mast-cell-activation-syndrome

Mast Cell Activation Syndrome (MCAS)

By Dr. David M. Brady and Danielle Moyer, MS

 

Mast Cell Activation Syndrome (MCAS) is a condition with newfound fame. MCAS first emerged in the 1980s, but has gained recognition and started to appear in the medical literature at a growing rate in the last decade [1]. It falls under the umbrella of mast cell activation diseases (along with systemic mastocytosis and mast cell leukemia) [2]. Such a new condition currently brings up more questions than answers, and more research is needed on diagnostic criteria, valid disease biomarkers, and treatment methods.

As a result, patients are searching for answers themselves about their chronic symptoms and suspected self-diagnosed MCAS. This has caused a rise of patient self-help groups on social media and lay literature surrounding MCAS. The size and discussion of these social media groups are “outpacing the science, which has led to controversy with regards to diagnostic criteria and treatment” [3]. Issues arise when individuals of these groups determine MCAS to be the cause of their complex systems, when they may be due to other conditions or diseases with similar symptomatology. Therefore, they may not be receiving or seeking the appropriate care and it is important to know the differences. 

What is Mast Cell Activation syndrome?

To explain MCAS, we have to begin by answering: “what are mast cells?” Mast cells are involved in our body’s natural inflammatory response, protecting our body from injury, infection, bacteria, and allergic reactions. MCAS occurs when these mast cells are overproduced and/or when their activation is higher than what is necessary for the body [4]. The altered mast cell production causes complex, multisystem symptoms involving the gastrointestinal, skin, respiratory, neurologic, and cardiovascular system [3]. It may even cause certain individuals to go into anaphylactic shock for no apparent reason (a condition called idiopathic anaphylaxis) [4].

According to research, here are some of the classic symptoms of MCAS [3-6]:

  • Gastrointestinal
    • Abdominal pain and cramping
    • Diarrhea
    • Nausea
    • Vomiting
    • Abdominal bloating
    • Gastroesophageal acid reflux
  • Skin
    • Flushing
    • Hives
    • Itching
  • Respiratory
    • Throat tightening sensation
    • Stuffy nose and sinus irritation
    • Difficulty breathing and wheezing
  • Neurological
    • Headache
    • Brain fog
  • Cardiovascular
    • Feeling faint (without actually fainting)
    • Heart palpitations  
    • Low blood pressure (hypotension)

These symptoms are worsened by predictable triggers, like certain foods, strong scents, temperature changes, stress, alcohol, or certain medications. Patients suffering from MCAS may need assistance in identifying their triggers and education on proper avoidance [3].

How do you get diagnosed with Mast Cell Activation Syndrome?

There are three criteria used when diagnosing a patient with MCAS in order to avoid misdiagnosis, as well as overgeneralization of clinical symptoms that a patient may exhibit [7].

The first criterion is display of the previously listed symptoms involving two or more organ systems at the same time. The symptoms must be recurring and/or chronic, independent of other conditions or disorders, and must require treatment or therapy [2,7].

The second criterion is the elevation of certain blood markers called serum tryptase or mast cell-derived metabolites while actively suffering from MCAS symptoms. Diagnostic markers in the blood vary, as increased MCAS symptoms may last for varied times (from hours to days to weeks). Patients who do not meet the laboratory criteria for MCAS may be considered to have “suspected MCAS”. These patients will receive trials of different therapies, but with ongoing testing for other conditions [2,7].

The third criterion relates to how MCAS is treated. If a patient responds positively to drugs that inhibit mast cell mediators or block mast cell release, this can fulfil the third co-criterion of a MCAS diagnosis [2,7].

How is Mast Cell Activation Syndrome treated?

There is no cure for MCAS, so an individual’s treatment plan is tailored to target their specific symptoms. As stated above, effective treatment for MCAS is considered to be a criterion for the diagnosis of MCAS [2,7]. If the patient's symptoms are decreased in frequency, severity, or goes away with the avoidance of known triggers, or with medications including H1 and H2 histamine receptor antagonists (blockers), anti-leukotrienes, or mast cell stabilizers, this can further support the diagnosis of MCAS [3]. 

What other conditions or diseases can Mast Cell Activation Syndrome be confused with?

MCAS is an incredibly complicated disorder that results in both common and unusual symptoms across many different body systems. That being said, it is easy to confuse symptoms caused by MCAS with those from other conditions or diseases, including:

  • Systemic mastocytosis
    • Systemic mastocytosis falls under the same umbrella as MCAS - “mast cell activation diseases.” Systemic mastocytosis results from genetic mutations and leads to an abnormal accumulation of mast cells in one or more organ systems, including the bone marrow, skin, and gastrointestinal tract. MCAS differs from systemic mastocytosis, although they do have similar presentations and symptoms [3].
  • Irritable Bowel Syndrome (IBS)
    • Patients with IBS have been shown to have increased mast cell activation in their intestines compared to healthy subjects. The difference between IBS and MCAS is that IBS symptoms are congregated and isolated in the gastrointestinal tract, whereas MCAS symptoms are in more than one organ system [3].
  • Histamine Intolerance
    • Histamine Intolerance is an imbalance of histamine (an amino acid compound in the body involved in local immune responses and inflammation) in the body and a reduced ability to process them. Symptoms of histamine intolerance mirror those of MCAS including headache, hypotension, facial flushing, diarrhea, nausea, vomiting, abdominal pain, congestion, and asthma. However, these symptoms only occur when eating histamine-rich foods in contrast to MCAS symptoms which can have various triggers [3]. Symptoms of histamine intolerance may also be reduced, or eliminated, by taking the histamine degrading enzyme diamine oxidase (DAO) with meals. 
  • Those with prominent gastrointestinal symptoms with suspected MCAS may also consider ruling out other inflammatory conditions like [3]:
    • Celiac disease
    • Eosinophilic Esophagitis (EoE)
    • GI tract malignancies, or anatomic defects
    • Small intestinal bacterial overgrowth (SIBO)
    • Intestinal dysbiosis (an imbalance in gut microbes)
    • Bile salt diarrhea, especially in those who have had abdominal surgeries, especially gallbladder removal (cholecystectomy).
  • There are several chronic symptom disorders that may be confused with MCAS [3]:
    • Chronic pain syndromes
    • Chronic fatigue syndromes (CFS)
    • Fibromyalgia (FMS/FM)
    • Multiple chemical sensitivity syndrome (MCS)
    • Chronic syndromes from infections or other exposures, such as chronic Lyme disease syndrome and/or other tick borne co-infections.
    • Various auto-immune diseases
    • Endocrinopathies
    • Psychiatric conditions

Recent evidence suggests that there is a common familial occurrence of systemic mast cell activation diseases, meaning there may be a genetic component. If a family member has one of these diseases, your risk may be increased as well [8].

The Takeaway

Mast cell activation syndrome (MCAS) is an incredibly complex condition. Some research theorizes that the incidence and prevalence of MCAS may increase in relation to the increase of other allergic or hypersensitivity conditions [3]. However, more research is needed for improved recognition, diagnosis, treatment, and patient counseling of MCAS beyond the current social media “experts” and patient blogs. Although many patients out there have a large assortment of chronic, multisystem symptoms for seemingly unknown reasons, it is incredibly important to distinguish MCAS versus other diseases or conditions for proper treatment as more research is discovered.

 

References

 

  1. Afrin LB, Ackerley MB, Bluestein LS, et al. Diagnosis of mast cell activation syndrome: a global “consensus-2.” Diagnosis. 2021;8(2):137-152. doi:10.1515/dx-2020-0005
  2. Frieri M. Mast Cell Activation Syndrome. Clinic Rev Allerg Immunol. 2018;54(3):353-365. doi:10.1007/s12016-015-8487-6
  3. Hamilton MJ, Scarlata K. Mast Cell Activation Syndrome – What it Is and Isn’t. PRACTICAL GASTROENTEROLOGY. Published online 2020:7.
  4. Akin C. Mast cell activation syndromes. Journal of Allergy and Clinical Immunology. 2017;140(2):349-355. doi:10.1016/j.jaci.2017.06.007
  5. Valent P. Mast cell activation syndromes: definition and classification. Allergy. 2013;68(4):417-424. doi:10.1111/all.12126
  6. Mast Cell Activation Syndrome (MCAS). American Academy of Allergy, Asthma & Immunology website. https://www.aaaai.org/conditions-treatments/related-conditions/mcas. Accessed July 2, 2021. 
  7. Overview & Diagnosis. The Mast Cell Disease Society, Inc. website. https://tmsforacure.org/overview/. Accessed July 2, 2021. 
  8. Molderings GJ, Haenisch B, Bogdanow M, Fimmers R, Nöthen MM. Familial Occurrence of Systemic Mast Cell Activation Disease. PLOS ONE. 2013;8(9):e76241. doi:10.1371/journal.pone.0076241

Sun Exposure: The Bright and Dark Sides

By Dr. David M. Brady and Danielle Moyer, MS

 

Summer is here and the sun is out!

Being cooped up in our homes for the last year has made many of us seek every opportunity to step outside and experience the fresh air.

If you ask yourself, “Do I have to wear sunscreen?” before stepping outside – you are not alone!

There are both health benefits and risks, and it is challenging to know what actions to take to protect yourself.

 

The “bright” sides to sun exposure:

1. Vitamin D

The best-known benefit of sunlight is vitamin D. When ultraviolet (UV) rays hit our skin, it allows our liver and kidneys to create the active form of vitamin D. Vitamin D improves bone health, reduces inflammation, enhances the immune and nervous systems, and may even regulate blood sugar. It is difficult to get enough vitamin D from food sources alone (fatty fish, mushrooms, tofu, eggs, and fortified milks and cereals), making the sun a much more reliable source [1].

2. Serotonin & mental health

Getting enough vitamin D from the sun has been shown to enhance serotonin production in the brain! Serotonin ,the “happy hormone”, helps stabilize mood and helps with sleeping, eating, and digestion [2].

This helps to explain seasonal affective disorder (SAD). SAD is a specific type of depression and a chronic disease that happens during darker, colder months. Researchers have said that SAD is the most intense during January and February, and affects around 1.5 to 9% of the US population [3]. Studies have shown that a root cause of this disease is the reduction of sun exposure, vitamin D, and serotonin, all of which can be reversed during the sunnier months [4-5]. 

3. Skin, bone, and other health benefits 

Doctors have used UV radiation exposure to treat or help multiple skin diseases, including psoriasis, eczema, dermatitis, or vitiligo, as well as improve bone health by lowering the risk of bone fractures [6]. Sun exposure has also helped treat rheumatoid arthritis, lupus erythematosus, thyroiditis, and inflammatory bowel disease [7]. These benefits can largely be due to vitamin D’s role in inflammation and the immune system.

4. Cancer protection

Research from recent decades shows that the three main forms of skin cancer (melanoma, basal cell carcinoma, and squamous cell carcinoma) can be attributed to excess sun exposure. In fact, skin cancer is one of the most common forms of cancer worldwide.  However, there are some cancers that can result from too little sun. Higher latitude countries with little sunshine tend to have higher rates of Hodgkin lymphoma as well as breast, ovarian, colon, and pancreatic cancers compared to sunnier countries [8-10].

