become less reactive with age. But climate change is robbing us of this natural protection. Unfortunately, some older adults are actually developing allergies for the first time in their lives. While others are suffering longer and more intense seasons. In many areas, high pollen counts can start in early March and go through late October (even through Halloween!). Microparticles of pollen can continue to linger into the winter season. Treating allergens can also keep you healthier when it comes to warding off viruses. That’s because if you have allergies, your airways are more reactive to viral illnesses. So suppressing flare-ups may improve your overall immunity keeping your defenses up to fight off colds and flu.

Here are some things you can do to help reduce your sneezing, coughing congested symptoms.

  • Start treatment early: It’s easier to prevent your immune system from getting overwhelmed and overly aroused than it is to calm it down. So for the fall ragweed season, start treatment in August. The dates differ depending on what part of the country you live in. Consider starting with a nasal steroid spray. Over-the-counter nasal sprays include fluticasone (Flonase), triamcinolone (Nasacort) or budesonide (Rhinocort). These nasal sprays reduce nasal swelling and mucous production but can take a week to work so start early. Which one to choose? Some people find Flonase irritating because it contains alcohol so you can start with Nasacort. Anti-histamine nasal sprays are also available that treat itchy, runny nose symptoms and sneezing. These include prescription azelastine (Astelin, Astepro) and olopatadine (Patanase).
  • Oral antihistamines are also effective. Most over-the-counter medications work well. They include loratadine (Claritin), fexofenadine (Allegra) which are both non-drowsy formulas. Cetirizine (Zyrtec) or levocetirizine (Xyzal) are sedating so they should be taken at night. Natural products that have antihistamine effects include Quercetin, Stinging Nettles and Vitamin C. Still suffering? Consider allergy shots or immunotherapy.
  • Mask up if you are outdoors on high allergen days. Check the pollen counts daily on apps such as pollen.com, weatherbug.com and weather.com. These resources show counts and ratings for the day. If high, then try to shift outdoor activities indoors. Or you can avoid outside activities when pollen release is at its peak especially on windy and warm days. Those are 5-10AM and after 4 PM to dusk.
  • Avoid indoor allergens too. The sheer load of allergens can make symptoms worse. Common indoor allergens include pollen, dust mites, dander and mold. Zip up box springs and mattresses with dust mite covers. Vacuum carpets frequently, and keep windows closed while setting up a HEPA air purifier if you are allergic to your pet. Make sure to get roof leaks fixed and keep the indoor humidity to 40% to reduce mold in your home.

Being aware of your allergens is the first step toward taking preventative measures. Speak to your practitioner or see an allergist for testing if you are unsure.

References: Migala, J. Allergies: The next wave. AARP Bulletin April 2022.

Extreme Allergies and Climate Change. Asthma and Allergy Foundation of America. aafa.org

 

Overuse of Proton Pump Inhibitors

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The use and availability of proton pump inhibitors (PPI) have become very convenient. The common over-the-counter names of these drugs are esomeprazole (Nexium), lansoprazole (Prevacid) and omeprazole (Prilosec). They are used to treat heartburn and recommended to be used for no more than 14 days. But there seems to be an overuse of proton pump inhibitors.  Unfortunately 1/4 of patients end up taking these drugs for over 1 year, and the majority of the time, these drugs are over-used (2/3 of patients) with no indication for treatment.

When you overuse proton pump inhibitors for the long term, you have an overproduction of acid producing parietal cells, and when these drugs are discontinued, you have a hyperacid environment and the symptoms return which is why people stay on them. There are some indications for staying on these acid blockers. They include: High grade erosive gastritis, Barrett’s esophagus, esophageal strictures from gastroesophageal reflux (GERD), gastroprotection of those at high risk for GI bleed, protection from idiopathic pulmonary fibrosis, eosinophilic esophagitis and Zollinger-Ellison syndrome. So it’s between you and your practitioner on whether long-term treatment is necessary and whether the benefits outweigh the risks. And yes…there are risks.

We need to remember that we need stomach acids for absorption of many nutrients, primarily proteins and minerals. Deficiencies include Vitamin B12, iron, calcium, magnesium, zinc, and folic acid. Other dangers associated with long-term use of PPI’s include osteoporosis, kidney disease, pneumonia, stroke and contracting Clostridium difficile (C.diff) bacterium.

The real concern of the progression to adenocarcinoma with Barrett’s esophagus would make the decision of staying on PPI’s quite easy, except for the fact that studies have found no protective effect.

The same goes for eosinophilic esophagitis which is an allergic condition that occurs in the esophagus. The esophagus becomes inflamed and has difficulty contracting properly, getting more narrow and developing rings or abscesses. Although acid suppression helps manage the symptoms of eosinophilic esophagitis, it should only be used after eliminating foods that are triggering an allergic reaction. Eliminating the triggered foods cures the problem in about 50% of patients. There is also some concern that staying on PPI’s may continue to promote the condition. Acid activates proteolytic enzymes to help break down food to make it more digestible. When acid is not available to stimulate digestion, then exposure to undigested foods can trigger eosinophilic inflammation along the gut’s immune system.

So how can we de-prescribe these medications?

