Vitamin B2- Riboflavin

English: One milliliter of (approximately) 0.1...

One milliliter of riboflavin

Next up in our vitamin march is Vitamin B2, also known as riboflavin. Riboflavin in our diet mostly comes from meat, dairy products, eggs, green leafy vegetables, almonds, or mushrooms. Yeast, liver, and kidney are particularly rich in riboflavin. Also, like thiamine riboflavin is found in cereal grains such as wheat and rice but again is mostly in the outer portion or the germ and therefore much of it is lost in processed grains (yet again, it is important to eat whole grains when possible). Riboflavin is easily destroyed by UV light so some recommend buying dairy products in containers that do not allow light to pass through.

This is the vitamin that gives your urine that neon yellow appearance if you take B vitamin supplements or a multivitamin with high doses of riboflavin. Riboflavin is important for energy metabolism and is required in the processing of other vitamins including Vitamin A, Vitamin B6, and Vitamin B3 and the absorption and processing of iron. It helps maintain normal adrenal gland and nervous system function.

The recommended daily allowance of riboflavin is 1.2 mg per day. However, the recommended daily allowance of Vitamin B2 (and for all the other vitamins) given the data we have should be seen more as a bare minimum for survival and not as a goal for intake per day. Like the other B vitamins, riboflavin is a water-soluble vitamin, so it is not stored by the body in significant amounts and if intake is not sufficient deficiency will occur quickly (within days or weeks). However, this water-soluble quality also makes riboflavin very safe to take in higher quantities as the excess is easily excreted by the body in the urine. However very high doses possibly may increase the risk for kidney stones and may cause some skin irritation. 

deficiency of riboflavin (a condition known as ariboflavinosis) usually presents with weakness, fatigue, dry cracked lips, inflammation of the mouth and tongue, sore throat and mouth ulcers. Dry scaly skin, irritation of the eyes, and anemia may also occur.

Some recognized uses of riboflavin are supplementation to infants receiving UV light for neonatal jaundice (the yellowing of the skin due to bilirubin from broken down red blood cells that is treated with the famous bili blanket) because the UV light breaks down the riboflavin in the baby’s blood. It is also used in conjunction with UV light that is used to sterilize pathogens in blood products that are donated and applied to the cornea before UV treatments for Keratoconus (a thinning and mis-shaping of the cornea into a cone shape).

There was some excitement when it was found that pregnant women who were riboflavin deficient had a nearly 5 times increased risk for preeclampsia. Preeclampsia is a condition in pregnant women of unknown cause where they develop protein in the urine and elevated blood pressure in the later stages of their pregnancy. The blood pressure can get dangerously high and it can progress to eclampsia which is when those with preeclampsia then have seizures. The hopes were that riboflavin supplemenation would prevent and treat this. However this was studied by Neurgebauer et. al in good placebo controlled trial in 450 pregnant woman, and they found no decrease in risk of preeclampsia with riboflavin supplementation.

Multiple studies have shown a decrease risk for cataracts in those that eat higher amounts of riboflavin. This would make sense as well as deficiency is known to cause eye irritation. However a good randomized placebo controlled trial of riboflavin supplementation to prevent cataracts has yet to be done despite this being one of the most common conditions of old age and cataract surgery is the most common surgery done on the elderly in America. Over 20 million Americans have catract and it affects 50% of those over the age of 80. The surgery for cataract is performed on approximately 3 million Americans per year and costs Medicare an estimated 3.4 Billion dollars per year.

Multiple smalls studies have also shown a benefit to migraine headache sufferers with riboflavin. When taken together the strength of these studies is quite strong and they were placebo controlled. There is also good science behind why this may work. Riboflavin helps with energy metabolism in the mitochondria (a part of cells that is devoted to energy production) and some studies have shown that oxygen metabolism by mitochondria may play a role in migraines. Interestingly the maximum benefit seemed to not be achieved until about 3 months of treatment. The reason for this is unclear.