 

The dark sides to sun exposure:

Unfortunately, UV radiation can also be a carcinogen, meaning an agent that causes cancer in humans. UV radiation is linked with skin cancer. More than one million people in the United States are diagnosed with skin cancer each year. An estimated 90% of non-melanoma skin cancer and 65% of melanoma skin cancers are associated with the exposure to UV radiation from the sun [11]. UV radiation also contributes to premature aging of the skin, eye damage, and skin color changes [12].

A person’s skin type affects the degree to which people burn. Those with fair skin tend to burn more rapidly and more severely, whereas those with darker skin do not burn as easily. Furthermore, those with a large number of freckles or moles tend to have higher risks of developing skin cancer. However, regardless of race or ethnicity, everyone is subject to the potential adverse effects of overexposure to the sun. Other factors that increase a person’s risk can be their disease and medication status. Certain diseases, such as lupus, can make a person more sensitive to sun exposure, as well as medications such as antibiotics and antihistamines [13].

 

How do you find the balance?

Many of the health benefits of the sun come from vitamin D. Therefore, the key is to get it safely.

It is best to avoid direct sunlight without protection when the sun’s rays are strongest, usually between 10 AM to 4 PM. If you are outdoors during those hours without sunscreen, the World Health Organization states that 5 to 15 minutes of casual sun exposure to hands, face, and arms two to three times a week during the summer months is sufficient to keep vitamin D levels in the normal range [12]. However, this does not imply that this will allow your vitamin D levels to reach more optimal ranges, prompting many to recommend longer duration (15-30 minutes) of casual sun exposure prior to application of sunscreen. If you live closer to the equator where UV levels are higher, shorter periods of time may suffice. On the other hand, if you have a darker skin tone, you may need more time in the sun (20-30 minutes, two to three times a week) to obtain sufficient vitamin D levels [13]. It is best to check the UV index of your area to help you plan your outdoor activities in a way to prevent sun overexposure.

The best way to assess your vitamin D levels is through a blood test called 25-Hydroxy Vitamin D. Most experts define vitamin D deficiency as a level of less than 20 ng/mL. Whereas the “optimal range” of vitamin D levels has been debated, but many agree upon the range of 40-60 ng/mL [14]. There are also advocates in the integrative medical community of vitamin D levels being maintained in the 60-100 ng/mL range, but evidence for these levels is somewhat scant. 

A lot of individuals are starting to take supplements to ensure proper vitamin D levels. Though you should speak with your doctor or nutritionist about what dosage is right for you, the Recommended Dietary Allowance for adults 19+ years old is 600 IU, and for adults 70+ years old is 800 IU daily. The maximum daily intake for most individuals is 5,000 IU [1], although higher dosages are sometimes used for specific medical reasons under supervision. Supplements are commonly taken in doses varying from 1,000-2,000 IU/day safely (in addition to sunlight) During the winter months, this dosage can be increased. Note that vitamin D is a fat-soluble vitamin, so it must be taken with food for proper absorption. Always consult with your doctor and/or nutritionist before taking any supplements.

 

How do you choose the right sunscreen?

“Sunburns significantly increase the lifetime risk of developing skin cancer, especially for children,” says the US Environmental Protection Agency [13]. In addition to shade and protective clothing and accessories , sunscreen is essential for protection. Sunscreen contains chemicals that absorb or reflect both types of UV radiation (UVA and UVB) to protect you from the sun’s rays.

In 2019, the FDA released a goal of updating sunscreen regulations for the first time since 2011, but had to withdraw their plans. In the FDA’s proposed statement, they recognized only two ingredients as safe and effective in sunscreen: Zinc oxide and titanium dioxide. These two ingredients are classified as “Mineral Product” sunscreens [15-16]. 

Other common sunscreen ingredients (oxybenzone, avobenzone, homosalate, octinoxate, octisalate, octocrylene) used in about 60% of the sunscreens have more questions regarding their safety and efficacy. Though they are not flagged as “unsafe”, the FDA requested additional safety information from the sunscreen industry to consider in their upcoming policy. 

The FDA has flagged one particularly concerning sunscreen ingredient called oxybenzone. The FDA is concerned that oxybenzone could interfere with normal functioning of a number of hormones, including estrogen. Because of this and other potential health concerns, the American Academy of Pediatrics (AAP) advises parents to avoid using sunscreens with oxybenzone on children [15-16]. If you don’t want it on your children, you probably don't want it on you either. 

SPF (sun protection factor) rates how well the sunscreen can block the UV rays. While no sunscreen’s SPF protects you fully from the sun, an SPF of 15 or below must carry a label that it only protects against sunburn, not skin cancer or skin aging. Therefore, it is recommended by the American Cancer Society to use an SPF of 30 or higher. SPF ratings mainly apply to UVB rays, so sunscreen manufacturers that contain SPF that protect against UVB and UVA are labeled “Broad Spectrum” and are highly recommended [17]. 

Sunscreen must be reapplied at least every 2 hours, and maybe more frequently depending on how much you are swimming, sweating, and whether the sunscreen is “water resistant”. Read the label of each sunscreen to know how long it lasts specifically [17]. 

The Environmental Working Group (EWG) is a third-party group that provides a great guide to sunscreen, where you can even “search” your sunscreen brand and see how they rate the ingredients.

 

The takeaway

Balance is key! Both the benefits and risks of sun exposure encourage everyone to find a reasonable “middle-ground”. You can keep yourself safe by wearing appropriate sun-protecting clothes and accessories, applying safe sunscreen, sitting in shade, checking your city’s UV ray index, and timing your sun exposure. Additionally, checking your vitamin D levels at least once a year (ideally once during the winter and once during the summer) can determine what actions are needed to achieve an optimal vitamin D status. 

Safe sun exposure is possible! So, get out there, enjoy the outdoors, and protect your skin. 

 

References

  1. Vitamin D. National Institute of Health website. https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/. Updated March 26, 2021. Accessed June 15, 2021. 
  2. Bancos I. What is Serotonin? Hormone Health Network website. https://www.hormone.org/your-health-and-hormones/glands-and-hormones-a-to-z/hormones/serotonin. Updated December 2018. Accessed June 15, 2021. 
  3. Nussbaumer-Streit B, Forneris CA, Morgan LC, et al. Light therapy for preventing seasonal affective disorder. Cochrane Common Mental Disorders Group, ed. Cochrane Database of Systematic Reviews. Published online March 18, 2019. doi:10.1002/14651858.CD011269.pub3
  4. Penckofer S, Kouba J, Byrn M, Ferrans CE. Vitamin D and Depression: Where is all the Sunshine? Issues Ment Health Nurs. 2010;31(6):385-393. doi:10.3109/01612840903437657
  5. Patrick RP, Ames BN. Vitamin D hormone regulates serotonin synthesis. Part 1: relevance for autism. FASEB J. 2014;28(6):2398-2413. doi:10.1096/fj.13-246546
  6. Rathod DG, Muneer H, Masood S. Phototherapy. In: StatPearls. StatPearls Publishing; 2021. Accessed June 15, 2021. http://www.ncbi.nlm.nih.gov/books/NBK563140/
  7. Schwalfenberg GK. Solar Radiation and Vitamin D: Mitigating Environmental Factors in Autoimmune Disease. Journal of Environmental and Public Health. 2012;2012:e619381. doi:10.1155/2012/619381
  8. Holick MF. Vitamin D and Sunlight: Strategies for Cancer Prevention and Other Health Benefits. CJASN. 2008;3(5):1548-1554. doi:10.2215/CJN.01350308
  9. Baggerly CA, Cuomo RE, French CB, et al. Sunlight and Vitamin D: Necessary for Public Health. Journal of the American College of Nutrition. 2015;34(4):359-365. doi:10.1080/07315724.2015.1039866
  10. Hoel DG, Berwick M, de Gruijl FR, Holick MF. The risks and benefits of sun exposure 2016. Dermatoendocrinol. 2016;8(1). doi:10.1080/19381980.2016.1248325
  11. Kim I, He Y-Y. Ultraviolet radiation-induced non-melanoma skin cancer: Regulation of DNA damage repair and inflammation. Genes Dis. 2014;1(2):188-198. doi:10.1016/j.gendis.2014.08.005
  12. Radiation: The known health effects of ultraviolet radiation. World Health Organization website. https://www.who.int/news-room/q-a-detail/radiation-the-known-health-effects-of-ultraviolet-radiation. Published October 16, 2017. Accessed June 15, 2021. 
  13. The Burning Facts. United States Environmental Protection Agency website. https://www.epa.gov/sites/production/files/documents/sunscreen.pdf. Published September 2006. Accessed June 15, 2021. 
  14. Mead MN. Benefits of Sunlight: A Bright Spot for Human Health. Environ Health Perspect. 2008;116(4):A160-A167.
  15. EWG’s Sunscreen Guide. Environmental Working Group website. https://www.ewg.org/sunscreen/report/executive-summary/. Accessed June 15, 2021. 
  16. Wadyka S. What You Need to Know About Sunscreen Ingredients. Consumer Reports website. https://www.consumerreports.org/sunscreens/what-you-need-to-know-about-sunscreen-ingredients/. Updated May 22, 2019. Accessed June 15, 2021. 
  17. Choose the Right Sunscreen. American Cancer Society website. https://www.cancer.org/latest-news/choose-the-right-sunscreen.html. Accessed June 15, 2021. 

beating-brain-fog

Beating Brain Fog

By Dr. David M. Brady and Danielle Moyer, MS

 

We have all experienced the feeling at least once: you don’t get enough sleep and the next day you feel sluggish and can’t concentrate. That is the feeling of “brain fog”. Brain fog is not a medical condition, but rather a feeling of confusion, disorganization, and difficulty concentrating or focusing. But what happens when this becomes a chronic sensation? What is causing it and what can you do?

There are numerous explanations for chronic brain fog. It can result from poor sleep, stress, hormonal changes, poor diet, infections, heavy metal exposure, side effects of certain medications, or due to a medical condition, such as anemia, chronic fatigue syndrome, or fibromyalgia [1]. One study revealed through MRI scans that even non-celiac gluten sensitivity can induce brain fog in those who do not have celiac disease or a wheat allergy, but report gastrointestinal upset from gluten [2]. Additionally, long-haul COVID syndrome has been shown to impact a person’s cognitive dysfunction and fatigue for months after contracting COVID.

The good news is one of the strongest influences we have on our brain is through our gut.

