Osteoporosis Why is Osteoporosis of concern?

• Over 80% of all fractures in people 50+ are caused by osteoporosis.
• Causes a great deal of disability and is a burden on the health care system.
• Modern diet and lifestyle predispose to osteoporosis.
• Increased life expectancy makes osteoporosis prevalent, compared to the 1700s-1800s
• Preventable disease?

Risk Factors : 

• Measured height loss greater than 6 cm since peak height (in young adult years), or loss of more than 2 cm within the past year.
• Recurrent history of fractures/falling
• Chronic or acute back pain (vertebral compression fracture)
• History of use of certain medications: eg: corticosteroids, aromatase inhibitors, antiretroviral therapy…ect.
• Chronic endocrine diseases: Hyperthyroidism/Hyperparathyroidism, Cushing syndrome… ect.

Investigations: 

•  Usually labs are normal, including Calcium and Vitamin D.
• TSH if thyroid problem is suspected.
• Diagnosis is confirmed through Xray and BMD measurement (eg: DEXA scan).
• There are some “Fracture risk assessment tools”, which can predict the risk of fracture in the future, based on the BMD and age. Those were developed to assess the patients for eligibility to Pharmacological therapies as a preventative measure. Examples of such scores: CAROC and FRAX. 

The non pharmacologic choices include:

• Exercise, especially impact exercises .
• Fall prevention.
• Smoking cessation.
• Diet (mostly prevention): according to the CTC: encourage protein, calcium and vitamin D, reduce alcohol (less than 2 drinks/day) and caffeine (less than 4 cups/day).

Calcium: Best available evidence suggests that Calcium supplementation’s risks outweigh the benefits. Best practice is to consume calcium from food. If supplementation is necessary, it should not be for the long term.

https://e-jbm.org/journal/view.php?doi=10.11005/jbm.2014.21.1.21

Hazards of calcium supplementation: • Increase cardiovascular events. • Kidney stones. • GI symptoms, sometimes so severe, require hospitalization. However, Combining calcium and vitamin D seems to be beneficial. In a 2016 meta-analysis, pooling of data showed that supplementation of calcium+vitamin D reduced the risk of total fractures by 15%, and the risk of hip fractures by 30%.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4715837/

Vitamin D: In a 2014 Cochran review, they concluded that Vitamin D alone is unlikely to prevent fractures in older people. However, both vitamin D and Calcium supplementation may prevent hip and/or total fractures. The combination of calcium and vitamin D showed a small increase in the GI symptoms and renal disease, however, it did not affect mortality. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000227.pub4/full

Milk and dairy products: Best available evidence encourages the consumption of animal milk and dairy products, in all age groups, specially kids and adolescents, for the following known reasons: • Source of high availability protein • Source of Calcium • Source of Vitamin D • Source of Phosphorus • Promotes healthy gut microbiome, which increases the absorption of calcium and other important minerals. It also promotes the production of short fatty acids and serotonin, which directly impact bone health.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8072827/

Can I use a plant milk alternative? Benefits are not equal, unless it’s fortified, with calcium and vitamin D. Best option is SOY, because it’s the closest to cow’s in mineral/vitamin/protein content. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8072827/

Is skimmed milk ok? According to WHO, skimmed milk is not recommended in infants under 12 months. They need the essential fatty acids and the fat soluble vitamins in milk. Partially skimmed milk can be introduced to children 1 year or older. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8072827/

How much dairy is enough? 3 portions of dairy, or 3 cups of skimmed/low fat milk, are enough to get you your daily requirement of calcium, vitamin D and high quality protein.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8072827/

Vitamin K?

A meta-analysis of 10 RCTs showed that supplementing calcium with Vit K increased BMD, especially lumbar. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8515712/

Protein? Protein is a component of bone, essential for bone health. The question is, Animal or plant protein?