I had also noted the symptoms of riboflavin deficiency are almost identical to a condition called mucositis that we see in many cancer patient’s receiving chemotherapy or radiation. Mucositis causes severe mouth, tongue and throat irritation and ulcers, sometimes to the point patients cannot eat. Sure enough, when I went to the literature there was evidence that riboflavin supplementation may prevent this. However it is still in the preclinical phase and trials on actualy patients have yet to be done. Vitamin E has also been shown to be effective. Topical Vitamin E seems to be more effective than Vitamin E pills.

Given the data I feel riboflavin needs to be tested in a large randomized study to see if it can alleviate mucositis. This is a debilitating condition that causes severe pain to cancer patient undergoing so much pain and suffering already.  We also need a large randomized trial to definitively assess the role riboflavin supplementation may play in cataract prevention.

However, I feel it would be appropriate to start migraine sufferers and elderly on B complex supplementation with the data we have given riboflavin’s almost complete lack of side effects and risk for toxicity. However in cancer patients undergoing chemotherapy and radiation with mucositis this would have to be looked at more closely as the supplementation’s effect on their chemotherapy and cancer is still not known. However topical Vitamin E seems very promising and giving it topically dramatically decreases any risk for interaction with chemotherapy or effect on the cancer.

References

Riboflavin and preeclampsiaNeugebauer J, Zanre Y, Wacker J. Riboflavin supplementation and preeclampsia. Int J Gynaecol Obstet

Riboflavin and cataracts

American Journal Epidemiology 1995 Diet and nuclear lens opacities

 
Riboflavin and Migraines

Vitamin B1- Thiamine

Next up is one of the B vitamins, Vitamin B1, otherwise known as thiamine. All living things need thiamine. However, plants, bacteria and fungi can produce their own. Animals such as ourselves have to obtain it in our diet. Thiamine was the first water-soluble vitamin discovered. It was first recognized in 1884 when a surgeon general in the Japanese Navy Kanehiro Takaki noticed health benefits when a more varied diet was used on Navy ships instead of just the standard white rice predominant diet. This change in diet helped to alleviate many of the nerve and heart problems seen in the sailors. Unfortunately the Japanese navy did not feel it was worth the expense of the more varied diet.

Thiamine and other B vitamins are important for breaking down starch, sugars and carbohydrates to use as energy and also play a key role in nerve signal transmission. These functions make thiamine important for energy levels, the nervous system, muscle health and the digestive system.

Thiamine is found in a wide variety of foods but the highest concentration is in yeast, pork, and beans. The main source of thiamine in the diet is from grains. However, yet another reason to eat whole grains rather than highly processed ones is that thiamine is mostly found in the outer layers and germ of the grains that are removed during processing. In the US thiamine is added back in to processed flour. Thiamine is not stored by the body so symptoms of thiamine deficiency can form after even short periods of not eating enough (in as little as 2 weeks).

The recommended daily allowance for Thiamine is 1.4 mg. However some studies have shown benefits to higher doses up to 50 mg. It is likely the lower limit for ideal health lies somewhere around 5 mg or greater as it has been observed that the bodies absorption of thiamine decreases above this level. There are no adverse effects to excess thiamine as it is a water-soluble vitamin and excess amounts are easily excreted by the body in the urine.

Thiamine deficiency causes two main well know syndromes. The first one is Beriberi. Dry beriberi is a disease mostly of the peripheral nerves (those nerves further down than the spinal cord). This causes what is called a peripheral neuropathy where these nerves are damaged causing numbness, tingling, weakness, difficulties walking, and abnormalities in the reflexes. Wet beriberi has all of these symptoms from peripheral neuropathy but also leads to heart failure as well. It is called wet because the heart failure leads to a back up of fluid into the lungs and lower extremities causing swelling/edema. When treated the heart failure can improve rapidly but peripheral nerves can regenerate themselves (unlike central nerves like those in the spinal cord and brain) but this process takes months to correct.

