Are your legs restless for relief?

Restless legs syndrome (RLS) has become a popular target for drug therapy. Two popular medications used to treat RLS are levodopa and ropinirol (Requip). Not a whole lot is really known about RLS; therefore treatment algorithms and standards have yet to be consistently used.

Separately from drug treatment, several studies have identified that iron metabolism is abnormal in individuals with RLS. There is some thought that normalizing these imbalances is an important part of treating the syndrome.

However, one group of researchers identified that physicians, rather than doing a comprehensive metabolic/nutritional evaluation and treatment of RLS, tend to jump right into prescribing medication. The treatment protocols for 27, 22 of which were on levodopa and 5 were on ropinirol, were studied after a year of medication treatment.

Severity of symptoms was only documented in 2 of these patients! If you don't create a measurement of baseline, there is no way progress can be measured...and in turn appropriateness of continued medication cannot be determined. This is akin to a person complaining of lightheadedness. Then, without even measuring blood pressure, prescribing an antihypertensive agent and not having any idea of how you're going to decide if the drug of choice was appropriate, effective, or devoid of side effects.

Despite the fact that iron status has been documented to be a significant contributor to restless legs in a fair number of people, serum ferritin levels were not obtained in 18 and transferrin-iron saturation (Tsat) percentages were not obtained in 20 of the study subjects.

An interesting aspect of this study is that 96% of the prescribing physicians were family practitioners. They were not neurologists or psychiatrists, who would be the specialists most likely to have strong experience in treating restless legs, as well as in working with medications used to treat them. This finding is similar when it comes to antidepressants--more than 90% of all scripts for medications in this category are written by family practitioners, not psychiatrists.

Makes you wonder if the burden of what needs to be known in a more generalist type of work such as family practice, places these physicians in a position to know too little about too many things. On the other hand, in my work, when I am asked to provide treatment (or even an opinion, for that matter), about an area of nutrition or medicine about which I am not an expert, I recognize my limits and I refer to someone better equipped to do the right job.

For more information on RLS and iron, please visit this link from the National Institute of Health:
http://www.ninds.nih.gov/disorders/restless_legs/detail_restless_legs.htm

Molokwu OC. Appropriate use of dopamine agonists and levodopa in restless legs syndrome in an ambulatory care setting. Ann Pharmacother. 2008 May;42(5):627-32.

I'd like to introduce you to some of my other writing!

I've been a little quiet here, haven't I? Here in Phoenix we had a wacky weather week, starting out in the triple digits and then plummeting to the point where I had to turn my heat on a couple of mornings. Knowing just what kind of scorching rebound is just around the corner, and knowing I'll be hiding out inside, working to avoid the heat, I decided to drop the work for a few days, get some great long runs in on those wonderfully cool mornings, and hole up with a few reads that had absolutely nothing to do with neurons, medications, or medical diagnoses. If you're looking for a novel that will start you out laughing, then catch you completely by surprise with the premise that suddenly shows up mid-book, check out Life of Pi. I sat down with my morning coffee today and I only looked up because one of my cats jumped on the sofa to remind me I'd forgotten her lunchtime treat. Great way to spend a lazy Sunday!

Anyway...

...I have also been non-blogging because I've been updating some of my consumer booklets. I thought I'd share a couple of sample pages from the three most popular here in case any of you are interested.

Polycystic Ovary Syndrome
I do most of my work with polycystic ovary syndrome (PCOS), the #1 cause of infertility in the US, which is related to several mental health issues and often exacerbated with the administration of psychiatric medications. Here is a sample from the 30 page booklet:

















Depression
I decided to write this booklet because most information I found about depression was, well....depressing! Most of it focused on external reasons for being depressed, and very little educated about hormones, neurons, and the disease process that depression truly is. I wanted to empower people with depression to view their diagnosis as something as neutral to discuss as high blood pressure, not something to be embarrassed about. I also wanted to share a lot of ideas for preventing or recovering from depression that did not involve prescription medications.

These .jpg files are coming out a little small, but if you copy them and enlarge them you can hopefully see them.
















Post-traumatic Stress Disorder

This booklet came about after 9/11. I felt very helpless sitting all the way out here in Phoenix when one college classmate had to make her way down 75 flights of stairs to safety, while another was conducting a meeting in the Pentagon when the building was hit. This was initially part of my own grief process, but it's turned out to be useful to people with PTSD from a number of different causes.