Animal versus plant protein and adult bone health: A systematic review and meta-analysis from the National Osteoporosis Foundation Consumption of soy protein is not more advantageous than animal protein, or vice versa. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5825010/

Are vegetarians at risk? Vegetarian diet lacks the following: • High quality protein • Calcium • Vit D You can consume high quality legumes, whole grains, fruits and vegetables, soy products to compensate, however, supplementation might be necessary in long term vegetarians. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8059457/

Acid balance? Theoretically, a diet high in acid precursors increases the burden on the Kidney. If the kidney is unable to clear/balance the excess acid, this will directly impact bone health. Therefore, acid balance might be problematic to bone health, as one ages. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5946302/

References

https://osteoporosis.ca/facts-and-stats/#:~:text=Over%202.3%20million%20Canadians%20are,re%2Dfracture%20within%20one%20year.

Gaby 2011

Polycystic Ovary Syndrome. (PCOS)

• A syndrome associated with a range of metabolic abnormalities and endocrine disorder which can lead to long-term health problems
• A constellation of signs and symptoms that present in a variable manner. most commonly:  hirsutism (90%), menstrual irregularity – with anovulation (90%) and infertility (75%)
• Surgical exploration of these women showed enlarged ovaries (2-4x the normal size), with tiny fluid filled cysts.

Diet and Lifestyle Interventions 

Exercise 

There is one systematic review on this topic.  Outcomes measured included cardiovascular risk factors [insulin resistance (IR), lipid profiles, blood pressure and weight] and reproductive measures (ovulation, menstrual regularity and fertility outcomes). . All studies involved moderate intensity physical activity and most were of either 12 or 24 weeks duration with frequency and duration of exercise sessions ranging between studies. The most consistent improvements included improved ovulation, reduced IR (9-30%) and weight loss (4.5-10%). Improvements were not dependent on the type of exercise, frequency or length of exercise sessions.

Exercise is crucial for so many reasons, however, in those with PCOS, we see an increased risk of cardiovascular disease, T2DM and psychological pathologies.  Exercise may also improve these long-term risks in these individuals.

Weight Loss 

Approximately 50% of patients with PCOS are obese.  Being overweight exerts and additive effect on metabolic and hormonal imbalances of PCOS (cardiovascular risk, oligomenorrhea, reduced insulin sensitivity, T2DM).

Individuals with PCOS often report that they find it very difficult to lose weight and very easy to gain weight.

Individuals with PCOS who lose as little as 5-10% of their body weight report returning to normal menstruation.

A combination of diet and exercise modifications has been shown to be the most effective method of weight loss in folks with PCOS.

Individuals with low BMI and PCOS often still have metabolic dysfunction. Reducing simple carbohydrates, increased complex carbohydrates, and an overall healthy diet, will still serve to improve health outcomes and  can help to restore menstrual irregularity.

Soy

Generally, soy phytoestrogens have a weak estrogenic effect in some parts of the body.  Early research shows that soy phytoestrogens (specifically genistein) may benefit lipid parameter, decrease serum androgens, and may benefit glucose dysregulation.

Nutritional Supplements 

Myo-Inositol

Use with caution in bipolar, or schizophrenia as it can exacerbate manic episodes.

Calcium and Vitamin D 

May improve insulin secretion and lipid parameters.

Increase protein intake

N-Acetyl Cysteine 

Precursor to glutathione, acts as an antioxidant.  Improves insulin sensitivity.

Fish Oil 

Can improve metabolic pathways in PCOS

Vitex

Lowers prolactin due to dopaminergic effects

Chromium 

Chromium has been shown to enhance the effects of insulin on target tissues.

IV Vitamin C treatment on viral Fatigue with Focus on Long COVID

Do the antioxidant, anti-inflammatory  and immunomodulatory effects of high-dose IV vitamin C might be a suitable treatment option?

Fatigue is coming into focus as a major symptom of long COVID. Patient data from all over the world show that COVID-19 not only attacks people’s health during the acute infection but also often results in post-infection problems, which are summarized under the term long COVID.

