As a result of this knowledge, the gluten-free diet has become more accepted. Gluten-free foods have been filling grocery store aisles and are being featured on many restaurant menus. Still, while the quality, variety, and availability have all increased, there are a lot of misperceptions today about who should and shouldn’t be following a gluten-free diet.

Who Should Be Gluten Free

“If you notice symptoms of intolerance after you consume gluten, perhaps you should try a gluten-free diet,” says Jenna Rosenfeld, a registered dietitian at NewYork-Presbyterian Hospital/Weill Cornell. “It’s important to completely eliminate gluten, while also keeping all other dietary choices stable, for a few weeks. Note how you feel during this time, and then try reintroducing gluten to check for any return of symptoms.”

Symptoms of a non-celiac gluten or wheat intolerance include mental changes (“foggy mind”, depression, ADHD-like behavior), gastrointestinal distress (abdominal pain, bloating, diarrhea, constipation), or headaches, bone or joint pain, and chronic fatigue.

Take extra care when starting a gluten-free diet, as it can be deficient in fiber, B vitamins (thiamin, niacin, riboflavin, and folate) and iron. Other food sources of fiber include fresh fruits, vegetables, and gluten-free grains like quinoa, brown rice, amaranth, buckwheat and millet. B vitamins can be found in sunflower seeds, black beans, green peas, lentils, mushrooms, soybeans, avocado, broccoli, tuna, salmon, chicken breast, and green leafy vegetables (spinach, romaine lettuce, turnip greens). While many people meet their iron needs through fortified flours, cereals, and breads, healthier suppliers of iron include turkey, lean beef, lentils, spinach, fortified oats, and soybeans.

Lastly, when starting a gluten-free diet, be sure to read nutrition labels. There are many surprising foods that may contain gluten: oats (which are gluten-free but often become contaminated in processing), gravies, hot dogs, bouillon cubes, candy (such as licorice) and even some medications and vitamins. To be absolutely certain, choose products with the verified “gluten-free” label.

Who Shouldn’t Be Gluten Free

“If you tolerate gluten and wheat without any issues, you do not need to follow a gluten-free diet,” says Rosenfeld. Many people try a gluten-free diet to lose weight and be healthier. “Unfortunately a gluten-free diet may not be as helpful as you believe,” says Rosenfeld. “For example, many gluten-free breads or crackers are higher in calories than a whole-wheat product, but lower in fiber and vitamins.”

If you have medical reasons for being on a gluten-free diet, discuss your health situation with your health-care provider and a registered dietitian to ensure you are following the most nutritious diet.

Lack of Sleep Weakens Willpower, Increases Cravings

Lack of sleep is tied to increased risk for obesity, diabetes, and heart disease. It also increases stress hormones, which can lead to increased sugar cravings. A study published in The Journal of Neuroscience, Dec. 17, 2018, subjected 32 lean, healthy men to a good night’s sleep vs. a night of sleep deprivation. After each night of deprivation, their peptide hormone “ghrelin”—which promotes appetite—increased. Also, they were willing to spend more money on food after sleep deprivation than after a good night’s rest, and their desire for food rewards—such as foods that taste good but are not necessarily healthy—was increased.

The post Who Should and Shouldn’t Be Eating Gluten-Free Foods appeared first on University Health News.

Stress as a Cause of Fatigue

Chronic or severe stress is a very common cause of fatigue. Stress is a real or interpreted threat that results in physical and be-havioral responses that are designed to help the body adapt. Situations that are new, unpredictable, or that appear threatening or uncontrollable activate the body’s stress response systems, which are controlled by the brain, the nervous system, and the ad-renal glands. The purpose of these responses is to mobilize the energy necessary for your body to adapt to the demands of a stressful situation.

In the short term, stress can be positive, because it can help you to grow, to learn, and to adapt. In the long term, however, when stress becomes chronic, uncontrollable, unpredictable, and difficult to cope with, it begins to take a toll on your health.

Stressors may be physical, chemical, and emotional. They may be real or exist only in your mind. Sources of acute stress are usually fairly obvious, but it is vital for you to identify and address your unique sources of chronic stress to overcome your fatigue.

There are many forms of chronic stress. Mental and emotional stress are the most obvious, but sleep disorders, blood sugar dysregulation, oxidative stress, and chronic inflammation are all forms of chronic stress.

Your overall stress load is made up of multiple factors, including your genetic predispositions; recent and distant history (especially trauma, abuse, or major life events); coping behaviors; habits and lifestyle; and exposure to environmental toxins.

When your body is bombarded by repeated stress triggers and prolonged stress, your overall well-being pays the price. Your stress response systems can become sluggish, ineffective, or prolonged, or they may not start or stop correctly. This, in turn, taxes your body’s nervous, hormonal, immune, metabolic, and cardiovascular systems, causing fatigue among a variety of other physical and psychological problems.

Fatigue is one of the primary symptoms that can result from chronic stress and a dysfunctional stress-response system. If you perceive yourself to be highly stressed, studies show that you are much more likely to suffer from not only greater fatigue, but from daytime sleepiness, poor sleep quality, and decreased sleep duration. You are also at higher risk for sleep apnea. Which of these apply to you?

• Work-related stress
• Stress caused by over-commitment
• Lack of social support
• High demands
• Lack of control
• Lack of rewards

All of these have been shown in studies to drain energy resources and cause fatigue.

Stress, Adrenal Fatigue, and HPA Axis Dysfunction

In order to understand how stress causes fatigue, it’s helpful to understand a little about what’s known as the the hypothalamic pituitary adrenal (HPA) axis.

The HPA axis makes up your body’s hormonal system for responding to stress. “HPA” refers to three hormone-secreting glands:

• The portion of the brain known as the hypothalamus
• The pituitary gland in the brain
• The adrenal glands, which sit on top of the kidneys

The HPA axis can be activated by an array of mental and physical stressors. Activation occurs when the brain interprets a threat, causing nerve cells in the hypothalamus to secrete a hormone called “corticotropin-releasing hormone” (CRH).

The CRH travels to the pituitary gland, which responds to its presence by secreting a pulse of another hormone called “adre-nocorticotropin hormone” (ACTH).

ACTH is then carried to the adrenal glands, where it stimulates the secretion of cortisol. In a properly functioning HPA axis, chemicals in the hypothalamus are sent to the pituitary gland, which triggers the production of a hormone that is sent to the the adrenal cortex, triggering the production of cortisol.

Cortisol

Of all the hormones involved in the HPA axis, the adrenal stress hormone cortisol receives the most attention. This is because of the direct relationship cortisol has with energy levels and fatigue. Cortisol regulation is intricately related to both physical and psychological well-being and aids in the healthy functioning of a wide variety of systems throughout the body.

• In the nervous system, cortisol is involved in learning, memory, and emotion.
• In the metabolic system, cortisol helps regulate blood sugar.
• In the immune system, cortisol regulates inflammation and the development of immune cells.

Cortisol measurements can be used to determine whether your HPA axis is functioning properly (i.e., whether your body and your mind have the energy they need to adequately adapt to challenges and stressful situations).

HPA axis activity may be assessed by measuring levels of cortisol in samples of saliva taken at different times of the day. When an HPA axis is functioning properly, cortisol levels are highest approximately 30 to 40 minutes after waking and decline over the course of the day, when levels reach a trough, prior to sleep onset. Many labs now offer salivary cortisol testing in a take-home kit.

Healthy HPA axis functioning requires HPA resilience, which refers to the ability of the HPA system to react appropriately to stressful conditions. Either one big stressful event or chronic stress over time can cause the HPA axis to lose resilience and function incorrectly.

It is thought that high levels of stress experienced early on in life can interfere with the successful development of a child’s HPA axis.

Childhood stress may negatively affect the way a child develops his or her ability to deal with subsequent stresses that occur later on in life. Studies have confirmed that childhood trauma is a direct risk factor for HPA axis dysfunction as measured via cor-tisol levels, for fatigue in adulthood, and for chronic fatigue syndrome.

Once it has lost resilience, the HPA axis may either overreact or “under-react” to stressful events. In other words, stress can both increase and decrease HPA axis activity, depending on the individual and on the nature of the stress.

Both overactivity and underactivity of the HPA axis can result in fatigue, although it is underactivity of the HPA axis with which fatigue is most frequently associated. When the HPA axis is under-
reactive and cortisol levels become chronically reduced, fatigue and other symptoms worsen.

The main symptoms of low cortisol levels are:

• Fatigue
• Pain
• Increased sensitivity to stress

As the body’s main stress hormone, cortisol is the first thing you may want to check off your list of potential fatigue factors. In patients with chronic fatigue syndrome, dysfunction of the HPA axis characterized by low cortisol levels is one of the hallmark features.

Studies have shown that the lower the cortisol levels in those with CFS, the more severely one may experience fatigue and other symptoms.

A number of other fatigue-related conditions, in addition to CFS, also are associated with stress, hypoactivity of the HPA axis, and low cortisol. These conditions include fibromyalgia (a disease that causes chronic and widespread pain and fatigue), post-traumatic stress disorder (PTSD), and certain types of depression.

Even those considered healthy by conventional standards can suffer from low cortisol. In one study, healthy adults who felt significantly sleepier during the day, were more likely to feel anxious or exhausted, and were more likely to experience poor health when they had low cortisol levels upon awakening

In some people—fibromyalgia patients, for example—studies have found that, while cortisol levels appear normal, the cells’ receptors for cortisol (glucocorticoid receptors) do not function properly. This renders the cortisol ineffective and results in a situation that mimics low cortisol.

On the opposite end of the spectrum of HPA axis dysfunction, cortisol levels are chronically elevated rather than low. This also can cause fatigue. A “burnt out” feeling and certain types of depression are often associated with high cortisol levels during the day.

DHEA

In addition to cortisol, the adrenal glands are responsible for secreting the steroid hormones dehydroepiandrosterone (DHEA) and DHEA-sulfate (DHEAS). DHEA is converted into testosterone and estrogen in body tissues.

DHEA and DHEAS also are made and used directly by the brain.

In fact, DHEA and DHEAS are the most abundant steroid hormones in the human body. Surprisingly, in spite of this, their part in the human body is not well understood by scientists.

It is known that DHEA secretion declines steadily with age and in conjunction with chronic stress, inflammation, and illness. DHEA plays an important role in:

• Maintaining overall health
• Protecting the nervous system
• Proper immune function
• Helping prevent diabetes
• Preventing blood sugar imbalance
• Preventing obesity and cancer
  Preventing memory loss
• Slowing the effects of aging

Research into the role of DHEA in fatigue is conflicting. Some studies have found that high DHEA levels predict the length of life in men, while other studies have found that low DHEA levels were associated with fatigue, anxiety, depression, and overall low mood. However, there is a lack of solid evidence that DHEA supplementation reduces fatigue or stress. Small studies show potential benefits in fatigue associated with depression and Addison’s disease (a rare adrenal disorder).

Testing for DHEA is not common and the results can be difficult to interpret, but tests can be useful in investigating HPA axis dysfunction.

Depression and Anxiety as Causes of Fatigue

Depression is a treatable medical illness characterized by prolonged intense feelings of sadness. Fatigue is the symptom of depression that is most commonly reported to family practitioners and the symptom that correlates most strongly with a lack of so-cial functioning, days of lost work, and low work productivity.

The severity of fatigue in those suffering from depression depends on the severity of the depression itself. Depression also may be accompanied by anxiety and insomnia, which may increase the amount of fatigue.

While fatigue is often a symptom of depression, the reverse is also true: Depression is often a symptom of fatigue.In addition, if you’re fatigued but not currently depressed, you’re at a higher risk for developing depression later on in life.

The insomnia, chronic sleep loss, poor sleep quality, and reduced amounts of rapid eye movement (REM) sleep that are typically associated with depression may be partly responsible for the fatigue and excessive daytime sleepiness frequently experienced by those with depression.

On the opposite end of the spectrum, people with depression also may tend to oversleep—and too much sleep is also a major cause of fatigue and excessive daytime sleepiness.

In some cases, sleep disturbances are a side effect of anti-depressant medications, rather than the depression itself.

Anxiety, Depression, and Fatigue

Anxiety disorders are characterized by excessive worrying. Fatigue is one of the many symptoms that often accompany anxiety, along with restlessness, feeling “keyed up” or on edge, difficulty concentrating, forgetfulness, irritability, muscle tension, and sleep disturbances (including difficulty falling or staying asleep, restlessness, or unsatisfying sleep). Headaches, muscle aches, and digestive symptoms are also common.

Anxiety disorders, such as generalized anxiety disorder, panic disorder, post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder, are the most common mental health problems in the U.S.

Over your lifetime, you have a 16.6 percent chance of experiencing an anxiety disorder. General anxiety that does not quite meet the criteria of an anxiety disorder is even more common.

When anxiety is treated conventionally, drugs are often the sole method, but clinical trials have shown that drugs alone are not effective on a long-term scale. Moreover, anxiety medications have side effects that are often as equally disruptive as the disor-der itself. Some of the most common side effects of traditional anxiety medications are:

• Drowsiness
• Dependency
• Impaired cognition
• Memory loss
• Sexual dysfunction

If you have anxiety or depression, you are suffering from a real illness. Healing is possible, but it takes time, commitment, and practice. In addition to therapy (and, in some cases, medication), lifestyle changes, nutritional support, and natural therapies can be immensely helpful in overcoming fatigue, depression, and anxiety. These natural treatments are covered later.

Thyroid Imbalance as a Cause of Fatigue

The thyroid gland and the hormones it produces play a critical role in your metabolism and your ability to achieve and maintain normal physical and mental energy.

A low-functioning thyroid can lead to a long list of chronic symptoms, often subtle and ignored, with fatigue usually near the top of that list. “Hypothyroidism” is the technical name for an underactive thyroid. It’s an extremely common hormone disorder, especially in women.

The thyroid gland is located in your neck and it produces two key hormones: T4 (thyroxine/thyroid hormone) and T3 (triiodo-thyronine hormone), which are crucial for metabolism and keeping your energy levels up.

Here are a few important definitions to refer back to in this section:

• Thyroid—The hormone-releasing gland located in your neck that acts as the metabolic accelerator in your body
• Hypothyroidism—The condition that results when your body is not producing enough thyroid hormone
• Autoimmune thyroid disease—A disorder in the body that causes the immune system to mistakenly attack the body’s thyroid gland and the most common cause of hypothyroidism
• T4—The “reserve” form of the thyroid hormone that must be converted by the body to the metabolically active thyroid hormone T3
• T3—The hormone that goes into body cells and performs the marvelous energy-producing metabolic work

Hypothyroidism is most commonly caused by autoimmune thyroid disease, a disorder in the body that causes the immune system to mistakenly attack the body’s thyroid gland.

The attack renders the thyroid incapable of producing enough thyroid hormone to keep your metabolism working at a normal pace, leading, ultimately, to fatigue and other symptoms.

Almost 5 percent of the United States population has been diagnosed with hypothyroidism, while 4 to 20 percent of people have what doctors call “subclinical hypothyroidism,” which, most experts agree, is the equivalent of the early stages of mild thyroid failure.

Symptoms of Hypothyroidism

Hypothyroidism causes your brain and body to slow down. Those affected feel tired, “heavy,” and slow, both physically and men-tally. It is important to determine whether you carry many of the symptoms of hypothyroidism.

Typical symptoms of hypothyroidism include:

• Fatigue
• Weight gain or obesity
• Depression
• Sensitivity to cold
• Thin and friable (easily crumbled) nails
• Muscle aches
• Headaches
• Decreased libido
• Low basal body temperature (consistently below 98.6°F)
• Weakness
• Cold intolerance
• Water retention
• Dry skin
• Thinning of the lateral 1/3 of the eyebrows
• Menstrual irregularities
• Memory loss and cognitive impairment
• High cholesterol levels
• Decreased tolerance for exercise

What Causes Fatigue in People with Hypothyroidism?

The general fatigue associated with hypothyroidism is caused by a number of different mechanisms but is primarily the result of an overall decrease in metabolism.

Cells throughout the entire body rely on thyroid hormone to perform their basic metabolic functions. A lack of thyroid hormone results in a slower basal metabolic rate. When metabolism is low, activity of the mitochondria within cells is impaired, which leads to low levels of ATP (adenosine triphosphate—an energizer in the cells) and, ultimately, to generalized fatigue. In addition to general fatigue, low ATP levels also contribute to muscle symptoms such as increased muscle tension, pain, and weakness.

Furthermore, patients with hypothyroidism are known to produce more lactic acid, which also contributes to muscle pain, muscle cramps, and fatigue.

Many individuals with hypothyroidism may notice fatigue especially with physical exertion. This is caused in part by the direct effects of thyroid hormone on heart tissue. Without enough thyroid hormone, the heart slows down and decreases the amount of blood pumped, reducing the flow of oxygenated blood to the tissues.

Because thyroid hormone also influences blood sugar metabolism and blood flow to the brain, thyroid hormone deficiency also can cause fatigue by decreasing the amount of glucose and oxygen available to the brain. This leads to the lethargy, forgetfulness, and depression common to those with hypothyroidism.

Diagnosis of Hypothyroidism

TSH, or thyroid stimulating hormone, is a hormone released by the pituitary gland in the brain. Its function is to stimulate thyroid hormone production by the thyroid gland. TSH can be measured in a simple blood test. This test is the most important factor for diagnosing hypothyroidism.

TSH levels within the normal range indicate a healthy thyroid. However, when the TSH level is high, your clinican will request a blood test for T4 levels. Many conventional clinicians will diagnose hypothyroidism when TSH is abnormally high and T4 is abnormally low. This combination indicates that the brain is trying very hard to stimulate the thyroid gland to make T4 thyroid hormone, but the thyroid gland is not able to do it.

Anyone who feels constantly tired, “in a fog,” cold, and unable to lose weight or keep weight off despite dieting should be checked for hypothyroidism.

If your thyroid gland is not producing enough thyroid hormone, you will continue to feel debilitating fatigue, despite whatever positive steps you might take in response to the suggestions highlighted in this book.

Subclinical and Sublaboratory Hypothyroidism

If you have an elevated TSH but your thyroid hormones (T4 and T3) are in the normal range, you have what is referred to as sub-clinical hypothyroidism.