Imagine there is a two-way street from your gut to your brain, where cars are continually driving up and down. Now instead of cars, imagine hormones. That two-way street is what we call the “Gut-Brain Axis”. “Listen to your gut” is advice that is actually backed up by science. Here are some hormones that drive up and down, influencing your emotions, mental function, and memory:

  • Leptin: This hormone signals to your brain that you are full after eating, thereby reducing your appetite. It has been shown to impact synaptic plasticity in your brain, influencing spatial learning and long-term depression.
  • Ghrelin: This hormone is secreted on an empty stomach, signaling to your brain to increase your appetite. It has also been shown to enhance spatial learning and memory function. 
  • Glucagon-Like Peptide 1 (GLP1): This hormone regulates energy metabolism by stimulating insulin secretion and energy uptake in muscle cells. It has also been shown to influence spatial memory, cognition, and emotion.
  • Insulin: This hormone is secreted while you are eating to allow your body to convert the newly ingested food into immediately usable energy. Insulin has been shown to alter cognitive processing and synaptic activity [3].

Another important modulator on our brain’s functioning is our immune system, which fights off foreign pathogens and toxins. Chronic infections can lead to chronic inflammation, thereby causing detrimental effects on cognitive function and brain fog [1]. The gut’s role in our immune system is underscored as 70% of our entire immune system is located in our gut [4]!

Making sure there are no roadblocks, traffic jams, or slow pokes on the streets of our gut-brain-axis is crucial for beating brain fog.

Here are some important things to do to clear the way…

 

Eat as many whole foods as possible.

Whole foods consist of fruits, vegetables, legumes, beans, meat, fish, seafood, nuts, seeds, and whole grains that are immunologically tolerated well by you. They are not processed or refined and have minimal added ingredients to them. Plus, they are rich in antioxidants, fiber, and macro and micronutrients. Whole foods influence cognition and emotions through our gut-brain-axis by providing a warehouse of essential nutrients that support hormonal regulation and proper digestion.

For example, omega-3 fatty acids found in flax seeds, chia seeds, walnuts, and fatty fish have been shown to ameliorate cognitive decline in the elderly. They have become a treatment method for mood disorders and improved learning and memory [3].

Poor diets filled with processed foods or “junk” foods can lead to multiple vitamin and mineral deficiencies and also introduce pro-inflammatory foods that can contribute to brain fog, such as trans fats or excess sugar. It is best to limit these foods as much as possible.

 

Eat prebiotics and probiotics.

We have a thing called the “gut microbiome” in our gastrointestinal tract. This is where billions of bacteria live to help us break down food, modulate our immune system, balance hormones, and more. There are both beneficial and harmful bacteria that can live in our GI tract, and it is key to support the beneficial kinds. When we have a plentiful array of healthy bacteria, they produce hundreds of chemicals that influence mental processes such as learning, memory, and mood. In fact, "good" gut bacteria produce about 95% of our body’s supply of serotonin, which is a hormone that impacts both our mood and GI function [5-6].

“Prebiotics” can be thought of as food for our good bacteria. Prebiotic foods have compounds that serve as “fuel” for the beneficial gut bacteria, allowing them to proliferate and positively impact cognition and emotions. Good sources of prebiotics are garlic, onions, leeks, tomatoes, carrots, apples, and asparagus. 

Probiotics are a way to introduce good bacteria into your gut via foods or supplements. This can re-balance your gut bacteria environment when there are too many harmful bacteria - a condition dubbed “dysbiosis”. Probiotic food sources include yogurt, kimchi, sauerkraut, kefir, miso, and pickled veggies.

 

Avoid/Lower Stress.

So, we know that the gut can influence the brain, but how does the brain influence the gut on this bidirectional street? Stress can cause changes to the microbiome, disrupting healthy gut microflora and, in turn, affecting the brain and behavior. Furthermore, chronically elevated stress can cause high levels of cortisol in the body. Cortisol has been shown to have adverse effects on the brain’s functioning by affecting memory, reducing cognitive function, and increasing brain fog [6].

 

Get Moving!  

Regular exercise has been shown to improve memory and thinking skills, and reduce brain fog. Exercise can help to regulate specific hormones, such as insulin, reduce inflammation, and benefit the gut microbiome [7]. A recent study found that 6 weeks of endurance-based exercise training of moderate to vigorous intensity (3 days a week for 30-60 minutes) significantly improved a person’s gut bacteria, which reduced inflammation and enhanced metabolism [7]. Thinking purely of the brain, exercise can affect the health of brain cells, the growth of new blood vessels in the brain, and the abundance and survival of new brain cells. Exercise also benefits mood and sleep and reduces stress and anxiety, which all contribute to reducing brain fog [8]. If you are one of those people who say they “don’t have time to work out”, you may want to read How to Get the Best Bang from Exercise for the Investment in Time.

 

Get a Good Night’s Sleep.

If the brain is foggy and tired, it may be time to look at how well you are sleeping. We have discussed the importance of sleep before in the Sleep Position May Influence Brain Health, The Sleep-Deficit and Chronic Disease Epidemic – Is There a Connection?, Better Sleep for Those with Fibromyalgia, and more. It is important to optimize both the quantity (number of hours) and quality of your sleep, as they are both necessary to reduce brain fog.

 

Although all these suggestions are far from revolutionary, they are all incredibly important. Brain fog can have numerous causes, varying from simply a lack of sleep or a chronic medical condition. Accordingly, brain fog can last from a couple hours to even years. There are supplements that help to alleviate brain fog, such as Brain Vitale, for short term use. However, if you are experiencing chronic brain fog, it is best to identify the underlying cause and work with a doctor and/or nutritionist to find a solution that is personalized to you. 

 

References: 

  1. Torres C. Brain Fog – What is Brain Fog? University of Medicine and Health Sciences website. https://www.umhs-sk.org/blog/brain-fog. Published October 21, 2020. Accessed May 18, 2021. 
  2. Croall ID, Hoggard N, Aziz I, Hadjivassiliou M, Sanders DS. Brain fog and non-coeliac gluten sensitivity: Proof of concept brain MRI pilot study. PLoS One. 2020;15(8). doi:10.1371/journal.pone.0238283
  3. Brain foods: the effects of nutrients on brain function. Accessed May 17, 2021. https://www-ncbi-nlm-nih-gov.libproxy.bridgeport.edu/pmc/articles/PMC2805706/
  4. Vighi G, Marcucci F, Sensi L, Di Cara G, Frati F. Allergy and the gastrointestinal system. Clin Exp Immunol. 2008;153(Suppl 1):3-6. doi:10.1111/j.1365-2249.2008.03713.x
  5. Carpenter S. That Gut Feeling. American Psychological Association website. https://www.apa.org/monitor/2012/09/gut-feeling. Published September 2021. Accessed May 18, 2021. 
  6. Carabotti M, Scirocco A, Maselli MA, Severi C. The gut-brain axis: interactions between enteric microbiota, central and enteric nervous systems. Ann Gastroenterol. 2015;28(2):203-209.
  7. Brady DM. Favorably Altering the GI Microbiome with Exercise. https://davidd139.sg-host.com/wp-content/uploads/2021/03/gut-exercise.pdf. Published July 2018. Accessed May 18, 2021. 
  8. Godman H. Regular exercise changes the brain to improve memory, thinking skills. Harvard Health Publishing website. https://www.health.harvard.edu/blog/regular-exercise-changes-brain-improve-memory-thinking-skills-201404097110. Published April 9, 2014. Accessed May 18, 2021.

Why Women Get More Fibromyalgia, IBS, and Anxiety Than Men

By Dr. David M. Brady and Danielle Moyer, MS

The occurrence of fibromyalgia is 10 to 20 times higher in women than in men [1]. Those women are also more likely than men to have severe tender points of pain, “pain all over”, sleep disturbances, and fatigue [2]. 

The incidence of Irritable Bowel Syndrome (IBS) is higher in women when compared to men. Internationally, the prevalence of IBS is 67% higher in women [3].

Anxiety disorders are more than twice as likely to occur in women when compared to men [4].

The question is: why?

Though the reasons are still being studied, research suggests that an interaction between biology, psychology, and sociocultural factors leads to higher occurrences of these diseases in women [5]. Of particular interest is the role of women’s hormonal and nervous systems, which respond somewhat differently to stress and trauma than those of men [1].

Research by the American Psychological Association looked at 290 studies between 1980 and 2005 to determine if men or women were more at risk for potentially traumatic events and PTSD (Post-traumatic Stress Disorder). The results concluded that, although men experience more traumatic events on average than women, women are more likely to meet diagnostic criteria for PTSD. PTSD is an anxiety disorder caused by a traumatic event and symptoms include “re-experiencing the trauma, avoidance and numbing and hyperarousal [6].” PTSD occurs in 10-12% of women and 5-6% of men, making the rate in women almost double [7]. Women’s PTSD also tends to last longer (on average four years), whereas men’s lasts one year on average [8]. 

The types of trauma men and women experience are different as well. Men are more likely to experience trauma from natural disasters, human-caused disasters, accidents, and combat, whereas women are more likely to experience trauma from domestic violence, sexual abuse, and sexual assault [6]. Sexual trauma has been shown to be particularly toxic to mental health, and can typically begin at a young age when the brain is still developing [8]. This can impact a woman's fear and stress response well into adulthood.

Trauma, stressors, and/or PTSD alter pain processing and incoming stimuli in an individual. They can frequently cause an excessive stress response, significant and chronic pain, and central sensitization disorders [1]. Central sensitization disorders cause a person’s nervous system to become regulated in a highly persistent state of reactivity, making their threshold to pain and touch incredibly low. This is associated with consistent and chronic pain [9]. Trauma, stressors, and/or PTSD can also affect the brain’s functioning by increasing hyperarousal, hypervigilance, and increased wakefulness and sleep disruption (learn more about sleep’s relationship to fibromyalgia here) [10]. 

Due to this, stressors or catastrophic events have been found to trigger the development of fibromyalgia, IBS, and anxiety. The intensity, multitude, or period of time of the “stressor” may even be a predictor of adverse health outcomes because they can lead to permanent changes in the human stress response systems [11]. 

In fact, studies show that “patients with fibromyalgia and related conditions may be more likely than nonaffected individuals to have experienced physical or sexual abuse in childhood. [11]” This intricate relationship can also cause an unfortunate domino effect. For example, increased hypervigilance from past traumas or stressors can cause a greater level of threat detection, which can then lead to increased anxiety, which can then increase hypervigilance yet again, and so on, creating a classic “feed-forward cycle”. Furthermore, increased hypervigilance has been shown to increase visceral pain perception in women with IBS and chronic pain states in women with fibromyalgia [12-14]. 

Female predominance in these syndromes and disorders can also be influenced by gender differences in… [15]

  • Sociocultural reactions to pain/coping mechanisms
  • Access to healthcare
  • Research and resources on women’s health conditions  
  • Physiological reactions to pain sensitivity and pain amplification to sensory stimuli
  • Hormonal and nervous systems stress and trauma responses, as described above 

More research is needed to explore this important connection between women’s trauma and subsequent health issues. We know that women are strong, but their vulnerability to developing fibromyalgia, IBS, and anxiety is unfortunately strong too. 

To learn more about PTSD, please visit the National Institute of Mental Health’s website.