Post-viral fatigue is associated with various infectious diseases (SARS coronavirus, Epstein–Barr virus, Ross River virus, enteroviruses, human herpesvirus-6, Ebola virus, West Nile virus, Dengue virus, and parvovirus; bacteria such as Borrelia burgdorferi, Coxiella burnetii, and Mycoplasma pneumoniae; and even parasites, such as Giardia lamblia),Post-viral fatigue syndrome is similar to Chronic Fatigue Syndrome (CFS) . It is interesting to note that CFS often begins with an infection during a period of increased physical activity or stress. Patients with long COVID are or were affected not only by the infection but likely also by psychological and/or somatic stress during the lockdown.

Claudia Vollbracht and , Karin Kraft examined nine clinical studies with 720 participants . Three of the four controlled trials observed a significant decrease in fatigue scores in the vitamin C group compared to the control group. Four of the five observational or before-and-after studies observed a significant reduction in pre–post levels of fatigue. Attendant symptoms of fatigue such as sleep disturbances, lack of concentration, depression, and pain were also frequently alleviated. Oxidative stress, inflammation, and circulatory disorders, which are important contributors to fatigue, are also discussed in long COVID fatigue.

The authors conclude that ” Oxidative stress and inflammation can cause and maintain fatigue, cognitive impairment, depression, and sleep disturbances. They disrupt the formation and functioning of important neurotransmitters and of blood circulation. Vitamin C is one of the most effective physiological antioxidants, showing anti-inflammatory effects, especially if applied intravenously in pharmacological doses. It restores endothelial function, and it is an enzymatic co-factor in the synthesis of various neurotransmitters. High-dose IV vitamin C has been investigated in four controlled and five observational or before-and-after studies in patients with cancer, allergies, and herpes zoster infections. The results show a reduction in fatigue and attendant symptoms such as sleep disturbances, depressive symptoms, pain, and cognitive disorders. COVID-19 is a multisystem disease in which oxidative stress is partly responsible for excessive inflammation and circulatory disorders such as immune thrombosis. Vitamin C deficiency has been demonstrated in COVID-19 and other acute severe infections and should also be investigated in long COVID. Furthermore, the effects of high-dose IV vitamin C on long COVID-associated fatigue should be investigated in clinical trials”

Reference 

Intravenous Vitamin C for Cancer Therapy Q&A

Vitamin C has essential functions within the body, including vital roles in many anti-cancer mechanisms (Du et al., 2012).Treatment of cancer is thought to require much higher doses of vitamin C than normal dietary intakes (Parrow et al., 2013). In fact, high dose intravenous vitamin C (IVC) has been administered by physicians for many years as an Integrative therapy for oncology patients (Padayatty et al., 2010)

Over the last 20 years, researchers have addressed many of Vitamin C’s important aspects in Cancer patients , such as the best route for administration, safety, interactions with chemotherapy, quality of life, and potential mechanisms of action.

How much, how often and for how long to administer IVC to oncology patients?

Anitra C. Carr and John Cook in a 2018 review tried to identify the current  gap of knowledge about what we know about Intravenous Vitamin C

Do oncology patients have compromised vitamin C status?

Yes, studies consistently show that patients with cancer have lower mean circulating vitamin C levels than healthy volunteers. Cancer patients have higher rates of Vitamin  C deficiency. Increasing the vitamin C status of oncology patients is likely to be of benefit.

Is IV the optimal route for vitamin C administration?

Yes, IV administration of vitamin C can provide significantly higher peak plasma concentrations because it bypasses the regulated intestinal uptake of oral vitamin C. These higher concentrations are believed to be required for some of the proposed anti-cancer mechanisms of vitamin C and may also enhance diffusion of the vitamin into the hypoxic core of solid tumors.

Is IVC safe?

Yes, IVC is remarkably safe, considering the massive (50-75 g) doses that are often administered. However,  caution is warranted in patients with impaired renal function due to their inability to adequately clear high IVC doses from circulation, and patients with G6PD deficiency due to inability to detoxify oxidative stress generated by high dose IVC administration. Caution is also required for patients requiring regular glucose monitoring due to the potential for IVC to interfere with glucose monitors.