  1. Identify foods that trigger your symptoms. Tomato based foods, caffeine and alcohol are common triggers I see clinically. I recommend a food list to my patients that can be found on line. Foods that cause GERD.
  2. I treat my patients naturally for a condition known as Helicobacter Pylori (H. Pylori), a bacteria that lives in the digestive tract which can cause similar symptoms as acid reflux and can lead to ulcers in the lining of the stomach. I use a combination product that has mastic gum, bismuth and zinc called “Pyloracil”. Mastic gum is a resin, or sap-like substance that comes from the mastic tree grown in the Mediterranean. It helps reduce stomach acid and protects the stomach and intestinal lining. Studies have shown it also fights bacteria including H. Pylori.  I recommend using it for 3 weeks while reducing their PPI from twice daily to once a day or if once a day use, to 1 every other day.
  3. If patients develop heartburn when reducing their PPI dose, I recommend “D-Limonene”, which is an orange peel extract on the days they are off of their medication. This can neutralize gastric acid and supports normal peristalsis. It has been used for the relief of heartburn and GERD.
  4. Deglycyrrhizinated licorice works well by soothing the stomach lining. You can find this over the counter in chewable tablets.
  5. Melatonin can help symptoms if they primarily occur at night. This sleep hormone increases the tone of the lower esophageal sphincter. Start with 1-3 mg before bed.
  6. Acupuncture can also be helpful.
  7. Stop the use of non steroidal anti-inflammatory medications (NSAID’s), which includes Naproxen, Ibuprofen and Diclofenac to name a few.

If a person has recurring symptoms that last over 3 weeks after stopping their PPI then they should contact their practitioner for possible referral to a GI specialist for an endoscopy. Make sure you discuss all your over-the-counter meds and supplements with your practitioner.

References: Rakel, D. Clinical Practice Update on De-Prescribing PPI’s. Primary Care. March 17, 2022.

Sun, J. D-Limonene: Safety and Clinical Applications. PubMed.ncbi.nlm.nih.gov. Altern Med Rev. 2007 Sept.

Aquatic Therapy for Chronic Back Pain

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floating woman on body of water

Back pain is no stranger to most of us. About 84% of adults have back pain sometime in their lives. For many people back pain is self-limiting. But it can become more of a problem if it continues more than 3 months which is considered chronic. So what about aquatic therapy for low back pain? A study based out of China randomized supervised aquatic exercise versus traditional physical therapy in 113 adults, ages 18-65 with moderate to severe low back pain (LBP). The study went on for 13 months, and participants were randomized to either supervised aquatic therapy or traditional physical therapy in twice weekly sessions for 12 weeks.

After 1 year, mean scores on a 24-point disability scale improved by about 4 points more among participants in the aquatic exercise group then among those in the traditional physical therapy group, which is a meaningful difference. The aquatic exercise group also had improvement on the pain scale vs the traditional exercise group. Significant improvements in other measures of functioning and sleep also favored the aquatic participants.

Aquatic Therapy, or hydrotherapy as it is otherwise known has been used as an alternative therapy for those with chronic pain, or recovering from an injury or surgery. The natural buoyancy of water helps to reduce weight and eases stress on joints, even those in the spine. It does offer some resistance which can increase strength without muscle fatigue. It can reduce muscular and neurological pain and improve flexibility and range of motion. Plus it can be soothing and comfortable when done in a rehab setting by a physical therapist trained in hydrotherapy.

A study in 2019 sited in Physical Therapy stated that “aquatic exercise produced sufficient muscle activation, intensity and exertion.” It also noted reduction of pain vs land exercises. Several other studies have praised its benefits, including its positive effects in those with spinal stenosis, which is a neurological condition affecting the lower back and neck.

Speak to your practitioner and physical therapist about whether this treatment is right for you. This may be an effective option for managing this very common and difficult to treat condition.

References: Thomm, M. Get in the Water: Hydrotherapy for Pain and Movement. Practical Pain Management 11/11/2021.

Peng M-S et al. Efficacy of therapeutic aquatic exercise vs physical therapy modalities for patients with chronic low back pain; A randomized clinical trial. JAMA Netw Open 2022 Jan 7; 5:e2142069.

Gut Microbiome and Medications

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There has been growing interest in the interaction between the gut microbiome (genes of gut bacteria) and medications. Some medications are known to effect the gut in certain ways. For example, antibiotics tend to change the amount and types of bacteria in the gut which can cause side effects such as nausea and diarrhea. The drugs associated with lowering stomach acids such as PPIs (protein pump inhibitors), is associated with an increase in oral bacteria (that’s right…bacteria that’s found in the mouth) and potential pathogenic bacteria in the gut. There are interactions between the gut microbiome and medications.

Researchers studied the effects of 15 drugs on 25 strains of human gut bacteria and found a variety of drug-bacteria interactions. Some bacteria store the drug without chemically changing it while other bacteria chemically modify it to make it more or less bioactive. In other words, the gut bacteria can determine the amount of a drug (or an active drug metabolite) that is available to the body.

The opposite is also true. A particular drug can also affect a patient’s gut bacteria, both the number and function of that bacteria. For example, the build-up of a drug within a strain of bacteria can change the growth rate of those bacteria. Sometimes a drug can even change the molecules that are secreted by bacteria. This doesn’t sound like a big deal until you understand that the molecules can include hormones, neurotransmitters and molecules of inflammation that effect our physiology. There are clearly interactions between the gut microbiome and medications.

The drug variability can be due to either a person’s genetics or due to the person’s gut flora. Association studies have shown changes in the abundance of various gut bacteria in individuals with inflammatory bowel disease, irritable bowel syndrome and colorectal cancer.  This has also been found in other systemic diseases such as cardiovascular, metabolic conditions, autoimmune and psychiatric disorders.

As you can see here, there is a complex bidirectional interaction between commonly used drugs and the gut microbiome. This means that among people who have the same disease, a particular drug can vary greatly in its effectiveness and adverse effects. Perhaps this will help us in finding interventions to modulate the gut microbiome and optimize effectiveness of treatment.

Reference: Klünemann, M et al. Bioaccumulation of therapeutic drugs by human gut bacteria. Nature 2021 Sep; 597:533

Weersma, R et al. Interaction between drugs and the gut microbiome. Gut 2020 Volume 69, Issue 8. gut.bmj.com