Agree. These medications probably have little value. See a cohort study: Global Effect of Modifiable Risk Factors on Cardiovascular Disease and Mortality. The Global Cardiovascular Risk Consortium*published in NEJM 10/2023 about cardiovascular risk factors. Notice the graphics in particular that compare risks of cardiac events and death with relation to BMI, BP, smoking, diabetes, and non-HDL cholesterol. Some signal for stroke and heart attack, but no difference in hazard ratios for death with non-HDL cholesterol risk factor. One might wonder that a stroke could be worse than death if you are debilitated after the stroke, of course. Diabetes is the strongest risk factor in this study, BY FAR. I have heard of the increased risk of diabetes with statin medications and am not sure if this is causation or association. I would sure hate to prescribe a statin if it increases risk for diabetes, as this sounds like a risky move. As a family physician, I lay out this controversy to actively involve the patient in the decision, but I do not strongly recommend lipid lowering medications due to the side effect profile and non-effectiveness in general.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

**Headache**

The incidence of migraine headaches rose dramatically during the 1980s, particularly in women, according to a new study by researchers at the Mayo Clinic. The study, which was published October 2022 in the Journal of Neurology, compared first-time migraine diagnoses documented in patient medical records from 1979 to 1981 with those from 1989 to 1990. Records from 1342 patients were included in the study. Overall, the incidence of migraine increased by 56% in women and 34% in men. The most striking rate of increase was in women aged 20 to 29—from 600 to 1000 new cases per 100,000 women per year. In men the same age, the rate increased from 200 to 250 per 100,000 men per year. This brings up obvious questions. Maybe, healthcare providers are identifying headaches more easily? Are these headaches related to diet changes? I suspect many times diet strongly contributes to headache intensity and frequency.

Some specific headache types:

Migraine, tension, medication overuse, daily persistent headache, menstrual migraine, traumatic brain injury, cluster headache.

Acute treatment:

NSAIDs, acetaminophen, triptans, calcitonin gene related peptide (CGRP) receptor antagonists, muscle relaxants, antiemetics, dihydroergotamine, oxygen.

Prophylactic treatment:

First-line: Beta-blocker, amitriptyline, topiramate (possible CGRP receptor antagonist), valproic acid (not for use when childbearing potential)

Second line: CGRP receptor antagonist monoclonal antibodies (aimovig, ajovy, emgality, vyepti), calcium channel blocker, magnesium, muscle relaxants

Third line: Pregabalin, cyproheptadine, botulinum toxin injection, monoclonal antibodies targeting calcitonin gene related peptide receptor

Diet: Restriction of specific triggers. Headache triggers: Alcohol, artificial sweeteners, beans, caffeine, cheeses, yogurt, foods containing monosodium glutamate, processed meats, some herbal supplements extremely cold or extremely hot foods (think Carolina Reaper pepper).

*Consider carbohydrate restriction.*

-Ketones are more efficient energy than glucose. Ketones increase mitochondrial efficiency and production.  Ketones also have an antioxidant effect on mitochondria, and decreasing damage to cells.
-Ketones increase GABAergic tone and decrease Glutamateric tone. Increasing GABAergic tone results in inhibition of neurotransmission, improves sleep, improves anxiety, “calming effect”. Glutamate can damage or kill nerve cells if overactive.  Excessive glutamate has also been associated with the following conditions: ALS, MS, Alzheimer's disease, Parkinson's disease, Huntington's disease, stroke, fibromyalgia, and chronic fatigue syndrome.  Mental health conditions associated with a glutamate disorder include: Anxiety, autism, depression, obsessive-compulsive disorder, and schizophrenia.
-Ketones increase the release of BDNF (brain-derived neurotrophic factor), promotes survival and maintenance of nerve cells.

Treatments based on etiology of headache:

**Traumatic brain injury:**

Pathophysiology: Metabolic, physiologic, and micro structural injury to the brain.  Autonomic nervous system dysregulation occurs.  The autonomic nervous system regulates cerebral blood flow, blood pressure, and heart rate.  Heart rate variability post injury due to damage in the vagal nerve tracts can result in early fatigue, and inappropriate increases in blood pressure and heart rate during activity. (See my other post regarding concussion).

Treatments:

Limited rest, then low level activity as tolerated

Preventing blood sugar and insulin excursions with low carb, high fat diet, intermittent fasting

Stimulate the endocannabinoid system with exercise, meditation, and foods such as: Truffles, dark chocolate, coffee, oregano, curcumin, cinnamon, Chia seeds, hemp, walnuts, sardines, eggs, anchovies.

Some evidence that CBD oil is helpful also

Meditation and non-sleep deep rest

Cold Thermogenesis therapy.  Stimulates dopamine and adrenaline.

Stress reduction techniques including: Singing, cold exposure, and abdominal belly breathing increase parasympathetic tone.

Low-dose naltrexone decreases inflammation, increases endorphins, and improves immune function

Other medications can be used to stimulate serotonin, dopamine, etc. such as amitriptyline and SSRIs

Use a red light and low light conditions at home.  When red light is used within 3 hours of wakening, you have decreased free-radicals in the mitochondria, improved cellular ATP production, and improved cell function.

Use blue blocker glasses or other sunglasses to cut down on eye strain

Medications such as propranolol and indomethacin

Optimize vitamin D levels

Optimize sleep.  Address mouth breathing, allergies, sleep apnea, sleep hygiene, use white noise

Elevate heels by 12 degrees.  Improves glymphatic system washout (clearance of cellular debris from brain).

Creatine monophosphate supplementation up to 5 g daily.  Helps regulate calcium, ATP production, and neuronal function.

**Tension headache**

Seems to have central and peripheral sensitization pathology.  Due to muscle contraction, tight muscles, and possible inflammation.

Upper back/postural exercises-for tension component of headache

1.  Dead hangs (both arms, advanced to single arm at a time)
2.  Face pulls (adjust to about level of throat)
3.  Ring reverse push-ups with feet on a bench
4.  Close grip rows for latissimus, wider grip for upper back and trapezius
5.  Y, I, T-raises (semi-prone and bring both arms up and lateral with free weights)

Osteopathic manipulative technique, gentle indirect and stretching techniques to the neck and upper back.

Seventy-percent of all headaches are either migraine, tension, or menstrual-related.

**Migraine headache**

Etiology is felt to be secondary to the triggering of nociceptors in the trigeminovascular pathway.  C nociceptors in the dura are also activated in migraine.  When activated, these nerve endings release CGRP.  Resultant cortical spreading depression occurs in the cortex of the brain activating nociceptors and triggering neurogenic inflammation with vasodilatation and even mast cell degranulation.  Serotonin and CGRP also appear to be connected.  Low serotonin levels can dilate blood vessels and initiate migraine.  Triggers include: Menstruation, emotion, light, lack of sleep, alcohol, certain odors (perfumes most frequent), heat, exercise, stress, decreasing barometric pressure changes (altitude or storms), and foods.  Caffeine may worsen or improve.  Some meds that can be helpful for prophylaxis including: Cyproheptadine (serotonin and histamine antagonist?), benzodiazepines, and dopamine antagonist.

**Tension and migraine headache treatments:**

Omega-3 fatty acids, 1 g/day, Botox treatment (possibly blocks neurotransmitters regarding pain signals), acupuncture, peppermint, and eucalyptus oil, curcumin 80 mg to 2 g anti-inflammatory effect (caution with anticoagulants, also will potentially interfere with dihydrotestosterone). Ginger possibly decreases CGRP levels.

**Premenstrual syndrome-related headache treatments:**

During the late secretory phase of the menstrual cycle, estrogen is low and the production of serotonin decreases.  This leads to an increase in CGRP and substance P from the trigeminal nerves.  These substances cause vasodilation of intracerebral vessels and sensitization of the trigeminal nerve.  The blood brain barrier permeability increases and pro inflammatory mediators affect the meninges.  Estrogen increases endothelial cell nitric oxide synthetase activity, resultant increased production of nitrous oxide, a vasodilator.  This increases during the luteal phase of menses at the same time a drop and serotonin occurs.  Omega-3 fatty acids 1 g/day.  Oral contraceptives may help prevent estrogen drop (focus on continuous dosing)

Occipital nerve block.

This can be helpful for occipital neuralgia, chronic migraine, cluster headache, and hemicrania continua.  Use either lidocaine 1 to 2% or bupivacaine 0.25% or 0.5% approximately 2 to 4 cc per nerve block, use 1.5 inch 27 gauge needle.  Steroid mixed in with local anesthetic has not been proven to improve recovery or prevent recurrence of headache.

***This post was a fairly comprehensive discussion of headaches. The best practice is to avoid complicated abortive and headache preventative medication regimens. Use proper diet and stress-reduction to increase your chances of being headache-free!***

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Comprehensive discussion of headaches types, treatments, and possible interaction with diet.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

In another post, I spoke about small intestinal bacterial overgrowth (SIBO). In that post, one of the potential treatment recommendations for SIBO is a low FODMAP diet. This piece is essential for understanding FODMAP's.

**FODMAP DIET**

Meaning: Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols

Foods to meet this criteria: Fructose found in fruits and vegetables, lactose found in dairy, fructans found in foods such as grains like wheat, spelt, rye, and barley, galactans found in legumes, polyols found in xylitol, sorbitol, maltitol, and mannitol (sugar alcohol sweeteners).

Theory: In the small intestines, these foods attract water.  When these foods reach the colon they get fermented and are used by gut bacteria for fuel.  The byproduct of this process is methane and hydrogen.  The increased water content can cause intestinal distention.  This may lead to gas, bloating, stomach pain, cramps, and constipation.  Some people suffer from diarrhea.

This diet has been studied in people with irritable bowel syndrome.  Some studies indicate that 75% of people affected with irritable bowel syndrome can improve with a low FODMAP diet.  When implementing this restriction diet, initial strict elimination phase should be for 2 to 6 weeks duration.  After this, for 8 to 12 weeks, patients may try to gradually reintroduce foods to assess results and refine what works for them.

