Drug-Induced Nutrient Depletion, Lowering LDL Naturally, Treat the Cause
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May Health News

Michelle Crowder, ND - Licensed Naturopathic Physician

Click here to view the last newsletter from April 2014.
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May has been a busy and beautiful month.  

Dr. Dimpi Patel and I completed two successful talks on Food Sensitivities & Digestive Health at Better Health markets in Novi and Bloomfield. We will be collaborating more in the future, so please stay on the lookout...  

I am currently guiding a 14-Day Spring Detox with a delightful, motivated group. We are eliminating some of the most common triggers of inflammation and gently supporting our body's own mechanisms of detoxification and elimination. One goal of my 14-day program is to help people understand the factors that influence their symptoms, so that they have more control over their own health. The ultimate goal is to lead a balanced life, enjoying a wide variety of healthy foods and activities without problems. I am always impressed with the effort put forth by the participants, and the progress they make.  

I am on Facebook! If you have not already, please "like" my page to get more frequent updates on classes and presentations, local events, and of course the various health-related articles I find on the web each week.  I am still on Twitter, as well. Thank you for your support!

Finally, I have been spending more time outdoors going for walks and runs, and sitting in splendid weather with family. Amazing how a leisurely afternoon in the backyard can be so rejuvenating.

En salud,

75 Barclay Circle, Suite 225
Rochester Hills MI 48307

Drug-Induced Nutrient Depletion

Pharmaceuticals are a daily reality for many people.  They can be wonderful, life-saving interventions. For the most part, I believe that we are fortunate to have them at our disposal. That being said, medications - like most things in life - do not come without risks. Due to their impact on factors like nutrient absorption, synthesis, and metabolism, use of some medications is associated with specific nutritional deficiencies.  In fact, some side effects are actually symptoms of nutrient deficiency. The nutritional consequences of medication use, although documented in scientific literature for many drugs, are often not communicated to patients. I am trained in pharmacology, and although I am not licensed to use it in Michigan, I do make this information available to my patients whenever possible. My goal is to increase awareness and prevent nutritional deficiencies from developing.

Common medications that can affect nutritional status include: 
Acid-Suppressing Medications
These drugs work by one of two mechanisms: Proton-Pump Inhibitors (PPIs) inhibit the release of acid from parietal cells of the stomach; examples are Prilosec, Nexium, Prevacid, and Protonix. Histamine 2 Receptor Antagonists (H2 Blockers) block the signal to parietal cells of the stomach to release acid; examples are Pepcid, Tagamet, and Zantac. The overall effect is a reduction in pH of the stomach, a measure of acid concentration.

Stomach acid has many functions. It helps us cleave nutrients from our food, making them available for absorption. This is especially important for Vitamin B12 and all minerals, including iron, calcium, magnesium, and zinc. An acidic environment in the stomach also protects us from pathogens, many of which arrive through our mouth. Use of acid-suppressing medications is associated with higher risk of community-acquired pneumonia, and the potentially life-threatening intestinal infection Clostridium difficile

Many people are not aware that although these drugs are available over the counter, they are not meant to be used long-term. For example, use of Tagamet has not been studied past 12 weeks; Prilosec is indicated for the treatment of GERD without esophageal lesions for 4 weeks. From my perspective, if these medications are used for a longer amount of time, we need to address the cause, rather than continuing to suppress the symptoms (see last article below for more on this). 