References

  1. Brady DM, Schneider, MJ. Pain and Fatigue: When It’s Fibromyalgia and When It’s Not. Townsend Letter. October 2012;351:44-50.
  2. Forbes D, Chalmers A. Fibromyalgia: revisiting the literature. J Can Chiropr Assoc. 2004;48(2):119-131.
  3. Canavan C, West J, Card T. The epidemiology of irritable bowel syndrome. Clin Epidemiol. 2014;6:71-80. doi:10.2147/CLEP.S40245
  4. Anxiety Disorders. Office on Women’s Health website. https://www.womenshealth.gov/mental-health/mental-health-conditions/anxiety-disorders. Published January 30, 2019. Accessed April 14, 2021. 
  5. Yunus MB. The role of gender in fibromyalgia syndrome. Curr Rheumatol Rep. 2001;3(2):128-134. doi:10.1007/s11926-001-0008-3
  6. Tolin DF. Women Are Diagnosed with PTSD More than Men, Even Though They Encounter Fewer Traumatic Events, Says Research. American Psychological Assocation website. https://www.apa.org/news/press/releases/2006/11/ptsd-rates. Published 2006. Accessed April 14, 2021. 
  7. Olff M. Sex and gender differences in post-traumatic stress disorder: an update. Eur J Psychotraumatol. 2017;8(sup4). doi:10.1080/20008198.2017.1351204
  8. Greenberg M. Psychology Today website. https://www.psychologytoday.com/us/blog/the-mindful-self-express/201809/why-women-have-higher-rates-ptsd-men. Published September 25, 2018. Accessed April 14, 2021.
  9. McAllister MJ. What is Central Sensitization? Institute for Chronic Pain website. https://www.instituteforchronicpain.org/understanding-chronic-pain/what-is-chronic-pain/central-sensitization. Published March 23, 20213. Reviewed May 29, 20217. Accessed April 20, 2021. 
  10. Sherin JE, Nemeroff CB. Post-traumatic stress disorder: the neurobiological impact of psychological trauma. Dialogues Clin Neurosci. 2011;13(3):263-278.
  11. Harris RE, Clauw DJ. Newer treatments for fibromyalgia syndrome. Ther Clin Risk Manag. 2008;4(6):1331-1342.
  12. Kimble M, Boxwala M, Bean W, et al. The Impact of Hypervigilance: Evidence for a Forward Feedback Loop. J Anxiety Disord. 2014;28(2):241-245. doi:10.1016/j.janxdis.2013.12.006
  13. Meleine M, Matricon J. Gender-related differences in irritable bowel syndrome: Potential mechanisms of sex hormones. World J Gastroenterol. 2014;20(22):6725-6743. doi:10.3748/wjg.v20.i22.6725
  14. Behavioral and Neuronal Investigations of Hypervigilance in Patients with Fibromyalgia Syndrome. Accessed April 14, 2021. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0035068
  15. Kim SE, Chang L. Overlap between functional GI disorders and other functional syndromes: what are the underlying mechanisms? Neurogastroenterology & Motility. 2012;24(10):895-913. doi:https://doi.org/10.1111/j.1365-2982.2012.01993.x

mitochondrial-health-and-energy

Mitochondrial Health and Energy

By Dr. David M. Brady and Danielle Moyer

 

If there is one thing we remember from middle school biology, it is that the mitochondria are the powerhouses of the cell. 

But, let’s break that down a little. 

We get energy from the food we eat. That is why humans tend to be more productive, be physically active, or work better together when they are well fed. However, a piece of broccoli does not just magically turn into energy when you put it in your mouth. Instead, your body initiates a complex set of reactions that convert protein, fats, and carbohydrates into usable forms of energy called ATP, or adenosine triphosphate. The mitochondria are the organelles in the cell that perform this energy conversion. 

Here is some useful information to know about mitochondrial energy production [1]: 

  • Our mitochondria can never “turn off”. Our cells must create energy every second of the day to survive because we have no storage for ATP! 
  • The mitochondria produce over 90% of our energy. 
  • Mitochondria are inherited entirely from your mother. Thanks mom!
  • Each cell in our body can contain anywhere between 1,000 to 2,500 mitochondria per cell. 
  • Different bodily cells will have different amounts of mitochondria depending on how much energy production they require. For example, cells found in the muscle and liver contain some of the highest number of mitochondria per cell.
  • The brain uses up about 70% of our energy production. Talk about brain power!
  • A single cell produces 10 billion ATP per day.
  • In one day, a healthy person will produce the equivalent of 1200 watts of energy in ATP.

Our bodies are designed to produce fast, efficient energy from our mitochondria. Unfortunately, mitochondria are not invincible. They are incredibly susceptible to damage from poor diets, nutrient deficiencies, or environmental toxins (e.g. heavy metal exposure, alcohol, pollutants, or prescription drugs), which affects our energy levels [1]. 

Because of the mitochondria’s essential role in cellular life or death, mitochondrial damage or dysfunction can cause or aggravate some common diseases. These include diabetes, cardiovascular disease, Alzheimer’s disease, chronic fatigue syndrome, Parkinson’s disease, migraine headaches, cancer, autism, and/or dementia [1-3]. Additionally, as we grow older our mitochondrial damage can accumulate, which can explain why people tend to “lose energy” when they hit around 55 years old [1]. 

Nevertheless, we are not doomed! 

One key strategy to improve or maintain mitochondrial health is to provide the body nutrients that facilitate ATP production and/or protect the body from toxins that would damage the mitochondria. For example, our mitochondria require nutrients including magnesium, vitamin B2 (riboflavin), and vitamin B3 (niacin) to properly create ATP [1]. This means magnesium, vitamin B2, and vitamin B3 can be considered “cofactors” to energy production and should be consumed every day. 

Any type of food you eat will give your body the opportunity to convert that food into energy. However, your body’s level of specific nutritional cofactors will determine how well your body will successfully or efficiently convert the food into energy. Essentially, we need to provide the right tools for the machinery to work. 

Other ways to improve mitochondrial function is to decrease toxin exposure, which can lower mitochondrial damage, and to build muscle mass, which can increase ATP production due to muscular cells having large amounts of mitochondria [1]. Having a well-rounded, nutrient-dense diet that supplies the body with essential cofactors begins with our food choices, but can be supplemented with a high-quality multivitamin and multimineral, or in a better way with a targeted mitochondrial nutrient formulation such as Mitochondrial-NRG, formulated by Dr. Brady, which includes the required activated B-vitamins, along with energy co-factor nutrients such as CoQ10, ribose, L-carnitine, and more. 

One vitamin that has emerged as a focus for mitochondrial health is niacin, or vitamin B3. Niacin can be found naturally in chicken, tuna, turkey, salmon, beef, peanuts, lentils, lima beans, and fortified foods [4]. Niacin converts into NAD+, or nicotinamide adenine dinucleotide, in the body. NAD+ is required for all living cells and their mitochondrial energy production, DNA repair, and cell survival [4-5]. Considering this, my practice has been using a supplemental form of niacin called nicotinamide mononucleotide (NMN) called Liposomal NMN Synergy to rebalance the energy biochemistry and respiration in the body at a cellular level for those with Long Haul COVID [6]. To learn more about Long Haul COVID, click here: https://drdavidbrady.com/long-haul-covid-syndrome/

Now that we have refreshed our memories of middle school biology (and hopefully not too much else about middle school) we remember just how important our mitochondria are for our cell’s energy and survival. It is no surprise that the powerhouses of the cell have such a powerful reputation.

References: 

  1. Pizzorno J. Mitochondria—Fundamental to Life and Health. Integr Med (Encinitas). 2014;13(2):8-15.
  2. Javadov S, Kozlov AV, Camara AKS. Mitochondria in Health and Diseases. Cells. 2020;9(5). doi:10.3390/cells9051177 
  3. Kramer P, Bressan P. Our (Mother’s) Mitochondria and Our Mind. Perspect Psychol Sci. 2018;13(1):88-100. doi:10.1177/1745691617718356
  4. Cantó C, Menzies K, Auwerx J. NAD+ metabolism and the control of energy homeostasis - a balancing act between mitochondria and the nucleus. Cell Metab. 2015;22(1):31-53. doi:10.1016/j.cmet.2015.05.023
  5. Hidgon J. Niacin. Linus Pauling Institute website. Published 2000. Reviewed March 2018. Accessed March 23, 2021. https://lpi.oregonstate.edu/mic/vitamins/niacin 
  6. Liposomal NMN SynergyTM. Designs for Health website. Accessed March 23, 2021. https://shop.designsforhealth.com/liposomal-nmn-synergy?quantity=1&custcol_dfh_size=8 

 


fibro-better-sleep

Better Sleep for Those with Fibromyalgia

By Dr. David M. Brady and Danielle Moyer

 

What would be the perfect storm for disrupted sleep? Probably some combination of widespread pain, abnormal pain perception, and heightened awareness and sensitivity to stimuli (touch, light, and sound), and anxiety [1]. Unfortunately, these are the exact symptoms of fibromyalgia, a syndrome that impacts over 4 million US adults every day - about 2% of the population [2]. Sleep disturbances affect 90% of fibromyalgia patients, whose complaints include, “nocturnal restlessness, involuntary leg movements, frequent awakenings and a perception that sleep is light and non-refreshing, with fatigue and stiffness upon waking”[3].

To understand this more, sleep can be broken down into different stages. Approximately 5% consists of wakefulness, 25% is spent in the REM cycle, 50% in the “light” and “intermediate” sleep stage, and 20% in the short-wave sleep. Short-wave sleep is believed to be crucial for restoration, as that is where heart rate, blood pressure, energy use, and stress hormones are decreased, while growth hormone is released. Patients with fibromyalgia, as compared to healthy individuals, have been shown to have reduced short-wave sleep, impacting their quality of sleep. Additionally, during the non-REM portion of sleep, the abnormal pain processing of fibromyalgia triggers something called “alpha-wave intrusion” sleep patterns. Alpha-wave intrusions are associated with wakefulness during deep delta-wave sleep, reinforcing the “nonrestorative” sleep pattern and daytime fatigue in fibromyalgia patients [3].

Looking more closely at the relationship of fibromyalgia and sleep, researchers have found that sleep and pain have a bidirectional role in their progression. On one hand, poor sleep quality can worsen or even initiate symptoms of fibromyalgia, resulting in increased pain, altered pain processing, worsened physical functioning, and altered mood [4]. On the other hand, the abnormal pain processing of fibromyalgia correlates to the reduced deep short-wave sleep and triggered alpha-wave intrusion frequencies explained above. Studies have shown that the interaction of pain and sleep disturbances are associated with the prevalence of depression, anxiety, and stress in patients with fibromyalgia as well [4].

Essentially, studies show that fibromyalgia patients who experience intense pain also tend to experience poor sleep, and vice versa. As a result, therapeutic approaches capable of reducing or eliminating sleep disruptions should have a similar effect on the pain and fatigue symptoms in patients with fibromyalgia [5].

So, how does one break this vicious cycle?