Thiamine deficiency causes central nerve problems in the brain as well. In developed countries this usually happens in alcoholics as alcohol interferes with thiamine uptake by the body and displaces food in the diet that is normally the source of thiamine. It causes two conditions referred to as Wernicke encephalopathy and Korsakoff syndrome. But they so commonly happen together that they are often referred to as a blanket term Wernicke-Korsakoff syndrome. The Wernicke encephalopathy is a constellation of problems with eye movements, altered mental status, and difficulties walking. Kosackoff is a thiamine deficiency induced severe impairment in memory. Thiamine deficiency can also lead to visual disturbances.

Thiamine is mostly only used in medical practice whenever a person struggling with alcoholism is admitted to the hospital. They are routinely given thiamine to help prevent Wernicke-Korsakoff syndrome. Other than that thiamine is rarely used in medical practice.

Some studies have looked at the role of thiamine in Alzheimer’s disease. This article described some of the results showing that thiamine supplementation does show benefit in the cognition of those with Alzheimer’s disease. As this study showed there is an issue with many of the studies done with thiamine as they will often use doses as low as 3 mg per day which is likely lower than what the average person should be eating a day. The elderly absorb thiamine even less effectively than younger people so treatment doses should likely be well in excess of 10 mg but studies rarely do this. Giving IV is another option but this limits using the results for the general public as outpatients. However, what studies have been done show little or no benefit and studies looking at thiamine levels in the cerebrospinal fluid (CSF) showed no correlation with the level and risk for Alzheimer’s. Therefore it seems unlikely that thiamine will play a major role in the treatment of Alzheimer’s. However supplementation or increased intake in the diet may help a little. (however studies do show that Vitamin A may play a role in the treatment of Alzheimer’s Dementia. Please see my previous post and this study.)

In heart failure some studies have shown that thiamine deficiency may play a role, which is logical given the known syndrome of wet beriberi. However, even in patients with heart failure due to other reasons such as coronary artery disease these patients often receive a diuretic called lasix to help keep fluid levels low in the body. It has been shown that lasix causes increased excretion of thiamine which leads to low levels further worsening heart failure. Finally this was studied in a well designed but disgracefully small study (9 patients). The study showed a 4% improvement in cardiac function (which in heart failure patients is a lot) with thiamine supplementation. There is also a well-known heart failure in alcoholics called alcoholic cardiomyopathy which could easily at least partially be explained by thiamine deficiency yet few of these patients receive thiamine supplementation at home. And then there is a large group of what we call idiopathic cardiomyopathies where patients have heart failure of unknown cause. Despite not being able to find a cause thiamine deficiency is rarely if ever entertained and thiamine is equally rarely given. Given the data I see no reason why every single hear failure patient shouldn’t be given thiamine supplementation. Many of them are on lasix anyway which deplete thiamine and may further worsen their heart failure. And in a small group we may find that thiamine deficiency was the sole cause of their heart failure and they will be cured. The study to look into the effect of thiamine on heart failure would be easy to do with a randomized controlled trial. However, given thiamine’s almost complete lack of risk for toxicity and being very cheap I see no reason not to give all heart failure patients thiamine now with the data we already have.

Early studies are showing too that thiamine may be especially helpful for diabetics especially in preventing damage to peripheral nerves which can cause a condition called diabetic neuropathy, which causes tingling, pain, or numbness in the toes, feet and legs. This article even lays out how thiamine deficiency may play a key role in the damage to blood vessels that lead to heart disease, eye problems and strokes in diabetics.

This placebo controlled trial showed an improvement in energy levels, mental clarity and response times with thiamine supplementation of 50 mg/day. This was in individuals who at baseline had what was considered adequate thiamine intake and levels.