Long-term use of acid-suppressing medications is associated with the following nutrient deficiencies and sequelae:
  • Vitamin B12 is a tricky vitamin to absorb.  First, it must be cleaved from dietary protein by acids in the stomach. Then, in the less acidic environment of the duodenum (the start of the small intestine), it attaches to a protein called Intrinsic Factor (IF). The B12-IF complex travels down the small intestine where it is absorbed at the terminal ileum. In addition to reducing stomach acid, H2 Blockers create another roadblock to B12 absorption: IF is secreted by the parietal cells of the stomach, and its secretion is inhibited by H2 Blockers; without IF, B12 cannot be absorbed. Deficiency of B12 with use of acid-suppressing medications is well-documented (1, 2, 3). It is associated with fatigue, anemia, cognitive impairment, depression, neurological disorders, neuropathy, and heart disease.
  • Vitamin D. In order to be used by the body, Vitamin D must pass through a series of steps to “activate” it. This is done in the liver and kidney by specific enzymes. Cimetidine (Tagament) has been shown to block the activity of one of these enzymes, Vitamin D 25-hydroxylase, in the liver. Vitamin D levels have been shown to increase after discontinuation of the drug.
  • Minerals. Like Vitamin B12, minerals need stomach acid in order to be cleaved from food and absorbed. In one study, Iron absorption was reduced by 28% to 65%, depending on dose of Tagamet. Iron-deficiency anemia has been found to improve upon discontinuation of PPIs. Iron deficiency is associated with fatigue, hair loss, anemia, cognitive impairment, and thyroid dysfunction. Calcium and Zinc must be solubilized in water, a pH-dependent process. Zinc deficiency can affect immune function, health of skin and nails, sense of taste and smell. The mechanism of Magnesium depletion is less clear, but is likely related to reduced absorption in the intestines. Magnesium deficiency can lead to muscle spasm, heart arrhythmia, high blood pressure, and depression. One very concerning consequence of prolonged mineral deficiency is reduced bone density. Long-term use of acid suppressing medications (especially PPIs) is associated with increased risk of hip and other fractures in multiple studies (1, 2, 3). This is a good review article to discuss with your healthcare provider if you are concerned. 
  • As an aside, use of acid suppressing medications is associated with altered gall bladder function, possibly increasing risk of gall bladder disease. They have also been linked to increases in mucosal permeability, or “leaky gut,” a topic on which I have previously written.

Lipid-Lowering Drugs
Lipid-lowering drugs, or “Statins” inhibit the action of our enzyme HMG-CoA Reductase. This enzyme is responsible for the synthesis of cholesterol, as well as the nutrient Coenzyme Q10 (CoQ10). Use of statins is associated with the following deficiencies:  
  • Coenzyme Q10 (1, 2) is important in intracellular energy metabolism, and it also has antioxidant capacity. It is especially important for heart muscle function. Many of the side effects of statin drugs are likely due to CoQ10 depletion, including fatigue, decreased exercise tolerance, muscle pain, and muscle breakdown. CoQ10’s role in blood sugar metabolism may also explain why long-term statin use is associated with a higher risk of diabetes (1, 2). 
  • Essential Fatty Acids. As I have previously written, EFAs are important for controlling inflammation throughout the body, and favorably modify many markers of cardiovascular disease. Interestingly, statins have been shown to decrease overall levels of EFAs, as well as shift the balance toward less beneficial forms (1, 2). Theoretically, this could lead to a worsening of cardiovascular disease, which was the original reason for taking the statin in the first place.
Acetaminophen is a commonly-used pain reliever and fever reducer found in products such as Tylenol, Excedrin, Panadol, Apap and Theraflu. When this drug is metabolized by the liver, a toxic intermediate called NAPQI is formed. Under normal circumstances, NAPQI is quickly combined with glutathione, one of our body’s most important antioxidants, rendering it non-toxic and ready for excretion.

Problems arise when (1) large doses of acetaminophen are taken, creating large amounts of NAPQI that overwhelm glutathione’s detoxification capacity, or (2) when insufficient glutathione is available. Both of these scenarios set the stage for liver toxicity and can be life-threatening. (It is worth mentioning that acetaminophen is implicated in nearly 50% of all acute liver failure in the US. In early 2014, the FDA recommended health care professionals discontinue prescribing and dispensing prescription combination drug products with more than 325 mg of acetaminophen to protect consumers.  Doses above 4000 mg in a 24-hour period carry a high risk of liver toxicity, although doses much lower than that can be damaging in many individuals.)

Use of acetaminophen is associated with glutathione depletion (1, 2).
In addition to its role in acetaminophen metabolism, glutathione is involved in the detoxification of alcohol, tobacco smoke, and many other compounds. It is the most abundant antioxidant in the brain and lungs. As such, glutathione deficiency is associated with an increased risk of asthma, COPD, and neurodegenerative diseases such as Parkinson’s and Alzheimer’s (1, 2, 3). Lower capacity for glutathione synthesis has been found in Autism Spectrum Disorders.  Because of its essential role as an antioxidant in tissues throughout the body, glutathione deficiency could be at the root of any chronic disease. On the bright side, restoring glutathione levels has been shown to reduce the damage done to liver cells. 