Approaches to improving sleep begin with education around sleep hygiene and management [5]. Here are some tips that would help anyone, including patients with fibromyalgia, improve their sleep through time:

  • Set a regular sleep pattern where you go to bed and wake up at the same time every day (including weekends) [6]. One should allow their body 7-8 hours of sleep to repair itself, physically and mentally. This includes considerations of “sleep opportunity” and sleep itself. For example, someone’s sleep opportunity may be the 8 hours they lay in bed, despite actually sleeping for only 6 hours.
  • Make your bedroom a relaxing environment. Keep the room dark, quiet, and cool (65 degrees Fahrenheit) [7]. Invest in a comfortable mattress and bedding. Use your bed for sleep – avoid doing work, watching TV, reading, or checking your phone once you’re in bed. Avoid having pets in bed with you that may disturb your sleep.
  • Make time to relax every day. Relax with deep-breathing exercises, meditation, listening to soft music, taking a warm bath, and getting out into nature. This can reduce stress and improve sleep quality.
  • Exercise frequently, but not within 3 hours of bedtime. With fibromyalgia, exercising can be difficult at first due to the pain. However, studies show that regular exercise and movement can often reduce pain symptoms and fatigue in fibromyalgia. Even walking around one’s neighborhood or home can help to relieve symptoms. Start low and slowly increase the activity through time. Working with a physical therapist, chiropractic physician, trainer, or other knowledgeable health professional can be beneficial. Additionally, exercise is best done earlier in the day to not interfere with sleep [6].
  • Avoid drinking caffeine or alcohol, using nicotine, or eating large meals before bedtime [8]. Avoiding any large amount of liquids before bed can lower the chances of having to go to the bathroom in the middle of the night. Caffeine can be snuck into desserts (chocolate), medications, and tea. Alcohol contributes to frequent waking and increased trips to the bathroom during the night. Nicotine in cigarettes acts as a stimulant, which can further disrupt sleep problems [6].
  • Lower exposure to stimulating activities right before bed. No scary or intense movies, books, or projects that might make it difficult to fall asleep. The more you can avoid electronic screen exposure within 2-hours of bedtime the better. 
  • Consider Cognitive Behavioral Therapy (CBT). This encourages patients to change their thought patterns for the better, letting go of negative thoughts that might be inhibiting their ability to sleep [9].
  • Research whether your medications may be affecting your sleep as a side effect. Some medications worsen sleep, whereas others improve sleep. Knowing which one you have is important.

There are also other agents, such as supplements, that have been shown to improve sleep overall for people and patients with fibromyalgia. Before taking any supplements, please talk with your doctor, nutritionist, or other healthcare practitioner to see if they are right for you.

  • Vitamin D. Vitamin D can reduce pain in patients with conditions such as fibromyalgia, and it has also been shown to improve sleep hygiene in patients with fibromyalgia [10]. It is recommended to get your vitamin D levels checked at your doctors, as it can depend on your geographic location, exposure to sun, and time of the year.
  • Melatonin. Melatonin is a natural hormone that the body produces to regulate sleep cycles, but the production of it declines as we age. As a result, taking it in supplemental form can benefit people with fibromyalgia by improving sleep quality and reducing fatigue, as well as reducing pain [11-12].
  • 5-HTP (5-Hydroxytryptophan). 5-HTP is converted to the hormone serotonin in the body, which helps us fall asleep. Clinical evidence has shown that taking 100 mg of 5-HTP orally three times a day for 30 to 90 days can improve pain, tenderness, sleep, anxiety, fatigue, and morning stiffness in people with primary fibromyalgia syndrome [13-14].
  • Botanical Herbs. Herbs have been used as remedies to improve sleep for decades, and some of the most researched and well tolerated are below [15]. One can find them individually packaged in supplements, or often in combination supplements.
    • Valerian (Valeriana officinalis)
    • Passionflower (Passiflora incarnata)
    • Chamomile (Matricaria chamomilla)
    • Lavender (Lavandula angustifolia)
    • Lemon Balm (Melissa officinalis)
  • L-theanine. L-theanine is a compound found in tea leaves and has been shown to promote relaxation, decrease stress, and relax the mind to promote better sleep, without causing drowsiness or acting as a sedative [16].

When working with a healthcare provider to improve sleep with fibromyalgia, the first step to any therapeutic approach would be to get the patient’s sleep history. This includes factors about their sleep hygiene: Activities done before bed (physical exercise), attitude towards sleep (anxiety present), daytime activities that can impact sleep, dietary and lifestyle factors (caffeine, alcohol, and nicotine use), medications that affect sleep, and any other sleep-disrupting disorders [5].

Improving a person’s sleep is important for anyone, but especially for those with fibromyalgia. Look at the recommendations above and identify one or two that you can start right away. Not only will you feel more rested, but your pain may be lowered as well. Win, win.

 

References:

  1. Schneider MJ, Brady DM, Perle SM. Commentary: differential diagnosis of fibromyalgia syndrome: proposal of a model and algorithm for patients presenting with the primary symptom of chronic widespread pain. J Manipulative Physiol Ther. 2006;29(6):493-501. doi:10.1016/j.jmpt.2006.06.010
  2. Fibromyalgia. Centers for Disease Control and Prevention website. https://www.cdc.gov/arthritis/basics/fibromyalgia.htm. Reviewed January 6th, 2020. Accessed February 23, 2021. 
  3. Choy EHS. The role of sleep in pain and fibromyalgia. Nature Reviews Rheumatology. 2015;11(9):513-520. doi:10.1038/nrrheum.2015.56
  4. Keskindag B, Karaaziz M. The association between pain and sleep in fibromyalgia. Saudi Med J. 2017;38(5):465-475. doi:10.15537/smj.2017.5.17864
  5. Spaeth M, Rizzi M, Sarzi-Puttini P. Fibromyalgia and Sleep. Best Practice & Research Clinical Rheumatology. 2011;25(2):227-239. doi:10.1016/j.berh.2011.03.004
  6. Amigues I. Fibromyalgia. American College of Rheumatology website. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Fibromyalgia. Reviewed March 2019. Accessed February 23, 2021. 
  7. Pacheco D. The Best Temperature for Sleep. Sleep Foundation website. https://www.sleepfoundation.org/bedroom-environment/best-temperature-for-sleep. Reviewed October 29, 2020. Accessed February 23, 2021. 
  8. Clauw D. Fibromyalgia. Office of Women’s Health website. https://www.womenshealth.gov/a-z-topics/fibromyalgia. Reviewed April 1, 2019. Accessed February 23, 2021. 
  9. Bennett R, Nelson D. Cognitive behavioral therapy for fibromyalgia. Nat Clin Pract Rheumatol. 2006;2(8):416-424. doi:10.1038/ncprheum0245
  10. Oliveira DL de, Hirotsu C, Tufik S, Andersen ML. The interfaces between vitamin D, sleep and pain. Journal of Endocrinology. 2017;234(1):R23-R36. doi:10.1530/JOE-16-0514
  11. Hussain SA-R, Al-Khalifa II, Jasim NA, Gorial FI. Adjuvant use of melatonin for treatment of fibromyalgia. J Pineal Res. 2011;50(3):267-271. doi:10.1111/j.1600-079X.2010.00836.x
  12. Citera G, Arias MA, Maldonado-Cocco JA, et al. The effect of melatonin in patients with fibromyalgia: a pilot study. Clin Rheumatol. 2000;19(1):9-13. doi:10.1007/s100670050003
  13. Caruso I, Sarzi Puttini P, Cazzola M, Azzolini V. Double-blind study of 5-hydroxytryptophan versus placebo in the treatment of primary fibromyalgia syndrome. J Int Med Res. 1990;18(3):201-209. doi:10.1177/030006059001800304
  14. Sarzi Puttini P, Caruso I. Primary fibromyalgia syndrome and 5-hydroxy-L-tryptophan: a 90-day open study. J Int Med Res. 1992;20(2):182-189. doi:10.1177/030006059202000210
  15. Guadagna S, Barattini DF, Rosu S, Ferini-Strambi L. Plant Extracts for Sleep Disturbances: A Systematic Review. Evid Based Complement Alternat Med. 2020;2020. doi:10.1155/2020/3792390

Rao TP, Ozeki M, Juneja LR. In Search of a Safe Natural Sleep Aid. J Am Coll Nutr. 2015;34(5):436-447. doi:10.1080/07315724.2014.926153


woman wearing mask

Long-Haul COVID Syndrome

By Dr. David M. Brady and Danielle Moyer

 

It has been over a year since the COVID-19 virus unleashed a pandemic onto the world. We have witnessed the catastrophic effects of the virus on the individual, varying case-by-case. Some were asymptomatic, some only got mildly sick, some had severe cases with acute illness or respiratory distress syndrome, and some sadly succumbed to the disease. A year later, there exists a large group of COVID victims that have not been as recognized as they so rightfully deserve – the COVID long-haulers.

“Long-haulers” refers to those who had COVID-19 and have recovered from the acute symptoms of the virus. Yet, they experience long-term symptoms that extend far beyond the two-week viral infection period or what the “normal” time of recovery would be. These symptoms could last for weeks or, in some cases, more than 6 months after initial  COVID-19 infection [1].

Long-haul COVID is not well-defined or understood, as research limitations can only evolve as time progresses. The symptoms are sometimes vague and nonspecific, and the variety and commonality of them make it hard to make a confirmed COVID-related diagnosis. These non-specific symptoms are often described as intermittent, where improvement in health is quickly followed by recurring suffering [1].

I have witnessed these long haulers in my medical practice and personal life. In fact, my lovely wife is one of them.

At the World Health Organization’s international “Long-COVID Forum” on December 9, 2020, it was proposed that probably more than five million people on the planet have long-haul COVID. “Many of (the five million) are living and suffering in the U.S.” [1]. One study looked at all the COVID-19 hospitalizations in Bergamo, Italy, and revealed that more than 50% of the patients reported ongoing chronic symptoms significant enough to alter their daily lives months after being infected [2]. A more recent, larger study surveying thousands of patients from 56 countries now suggests that this chronic dysfunction is experienced by an even larger percentage of those who have had COVID than in the Bergamo study. This includes those who never had a positive COVID test despite showing all the hallmark symptoms of COVID-19. In fact, 96% of respondents in this study had some remaining symptoms after 90 days [3].

King’s College in London created a self-reporting app from the health-sciences company ZOE, where 4 million users in the UK tracked and monitored their COVID-symptoms over time. Since March 24, 2020, data from this app and similar studies have been used to study the patterns and durations of COVID-19 symptoms. The researchers state that their understanding of long-haul COVID is still in the early stages, but provided the following as the most common reported symptoms cited in various studies from a few days to a few months post infection [4].