The term subclinical hypothyroidism often gets misused and is, indeed, confusing, given that the signs and symptoms (fatigue, depression, weight gain, and high cholesterol) are very often clinically significant and can reduce your quality of life.

Furthermore, even though subclinical hypothyroidism is considered a mild form of hypothyroidism, studies show that if left untreated, it poses serious risks, including:

• Increased risk of other serious diseases, such as heart disease and insulin resistance
• Increased risk of dying from any cause

On the other hand, studies have proven that treatment for subclinical hypothyroidism can:

• Significantly reduce fatigue
• Decrease risk factors for cardiovascular disease, including high cholesterol, waist-to-hip ratio, and endothelial dysfunction, an early marker of atherosclerosis (hardening of the arteries)

Sublaboratory hypothyroidism, which is very similar to subclinical hypothyroidism, refers to the condition in which the signs and symptoms of hypothyroidism are present, even though standard TSH, free T4, and free T3 tests produced normal results.

Why Does Sublaboratory Hypothyroidism Occur?

There are various reasons hypothyroidism may not be recognizable.

There’s currently a wide range for normal TSH and other thyroid hormone values, and these ranges are controversial. A threshold of 4 to 5 has been conventionally used to diagnose an elevated TSH, but data from large population studies have suggested a much lower TSH cut-off, with an upper limit of 2 to 2.5. If you have had your TSH measured and it fell somewhere be-tween 2 and 5, your doctor likely assumed your TSH was normal and, therefore, that you did not have hypothyroidism.

The time of day, the season, and your genetics all cause considerable variations in thyroid hormone levels. Levels fluctuate throughout the day, so it is possible you were tested at a time when your levels were within the normal range, missing the fact that more often they are abnormal.

Tissue levels of thyroid hormone may be low. Emerging evidence shows that, although standard blood test results might be normal, levels of thyroid hormones, specifically T3 (the more metabolically active thyroid hormone), in body tissue might still be low.

T3 functions inside the cells of your tissues, rather than in your blood. It is in the tissues that T3 stimulates energy production via its ability to act as a “key” on cellular receptor sites and increase the production of ATP from the cell. In medical terms, this phenomenon is sometimes referred to as “cellular resistance to thyroid hormone.”

Normally, once the thyroid gland produces and releases T4, the T4 travels to various tissues in the body, via the blood, where it is converted to the more metabolically active T3. However, in a number of conditions ranging from depression to obesity, the enzyme that is responsible for the conversion of T4 to T3 may be suppressed.

This suppression occurs everywhere in the body except the pituitary, where the enzyme doesn’t function in the same way. The pituitary is still able to perceive normal T3 levels, even though T3 is low throughout the rest of the body’s tissues, and continues to produce a normal amount of TSH, resulting in a normal TSH blood test.

T4 may be converting into a molecule called reverse T3 (rT3) instead of active T3. Reverse T3 acts as a metabolic “brake” during periods when a system requires less energy. Reverse T3 is called the “anti-thyroid” hormone because, during times of signifi-cant bodily stress or illness, it blocks T3 from having an effect. Increased levels of rT3 reduces metabolism, suppresses T4 to T3 conversion, and reduces T3 levels inside of cells. Reverse T3 can be measured in the serum. An abnormally high serum level of reverse T3 indicates low T3 activity inside of cells, even if serum TSH and T3 are normal.

With significant stress, chronic illness, inflammation, and aging, TSH tends to decrease, as does conversion of T4 to T3 inside the cell. In these conditions, instead of converting to T3, T4 is converted to reverse T3 and TSH production becomes suppressed, though it still appears to be within the “normal” range.

There is no easy way to measure tissue level of hormones directly. Health-care providers must rely on serum testing, despite the fact that it reflects only the levels of thyroid hormones in the blood. However, studies indicate that measuring the ratio of two subsets of T3 (rT3 and free T3) can be a useful indicator of tissue thyroid levels. Free T3 and rT3 tests can be ordered at most major clinical laboratories. Even though this method is still just a measure of the amount of T3 in the serum and not of what is in-side cells, it is a more accurate reflection of the amount of T3 that is “available” for the body to use.

Kent Holtorf, MD, who specializes in alternative treatments for hypothyroidism, chronic fatigue syndrome, and complex hor-mone disorders, states that a free T3/rT3 ratio of less than 1.8 picoggram/nanogram (pg/ng) is consistent with low tissue thyroid activity. Dr. Holtorf notes that patients with a free T3/rT3 ratio of less than 1.8 and symptoms of hypothyroidism who test normal for TSH and T4 levels often notice significant improvement with their symptoms when treated with T3 replacement.

Because the normal process of converting T4 to T3 can be diminished, it’s not surprising that T4 supplementation has little ef-fect on some people who find treatment with T3 or T4 and T3 combinations significantly more effective.

Central Hypothyroidism

Another culprit of deceptively normal thyroid testing is central hypothyroidism. This condition develops when the thyroid gland produces too little thyroid hormone, which results because of the malfunction of one or both of the structures in the brain that regulate the thyroid gland (the hypothalamus and the pituitary gland).

The deficiency results in insufficient production of thyroid stimulating hormone (TSH) despite an otherwise normally functioning thyroid gland, which renders it unable to produce sufficient thyroid hormone.

Central hypothyroidism is much less common than primary hypothyroidism and is usually caused by brain cancer (pituitary ad-enomas) or traumatic brain injury. The main symptom of central hypothyroidism, as with all types of hypothyroidism, is fatigue.

Lab tests typically reveal normal to low-normal TSH levels, along with low-normal T3 and T4 levels. Diagnosis is confirmed by the TRH stimulation test.

Conventional therapy is usually levothyroxine (T4). The dose is typically slowly increased until fatigue and other symptoms im-prove. Health-care practitioners also may utilize some form of T3 replacement, as we’ll discuss later.

Thyroid Hormone Deficiency? How to Find Out

How do you know if you do have a thyroid hormone deficiency? And how can someone suffering from debilitating fatigue deter-mine whether a dysfunctional thyroid is an underlying cause?

First, look at your symptoms and compare them to the typical symptoms listed earlier in this chapter and repeated, for quick reference, in the sidebar on this page. The more symptoms you have from this list, the more likely it is that you have a thyroid imbalance.

If your symptoms appear to match those of a typical thyroid patient, ask your doctor to run blood tests that include the meas-urement of free T3 and rT3.

Remember, this test can be ordered from most clinical laboratories. If the ratio of free T3/rT3 is low (less than 1.8 pg/ng, de-pending on the laboratory’s methods) your condition is consistent with low tissue thyroid activity regardless of whether your TSH levels are in the standard lab range or not.

The good news is that patients with low tissue thyroid levels and normal TSH levels often experience significantly reduced symptoms of fatigue, depression, weight gain, and other problems when treated with thyroid hormone replacement that includes T3.

If you do in fact have a thyroid problem, correcting it will produce remarkable improvements: You’ll have a new spring in your step and a new zeal for life.

Fatigue and Sex Hormone Decline or Imbalance

As we hit middle age, there’s a slow but gradual decline in all physiological functions. Energy loss, loss of muscle mass, and in-creased fat mass are tied to declining hormone levels. This age-related drop in hormone levels is referred to as menopause in women and andropause in men.

Hormone loss is the result of deteriorating hormone-secreting glands like the thyroid, pancreas, adrenals, testes, ovaries, and pituitary glands. Testosterone in men and estrogen and progesterone in women are the primary sex hormones covered in this chapter, but a lack of thyroid hormone, DHEA, growth hormone, melatonin, and other pituitary hormones are important to consider.

Andropause

Testosterone deficiency affects at least 20 percent of men in the United States over the age of 50 and at least 25 percent of men over 70. Fatigue is a key symptom.

Men with low testosterone levels report lower energy and vitality compared to men of the same age with normal testosterone. Low testosterone levels also have been associated with poor general health, poor cognitive function, and poor sexual health.

The following symptoms are associated with low testosterone levels:

• Fatigue
• Inability to perform vigorous activity
• Depression
• Reduced sex drive
• Erectile dysfunction
• Memory loss
• Weight gain (especially around the waist)
• Anemia
• Decreased muscle mass and strength
• Decreased bone mineral density

As you can see, testosterone is about more than just sexual health or muscle strength. If you have fatigue accompanied by a decreased desire for sex or problems with erections, low testosterone levels may be to blame.

The most common way to measure testosterone is with a blood test. A total measurement of testosterone in the serum of less than 200 to 250 nanograms per decilite is considered low in most laboratories; values between 250 and 350 ng/dL are usually considered borderline low, although standards may vary.

Just as with thyroid blood tests, the total testosterone level doesn’t give the full picture: It’s possible to have a normal total testosterone level but, at the same time, have low levels of testosterone available to the body’s tissues.

“Free testosterone” is the portion of the total testosterone that’s not bound to proteins and, therefore, is available for the body to utilize. Free testosterone makes up about 2 percent of the body’s total testosterone and is considered the “active” version of the hormone.

Menopause and Perimenopause

In women, the drop in hormones (progesterone and estrogen in women) occurs much more suddenly than in men, which is why menopause can lead to more extreme and obvious symptoms.

Menopause is the process that marks the end of menstruation in women and usually occurs in women between 45 and 55 years old. Hot flashes and fatigue are two of the most common complaints associated with menopause. Perimenopause refers to the interval just before menopause, during which ovarian function begins a steadier decline.

Menopause and perimenopause symptoms include the following:

• Fatigue
• Hot flashes
• Thinning of the vaginal mucosa (which can cause burning, itching, bleeding, and painful intercourse)
• Thinning of the urinary mucosa (which can lead to frequent
  urinary tract infections or painful urination)
• Incontinence
• Thinning and loss of elasticity of the skin
• Insomnia
  Difficulty concentrating
• Anxiety
• Headaches

Estrogen deficiency associated with menopause can contribute to a decrease in bone density and an increased risk of osteo-porosis and bone fractures.

A deterioration of cholesterol levels also occurs, characterized by decreased levels of “good” cholesterol (HDL) and increased levels of “bad” cholesterol (LDL) and triglycerides—and, as a result an increased incidence of cardiovascular disease.

Sleep Disturbances and Fatigue

Sleep disturbances in menopausal and perimenopausal women are mainly attributed to hot flashes during the night, or “night sweats.” Frequent menopausal sleep disturbances have been found in other studies to be related to the following negative side effects:

• Psychological symptoms
• A diminished self-perceived health status
• A prevalence of unhealthy behaviors
• Arthritis

Research shows that fatigue in older women also can be related to stress, depression, and excessive weight gain.

Even genetic differences that determine the way women process and metabolize estrogens have been found to make a difference in menopausal symptoms. As with all genetic factors, however, keep in mind that your genes are not your destiny. Just because you may have a genetic predisposition toward menopause-related fatigue doesn’t mean you have to continue to experience it, or that you will.

Your actions and your environment play a large role in determining which genes are expressed. Smokers, for instance, are known to have more serious problems with menopausal symptoms because of interactions between genes that metabolize estrogens and toxins from cigarettes.

The decisions you make now have very real consequences over your general health—even the genetic aspects of it that can seem outside of your control.

Poor Sleep and Fatigue

Sleep is the most important restorative process for your body and your mind. The regeneration that occurs during deep sleep renews your energy and helps to determine your long-term health. Not surprisingly, sleep issues can lead to fatigue and excessive daytime sleepiness. Three of the most common sleep-related causes of fatigue are:

• Not being able to fall sleep or stay asleep (insomnia)
• Not allowing yourself enough sleep time (sleep deprivation)
• Having a sleep disorder related to breathing (sleep apnea)

Each of these conditions produces sleep disturbances and results not just in fatigue, but other symptoms such as depression, tension, mood disturbances, and reduced attention, motivation, vigilance, and concentration.

Adequate quantity and quality of sleep are necessary not just to keep you energized during the day, but to regulate the proper functioning of your immune, inflammatory, nervous, and hormonal systems. For this reason, sleep disorders and sleep deficiency either directly cause or aggravate many health problems, and yet they’re often overlooked causes of adverse health effects and increased mortality rates. The poorer you sleep, studies show, the more health issues you tend to experience.

Part of the reason that these negative effects of sleep deprivation occur is because growth hormone, the “anti-aging” hormone, is secreted during sleep. Growth hormone helps support you in terms of:

• Regenerating tissue
• Cleansing the liver
• Building muscle
• Breaking down fat stores
• Normalizing blood sugar

The fatigue and health issues that arise from poor sleep also are related to free radicals and inflammation. Many physiological and pathological processes, such as infections and environmental toxins, increase the body’s concentrations of oxidizing sub-stances, known as free radicals. During sleep, free radicals are removed from the brain, reducing oxidative stress and minimizing cell aging.

Sleep loss also is known to result in a state of low-level systemic inflammation, which can further exacerbate fatigue. This is why focusing on decreasing inflammation is one of the natural strategies for treating fatigue, as we will see later.

In the next three sections of this chapter, we’ll look more closely at three prevalent sleep-related causes of fatigue.

Sleep Apnea

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder, affecting 3 to 7 percent of the population.

In obstructive sleep apnea, the airway narrows or collapses, causing sufferers to stop breathing for brief, repeated periods throughout the night, and reductions in the body’s oxygen levels. People with sleep apnea usually snore loudly and may experi-ence apnea “episodes,” or lapses of breathing that interrupt snoring and end with snorts. (See sidebar for a list of other common sleep apnea symptoms.)

An overnight sleep study, called a polysomnograph, is required to diagnose obstructive sleep apnea. It is a recording of sleep breathing patterns that usually involves in-laboratory measurement of brain waves and arousals, eye movement, chin movements, airflow, respiratory effort, oxygen levels, electrocardiographic (ECG) tracings, body position, snoring, and leg movements.

If you think you might have sleep apnea, it’s imperative that you get diagnosed and treated, given the severe health risks associated with this disorder. (Sleep apnea may increase your risk of atrial fibrillation, cancers, chronic kidney disease, stroke, ather-oschlerosis, high blood pressure, glaucoma, metabolic disorders, according to the National Institutes of Health.)

Sleep Deprivation

Sleep deprivation is the most common cause of excessive daytime sleepiness. The medical term for sleep deprivation is “insufficient sleep syndrome.” It is considered a disorder that occurs in individuals who persistently fail to obtain the sufficient amount of sleep required to achieve normal, alert wakefulness.

Most people require around seven hours of sleep during their main sleep episode to feel refreshed and alert during the day-time. Yet many people experience shorter amounts of sleep to meet work, family, social, and educational demands. This habit comes at a high price. People who suffer from insufficient sleep syndrome struggle with impaired functioning associated with excessive daytime sleepiness and fatigue and put their overall health at risk.

Restricting sleep time to six hours a night for 14 consecutive nights has been shown in studies to significantly impair functioning.

In fact, symptoms of sleep deprivation can occur after only one night of sleep loss. Often, those who are sleep-deprived are not even aware of their impaired functioning. Studies have found that people who are chronically sleep deprived are often una-ware that they are demonstrating increased deficits in performance and brain function.

Sleep is a process the body uses to help maintain balance and regulation of the immune system. Sleep deprivation or disturbance of sleep cycles also have been found to suppress immune function, in part by increasing release of inflammation-producing chemicals, known as cytokines.

Having a good night’s sleep is now understood to be crucially important for weight control.

Lack of sleep can lead to weight gain, increased belly fat, and obesity. The increased fatigue and tiredness associated with sleeping too little makes the maintenance of a healthy lifestyle more difficult, weakening your resolve to take care of yourself by eating healthy foods and exercising.

Studies have shown that sleep restriction also leads to a set of hormonal changes related to appetite control. Not getting enough sleep decreases your body’s ability to regulate blood sugar, elevates cortisol concentrations, disrupts the stress and HPA axis, decreases the “satiety hormone” leptin, increases the appetite-stimulating hormone ghrelin, and increases hunger and appetite.

Insomnia

Almost all of us have experienced the occasional night of sleeplessness, had difficulties falling or staying asleep, or had non-restful sleep.

But, insomnia is chronic sleeplessness that is defined as difficulty initiating or maintaining sleep or experiencing non-restorative sleep for at least one month, causing significant daytime impairment. An estimated 10 to 30 percent of the population experiences insomnia.

Fatigue is the most consistent daytime symptom associated with insomnia. Studies suggest, however, that poor sleep may not be the only reason for fatigue in individuals with insomnia.
Sleep studies on people with chronic insomnia have shown that the severity of sleep disturbance is not the only factor in determining the severity of fatigue. Other factors, such as depression and the subjective feeling of poor sleep quality, are more related to fatigue in insomniacs than actual sleep loss.

However, most people with chronic insomnia actually do not have daytime sleepiness. In fact, most insomniacs are unable to sleep during the day when provided with opportunities to do so, despite feeling excessively tired or fatigued.

Chronic insomnia decreases your quality of life and productivity, and increases your chances of becoming ill. Insomnia can cause mood disturbances (such as anxiety and depression) that can lead to employment and relationship problems. Poor stress-coping strategies have been linked with an increased risk of developing insomnia.

If you’re suffering from insomnia, getting this sleep disorder under control is imperative for overcoming your fatigue. Curing insomnia takes more than a just a pill; it requires a comprehensive approach that almost always involves lifestyle changes. Thou-sands of individuals have overcome insomnia by making these kinds of changes to their lifestyle, and so can you.

Fatigue Causes: Poor Nutrition, Poor Digestion

The relationship between your energy levels and the quality of your diet cannot be understated. In fact, making dietary changes can be profoundly effective, and even curative, in many cases of fatigue.

There isn’t a single diet that’s best for treating fatigue or fatigue-related medical conditions, but there are some general nutritional practices that do stand out. Research shows that standard American (or Western) diet lacks the nutrients necessary for the energy that people need to function healthily everyday. This diet leads to many fatigue-inducing problems, such as inflammation, blood sugar dysregulation, and insulin resistance, food allergies, and poor digestive health.

The Role of the Western Diet on Fatigue

The all-too-typical U.S. eating patterns of the Western diet include almost 40 percent refined grains and sugars and almost 20 percent refined vegetable oils.

Numerous studies show that Western diets rich in fried foods, processed meats, and commercial baked goods are associated with fatigue and fatigue-related illnesses, whereas diets rich in fruits, vegetables, whole grains, lean proteins, and healthy fats are associated with higher energy levels. Why does the Western diet cause more instances of fatigue?