Thiamine and cancer is being actively investigated. It has been shown that thiamine levels are very low in cancer patients. However, this does NOT mean that thiamine deficiency causes or even increases the risk for cancer. It is entirely possible that the thiamine deficiency is caused by the cancer or is actually part of the body’s defense mechanisms against the cancer. One supporting piece of information for this is the observation in one study that cancer growth actually increased at doses a few times higher than the recommended daily allowance. However it has also been shown that thiamine doses thousands of times higher than the RDA dose actually inhibit cancer growth. This is an ongoing area of investigation and will be very interesting to watch going forward. But given the current data giving thiamine to cancer patients without thiamine deficient symptoms would not be advisable as data to date shows no benefit and possible harm.

Overall with the data we have so far the role of thiamine in heart failure and diabetes should be investigated with larger placebo controlled trials. But given its almost complete lack of toxicity and the data we already have so far likely all patients with heart failure and all diabetics should be on a relatively high does of thiamine (about 50 mg) daily.

Thiamine is a prime example of how vitamins can serve as medicine while being far cheaper and safer than modern pharmaceuticals.

References

Thiamine and Alzheimer’s http://www.ncbi.nlm.nih.gov/pubmed/22218733

CSF thiamine levels and Alzheimer’s http://www.ncbi.nlm.nih.gov/pubmed/12111441

Vitamin A and Alzheimer’s – http://www.ncbi.nlm.nih.gov/pubmed/22221326

Lasix, heart failure and thiamine – http://www.ncbi.nlm.nih.gov/pubmed/1867241

Small but well designed thiamine study – http://www.ncbi.nlm.nih.gov/pubmed/22057652

Thiamine and Diabetic neuropathy – http://www.ncbi.nlm.nih.gov/pubmed/21342411, http://www.ncbi.nlm.nih.gov/pubmed/19057893

Article on thiamine and its role in vascular damage in diabetics – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3376872/

 

Vitamin A

Polar Bear (Sow), Arctic National Wildlife Ref...

Vitamin A is actually a group of compounds that include retinol and beta-carotene among others. The science behind it dates back to 1816 when scientists noticed nutrition deprived dogs developed corneal ulcers. It was later found to be a fat soluble vitamin (as opposed to water-soluble) meaning it is stored in the fat (along with vitamins D, E, and K).

Vitamin A is indeed important in maintaining good vision. It is also important for cell growth and differentiation, skin health, and the immune system. For women the recommended daily allowance (RDA) is 700 mcg and 900 for men. The widely considered upper safe limit is considered to be 3000 mcg.

Animal sources of vitamin A include cheddar cheese, eggs, butter, and liver. Plant source include carrots, broccoli, kale and spinach. Dandelion greens have a particularly high amount of vitamin A and are used in natural medicine.

Worldwide Vitamin A deficiency is a huge problem. Approximately one-third of children are estimated to be vitamin A deficient. Nearly a half a million children a year go blind each year due to vitamin A deficiency. It often presents first with night blindness. Also early on a condition called xerophthalmia occurs where the eye is unable to produce tears. This leads to eye dryness, then plaques and eventually ulcerations. Other symptoms include increased infections due to an impaired immune system and poor forming of tooth enamel.

Vitamin A overdose is a significant risk as it is fat soluble, which means the body stores it in fat cells so excess amounts cannot be cleared easily. Excess vitamin A in pregnant women has been shown to cause birth defects in their offspring (however vitamin A deficiency also causes issues for the fetus as well). Toxic levels can cause nausea, vomiting, hair loss, weakness, and headaches and can lead to osteoporosis. Liver damage has also been seen at high doses. However, it is interesting to note that these toxicities and teratogenicity (damage to unborn fetuses) are only seen with preformed vitamin A (retinoid) as found in animal sources of Vitamin A such as in liver or supplements with retinol or retinoic acid. It is not seen with carotenoid forms (such as beta-carotene) which are found in plant sources such as carrots and are molecules that have to be converted into vitamin A by the body. Carotenoids are water-soluble and not stored by the body hence they are rarely if ever toxic. Beta-carotene is the most common carotenoid in supplements but there are many more (approximately 500 known so far) but only about 10% of those are made into vitamin A. Therefore if one is going to supplement vitamin A levels they should avoid retinol or retinoid acid and instead try to get a supplement with a mixture of carotenoids.