  • Excessive fatigue and exhaustion (the most commonly reported long-haul symptom)
  • Breathlessness
  • Headache
  • Insomnia
  • Muscle fatigue/pains
  • Chest pains
  • Persistent cough
  • Loss of taste and smell
  • Intermittent fevers
  • Skin rashes
  • Post-exercise malaise (overtraining leads to symptoms coming back)

There are some fewer common symptoms that have been self-reported by long-haul sufferers that have yet to be confirmed in studies [4]…

  • Hearing problems
  • Cognitive issues, such as “brain fog”
  • Mental-health problems
  • Hair loss

In my practice, I have seen my long-haul patients with the symptoms above, as well as specifically…

  • Inflammatory pain. Predominantly in the small joints of the hands, fingers, and wrists, as well as the rib cage
  • An electric, buzzing sensation in the body, which is quite strange and unique to COVID-19
  • Excessive fatigue
  • Tachycardia, or intermittent, rapid heartbeat

For the patients who have experienced erratic heartbeats, some echograms and stress tests of patients show seemingly normal function. However, despite its label as a respiratory disease, we know that the virus can also impact organs beyond just the lungs. It has a particular affinity for the heart. After COVID-19, one can see a physical or physiological change to the cardiac muscle, or myocardium. Damage to the heart from the virus can help to explain some of the frequently reported long-haul COVID symptoms, such as shortness of breath, chest pain, and heart palpitations [4].

The King’s College self-reporting app interestingly found that a person’s COVID-19 experiences during the active two-week viral stage can correlate to how likely they are to experience long-haul COVID symptoms as well. For example, if a person experienced a “persistent cough, hoarse voice, headache, diarrhea, loss of appetite and shortness of breath in the first week,” they were two to three times more likely to get long-haul COVID symptoms [4]. The researchers also determined that long-haul COVID syndrome is twice as common in women as in men, and the average age of a long hauler is 45 years old, though young people can be long haulers too. One study from the US found that one in five people between the ages of 18 to 34 years old without preexisting chronic medical conditions reported cases of long-haul COVID after their initial infection [4].

Through self-reporting, these sufferers are demonstrating that long-haul COVID is real and can cause chronic health manifestations. The symptoms can be debilitating, and have been shown to affect mental health, physical function, and ability to work [3].

What are these long-haulers doing? Due to the limited research, the answer can be boiled down to “trying their best”. Often, they find solace in online support groups on Facebook [1]. Here they can share their stories, discuss what has been helping their symptoms, report what hasn’t been helping, and simply, feel less alone in their experiences. There is one Facebook support group called “Long Covid Support Group'' with 35.1K members as of February 2021 [5] . 

There are multiple different theories on the origin of long-haul COVID syndrome. Most agree that it is not an active COVID-19 infection, but rather it is a re-programmed immune response that occurred because of the virus. The initial infection of the virus changes immunity patterns, which can put someone into a more aggressive immunity stance. Some have even speculated (and I would not be surprised if it were true) that the virus has created an autoimmune attack of the body against its own tissues. The exact pathophysiology is unknown.

Currently, there are no proven treatments for long-haul COVID syndrome. We are learning and rushing to figure out the best way to  provide relief to those who are suffering. The sheer number of long haulers is terrifying and will only continue to grow,  indicating that this pandemic will remain in us much longer than hoped. Potentially, ailments may remain for a lifetime in those affected. The toll this takes on our healthcare system is incalculable at this time.

Right now, I want to share what I am using with my patients and my wife to help with some of their long-haul symptoms. This is not intended to be direct advice on what to do or what to take. One must really work with their doctor or healthcare provider. Instead, I offer these suggestions to discuss with your provider as options to explore in the hopes that they may help you.

Studies have shown that it is possible for the SARS-CoV-2 virus to directly impair mitochondrial energy metabolism by targeting the action of oxygen availability and utilization in the cell [6]. This can cause a breakdown in energy production, particularly around a pathway involving NAD+, or nicotinamide adenine dinucleotide [6-10].

To address this, we are using NAD+ precursors to rebalance this energy biochemistry and respiration in the body at a cellular level. This includes administering products containing nicotinamide riboside (NR) or nicotinamide mononucleotide (NMN) to assist in mitochondrial production. Other well-known nutrients that support mitochondrial energy production are Co-enzyme Q10 (CoQ10) and ribose. CoQ10 is especially helpful for the cardiac muscle, which is beneficial for the rhythm or beating of the heart.

When a patient is experiencing shortness of breath, lung irritation, or respiratory issues, we are using nebulized glutathione or oral glutathione, or a medicinal peptide called Thymosin-Alpha-1. Thymosin-Alpha-1 is a prescription peptide that has been previously used in autoimmune conditions and in immune deregulatory symptoms. Essentially, it talks to the immune system to get it back on track, quelling any hyper response of the immunity system.  

If you are a long hauler suffering, I hope this article serves as acknowledgement and recognition of you. Many of us in the medical and health fields are doing everything we can to figure this out and trying to find viable ways to make your experience better. In the meantime, I highly encourage you to get involved with the online support groups. You will learn from others and will not feel so isolated in your experience.

Please listen to the video I made on “Long-Haul” if you have any interest in the topic, knowing that it was recorded with all of those who are suffering in mind: 

https://www.youtube.com/watch?v=lHewi7W1Qps

To read more information about Long-Haul COVID, please see this excellent article in Scientific American: https://www.scientificamerican.com/article/the-problem-of-long-haul-covid/

Again, if any of you are suffering from COVID in the short or long term, we are thinking of you. 

 

References

  1. Barber C. The Problem of ‘Long Haul’ COVID. Scientific American website. https://www.scientificamerican.com/article/the-problem-of-long-haul-covid/. Published December 29, 2020. Accessed February 10, 2021. 
  2. Harlan C, Pitrelli S. Italy’s Bergamo is calling back coronavirus survivors. About half say they haven’t fully recovered. The Washington Post website. https://www.washingtonpost.com/world/2020/09/08/bergamo-italy-covid-longterm/?arc404=true. Published September 8, 2020. Accessed February 10, 2021. 
  3. Davis HE, Assaf GS, McCorkell L, et al. Characterizing Long COVID in an International Cohort: 7 Months of Symptoms and Their Impact. medRxiv. Published online December 27, 2020:2020.12.24.20248802. doi:10.1101/2020.12.24.20248802
  4. Sleat D, Wain R, Miller B. Long Covid: Reviewing the Science and Assessing the Risk. :18.
  5. Long Covid Support Group. Facebook website. https://www.facebook.com/groups/longcovid/. Accessed February 10, 2021. 
  6. Stefano GB, Ptacek R, Ptackova H, Martin A, Kream RM. Selective Neuronal Mitochondrial Targeting in SARS-CoV-2 Infection Affects Cognitive Processes to Induce ‘Brain Fog’ and Results in Behavioral Changes that Favor Viral Survival. Med Sci Monit. 2021;27:e930886-1-e930886-4. doi:10.12659/MSM.930886
  7. Omran HM, Almaliki MS. Influence of NAD+ as an ageing-related immunomodulator on COVID 19 infection: A hypothesis. Journal of Infection and Public Health. 2020;13(9):1196-1201. doi:10.1016/j.jiph.2020.06.004
  8. Kouhpayeh S, Shariati L, Boshtam M, et al. The Molecular Story of COVID-19; NAD+ Depletion Addresses All Questions in this Infection. Published online March 23, 2020. doi:10.20944/preprints202003.0346.v1
  9. Heer CD, Sanderson DJ, Voth LS, et al. Coronavirus infection and PARP expression dysregulate the NAD Metabolome: an actionable component of innate immunity. bioRxiv. Published online October 6, 2020:2020.04.17.047480. doi:10.1101/2020.04.17.047480
  10. Miller R, Wentzel AR, Richards GA. COVID-19: NAD+ deficiency may predispose the aged, obese and type2 diabetics to mortality through its effect on SIRT1 activity. Medical Hypotheses. 2020;144:110044. doi:10.1016/j.mehy.2020.110044

Woman running on treadmill

How to Get the Best Bang from Exercise for the Investment in Time

By Dr. David M. Brady and Danielle Moyer

 

Before performing any of the following physical exercises, please consult with your doctor about whether this is appropriate for you. 

Some of us have heard the saying “sitting is the new smoking.” Such a bold statement hints that our sedentary lifestyles of sitting at our computer, taking Zoom calls, and watching television have enormous impacts on our health. But how? We know that exercise can help with weight loss, but it can also help to prevent chronic diseases such as Parkinson’s and Alzheimer’s, improve your mood, boost your immunity, improve cardiovascular function, and promote a healthy gut and microbiome.1-5

So, if exercise is so good for us… Why don’t we do it?

One word: Time.

Trying to find time for work, family, self-care, healthy eating, errands, and being a normal human can be exhausting some days! If one isn’t familiar with exercise, it seems like a daunting, frustrating, and time-consuming task.

The World Health Organization recommends that adults engage in moderate-intensity exercise for 150 minutes per week to maintain proper cardiovascular health.6 But let’s face it. Most of us need 150 more minutes of sleep.

Unsurprisingly, the number of adults that remain sedentary is high. This can increase the risk of mortality, cardiovascular disease, cancer, and diabetes. In fact, one out of five adults are physically inactive across the globe.6 

There is some good news. Since so many people face this issue, in the last two decades we found a solution: High-Intensity Interval Training (HIIT).

HIIT consists of short, intense exercises that last around 10 to 30 minutes. It is designed to alternate consistently between two modes: an intense “work period” and a “recovery period”.

The intense work period should be performed at 80% to 95% of a person’s estimated maximal heart rate. The recovery period is performed at 40% to 50% the person’s estimated maximal heart rate.7-8 Estimating your maximal heart rate will vary person-to-person depending upon your level of fitness. The objective during the intense work period is to feel your heart pumping such that you would have trouble carrying on a normal conversation. The active recovery period is when you are able to speak full sentences, but would have trouble singing.8

*Note: To make your HIIT workouts really work efficiently and maximally, begin to monitor your heart rate variance during your “work” and “recovery” periods. This can be done via a heart rate monitor on your chest or wrist. For example, one person may only need to run at speed 4 on a treadmill to get their heart rate in the 80% to 95% zone, whereas someone else may need to go to speed 7. It is individualized to you. Monitoring your heart rate variance during HIIT gives your workout even more intent and purpose.

HIIT is a class of exercise first largely used by elite athletes.9 Now, even the AARP dubs HIIT as the ‘miracle’ workout that everyone should be doing.10 HIIT is not only designed to be short and time-effective, but studies show that HIIT may result in even more health benefits than moderate intensity “aerobic” exercises.9-12 Additionally, it is found to be enjoyable, safe and tolerable for most adults.12

One of the best benefits of HIIT is its effect on heart-rate variability (HRV).7  Heart rate variance is a way to evaluate your cardiovascular health non-invasively. It has been shown that people who have high HRV have greater cardiovascular fitness and are more resilient to stress, and this can improve with time the more one works out.13 It’s a good idea to track your heart rate variance when exercising to track your performance, such as using a heart rate monitor chest strap. HIIT has been shown to be superior to typical moderate exercises in improving HRV in physically inactive adults.7

Other benefits of HIIT include…6-12,14-16

  • Improves blood pressure
  • Improves cardiovascular health
  • Improves insulin sensitivity
  • Burns more calories than traditional workouts in same amount of time
  • Helps burn fat
  • Increases muscle mass for non-active individuals
  • Increases metabolism for hours after exercising
  • Improves cellular function

 

Here are some quick guidelines for HIIT:

1)      How long should each HIIT workout be?