• Western diets provide plenty of calories but insufficient nutrients, phytochemicals (chemical compounds that occur naturally in plants), and antioxidants, all of which are necessary for proper functioning of the thousands of biochemical and physiological processes that keep you balanced and energized.
• Western diets wreak havoc on your blood sugar metabolism, causing blood sugar highs and lows and insulin resistance, which result in fatigue.
• Western diets promote inflammation, another major cause of fatigue.

We’ll explore each of these topics now in greater depth.

Nutritional Deficiencies and Imbalances

Fatigue is an early symptom of vitamin and mineral deficiencies. Cells rely on vitamins and minerals to generate energy. Deficiency in one’s diet is a surprisingly common malady in today’s over-fed and under-nourished population.

A high percentage of adults in the U.S. consume less than the minimum daily allowance of many essential vitamins and minerals. Adequate amounts and the proper balance of the essential vitamins and minerals, along with the right phytonutrients and essential fats, are important for disease prevention and optimal health.

Let’s take a closer look at some of the most important vitamins and minerals related to fatigue.

Vitamin C

Vitamin C (ascorbic acid) regulates many genes, some of which are responsible for energy metabolism. The recommended daily allowance for vitamin C is between 60 to 75 milligrams (mg) per day for women and 90 mg per day for men. However, 20 to 30 percent of American adults consume less than 60 mg of vitamin C daily.

According to the National Institutes of Health, “Vitamin C deficiency is much more common than is generally recognized, especially because the first symptom of deficiency is fatigue, a nonspecific and common complaint.”

Studies have tested the ability of vitamin C (taken orally with other vitamins, minerals, and/or antioxidants) to combat fatigue. In one randomized, placebo-controlled, double-blind study, the effects of a daily effervescent tablet containing 500 mg vitamin C, B vitamins, calcium, magnesium, and zinc was tested in 215 healthy males ages 30 to 55 years. After 33 days, when compared to those who were given a placebo, participants taking these daily vitamins reported:

• Increased energy and “vigor”
• Less mental tiredness
• Improved general mental health
• Lower subjective stress
• Significantly higher scores on a series of mental tests designed to detect sluggishness

Healthy individuals should be able to get enough vitamin C from a diet rich in fruits and vegetables. However, people who smoke, are exposed to second-hand smoke, and have a restricted diet, cancer, kidney disease, or malabsorption may struggle to get adequate vitamin C from diet alone and may benefit from supplements.

Traditionally, supplements have been taken orally, but today there’s an increasing trend to give vitamin C and other vitamins and nutrients intravenously. Early research into the effectiveness and safety of this method is promising in treatment for fatigue in both healthy adults and those with a history of cancer.

Investigators in one study evaluated the effect of intravenous vitamin C on fatigue in 141 healthy office workers ages 20 to 49 in a randomized, double-blind, controlled clinical trial. Volunteers received either 10 grams of vitamin C with saline or saline only intravenously. Fatigue scores were measured before intervention, two hours after intervention, and one day after intervention. The fatigue scores measured after one day varied significantly different between the two groups: Fatigue scores decreased in the vitamin C group after two hours and remained lower the following day.

Vitamin E

Vitamin E is actually a group of eight antioxidants:

• Four tocopherols (alpha, beta, gamma, and delta)
• Four tocotrienols (alpha, beta, gamma, and delta)

Alpha-tocopherol is the form of vitamin E found in the largest quantities in the blood and tissues and appears to have the greatest nutritional value.

The main function of alpha-tocopherol is its role as an antioxidant (a molecule that inhibits the oxidation of other molecules). Fats, which are an integral part of all cell membranes, are especially vulnerable to destruction through oxidation by free radicals.

Because alpha-tocopherol is a fat-soluble vitamin, it is uniquely suited to intercept free radicals and prevent a chain reaction of lipid destruction that would destroy cell membranes throughout the body.

Another function of alpha-tocopherol not related to its antioxidant capacity include its role in controlling molecules and enzymes in immune cells and inflammatory cells. The generation of excessive free radicals, otherwise known as reactive oxygen species, contributes to exercise-induced skeletal muscle damage, which results in muscle fatigue and soreness.

Antioxidants like vitamin E have been shown in some (but not all) studies to reduce the oxidative damage that occurs as the result of skeletal muscles contracting. Although some studies have shown that lower levels of vitamin E were associated with in-creased severity of fatigue and muscle pain in CFS, there is limited, inconclusive evidence of the benefits of taking vitamin E supplements for the treatment of fatigue.

Probably the best way to improve your vitamin E levels is to eat more vitamin E–rich foods, including: green leafy vegetables, whole grains, fortified cereals, vegetable oils, and nuts.

B Vitamins
The B vitamins include:

• B1 (thiamine)
• B2 (riboflavin)
• B3 (niacin)
• B5 (pantothenic acid)
• B6 (pyridoxine)
• B7 (biotin)
• B9 (folic acid)
• B12 (cobalamins)
• Biotin

These vitamins help facilitate the body’s ability to receive or create energy from food. Vitamin B deficiency, due to increased needs or a poor diet, compromises the ability of mitochondria in the cells to generate energy.

A lack of even just one of the B vitamins can compromise the entire sequence of biochemical reactions necessary for trans-forming food into energy. Vitamin B12 deficiency, in particular, is associated with fatigue. Ten to 15 percent of aging adults have a B12 deficiency.

Patients with CFS have been found to have low levels of B vitamins in some but not all cases. One group of researchers found a 50 percent prevalence of folate deficiency in CFS patients, while another group found high homocysteine levels in cerebrospinal fluid (which they attributed to lack of B12). Both the low B12 and high homocysteine levels were found to correlate to the severity of the patients’ fatigue.
Researchers from King’s College in London found what they called “functional deficiencies” of three other B vitamins: B6 (pyr-idoxine), B2 (riboflavin), and B1 (thiamine). The term “functional deficiency” refers to how nutrients actually function inside the body’s cells. Instead of measuring the actual amount of the vitamins found in the blood, these researchers used a specialized la-boratory that measures how vitamins function inside cells—specifically white blood cells.

Some patients with fatigue report greatly improved energy with the introduction of B vitamin supplements, whether they have a deficiency or not. However, as with many natural therapies, there are few studies testing whether B vitamin supplementation can actually help reduce fatigue.

Of the studies that have been conducted, results are mixed and often difficult to interpret, since so many different forms and methods of using B vitamins are available. Injections seem to work better than oral supplements for some, while other studies show that, at least with vitamin B12, tablets that dissolve under the tongue increase levels just as effectively as injections.

Only you can determine whether B vitamin supplementation will reduce your fatigue. It may be helpful to undergo at least a six-week trial with a high-potency B complex supplement, along with an additional 2,000 micrograms of sublingual (under the tongue) B12, if you believe you may be suffering from a deficiency.

Magnesium

Magnesium is an essential mineral. It is involved in more than 300 metabolic reactions, including energy production. In addition to being needed to produce ATP (the energy on which the body runs), magnesium is important for:

• Bone health
• Protein
• Fatty acid formation
• Making new cells
• Activating B vitamins
• Relaxing the muscles

Magnesium deficiency impairs the energy production pathway required by mitochondria to generate ATP and reduces the mitochondria’s ability to resist free-radical damage. It can result in excessive production of oxygen-derived free radicals and low-grade inflammation. Chronic inflammation and oxidative stress have both been identified as causative factors in several fatigue-related conditions, such as depression and CFS.

Twenty-three percent of adults in the U.S. fail to meet the recommended dietary intake of magnesium. Low magnesium levels have been linked to an increased risk of chronic fatigue as well as numerous other health-related conditions, including:

• High blood pressure
• Stroke
• Heart disease
• Glucose intolerance
• Insulin resistance
• Type 2 diabetes
• Obesity
• Metabolic syndrome
• Inflammation
• Oxidative stress
• Asthma
• Osteoporosis
• Migraines
• Colon cancer
• Depression

Magnesium deficiency is best determined by looking at the level of magnesium present in red blood cells, rather than in se-rum. In some studies, patients with chronic fatigue syndrome were found to have significantly lower red blood cell magnesium levels than the general population.

Even in CFS patients without apparent magnesium deficiency, supplementation with magnesium has been found to significantly improve oxidative stress. Foods that are rich in magnesium include spinach, black beans, nuts, and seeds.

Iron Deficiency and Anemia

Anemia, a common cause of fatigue, is characterized by a reduced number of red blood cells and a reduced concentration of hemoglobin (the iron-containing protein in red blood cells that transports oxygen). There are many causes of anemia, including nutrient deficiencies. Iron deficiency is a common cause of anemia, but deficiencies of folate or vitamin B12 are also causes.

Here are a few key facts about anemia:

• Even mild anemia is linked to fatigue and a lesser quality of life.
• Your chance of being mildly anemic increases with age.
• Mild anemia affects more than one in 10 elderly individuals.
• In older women, anemia is associated with depressive mood, which may further exacerbate feelings of fatigue.

Anyone with unexplained fatigue should be tested for anemia. Anemia is diagnosed with a simple and inexpensive blood test known as a complete blood count, or CBC. To determine the cause of anemia, further testing may be needed. Anemia occurs when the concentration of hemoglobin in the blood is lower than 12 g/dL in women and 13 g/dL in men. Mild anemia is typically defined as a hemoglobin concentration between 10.0 and 11.9 g/dL in women and between 10.0 and 12.9 g/dL in men.

Anemia can occur at any age. In people over 65 years of age, the underlying cause of mild anemia remains unexplained in about a quarter of cases.

It is possible, especially in menstruating women, to become deficient in iron without becoming fully anemic. Like anemia, iron deficiency has been shown to cause fatigue and is associated with less vitality and poor mental health. It has also been shown to negatively affect physical work performance and cognitive functioning and to decrease immune function.

Besides heavy menstruation, other common causes of low iron levels include:

• Regular blood donation
• Pregnancy
• A diet low in bioavailable sources of iron

The best way to determine whether you have an iron deficiency is by measuring your ferritin levels rather than your actual iron levels. 
Ferritin is a protein found inside cells that stores iron so your body can use it later. If your ferritin level is low but still within the “normal” range, it is likely that you do not have enough iron.

A recent study in France found that iron supplementation for 12 weeks decreased fatigue by almost 50 percent from base-line—a significant difference compared with a placebo—in menstruating, iron-deficient, non-anemic women with unexplained fatigue and low ferritin levels.

Iron Excess

You may be surprised to know that high iron levels (a condition referred to as “iron overload”) are relatively common and may also induce fatigue. In fact, fatigue is the most commonly reported symptom of excess iron. In one European study, researchers found iron overload in 1.8 percent of the population (whereas they found iron deficiency and anemia in 0.5 percent of males and 6 percent of females).

In the U.S., one out of every 200 to 300 people has hereditary hemochromatosis, the most common cause of excess iron. White men over 40 are most at risk.

Besides fatigue, other common symptoms of iron overload include:

• Joint pain
• Low libido
• Erectile difficulties

Liver disease and diabetes also may occur in the later stages of the disease because the excess iron accumulates in these organs.

The treatment for excess iron is relatively simple and typically consists of regular blood removal (“therapeutic phleboto-my”—like a blood donation, only your blood is discarded). Ingesting less iron and watching your alcohol intake to protect your liver is also typically recommended.

Vitamin D

Vitamin D is a hormone now known to control more than 200 genes and to be important for much more than just bone health. Research on the wide-reaching affects of vitamin D has exploded over the past decade. It has been established that vitamin D deficiency—a global epidemic estimated to affect more than a billion people—is highly prevalent in people with fatigue and CFS.

In studies, low vitamin D levels have been linked to numerous other symptoms and chronic diseases, including:

• Muscle weakness
• Chronic pain
• Lower-back pain
• Metabolic syndrome
• Type 2 diabetes
• High blood pressure
• Breast cancer
• Colon cancer
• Prostate cancer
• Poor stress resilience
• Depression
• Hypothyroidism
• Cognitive decline
• Reduced work productivity
• Lung disorders such as COPD (chronic obstructive pulmonary disease) and asthma
• Increased risk for falls and disability among the elderly
• Death from all causes

Vitamin D deficiency and borderline deficiency (or “insufficiency”) is surprisingly common, even among those who live in areas with year-round sunshine. Therefore, it’s worth having a blood test to determine whether you’re deficient. Some studies have shown significant improvement in patients’ energy levels with vitamin D supplementation.

L-Carnitine

L-carnitine is a naturally occurring nutrient made in the body from the amino acids lysine and methionine. L-carnitine is required for energy production in the powerhouses of the cells (the mitochondria) through the release of energy from fats. It transports fatty acids into the mitochondria and is especially important for energy generation in heart and skeletal muscle tissue.

In situations of high-energy needs, the body can run out of this important nutrient. Therefore, L-carnitine is considered a “conditionally essential” nutrient.

Acetyl-L-carnitine is similar in form to L-carnitine and has some like functions, including its involvement in metabolizing food into energy. The acetyl group that is part of acetyl-L-carnitine contributes to the production of the neurotransmitter acetylcho-line, which is required for normal mental functioning.

L-carnitine deficiencies have been found in some CFS sufferers, as have abnormalities in the way acetyl-L-carnitine is used by the brain. Elderly people also are more likely to have low L-carnitine levels and to benefit, in terms of energy levels, when taking L-carnitine as a supplement.

Coenzyme Q10

Coenzyme Q10 (CoQ10) is present in the membrane of every cell in the body. CoQ10 has two crucial functions in cells:

• It plays a critical role in the production of energy as ATP within the mitochondria of cells.
• It is a powerful free radical scavenger (or antioxidant) that can mitigate damage caused by oxidative stress.

Though CoQ10 is produced naturally in the body, aging and various diseases or pathological mechanisms can disrupt its synthe-sis, leading to CoQ10 deficiency. CoQ10 deficiency is associated with decreased energy (due to lower ATP levels) and increased oxidative stress. Low levels of CoQ10 in the blood have been detected in chronic fatigue syndrome, fibromyalgia, and depression.

Blood Sugar Dysregulation

The Western diet, high in simple sugars and processed foods, is notorious for causing issues with blood sugar regulation. If you eat a meal loaded with sugar and refined carbohydrates, you can experience wild swings in blood sugar that make you feel tired, anxious, irritable, and hungry for more quickly absorbed sugars. This type of eating pattern is also known as a high-glycemic-load diet, meaning it contains high amounts of the kind of carbohydrates that release glucose into the blood very quickly.

High-glycemic-load diets have been shown in studies to cause:

• Sleepiness
• Nighttime sleep disruptions
• Slow reaction times in tests of cognitive performance

When you repeat the process, day in and day out, of eating a diet full of empty calories, refined and simple carbohydrates (bread, pasta, rice, potatoes), sugars, and sweetened beverages (sodas, juices, sports drinks), your cells start to become resistant, or unresponsive, to insulin. As a result, your pancreas ends up secreting more and more insulin in an attempt to lower your blood sugar. Insulin resistance is a pre-diabetic condition that has reached epidemic levels.

Experiencing fatigue and other low blood sugar symptoms two to four hours after a high-carb meal may be a warning sign that you have insulin resistance or are in the early stages of diabetes. Despite how common it is to feel sleepy following a high-glycemic-load meal, it’s not normal, nor is it healthy. This type of sleepiness is the classic sign of what is known as reactive hypoglycemia—and an early symptom of prediabetes or insulin resistance.

Reactive hypoglycemia is characterized by low blood sugar symptoms after eating large amounts of sugar or refined carbohydrates. Common symptoms:

• Fatigue
• Weakness
• Tiredness
• Dizziness
• Sweating
• Shakiness
• Palpitations
• Anxiety
• Nausea
• Hunger
• Difficulty concentrating

Take a typical breakfast these days: Swigging a large, sweetened coffee drink and grabbing something from the pastry case will give you a big energy surge by causing your sugar and insulin levels spike. What follows, however, is the inevitable “crash,” when your blood sugar level plummets. With this crash comes low blood sugar symptoms, like fatigue.

A high insulin level in your blood, which can easily be measured by your doctor, is the classic sign of insulin resistance. High insulin causes your body to lose muscle and create belly fat while also causing inflammation and oxidative stress. The downstream effects of insulin resistance, in addition to an expanding waistline and fatigue, are worth considering.

• High insulin levels and insulin resistance are linked to:
• High blood pressure
• High cholesterol
• High triglycerides
• Low HDL (high density lipoprotein, or “good cholesterol”)
• Low sex drive
• Infertility
• Depression
• Heart disease
• Stroke
• Dementia
• Cancer

A person crosses the line from insulin resistance and prediabetes to diabetes when the cells become so resistant to insulin that the insulin can’t do its job (i.e., it can no longer get the sugar out of the bloodstream and into the cells). This causes blood sugar levels to remain elevated and the pancreas to go into overdrive to produce enough insulin to fight against high blood sugar and resistant cells. At some point, the pancreas becomes unable to produce enough insulin.

If you do cross the line and become diabetic, studies show that you’re even more likely to have general, physical, and mental fatigue, as well as excessive daytime sleepiness.

Should You Eat Meat?

In terms of fatigue, there is no single right answer to the question of whether one should consider adopting a meat-free lifestyle. Studies have shown that both meat-including diets and vegetarian (or vegan) diets can work against fatigue. The key, of course, is the quality of the diet and the inclusion of plenty of vegetables and fruit.

A diet that consists largely of fruits and vegetables is associated with significantly less fatigue as measured by the SF-36, a commonly used, standardized, health-related quality-of-life questionnaire that measures fatigue.

A study of college-age women found that fatigue was associated with not eating enough fruits and vegetables, eating meals at irregular intervals, missing breakfast, eating more “instant” foods, and eating candy. Compared to meat eaters, vegetarians and vegans report significantly less fatigue. Studies show that switching to a vegan diet can improve fatigue and increase feelings of vitality.

In one study at George Washington University, overweight and/or type 2 diabetics received either weekly group instruction on a low-fat, vegan diet or received no diet instruction for 22 weeks. Results determined that the vegan group reported significant improvements in vitality (a measure of fatigue), as well as in general health, physical functioning, and mental health. They also reported that their productivity at work and in regular daily activities was significantly improved.