An interesting note about the booklet: I originally wanted to use clip arts depicting different cultures from all around the world as a way to communicate togetherness during a crisis. However, I could not find a single clip art of a Muslim in traditional dress participating in a modern day activity. I figured that using the art that I found would only make things worse...so I came up with "Plan B", which was to engage my nephews in the illustration work. I think it was meant to be illustrated by them all along, because the most frequent comment I get about the book is that the children's art really softens the message and makes it a lot easier to read about something that is very hard to experience, let alone discuss.

What we would do without the children in our world!

Here is a sample page:


This last one is my absolute favorite, but it's a little difficult to market. I never feel it's appropriate to try to sell something to a person who's in pain...so I have this one on my website in the hopes that friends and loved ones will find it.
If you know people who you think might benefit, perhaps you can let them know about it.

All of these items can be ordered in my bookstore, at
http://yhst-34497545168533.stores.yahoo.net/consumer-publications.html

I hope you all are enjoying your holiday and doing as much socializing and non-work as I am...I need to finish up my novel tomorrow, and then it's back to reading and writing about research.

See you later in the week!

It's the marijuana, stupid

Much of my work is with polycystic ovary syndrome, PCOS, an inflammatory syndrome that is the leading cause of infertility in the United States. Women who have this syndrome are plagued with intense carbohydrate cravings that can make it nearly impossible to follow any kind of healthy diet.

A dietitian with the syndrome, who had a master's degree in nutrition, once told me, "If it's carbohydrate, and it's not nailed down...I eat it."

It happens more often than not, when I work with clients who have PCOS, that they cannot conceive of being in a physiological state where the majority of their thoughts revolve around sugar and where to find more. They might politely listen to what I have to say about how to eat to quell these cravings, but the inevitable question at the end of my pitch for my nutrition plan is, "OK, but what am I going to do when I crave sugar?" They have absolutely no knowledge of a time when cravings did not rule their food choices, and their experience causes them to assume that my program is going to fail their expectations just as every other diet has done.

That's why I work so hard for those clients who are willing to trust me and try my program. It's incredibly rewarding to talk to them a couple of weeks later and hear the surprised delight over not spending hours of time and energy trying to suppress the urge to binge on a chocolate cake.

It seems that one of the reasons women with PCOS have so much trouble with their carbohydrate cravings, is that their endocannabinoid systems are out of balance.

You may know of cannabinoids as the substance in marijuana that causes the munchies. These compounds have been found to be important appetite regulators.

Of course, in Western medicine, when receptor trouble is identified, that means dozens of scientists in drug companies around the world race to find the right chemical to fix the troubled receptor.

Currently, a drug has been developed designed to "improve" the function of cannabinoid receptors. For a lot of obesity scientists, this drug, rimonabant, (Acomplia), was supposed to be the obesity miracle drug. However, Acomplia was tripped up during the FDA approval process, because there were concerns about an increased risk of severe depression being a major side effect. That is what has been tested and observed with Acomplia use.

What is also apparently a concern is that since this drug is somewhat like "anti-marijuana," it has potential for antagonizing many of the neuroprotective properties that marijuana may actually have. In other words, users of Acomplia may find themselves at increased risk of neurodegenerative diseases such as Multiple sclerosis, Alzheimer's disease, Amyotrophic lateral sclerosis (ALS), Parkinson's disease, and Huntington's disease.

So what are women with PCOS--and men whose obesity is also fueled by carbohydrate cravings supposed to do?

If you're a regular reader of this blog, you should know by now that the first answer to any question should always be fish oil. :) Yup, fish oil can help to silence the marijuana munchies.

I included a reference for your perusal, but I have to say, it was a client who taught me about this. We'd spent a couple of hours in our initial assessment, and I gave her my standard omega-3 and diet protocol. She had been embarrassed to tell me in that initial meeting, that every Sunday evening she baked a chocolate cake, which she used to satisfy her voracious carbohydrate appetite. Two weeks into using fish oil, she had thrown out two chocolate cakes, because her appetite for sweets had so radically diminished, she didn't even think about bingeing.