**Expanded list of high FODMAP foods-COULD MAKE SYMPTOMS WORSE.**

Fruits: Apples, applesauce, apricots, blackberries, boysenberries, canned fruit, cherries, dates, figs, peaches, pears, and watermelon

Sweeteners: Fructose, high fructose corn syrup, honey, maltitol, mannitol, sorbitol, xylitol

Dairy products: Ice cream, milk, yogurt, soft cheese, sour cream, whey protein supplements

Vegetables: Artichokes, asparagus, beet root, broccoli, brussels sprouts, cabbage, cauliflower, fennel, garlic, leaks, mushrooms, okra, onions, peas, shallots

Legumes: Beans, baked beans, chickpeas, lentils, red kidney beans, soy beans

Wheat: Biscuits, bread, breakfast cereal, crackers, pancakes, pasta, tortillas, waffles

Other grains: Barley, rye

Drinks: Beer, wine, fruit juices, milk, soft drinks with high fructose corn syrup, soy milk

**SAFE foods on low FODMAP diet**

Meat, fish, eggs, fats, oils, herbs, spices, nuts, seeds, blueberries, cantaloupe, grapefruit, grapes, kiwi, lemons, lime, mandarins, melons (except watermelon), oranges, passion fruit, raspberries, strawberries, maple syrup, molasses, Stevia, hard cheese, alfalfa, Bell peppers, bok choy, carrots, celery, chives, cucumbers, eggplant, ginger, green beans, kale, lettuce, olives, parsnips, potatoes, radishes, spinach, squash, sweet potatoes, tomatoes, turnips, water chestnuts, zucchini, corn, oats, quinoa, rice, sorghum, tapioca, water, coffee, tea

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Definition of FODMAP. List of low and high-FODMAP foods. Low FODMAP diet could be used for SIBO treatment.


Vlada,
Very detailed explanation of the metabolism of cholesterol and triglycerides. Good Job! When I am trying to explain this to my patients, of course, I have to skip multiple steps of this discussion. I do focus on the insulin piece and inform them that high insulin levels prevent weight loss and causes weight gain. I also stress, as you mentioned, dietary intake of cholesterol and triglycerides, has little effect on these numbers, instead, focus on carbohydrate intake to move the needle. I include in my discussion, that total LDL mass may not be a great measure and talk about large buoyant LDL vs. small dense LDL (seems to be evidence of a difference in risk). I let them know that low-carb, high-fat diet causes a shift from small-dense to large buoyant LDL in most. I discuss how the circulating apo B proteins become altered in a high glucose environment, preventing the liver reuptake receptors from recognizing them, resulting in a longer time in circulation, more opportunity for oxidation, and hence theoretically, more likelihood of atherosclerosis. I also acknowledge that almost all other physicians will try to prescribe a statin or other medication to lower their LDL. I tell them that these will indeed lower the LDL cholesterol. I am very skeptical that these reduce mortality risk, however. We discuss statin side effects, as well. In those patients that fit the phenotype of lean-mass hyper-responders (see Dave Feldman's work) and are also low-carb, high-fat eaters(which I am one), I counsel them about risk. Sometimes, we even get a CAC score for further clarification and tracking. I admit, I took the wrong approach for 20+years in medicine, but I feel that you and I are on the correct path now. This is an uphill battle against the established dogma, stay strong and true!


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

Low-dose naltrexone treatment discussion

Naltrexone is not just for addiction.

This drug was developed in the 1960s and was approved by the FDA in the 1980s. Naltrexone is used to treat opioid and alcohol addiction. To learn more about the details of low-dose naltrexone (LDN), feel free to review my Williams Family Medicine Channel YouTube video titled: The Power of Low Dose Naltrexone at: https://youtu.be/0WUXNar7at8.

Compounded LDN can be used off-label in:  chronic pain disorder, complex regional pain, fibromyalgia, cancer pain, prevention of cancer recurrence, Parkinson's disease, Alzheimer's disease, amyotrophic lateral sclerosis, emphysema, human immunodeficiency virus infection, depression, irritable bowel syndrome, small intestinal bacterial overgrowth, impaired bowel motility, Crohn's disease, mast cell activation syndrome, chronic fatigue syndrome, sarcoidosis, rheumatoid arthritis, multiple sclerosis, allergies, and thyroiditis. The literature suggests that multiple sclerosis, cancer pain, intestinal disorders, and fibromyalgia seem to be the conditions treated most commonly with LDN.

LDN doses of 0.05 to 6 mg orally once daily(instead of 50 mg dosage once daily for addiction) can be prepared at a compounding pharmacy. Most experts recommend starting with lower doses, then titrating up monthly. Common starting dosage is 0.5-1.5 mg daily. A common effective final dose is 4.5 mg, often taken at bedtime. Some providers use pulse dosing: 3 weeks on and 1 week off.

Some LDN side effects: Diarrhea, constipation, dizziness, nausea, insomnia, anxiety, abdominal pain, headache, joint pain, mood changes, vivid dreams. Those GI side effects seem to go away for many people when they switch fillers to something like sucrose or ginger. Avicel (and other forms of cellulose), lactose, acidophilus, etc. seem to be more likely to cause GI problems.

You can use LDN alongside other short acting opioids: Must administer the dose either 4 hours before or 4 hours after the opioid dose for optimal results.

Possible drug interactions: Cytochrome P450 medications.

LDN time of onset of action: Trial for at least 3 month

Precautions: If you have a thyroid disorder and use LDN, your thyroid function often will improve, requiring thyroid medication dosage adjustment.

Basics of opioid receptors:

*Endorphin* is the endogenous ligand for mu receptors. This has a significant impact on analgesia.

*Enkephalin* is the lambda receptors endogenous ligand and it protects myocardial tissue from ischemia.

*Dynorphin* is the endogenous ligand for kappa receptors. This has analgesic properties, can induce anxiety, and can weakly inhibit respiration.

LDN mechanism of action: Anti-inflammatory effects attributed to antagonist effect on toll-like receptor 4, nonopioid receptors found on macrophages and micro glial cells. Toll like receptor 4 belongs to a family of pattern recognition receptors. These receptors are key to infectious and noninfectious stimuli producing an inflammatory response in your body. These receptors are found on blood cells, endothelial cells, cardiac muscle cells, and cells in the central nervous system. Microglia are central nervous system immune cells that produce: inflammation, sensitivity to pain, fatigue, sleeplessness, mood disorders, and cognitive problems. Traditional mechanism is competitive antagonist activity at mu opioid receptors. Low-dose naltrexone promotes T regulatory cell function. T regulatory cells keep the immune system in balance and turn inflammation off.

The LDN mechanistic papers revealed that a short-term opioid receptor blockade with naltrexone (LDN), a general opioid receptor antagonist devoid of intrinsic activity, resulted in an elevation in production of endogenous opioids in response to the blockade. Interference of opioid peptide–opioid receptor interactions for a short time each day (from 4-6 hours) with LDN provided a subsequent window of time (18–20 hours) for the increased levels of endogenous opioids and opioid receptors to elicit a robust functional response and inhibit cell proliferation. In addition, many patients reported an improved sense of well-being and decrease in overall pain, as one might expect with higher levels of opioid production in the body.

*Effectiveness*:

About 30% of patients with inflammatory bowel disease (Crohn's and ulcerative colitis) are refractory to current medications or relapse over time. LDN boasts a 70% remission rate with mucosal healing in patients that have Crohn's disease. Consider the cost of low-dose naltrexone at $15-100 per month versus Remicade infusion at $5,000 per month. Anecdotal successes have been reported in the following: Hashimoto's disease, Graves' disease, rheumatoid arthritis, lupus, psoriasis, chronic fatigue syndrome, Parkinson's disease, and Alzheimer's disease.

*Consider LDN as an alternative to opioids in some cases.*

Therapeutic and chronic use of some opioids decrease optimal functioning of the immune system. Immune system effects appear to be mediated by action of opioids on target cells or indirect centrally mediated pathways. Immune cells differentially express opioid receptors. Opioids affect your innate immunity, which includes: macrophages, neutrophils, mast cells, natural killer cells, dendritic cells, and even intestinal barrier integrity. Specifically, morphine has been shown to disrupt tight junction proteins and gut epithelial cells. This disruption can allow translocation of bacteria. In addition, morphine alters the gut microbial composition, reducing bile-deconjugating strains of bacteria and expanding gram-positive pathogens. Opioids also affect adaptive immunity which includes: T cells and B cells. When these 2 aspects of immunity are affected, your body will have decreased pathogen clearance.

Important note: immune altering factors are released from tissue injury. Consider this in the case of surgery and acute injury.

Do not forget other add-on therapies for immune function. Vitamin D promotes T regulatory cell function. Adequate levels of selenium, zinc, and iodine also are important for immune function. Bacillus species probiotics also promote T regulatory cell function. Vitamin A (cod liver oil), curcumin, and omega-3 fatty acids such as EPA and DHA seem to be helpful for immune function.

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Low dose naltrexone treatment for chronic disease


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

As a family physician, I have daily conversations with patients about supplements. Almost all people use vitamins and supplements for various reasons. Evidence for supplements and vitamins is sometimes sparse and often lower quality than what might be seen in larger well-designed pharmaceutical company randomized-control trials. Of course, even these larger trials can be biased or the findings can be interpreted incorrectly. Nevertheless, biochemistry and clinical evidence supports the value of many different supplements. I will always recommend eating whole foods, while avoiding processed foods that lack nutritional value. In today's society, we don't always consume a diet that takes care of our vitamin and micronutrient needs. Using supplements may improve health in these instances. I have included a short list of some of the common recommended supplements, with suggested dosing and proposed benefits, that many health experts agree have value. As the supplement industry is not regulated in the same way as the Food and Drug Administration, it is wise to investigate the company representing the particular supplement of interest. For a comprehensive general data repository on supplements, I would suggest the site: examine.com.

Here is the list:

*Vitamin D3 and Vitamin K2* 5,000 international units (125 mcg) daily or 10,000 international units (250 mcg) daily depending on need

Benefits: Improve hypertension, reduce risk of osteoporosis, decrease inflammation, increase dopamine release and activation of oxytocin (feel good hormones), improve mental health disorders

*Omega-3 fatty acids* (EPA plus DHA) 1,000 mg daily, (up to 4,000 mg daily for hypertriglyceridemia)

Benefits: Improve anxiety and depression, decrease risk of macular degeneration, improve risk of cardiovascular disease, improve attention deficit symptoms, improve metabolic syndrome, decrease inflammation, improve mental health disorders, prevent age-related cognitive decline.