If you do choose to eat meat, studies show that the quality of the meat matters. A diet that includes high-quality (naturally raised, grass-fed) lean meat, as well as fruit, vegetables, and whole grains, may decrease the fatigue associated with depression and anxiety.

A large study conducted by researchers at the University of Melbourne in Australia found that women who regularly consume a whole-foods-based diet (a diet consisting of foods that are unprocessed and unrefined or processed and refined as little as pos-sible) and high-quality meat were more than 30 percent less likely to experience depression and anxiety compared to those with a Western diet.

In addition, those eating a Western diet (again, heavily processed foods, fried foods, refined grains, sugary products, and beer) tended to be approximately 50 percent more likely to experience depression.

Dr. Felice Jacka, the study’s primary researcher, explained in an interview that high-quality meat is more difficult to come by in the United States, where most cattle are raised in feed lots and given a corn-based diet. This increases their saturated fat and omega-6 fatty acids and decreases very important anti-inflammatory omega-3 fatty acids.

Grass-fed cattle, on the other hand, have healthier levels of omega-3 fatty acids and their meat is generally healthier and less inflammatory.

Digestive Problems and Leaky Gut

The link between digestive problems and fatigue has been noted for years, but it wasn’t until recently that researchers began to really put together the pieces of the puzzle to determine how abnormalities in the digestive system are related to fatigue and what can be done to resolve these issues. It is likely that you have a “leaky gut,” an overgrowth of “bad” microbial flora, and not enough healthy flora if you feel chronically tired and experience digestive symptoms like:

• Abdominal pain
• Bloating
• Loose stools
• Diarrhea
• Alternating diarrhea and constipation
• Gas
• Reflux

Leaky gut is a term for increased intestinal permeability and is known to be at least partly to blame for fatigue and symptoms similar to irritable bowel syndrome (IBS). Leaky gut is caused by a loosening of the tight junctions in the gut lining that form a barrier between the inside and outside of the digestive tract.

Leaky gut can be caused by:

• Any type of inflammatory process, including yeast infections, viruses, and bacteria
• Long-term or very frequent use of antibiotics
• Repeated use of pain-killers, NSAIDs (nonsteroidal anti-inflammatory drugs), or alcohol
• Long-standing psychological stress
• Extended exercise (athletes)
• Food allergies or sensitivities (such as gluten sensitivity)
• Insufficient intake of antioxidants

When any of these factors increase the permeability of the intestinal wall, unwanted bacteria, proteins, and other compounds can leak through. To deal with these foreign compounds, the body mounts an immune response, which leads to inflammation.

Researchers have found that if you have chronic fatigue syndrome, your body likely produces high levels of immune cells in order to battle the toxins given off by unhealthy stomach bacteria. This high level of immune cells is a sign of leaky gut and a cause of inflammation.

In fact, the severity of both chronic fatigue symptoms and digestive symptoms was found to directly correlate with the number of these immune cells that are directed against toxin-generating stomach and intestinal bacteria.

Food Allergies and Intolerances

Like millions of Americans, you may be suffering from the symptoms of food allergy or intolerance and not know it. Consuming foods to which you have an allergy or intolerance can result in a variety of physical and mental symptoms including headaches, heartburn, and fatigue. Other reactions can occur suddenly, are generally more serious, and can produce symptoms as severe as:

• Difficulty breathing
• Hives, itching, or rash
• Shock, with a drop in blood pressure

People who react in this way to certain foods usually know that they have a food allergy. More often, unsuspected food intol-erances, sensitivities, or allergies produce a variety of milder, annoying symptoms, which may not occur until hours or days after the food is ingested. These symptoms typically linger and recur.

The concept of food intolerances, sensitivities, and “delayed food allergies” is still deemed controversial by many conventional physicians. However, studies have shown significant improvements in a variety of symptoms and conditions when these types of food reactions are identified via blood testing and the reactive foods are eliminated from the diet.

Celiac Disease/Gluten Sensitivity

Fatigue is a symptom of two conditions related to the ingestion of gluten-containing foods: celiac disease and gluten sensitivity.

Celiac disease is an autoimmune disorder affecting nearly one out of every 133 Americans. In people with celiac disease, gluten sets off an autoimmune reaction that causes the flattening of the villi (a finger-like projection of the lining) in the small intes-tine. People with celiac disease produce antibodies that attack the intestine, causing damage and illness throughout the body.

People with untreated celiac disease typically experience major fatigue that disrupts their quality of life. The fatigue experienced in those with celiac disease can come and go, as can gastrointestinal symptoms. In fact, some patients with celiac disease suffer from debilitating fatigue but do not have any gastrointestinal symptoms at all.

If you have hypothyroidism due to autoimmune destruction of your thyroid gland (also known as Hashimoto’s thyroiditis, the most common cause of hypothyroidism), your chances of developing celiac disease and some other autoimmune diseases are significantly increased.

The reverse is also true: If you have celiac disease, you are more likely to develop autoimmune thyroid disease. A gluten-free diet has been shown in some studies to prevent people with celiac disease from developing autoimmune thyroid disease. This link between celiac disease, hypothyroidism, and fatigue means it’s important to get tested for celiac disease if you’ve been found to have Hashimoto’s thyroiditis.

Diagnosis of celiac disease is based primarily on blood tests that detect and measure two specific antibodies:

• Immunoglobulin A (IgA) anti-tissue transglutaminase (tTG) antibody
• Immunoglobulin A (IgA) antiendomysial antibody (EMA)

The tests are complex, and sometimes other blood tests are used in conjunction with them. If your test results are positive, your doctor may perform a biopsy of the small intestine to confirm the diagnosis.

As for gluten sensitivity, it’s just what it sounds like: a less severe negative reaction to ingesting gluten. It is sometimes also referred to as gluten intolerance or “non-celiac gluten sensitivity.”

Research at the University of Maryland Center for Celiac Research shows that gluten sensitivity is different from celiac disease in that it typically does not result in the intestinal inflammation that leads to a flattening of the villi of the small intestine (a characteristic of celiac disease).

In addition, auto-antibodies called tissue transglutaminase (tTG), used to diagnose celiac disease, are not present in subjects with gluten sensitivity.

The immune system is activated in gluten sensitivity, and symptoms can arise throughout the body, ranging from fatigue and foggy mind to diarrhea, depression, and joint pain.

The best way to determine whether you have gluten sensitivity is to do a three-month trial on a strict gluten-free diet, monitoring your symptoms as you go along. If your fatigue and other symptoms improve, you likely have gluten sensitivity.

At the end of the three months, you can perform a “challenge” by eating a few normal-sized servings of a gluten-containing food during the day.

Monitor your symptoms on the day of the challenge and for another day or two after. If you notice your symptoms returning, you have confirmation that you’re gluten-sensitive.

Obesity

Individuals who are overweight, obese, or simply have too much belly fat experience more fatigue and excessive daytime sleepiness, according to studies.

It was long believed that one of the primary reasons obese individuals experience higher rates of excessive daytime sleepiness is the increased rate of sleep apnea and sleep disruption in people who are overweight. It is, after all, well known that obesity is the number one risk factor for obstructive sleep apnea.

However, recent research shows that increased daytime sleepiness occurs in obesity regardless of sleep loss or sleep apnea. The new hypothesis is that obesity-related daytime sleepiness and fatigue are associated primarily with metabolic disturbances like insulin resistance and psychological factors.

The interaction of inflammation (characterized by increased cytokines) and cortisol also may play a role in obesity-related fatigue.

Dehydration

Water is the most essential component of your body and the most essential nutrient in your diet. Water comprises about 60 per-cent of your body weight. Without it, you can survive for two to four days. Water is necessary for circulation, biochemical reactions, metabolism, transportation of substances into and out of cells, temperature regulation, and numerous other bodily processes.

Inadequate water intake leads to dehydration, a well-known cause of decreased physical and mental function and mood. The decrements in physical and mental performance typically become apparent when 1 to 2 percent of total body weight is lost.

How do you know if you’re dehydrated? Common signs of dehydration include:

• Reduced skin elasticity
• Dry lips and mouth
• Headache
• Constipation
• Dark urine (straw-colored urine indicates adequate hydration)
• Infrequent urination

Studies indicate that even mild dehydration can cause the following symptoms:

• Increased fatigue
• Decreased physical endurance
• Reduced motivation
• Increased perceived effort
• Disruptions in mood (including confusion and anger)
• Disruptions in cognitive function (including concentration, alertness, and short-term memory)

As you age, the likelihood of becoming dehydrated increases. In aging individuals, the body’s regulation of thirst and fluid in-take undergoes small changes. Older people tend to feel less thirsty and hence drink less than younger individuals.

Studies also show that older individuals, when dehydrated, tend to drink insufficient water to replenish the body’s water defi-cit. Because of this, researchers now believe it may be best for older adults to practice drinking water regularly, even though they
may not feel thirsty.

Caffeine

The most popular stimulant drug in the world is caffeine. The worldwide popularity of tea, coffee, soft drinks, and—now more than ever before—energy drinks is due at least in part to caffeine’s ability to make us feel alert.

Coffee has been proven to enhance alertness and performance in studies of non-tolerant (non-habitual) users. In habitual users, however, caffeine has downsides.

Daily caffeine drinkers who abstain from caffeine experience fatigue and drowsiness as side effects of caffeine withdrawal. And there’s a lesser-known but even more important downside to regularly ingesting caffeine: Although habitual caffeine drink-ers feel like caffeine makes them more alert, evidence suggests that overall there is no total increase in alertness.

The feeling of becoming more alert by drinking caffeinated beverages is merely the reversal of the fatigue that’s caused by acute caffeine withdrawal. In other words, with frequent consumption of caffeine, we don’t experience a net benefit.

When we abstain from consuming caffeine, we’re less alert; consumption of caffeine at this point merely returns your alertness to baseline.

According to some studies, additional negative effects of caffeine include:

• Increased anxiety
• Increased cortisol levels
• Impaired blood sugar management
• Increased cholesterol

Caffeine has been shown in functional MRI studies to activate the part of the brain that perceives threats and that correlates with anxiety levels. Certain individuals are more genetically susceptible to the anxiety-inducing effects of caffeine.

But with modest, regular intake, even those who are more susceptible can develop a tolerance to the anxiety-provoking effects.

Symptoms of caffeine withdrawal begin 12 to 24 hours after the last dose of caffeine. In addition to fatigue and sleepiness, caffeine withdrawal symptoms include:

• Headache (experienced by about 50 percent of users)
• Depressed mood
• Difficulty concentrating/decreased cognitive performance
• Irritability
• Nausea/vomiting
• Muscle aches/stiffness

It is also important to note that caffeine withdrawal symptoms may intensify with the use of energy drinks and shots. This is be-cause energy drinks vary widely in caffeine content, ranging from 50 mg to a dangerous 505 mg per can or bottle. (For compari-son, the caffeine content of a large cup—16 ounces—of brewed coffee is about 188 mg.)

Energy drinks also contain other substances such as B vitamins and amino acids (like taurine and tyrosine). But caffeine typically is the main active ingredient in energy drinks. Plus, they may contain various herbal extracts—some that also contain caffeine,usually in “proprietary” amounts that are not disclosed on the label. Thus, despite their popularity, energy drinks and shots should be avoided.

Lack of Exercise as a Cause of Fatigue

Physical inactivity is consistently associated with fatigue. In U.S. adults ages 20 to 59, those who report feeling tired are almost twice as likely to get insufficient physical activity. Those who report feeling exhausted are almost four times more likely to get insufficient physical activity. In teens, an average of nine hours per day using electronic media doubles the risk of persistent fatigue.

In people who have been exercising regularly (at least 30 minutes three times a week), fatigue begins to appear about one week after they abandon exercise.

Studies show that, in people who do not exercise, even relatively small amounts of routine physical activity within a normal lifestyle are associated with more energy and less fatigue.

Being sedentary may increase fatigue for a number of reasons, including the following.

• Prolonged periods of inactivity cause decreased muscle mass. As muscle is reduced, the number of mitochondria inside muscle tissue also decreases. Within every cell, mitochondria generate the energy used to power all metabolic activities. As muscles lose mito-chondria, they become less efficient (they experience a reduction of strength, tone, and size). This leads to the feeling of a lack of power or energy, stiffness, heaviness (because of blood pooling in the lower limbs), weakness, and pain after normal exercise and activity.
• Prolonged inactivity causes fatigue by deconditioning the cardiovascular system. This causes reduced blood volume, lowered oxygen levels, and less aerobic fitness as measured by VO2 max (the maximum capacity of an individual’s body to transport and use oxygen during incremental exercise). Deconditioning of the cardiovascular system reduces heart and lung function and is associated with dizziness and breathlessness.
• Being sedentary dulls the brain and alters your biological clock (circadian rhythms). It also changes your perception of temperature, noise, and light. These changes lead to impairments in:
• Coordination
• Concentration
• Memory
• Sleep
• Appetite
• Immune function
• Hormone production
• Lack of exercise decreases levels of dopamine, norepinephrine, and serotonin—energy-promoting and mood-enhancing neurotrans-mitters in the brain.

To stay healthy and energetic, you need to be physically active on a regular basis. There is no way around it. The type and duration of physical activity doesn’t matter nearly
as much as the mere act of doing something. Research shows
that any amount or kind of movement is better than none
for improving self-reported energy levels, raising energy-inducing neurotransmitter lev-els, and increasing the number of energy-producing mitochondria inside your cells.

Inflammation, Oxidative Stress, and Mitochondrial Dysfunction

Medical researchers are mapping out the network of connections among inflammation, oxidative stress (caused by free radical damage), and mitochondrial dysfunction. These three processes have been found to either be linked to or lead to fatigue and fatigue-associated chronic conditions, such as:

• Chronic fatigue syndrome
• Depression
• Fibromyalgia
• Insulin resistance/metabolic syndrome

Mitochondrial Dysfunction

Mitochondria are the organelles inside cells that are responsible for supplying upwards of 95 percent of the body’s energy needs. They are often called “the cell’s power plants,” since they convert the energy from food into a form that the body can use.

When the total number, structure, or functioning of the mitochondria decreases or becomes impaired, fatigue is the result. Researchers have found that in people with chronic fatigue syndrome, the structure and function of the mitochondria is dam-aged, and their ability to produce energy is diminished.

How and why does this happen? One way the function of mitochondria becomes compromised is through the generation of reactive oxygen species, known as free radicals.

Free radicals are atoms or groups of atoms with an odd (unpaired) number of electrons that can be formed when oxygen in-teracts with certain molecules. When too many free radicals are generated for the body to handle efficiently, a situation called “oxidative stress” develops.

Oxidative Stress

The process of oxidation—removing electrons from an atom or molecule—can be destructive (think of rusting iron). Oxidation occurs during normal mitochondrial function producing harmful free radicals as a byproduct.

Free radicals are unstable. In order to gain stability, they rob electrons from any other molecules they meet. This creates a domino effect wherein other molecules are left unstable in their wake. A free radical chain can cause extensive cellular damage and even kill cells altogether before eventually fizzling out.

Oxidizing activity from the environment—like radiation, toxins, “bad” foods, and tobacco smoke—further damages cells. Oxida-tive stress is the total burden of this oxidizing activity.

Luckily, your body has developed a number of strategies for containing and minimizing the damage. One such strategy is anti-oxidants, which neutralize free radicals by donating electrons to them.

You consume antioxidants, such as vitamins C and E, in your diet.Your body also has complex mechanisms that repair damage that has already occurred. You even have a system of oxidative stress responses that include a programmed cell au-to-self-destruct, for when the damage becomes too great.

The mitochondria especially depend on these defenses. If free radical production is too great or if antioxidant defenses be-come depleted, oxidative damage occurs and accumulates, resulting in oxidative stress.

The energy-generating mitochondria are some of the first parts of the body to suffer the effects of oxidative stress. Reactive oxygen species focus their attack on the DNA of mitochondria. The resulting damage leads to mitochondrial dysfunction, which is characterized by deficiencies in the mitochondria’s ability to produce energy. Furthermore, oxidative stress can result in inflammation.

Inflammation

You just learned how oxidative stress reduces the ability of the mitochondria within cells to function, resulting in fatigue.

Mitochondrial dysfunction and oxidative stress also lead to fatigue by causing low-grade activation of the immune system in a manner that provokes inflammation. With mitochondrial dysfunction and oxidative stress, the body produces excessive amounts of inflammatory compounds called cytokines.

Cytokines are substances secreted by cells of the immune system that carry signals locally between cells. Some cytokines are pro-inflammatory, meaning they promote inflammation, while others are anti-inflammatory. Over time, the chronic production of pro-inflammatory cytokines leads to a state of chronic, low-grade, body-wide inflammation that causes fatigue.

Two specific pro-inflammatory cytokines—tumor necrosis factor alpha (TNF‑) and interleukin-6 (IL‑6)—are known to cause sleepiness and fatigue. Related illnesses, including depression, obesity, metabolic syndrome, and sleep apnea, have been shown in studies to result in higher levels of IL‑6 and TNF‑, which indicates abnormally high levels of inflammation.

Exactly how the inflammatory cytokines cause fatigue is still under investigation. Researchers believe there are probably nu-merous direct and indirect mechanisms by which chronic inflammation triggers fatigue.

Some of the fatigue is due to the effects of inflammation on the nervous system. And in people with chronic fatigue syndrome, inflammation may be the cause of decreased activation of “the brain’s reward center,” a group of nuclei known as the basal ganglia.

The basal ganglia help to control motion and motivation and are exceptionally vulnerable to the effects of certain pro-inflammatory cytokines. A reduced response in this part of the brain is seen in patients with CFS.

Levels of pro-inflammatory cytokines like TNF-alpha and IL-6 can be measured in the blood and often are used for research purposes. However, they are rarely measured by the average physician.

A much simpler, more widely available, and less expensive way to measure chronic, systemic inflammation is through a blood test called C-reactive protein (CRP). CRP is a non-specific protein, the levels of which increase in the blood in response to inflammation or tissue injury.

Blood levels of CRP are typically higher in those who have CFS or experience chronic fatigue than in people who don’t feel fatigued.