Does IVC interfere with chemotherapy or radiotherapy?

Clinical trials indicate that IVC does not adversely interfere with chemotherapy and pre-clinical studies indicate that it may in fact act synergistically in combination with different chemotherapeutic agents. There is as yet limited research around interference with radiotherapy, with conflicting results likely due to the timing of the interventions.

Does IVC decrease the toxic side effects of chemotherapy and improve quality of life?

Both pre-clinical and clinical studies indicate that IVC can decrease the  toxicity of chemotherapeutic agents, likely through its antioxidant and anti-inflammatory activities, without affecting the anti-cancer activities of the chemotherapeutic agents. The reduction in specific chemotherapy-related side-effects results in an overall improvement in the health-related quality of life of oncology patients.

What are the optimal doses, frequency, and duration of IVC therapy?

There is still little consensus as to how much, how often and for how long to administer IVC to oncology patients. Higher doses (>50 g/d) being required for some anti-cancer mechanisms, and lower doses (≤10 g/d) being sufficient for decreasing symptoms and improving quality of life. It is possible that antitumor activity may require long term treatment and follow-up, e.g., over years rather than just the few weeks or months of most clinical trials.

Reference 

Intravenous vitamin C ( IVC )in the treatment of allergies

During acute allergic inflammation and in allergy-related respiratory or skin infections, the production of reactive oxygen species (ROS) plays an important role. A targeted antioxidant intervention to counteract the increases in ROS can be achieved by Vitamin C (ascorbate) as one of the most effective antioxidants in human blood plasma for protection against oxidative stress.

Data from multicenter, prospective, observational documented the clinical effects of high-dose iv vitamin C in the treatment of patients with known respiratory or cutaneous allergies.

This observational study was conducted to investigate the change in disease-specific and nonspecific symptoms (fatigue, sleep disorders, depression, and lack of mental concentration) during adjuvant treatment with intravenous vitamin C in 71 patients with allergy-related respiratory or cutaneous indications.

The authors conclude that there is a reduction of oxidative stress and inflammation by vitamin C and Vitamin C can be beneficial in patients with allergic diseases. This provides evidence of the use of high-dose iv vitamin C in clinic practice for the treatment of respiratory and cutaneous allergic diseases.

Reference

Intravenous vitamin C in the treatment of allergies: an interim subgroup analysis of a long-term observational study Claudia Vollbracht et al .J Int Med Res

Glutathione IV

Glutathione is known as the Master Antioxidant, Its primary purpose is to neutralize free radicals by offering them an oxygen molecule and protecting cells from damage. Glutathione keeps cells healthy and functioning all over the body.

Glutathione is one of 4 amino acids (Including Glutathione, Levocarnitine, Taurine, and Tryptophan) that can be administered Intravenously by Naturopathic Doctors in Ontario.

What are the Glutathione IV indications?

1. Chemotherapy Toxicity ( chemotherapy induced neuropathies)
2. Liver Support
3. Detoxification
4. Anti-Aging
5. Prevention of oxidative damage (post-stroke, pre-oncologic radiation)
6. Neurological support in neurodegenerative illnesses
   1. For example, Parkinson’s Disease
7. Chelates Pb, Hg, Cd, Ar
8. Inhibits chemical carcinogenesis
9. Helps maintain steady glutathione levels
   1. Low glutathione is commonly observed in wasting and negative nitrogen balance, as seen in cancer, HIV/AIDS, sepsis, trauma, burns, and athletic overtraining.
10. Maintaining and recirculating other exogenous antioxidants such as vitamins C and E
11. DNA synthesis and repair, protein synthesis, Prostaglandin Synthesis, amino acid transport, and enzyme activation
12. It has a vital function in iron metabolism, anti-viral properties, hepatoprotective, neuroprotective, etc.
13. Deactivates tyrosinase leading to inhibition of melanin

Why is Glutathione IV often combined with other IV vitamins in the same visit?