The relationship between carbohydrates and omega-3 balance is so strong, that I know I've titrated the right dose of fish oil with the right amount of other fats when the cravings are gone.

If you've taken fish oil and you have not experienced a drop in carb cravings, chances are you either aren't taking enough of the stuff...or you haven't eliminated enough of the other fats that get in the way of fish oil doing its amazing job.

So don't despair because the FDA kept rimonabant out of the drug supply and out of YOU. Give thanks, and look to the ocean for an even better way of getting the same results.

Pasquali R, Gambineri A, Pagotto U. The impact of obesity on reproduction in women with polycystic ovary syndrome. BJOG. 2006 Oct;113(10):1148-59. Epub 2006 Jul 7.

http://www.springerlink.com/content/41v7536525023722/

Kim AH, Kerchner GA, and Choi DW. Blocking Excitotoxicity. Chapter 1 in CNS Neuroprotection. Marcoux FW and Choi DW, editors. Springer, New York. 2002. Pages 3-36.

Engeli S, Heusser K, Janke J, Gorzelniak K, Bátkai S, Pacher P, Harvey-White J, Luft FC, Jordan J. Peripheral endocannabinoid system activity in patients treated with sibutramine. Obesity (Silver Spring). 2008 May;16(5):1135-7.

Watanabe S, Doshi M, Hamazaki T. n-3 Polyunsaturated fatty acid (PUFA) deficiency elevates and n-3 PUFA enrichment reduces brain 2-arachidonoylglycerol level in mice. Prostaglandins Leukot Essent Fatty Acids. 2003 Jul;69(1):51-9.

Speak up! There may be options that don't cause weight gain

Schizophrenia is a challenging problem to manage. I'm not a huge fan of medication, but I AM a huge fan of keeping people safe as well as healthy. And in the case of schizophrenia, that often means medication MUST be part of the treatment plan.

I wish, though, that in the process of keeping our schizophrenic loved ones safe with regards to reducing self-harming and otherwise destructive behaviors, we could keep them metabolically safe. In other words, I wish we could also create an antipsychotic that didn't significantly increase weight gain, as well as risk of diabetes and heart disease. The most we seem to be able to do, right now, it seems, is be aware of the relative health risks that medications in this category pose.

One medication that seems to be working well, is ziprasidone (Geodon). One hundred eighty five individuals with schizophrenia or schizoaffective disorder who were initially on either risperidone (Risperdal), olanzapine (Zyprexa), or conventional antipsychotic agents, were switched to ziprasidone, and maintained on this medication for one year. Cholesterol, triglyceride, weight, and behavioral measures were recorded at regular follow-up intervals during this time.

In the individuals who had been switched from risperidone or olanzapine, there were overall significant improvements in weight, total cholesterol, and triglyceride levels. These changes did not seem to show up, however, in those who were switched over from other antipsychotics.

The take home message here is that there seems to be a spectrum along which these medications lie, from most weight-neutral to least weight-neutral. It's important to be aware that if you or someone you know is on medications and you notice changes in metabolic health, that you ask about alternatives.

I know that there are many other reasons why psychiatrists make medication choices in their treatment planning. I have several clients in my case load who simply are not well managed unless they are using the weight-promoting antipsychotics. Their treatment goals are different than what I am referring to here.

If there is a weight/cholesterol/diabetes issue whose onset seems to correlate with the use of an antipsychotic medication, and there are medication options that have not been considered, it is surely worth inquiring about the possibility of using them. Often times, the burden of this communication falls on the loved one, as the person with the problem is not in a cognitive place to be able to do this for himself/herself.

Just know, often times there are options, and it is your right to ask for a discussion about what those options are.

Weiden PJ, Newcomer JW, Loebel AD, Yang R, Lebovitz HE. Long-Term Changes in Weight and Plasma Lipids during Maintenance Treatment with Ziprasidone. Neuropsychopharmacology. 2008 Apr;33(5):985-94

Eye see some potential problems with Ritalin

Ritalin has its purpose. But Ritalin is also given to an awful lot of children. In fact, one source I found estimates that as many as 10 to 15% of all children have been placed on Ritalin at some point. Some researchers believe that children who are sleep deprived can act as if they have ADHD. And sometimes they get the diagnosis simply because they aren't behaving. Often, Ritalin is given before any behavioral, nutritional, or otherwise alternative options are considered. What that all means, potentially, is that there are many, many children out there who are at risk for what the researchers in this study discovered.