In a sample of 70-year-old women, CRP levels were 40 percent higher in those with fatigue, compared to those without it. A host of fatigue-related conditions besides CFS also are associated with higher CRP levels. Among them:

• Fibromyalgia
• Type 2 diabetes
• Cancer and post cancer
• Infections
• Heart disease
• Arthritis
• Autoimmune diseases
• Inadequate sleep (less than six hours)

The foundational treatment for fatigue must include the reduction of inflammation and oxidative stress and the repair and production of new mitochondria. The good news is that these crucial processes are possible with natural therapies involving nu-trition, exercise, lifestyle changes, and supplements.

Understanding is only the first step. Later in this report, you’ll learn simple, effective strategies for decreasing inflammation, preventing oxidative damage from free radicals, and improving the healthy processes of the mitochondria.

Other Causes of Fatigue

In addition to the causes of fatigue discussed in this chapter, there are others worth mentioning. Among them:

• Cancer treatments
• Chronic pain
• Medications
• Poor detoxification mechanisms
• Toxic exposures

Still another possible cause of fatigue: infections, which we’ll examine below.

Infections

Infections can result indirectly from fatigue and vice versa. In some cases, in fact, patients end up in a vicious cycle of fatigue and infection.

Viruses, bacteria, fungi, and parasites can all cause infections and fatigue. Invasion of body tissues by disease-causing microor-ganisms, like the viruses listed below, are especially notorious for causing fatigue among other symptoms.

• Cytomegalovirus (CMV)
• Enteroviruses
• Epstein-Barr virus (EBV)
• Hepatitis C
• Human herpesvirus-6 (HHV-6)
• Human immunodeficiency virus (HIV)

In most cases, the body is eventually able to contain infection, and the fatigue and other symptoms are resolved. In other cases, such as with hepatitis C or HIV, the infection is not curable, although antiviral treatments can slow the course of the disease and may lead to a near-normal life expectancy.

Many times, chronic fatigue syndrome (CFS) follows a period of viral infection. If fatigue is not cured quickly enough, it may af-fect the body’s ability to fight off infection, providing viruses the chance to remount an attack.

CFS is sometimes considered a “post-viral fatigue.” Indeed, the syndrome sometimes does tend to follow a viral infection, such as a gut infection, or one of the others we’ve listed. Some patients with CFS clearly recall symptoms of an infectious illness before their fatigue took hold—fever, chills, body aches, sore throat, rash, or swollen glands—while other CFS patients recall no such symptoms.

In any case, once chronic fatigue sets in, there is usually no laboratory evidence of an active infection, although disturbances in immune function may be apparent. Some researchers believe these immune disturbances are triggered by chronic viral infections.

Inflammation is another part of the infection–fatigue connection. Specific types and ratios of inflammatory cytokines found in the blood of CFS patients (IL‑10 and TNF‑) may indicate the presence of persistent bacterial, fungal, or viral infections. The underlying presence of a viral infection may be the cause of the fatigue and excessive inflammation.

The Vicious “Infection–Stress–Fatigue” Cycle

Are you caught in a vicious cycle of stress, fatigue, and infection? While it’s easy to see how fatigue can result from chronic stress or infection, you may not be aware of how fatigue also may cause stress.

You also may be unaware of the fact that both fatigue and chronic stress can compromise the immune system, making you more susceptible to infections. A frustrating cycle of fatigue and illness can occur, with one contributing constantly to the other.

Researchers hypothesize that fatigue itself is a significant body stressor that makes you more susceptible not only to new infec-tions but to reactivation of latent viral infections to which you were exposed years ago.

Studies in fatigued and sleep-deprived medical patients show that under stressful conditions, the herpesviruses Epstein-Barr (“mono” or herpesvirus 4) and the common cold sore (herpes simplex I) are reactivated, and the amount of the virus measured in the patients’ bloodstream significantly increases.

The infections that play a role in many cases of chronic fatigue are part of an even wider interconnected web of fatigue, stress, inflammation, and nervous system dysfunction.

The key is to break the cycle and treat the underlying infection while using natural medicines and treatments to support the underlying immune, inflammatory, and stress-response systems.

Health-care practitioners all over the world understand these connections and are helping patients with chronic fatigue to break the cycle and regain their energy. Energy systems are being restored and rebalanced using:

• Natural therapies (the use of nutritional medicine, vitamins, vitamins, minerals, and other nutrients)
• Botanical medicine (the use of medicinal plants such as herbal extracts)
• Lifestyle changes (such as diet, exercise, and stress reduction)

Treatment of an underlying infection begins with diagnosis. Lab tests can help confirm current, recent, and past infections by checking for various antibodies (which indicate exposure to a virus) and various viral titers, or traces of the virus (which can con-firm current viral activity).

However, in the end—even with the most sophisticated lab testing—it may not be entirely possible to determine whether an infection is to blame for your fatigue.

If the presence of an infection cannot be determined, most fatigued individuals still find help via the recommendations provided in this book: improving diets, fixing nutrient deficiencies, decreasing stress, treating oxidative stress and inflammation, and improving the overall functioning of the immune system.

Putting It to Practice

We have gone over so many causes of fatigue by now that you may be feeling overwhelmed trying to determine which specific cause or causes apply to you. But don’t give up!

The next step is to use laboratory testing to find your cause of fatigue, and then employ one or more of the natural healing techniques to boost your energy levels and feel alive again.

The post 2. What Causes Fatigue? appeared first on University Health News.

Myth #1: All Grains are Bad News

Sensationalist diets may attempt to pin everything from heart disease to brain fog on grains, but research shows this food group definitely should not be blamed for all of society’s ills. Case in point: A 2016 study in The Journal of Nutrition showed that people who ate a whole-grain heavy diet for two months experienced improvements in blood pressure numbers. Scientists in Denmark found that among more than 55,000 people studied those who ate the most servings of whole grains had a lower risk of developing type 2 diabetes. One recent study even found that people who consumed a low carbohydrate diet, which often means being skimpy in grains, were at greater risk of premature death from maladies like heart disease. Just like other food groups, grains should play a role in an overall healthy diet. The key is to double down on unrefined whole grains such as quinoa and oats because these will give you more nutritional bang for your buck compared to refined grains and sugar.

Myth #2: High Carb Diets are Fattening

In fact, the opposite can be true. Many people will maintain a healthy weight while eating plenty of carbs—and not just ultra-endurance athletes. A 2018 study published in Nutrients showed that people who followed a plant-based high-carb diet (about 70% of daily calories) for four months experienced benefits in their body composition including a drop in body fat levels. A separate investigation showed that higher intakes of carbs, specifically those containing more fiber, when consumed as part of a calorie controlled diet played a big role in weight loss success among people at risk for diabetes. “This just shows that no one food will make you fat, just like no one food will make you thinner,” says Alissa Rumsey MS, RD, founder of Alissa Rumsey Nutrition and Wellness in New York City. What matters most she says, whether you’re following a high-carb or low-carb diet, is that your overall diet contains mostly high-quality foods in appropriate portions. But, yes, polishing off a half loaf of bread will make most people gain weight.

Myth #3: Fret Not About Natural Sugars

Maple syrup, honey, high fructose corn syrup or table sugar—they’re all very similar from a health perspective. A 2015 study in The Journal of Nutrition found that when people ate the same amount (about two tablespoons) of honey, sucrose (i.e. white sugar) or much-maligned high fructose corn syrup every day for two weeks, they experienced the same concerning metabolic changes including a rise in blood triglycerides and markers of inflammation, both risk factors for heart problems. Though “natural” sweeteners like coconut sugar and maple syrup may contain higher amounts of certain nutrients and antioxidants, it’s hardly enough to outweigh the concerns of eating too much of them. “The key is to make the choice to eat foods with added sugars as long as you are eating an overall balanced, nutritious diet,” notes Rumsey.

Myth #4: Whole Grains Should be Your Go-To Fiber Source

The Academy of Nutrition and Dietetics recommends women aim for 25 grams of fiber per day and 38 grams per day for men.Yes, whole grains can help you nail this quota but you’re likely going to need more help to get there. For instance, a half-cup serving of brown rice has about three grams of fiber while certain brands of whole-wheat bread may only deliver a single gram per slice. “The key to getting the fiber you need daily is to vary your sources including fruits, vegetables, pulses and whole grains,” Rumsey says.

Myth #5: Today’s Wheat Has More Gluten

Despite the internet gossip, Rumsey says there is no proof that the gluten content of wheat has increased with modern agriculture. But regardless of wheat’s gluten potency, research continues to show that the vast majority of people experience no health benefits from avoiding gluten (a protein, ironically, not a carb). In fact, a study published in the BMJ found that people who follow a gluten-free diet but don’t have celiac disease can be at a greater risk for heart disease, largely because they aren’t consuming enough whole grains and the nutritional benefits that come with those.

Myth #6: Avoid Fruit Because it Has Sugar

Criticism of sugar is so widespread that the naturally occurring sugar in foods such as fruit and milk has also come under fire. But comparing the sugar in an apple to the sugar in candy just doesn’t work. “The sugar in fruit is also bundled with fiber, vitamins and antioxidants which you don’t get when consuming sugar from highly processed foods,” says Rumsey. Besides, you get much less sugar from a piece of fruit compared to what you get from sweetened items, like soda and boxed cereal. For example, a medium orange has about 13 grams of sugar, while a can of soda delivers three times as much. No wonder you’d be hard pressed to find a study linking fruit intake with weight gain and health woes.

—Matthew Kadey, MS, RD

The post Are Carbs the Enemy? Six Myths about Carbs appeared first on University Health News.

What Is Hummus?

Hummus is a Levantine Arabic dip made of cooked and mashed chickpeas, tahini (a condiment made from toasted sesame seeds), olive oil, garlic, lemon juice, and salt. While the dip has been popular in the Middle East and the Mediterranean for centuries, it has recently gained popularity across the globe, including the U.S.

Traditionally, hummus is served as an appetizer along with pita bread, falafel, meat, poultry, fish and/or vegetables. It’s often topped with various garnishes such as olive oil, parsley, paprika, sumac, olives, pickles, tomatoes and whole chickpeas.

Hummus can also be used as a dip for raw vegetable platters that include carrot and celery sticks, and cucumber slices, and is sometimes used as a healthier alternative to mayonnaise on sandwiches and in salads. It’s also a popular choice of protein for those following a vegetarian or vegan diet.

Why You Should Be Eating Hummus

According to the USDA, two tablespoons of commercially made hummus contains 60 calories, 2 grams of protein, 5 g of fat, 3 g of carbohydrates, 80 milligrams of sodium, and 1 g of fiber. Each serving is free of sugar and cholesterol contains a good source of iron and vitamin C.

What makes hummus so good for you is that each ingredient in the dip contains a powerhouse of nutrients that will benefit your heart, bones, and more. Let’s break everything down:

• Chickpeas: Also known as garbanzo beans, chickpeas are a popular member of the legume family because of their high fiber and protein content. They’re often used as an animal protein replacement for those following a plant-based diet; they contain an adequate source of calcium, potassium, manganese, magnesium, zinc, vitamin K, and choline, which can decrease inflammation.
• Garlic: It contains allicin, which has anti-microbial and antibacterial effects, and can help treat hypertension, blood coagulation, and certain cancers.
• Olive oil: Loaded with healthy fats and antioxidants, olive oil is believed to help reduce inflammation, treat rheumatoid arthritis, prevent strokes and heart disease, and fight Alzheimer’s disease.
• Tahini: This condiment’s main ingredient is sesame seeds, which are a good source of zinc, calcium, phosphorus, fiber, and copper.
• Lemon juice: Lemons are rich in vitamin C, pectin, and d-limonene, which can benefit your heart and protect you from anemia, cancer and kidney stones.

And like most foods in our diet, hummus should be eaten in moderation. Two tablespoons of hummus is considered to be one serving, which is a probably a lot smaller than what most people eat in one sitting. It’s more likely that we consume between two and three servings in one sitting, which can be a problem since many commercially produced brands of hummus contain more salt than the homemade variety.

It’s also important to read the ingredients so that you can skip any brands containing colorants, thickeners, stabilizers, and preservatives.

Is Hummus Healthy If I Make It at Home?

Definitely! Making hummus at home will allow you to control the amount of salt and oil going into the dip, thus avoiding excess sodium and fat. You can also top your hummus with garnishes that are beneficial to your specific nutritional needs, such as:

• Black pepper for antioxidants and anti-inflammatory effects
• Turmeric to reduce inflammation
• Cinnamon for glucose control
• Oregano for additional calcium, vitamin C, vitamin A, and fiber
• Bell peppers for vitamins A, C, and B5.

If you have a decent food processor or blender at home, hummus is easy to make. Just combine canned chickpeas that have been rinsed and drained with garlic, lemon juice, olive oil, and tahini and blend until smooth. Tahini is often located in the “ethnic” section of grocery stores, or in the condiments aisle. You can experiment with different types of legumes (beans, peas, and lentils) and flavor combinations.

Go Thai-style by adding turmeric, coriander, cilantro, and curry powder, or spice it up with cayenne pepper, sriracha, chipotle, or your favorite variety of hot peppers. Check out BonAppetit.com for 20 different hummus recipes, some of which include unique ingredients such as avocado, beets, peanuts and sweet potato. And if you’re following a gluten-free diet, check out the sidebar below for a recipe from our sister publication Gluten Free and More.

This article was originally published in 2018. It is regularly updated.

The post Is Hummus Healthy? appeared first on University Health News.

But they have more in common than just an aversion to gluten and their gluten-free diet regimen.

“We absolutely crave bread,” says Mary from her prim domicile located in a Houston suburb. “That means we have to get creative.”

Gluten-Free Diet: Flour Choice Is Key When it Comes to Baking

In sticking to a gluten-free diet, Mike and Mary rely on the host of alternative flours and flour blends to achieve the tasty—and safe—baked goods they thought they would never enjoy again following Mike’s celiac disease diagnosis.

How do they do it? With these alternative flours, Mike and Mary learned how to make their favorite foods without compromising taste and texture. In fact, you can add essential vitamins, minerals, protein, and fiber to your baked goods, fortifying your gluten-free diet in flavorful ways. From beans and grains to tubers and seeds, there’s a rich and wonderful array of delicious and nutritious flours waiting for you.

• Bean flours: Varieties include chickpea (garbanzo), bean (navy, pinto, and red) and soy. Garfava flour is a blend of flours made from garbanzo, fava beans and Romano beans. High in protein, fiber and calcium, these flours work best with heavier foods, such as breads and spice cakes.
• Pea flour and green pea flour: Both have benefits similar to bean flours but without the strong aftertaste. High protein content adds structure to baked goods without any distinct flavor.
• Amaranth: An ancient food used by the Aztecs, the seeds of the broad-leafed amaranth plant are milled into flour or puffed into kernels for breakfast cereals. High in protein, calcium and iron, this mildly nutty-tasting flour adds structure to gluten-free baked goods and helps them brown more quickly.
• Corn flour: Milled from corn kernels, this is finely ground cornmeal that comes in yellow and white varieties. One form of corn flour is masa harina (milled from hominy) used in making corn tortillas. If corn flour isn’t available, you can make your own by grinding cornmeal into a fine powder in a food processor. High in fiber with a slightly nutty taste, corn flour is a good source of fiber, riboflavin, niacin, folate, iron, and thiamin.
• Cornstarch: A flavorless white powder that lightens baked goods to make them more airy. Cornstarch is highly refined and has little nutritive value. Store in a sealed container in a dry location.
• Cornmeal: With a larger particle size than corn flour, cornmeal lends excellent texture to foods and has a nutty and slightly sweet taste. Cornmeal comes in yellow and white varieties and in fine, medium and coarse grinds. Select finer grinds for baking and for polenta. Use coarse meal for breading. High in fiber, iron, thiamin, niacin, B-6, magnesium, phosphorus, and potassium.
• Millet: An ancient food, possibly the first cereal grain used for domestic purposes, millet imparts a light beige or yellow color to foods. Millet is easy to digest, and its flour creates light baked goods with a distinctive mildly sweet, nut-like flavor. High in protein and fiber and rich in nutrients, millet adds structure to gluten-free baked items.
• Oat flour and oats: High in fiber, protein, and nutrition, pure, uncontaminated gluten-free oats add taste, texture and structure to cookies, breads, and other baked goods. If oat flour is not available, you can make it by grinding oats in a clean coffee grinder or food processor. (Quinoa flakes can be substituted for whole oats in most recipes.) Store in a tightly sealed container in a cool, dry place or freeze to extend the shelf life. (See also our post “Is Oatmeal Gluten-Free?“)
• Rice flour: This is the gluten-free flour that’s used most often by those on a gluten-free diet. It’s available as brown rice (higher in fiber), sweet rice (short grain with a higher starch content), and white rice. Rice flour is easy to digest and blend. The texture varies depending on how it’s milled—fine, medium, or coarse. Fine grind is used for cookies, biscotti, and other delicate baked goods. Medium grind, the most readily available, is suitable for most other baking. Coarsely ground is best for cereal and coatings. White rice flour has a bland taste. Brown rice is slight nutty.
• Sorghum flour: Some believe this flour, also called milo or jowar flour, tastes similar to wheat. Available in red and white varieties, it has a slightly sweet taste and imparts a whole-wheat appearance to baked goods. Sorghum is high in protein, imparting all-important structure to gluten-free baked goods. It’s also high in fiber, phosphorous, potassium, B vitamins, and protein.
• Teff flour: Milled from one of the world’s smallest grains, teff is a key source of nutrition in Ethiopia. It’s available in dark and light varieties. High in protein, fiber, and calcium, teff imparts a mild, nutty taste to cookies, cakes, quick breads, pancakes, and waffles.

Originally published in 2016, this post is regularly updated.