Vitamin A research is severely limited due to its overblown risks for toxicity. Most people I know during medical school were told of a group of arctic explorers that died due to Vitamin A toxicity from eating polar bear livers. Of course liver is the richest possible source of vitamin A in the diet. It is also all in the preformed retinoid form which is the most toxic. I personally have never, not once, seen a case of vitamin A toxicity. And that is in spite of the fact that I live within a short drive of Herbalife headquarters and in southern California where people take supplements galore.

Vitamin A is most commonly used to treat Acne most commonly in the form of isotretinoin (Accutane). It is effective but does come with significant side effects and very high risk for birth defects if a woman becomes pregnant on it. Therefore women have to pledge to use contraception while using it.

Vitamin A is also used rarely for cancer in the retinoid form which is the active metabolite of vitamin A. Mostly it is used in rare pediatric tumors such as acute promyelocytic leukemia and neuroblastoma. The role of Vitamin A and cancer is still being evaluated as described in this study. Vitamin A may also play a role in cancer prevention.

Research has also shown that Vitamin A can dramatically decrease the complications and death rate from measles. It has also been shown since the 1990s that vitamin A helps to decrease morbidity and mortality from HIV, however this has not been adequately looked at and few if any doctors given Vitamin A to their HIV patients despite these results.

Vitamin A is still plagued with incomplete research due to a variety of reasons. Lack of profit of course is one, but also Vitamin A’s multiple forms and knowing which one to use for trials is not clear. Also complicating the matter is its risk for toxicity and teratogenicity. However, the risk is quite low for toxicity if given in reasonable doses and I feel naturopathic doctors could give us a lot of guidance as to what forms to use for supplementation as they have been using them for centuries.

There are many possible exciting avenues for research for vitamin A. The pharmaceutical industry is already trying to form more patentable versions for cancer treatment. It would be interesting to see if traditional vitamin A supplements (particularly mixed carotinoids) would help with cancer treatment.

However, I feel given the dramatic results from HIV and measles research that has already been done, the most promising avenues of research would be those for viral illnesses. Hepatitis C and HIV are two of the most devastating and costly viral illnesses we struggle with. Hepatitis C has a very high treatment failure rate and it would be fascinating to see if treatment with Vitamin A supplements in addition to normal treatment for Hepatitis C increased the treatment success rate. It would also be great to see if Vitamin A supplements decrease viral load levels in HIV patients on medication. Preliminary research already points to the fact that it likely does.

One main issue with the studies done so far is that they are often done with the active forms (retinoids) which carry the high risk for toxicity. It is possible carotenoids may not have the same effects as the body may regulate the conversion by the body to levels not high enough to see the effects achieved with direct supplementation with active retinol vitamin A. However, studies would be much easier, safer, and more generalizable to medical practice if carotenoids were used. Many studies have been done with beta-carotene but this is likely flawed. This is only one of over 50 carotenoids the body makes into Vitamin A and when you eat Vitamin A naturally you get many of these all at once. They do not come in isolation. Studies are showing that likely this mixture of carotenoids is what leads to the beneficial effects of Vitamin A, so supplementing one carotenoid in isolation may have little or no effect or may even been detrimental. If one is to supplement vitamin A the best way of course is with Vitamin A rich foods such as carrots or spinach. But for studies to allow for a placebo they would have to be given as pills to allow for a placebo. So mixed carotenoids would be best to allow for a good chance of beneficial effect while avoiding the toxicity seen with retinol or retinoic acid.

It is time we stop fearing this Vitamin and start using it to our advantage. It could end up being one of our most powerful weapons against viruses and maybe even cancer.