HIIT is designed to consistently alternate between work and recovery periods, totaling anywhere from 10 to 30 minutes, depending on your goals and exertion levels.

The nice part about HIIT is you can easily modify your preferred difficulty level and workout time. Experiment with different time durations and repetitions to find what is best for you. Here are two methods to get your started:

The 4x4 method7

True to its name, it is called the 4x4 method because it involves 4 rounds of burst high intensity exercise for 4 minutes, with 3 minutes of active recovery in-between each. The workout is bookended by 3-minute moderate intensity warm-up and cool-off periods, bringing us to a grand total of about 30 minutes.7

The Wingate Method7  

This method includes shorter, higher intensity bursts of energy. After warming up with 3 minutes of moderate intensity, one would work for 30 seconds at vigorous intensity, followed by a recovery period for 2-5 minutes. Repeat 6 to 8 times.7

After reading those, you may be tempted to start out with a beginner workout. Try the 10-minute model HIIT workout one time a week. This would include a 3-minute moderate intensity warm up, a work period of 20 seconds and a moderate recovery period for 1-2 minutes. Repeat those repetitions two more times.10

2)      How many times a week do I have to do HIIT workouts?

Again, this is up to you. You can begin with one time a week for 10 minutes, and slowly increase to two to three times a week for 30 minutes. Because it is more exhausting than endurance workouts, such as going for a 30-minute light jog, it is recommended to spread the HIIT workouts throughout the week to optimize longer recovery periods (at least 24 hours between sessions).8

3)      What exercises can be done with the HIIT model?

Another excellent thing about HIIT is you can tweak aerobic exercises you do now to match the HIIT model. No fancy machines are necessary - just a timer and commitment to ratchet-up the intensity of the workout to achieve the desired maximal heart rate for the intended duration! 

This includes running, walking, jogging, rowing, biking, swimming, cycling, elliptical training, stair-climbing, dancing, kickboxing, spinning, hiking, or any other exercises (burpees, jump squats) that get your heart pumping. However, probably the most often used exercise to accomplish high intensity burst training is sprinting on a treadmill, followed by walking during the recovery period, and then repeating this pattern the desired number of times. 

Overall…

As with any exercise, there are potential risks of injuries, so speak with your doctor before starting any new routine. If you are low on time, high-intensity interval training (HIIT) can be considered the best exercise for time management and to attain the best “bang for your buck”! Start slowly and build it up through time. When it comes to HIIT, every second counts!  

 References:

  1. Cheng S-T. Cognitive Reserve and the Prevention of Dementia: the Role of Physical and Cognitive Activities. Curr Psychiatry Rep. 2016;18(9):85. doi:10.1007/s11920-016-0721-2
  2.  Aylett E, Small N, Bower P. Exercise in the treatment of clinical anxiety in general practice - a systematic review and meta-analysis. BMC Health Serv Res. 2018;18(1):559. doi:10.1186/s12913-018-3313-5
  3.  Healthy Mind, Healthy Body: Benefits of Exercise. Harvard Medical School website. https://hms.harvard.edu/sites/default/files/assets/Sites/Longwood_Seminars/Exercise3.14.pdf. Updated March 13, 2014. Accessed January 8, 2021.
  4. Warburton DER, Nicol CW, Bredin SSD. Health benefits of physical activity: the evidence. CMAJ. 2006;174(6):801-809. doi:10.1503/cmaj.051351
  5.  Johannesson E, Simrén M, Strid H, Bajor A, Sadik R. Physical activity improves symptoms in irritable bowel syndrome: a randomized controlled trial. Am J Gastroenterol. 2011;106(5):915-922. doi:10.1038/ajg.2010.480
  6. Alansare A, Alford K, Lee S, Church T, Jung HC. The Effects of High-Intensity Interval Training vs. Moderate-Intensity Continuous Training on Heart Rate Variability in Physically Inactive Adults. Int J Environ Res Public Health. 2018;15(7). doi:10.3390/ijerph15071508
  7. Ito S. High-intensity interval training for health benefits and care of cardiac diseases - The key to an efficient exercise protocol. World J Cardiol. 2019;11(7):171-188. doi:10.4330/wjc.v11.i7.171
  8. ACSM Information on… High Intensity Interval Training. American College of Sports Medicine website. https://www.acsm.org/docs/default-source/files-for-resource-library/high-intensity-interval-training.pdf?sfvrsn=b0f72be6_2. Accessed on January 8, 2021.
  9. Mekari S, Earle M, Martins R, et al. Effect of High Intensity Interval Training Compared to Continuous Training on Cognitive Performance in Young Healthy Adults: A Pilot Study. Brain Sci. 2020;10(2). doi:10.3390/brainsci10020081
  10. Furchgott R. High-Intensity Interval Training: Why It Just May Be a ‘Miracle’ Workout. AARP website. https://www.aarp.org/health/healthy-living/info-2018/high-intensity-interval-training-workout/. Published November 7, 2018. Accessed January 8, 2021
  11.  Kong Z, Fan X, Sun S, Song L, Shi Q, Nie J. Comparison of High-Intensity Interval Training and Moderate-to-Vigorous Continuous Training for Cardiometabolic Health and Exercise Enjoyment in Obese Young Women: A Randomized Controlled Trial. PLoS One. 2016;11(7). doi:10.1371/journal.pone.0158589
  12. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334-1359. doi:10.1249/MSS.0b013e318213fefb
  13. Campos M. Heart rate variability: A new way to Track well-being. Harvard Health Publishing: Harvard Medical School website. https://www.health.harvard.edu/blog/heart-rate-variability-new-way-track-well-2017112212789. Published November 22, 2017. Accessed January 8, 2021.
  14. Wewege M, van den Berg R, Ward RE, Keech A. The effects of high-intensity interval training vs. moderate-intensity continuous training on body composition in overweight and obese adults: a systematic review and meta-analysis. Obes Rev. 2017;18(6):635-646. doi:10.1111/obr.12532
  15. Damas F, Phillips S, Vechin FC, Ugrinowitsch C. A review of resistance training-induced changes in skeletal muscle protein synthesis and their contribution to hypertrophy. Sports Med. 2015;45(6):801-807. doi:10.1007/s40279-015-0320-0
  16. Falcone PH, Tai C-Y, Carson LR, et al. Caloric expenditure of aerobic, resistance, or combined high-intensity interval training using a hydraulic resistance system in healthy men. J Strength Cond Res. 2015;29(3):779-785. doi:10.1519/JSC.0000000000000661

Woman with lower back pain

Common Risk Factors Associated with Fibromyalgia

By Dr. David M. Brady and Danielle Moyer

Fibromyalgia syndrome (FMS) is hallmarked by complex symptoms and difficulty of diagnosis. Studies show that fibromyalgia is properly diagnosed in as low as 34% of cases, meaning that the other 66% were due to other symptoms that mimicked fibromyalgia.1 What causes such an alarmingly high number of misdiagnoses?

The high percentage of misdiagnosed cases are referred to as “Pseudo Fibromyalgia” (pseudo meaning false, or having the appearance of).1 These constitute various disorders cause unknown or undetermined pain (not necessarily widespread pain), but are not FMS. Examples include anemia, hypothyroidism, Lyme disease, functional nutritional deficiencies, mitochondrial energy production deficiency, dysfunctional liver detoxification, joint dysfunction, muscle imbalance, and even postural distortion.2 Why does this occur so often? One significant reason may be that FMS is not based upon any specific laboratory or diagnostic tests. Rather, it is based on symptomatic criteria and medical history. And unfortunately, many conditions or diseases can be associated with fatigue and muscle tenderness, further confusing doctors.

The properly diagnosed cases are often called “Classic Fibromyalgia syndrome”, which follows the specific symptom patterns of FMS. These symptoms include “global” or widespread genuine pain, changes in pain processing, and heightened awareness and sensitivity to stimuli (touch, light, sound). The most pronounced symptom that differentiates FMS from other medical conditions is the pronounced widespread tenderness and extremely low tolerance to sensory stimulation. This is caused by an abnormality of the central nervous system, rather than a primary muscle or soft-tissue dysfunction.3

Separating “Classic FMS” from “Pseudo FMS” is challenging, yet crucial. Elements of diagnosing FMS include an in-depth patient history, physical examination, neurotransmitter evaluation, and differentiation of other diagnoses or pain-related disorders via comprehensive laboratory testing.1

Fortunately, the presence of common risk factors associated with FMS can act as a differentiators between “Classic” and “Pseudo” FMS. These risk factors include…

1. Common comorbidities/conditions

These include symptoms of persistent fatigue, sleep disorders (non-refreshing sleep), headaches, teeth grinding, cold sensitivity, exercise intolerance, cognitive deficits, Raynaud’s phenomenon, irritable bowel syndrome (IBS), and irritable bladder syndrome.3 All of these symptoms suggest increased sympathetic nervous system activity, hence their correlation. In fact, FMS exhibits almost 100% comorbidity with IBS, where FMS patients almost all have IBS.1 Additionally, about 20% to 50% of FMS patients experience significant depression or anxiety.2

When someone has a metabolic disorder masquerading as fibromyalgia, such as thyroid disorders, adrenal stress, or nutritional deficiencies, they typically do not have a sleep disorder, chronic anxiety, or irritable bowel syndrome, which are all associated with classic FMS.1 According to the American College of Rheumatology Diagnostic Criteria for Fibromyalgia, even if a person scores “high” on their FMS questionnaire, the source of their body pain and aches may not be from classic FMS if they do not have at least two symptoms of anxiety, depression, non-refreshing sleep, or irritable bowel syndrome (IBS).4

2. Family history

 

FMS almost always involves dysregulation and lower levels of serotonin. Evidence shows that individuals can have genetic mutations that impact serotonin levels passed down to them. Research also suggests that within FMS patients, there are associations with lower pain pressure thresholds in families.1

3. History of trauma, abuse, or chronic stress

Trauma can alter the processing of pain and incoming stimuli of an individual. As a result, trauma can frequently cause an excessive stress response, significant and chronic pain, and central sensitization disorders, such as FMS, anxiety and IBS.1 It has been shown that FMS patients have a “significantly higher prevalence of emotional, physical, or sexual trauma, associated with the onset of FMS symptoms.”1 A pattern of progression in classic FMS can be similar to the progression of depression, both of which can be latently triggered by emotional trauma such as a divorce or death in the family. Many FMS patients have experienced childhood trauma, neglect, verbal and emotional abuse, intense psychological trauma, or chronic stress. Lastly, the symptoms of FMS can be triggered by physical trauma, such as a severe car accident, botched surgery, or physical or sexual abuse.1

4. Being a woman

Disorders that cause low serotonin in the body are much more prevalent in women, where fibromyalgia syndrome is 10 to 20 times more common in women than in men. The suspected reason is due to women’s hormonal and nervous systems responding to stress and trauma differently than men’s.3 Research explored the impact of menstruation and hormonal changes as possible factors, but the data is lacking in supporting specific hormonal abnormalities unique to female FMS patients.2

5. Age

According to the Centers for Disease and Control (CDC), FMS can affect people of all ages, including children. However, most people are diagnosed during middle age.5 

These risk factors, including comorbidities and medical history, should be considered along with medical examination and appropriate lab screening tests to lower the alarmingly high trend FMS overdiagnosis in primary care medicine. If you are exhibiting FMS-like symptoms, it is recommended to seek the care of an experienced and specialized medical practitioner in this field to properly differentiate between “Classic FMS” and “Pseudo FMS”, which is easier said than done. 