Glutathione needs cofactors to facilitate its function and support the Glutathione level . They are: Vitamin B complex,Vitamin C ,Magnesium ,Zinc, N-Acetyl-Cysteine,L glutamine …etc

What is Glutathione Adverse effects

1. Little reported , can be transient Irritability, lightheadedness, headache, dizziness, nausea

Is Glutathione IV Therapy Covered by Health Benefits Plans /Group Insurance?

The Initial IV assessment and subsequent IV visits can be covered under Naturopath , The cost of Injectables are not covered “Glutathione”

Research

Glutathione for Skin Whitening

30 women aged 30 to 50 years in a randomized, double-blind, matched-pair, placebo-controlled clinical trial applied topical Glutathione to one side of the face and a placebo lotion to the other side twice daily for 10 weeks. The conclusion was Topical Glutathione is safe and effectively whitens the skin and improves skin condition in healthy women.

Research link :

https://pubmed.ncbi.nlm.nih.gov/25378941/

Glutathione IV for Anti-Aging and Anti-Melanogenic Effects

A randomized, double-blind, placebo-controlled, parallel, three-arm research for 12 weeks concluded that oral glutathione, 250 mg/d, effectively influences skin properties.
Research link : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3789163/

Glutathione IV for Liver Health

ALT liver enzymes levels significantly decreased following treatment with glutathione for 4 months. In addition, triglycerides, non-esterified fatty acids, and ferritin levels also decreased with glutathione treatment. This pilot study demonstrates the potential therapeutic effects of glutathione in practical dose for patients with in patients with nonalcoholic fatty liver diseaseNAFLD

Research link https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5549431/pdf/12876_2017_Article_652.pdf

Glutathione IV for Parkinson’s Disease

1. Hauser, R. A., Lyons, K. E., McClain, T., Carter, S., & Perlmutter, D. (2009). Randomized, double‐blind, pilot evaluation of intravenous glutathione in Parkinson’s disease. Movement Disorders, 24(7), 979-983.
2. Sechi, G., Deledda, M. G., Bua, G., Satta, W. M., Deiana, G. A., Pes, G. M., & Rosati, G. (1996). Reduced intravenous glutathione in the treatment of early Parkinson’s disease. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 20(7), 1159-1170.

References 

Smyth JF, Bowman A, Perren T, et al. Glutathione reduces the toxicity and improves quality of life of women diagnosed with ovarian cancer treated with cisplatin: results of a double-blind, randomised trial. Ann Oncol 1997;8:569-73. PMID: 9261526 Cascinu S, Cordella L, Del Ferro E, et al. Neuroprotective effect of reduced glutathione on cisplatin-based chemotherapy in advanced gastric cancer: a randomized, double- blind, placebo-controlled trial. J Clin Oncol 1995;13:26-32. PMID: 7799029 Links M, Lewis C. Chemoprotectants: a review of their clinical pharmacology and therapeutic efficacy. Drugs 1999;57:293-308. PMID: 10193684 Leone R, Fracasso ME, Soresi E, et al. Influence of glutathione administration on the disposition of free and total platinum in patients after administration of cisplatin. Cancer Chemother Pharmacol 1992;29:385-90. PMID: 1312907 Graziano F, Cardarelli N, Marcellini M, et al. A pilot clinical trial of postoperative intensive weekly chemotherapy using cisplatin, epi-doxorubicin, 5-fluorouracil, 6S- leucovorin, glutathione and filgrastim in patients with resected gastric cancer. Tumori 1998;84:368-71. PMID: 9678619 Plaxe S, Freddo J, Kim S, et al. Phase I trial of cisplatin in combination with glutathione. Gynecol Oncol 1994;55:82-6. PMID: 7959273 Locatelli MC, D’Antona A, Labianca R, et al. A phase II study of combination chemotherapy in advanced ovarian carcinoma with cisplatin and cyclophosphamide plus reduced glutathione as potential protective agent against cisplatin toxicity. Tumori 1993;79:37-9. PMID: 8497920 Di Re F, Bohm S, Oriana S, et al. High-dose cisplatin and cyclophosphamide with glutathione in the treatment of advanced ovarian cancer. Ann Oncol 1993;4:55-61. PMID: 8435364 Parnis FX, Coleman RE, Harper PG, et al. A randomised double-blind placebo controlled clinical trial assessing the tolerability and efficacy of glutathione as an adjuvant to escalating doses of cisplatin in the treatment of advanced ovarian cancer. Eur J Cancer 1995;31A:1721. PMID: 7488438 Cascinu S, Frontini L, Comella G, et al. Intensive weekly chemotherapy is not effective in advanced pancreatic cancer patients: a report from the Italian Group for the Study of Dig. Tract Cancer (GISCAD). Br J Cancer 1999;79(3-4):491-4. PMID: 10027318 Cascinu S, Labianca R, Alessandroni P, et al. Intensive weekly chemotherapy for advanced gastric cancer using fluorouracil, cisplatin, epi-doxorubicin, 6S-leucovorin, glutathione, and filgrastim: a report from the Italian Group for the Study of Digestive Tract Cancer. J Clin Oncol 1997;15:3313-9. PMID: 9363860