*Magnesium* 500 mg daily (glycinate) is the most bioavailable and least likely to cause diarrhea)

Benefits: Improve anxiety, sleep, headaches, muscle cramps.

*Turmeric* 500 mg twice daily

Benefits: Reduce depression, decrease inflammation and pain

*Ashwagandha* 500 to 1,000 mg daily

Benefits: Decrease stress, improve cognition, improve sexual function

*B complex with vitamin B-12* (500 mcg B12 minimum daily).

Benefits: Increase energy production, improve hormone metabolism, decrease cardiovascular risk, improve neurotransmitter function, enhance DNA synthesis.

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Physician-recommended Vitamins and Supplements

List of common vitamins and supplements that can be useful. Discussion of dosing and benefits.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

If you or a loved one are wondering if you have diabetes mellitus type 1 or 2, here is a list of physical characteristics that make this diagnosis likely:

**Elevated blood sugar and dyslipidemia affect collagen**

*Adhesive capsulitis (frozen shoulder syndrome)*

*Skin tags*

**Elevated blood sugar/insulin resistance affects cell turnover, increases androgen secretion, and impairs immunity.**

*Hidradenitis suppurativa*

*Acanthosis nigricans*

**Elevated blood sugar damages blood vessels that supply nerve function**

*Numbness and tingling*

*Fatigue*

*Anxiety*

*Difficulty concentrating*

**As the kidneys are trying to clear excess sugar, excess fluid is also removed causing dehydration**

*Dizziness*

*Fatigue*

*Frequent urination*

*Excessive thirst*

*Dry skin*

**Elevated blood sugar causes swelling of the lens of the eye**

*Blurred vision*

**Elevated blood sugar interferes with immune function and damages blood vessels in the skin**

*Poor wound healing*

*Skin infections*

**Elevated blood sugar/insulin resistance prevents glucose from entering muscle to generate energy**

*Excessive hunger*

*Fatigue*

**Elevated blood sugar/insulin resistance stimulates increased androgen secretion at the adrenal gland and ovary causing anovulation**

*Irregular menstrual cycles*

*Infertility*

*Ovarian cysts*

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Characteristics that are found with diabetes mellitus type 1 or 2.


Yes, you are correct!


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

**Metabolic Exercise Recommendations**

 Lifting heavy weight seems to have the most metabolic benefit for people that are attempting to prevent diabetes, put diabetes in remission, or lose weight.

For this technique, use a low number of repetitions, lift slowly, and use heavy weight to fatigue muscles over 30 to 90 seconds. Take a 30 to 60 seconds rest between muscle groups. Perform this exercise approximately 2-3 times weekly. If using machine equipment, perform exercises in this general order: Leg extensions, leg curls, chest rows, lateral arm raises, butterflies, bicep curls, and triceps pull downs.

If using resistance bands, perform exercises in this general order: Squats, straight leg dead lifts, rows, lateral arm raises, butterflies, bicep curls, and triceps.

Walking, jogging, dancing, swimming, and cycling are also great forms of exercise to incorporate into your routine. When attempting to initiate lifestyle changes that you can continue, you must make this activity fun! Having a workout partner also improves accountability and enjoyment. Distraction such as music, podcasts, or movies can help with the mundane aspects of exercise.

*Credit for the above exercise recommendations should go to Ben Bocchicchio, author of the book: “15 minutes to fitness: Dr. Ben’s SMaRT plan for Diet and Total Health*

I hope this information helps you and your loved ones!

Jason Williams, D.O.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

Most people can eat a low carbohydrate, high fat diet (LCHF). I have listed some reasons that you should not eat a LCHF diet: chronic kidney disease (later stage), pancreatitis, eating disorders, nutrient deficiencies, active gallbladder disease, active kidney stones, glycogen storage disease, porphyria, carnitine deficiency, carnitine palmitoyl-transferase deficiency, pyruvate carboxylase deficiency, and acyl-COA dehydrogenase deficiency.

Risks: Hyponatremia, kidney stones, gout, nutritional deficiencies, pancreatitis, constipation, and muscle cramps.

Assuming you would like to try a LCHF lifestyle, here are some possible benefits of LCHF lifestyle: weight loss, decreased blood glucose and insulin levels, decreased blood pressure, decreased inflammation, decreased acne, decreased acid reflux, reversal of PCOS, decreased pain, decreased cancer risk, decreased dementia risk, decreased risk of cardiovascular disease, decreased mental health disorders, increased energy level, and improved sleep.

Effects of LCHF eating are often most pronounced when first initiating this lifestyle change. More strict carbohydrate intake could intensify the symptoms. The symptoms often significantly diminish over time, unless you cycle in-and-out of the LCHF lifestyle. Some symptoms might include: fatigue, headache, muscle cramps, nausea, palpitations, trouble concentrating, decreased exercise tolerance, dizziness, constipation, and acetone breath.

LCHF lifestyle will result in loss of fluids and salt. This can sometimes cause electrolyte disturbances. This can result in fatigue, headache, muscle cramps, nausea, palpitations, dizziness, and weakness. You must drink plenty of water. You must use added salt on food and even in drinks. Consider ½ to 1 teaspoon of salt in a glass of water 1 to 2 times daily if needed. You can make bouillon broth or use pickle juice as a good source of salt. To replace potassium, use avocado, leafy greens, and mushrooms. To replace magnesium, use pumpkin seeds, Chia seeds, mackerel, almonds, and leafy greens. Most people should also use a magnesium supplement of 400 mg daily.

LCHF lifestyle can cause constipation. Drinking plenty of water helps alleviate this. Use milk of magnesia for constipation if necessary. Use fiber from vegetable intake to assist with constipation.

LCHF lifestyle can cause low blood pressure. You need to change positions slowly to prevent dizziness and falls.

LCHF lifestyle commonly causes decreased appetite. If you are not hungry, do not eat, as it is common to transition to some form of fasting spontaneously. When you are in this phase of lifestyle change, conventional meal timing and snacks no longer need apply.

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Avoiding "keto flu" on low-carb, high-fat diet


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

I am a firm believer that low-carbohydrate, high-fat (LCHF) eating is important for overall health in most individuals. Some people have specific ways of eating that they adopt for social/religious reasons or just personal preference. Vegans are one particular population that have restrictive challenges when considering a low-carbohydrate, high-fat way of eating. See tips below.

LCHF DIET WITH VEGANISM

Prioritize protein for essential amino acids. Consider: Lupini beans, lentils, black beans, pinto beans, chickpeas, garbanzo beans, green peas, soy beans, Tempe, Natto, edamame beans, tofu, hemp seeds, peanut butter, almond butter, almonds, sunflower seed butter, tahini.

Eat healthy fats including: olive oil, avocado oil, macadamia nut oil, coconut oil, cream. Also, cocoa butter.

Choose nutrient dense plants: hemp seeds (zinc and omega-3 fatty acids), sesame seeds (calcium, iron, and zinc), spinach (calcium, iron, and zinc)

Avoid grains of all types!

Avoid bread, pasta, rice, potatoes, cereal, sugar-containing drinks, sugar-containing foods!

Do not forget vitamin B12, vitamin D3, calcium, iron, zinc, and omega 3 fatty acid supplements.

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Tips for low-carb, high-fat eating in vegans.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

I hate being sick. Even a minor upper respiratory infection is quite annoying. It is amazing how bad you can feel and how easily you forget to have gratitude when you are feeling normal. I have a list of tips that some of my patients choose to use to improve immune function and hopefully not get sick as often. These strategies should not be viewed as "just another thing on my list to do" as they are overall very positive for your health, even irrespective of purported immune function boosting promise. Keep this in mind as you consider implementation.

**Stimulate the endocannabinoid system**-role in inflammation with immune suppression, regulate GABA neurotransmission (relaxing neurotransmitter)

Foods that function as endocannabinoids: Truffles, dark chocolate, coffee, oregano, curcumin, cinnamon, Chia seeds, hemp, walnuts, sardines, anchovies, eggs.

Omega-3 fatty acids help to synthesize endogenous cannabinoids.

Medium and high intensity exercise also stimulates the endocannabinoid system.

Stress lowering activities such as meditation and yoga stimulates the endocannabinoid system.

CBD oil also stimulates the endocannabinoid receptor system.

**Stimulate the endorphin system**-promotes T regulatory cell function, decreases inflammation with immune receptor interactions

Low-dose naltrexone can increase endorphin production by 300%.

Moderate intensity exercise increases endorphin release.

**Control blood sugar and insulin**-improves immune cell function, promotes healing

Low-carb high-fat diet

Fasting

Regular exercise

**Gut micro biome health**-promotes T regulatory function, maintains proper tight junctions Avoid certain foods such as gluten and lactose containing products.

Avoid processed foods.

Avoid high carbohydrate diet.

Prebiotic fibers

Probiotic fermented foods

Probiotic supplements

**Vitamin D**-promotes T regulatory function, modulate cell growth and apoptosis, improve glucose metabolism

Obtain adequate sunshine.

Vitamin D supplementation.

**Sleep**-increases necessary cytokines and T cells that can be used to mount an immune response

Address mouth breathing, allergies, and anatomic nasal or throat obstruction.

Exclude obstructive sleep apnea

Proper sleep hygiene, room temperature, lack of sound noise, normal schedule

**Live in community**-increased cancer and cardiovascular risk in those that live alone

Connection with family, faith-based body, hobby groups, etc.

**Exercise**-Pro and anti-inflammatory cytokines are released, lymphocyte circulation increases, favorable immune cell recruitment increases, decreased levels of reactive oxygen species (free radicals)

I hope this information helps you and your loved ones!

Jason Williams, D.O.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

When women hit perimenopause and menopause they often complain of hot flashes. These episodes of intense heat can occur at any time. Often, hot flashes occur at night, disrupting sleep. The severity of hot flashes can range from very mild to very severe in different people. Sometimes, women also have palpitations and visible flushing with these episodes. While we don't understand everything in medicine, I have included the proposed mechanism of hot flashes for those women who are inquisitive about this process that is terrorizing them.

The proposed mechanism of hot flashes requires some basic knowledge of the endocrine system and hormones. If you want to jump straight to the treatment options, then skip to the potential treatments section of this post.