Dr. Brady does accept and new patients through his Connecticut practice and can provide

remote video consultations via secure Zoom sessions. You can learn more about his practice and find contacts to the front desk for scheduling and to answer any questions on at: https://drdavidbrady.com/private-practice/ 

If that is not an option for you, your next best option is to try and find a clinician trained in the functional medicine model near you at: https://www.functionalmedicine.org/practitioner_search.aspx?id=117 

Because a healthcare provider is trained in functional medicine does NOT mean they understand the issues involved in fibromyalgia like Dr. Brady does, but it is probably your next best option and will assure the provider at least understand some of the more subtle metabolic issues that may be in-play in various cases.

 

References

  1. Brady DM, Schneider, MJ. Pain and Fatigue: When It’s Fibromyalgia and When It’s Not. Townsend Letter. October 2012;351:44-50.
  2. Brady DM, Schneider MJ. Fibromyalgia syndrome: A new paradigm for differential diagnosis and treatment. Journal of Manipulative and Physiological Therapeutics. 2001;24(8):529-541. doi:10.1067/mmt.2001.118202
  3. Schneider MJ, Brady DM, Perle SM. Commentary: Differential Diagnosis of Fibromyalgia Syndrome: Proposal of a Model and Algorithm for Patients Presenting with the Primary Symptom of Chronic Widespread Pain. Journal of Manipulative and Physiological Therapeutics. 2006;29(6):493-501. doi:10.1016/j.jmpt.2006.06.010
  4. 2011 Modification of the American College of Rheumatology Diagnostic Criteria for Fibromyalgia. https://cdn.shopify.com/s/files/1/1258/4853/files/Fibromyalgia_ACR_Diagnostic_Criteria_Questionnaire.pdf?130670129376981087. Accessed November 16, 2020.
  5. Fibromyalgia. Centers for Disease Control and Prevention website. https://www.cdc.gov/arthritis/basics/fibromyalgia.htm. Reviewed January 6, 2020. Accessed November 16, 2020. 

Fork and knife

Intermittent Fasting: What is it All About Anyway?

By Dr. David Brady

Danielle Moyer

Intermittent fasting has been happening long before it got the name “intermittent fasting”. For centuries, groups of people all over the globe have abstained from food for durations of time for cultural and religious reasons. So, why has intermittent fasting blown up so much in the world of nutrition? What is it all about anyway?

There are two concepts behind intermittent fasting that you may not have heard of: Migrating Motor Complex and Autophagy.

To begin, there are different paradigms of intermittent fasting. Typically, “Time Restricted Feeding” is when an individual will restrict their food intake for a window of 8 to 10 hours or less every day during the week. Examples of this are skipping a meal or reduced meal frequency. On the other hand, there are longer periods of intermittent fasting around 16 to 48 hours with little to no energy (food) intake. This includes “alternate day fasting”, the 16/8 method (eating only within an 8-hour period), fasting two days per week, or periodic fasting periods lasting anywhere between 2 to even 21 days. All of these constitute intermittent energy restrictions.

Performing short-term frequent fasting, or “Time Restricted Feeding”, allows one to achieve a Migrating Motor Complex (MMC).

Imagine you want to clean your floors. If you are having a party, you are going to hold off on cleaning! There is no point when more mess is constantly coming in. But what about a calm Sunday morning when you are home alone? That is the same concept for MMC. Essentially, MMC is the act of your gastrointestinal tract contracting and “cleaning” your gut. It can only happen when the party's over, or when you are not consuming any food. That is why MMC is called the “housekeeper” of the gut.

The duration of the entire MMC cycle length varies between individuals, but it ranges typically from 113 to 230 minutes (about 2 to 4 hours) of no food consumption. MMC allows us to empty our stomach and small intestine, and to send all remaining food into our large intestine to prepare for the next meal. When the body is unable to “clean” due to constant eating, this can leave our gastric content to stay for longer periods and potentially allow bacterial overgrowth or a variety of GI symptoms or occur. This has been correlated to small intestinal bacterial overgrowth (SIBO), as well as altered hunger signaling. Time restricted feeding encourages the full MMC cycle to complete.

The second element is induced by long-term fasting. It is called autophagy.

Autophagy literally translates to “eating of self” from the Greek meaning. Although that sounds alarming, autophagy is incredibly important for balancing our sources of energy, removing damaged cells, as well as eliminating potential pathogens. It is considered another “housekeeping” mechanism in our body. For that reason, autophagy has been associated in preventing diseases such as cancer, diabetes, autoimmune diseases, infections, liver disease, as well as neuroprotective effects in preventing diseases such as Alzheimer’s or Parkinson’s. In fact, autophagy is considered a promising target for cancer therapy, as it can play a role in inhibiting tumor growth.

The crucial element is that autophagy can only occur during states of starvation. It is an adaptive response of our cells and organisms during food-deprivation that promotes survival until energy is available again. However, this is not something that occurs in just 2 hours of no eating. It is difficult to assess exactly when autophagy is triggered, but one study found that it was significantly detected after 24 hours of food restriction. It was even more abundant after 48 hours of food restriction. Though that seems like a long time to go without eating, these periods allow cleansing throughout our entire body, including cleaning important organs, such as the heart and liver.

There are many other researched benefits of intermittent fasting. One, it is designed to prevent over-eating and increase your metabolic rate. This is associated with improvement in weight loss. Two, studies show it can improve cardiovascular effects, including improving insulin sensitivity and lipid profiles. Three, it has been shown to reduce oxidative stress and inflammation in the body.

Here are some guidelines on how to implement a fast:

  1. Analyze your schedule and determine which common method would be right for you, realistically. Choice considerations can be dependent on frequency per week or during a specific time frame of the day. Do you work at a high-paced job in the morning where it is best that you have breakfast? Do you get off work at 7 PM and can eat dinner only after that time? These are things to consider. 
    • Time-restricted feeding: An example of this is the 16/8 method, where you eat only within an 8-hour window. For example: 8 AM to 4 PM. The nice part about time-restricted feeding is it is the most flexible based upon your schedule. 
    • Whole day fasting: You can choose one to two days per week to do a complete fast, or choose to consume roughly 25% of your normal caloric intake. On the other days, you eat as you normally would. 
    • Alternate day fasting: On alternating days, you eat only one meal that provides about 25% of your normal caloric intake. For example, on Monday, Wednesday, Friday, you eat only one meal. On Tuesday, Thursday, Saturday, you would eat as you normally would. 
  1. Stay hydrated! A large percentage of our water intake on a daily basis comes from our food, so it is vital to drink water when you are not eating. This will lower the risk of fatigue, dry mouth, headaches, or thirst. Most people aim to drink 8.5 to 13 cups (2-3 liters) of water a day when fasting. 
  2. Find ways to entertain yourself that do not involve food. Eating is more than just consuming calories – people eat when they are bored, socializing, sad, angry, happy, etc. What can you do to stay calm and keep your mind engaged? You may be able to do a low-intensity exercise, such as walking or yoga, but be sure to ease into it at first. 
  3. During a fast, the feeling of “hunger” is expected. You may even feel tired or irritable. These are all normal! However, stop fasting if you ever feel unwell. If you feel faint, sick, nauseous, or concerned about your health, break your fast to nourish your body. 
  4. On your non-fasting days, do not “overeat” to compensate for the fasting days. Try to keep a normal diet inclusive of whole foods, lean protein, fiber, and fat. 

Though there are many benefits to intermittent fasting, it is important to remember that these can be offset from the potential psychological impacts of intermittent fasting. Episodes of fasting can potentiate disordered eating or eating disorders, specifically binge eating disorders. It is also important to consider if you have a medical condition or need to eat based on medication use. Therefore, it is best to consult with a healthcare professional first.

If you are interested in intermittent fasting, there are many ways to do it safely and effectively. Like learning a new hobby, it is wise to start slowly and progress to more advanced levels. Just think, you already “fast” every night while you are asleep! There is a reason breakfast is called break-fast as it is.

 

References:

Rynders CA, Thomas EA, Zaman A, Pan Z, Catenacci VA, Melanson EL. Effectiveness of Intermittent Fasting and Time-Restricted Feeding Compared to Continuous Energy Restriction for Weight Loss. Nutrients. 2019;11(10):2442. Published 2019 Oct 14. doi:10.3390/nu11102442

Takahashi T. Interdigestive migrating motor complex -its mechanism and clinical importance. J Smooth Muscle Res. 2013;49:99-111. doi:10.1540/jsmr.49.99

Deloose E, Tack J. Redefining the functional roles of the gastrointestinal migrating motor complex and motilin in small bacterial overgrowth and hunger signaling. Am J Physiol Gastrointest Liver Physiol. 2016;310(4):G228-G233. doi:10.1152/ajpgi.00212.2015

Glick D, Barth S, Macleod KF. Autophagy: cellular and molecular mechanisms. J Pathol. 2010;221(1):3-12. doi:10.1002/path.2697

Onorati AV, Dyczynski M, Ojha R, Amaravadi RK. Targeting autophagy in cancer. Cancer. 2018;124(16):3307 doi:10.1002/cncr.31335

Alirezaei M, Kemball CC, Flynn CT, Wood MR, Whitton JL, Kiosses WB. Short-term fasting induces profound neuronal autophagy. Autophagy. 2010;6(6):702 doi:10.4161/auto.6.6.12376

Glatigny M, Moriceau S, Rivagorda M, et al. Autophagy Is Required for Memory Formation and Reverses Age-Related Memory Decline. Current Biology. 2019;29(3):435-448.e8. doi:1016/j.cub.2018.12.021

Guelinckx I, Tavoularis G, König J, Morin C, Gharbi H, Gandy J. Contribution of Water from Food and Fluids to Total Water Intake: Analysis of a French and UK Population Surveys. Nutrients. 2016;8(10):630. Published 2016 Oct 14. doi:10.3390/nu8100630

Stockman MC, Thomas D, Burke J, Apovian CM. Intermittent Fasting: Is the Wait Worth the Weight?. Curr Obes Rep. 2018;7(2):172-185. doi:10.1007/s13679-018-0308-9