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• Strengthen your core for better balance, stability (Jan., 7)
• Reduce fracture risk with resistance exercises (Feb., 7)
• Keep your hands flexible and functional (Mar., 7)
• Ease the ache in your neck and shoulders (Apr., 7)
• Get a leg up on chronic knee pain (May, 7)
• Maintaining good balance is key to strength and mobility (June, 7)
• Keep your hips mobile to maintain lifelong health (July, 7)
• Improve your posture and reduce your risk of back problems (Aug., 7)
• Preventing or relieving a stiff neck (Sept., 7)
• Stay fit by strengthening your core (Oct., 7)
• Improve your lower body muscles with strength training (Nov., 7)

CANCER

• Cancer risk connected to ultra-processed foods (June, 3)
• Include these cancer-fighting foods in your daily diet (June, 4)
• Eating nuts may help prevent cancer’s return (June, 1)

CARDIOVASCULAR HEALTH

• Make a heart-healthy diet a top priority (Jan., 1)
• New goal has been set for blood pressure (Feb., 1)
• Small seeds are big in beneficial nutrients (Apr., 4)
• Which is worse, saturated fat or trans fat? (Apr., 8)
• Should I take an iodine supplement if I reduce salt? (Apr., 8)
• Foods that can help lower blood pressure (June, 2)
• High sodium output linked to high blood pressure (June, 3)
• Can drinking a glass of red wine a day reduce my cholesterol? (June, 8)
• Reduce processed meats to improve your heart health (July, 3)
• Vitamin D and heart health (Aug., 2)
• Heart-healthy food shopping (Oct., 1)
• The healthiest nuts (Dec., 1)

DISEASE PREVENTION/MANAGEMENT

• The pros and cons of turmeric (May, 4)
• What is prediabetes and can it be reversed? (May, 8)
• What do antioxidants do and where can I get them? (May, 8)
• Strict avoidance is the best way to handle an allergen (May, 8)
• Vitamin K’s role in preventing osteoporosis (June, 1)
• Fend off environmental allergy symptoms with nutrition choices (Aug., 1)
• A plant-based diet may help you live longer (Oct., 1)
• Eat your way to better immune health (Oct., 2)
• Lower your risk of type 2 diabetes with fruits, veggies (Nov., 2)
• Long-term weight loss reduces risk of metabolic disease (Nov., 2)
• Eating healthfully may stall asthma symptoms (Nov., 3)
• Low-potassium, low-phosphorus foods for people with chronic kidney disease (Nov., 8)

FEATURED FOODS

• Lean fish is a healthy choice, too (Jan., 2)
• Take a closer look at the coconut craze (Feb., 2)
• Why dark chocolate is healthier than milk chocolate (Feb., 8)
• Pros and cons of a plant-based diet (Mar., 1)
• Cocoa can provide a nutritious boost (Mar., 1)
• The benefits of cruciferous vegetables (May, 4)
• The pros and cons of turmeric (May, 4)
• The pros and cons of pomegranates (June, 2)
• Is garlic a cure-all? (July, 8)
• Healthy seafood alternatives (July, 1)
• Healthier fillings for your favorite sandwich (July, 4)
• Why the berry craze isn’t going away (Aug., 1)
• 5 whole grains you can learn to love (Sept., 1)
• Use herbs and spices to eat more healthfully (Sept., 1)
• How to cook with fall vegetables (Oct., 1)
• Root vegetables: A powerhouse of nutrients for your meals (Dec., 1)

FOOD SAFETY AND LABELING

• Is it safe to refreeze leftovers that have been defrosted? (Mar., 8)
• Dine at home to avoid chemicals in foods (July, 3)
• The truth about food expiration dates (Dec., 4)

GASTROINTESTINAL HEALTH

• Foods that cause indigestion (Jan., 1)
• Enzymes play an important role in digestion (Jan., 4)
• Dietary strategies to ease GERD symptoms (Apr., 1)
• Walnuts may improve gut health (Oct., 2)
• The best probiotics for resolving digestive stress (Nov., 2)
• Non-dairy sources of calcium (Dec., 2)

GENERAL HEALTH AND NUTRITION

• How to become a breakfast eater (Feb., 8)
• The importance of hydration (Mar., 2)
• Is almond milk healthier than cow’s milk (Mar., 8)
• Control your hunger with smart snacking (Apr., 1)
• Finding the healthiest whole-grain products (June, 1)
• Achieving a balanced diet (July, 1)
• Managing diabetes (Aug., 2)
• Will a gluten-free diet give me more energy and improve my health even if I don’t have gluten-related health issues? (Aug., 8)
• DASHing to better health (Sept., 1)
• Outdoor grilling the healthy way (Sept., 4)
• Oxalic acid, found in leafy greens, interferes with calcium absorption. How can I protect my bones and still get the right nutrients? (Sept., 8)
• Mediterranean-style diet may slow progress of eye disease (Oct., 3)
• The importance of unsaturated fats (Nov., 1)
• Planning a healthier holiday meal (Nov., 1)
• Leucine may help with protein absorption (Nov., 3)

MIND/MOOD/MEMORY

• Whether different types of alcohol affect the body differently (Jan., 8)
• Brain foods for improving mental functioning (June, 1)
• A healthy diet can prevent your brain from shrinking (Aug., 8)
• Dehydration can affect your ability to concentrate (Oct., 2)
• Lower your risk of dementia with a healthy diet (Oct., 3)
• Belly fat may reduce cognitive function in older adults (Nov., 8)

OBESITY/WEIGHT

• Advice for sticking to a weight loss diet (Jan., 8)
• Simple strategies for shedding pounds (Feb., 1)
• Fat-burning foods can improve your health (May, 1)
• Mediterranean-style diet ranked No. 1 by U.S. News and World Report (May, 2)
• Reduce leptin resistance (May, 6)
• How important is counting calories when I’m trying to lose weight? (June, 8)
• Tackle obesity with lifestyle changes, not diets (July, 2)

RECIPES

• Mediterranean salad (May, 2)
• Chickpea pasta with roasted vegetables (Aug., 2)
• Quick-serve berry ice cream (Aug., 6)
• Grilled veggies (Sept., 4)
• Spaghetti squash with herbs and cheese (Oct., 6)
• Wild rice or quinoa stuffing (Nov., 6)
• Healthier nondairy eggnog (Dec., 3)

SUPERMARKET SLEUTH

• Munch on this: Pre-popped popcorn (Jan., 5)
• Selecting the best nutrition bars (Feb., 5)
• Choosing the healthiest chocolate (Mar., 5)
• Hummus: A healthy option for dips and spreads (Apr., 5)
• Pointers for selecting frozen pizza (May, 5)
• Enjoy these healthy bottled iced teas (June, 5)
• Finding healthier, flavorful salad dressings (July, 5)
• Peanut butter: Healthy protein by the jar (Aug., 5)
• Choosing a mayonnaise with healthy ingredients (Sept., 5)
• Yogurt: A healthy way to start your day (Oct., 5)
• Whole-grain rice is rich in healthy nutrients (Nov., 5)
• Delicious low-sodium soups (Dec., 5)

VITAMINS/MINERALS/SUPPLEMENTS/MEDICATIONS

• The dangers of dietary supplements (Mar., 4)
• Get enough calcium in your daily diet (Apr., 1)
• Vitamin K’s role in preventing osteoporosis (June, 1)
• What is magnesium for and can I get enough of it from my diet? (July, 8)
• Vitamin D and heart health (Aug., 4)
• I don’t eat fish. Should I take a fish oil supplement? (Sept., 8)
• Multivitamins/minerals provide no clear health benefits (Oct., 3)

Key: Subject (month, page number)

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Food Allergies and Intolerances

If you have a food allergy or intolerance, reading dietary advice that tells you to eat foods you know you need to avoid can be frustrating. But, with a little help, most people can work around food limitations to create a healthful diet. If you’re concerned about your dietary pattern, ask for a referral to a registered dietitian nutritionist who can help you build an eating plan that fits your lifestyle and dietary needs.

Food allergies cause immediate, systemic problems, like hives, wheezing, and vomiting, possibly followed later by gastrointestinal symptoms and allergy symptoms like runny nose, coughing, and watery eyes. Food intolerances don’t typically cause symptoms immediately after eating, and they’re generally localized to your gut (pain, bloating, diarrhea, or constipation), although headaches and skin problems are possible. Sometimes people with an intolerance (or sensitivity) can eat a certain amount of the offending food or food component, but if they pass that tipping point, symptoms arise. Some common intolerances that impact dietary intake are gluten sensitivity and lactose intolerance.

Celiac Disease

Celiac disease is an autoimmune disorder that can happen in people who are genetically predisposed to it. When someone has celiac disease, ingesting gluten, a protein found in wheat, rye, and barley that makes dough stretchy, leads to damage in the small intestine. The only known treatment for celiac disease is a strict, lifelong gluten-free diet. Giving up every crumb of gluten is essential for the estimated 1 percent of the population with celiac disease. This includes avoiding cross-contamination from bread crumbs in toasters, butter dishes, and cooking utensils and pans, as well as avoiding gluten in medications and supplements. If you have been diagnosed with celiac disease, the basic dietary advice presented in this report does not change, but you do need to choose your whole grains and grain-based foods wisely.

An increasing number of tasty, gluten-free options are available in supermarkets and restaurants, including pizza, cookies, and packaged snacks. Although these options make life simpler, an overreliance on gluten-free goodies could lead eating habits astray. Not only do these processed foods often contain ingredients with little nutritional value, they also can displace healthful, naturally gluten-free foods, such as fruits, vegetables, legumes, nuts, lean meat, fish, poultry, and minimally processed, gluten-free whole grains, including teff, quinoa, and brown rice. If you’re newly diagnosed, ask your doctor for a referral to a registered dietitian nutritionist who is knowledgeable about gluten-free diets. Because symptoms of celiac disease may range from “silent” to mild to severe, and may not include the gastrointestinal tract, it’s important that anyone who suspects they can’t tolerate gluten be tested for celiac disease while they are still consuming gluten, to get an accurate test result.

Non-Celiac Gluten Sensitivity

Some individuals may test negative for celiac disease or a wheat allergy but have celiac-like symptoms when they consume gluten. These individuals may be diagnosed with non-celiac gluten sensitivity (NCGS). The dietary remedy is the same as for celiac disease—a gluten-free diet. It’s uncertain how many people NCGS affects but available estimates range from 0.6 to 6 percent of the population. Currently, there is no publicly available medical test that can reliably detect NCGS.

FODMAPs

In some cases, poor tolerance of wheat, rye, and barley products may not be due to celiac or NCGS but, rather, to bacterial fermentation of certain short-chain carbohydrates found in these grains. Other foods that contain various types of fermentable carbohydrates include milk products, fruits, certain vegetables, and legumes. Called FODMAPs (which stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols), these natural sugars and fibers can cause digestive problems in certain people and are being investigated as a potential trigger for irritable bowel syndrome (IBS). When FODMAPs move to the large intestine, they are fermented by bacteria, resulting in production of gas, which may be accompanied by abdominal bloating and pain, as well as nausea, diarrhea, and/or constipation.

Even people who have trouble with FODMAPs can generally tolerate some amounts of these foods. The trick is to find out how much of what foods work best for you. For example, the fruit sugar fructose is a FODMAP, but many people can tolerate a certain amount of fruit at each meal without symptoms; however, since bread made from wheat flour contains other FODMAPs (fructans), having both fruit and a roll could hypothetically be enough to trigger symptoms. Or perhaps you can enjoy an apple and a sandwich, as long as you hold the onions. Following a low FODMAP diet may reduce IBS symptoms.

While avoiding some FODMAPs, such as high-fructose corn syrup and agave nectar in many foods with added sugar, is advisable for everyone, cutting out foods like high-FODMAP whole grains, fruits, vegetables, and dairy makes it difficult to consume enough fiber and some essential nutrients. Ask for a referral to a registered dietitian nutritionist who is knowledgeable about the low-FODMAP diet. After a few weeks on such a diet, you can reintroduce each type of FODMAP, one at a time, to determine your tolerance. Cutting back on FODMAPs has a significant impact on what foods can be included in your dietary pattern, but with the help of an expert and some trial and error, it’s possible to construct a healthful, balanced eating plan.

Lactose Intolerance

Lactose is the naturally occurring sugar in dairy foods. All infants are born with the ability to make the enzyme lactase, which breaks down the milk-sugar lactose. But many adults, especially those from cultures where dairy products are not a diet staple, don’t produce enough lactase to adequately break down milk sugar. Lactose intolerance can result in uncomfortable gut symptoms, which typically begin within 30 minutes to two hours of consuming dairy products. Different dairy products have varying amounts of lactose, so the degree of intolerance may differ depending on the dairy product. For some people, simply reducing the portion sizes of milk products or consuming them as part of a meal with other foods can help, while other people may be intolerant even to small amounts. Some people take lactase enzyme pills to help digest dairy products.

Fermented dairy products, such as hard cheeses, yogurt, and kefir, are often better tolerated because the lactose gets broken down during the fermentation process. Another option is to purchase dairy alternatives that are fortified with calcium and vitamin D, such as some soy, rice, almond, and coconut “milks.” You can read more about these dairy-free options in Chapter 8. Dairy products are an excellent source of calcium, as well as other important nutrients. If you are unable to consume dairy, make sure you are getting enough calcium from other sources.

Heart Disease

Along with not smoking and making physical activity a regular part of your life, smart dietary choices are key to protecting your heart health. If you’ve had a heart attack or stroke or have risk factors for cardiovascular disease like high blood pressure, high cholesterol, or diabetes, you may have been told to change your diet. The good news is, the dietary patterns advocated in the earlier chapters of this book (MyPlate, the DASH diet, and a Mediterranean-style diet) are a move in the right direction.

Research is clear that a heart-smart dietary pattern emphasizes foods that contain specific nutrients known to promote better cardiovascular health—fruits, vegetables, whole grains—in place of refined grains, legumes, nuts and seeds, fish (preferably oily fish, with their healthful omega-3 fatty acids), skinless poultry, and plant-based proteins (such as legumes, soy and quinoa). On the flip side, it’s important to limit sugar, sodium, and saturated fat intake and cut trans fat. This means limiting red and processed meats, keeping dairy products low-fat or fat free, and watching for partially hydrogenated oils in processed and fried foods. This type of dietary pattern helps address factors that increase the risk for heart disease, like high blood pressure, elevated cholesterol, diabetes, and obesity.

The following sections will provide more detail on what to emphasize when dealing with specific cardiovascular disease risk factors.

High Blood Pressure

High blood pressure (or hypertension) is easy to ignore since many people have no symptoms, but it puts you at risk for heart attacks, strokes, and other health issues, so it must be taken seriously. If you have been diagnosed with hypertension, following your doctor’s advice and taking any prescribed medication is essential to protecting your health, but there also are steps you can take on your own to help.

To bring down blood pressure, start with a healthful dietary pattern. Then, watch your portion sizes. Blood pressure tends to rise with weight. Basing your meals on reasonable portions of low-sodium, high-potassium foods like fruits, vegetables, whole grains, legumes, and low-fat dairy while upping your activity level will help you reach and maintain a healthy weight. Losing just 5 to 10 percent of your body weight can make a big difference, but good nutrition and regular physical activity alone can improve blood pressure, too.

These suggestions may not be the quick fixes promised by advertisements and websites, but they’re proven to work. You can help take control of your blood pressure naturally by changing your diet and lifestyle.

High Cholesterol

Cholesterol is a waxy, fat-like substance found in all cells of the body. It’s essential to the functioning of the human body, where it’s used in making hormones, vitamin D, and the bile acids that help you digest food. Cholesterol travels in the bloodstream in small packages called lipoproteins. Low-density lipoproteins (LDL) circulate throughout the body, allowing cholesterol to be deposited in arteries as part of plaque, which can build up, causing hardening, narrowing, and potentially life-threatening blockages. High-density lipoproteins (HDL) remove cholesterol from other parts of your body and bring it to the liver to be metabolized, which lowers the amount of cholesterol in the body. That’s why high LDL is considered “bad,” and high HDL is “good.”

The body can manufacture all the cholesterol it needs, but we also get cholesterol from eating animal products. For a long time, it was thought that consuming dietary cholesterol raised blood levels of LDL cholesterol, but that thinking has recently been called into question. Based on the latest research, the Dietary Guidelines for Americans no longer recommends limiting intake of dietary cholesterol to 300 milligrams per day or less. This is a controversial change, and some health professionals disagree.

Most experts do agree, however, that saturated fat raises cholesterol levels and CVD risk, and that’s why this change is not really a big one. Most high-cholesterol foods (like cream, full-fat cheeses, and fatty meats) also contain high levels of saturated fat, so removing the ban on high cholesterol doesn’t put these foods back on your healthful plate. Some foods such as eggs, organ meats, and seafood including shrimp and lobster are high in cholesterol but not saturated fat, so your doctor or dietitian may give you the go-ahead to enjoy them in moderation.

Soluble fiber helps prevent the digestive tract from absorbing cholesterol, so be sure to choose foods with soluble fiber, like oatmeal, apples, bananas, oranges, pears, prunes, and legumes. Stanols in plant foods also help reduce absorption of cholesterol, which is one of the reasons filling most of your plate with veggies and whole grains and choosing plant-based foods more often can help bring your blood cholesterol levels down. Replace saturated fat with unsaturated choices, like vegetable oils and fatty fish.

Working to achieve a healthy weight and being as active as your health allows also are important steps that can help lower cholesterol. While you’re working on these lifestyle changes, cholesterol-lowering medicines can help lower your heart-disease risk. As your lifestyle changes bring your LDL levels down and HDL levels up, you and your doctor may be able to cut down your cholesterol medications or eliminate them altogether.

Diabetes

If you are living with type 2 diabetes or have been diagnosed with prediabetes, you may feel that standard dietary advice, which recommends covering three-quarters of your plate with carb-containing plant foods like whole grains and fruit and upping the intake of starchy beans, is not for you. However, the American Diabetes Association now recommends eating a variety of foods, including vegetables, whole grains, fruits, non-fat dairy foods, healthy fats, and lean meats or meat substitutes. Start with a smaller plate (a 9-inch diameter is preferred), fill half of it with non-starchy vegetables, one quarter with whole grains, and one quarter with lean protein. Enjoy a serving of dairy and/or fruit on the side. (Visit the American Diabetes Association’s website at diabetes.org for help with meal planning.)

It’s also important that you space out your meals throughout the day, don’t skip meals, and try not to eat too much food or too much of any one type of food. While highly restrictive diets and carb counting have fallen out of favor for diabetes management, some things remain the same: Learn all you can about diabetes, get physically active, take your prescribed medicine, check your blood glucose as prescribed by your doctor, and go to your appointments. Losing weight, even 10 to 15 pounds, also is very helpful for improving blood-glucose control. To learn more, ask for a referral to a Certified Diabetes Educator or a diabetes education program recognized by the American Diabetes Association.