References

Vitamin A in cancer study – http://www.ncbi.nlm.nih.gov/pubmed/21073338

Vitamin A and breast cancer – http://www.ncbi.nlm.nih.gov/pubmed/12452454

Vitamin A and cancer prevention – http://www.ncbi.nlm.nih.gov/pubmed/15134535

Vitamin A and measles – http://www.ncbi.nlm.nih.gov/pubmed/12521271

Vitamin A and multivitamin in HIV – http://www.ncbi.nlm.nih.gov/pubmed/17368322

Beta Carotene and HIV – http://www.ncbi.nlm.nih.gov/pubmed/8450402

Vitamin A and Hepatitis C – http://www.ncbi.nlm.nih.gov/pubmed/23213086

Vitamins – From A to K

Much of what I talk about in this blog is studying cheap and safe medications such as vitamins, minerals, and herbs to treat disease in addition to or in place of costly and sometimes toxic pharmaceutical drugs. I realized a good endeavour for my readers and myself would be to go through the vitamins one at a time, presenting their symptoms of deficiency and overdose and research so far done and what research should be done rather than single topics as I have been doing. Bear with me as this new approach will take lots of time and research but I think we all may benefit. Vitamin A coming soon.

Hepatic Encephalopathy- Enough with the Diarrhea

 

English: Liver veins (hepatic veins, portal vein)

Hepatic encephalopathy is a common condition in those that suffer from severe cirrhosis. Their liver does not detoxify the toxins in the blood well causing severe confusion, difficulties walking, hallucinations, and in later stages can cause coma or death. Controlling it is very difficult and the main therapies now include a non-absorbable antibiotic to kill off ammonia/toxin producing gut bacteria. However this is not that effective and costs close to $1000 a month. The other medication that does work very well and is very cheap comes at a very different price. It works by causing severe diarrhea. It is called lactulose and it is basically a sugar that cannot be absorbed by the intestines drawing water into the gut and causing diarrhea. The goal is to have the patient have 3 to 4 bowel movements a day to allow the toxins to clear in the stool.

Not great choices are they? Well it turns out there are other options that are not used. Zinc is one. It was studied as far back as 1984 in the journal Lancet. They did a tiny study of only 22 patients but they were randomized to receive zinc or not and it did show improvement in the zinc group and not in the placebo group. Another study done more recently in 2010 in Japan by Dr. Takuma at Kurashiki Central Hospital was slightly bigger, also randomized and also showed a benefit. In fact one group in the Netherlands published their study of a patient that they were able to induce encephalopathy by inducing zinc deficiency by giving oral histidine. It has also been clearly shown that zinc supplementation decreases blood ammonia levels, which happens to be the lab checked by physicians to confirm if a patient is having hepatic encephalopathy. And the reason for this is well-known. Zinc increases the activity of ornithine transcarbamylase which is an enzyme in the urea cycle. And yet despite all this no large trial has ever been done and it is rarely if ever used despite being extremely safe with few if any side effects and is very cheap.

The same can be said for L-carnitine which is an amino acid usually made by the liver to help the body produce energy. But of course people with cirrhosis do not have good liver function to make L- carnitine. And guess what. Lots of small studies, all show benefit, no big studies done and hardly ever if ever used despite being very cheap with few if any side effects.

Then there are probiotics. Now if you have been paying attention you may say “wait a minute, you are using antibiotics to kill gut flora to treat encephalopathy. Why would you want to give gut flora back in pill form?” Good question, but it has to do with the type of gut flora. The bacteria used in probiotics are not the same culprits that produce ammonia and other toxins that lead to hepatic encephalopathy. The good gut flora in probiotics can help displace these bad ones and indeed the few small studies that have been done show dramatic benefit from probioitics. Yet again, small studies show benefit, no big studies done and hardly ever used despite few if any side effects and being very cheap.

Do you see a trend here? If a person with cirrhosis were to use zinc, L-carnitine, and probioitics supplements the data show they would be highly unlikely to suffer any adverse reactions and statistically speaking they are very likely to get some improvement and more likely to see dramatic improvement. All while paying very little money and not having to induce diarrhea in themselves.

These studies need to be done. I have watched hundreds of people with cirrhosis suffer from hepatic encephalopathy and it is sometimes even harder on the family. Compliance to lactulose is extremely low and patients often lie about taking it because they simply cannot stand the diarrhea that comes with it. Zinc, L-carnitine and probitics show great promise for more humane treatments and yet they go unstudied. This needs to stop.