Hormones are chemical substances that are usually released in a pulsatile fashion into the bloodstream to send instructions to your organs or glands. The hypothalamus area of the brain is an integral part of the endocrine system and is connected to the pituitary gland at the base of the brain. The hypothalamus functions as a gland that regulates sleep, appetite, autonomic nervous function, blood pressure, heart rate, neurotransmitters, mood, temperature, and sex hormones. Hormones that are produced in the hypothalamus include: antidiuretic hormone, oxytocin, corticotropin releasing hormone, growth hormone releasing hormone, thyrotropin releasing hormone, gonadotropin releasing hormone (GnRH), somatostatin, dopamine, and oxytocin.

For the sake of this discussion, we will first focus on GnRH function in a premenopausal woman. GnRH stimulates the pituitary gland to release follicle stimulating hormone (FSH) and luteinizing hormone (LH). FSH release increases estrogen release from the ovary. Estrogen prepares the uterine lining for implantation of an egg. As the cycle progresses, just prior to when a follicle that contains an egg is released from the ovary, GnRH increases, causing an increased LH. This LH increase causes a follicle to be released. The follicle starts producing its own estrogen. Now, the ovary shifts to producing progesterone in greater amounts to support the uterine lining. If this woman's egg does not get fertilized, both estrogen and progesterone levels drop and the uterine lining sheds resulting in menstrual blood flow.

In the case of a post-menopausal woman, the ovaries are unable to produce adequate levels of estrogen and progesterone even though the pituitary gland is cranking out FSH and LH. There is some conversion of testosterone to estrogen, but eventually, not enough. When sex hormones such as estrogen, progesterone, and even testosterone decline, temperatures can fluctuate in a pulsatile fashion.  I have never received a satisfactory explanation of why these low levels of estrogen and progesterone mechanistically cause hot flashes. The hypothalamus does regulate temperature, so maybe some sort of thermal dysregulation at the level of the brain? Instead, are hot flashes due to temporary vasodilation (increasing blood flow) secondary to the effects of lower levels of estrogen and progesterone? Likely, a combination of these two mechanisms are responsible for hot flashes.

**Potential treatments for hot flashes**

Hormone replacement therapy (HRT) (estrogen, progesterone, and testosterone), black cohosh, vitamin E, B vitamins, vitex agnus (chaste tree berry), SSRIs (Paxil 7.5 mg is approved), clonidine, and gabapentin.

All women should follow a healthy diet and exercise for optimal health.

If you wonder about safety with HRT, I have addressed this in other posts and a YouTube video: https://youtu.be/KmrAWvl28NU.

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Discussion of hot flashes and treatments.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

We are facing an epidemic of metabolic health disorders such as obesity, diabetes mellitus type 2, fatty liver disease, hypertension, and many others. Sometimes, these conditions even begin in utero. I am a firm believer that early intervention is the best strategy to delay or prevent these metabolic health disorders.

Parenting can be challenging. I was not given an instructional manual to help me raise my own kids. I do want to empower my patients to guide their children wisely, though. Sometimes, I am guilty of over-complicating the issues. Hopefully, these simple recommendations can serve as your guide to raising healthy children.

This list of healthy diet basics for children was compiled by a practicing nutritionist:

*Eat real food.*

*Avoid processed food: things in a box, soda, electrolyte drinks, candy, etc.*

*Avoid added sugar.*

*Focus on meat, seafood, chicken, eggs, full cream dairy, brightly colored vegetables, nuts, seeds, and added fats.*

*Use grains very rarely.*

*Meal frequency: 3 meals daily, up to 2 snacks. If not hungry, don't eat.*

*Some added salt is perfectly fine.*

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Simplest Healthy Diet Basics for Children


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*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

ESTROGEN AND PROGESTERONE HORMONE SAFETY DISCUSSION

The Women’s Health Initiative (WHI) study began in 1998 and was stopped early in 2002.  This study had a randomized controlled clinical trial (RCT), an observational study, and a study of community approaches to developing healthful behaviors.  The WHI was designed to evaluate risk of heart disease, colon cancer, breast cancer, and osteoporosis in postmenopausal women.  This study was sponsored by the National Institute of Health and the National Heart, Lung, and Blood Institute.

The clinical trial included hormone replacement therapy (HRT) 1994-2004, dietary modification 1994-2005, and calcium/vitamin D supplementation 1994-2005.  This study did shape opinions about safety for HRT.  The recommendations resulting from this study dramatically affected both physicians and patients.  The mantra that was repeated in my training in the late 1990s and early 2000's was, “use the smallest doses of HRT for the least amount of time”.

161,000 women aged 50-79 were enrolled in either observation, low-fat diet, self-selected diet, estrogen + progesterone, estrogen alone, or calcium w/vitamin D.

A smaller hormone study arm involved 10,000 women who had a history of hysterectomy and received either estrogen or placebo. This smaller study was terminated early due to increased stroke risk in the treatment group.

The larger study involved about 16,000 women. One arm of this study was estrogen + progesterone. The other study arm was placebo. This study was terminated early due to excess breast cancer incidence.

These conclusions prompted a New York Times article: Hormone Replacement Study: A shock to the medical system.

**Below are some critiques of this study:**

Improper data interpretation. Data from the study has been reevaluated and new conclusions drawn that contradict prior conclusions. Subsequent papers were published covering this new information, but media did not cover these new findings with nearly as much interest.

Supposedly, deep critique of the study was not allowed at the time of publishing.

Apparently, some women with menopausal symptoms were dissuaded from participating in the study.

Menopausal vasomotor symptoms (hot flashes, night sweats, palpitations, swings in blood pressure) were not assessed. Had the vasomotor symptoms been assessed, the knowledge of the potential positive benefit of HRT may have prompted more people to enroll in the study or stay in the study for a longer duration.

Older post-menopausal women with higher overall disease risks were chosen for the WHI study. Large improvement in CHD risk was noted in the estrogen-treated group aged 50-59. Would initiating HRT earlier have improved the preventative effect of HRT?

The study used Premarin that contains 10 different estrogens, but very little estradiol (what the ovaries actually make).  A medication that is closest in structure to the natural hormone in your body is likely to work the best, as well as, have the least side effects.  Also, when taken as a pill, Premarin has a 1st pass effect through the liver increasing clotting factor production, and possible resultant increased stroke risk. Incidentally, transdermal estrogen or pellet-form estrogen have not been found to increase stroke and venous thromboembolism (VTE) risk.

Also, the WHI study used medroxyprogesterone. Recent data suggest that medroxyprogesterone in breast tissue might alter hormone receptors adjacent to estrogen receptors-creating a possible increased risk of estrogen-stimulated cancer. Recent study has shown that medroxyprogesterone interferes with the benefit of estradiol. In mice, it was found to increase aggression and anxiety. These symptoms may have significantly impacted quality of life for study participants.  The symptoms may have prompted many women to drop out of the study.

While there was a 1-year increased risk of CHD events in HRT group, there were more CHD events in the placebo group by year 6 of the study. This matches up with the heart and the estrogen/progestin replacement study (HERS) trial with HRT.  In the HERS trial, cardiac events in year 1 were slightly higher than placebo.  In years 4 and 5, cardiac events were 42% lower in the treatment group than in placebo.  A randomized controlled trial came out in 2012 titled: Effective hormone replacement therapy on cardiovascular events and recently postmenopausal women: Randomized trial.  This study took 1006 women aged 45-58 who are recently postmenopausal.  They were treated with 17 beta estradiol and if they had an intact uterus, also were given norethisterone.  After 10 years, 16 women had a cardiac event in the treatment group, versus 33 women in the control group.  Meaning, more cardiac events were observed in the women that were not treated with HRT compared to women that were treated with HRT.  The HRT group had significant risk reduction of mortality, heart failure, and MI.  No increased risk of breast cancer, DVT, or stroke was noted.  Even after 16 years, the protection was still present.

This WHI study statistical analysis used emphasized relative risks instead of absolute risks. To illustrate, the study touted a 29% increased CHD relative risk in the estrogen + progesterone arm, but this represented only a 0.07% increased CHD absolute risk. This magnitude of absolute risk is not statistically significant.

Other statistical analysis of this study revealed unadjusted wide statistical confidence intervals, even crossing 1, rendering the results not clinically significant. This was evident for example in VTE risk with estrogen treatment. It is puzzling to me that the authors of the 2004 published article for venous thromboembolic (VTE) risk state that the hazard-ratio is significant. In 2006, Venous thrombosis and conjugated equine estrogen in women without a uterus was published in the Archives of Internal Medicine. This published article using the same data as the 2004 article and indicates that the VTE risk hazard-ratio is not clinically significant. Stroke risk also had a confidence interval that crossed 1, meaning results are not clinically significant in the estrogen + progesterone arm with relation to stroke risk.

Authors note a 5-year peak in incidence in invasive breast cancer, VTE, and stroke. Could this be related to a decrease in the events in the placebo group? Could this be related to a high study participant drop-out rate?  The WHI study had a high drop-out rate; 42% in HRT group, 38% in placebo group. This high drop-out rate could have markedly skewed results.

The HRT study was halted due to invasive breast cancer rates. The initial study duration was planned for 8 years. The question remains, how long does it take to develop breast cancer? Also, the study seemed to predilect for older patients who would already have an increased breast cancer risk by nature of their age.  The WHI study indicated that the relative risk reduction in breast cancer cases was 25% in the placebo versus the treatment group.  When you look at the data, the treatment group experienced 4 cases of breast cancer per 1000 women per year versus 3 cases of breast cancer per 1000 women per year in the control group, minimal overall difference in the absolute risk reduction present.

Also, be aware that 75% of breast cancer cases occur in postmenopausal women, obviously a higher risk group to begin with.  In the Journal of obstetrics and gynecology 2001 an article titled: Review of studies published between 1975 and 2000 showed lack of consistent results on estrogen therapy and breast cancer risk.  45 studies were reviewed.  82% of these studies reported risk estimates not significantly different from 1, meaning no statistical significance noted in the rates of breast cancer in those treated with estrogen therapy.

Incidentally, in the estrogen plus progestin trial, the risk of colorectal cancer among postmenopausal women with an intact uterus was decreased.