What To Do About All of This
If you are taking any of these medications, this does NOT necessarily mean you should discontinue taking them. Sometimes the benefit of a drug, or the risk of not taking it, outweighs the risk of taking it. Part of the physician’s job is to navigate the available evidence to determine the best course of treatment for any given patient. If you are concerned, it is certainly worth discussing with your physician. As mentioned before, if a cause for your original symptoms can be identified and addressed, many people find that they no longer need certain medications. Please consult your physician for guidance.  
I expect this to be a popular topic and I would be happy to write more on it in the future. Other commonly-used medications associated with nutrient depletion include oral contraceptives (birth control pills), antibiotics, anti-depressants, anti-hypertensives, and drugs for diabetes.

Featured Therapy: Lowering LDL Naturally

We are still learning about the various factors that contribute to cardiovascular disease, as well as those that reduce risk of death from cardiovascular causes. We could all probably benefit from laughing, getting 30 minutes of moderate exercise 5 days per week, managing our stress (1, 2), and sleeping well. But what else is there to do? 

Despite all the focus on cholesterol levels, we are still not certain that high cholesterol leads to heart disease. Evidence is mixed (1, 2, 3, 4, 5). We are fairly certain, however, that LDL (Low-Density Lipoprotein) cholesterol is involved in the formation of atherosclerotic plaques, or “hardening of the arteries” (1, 2, 3). These plaques are associated with increased risk of heart attack and stroke (1, 2). It would make sense then, if LDL is too high, risk for plaque formation would be higher as well, simply due to more LDL being around. Optimal LDL levels are dependent on individual risk factors, and so vary by person. Most practitioners like to see LDL somewhere in the range of 70 – 130 mg/dl.

Non-Pharmaceutical, Evidence-Based Therapies that Lower LDL:
  • Phytosterols are plant-derived compounds that are similar in structure and function to cholesterol. They inhibit the absorption of cholesterol from the intestines, which seems to stimulate increased clearance of LDL particles, thereby reducing LDL cholesterol. Studies show that 2.0 – 2.3 grams of phytosterols per day can reduce LDL by up to 15% (1, 2, 3).
  • Dietary Fiber. Similar to the mechanism of phytosterols, soluble dietary fiber reduces absorption of cholesterol in the intestines, which leads to an overall decrease in LDL level. Soluble fiber in the range of 10-25 grams per day seems to be most effective at lowering LDL (1, 2, 3). A mix of soluble and insoluble fiber to get a total of 35-45 grams per day is a good general target. 

How To:
  1. Ground flaxseed is a good source of soluble fiber and plant lignans. Studies that showed a significant effect of flaxseed on LDL used 3-4 tablespoons of ground (“milled”) seed per day. Chia seeds may also be beneficial, although they are less studied. Psyllium husk has also been shown to decrease LDL. However, flaxseed has many other documented cardiovascular benefits, including reduction in inflammation, atherosclerosis, and heart arrhythmia; plus non-cardiovascular benefits like cancer prevention and hormone balance. See here for more on flax and chia seed.  
  2. Nuts are high in phytosterols, fiber, and essential fatty acids. I recommend all nuts except for peanuts, due to their inflammatory properties. The Portfolio Diet, which has an LDL-cholesterol lowering capacity similar to 20 mg lovastatin daily, includes about ¼ cup of almonds per day.
  3. Vegetables, legumes, and whole grains will give you a nice balance of soluble and insoluble fiber to complement the flaxseed.   
  4. A Note on Oxidation: Keeping LDL in an optimal range is important, but so is making sure that the LDL is not oxidized. LDL oxidation is thought to be one of the first steps in the formation of atherosclerosis. To prevent LDL oxidation, include plenty of antioxidant-rich foods like turmeric, berries, and green tea. Sulfur-rich foods like cabbage-family vegetables (kale, broccoli, cauliflower, etc.) will help increase your body’s own production of antioxidants such as glutathione
Not surprisingly, many of these therapies are features of the Mediterranean Diet, which has become an evidence-based “all-purpose” eating style for general health. But remember, there is no one “diet” that works for everyone. Your naturopathic physician can help you develop an approach that best suits your individual needs. 