Twenty-seven female rats were divided into 3 groups; each was given a different oral dose of methylphenidate (Ritalin). Changes in eye tissue observed (at all doses, the degree of change correlated with the dose) included:
(1) degenerative changes of the corneal epithelium, the protective layer of cells on the outside of the cornea. (these changes included the appearance of apoptotic bodies, which are vesicles produced by dying cells.)
(2) increased collagen (fibrous material) production
(3) edema (fluid accumulation) around corneal cells
(4) vacuolization in cell cytoplasm (appearance of vacuoles, which help to
remove unwanted material from cells)

Interestingly, a group of Australian researchers is reporting that children diagnosed with ADHD actually respond better to fish oil than they do to Ritalin. And...hmmm...fish oil can help to preserve eyesight.

I italicized the word "diagnosed" in that last paragraph, because while fish oil can help to improve the biochemical imbalance that is the foundation of ADHD, a child who is misbehaving because of poor parental boundaries including appropriate bedtimes...is not going to change with a single pill or supplement available on the planet. It's called taking the time to be a good parent.

Kids can be snotty, they can be weird, and they can challenge your patience to the max. But when they misbehave, they're not asking for medicine. They're asking you to show them you know they are there, that they are important, and that you have the ability to set the boundaries that help them to feel safe and to be healthy. Not an easy job in this day and age, but the children in our lives owe it to us adults to have a vision for their healthy futures, and to protect their vision in the process.

Gozil R, Take G, Bahcelioglu M, Tunc E, Oktem H, Caglar G, Calguner E, Erdogan D.Dose-dependent ultrastructural changes in rat cornea after oral methylphenidate administration. Saudi Med J. 2008 Apr;29(4):498-502.

http://www.add-adhd.org/ritalin.html

http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=391503&in_page_id=1774

An egg-selent idea for slowing down Alzheimer's

On my infertility (PCOS) blog, I post a weekly item about a food and its health benefits. This week I chose eggs, which have a couple of brain-related nutrients I thought you all, as readers of this blog would enjoy. So I am cross-posting for your benefit.


Aaahhh eggs, the misunderstood member of the nutrition family. Poor guys...when I graduated from college, in the height of the low cholesterol-low fat craze, we were indoctrinated to teach that "egg" was just another word for poison.

My how things have changed!

A couple of months ago I heard Dr. Susan Kleiner (www.goodmooddiet.com) speak at a conference. She shared that not once has there been a research study demonstrating that when you take eggs out of the diet, that this dietary change reduces cholesterol. As well, there has been research demonstrating that adding eggs (plus yolks) to the diet does NOT raise cholesterol. All those yolks I threw down the drain all those years...for nothing.

I figured I'd better find some hard research to back THAT one up, so here's a quick list of interesting titles I found in PubMed:
Dietary cholesterol from eggs increases plasma HDL cholesterol in
overweight men consuming a carbohydrate-restricted diet
Egg yolk improves lipid profile, lipid peroxidation and retinal abnormalities
in a murine model of genetic hypercholesterolemia.
There are many more, but here I just wanted to make my point. Egg yolks are not the ugly stepchild of the protein family anymore.

In fact, there are some great nutrients to be found in eggs.

1. Lutein and xeanthin are two carotenoid compounds that can help maintain visual health. One group of researchers reported that 6 eggs per week can help increase lutein and xeanthin levels in the macula, the part of the eye that degenerates in this country's leading cause of blindness, macular degeneration.

2. Eggs contain choline. This compound is very important for brain function. Choline is the building block for acetylcholine, the neurotransmitter involved in memory, and the one that many Alzheimer's medications seek to increase.

This compound is exceedingly hard to get in the diet. In fact, about the only two places you can find it, are egg yolks, and soy. (Well, also in cooked chicken, beef, veal, and turkey livers, but I didn't think that would have any of you running for your grocery lists so it goes in parentheses.)

If you've got PCOS, you've probably been told to avoid soy. So that leaves egg yolks for getting this very important memory booster.