The study did not address the benefits of HRT on Alzheimer's disease.  Women have an 8:1 increased incidence of Alzheimer's disease compared to men.  Estrogen appears to decrease apoptosis, programmed cell death.  Estrogen also has been demonstrated to decrease the beta amyloid deposition that is noted IN Alzheimer's dementia.

The study undervalued the risk of osteoporotic fractures. The incidence of osteoporotic fractures was compared to MI, stroke, and breast cancer risk. Fractures more prevalent by a factor of 3 for MI, factor of 6 for stroke, and factor of 8 for breast cancer. Osteoporotic fractures in post-menopausal women carry about a 10% 1-year death risk. Hip fractures can carry as much as a 36% 1-year increased risk of death.  Women lose 25% of bone mass from onset of menopause until age 60.  One half of women over age 50 will have an osteoporosis related fracture during her life.

The decision to terminate the study early would likely not have happened had they used statistically proper confidence intervals. Had the study run longer the results would have likely been favorable. Also, the rate of unblinding was 45%. Several warnings were sent to participants regarding adverse events. Now this trial becomes more equivalent to an observational trial rather than an RCT.

In a final WHI paper the following conclusions were made: improved CHD risk in younger, no increase in breast cancer, and thromboembolism risk increased in the estrogen alone arm.

In the Journal of American Medical Association dated September 2017 an article was published with the title: Menopausal hormone therapy and long-term all-cause specific mortality.  The Women's Health Initiative randomized trials.  The conclusions of the study were that hormone therapy was not associated with increased risk of all-cause mortality, cardiovascular risk, or cancer mortality during a cumulative follow-up of 18 years.

My opinion: I thought about the possible reasons for the initial WHI statistical analysis and the initial negative conclusions of the study.  Some of these reasons include: competency, over-conservative nature of study hosts, or possible ulterior motives.  I reviewed the history of that time period in the United States. At the time of the study, the third-wave of feminism was very active.  The feminist movement had pushed for women's rights, reproductive rights, and equality in the workplace.  There had been high-profile cases of sexual harassment at that time.  A treatment that could improve quality of life for women could have been perceived as a threat by men or by women who were acting contrary to this women's movement.  It is impossible to know if this had any influence on the outcome, but I was stumped at the way the results of the study played out and I wondered if there was any connection.

My recommendations: These studies cannot exclude the possibility of harm with respect to the incidence of breast cancer, CHD, VTE, and stroke. These studies also did not examine the effect of testosterone on women’s health. Testosterone is present in a much higher concentration than estrogen in women, even though testosterone is typically felt to be a man’s hormone.  Testosterone replacement in those who are deficient has been shown to offer many clinical benefits.  After discussing risk and possible benefits, brain health, bone health, cardiovascular health, sexual health, relationship health, metabolic health, and sense of wellbeing, I am likely to recommend HRT.

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Women's Health Initiative Study: HRT discussion

The Women's Health Initiative study scared people regarding hormone replacement therapy when it first came out. Review of this study with care reveals that the risks were likely quite over-stated.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

**Sneaky Sources of Gluten**.

From the book, Wheat Belly by William Davis, MD.

I give this handout to my patients that are considering a gluten-elimination diet.

Drinks: Ales, beers, lagers, bloody-Mary mixes, coffees, herbal teas, malt liquor, flavored teas, vodka, wine coolers, whiskey

Breakfast: Bran cereals, Cornflakes, granola cereals, SmartStart, Special K, Grape Nuts, trail mix crunch, Mueslix, Crackling Oat Bran, Honey Bunches of Oats, Corn Pops, Rice Krispies

Cheese: Blue cheese, cottage cheese, gorgonzola cheese, roquefort

Coloring, fillers, thickeners: Artificial colors, artificial flavors, caramel, dextrimaltose, emulsifiers, maltodextrin, modified food starch, stabilizers, textured vegetable protein

Meal replacement bars: Clif bars, Gatorade, GNC, coffee, Power Bars, Slim fast

Hot cereals: Cream of wheat, Malt-o Meal, oatmeal, oat bran

Meats: Breaded meats, canned meats, deli meats, hot dogs, imitation bacon, imitation crab meat, hamburger, sausage, turkey

Miscellaneous: Envelopes, lip gloss, lip balm, Playdoh, prescription medicine, over-the-counter medicines, nutritional supplements, lipstick, stamps

Sauces and dressings: Gravies thickened with wheat flour, ketchup, malt syrup, malt vinegar, marinades, miso, mustard containing wheat, salad dressing, soy sauce, teriyaki sauce

Seasonings: Curry powder, seasoning mixes, taco seasoning

Snacks and desserts: Cake frosting, candy bars, chewing gum, Chex mix, corn chips, dried fruit, dry roasted peanuts, fruit fillings, jellybeans, granola bars, ice cream, ice cream cones, licorice, nut bars, pies, potato chips, roasted nuts, tiramisu, tortilla chips, trail mixes

Soups: Bisques, broths, bouillon, canned soups, soup mixes

Soy/vegetarian: Veggie burgers, vegetarian chicken strips, vegetarian chili, vegetarian hotdogs, scallops, steaks.

Sweeteners: Barley malt, barley extract, dextrin, maltodextrin

I hope this information helps you and your loved ones!

Jason Williams, D.O.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

Here is the list of standard gluten sources.

**Sources of gluten**

Wheat, wheat berries, durum, emmers, semolina, spelt, farina, farrow, graham, kamut, einkorn wheat, rye, barley, triticale, malt, brewers yeast, wheat starch

**Common foods to avoid**

Pastas: ravioli's, dumplings, couscous, and gnocchi

Noodles: Ramen, udon, soba, chow mein, egg noodles

Bread and pastries: croissants, pita, naan, bagels, flat breads, corn bread, potato bread, muffins, donuts, rolls

Crackers: pretzels, goldfish, graham crackers

Baked goods: cakes, cookies, piecrust, brownies

Cereal and granola: Cornflakes, rice puffs

Breakfast foods: pancakes, waffles, french toast, grapes, biscuits

Breading and coating mixes: panko bread crumbs

Croutons: stuffing, dressings

Sauces and gravy's: soy sauce, cream sauce especially with a roux

Flour tortillas

Beer and malt beverages

Brewer’s yeast

Anything that has wheat flour as an ingredient

Source: Celiac Disease Foundation website

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Gluten-containing food list for reference.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

GOUT

Gout is an inflammatory arthropathy that occurs with supersaturated uric acid levels that form crystals in joints and cause severe pain and inflammation.  Gout has been steadily increasing worldwide and is now the most common type of inflammatory arthropathy in adults.  Estimates in the US are that about 4% of the adult population is affected.  This could be 9 million people.  Previously, gout was known as the disease of kings because, kings suffered from it due to lavish diet and alcohol consumption.  Dietary factors such as purine intake (in seafood and meat), alcohol, and fructose intake contribute to this.

Gout is commonly seen in those with obesity, metabolic syndrome, diabetes mellitus type 2, fatty liver disease, hypertension, diuretic use, and with chronic kidney disease.

Prevention of gout has been noted with low-fat dairy products, coffee, and vitamin C.

Most frequent food triggers of gout: Seafood 62%, alcohol 47%, red meat 35%, tomatoes 20%, vegetables 12%, fruit 12%, sugar-containing drinks 10%.  As the percentages do not add up to 100%, sometimes more than 1 food type has been shown to trigger gout in a particular patient.

***If you eat a low carb, high fat diet, you are less likely to have gout!***

Pro tip: If you RAPIDLY change from a high carb to low-carb diet, your risk of gout slightly increases in the short-term, but will decrease in the long-term if you have transitioned fully to low-carb, high-fat eating.

For more information regarding fructose, watch my Williams Family Medicine channel YouTube video titled: Fear the fructose. Here is the link: https://youtu.be/0qULpQ7CUaQ.

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Gout description. Connection between diet and gout.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

Warning: this is a technical post, but not out of reach for most.

Heart rate variability
The more your heart rate varies, the more resilient you are to adapt to changing conditions.  A higher heart rate variability indicates that your sympathetic and parasympathetic nervous system is likely well-balanced.  If you have a very low heart rate variability, you may have some form of chronic stress or inflammation and may be at risk for chronic disease.  Low heart rate variability has been associated with increased risk of cardiovascular disease, diabetes, inflammation, obesity, mental health disorders, and complications with SARS-CoV-2 infection.

The vagus nerve plays a role in the inflammatory reflex and controls immune responses.  The vagus nerve monitors peripheral inflammation and dampens the immune response.  Afferent vagus nerve fibers sense peripheral inflammatory molecules and convey signals to the brain.  Efferent vagus nerve fiber transmission results in cholinergic output to the spleen, liver, and GI tract. The vagus nerve regulates immune activation and suppresses pro inflammatory cytokine release from other cells. The vagus nerve helps to decrease inflammation.

C-reactive protein (CRP) is a protein produced by the liver in response to inflammation.  Levels of C-reactive protein increase following the secretion of interleukin-6 (also a cytokine) from macrophages and T cells.  This protein binds to the surface of dead cells and enhances the ability of antibodies and phagocytic cells to remove pathogens.  Higher levels of CRP are associated with greater risk of hypertension, diabetes, and cardiovascular disease.  The high-frequency component of heart rate variability predicted the level of CRP when measured.  The lower the heart rate variability, the higher the CRP level.

Higher levels of fasting insulin were associated with lower heart rate variability.  *Low-carb, high-fat eating* will lower your fasting insulin level over time, which could improve your heart rate variability.

*Oxytocin* has been found to increase high-frequency heart rate variability in humans, improve mood, and decrease the release of cortisol, reduce inflammation, elevate pain threshold, and stimulate endocannabinoid production and the production of the “feel-good” neurotransmitters: dopamine, serotonin, endorphins, and oxytocin. You can increase oxytocin by singing, listening to music, making love, receiving or giving massage, hugs, and petting your dog. *Be aware that oxytocin is activated by vitamin D.  Many autistic children have a low vitamin D level.  Possibly 50% of the general population has vitamin D deficiency.  *Vitamin D* naturally increases dopamine levels in the brain.  Vitamin C is a cofactor in the production of oxytocin also.  Fruits, vegetables, and supplements can increase your vitamin C level.  Magnesium increases the action of oxytocin at the oxytocin receptor. Lactobacillus reuteri probiotic significantly increases oxytocin levels in the brain through the work of the vagus nerve.