Fruit Lowers the Risk of Diabetes

English: Fruit stall in a market in Barcelona,...

The press is all over a recent study done at the Harvard school of public health that was published in the British Medical Journal last week. The study showed that those that ate fruit had a lower risk of diabetes. Specifically they singled out blueberries for a 25% reduction in risk. Grapes offered 11%, apples 5%, prunes 11%, pears 7%. This was not a randomized trial so there are a lot of uncontrolled variables but that being said they did look at 187,382 patients so that sample size does give this study a lot of weight. It also brings further support to a recommendation I have been giving to my diabetic or pre-diabetic patients for years, become a vegan and forget about the ADA (American Diabetes Association) diet.

A study done in 2006 published in Diabetes Care compared patients on a Vegan diet to patients on the ADA diet. The Vegan diet patients did better by every measure. They had better glucose control, they were able to stop more diabetic medications, their Hgb A1C improved more, they lost more weight, their cholesterol was better, and the their urine protein levels improved more. And keep in mind the vegan patients are only paying attention to avoiding meat and animal products. They are not paying attention to the sugar in their diet. The ADA diet concentrates mostly on restricting carbohydrates and sugars. Seems logical, the sugar in your blood is too high, so eat less. However, when we let diabetic vegans eat sweets and carbs unrestricted their diabetes does better than if they were on the ADA diet.

And here we are again, with the new British Medical Journal study out of Harvard we find this contradiction. Fruits that contain plenty of sugar can actually prevent diabetes. So what is going on here?

Well yet again we are likely thinking of diabetes too simply. Yes the blood sugar is too high but much of that may likely be inflammation related and not solely due to dietary intake of sugar. Meat, especially red meat is very inflammatory, and this may play a large role in increasing the glucose level and decreasing insulin sensitivity in diabetics. Whereas blueberries and many other fruits due to their antioxidants and countless other phytochemicals that we likely have yet to discover are generally very anti-inflammatory. It is well known by physicians that when a diabetic or even a non-diabetic has surgery or gets an infection such as pneumonia the blood glucose will go up. There is a myriad of complex mechanisms that cause this but they all tie back to inflammation.

So clearly our understanding of diabetes is still limited and we have much to learn, but one thing seems to be very clear from the data we have. If you are a diabetic, you better also be a vegan.

Back Pain- There has got to be a better option

Back pain

Chronic back pain is one of the most common and debilitating medical issues and study that was published in JAMA showed that it is increasing. In 1996 the rate was about 4% and by 2006 it was up to 10% of people over the age of 21. This likely has many factors contributing including the increasing rates of obesity, more sedentary life styles and overall poor health and diet. And despite how common and debilitating this problem is the treatments have changed very little over the last couple decades. Still to this day we treat with physical therapy and pain medications and if that doesn’t work the next option is surgery. And the number of patients for whom all three of these fail is immense. Daily in my practice I encounter at least one patient with chronic intractable back pain that is still intolerable despite all the efforts by the medical community. So have we tried everything?

Of course eating a healthier diet, getting more exercise and losing weight are all proven ways to prevent and/or treat back pain. But these are of course much bigger issues that we all are struggling with. And of course exercising when you have crippling back pain can be near impossible for even the most motivated individual. This leads to a vicious cycle of less activity, more pain, which means even less activity, causing more weight gain and more pain. So if one does not want to resort to surgery (which a study in 2009 Spine showed little benefit at 1 to 2 years followup) then they are left with physical therapy and nonsteroidal anti-inflammatory medications such as ibuprofen and opiate pain medications. Physical therapy likely does have benefit and has almost no harmful side effects so should be tried by everyone with back pain. However, ibuprofen and other nonsteroidal anti-inflammatory medications are well-known to cause kidney problems and stomach and intestinal ulcers. I have had many patients with life threatening stomach bleeds and some who even had to have part of their stomach removed due to long-term use of ibuprofen for back pain. And as for opiate pain medications, they are sedating, decrease mental clarity, can be addictive and due to tolerance often lose their effect over time. They are a blessing to those who need them, but everyone in medicine is agreed that we would gladly get rid of opiate pain medications if we had an alternative. Some resort to spinal injections of steroids or pain medications. These often have short effect with little long-term benefit and can be very expensive.