3. If you hate fish but you need to increase your fish-based omega-3 intake, omega-3 eggs are a very cost-effective option. If you struggle to get enough vegetables in your diet, omelets and frittatas are great ways to get them in. Just be sure you use olive oil when you cook them.

I thought it might be timely to include eggs on this blog, because as food prices rise, they can certainly be much more cost-effective than salmon, as well as other proteins that are now taxing your grocery bill.

Mutungi G, Ratliff J, Puglisi M, Torres-Gonzalez M, Vaishnav U, Leite JO, Quann E, Volek JS, Fernandez ML. Dietary cholesterol from eggs increases plasma HDL cholesterol in overweight men consuming a carbohydrate-restricted diet. J Nutr. 2008 Feb;138(2):272-6.

Fernández-Robredo P, Rodríguez JA, Sádaba LM, Recalde S, García-Layana A.
Egg yolk improves lipid profile, lipid peroxidation and retinal abnormalities in a murine model of genetic hypercholesterolemia. J Nutr Biochem. 2008 Jan;19(1):40-8.

Wenzel AJ, Gerweck C, Barbato D, Nicolosi RJ, Handelman GJ, Curran-Celentano J. A 12-wk egg intervention increases serum zeaxanthin and macular pigment optical density in women. J Nutr. 2006 Oct;136(10):2568-73.

Goodrow EF, Wilson TA, Houde SC, Vishwanathan R, Scollin PA, Handelman G, Nicolosi RJ. Consumption of one egg per day increases serum lutein and zeaxanthin concentrations in older adults without altering serum lipid and lipoprotein cholesterol concentrations. J Nutr. 2006 Oct;136(10):2519-24.

Windex, epilepsy, and bones

In an earlier post I discussed an emerging relationship between antidepressant use and decreased bone density. The problem is not limited to antidepressants. In fact, there is a large body of research devoted to the same issue in people with epilepsy.

The data is a little bit challenging to read through, as one study reports a finding that only one medication causes changes in bone health, while another finds problems in several. In digging through the available discussions on the topic, I discovered one article suggesting that the research discrepancies may be more related to our lack of knowledge about bone health, and therefore our ability to design a study that really tells us what is going on, than it does poor research methodology.

In this study, researchers looked at the effects of three antiepileptic medications on bone health. What they found that even though levetiracetam (Keppra) did not decrease bone mass, it did reduce bone strength and bone formation. What that means is that studies that define bone health only in terms of bone density/mass will not find changes in bone health even though they exist.

The more accurate thing to say is that antiepileptic medications change bone integrity, a more all-encompassing way to define the event, than to narrow the definition down to one method of measuring bone health and strength.

My statistics professor in graduate school used to always tell us, "If you torture the statistics long enough, they'll always confess," so if you really want a study to say what you want it to say, you can refine it and define it to do just that.

This blog is intended to help those people who use the medications, and the most important message seems to be here, is that if you take any kind of psychiatric medication, be sure you are diligent about following recommendations to maximize bone health: minimize your caffeine intake, and be sure you get calcium in your diet.

And here I go with my fish oil again. Fish oil can be a wonderful ally for two reasons: (1) if used properly, in many cases, it can minimize the necessary dose of a medication, therefore limiting the chances of encountering negative side effects, and (2) it in itself helps to strengthen bone.

My neighbor says I'm like the guy in My Big Fat Greek Wedding, only I'm waving fish oil at everything instead of Windex! I'm beginning to think she's right.

Ha! Made you read all the way through the post to see what in the heck Windex had to do with epilepsy and bones. That was my intent! :)

Pack AM, Morrell MJ, Randall A, McMahon DJ, Shane E. Bone health in young women with epilepsy after one year of antiepileptic drug monotherapy. Neurology. 2008 Apr 29;70(18):1586-93.

Chou IJ, Lin KL, Wang HS, Wang CJ. Evaluation of bone mineral density in children receiving carbamazepine or valproate monotherapy. Acta Paediatr Taiwan. 2007 Nov-Dec;48(6):317-22.

Nissen-Meyer LS, Svalheim S, Taubøll E, Gjerstad L, Reinholt FP, Jemtland R. How can antiepileptic drugs affect bone mass, structure and metabolism? Lessons from animal studies. Seizure. 2008 Mar;17(2):187-91. Epub 2008 Jan 3.