Heart rate variability decreases with age in general.  In your 20s, your heart rate may vary by 40 points, whereas at age 65 it may only vary by 20 points. You can look at heart rate variability charts for averages across age ranges. It is not useful to compare your own heart rate variability to that of someone else. It is useful for you to track changes in your heart rate variability with lifestyle intervention over time.

Heart rate variability is influenced by the volume and intensity of training and the balance between rest and workout days.  It is also greatly affected by diet and nutrition, alcohol, sleep habits, and stress level.  When you avoid eating close to bedtime this allows your body to focus on restorative processes instead of digestion.  Use of alcohol can suppress heart rate variability for 4-5 days.  Of course, chronic health problems, genetics, and age also affect heart rate variability.

*Tips to improve heart rate variability*
Exercise and train appropriately, good nutrition at the right time, low-carb, high-fat diet, fish consumption, multiple vitamins, weight loss, adequate hydration, avoidance of alcohol, sleep well and consistently, natural light exposure, cold thermogenesis, intentional breathing, mindfulness and meditation, and gratitude journaling.

Some heart rate variability monitoring device examples below if you choose to use them:
WHOOP bands (expensive monthly fee), Oura rings (expensively cost, also monthly fee), apple watch, Fitbit charge 5, and Polar H10 chest strap.

This post speaks about health optimization.  If you have a low heart rate variability, you may have a chronic condition that likely needs addressed with, at a minimum, some of the tips described above.  Even without understanding the technical details of nerve function and the autonomic nervous system, if you search your heart, it would make sense to implement these positive changes in your lifestyle.

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Heart rate variability described. How to improve heart rate variability with lifestyle intervention.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

Hashimoto's thyroiditis is a condition that seems to be triggered by autoimmunity. Autoimmunity can be described as the body mounting an inappropriate immune response against its own tissues, resulting in pathology. In Hashimoto's thyroiditis, the thyroid gland is the tissue attacked by such an immune response. As a result of this attack, the thyroid gland stops functioning properly. The thyroid gland is very important for overall metabolism.

Hashimoto's is 4-10 times more common in women than men.  Often develops between the ages of 30-50.  Family history can be important. May be associated with goiter.

Other autoimmune disorders that can be associated include: **Celiac disease**, lupus, rheumatoid arthritis, Sjogren's syndrome, type 1 diabetes.

Some complications of Hashimoto's include: hyperlipidemia, heart disease, heart failure, high blood pressure, and myxedema.

Symptoms:
Fatigue, weight gain, cold intolerance, joint pain, constipation, dry skin, heavy or irregular periods, bradycardia.

Causes: Some medications to treat bipolar disorder and other mental health problems can trigger this.  Iodine can trigger this.  Toxins and radiation can trigger this.

Treatment: Thyroid replacement.

Foods that interfere with absorption of thyroid medicine include: Grapefruit juice, espresso coffee, soy, and multivitamins that contain iron or calcium.

What about the link with celiac disease? We know this link exists. Is this link a causation or a mere association? We know celiac disease is quite prevalent, possibly affects 1 in 100 people. We know that the U.S. Nutritional Guidelines published in 1977 recommended that citizens shift to increased grain and carbohydrate consumption. If you read my other posts regarding celiac and gluten, you will have adequate information to allow you to intervene in your own health course and hopefully, feel better!

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Hashimoto's Thyroiditis Link to Celiac disease

Hashimoto's thyroiditis and other disease associations. Link between Hashimoto's and Celiac disease.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

**Gut Microbiome Health**

The gut microbiome is the collection of microorganisms that colonize your digestive tract.  By itself, an unhealthy gut microbiome can increase chronic disease.  Poor gut microbiome health is associated with many chronic diseases including: obesity, metabolic syndrome, diabetes mellitus type 2, inflammation, and cancer. Experts say that there are more neurotransmitters in the gut than in the brain, therefore, a poor gut microbiome can adversely affect mental health through the gut-brain-connection.

A healthy gut microbiome improves digestion of fiber, improves immune function, decreases inflammation, and decreases incidence of many of the above listed conditions.

Gut microbiome health gets disturbed by antibiotics.  Antibiotic usage has been linked to the following conditions: asthma, allergies, inflammatory bowel disease, obesity, and diabetes.

Intestinal health can also be disturbed by wheat products.  Evidence suggests that wheat products can interfere with tight junctions in the intestines and allow leakage of antibodies that trigger your body’s immune responses. These responses can result in: neurologic impairment, mental health disorders, skin eruptions, liver disease, nutritional deficiencies, irritable bowel syndrome, fibromyalgia, restless leg syndrome, sleep disorders, and possibly even diabetes type 1.

Treatment for poor gut microbiome health:

Diet: trial of low carbohydrate high fat or Paleo diet.

Prebiotic fibers act as food for the beneficial bacteria or fungi in your gut.  Some examples include: artichoke, garlic, onions, leeks, and asparagus.

Probiotics are live microorganisms that help to restore gut bacteria. Probiotic foods are fermented (chemically broken down to simpler substances).  Some examples include: yogurt, kefir, sauerkraut, kimchi, apple cider vinegar, and certain cheeses.  Keep in mind that if these products are not refrigerated, then they are likely preserved and not as beneficial for your health.  It is important to prevent these products from being light exposed for extended time periods.

William Davis, MD is a cardiologist who strongly believes in correcting your own gut microbiome for overall health. He has published a book called “Super Gut” that includes recipes with different bacteria probiotic types that can beneficially impact many different aspects of health.

Probiotic supplements are also available. Some experts recommend certain species of probiotics for certain conditions. Some of the most common probiotics species include: lactobacillus, bifidobacterium, and saccharomyces.

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Gut microbiome health discussion. Amazing connection with intestinal health and other chronic conditions.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

The association of joint pain with gluten intake is interesting. You may have heard other people discuss the resolution of their joint pain when eliminating gluten. I have personally experienced this phenomenon. Many of my patients that have eliminated gluten have echoed the same result.

Some benefits of gluten elimination

Decreased joint pain, blood sugar, and diarrhea. Also, improved weight, and brain functioning. See below to more fully understand the affect of gluten on joint pain.

Gluten causes a shift in the pH that can cause leaching of important minerals from bones resulting in osteoporosis and increased risk for fracture.

Gluten causes excess sugar (glucose). When glucose level in the circulation is high, glycation, a process that results in protein linkage to glucose occurs. This glycation product travels through the circulation and can settle in joints. These joints can become brittle and crumble causing pain and inflammation.

**Gluten is not the friend of your joints!**

I hope this information helps you and your loved ones!

Jason Williams, D.O.


In this referenced video I discuss Alzheimer's dementia.  This condition is incurable and is one of the top 10 causes of death in United States.  Nicholas Norwitz was the lead author on a paper titled: Precision nutrition for Alzheimer's prevention in ApoE4 carriers.  I reviewed this Journal article that came out in the Journal of Nutrients in 2021.  I briefly discussed Apo E4 alleles and incidence of Alzheimer's dementia.  I also discussed amyloid plaque and tau tangles.  I did discuss some of the impact of environment and genetics.  I briefly discuss neuro inflammation, cholesterol metabolism, blood flow issues, and hyperinsulinemia as pathology that increases risk for Alzheimer's dementia in combination with the ApoE4 mutation.  I discuss targeted treatment such as low carbohydrate, ketogenic, and Mediterranean diets.  I discuss certain foods such as extra virgin olive oil, vegetables, fatty fish and their benefit in prevention.  I discuss limiting or avoiding alcohol.  I also discuss certain supplements that can be beneficial.

Here is the link: https://youtu.be/-BheK2vS32Y.

I hope this helps you and your loved ones!

Jason Williams, D.O.

Learn about Alzheimer's disease prevention


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

As a family physician, I commonly see a patient with a diagnosis of acid reflux, GERD (gastroesophageal reflux disease), esophagitis, or dyspepsia. With these diagnoses, patients report symptoms of upper abdominal upset and burning sensation, vomiting, and difficulty sleeping to name a few. These symptoms can be debilitating and prompt patients to seek relief. Frequently, these people have been taking a proton-pump inhibitor (PPI) medication like Prilosec (Omeprazole). Sometimes, these patients have been taking these medications for many years. If you look at the prescribing information, it will say "for short-term use," sometimes 14 days.

Here is a list of some of these medications:
omeprazole (Prilosec), (esomeprazole) (Nexium), dexlansoprazole (Dexilant), pantoprazole (Protonix), lansoprazole (Prevacid), omeprazole plus sodium bicarbonate (Zegerid), and rabeprazole (Aciphex).

In general, PPIs are believed to have few adverse effects. A few minor side effects of short-term PPI use reported include: headache, rash, dizziness, and gastrointestinal symptoms, including nausea, abdominal pain, flatulence, constipation, and diarrhea.

What are the long-term side effects of PPI?
Although PPIs seem to have an encouraging safety profile, recent studies regarding the long-term use of PPI medications have noted potential adverse effects, including increased risk of bone fractures, pneumonia, autoimmune disorders, Clostridium difficile diarrhea, hypomagnesemia, vitamin B12 deficiency, chronic kidney disease, food allergies, gut dysbiosis (small intestinal bacterial overgrowth),  increased risk of stomach cancer, and dementia.

In general, with any GI symptoms I consider other causes besides GERD, including: stress, psychiatric disease, poor diet, gluten-sensitivity, altered gut micro biome, parasitic infection, intestinal dysmotility, small intestinal bacterial overgrowth (SIBO), and achlorhydria (lack of stomach acid).

*Sometimes, hard to tell if the treatment is causing the disease.* If patients are placed on PPI medications for inappropriate reasons, then things can go haywire. SIBO can occur if gastric acid, bile, digestive enzymes, and immunoglobulins are not functioning properly.  Inadequate gastric secretion and small intestinal dysmotility seem to be the 2 most common factors that predispose individuals to SIBO.  Consider prolonged proton pump inhibitor use as the potential cause of this cascade of events.

Adhesions, strictures, diverticuli, immunoglobulin deficiencies, pancreatic insufficiency, and cirrhosis can also predispose to SIBO.  Common symptoms of SIBO include: Bloating, flatulence, abdominal pain, diarrhea, and constipation.  Extra-intestinal manifestations of SIBO include: Restless leg syndrome, rosacea, anemia, arthralgia, interstitial cystitis, neuropathy, weight loss, chronic pelvic pain, dysuria, dyspareunia, prostatitis.