Obesity

If you’re overweight, even a small amount of weight loss may have big benefits. For example, losing just 5 to 10 percent of your body weight can result in more energy, a better mood, and improved health—although improved nutrition and physical activity habits deserve at least some of that credit. In some studies where participants experienced moderate weight loss of 5 percent or even less, they reported improvements in physical functioning, vitality, and mental health. Modest weight loss also has been found to reduce osteoarthritis knee pain, decrease urinary incontinence, lower the risk of type 2 diabetes, and improve cholesterol and blood pressure levels.

Many different dietary strategies can help you lose weight or prevent weight gain, but the key to success is making changes that you feel good about and can maintain long term. It also is essential that you don’t sacrifice the nutritional quality of your diet: A diet plan that excludes or severely limits any one food group or relies heavily on one particular food or food replacement carries the risk of being nutrient-deficient.If you carry extra weight, losing some might be good for your health, but giving your body the nutrients it needs to stay healthy is arguably more important.

The smart shifts recommended throughout this book all are good strategies for reaching or maintaining a weight that’s healthy for you, as long as you pay attention to portion control. Numerous studies have found that people tend to base their sense of fullness on the amount or volume of food they eat rather than on how many calories they’ve consumed. This means that filling your plate with healthful foods like fiber-rich whole grains, water-packed vegetables, and lean proteins can help fill you up and keep you satisfied without excessive calories. Known as “nutrient-dense,” foods high in water, fiber, or air have more nutrients per calorie than foods that are lower in water or higher in fat and/or sugar, such as dry snack foods, fatty meats, creamy sauces or dressings, fried foods, and rich desserts. Non-starchy vegetables, broth-based vegetable soups, fruits, low-fat dairy products, air-popped popcorn, and minimally processed whole grains all are examples of foods that pack fewer calories per bite. Nutrient-dense foods can fill many roles in your quest to eat less. A big salad of leafy greens, for example, takes up a lot of space on your plate, requires a lot of chewing, and stretches your stomach, which signals your brain that you’ve eaten a satisfying amount. Energy-dense foods aren’t necessarily off-limits, but be mindful of portion sizes and frequency.

Another helpful technique to help avoid accidentally taking in more calories than your body needs is mindful eating. Slow down and take time to notice the taste, texture, and aroma of your food. This not only can increase enjoyment of the food but also can help you recognize when you’re getting full. Avoid eating in front of the computer, while driving, when you’re talking on the phone, reading, or watching TV, because you may have no idea how much you’re consuming. If you’re distracted while you’re eating, you’re likely to miss your body’s signals and overeat. Feelings and emotions such as stress, sorrow, anxiety, and even boredom also may lead you to overeat. Finding ways to address the issues that influence your eating habits is important for physical and mental health and well-being.

A Word About the Glycemic Index

The glycemic index (GI) is a relative ranking of carbohydrate-containing foods on a scale from 0 to 100 according to how they affect blood sugar levels after eating. This rating scale was initially developed as a food-selection guide for diabetic individuals to improve their glycemic control by classifying foods into low (<55), medium (56-69), and high (>70) GI categories. You might also have heard the terms “slow carbs” and “fast carbs” used. However, use of the GI has gone beyond this original intent and is now being endorsed for use as a labeling tool to guide food choices to reduce chronic disease risk. It also serves as the basis for many popular diets. While there is some clinical data to support a modest benefit of low-GI diets in the management of diabetes, the evidence on the benefits of low-GI diets in non-diabetic populations is mixed, in part because recent research from Tufts University has found that glycemic response to white bread, long considered a high-glycemic food, can vary from person to person, and even in the same person when measured at different times. Rather than getting caught up in numbers, follow a healthy dietary pattern rich in a variety of healthful food choices. When you’re choosing vegetables, fruits, whole grains, and legumes, and combining them with adequate protein and healthy fats, you are eating in a way that will promote gentle fluctuations in blood sugar and steadier energy.

Do I Need Supplements?

Sometimes, special conditions make it difficult if not impossible to meet your nutrient needs through foods. That’s where appropriate amounts of high-quality supplements can make a difference. Among the most common options are vitamin, mineral, and herbal supplements. Such supplements come in many forms, such as tablets, capsules, powders, and liquids.

In most cases, it’s better to get nutrients from food sources—they’re absorbed more efficiently and don’t have the same safety concerns. Additionally, food components act synergistically to produce beneficial effects, so isolating individual components into supplements could produce unsatisfactory or unexpected results.

If you’ve made adjustments to your diet and you’re still falling short on certain vitamins and minerals, taking a nutritional supplement can help. A multivitamin/mineral supplement that provides around 100 percent of the Daily Value of most nutrients may be adequate for this purpose. However, if your doctor has identified a specific deficiency, you may need to take individual supplements at higher doses, such as for vitamins D or B₁₂, either temporarily or long-term. Here are some examples of groups that may need dietary supplements:

• Older adults. As you grow older, your calorie needs decline, yet vitamin and mineral needs generally remain the same or, in some cases, increase. Older adults are more likely to fall short on certain nutrients, such as calcium, vitamin D, vitamin B₁₂, and protein. Your doctor can easily test for nutrient deficiencies, such as vitamin D, while other deficiencies aren’t as easily detected. See “Nutrients of Concern for Older Adults,” in Chapter 2 for a more complete listing of nutrients and top food sources.
• Vegans. Vegans, and to some extent vegetarians, are at higher risk of falling short on nutrients commonly acquired by consuming animal products, including vitamin B₁₂, vitamin D, calcium, iron, iodine, zinc, and omega-3 fats. For information on food sources of these nutrients, “Nutrients of Concern for Vegans,” see Chapter 2.
• Osteoporosis or Lactose Intolerance. If you can’t meet your calcium needs through diet alone, calcium supplements can help. Look for one that also includes vitamin D, which improves calcium absorption, and magnesium, which helps convert vitamin D to its active form in the body. Calcium is best absorbed when taken in doses of 500 milligrams or less. Calcium carbonate should be taken at mealtime to increase absorption. Calcium citrate can be taken with or without a meal.

Cautions

Unlike medications, which must be proven safe and effective before the FDA allows them to be marketed, dietary supplements do not have to be approved by the FDA or any other agency before they can be sold. It’s the responsibility of manufacturers to ensure supplements are safe before they’re marketed. Unfortunately, the quality of dietary supplements varies greatly. An investigation by the New York State Attorney General’s Office found that over-the-counter herbal supplements often didn’t contain the ingredients claimed on the ingredient list. In some cases, the supplements contained unlisted fillers, including wheat and legumes, which are allergens for some people. Additionally, although you may find various claims about how supplements may help you, many of these products have limited research backing their purported benefits and may not be worth the money.

Some dietary supplements may be harmful when taken in high amounts, for a long time, or in combination with other supplements or certain medications. For example, supplements containing vitamin K, which is involved in blood clotting, interact with anticoagulant drugs, such as warfarin (Coumadin). Other supplements can have undesirable effects before, during, or after surgery. For instance, uncontrollable bleeding is a potential side effect of taking vitamin E, garlic, ginkgo biloba, or ginseng supplements in the two weeks before surgery.

The FDA advises that you consult with a health-care professional before using any dietary supplement, and always tell your surgeon about all supplements you use if you’ll be undergoing surgery.

Final Thoughts

When you have a chronic health condition that affects your food choices, it’s natural to focus on foods you should limit or avoid, which can be stressful. However, you’ll likely find eating more enjoyable if you shift your attention to what you can eat, choosing tasty, healthy foods that can help you manage your disease rather than dwelling on the foods you should pass up.

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We’ll go even further: Unquestionably, rice is the planet’s most important plant. It’s an ancient food staple for billions. Inexpensive, plentiful, and satiating, it appears in a wide assortment of shapes, sizes and colors and continues to inspire delicious culinary creations. Many of our most popular recipes depend on rice as a main ingredient.

That’s not to say rice doesn’t have “issues.” In 2014, Consumer Reports focused national attention on the arsenic levels in rice, which prompted the Food & Drug Administration (FDA) and the Environmental Protection Agency (EPA) to investigate. People in the gluten-free community who consume rice as their principle grain should be aware that there is some level of arsenic in certain types of rice grown in certain parts of the world. Consumers should understand how they can modify their rice consumption to address these concerns. Based on its analysis of arsenic levels in rice, Consumer Reports issued safety guidelines on November 18, 2014.

Lundberg Farms is a major producer of organic rice in the United States. Gluten Free & More published an informative interview with CEO Grant Lundberg about arsenic in rice in its June/July 2015 issue.

While we’re examining that widely asked question—Is rice gluten-free? —let’s talk about the different types of rice. There are more than 100,000 varieties! Conveniently, most fall into three main categories: long, medium and short-grain rice.

Long-grain rice: This is a classification of rice whose body is at least three times as long as it is wide. Long-grain rice generally cooks up light, fluffy and less sticky than other varieties due to higher levels of dry starch amylose. Best in: Savory dishes, salads, stir-fries, pilafs, curries, Indian, Mexican, Caribbean and Thai dishes, stuffing and fried rice.

Medium-grain rice: Typically, medium-grain rice is shorter but plumper than its long-grain kin. When cooked, this rice tends to remain moist and tender and sticks together more than long grain but less than short grain. Best in: Paella, risotto, casseroles, rice and beans, stuffing, meatloaf, rice salads, breads and desserts.

Short-grain rice: Short-grain rice has a wide, almost round body. When cooked, it tends to be quite moist and viscous due to high levels of waxy starch amylopectin. Because the grains stick together, short-grain rice is a practical choice for eating with chopsticks. Also called glutinous rice (don’t be confused–there is no gluten in it!), short-grain varieties tend to absorb less water and lose their shape during cooking. Best in: Sushi, desserts, puddings, rice balls, croquettes and risotto

Now that we’ve answered the question, “Is rice gluten-free?” are you ready to chow down on some delicious dishes? There are so many creative ways to use rice in every day cooking from Adzuki Bean Rice Burgers to Chicken Wraps with Coconut Rice, you’ll find tons of tasty recipes at GlutenFreeandMore.com.

Alicia Woodward is editor-in-chief of Gluten Free & More magazine.

Originally published in 2016, this post is regularly updated. 

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Lactose Intolerance

During normal digestion, the small intestine breaks down lactose (the predominant sugar found in milk) into glucose, a form that can be absorbed into the bloodstream and used by the body. An enzyme called lactase, which is produced in the lining of the small intestine, is responsible for digesting lactose. People with lactose intolerance have a shortage of lactase, and this impairs their ability to digest lactose. Lactose intolerance is not a dangerous condition, but it can be uncomfortable. It also can be hard to avoid the effects, since lactose is found in milk and other dairy products, including cheese, ice cream, and cottage cheese. It is also found in yogurt, but yogurt containing active cultures can break down lactose.

Sometimes, lactose intolerance has a distinct cause, such as a disease or injury to the small intestine. However, in most people, it is genetic and develops slowly over time. An estimated 40 percent of the world’s population is lactose intolerant, with Asian Americans, African-Americans, and Native Americans at particularly high risk.

Lactose Intolerance Symptoms

Undigested lactose ferments in the small intestine or colon, causing nausea, cramps, bloating, gas, and diarrhea. These symptoms usually occur about 30 minutes to two hours after eating or drinking foods containing lactose. Since people have varying degrees of lactose intolerance, the severity of symptoms will depend on how much lactose an individual can tolerate. Some people may be able to consume small amounts of dairy products, while others may need to avoid them altogether.

Diagnosing Lactose Intolerance

In people with symptoms of lactose intolerance, the diagnosis can be made with tests that measure the absorption of lactose in the small intestine. The tests include:

• Lactose tolerance test. This involves drinking a liquid that contains lactose. Blood samples are then taken to measure levels of blood glucose. This shows how well the lactose breaks down into glucose.
• Hydrogen breath test. This measures the amount of hydrogen in the breath. As undigested lactose ferments, hydrogen is produced. Hydrogen gets absorbed in the bloodstream and excreted in the breath—higher-than-normal amounts of hydrogen in the breath indicate that the body is not properly digesting lactose.
• Stool acidity test. The most common way of diagnosing lactose intolerance in young children, this test measures the amount of lactic acid (a byproduct of lactose digestion) in the feces.

Treating Lactose Intolerance

Lactose intolerance cannot be cured, but avoiding or limiting dairy products can help manage it. Young children with lactase deficiency should not eat any foods containing lactose. For older children and adults, total avoidance is usually unnecessary.

People with lactose intolerance also should be aware of other sources of lactose aside from dairy products. Small amounts may be found in bread and other baked goods, processed breakfast cereals, instant potatoes, soups, breakfast drinks, margarine, lunch meats, salad dressings, candies and other snacks, pancake mixes, biscuits, cookies, and powdered meal-replacement supplements. Carefully check the labels of these products for milk by-products, whey, curds, dry milk solids, and non-fat dry milk powder. The amount of milk that is tolerable varies from person to person. Some people can handle a little bit—others may tolerate ice cream and aged cheeses, but not other dairy products. Today, most supermarkets carry reduced-lactose milk and nondairy alternatives.

Lactase enzymes also are available for people who react to even small amounts of lactose, or who wish to consume dairy foods. These come in tablet and liquid form and are available without a prescription.

Dairy products are a major source of nutrients, particularly calcium. Calcium is essential for keeping bones strong and preventing osteoporosis. Therefore, people with lactose intolerance need to be mindful about getting enough calcium from other food sources if they must limit or eliminate milk from their diet.

Celiac Disease

For the food we eat to be useful to the body, all of the processes involved in digestion must work correctly. One essential process is the absorption of nutrients from the small intestine into the bloodstream. Disorders that interfere with nutrient absorption are called malabsorption disorders. One of the most common of these disorders is celiac disease (also called celiac sprue), a condition in which damage to the small intestine prevents nutrients from being absorbed properly.

The process of absorption takes place through villi, which are tiny, finger-like protrusions on the lining of the small intestine. If the villi are damaged, nutrients may not be absorbed, and the person becomes malnourished. Damage to the villi occurs because a person with celiac disease cannot tolerate gluten, a protein found in wheat, rye, and barley. The body mistakenly treats gluten as a dangerous invader and attacks it. This triggers inflammation in the small intestine, and the inflammation irritates and damages the villi, impairing their ability to do their job.

The exact cause of celiac disease is not understood, although there is a genetic component (it occurs in 5 to 15 percent of the offspring and siblings of a person with celiac disease). It can occur at any time in life, and may be triggered by stress.

Celiac Disease Symptoms

The severity of celiac disease varies from no symptoms at all to very troublesome symptoms. Some symptoms, like diarrhea, relate directly to the digestive system. But because celiac disease can lead to malnourishment, the disease can affect other systems of the body as well. Celiac disease can cause:

• Chronic diarrhea
• Recurring abdominal bloating, gas, and pain
• Anemia (iron deficiency)
• Abnormal results on tests of liver function
• Weight loss
• Bone and joint pain
• Osteoporosis
• Muscle cramps
• Pale, foul-smelling stool
• Behavior changes
• Tingling and/or numbness in the legs
• Fatigue
• Pale sores inside the mouth
• Itchy skin rash (dermatitis herpetiformis)
• Tooth discoloration or loss of enamel
• Seizures.
• Failure to thrive in infants
• Delayed growth in children

Diagnosing Celiac Disease

When celiac disease is suspected, the physician will order a blood test to determine whether the body’s immune system is making antibodies against gluten or any other enzyme involved in the disease process. Antibodies are substances produced by the body to attack “foreign invaders” such as bacteria and allergens. Gene testing to help identify a genetic predisposition to the disease is also available.

If the blood test shows the presence of antibodies, a biopsy of the small intestine will be taken during an endoscopy (see Chapter 2). Examination of the tissue under a microscope will reveal characteristic changes in the villi that indicate celiac disease. Confirmation of celiac disease is important, since strict adherence to a gluten-free diet can eliminate symptoms and prevent complications. Left untreated, damage to the small intestine can put people at risk for cancer, osteoporosis, anemia, seizures, and liver disease.

Treating Celiac Disease

The treatment for celiac disease is to avoid all gluten. Consultation with a dietitian with experience in celiac disease management is a valuable part of the treatment plan. Once gluten is removed from the diet, the body’s immune reaction to gluten stops, and inflammation resolves. The small intestine begins to heal, and the absorption of nutrients returns to normal. The small intestine should be completely healed after following a gluten-free diet for three to six months in children and younger adults, and two years in older adults.

Following a gluten-free diet can be challenging because it requires avoiding all wheat, rye, and barley. This means no more pasta, cereal, or bread made with these grains. Instead, people with celiac disease need to find substitute products. Grains that are naturally gluten free include oats, corn, quinoa, amaranth, brown rice, buckwheat, and millet. You also may be able to obtain flour made from potato, soy, or beans. Many stores carry gluten-free products, and you should check labels carefully to avoid hidden sources of gluten in some products, including additives like modified food starch, preservatives, and stabilizers. Eating out in a restaurant can be challenging, since gluten is found in many unsuspected products, such as soy sauce. It is best to order dish-es without breading, gravies, or sauces. You also can ask the waiter or chef about ingredients in a particular dish, but if in doubt, order something else. Because a gluten-free diet requires a substantial change in dietary habits for most people, a dietitian can be helpful.

Since cross-contamination is possible, people with celiac disease can unknowingly consume gluten. Even the smallest amount can trigger symptoms; however, a new drug is being developed to help people who accidentally ingest gluten (see, “New Drug Eases Effects From Low Amounts of Gluten”).

Keep in mind that a gluten-free diet is a medically necessary diet—despite ambitious marketing efforts, it does not offer spe-cific health benefits for people without celiac disease or gluten sensitivity (see “Gluten-Free Diets Won’t Help Reduce Heart Dis-ease Risk in People Without Celiac Disease”).

More than one company is trying to devise a drug that would allow people with celiac disease to tolerate consumption of gluten-containing foods. One such drug, larazotide acetate, is now in phase-3 clinical trials, the last stage before approval by the Food and Drug Administration. The drug works by preventing gluten from crossing the lining of the small intestine.

Diarrhea

Diarrhea is a common digestive disorder that happens to just about everyone at some time. The loose, watery stools that require frequent trips to the bathroom can have numerous possible causes ranging from minor to more serious. Most cases are caused by mild food poisoning or a viral infection, and the problem goes away on its own after a day or two. Diarrhea that lasts longer than that may be a symptom of disease, and should be checked out by a physician. Prolonged diarrhea can lead to dehydration, which itself can be serious.