Principles of Naturopathic Medicine Series

In 1989, a group of Naturopathic Doctors met to define our profession. The Six Principles of Naturopathic Medicine were born out of these meetings.  The principles have been refined over time, most recently in 2011, and serve as a framework for both defining our medicine and influencing clinical decision-making.  As a way to further relate what I do, I will be reviewing one principle per newsletter for the next several months.
3. Treat the Cause
4. Treat the Whole Person
5. Doctor as Teacher
6. Prevention 

Treat the Cause

Before we can treat the cause, we need to identify it - or more commonly - identify the multiple causes. This is part of the reason I do such an extensive history - I want to identify the factors throughout your life that have contributed to your current health status. Having access to past medical records is also essential, so that I can see what workup has been done and what the findings were. The more thoroughly I am able to understand the causes in your particular case, the better I am able to tailor my recommendations, which will generally translate into improved outcomes.
Many pharmaceuticals "silence" the body's signals by suppressing symptoms, no matter what the cause. However, if the underlying imbalances are not addressed, they may manifest elsewhere over time. For example, if a stressful lifestyle is at the root of your digestive issues and it is not addressed, it could contribute to other stress-related illnesses such as heart disease or diabetes. Addressing the root cause generally requires more effort than taking a pill, but the benefits are multi-dimensional and long-lasting.   

What is Naturopathic Medicine?

In short, Naturopathic Medicine combines the best of conventional and alternative medicine into an individualized, whole-person approach to primary health care. NDs are trained as primary care providers with an emphasis on natural and common sense approaches including clinical nutrition, lifestyle counseling, and botanical medicine.

What to Expect from Your Visit

I work with my clients to identify the root causes of disease, taking into account the various factors that influence health, including lifestyle, genetics, physiology, and mental-emotional state. First visits are 90 minutes and include a thorough health history, followed by discussion of my preliminary assessment and recommendations. I may order conventional or specialty lab work to aid in my understanding of your condition. We work together to devise a plan that will meet your health goals.

Follow-up visits generally last 30-45 minutes and are important so that I can better get to know your unique physiology, track your progress, and refine my recommendations. I can consult with your other health providers and make referrals as necessary.

Integrative Medicine

I am fortunate to work in an integrative primary care practice, alongside a D.O. (Doctor of Osteopathy), N.P. (Nurse Practitioner), and P.A. (Physician's Assistant).  We share patients and regularly consult with each other to coordinate care. 

I believe this approach benefits patients by offering them the best of both worlds - conventional and natural.  These two worlds are not mutually exclusive; in fact, many health concerns are best addressed by a multifaceted approach.  The power of Integrative Medicine is backed by research, especially for chronic conditions such as heart disease.
I am now offering Gift Certificates for my services. They are available for a 90 minute New Patient appointment, 1 hour Follow-Up, and 30 minute Follow-Up.  Please call my office with questions, or to order one for a friend or family member.

FYI: Licensing and Regulation of Naturopathic Medicine

Licensed Naturopathic Physicians attend a 4-year post-graduate medical school accredited by the Council on Naturopathic Medical Education and recognized by the U.S. Department of Education. They must pass basic science and clinical licensing exams administered by the North American Board of Naturopathic Examiners. Currently, 16 states license Naturopathic doctors as primary care providers. National and state legislative efforts are organized by the American Association of Naturopathic Physicians.  Because NDs are not currently licensed in Michigan, they function as complementary providers.

For more information about the active legislative efforts to license Naturopathic Medicine in Michigan, visit the Michigan Association of Naturopathic Physicians.


About Michelle Crowder, ND

Michelle Crowder, ND is a licensed Naturopathic Physician with a focus in holistic and preventative primary care.  She works with people of all ages to identify and treat the root causes of disease, empowering her clients with the tools they need to understand and take control of their own health. Areas of special interest include digestive health, hormone imbalance, and immune dysfunction, including thyroid disease.

National College of Natural Medicine, Doctorate of Naturopathic Medicine, High honors
University of Vermont, Master of Science in Botany, Summa Cum Laude
University of Michigan, Bachelor of Science in Biology, Summa Cum Laude
Copyright © 2014 Michelle C Davila, ND, All rights reserved.
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