SIBO can increase leaky gut, which can cause inflammation and immune activation, including mast cell activation (see prior posts about mast cell activation syndrome).

Consider breath testing to diagnose SIBO. If positive for methane, then SIBO likely.

If SIBO is present, you will likely have poor digestion of fats and poor nutrient absorption with deficiency in: Vitamin B12, vitamin A, vitamin D, vitamin E, vitamin K, calcium, magnesium, and iron.

Treatment: Consider carbohydrate and lactose elimination diet if SIBO.  Consider low FODMAPS diet (see other post). Use probiotics.  Consider a temporary liquid elemental diet in severe cases.  Replace vitamins. Consider down-regulating mast cell function with quercetin and resveratrol supplementation.

Consider oregano, thyme, olive leaf, and berberine extracts for their antimicrobial effect.

Antibiotics for SIBO: rifaximin 550 mg 3 times daily x14 days.  Second line includes: Bactrim, Cipro, Augmentin, and doxycycline for 10 days.  If 2 courses of antibiotics do not improve symptoms, consider other diagnoses.

SIBO is present in 80% of people with irritable bowel syndrome (a very common diagnosis).

Approach to patients with hypochlorhydria (low-stomach acid).

Possibly replacement with Betaine HCL and pepsin helps.  Do not institute if patient has active gastritis, esophagitis, or duodenitis. *Of course, PPIs will make a low-acid condition worse, not better.*

Be wary. If your doctor tells you to take a PPI, this may not be the right choice for you. Be willing to consider other causes. I encourage you to contemplate the root cause of your symptoms that could be treated, instead of covering up the symptoms with a medication that has potential down-stream consequences. As you will note, one of the main treatments for SIBO is carbohydrate elimination.  Low-carbohydrate, high-fat diet can be very helpful for GI symptoms. *I don't want you think of SIBO as some fancy diagnosis, just do the right thing with your diet and often the rest of your health will fall in line.*

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Discussion of GERD and dyspepsia. Discussion of PPI medications. Discussion of alternative explanations for your symptoms. Recommend low-carb, high fat diet


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

**ERECTILE DYSFUNCTION**

Many men are embarrassed and don't want to admit they have erectile dysfunction. As a doctor, I am "a safe place" for this conversation for those that want to be honest. Most patients immediately jump to the next topic which is "the blue pill," of course meaning Viagra or its many cousin medications. Erectile dysfunction is very common and is markedly increasing in incidence. Of course, this increasing prevalence runs in parallel with the increase in metabolic health disorders such as, ***diabetes, obesity, hypertension,*** etc. These metabolic health conditions are mostly caused by our diet. If you fix the root cause (poor diet), then you might correct or even prevent erectile dysfunction. Doctors and the medical establishment have "programmed" patients to think in terms of, "we have a medicine for that." In this case, we have many medications that could bring on or worsen erectile dysfunction. Consider causative agents, including: medications that increase aromatase activity. Aromatase results in the excess conversion of testosterone back to estrogen, not so helpful in men.

Here is a list of some possible medications: antihistamines, nonsteroidal anti-inflammatory drugs, anti-Parkinson's medications, antiarrhythmics, anti-hypertensives, anxiolytics, antidepressants, muscle relaxants, *statins,* prostate cancer medications, and chemotherapy drugs.

Other medical conditions that can contribute to erectile dysfunction include:  psychiatric illness, smoking, alcohol abuse, illicit drug abuse, and vascular disease.

**Treatment:**

Arteriosil supplement. Made from seaweed. In research studies, arteriosil stabilizes the endothelial glycocalyx (see my post about the endothelial gylcocalyx). Arteriosil has anti-inflammatory, anticoagulant, anti-adhesive, and antioxidant properties. Arteriosil improves nitric oxide release. Nitric oxide is important in developing an erection.

As a patient, you don't need to know this, but FYI, phosphodiesterase type 5 (PDE 5) inhibitors work by preventing the breakdown of cGMP. Nerves and endothelial cells release nitric oxide in the penis that stimulates guanylyl cyclase to produce cGMP and decrease calcium levels. This decreased calcium level mediates smooth muscle relaxation that results in arterial dilatation, venous constriction, and erection. I do prescribe these medications for those that need them.

PDE5 inhibitor medications include: Cialis(Tadalafil), Viagra(Sildenafil), Levitra(Vardenafil), Stendra(Avanafil).

Special instructions:

Cialis can last as long as 36 hours.

Viagra and Levitra cannot be taken with food.

Side effects of PDE5 inhibitors: flushing, headache, indigestion, vision changes, nasal congestion, back pain, hearing loss, priapism (painful prolonged erection-medical emergency that requires draining the blood from the penis with a needle).

Contraindications: Nitrate medications, hypotension, uncontrolled hypertension, severe liver disease, end stage kidney disease.

**Some other treatments for erectile dysfunction:**

Testosterone supplementation

Smoking cessation

Alcohol avoidance

Supplement low Vitamin D levels

Low-carb, high-fat diet/lifestyle intervention

Implantable pump devices

Intracavernosal injections (injections into the penis), cream, or intraurethral suppository-alprostadil

If you are blessed with the opportunity, my recommendation is to try to prevent erectile dysfunction by making the right choices early on in your life.

**EAT A LOW-CARB, HIGH-FAT DIET AND EXERCISE REGULARLY.**

These 2 strategies are paramount in your longevity and quality of life. Simple, but effective!

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Discussion of erectile dysfunction and how it is linked to poor metabolic health. I discuss some of the medications that can contribute to the problem. I discuss treatments.


Very accurate! Research is tainted. I don't debate that statins lower LDL, I think they do. This reduction does not equate to reduced morbidity or mortality though. Even through that lens, if you look at absolute risk reduction (instead of relative risk reduction) in these statin trials, it is dismal-as a population, mind you, possibly gain 30 days of life in the most generous interpretation of the data. My wife saw a diagnosis on a patient chart the other day that had a diagnosis of "intolerance to statin". She is a physical therapist who has joined me in the quest for truth. She joked, "it is like you are SUPPOSED to take these medications, your body does not have enough statins." I think this speaks to how far this medical misinformation has gone. I am not afraid to tell my patients that I feel that triglycerides and VLDL cholesterol are more important and a great marker for insulin triggering and glucose load. I explain the VLDL, triglyceride, sugar connection. I also warn them that other doctors will likely immediately recommend you take a statin if they see you. I tell the patients why, so they are prepared, because it is confusing. For me, bitcoin lead me to Twitter. Twitter lead me to stumble across the low-carb, high-fat community and the rest is history.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

**Endocannabinoids**

Stress is a common condition in our society. Stress can promote (i) inflammatory diseases such as asthma, eczema or urticaria, rheumatoid arthritis, ulcerative colitis, and sickness syndrome; (ii) pain disorders such as headaches and abdominal, pelvic, and lower back pain; (iii) gastrointestinal dysfunction such as diarrhea, constipation, and peptic ulcers; (iv) mental illnesses such as anxiety, depression, psychosis, cognitive dysfunction, and insomnia; (v) metabolic diseases such as diabetes mellitus, hypercholesterolemia, visceral obesity, and sarcopenia; (vi) ischemic heart disease; (vii) neurodegenerative diseases; and (viii) osteopenia and osteoporosis. This is not an exhaustive list, but gives insight into the widespread manifestations of stress. When I discuss the pillars of health with my patients, stress comes up. Leveraging the endocannabinoid system can help reduce stress.

The endocannabinoid system is a widespread neuro modulatory system that plays important roles in central nervous system development, synaptic plasticity, and response to endogenous and environmental insults.  The endocannabinoid system is a retrograde system, functioning post to pre-nerve synapse, allowing it to be a master regulator in the body.  At the synapse, endocannabinoids inhibit the release of many excitatory and inhibitory neurotransmitters.  Therefore, endocannabinoid's post-synaptic target cells can influence their own incoming synaptic signals.  The endocannabinoid system functions through the regulation of neurotransmitter function, apoptosis (programmed cell death), mitochondrial function, and ion-gated channels.  The endocannabinoid system runs through adipose tissue, important in adipogenesis, lipogenesis, and glucose uptake, all stimulated by the CB 1 receptor.  Dopamine activity is tied to endocannabinoid activity.  CB 1 receptors are located across the striatal regions of the brain that mediate reward function.

Endogenous cannabinoids are endogenous lipids that engage with cannabinoid receptors.  These are synthesized from omega-3 and omega 6 fatty acids.  Examples include Anandamide or N-arachionyolyethanolamine (AEA), (first endocannabinoid discovered) and 2-arachidonolyl glycerol (2-AG).  AEA may be very important for pain control.  AEA also has ability to make or break short-term connections and nerve cells that affect memory.  Utility may be to decrease PTSD.  2 AG is the most prevalent endocannabinoid in the body.  It seems to play a role in inflammation through immune suppression.  Also, 2-AG has psychoactive properties when bound to CB1 receptors.  Cannabinoids are rapidly synthesized and degraded, therefore, do not stay in the body for a long time, possibly a safer alternative to opioids and benzodiazepines.  Endocannabinoid's have antiproliferative, anti-inflammatory, and anti-metastatic effects.

Cannabinoid receptors are present throughout the body and in the brain.  There are CB1 and CB2 receptors.  CB1 receptors are in the brain and CNS.  They control the level and activity of most of the other neurotransmitters.  In the process, they also help to regulate hunger, temperature, sleep, memory, fertility, bone remodeling, motor control, liver function, stress, and alertness.  The drug rimonabant blocked the CB1 receptor.  It was developed as an anti-obesity drug due to the effect of the endocannabinoid system on hunger.  It was successful in promoting weight loss through decreased hunger, however, it caused significant effects on mood.  Blocking CB1 receptors can result in suicidal ideation.  CB2 receptors are mostly present in the peripheral nervous system and immune cells and help control inflammation.  When these receptors are stimulated, patients do not experience "a high".
When 2-AG is activated, it increases the effects of the GABA system, results in CNS “relaxation”. Endocannabinoids have a calming effect. They may be responsible for the “runners high” experience and seem to be more likely than endorphins.  Endocannabinoid's can easily pass the blood-brain barrier promoting short-term psychoactive effects.