So have any safer treatment modalities been tested? Well indeed they have. Multiple articles have looked at Vitamin D for people with back pain. A 2009 article in the Journal of the American Board of Family Medicine showed a clear improvement in back pain in those given vitamin D. Again in 2003 Spine showed 95% of back pain patients reported improvement when given vitamin D. The Scandinavian Journal of Primary Care in 2011 also showed this benefit along with many others. Yet have any large randomized trials of vitamin D for back pain been done? Not that I know of. And despite all the evidence above it is still not standard practice (in fact it is hardly ever done) to check vitamin D levels in back pain patients.

And that’s not all. There was a randomized trial in the journal European Review Medical Pharmacology 2000 that showed a statistically significant improvement as compared to placebo with Vitamin B12. But of course the sample was small, only 60, which only makes it that much more impressive that they reached statistical significance. But a larger trial needs to be done.

Then there is omega 3 fish oils, well-known to have an anti-inflammatory effect. In 2006 in the journal Surgical Neurology a controlled trial showed a 59% reduction in nonsteroidal anti-inflammatory medication (such as ibuprofen) use and a 60% reported improvement in pain with omega 3s.

And then there are the copious herbal supplements used for inflammation and joint pain. I already reviewed the literature for turmeric in a previous post and it is still growing daily. There is also an herbal supplement called Boswellia. In a 2003 article in Phytomedicine in a controlled study it was found to have a statistically significant and impressive improvement in arthritis related knee pain. It has not been studied in back pain specifically that I know of but the causes of joint pain and back pain are very closely linked.

Then there there are the more hands on approaches to back pain such as accupuncture, massage and chiropractic work such as manipulation. Each of these actually has a surprising amount of research on each, however these studies are fraught with one main problem, a lack of a good placebo. There really is no control group in these studies as there is no good placebo for massage, or manipulation. There is a sham procedure used to be a placebo for accupuncture that is pretty good as a placebo but still likely not completely inert. However, of the three, accupuncture definitely has the strongest evidence supporting it. A review of studies in 2008 by Cochran and another great review of 11 randomized controlled trials in 2013 in the Clinical Journal of Pain showed a clearly statistically significant benefit of accupuncture. As for physical therapy, massage and chiropractic manipulation the data is not as impressive but mostly because it is of much worse quality. The initial study in 1996 of chiropractic care by Assendelft showed no significant benefit. A 1998 article in New England Journal of Medicine showed little benefit for physical therapy or chiropractic care. However, mostly the lack of benefit seen was in large part due to poor quality studies. Personally I don’t think it has been proven one way or the other and I feel likely both have some benefit but not significantly so. Likely we will never know as studying these is extremely difficult given the lack of a good control group and reliance on patient follow up and cooperation which will be highly reliant on the severity of the patient’s pain. However, I would highly support massage either way as it seems to fix everything and anyone who suffers wtih chronic back pain deserves a good massage.

Chronic back pain has been plaguing our lives for as long as we have walked upright. And as we live longer and have less active lives and live those lives with more pounds on board the problem will only get worse. We need new treatments desperately. Vitamins, omega 3 fish oils, accupuncture and herbal supplements offer treatments that are far less toxic than the medications used today and may allow a patient to delay or hopefully avoid surgery. And these supplements are far cheaper than many of the medications and certainly cheaper than spinal injections. These need to be studied immediately to offer doctors other options for their patients. And if even one of these is found to be as effective as nonsteroidal anti-iflammatory medications such as ibuprofen the savings to the medical system could easily be in the billions.