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What Scientific research is telling us about non pharmacological treatment options for Insomnia?

Insomnia is an Inadequate or poor quality sleep;Difficulty falling asleep,Difficulty maintaining sleep, Waking up too early and Non-refreshing sleep.

Cognitive Behavioural Therapy-Insomnia

Psychological and behavioral treatments for chronic insomnia include a variety of nonpharmacologic .CBT-I is generally regarded as the treatment of choice, has the most evidence available in the literature and Strongly recommended . A Combination of:,Sleep hygiene,Stimulus control, Relaxation therapy,Cognitive therapy and Sleep restriction could be effective in Chronic insomnia

Changing misconceptions about sleep need to be addressed prior to recommending behaviour change.There is a large evidence base to support the use of behavioural and psychological treatments, particularly CBT-I for patients with insomnia disorder

Exercise

Exercise regimens of 60 minute sessions 4-5 times per week for 8-12 weeks can improve sleep quality in people with primary insomnia

Reference

A systematic literature review and meta-analysis of the clinical effects of aroma inhalation therapy on sleep problems

Cheong MJ, Kim S, Kim JS, Lee H, LyuY-S, Lee YR, Jeon B, Kang HW. Medicine 2021. Mar 5;100(9):e24652.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7939222/

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Vitamin B12 Supplementation in Diabetic Neuropathy

Diabetic neuropathy (DN) is one of the most common complications of diabetes. At the time of diagnosis of diabetes, 10–18% of patients present with nerve damage, neuropathy can occur even in prediabetes and is associated with foot infections, ulcers, Charcot arthropathy, fractures, and amputations. Strict glycemic control has been considered to be the cornerstone of the treatment of DN. However, it has only modest effects on the progression of DN. It is of particular note that strict glycemic control needs to be maintained for three-to-five years to provide any clinical benefit.In addition to any antiglycemic therapy aiming at strict glycemic control, vitamin B12 (B12) has been probably the most commonly used supplement. The first reason is that vitamin B12 deficiency is quite common in patients with DM2, and the second is that vitamin B12 deficiency may cause neurological disorders, such as peripheral, autonomic (including cardiovascular), and painful neuropathy.

Ninety adult patients were enrolled in a RCT study to investigate the efficacy of normalizing vitamin B12 levels with 1000 µg of methylcobalamin daily in DM2 patients with good glycemic control and generalized neuropathy.B12 supplementation resulted in improvements of somatosensory symptoms such as pain and paresthesia.Unexpectedly, the active treatment group did not show a significant improvement in cardiovascular autonomic reflex tests. This study showed that the increase of B12 levels with an oral dispersible tablet containing 1000 µg methylcobalamin for 12 months in patients with DN improved the patients’ neurophysiological parameters, sudomotor function, pain score, and Quality of Life .

Reference

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