Mental health disorders such as schizophrenia have been linked to a malfunctioning endocannabinoid system.  THC can bind to both CB1 and CB2 receptors.  Increased use of THC cannabis is associated with increased incidence of schizophrenia and psychosis.

CBD does not bind to CB1 or CB2 receptors in the same fashion that THC does.  It is possible that CBD prevents other Endocannabinoids from being broken down.

Foods that function as Endocannabinoids: Truffles, dark chocolate, coffee, oregano, curcumin, cinnamon, Chia seeds, hemp, walnuts, sardines, anchovies, eggs.

Medium and high intensity exercise also stimulates the endocannabinoid system.  Moderate intensity exercise dramatically increased concentrations of anadamide in blood plasma levels.

Stress lowering activities such as meditation will also stimulate the endocannabinoid system. A 4 day yoga-meditation retreat reveals blood level changes and survey reported improved depressive and anxiety symptoms.

Supplements: Omega-3 fatty acids, vitamin C

CBD oil: CBD appears to act on opioid, serotonergic, and cannabinoid receptor systems.  CBD also activates PPAR gamma, reducing neuroinflammation and excitotoxicity associated with stress. Binds to CB2 receptors to help with immune support, but do not feel euphoria.  CBD is used by up 10% of the population to relieve stress and over 90% of people that tried it reported feeling less stressed based on subjective report.  The FDA has issued a caution about safety.  CBD is only approved for seizure treatment for Lennox Gastaut, Dravet syndrome, or tuberous sclerosis complex seizures.  Reported risks/concerns with CBD oil: Dry mouth, diarrhea, decreased appetite, drowsiness, fatigue, liver injury and interaction with blood thinner medications.

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Endocannabinoids, stress, and what to do about it.


*While I am a fully licensed physician in Kansas, this communication does not constitute personal medical advice or establish a physician-patient relationship. See your own physician to discuss your particular diagnosis and treatment*

**CELIAC DISEASE**

Other names for this condition: Celiac sprue, non-tropical sprue, gluten-sensitive enteropathy.  Condition that is gluten related.  This condition can affect 1 and 100 people worldwide.  It is estimated that 80% of celiac disease remains undiagnosed.  If you have a first-degree relative with this condition you have a 1 and 10 risk of developing this condition yourself.  HLA associated T-cell mediated attack on enterocytes, immunological disease.  If you have this condition, when you eat a protein found in wheat, rye, and barley, the body mounts an immune response that attacks the small intestine.  Nutrients cannot be properly absorbed when this occurs.

Common symptoms in children: Abdominal bloating and pain, diarrhea, constipation, foul-smelling stools, nausea and vomiting, weight loss, delayed onset puberty, failure to thrive, fatigue, headaches, irritability, anxiety, depression, ADHD, learning disabilities, seizures, and lack of muscle coordination.

Common symptoms in adults include abdominal pain, bloating, gas, nausea, vomiting, constipation, diarrhea, depression, cognitive impairment, anxiety, fatigue, headaches, skin rash, arthralgia, menstrual irregularity, mouth ulcers, weight loss, osteomalacia, and neuropathy.

If you have celiac disease, your risk of developing coronary artery disease is double and your risk of developing small bowel cancers is 4 times that of the regular population.  Untreated celiac disease can also lead to the development of other disorders including: anemia, thyroid disease, dermatitis herpetiformis, lymphocytic colitis, diabetes mellitus type 1, peripheral neuropathy, ataxia, multiple sclerosis, osteoporosis, infertility, miscarriage, epilepsy, migraines, poor growth, heart disease, gallbladder dysfunction, iron deficiency anemia, lactose intolerance, liver failure, malnutrition, attention deficit hyperactivity, headaches, seizures, dementia, neuropathy, myopathy, pancreatic insufficiency, vitamin and mineral deficiencies, and intestinal cancer.

Diagnosis: Tissue transglutaminase IgA antibody and endomysial IgA antibodies (must be on a gluten-containing diet to trigger this immune response).  IgA antibody (if you have IgA deficiency, you can have a false negative tissue transglutaminase and endomysial antibody).  Deamidated gliadin peptide can be tested if you are IgA deficient.  Intestinal biopsy.  If you have dermatitis herpetiformis, the skin biopsy is sufficient for diagnosis.  Can order genetic testing as well.

Other lab considerations: CBC, iron studies, vitamin B studies, thyroid function, liver enzymes, calcium, phosphate, vitamin D, copper, and zinc levels.

Other considerations: Bone density test to screen for osteopenia.

Treatment: Gluten-free diet.  May need nutritionist referral.  Supplementation might include: Fiber, iron, calcium, magnesium, zinc, folate, niacin, riboflavin, vitamin B12, and vitamin D.  In patients with dermatitis herpetiformis, consider short-term use of dapsone or sulfapyridine to control skin manifestations.

Ongoing research is assessing the effect of modulating CD8 T cells as a seem to be responsible for some of the immune response causing this disorder.

If continued symptoms consider continued gluten ingestion as the cause.  Patient may also have an inflammatory bowel disease or another form of colitis.  Consider small intestinal bacterial overgrowth, pancreatic insufficiency, and other food intolerances (low FODMAP diet trial might help).

Non-response to vaccines.  Study in Turkey in 2010 revealed hepatitis B nonresponse 32.5% in celiac patients versus 14.8% in non-celiac patients.  Reference: The response to hepatitis B vaccine: Does not differ in celiac disease?  European Journal of gastroenterology and hepatology. 2010 Jul; 22(7): 787-93. Ertem, et. al.

Connection of celiac disease with diabetes type 1.  1 study showed that the prevalence of celiac disease and diabetes mellitus type 1 has increased since 1994 (10.6% versus 6.6%). Salardi, S.; Volta, U.; Zucchini, S.; Fiorini, E.; Maltoni, G.; Vaira, B.; Cicognani, A. Prevalence of Celiac Disease in Children with Type 1 Diabetes Mellitus Increased in the Mid-1990s: An 18-year Longitudinal Study Based on Anti-endomysial Antibodies. J. Pediatr. Gastroenterol. Nutr. 2008, 46, 612–614.

Retinopathy and nephropathy present much earlier in type 1 diabetes patient's that have celiac disease versus those that do not.  Diabetes type 1 and celiac disease both share similar HLADQ2 and DQ8 heritability.  Unrecognized celiac disease can be associated with elevated homocysteine levels, likely result of folic acid and other B vitamin deficiency.  Supplementing with B vitamins can significantly lower homocystine levels and reduce risk of vascular disease.  High prevalence of microvascular complications in adults with type 1 diabetes and newly diagnosed celiac disease.  Diabetes care.  2011 October; 34 (10): 2158–2163. Leeds, et. al.

Enterovirus infection specifically coxsackie, and rotavirus infection has been linked to increased risk of diabetes mellitus type 1 and celiac disease. Filippi, C.M.; von Herrath, M.G. Viral Trigger for Type 1 Diabetes: Pros and cons. Diabetes 2008, 57, 2863–2871. Kahrs, C.R.; Chuda, K.; Tapia, G.; Stene, L.C.; Mårild, K.; Rasmussen, T.; Rønningen, K.S.; Lundin, K.E.A.; Kramna, L.; Cinek, O.; et al. Enterovirus as trigger of coeliac disease: Nested case-control study within prospective birth cohort. BMJ 2019, 364, l231. Stene, L.C.; Honeyman, M.C.; Hoffenberg, E.; Haas, J.E.; Sokol, R.J.; Emery, L.; Taki, I.; Norris, J.M.; Erlich, H.A.; Eisenbarth, G.S.; et al. Rotavirus Infection Frequency and Risk of Celiac Disease Autoimmunity in Early Childhood: A Longitudinal Study. Am. J. Gastroenterol. 2006, 101, 2333–2340.  It is suspected that altered gut permeability and microbiota seem to contribute to the development of both celiac and diabetes mellitus type 1.

With a diagnosis of diabetes type 1 and additional symptoms including: Neuropathy, ataxia, diarrhea, constipation, weight loss, iron deficiency anemia, and decreased low bone density it is useful to test for celiac disease.  A 2019 RCT study confirmed that those patients with celiac disease and diabetes type 1 treated with a gluten-free diet have less hypoglycemic episodes and a reduced hemoglobin A1c compared to those on standard diet. Effect of gluten-free diet on metabolic control and anthropometric parameters and type 1 diabetes with subclinical celiac disease: A randomized control trial. Kaur P, Agarwala A, Makharia G, Bhatnagar S, Tandon N. Endocrine Practice. 2020; 26: 660-667.

Connection of vitamin D deficiency and celiac disease.  Ingested vitamin D is absorbed in the jejunum and ileum of the small intestine.  Celiac disease damages the jejunum of the small intestine.

Connection of celiac disease with mast cell activation syndrome and hereditary alpha tryptasemia syndrome.

**Other items of interest possibly related to celiac disease.**

Mast cell activation syndrome.  Mast cells are produced in the bone marrow and mature in the skin, lungs, GI tract.  Mast cells may protect us from parasites, but also contribute to allergic responses by release of histamine.  Symptoms that occur are very similar to those that occur with hereditary alpha tryptasemia.  Mast cells respond to gliadin peptides that may contribute to a direct role in the onset of celiac disease.  Mast cells also directly react against a gluten challenge suggesting that the innate immune system contributes to initiating this immune response to gluten.  Observed changes in types and amounts of mediators released by mast cells during the progression of celiac disease indicate that mast cells may vary their activity and response to changes in the environment.  International Journal of molecular sciences.  2019 Jul; 20(14):3400.  Celiac disease and mast cells. Frossi, et. al.

Hereditary alpha tryptasemia.  This disorder can affect up to 6% of the general population per estimates.  In this disorder, you have an elevated tryptase level.  Symptoms that you might experience include: Skin itching, flushing, hives, anaphylaxis, bloating, abdominal pain, diarrhea, constipation, heartburn, reflux, difficulty swallowing, hypermobile joints, scoliosis, palpitations, blood pressure swings, syncope, anxiety, depression, chronic pain, panic attacks.

I hope this information helps you and your loved ones!

Jason Williams, D.O.

Celiac disease discussion. Symptoms noted. Treatment options. Other health conditions connected to celiac disease.