Common causes of diarrhea include:

• Bacterial infections. The most common cause of hospitalization for diarrhea worldwide is infection with the bacterium Clostridium difficile (C. diff). The most common cause of C. diff infection is antibiotic use—one study found that 78 percent of community-acquired C. diff infections arose from antibiotic use within the prior 90 days.There are several strains of C. diff, one of which causes serious illness and even death (this strain accounts for about one-third of C diff cases). Diarrhea also may be caused by food or water contaminated with Campylobacter, Salmonella, Shigella, Yersinia or Escherichia coli.
• Noroviruses. These are the leading causes of food-borne disease outbreaks in the United States, and result in symptoms that in-clude diarrhea, vomiting, and stomach pain. Noroviruses are highly contagious, but the infection is usually not serious, and most people recover fully in one to two days. In those who are susceptible to more severe illness, including young children and old-er adults, excessive diarrhea may occur. This can cause dehydration, and may require hospitalization to replace fluids. No-roviruses are transmitted by consuming food or water contaminated with the virus, or by direct person-to-person contact. Effective transmission makes noroviruses a common cause of outbreaks of illness where people are closely confined and sharing resources, such as cruise ships, nursing homes, and daycare centers. An infected person is contagious for at least three days after starting to feel ill, and possibly as long as two weeks after recovering.
• Food intolerances, including lactose intolerance and other conditions that impair a person’s ability to digest some component of food.
• Parasites, such as Giardia lamblia, Entamoeba histolytica, and Cryptosporidium, which enter the body in food or water and settle in the digestive tract. Traveling to undeveloped countries raises the risk of contamination with a parasite.
• Medications, including antibiotics, blood pressure medications, and antacids containing magnesium. (Stopping the drug or lowering the dose may eliminate the problem, but never try this without your doctor’s permission.)
• Intestinal diseases, including inflammatory bowel disease, celiac disease, and irritable bowel syndrome with diarrhea-predominant symptoms.

Diarrhea Symptoms

As well as cramping and loose, watery bowel movements, patients with diarrhea may sometimes experience fecal incontinence (loss of bowel control). If this occurs regularly, report it to your doctor.

Although short bouts of diarrhea can be harmless, a doctor should be consulted if it lasts more than three days or is accompanied by severe pain in the abdomen or rectum, a fever of 102 degrees Fahrenheit or higher, bloody stools, or signs of dehydration. Dehydration can be serious, because along with water the body loses electrolytes (potassium and sodium), which are necessary for proper organ function. Dehydration is particularly dangerous for children, who can die from it within a matter of days.

Signs of dehydration include:

• Thirst
• Dry or sticky mouth
• Fatigue
• Dry skin
• Less frequent urination
• Light-headedness.

Diagnosing Diarrhea

It may not be possible to determine the exact cause of mild cases of diarrhea, but as long as the problem does not last long, diagnostic tests and treatments are not necessary. To determine the underlying cause of long-lasting diarrhea, one or more diagnostic tests may be needed. These may include a stool culture to look for bacteria, viruses or parasites, blood tests, fasting tests to identify food intolerances, sigmoidoscopy, and colonoscopy.

Treating Diarrhea

The appropriate treatment will depend on what is causing the diarrhea. Treatment for digestive disorders such as celiac disease, inflammatory bowel disease, and irritable bowel syndrome are discussed in those sections of this report.

If the culprit is bacterial, antibiotics may be prescribed—for example, diarrhea caused by C. diff is treated with the medication fidaxomicin (Dificid). Fecal microbiota transplantation, a newer alternative, also can be highly effective. In this procedure, a tiny amount of stool from a healthy individual is inserted in the colon of a person with diarrhea. The healthy bacteria found in the normal stool quickly populate the intestines, resolving diarrhea in as little as a couple of hours.

Drugs that stop diarrhea may be used in some cases of diarrhea. However, if the cause is a bacterium or a parasite, these drugs will trap the organism in the digestive tract. Although it may be unpleasant to continue having diarrhea, it is better to allow the body to naturally eliminate the invaders.

Some food and drinks can aggravate diarrhea. These include milk products and foods that are greasy, high in fiber, or have high sugar or artificial sugar content, and it’s best to avoid these until the diarrhea subsides.

Anyone experiencing diarrhea should take steps to avoid dehydration. Drink plenty of water, along with fluids that contain so-dium and potassium. Good options for rehydration include chicken or beef broth, fruit or vegetable drinks, ginger ale, Gatorade, and Pedialyte.

In some people, using probiotics may lessen the risk of C. diff. In healthy people, probiotics occur naturally in the gut, but anti-biotics can eradicate them. The two most common probiotics—lactobacillus and bifidobacterium—are found in yogurt and other dairy products. They also can be purchased in supplement form (typically capsules) at health food stores.

The post 8. Diseases and Disorders of the Small Intestine appeared first on University Health News.

Constipation

Many people believe they are constipated if they don’t have a bowel movement at least once a day every day. But in fact, the frequency of bowel movements considered normal ranges from three times a day to three times a week.

During the digestive process, after the nutrients have been extracted in the small intestine, undigested fiber and other waste moves into the large intestine, where muscle contractions help move it along. As this waste passes through the colon, water is absorbed, forming a solid waste product (stool) that will be eliminated. However, if the muscle contractions that propel the stool along become sluggish, the stool will move too slowly. This allows too much water to be absorbed, creating a hard, dry stool and causing constipation (if insufficient water is removed, the result is diarrhea).

Constipation that does not have a specific cause is called primary constipation. There are three categories: normal-transit constipation, slow-transit constipation, and dyssynergic defecation. Up to one-third of people with chronic constipation have the lat-ter. People with this disorder do not completely expel feces from the rectum when having a bowel movement, because the mus-cles responsible for moving stool out of the body do not relax sufficiently while straining to defecate.

Common causes of constipation include:

• Insufficient fiber in the diet. Although the body can’t digest all fiber—it passes in the stool—fiber holds water and helps to create stool that is soft enough to pass easily through the large intestine and out of the body. Fiber is found in beans, vegetables, fruits, nuts, seeds, and whole grains.
• Insufficient liquids. Water and other liquids make the stool softer and easier to pass.
• Lack of exercise. It’s not clear why exercise is important for preventing constipation, but being sedentary can lead to constipation, and being physically active can prevent it. If you are constipated, even walking may be helpful.
• Taking certain medications. Many medications can cause constipation, including pain medications (particularly opioids), antacids containing aluminum and calcium, calcium channel blockers (used to lower blood pressure), anti-Parkinson’s drugs, antispasmodics, antidepressants, iron supplements, diuretics, and anticonvulsants.
• Irritable bowel syndrome. People with irritable bowel syndrome can suffer from both constipation and diarrhea.
• Changes in life or routine, such as pregnancy or travel. Hormonal changes during pregnancy can cause constipation. Any upset to a normal routine and diet, such as those experienced while traveling, can cause temporary constipation.
• Ignoring the urge to have a bowel movement. This can dull rectal nerve sensitivity and cause stool to harden, since the longer stool remains in the rectum the more water is absorbed from it.
• Some diseases. People who’ve had a stroke, or who have a neurological condition such as Parkinson’s disease, can become constipated. Paraplegics who have suffered a spinal cord injury, and people with thyroid disease also can experience constipation.

Constipation Symptoms

Constipation means passing small amounts of hard, dry stool, usually less than three times a week, and straining to have a bowel movement, which can be painful. It also may cause the sensation of not having completely emptied your bowels. Other symptoms include feeling bloated, uncomfortable, and sluggish.

Diagnosing Constipation

Constipation is a common problem that usually lasts a short time and is not serious. But chronic constipation is another matter, as it is associated with a greater risk for chronic kidney disease (CKD) and kidney failure. A 2016 study reviewed the records of 3,504,732 U.S. veterans and found that those with constipation were 13 percent more likely to develop CKD and 9 percent more likely to develop kidney failure than those who were not constipated.

Constipation is considered chronic if two or more of the following symptoms have occurred at least 25 percent of the time over the previous three months:

• Straining to pass stools
• Lumpy or hard stools
• Sensation of incomplete emptying
• Sensation of obstruction or blockage in the rectum or anus
• Need for using manual maneuvers to facilitate bowel movement
• Less than three bowel movements per week
• Loose stools are not present without laxative use
• There is little or no abdominal pain.

To diagnose chronic constipation, your doctor may order blood tests to ascertain whether an underlying disease or condition is contributing to your constipation. Other tests that may be performed include sigmoidoscopy, colonoscopy, anorectal manometry, and a balloon expulsion test (see Chapter 2 for more on these tests).

Treating Constipation

Most cases of constipation can be treated by increasing your activity levels, drinking more fluids, and consuming more dietary fiber. Laxatives are usually not necessary, but if lifestyle changes don’t do the trick, laxatives or enemas may be used for a short period of time. No treatments for constipation should be used regularly, unless recommended by a physician.

Most treatments for occasional constipation fall into one of four groups:

• Bulk or fiber agents (such as Metamucil, Citrucel, Konsyl, Serutan, Fibercon, and Benefiber) hold water in the intestines, and make stools softer and easier to pass. Patients using bulk laxatives should drink at least eight glasses of fluid (water, juice, milk, coffee or tea) a day to avoid side effects.
• Osmotic laxatives (such as Milk of Magnesia, lactulose, MiraLAX, and sorbitol) cause the intestines to secrete water into the colon, which can help keep the stool soft and moving along. These laxatives also require drinking eight glasses of fluid a day.
• Stool softeners (such as Colace and Surfak) provide moisture to the stool, and prevent dehydration.
• Stimulants (such as Correctol, Dulcolax, Purge, and Senokot) cause muscle contractions in the intestines to help move the stool through more quickly.Because people have different expectations about how often they should have a bowel movement, some people overuse laxatives. Laxatives should only be used for a short time if a fiber-rich diet, fluids, and exercise fail to resolve constipation.If lifestyle changes and over-the-counter (OTC) laxatives fail to resolve chronic constipation, lubiprostone (Amitiza), linaclotide (Linzess), lactulose (Cephula, Chronulac, Constulose, Duphalac, Enulose), or polyethylene glycol (MiraLAX, Glycolax) may be prescribed.Research suggests that the most effective method for treating dyssynergic defecation constipation is biofeedback, which is used to train the body to relax these muscles.For people who suffer from chronic idiopathic constipation—where you have constipation symptoms, but the cause is un-known—increasing your fiber intake or using a psyllium product may offer relief. Otherwise you could check with your doctor about using specific drug classes that have been shown to offer relief (see “Certain Drugs Can Help with Chronic Idiopathic Constipation”).

Irritable Bowel Syndrome

About 10 to 15 percent of Americans suffer from irritable bowel syndrome (IBS): a condition characterized by cramp-like abdominal pain, bloating, diarrhea, and constipation. Women are more susceptible to the condition than men, and it usually begins around age 20. IBS can be uncomfortable and distressing, but does not permanently harm the intestine, or lead to a more serious disease, such as cancer.

The cause of IBS is not known—it is called a functional disorder rather than a disease, because no organic cause for the symptoms can be found. Emotional stress has often been blamed for causing IBS, since no physical damage to the colon is detected. Stress may worsen IBS symptoms, but other factors are also at play—for example, in people with IBS, the intestinal muscles that contract to help move contents through the colon (motility) may not work properly.

The colon of a person with IBS is unusually sensitive and reactive, and even mild stimulation can cause muscle spasms that in-terrupt normal motility. In some cases, the colon reacts to stimulation by moving contents too quickly. When this happens, insufficient fluid is absorbed from the waste, and the result is watery diarrhea. The colon also may slow down the movement of its con-tents—this causes too much fluid to be absorbed, and results in constipation.

In people with IBS, the colon may respond strongly to stimuli that would not bother other people. The following have been re-ported to worsen IBS symptoms:

• Large meals
• Gas in the colon or small intestine
• Certain medications
• Wheat, rye, barley, chocolate, milk products, alcohol
• Caffeinated beverages, such as coffee, tea, and cola
• High levels of fructose in fruits, fruit juice, honey, and high‑fructose corn syrup
• Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs, see Chapter 1)
• Insoluble fiber found in wheat and bran
• Large amounts of fat
• Stress, conflict, or emotional upsets
• Women with IBS may experience more symptoms during their menstrual periods, suggesting that reproductive hormones may exacerbate IBS.

Irritable Bowel Syndrome Symptoms

Common symptoms of IBS include:

• Constipation
• Diarrhea (often with an urgent need to move the bowels)
• Alternating constipation and diarrhea
• Bloating and gas
• Mucus in the stool
• Urge to move the bowels, but being unable to do so
• Abdominal pain and cramping that may disappear after a bowel movement.

Although IBS can cause some intermittent pain, severe, persistent pain is not associated with IBS and is probably caused by something else. Nor are bleeding, fever, or weight loss symptoms of IBS.

Several studies suggest a link between IBS and celiac disease. One study found that people with IBS-type symptoms were more than four times as likely to have celiac disease as people without symptoms. In these people, following a gluten-free diet may alleviate symptoms.

Diagnosing Irritable Bowel Syndrome

Diagnosis generally begins with a complete medical history and physical examination. The diagnosis of IBS is made when ab-dominal pain or discomfort has been present for at least three days per month for the past three out of the previous six months. The abdominal pain or discomfort must have two of the following three features:

• It is relieved by having a bowel movement
• There is a change in how often a bowel movement occurs
• There is a change in the form or appearance of the stool.

Extensive diagnostic testing is not necessary for people with typical IBS symptoms, but symptoms such as rectal bleeding, weight loss, anemia, or a family history of colon cancer or inflammatory bowel disease suggest a more serious condition that calls for investigation. For these patients, stool or blood tests, x-rays, or an endoscopy may be ordered. Patients over age 50 may be given a colonoscopy to screen for colon cancer. Those with diarrhea-predominant IBS or constipation-predominant IBS may be tested for celiac disease.

Treating Irritable Bowel Syndrome

IBS cannot be cured, but it can be treated with diet, stress management, and medications. Unfortunately, the quality of evidence for various IBS treatments is poor, either because too few clinical studies have been conducted, or because those that have been had too few participants, or were not structured well enough to draw conclusions. For this reason, treatments may be performed on a trial-and-error basis.

Treating IBS often begins with avoiding foods that may trigger symptoms (many people with IBS find it useful to review their di-ets with a registered dietitian or physician). Because different people may react to different foods, it is necessary to identify which foods are causing distress, so they can be avoided. Before consulting a dietitian or physician, it is a good idea to keep a food journal and note what foods seem to be causing problems. It may be worthwhile to try eating several small meals a day rather than three large meals, as well as drinking six to eight glasses of water a day and avoiding fatty foods. Increasing the amount of fiber in your diet may lessen constipation, but increase gas and bloating. This can be avoided by increasing fiber slowly, to allow the body to adjust.

Vitamin D deficiency can be common among IBS sufferers, in which case a supplement might be helpful (see “Vitamin D Sup-plements May Ease IBS Symptoms”). Some people with IBS also report relief after incorporating stress-management techniques, meditation, regular exercise, and regular sleep into daily life.

Inflammatory Bowel Disease

Inflammatory bowel disease (IBD)—not to be confused with IBS—is a collective term for diseases in which abnormal immune sys-tem activity in the intestine leads to inflammation. The two major forms of IBD are ulcerative colitis and Crohn’s disease:

• Ulcerative colitis causes inflammation and ulcers in the inside lining of the large intestine (rectum and colon). It affects only the top layer of the intestinal lining (called the mucosa).
• Crohn’s disease also causes inflammation, usually at the end of the small intestine and beginning of the colon. However, it can affect all four layers of the intestinal wall in any area of the gastrointestinal tract, from the mouth to the anus.

Both of these conditions are serious diseases that are best managed by an experienced specialist.

Approximately 1.6 million people in the United States have IBD. Symptoms usually begin between the ages of 15 and 30, although there is a smaller peak between the ages of 50 and 70. It also can start before age 10 or after age 70. Both Crohn’s disease and ulcerative colitis affect men and women equally. Those who smoke are at increased risk for eye and skin diseases, and joint pain. Both diseases go through cycles of flare-ups and remissions—in fact, patients with IBD often will go for months, or even years without experiencing any symptoms.

The exact cause of IBD is unknown, but some interaction between hereditary factors, the environment, and the immune system is probably at work. In IBD, the body’s immune system overreacts to viruses or bacteria in the intestines and launches an at-tack. White blood cells travel to the intestinal lining to drive out the invaders, and in the process, create inflammation. When the process never stops, inflammation becomes chronic, harming the intestine. This abnormal immune system reaction generally occurs in people who are genetically predisposed to IBD.

Now, there is some evidence that bacteria interacting with a fungus also may be a cause. For instance, people with Crohn’s disease have energetic immune systems that seek out and destroy bacteria living in the gut. But in a 2016 study, researchers who looked at both bacteria and fungi were surprised to find that levels of two bacteria (E. coli and Serratia marcescens) and one fungus (Candida tropicalis) were much higher in patients with Crohn’s than in patients without. The researchers discovered that the three microorganisms join together to produce a slimy layer that lines the intestinal wall, causing inflammation. At the same time, people with higher levels of the two bacteria have lower levels of beneficial bacteria in the gut.

Crohn’s also has a strong genetic component, with one gene (IL23R) associated with the disease, and variations in three others (ATG16L1, IRGM, and NOD2) known to increase the risk. These genes instruct proteins involved in immune system function. Variations in the genes appear to disrupt the ability of cells in the intestine to respond normally to bacteria. Variations in chromosome 5 and chromosome 10 also appear to increase the risk of Crohn’s.

Due to inflammation, people with IBD are at increased risk for blood clots and heart disease. In fact, those with IBD have a markedly higher risk for ischemic heart disease (the kind that causes heart attacks) as early as the first year following an IBD di-agnosis. IBD patients also are at greater risk for colorectal cancer, and typically begin colorectal cancer screening earlier than the recommended age (50 years) for people at average risk.

Inflammatory Bowel Disease Symptoms

The main symptoms of ulcerative colitis are cramp-like abdominal pain, especially on the lower-left side of the abdomen, and bloody diarrhea. Loss of appetite, weight loss, nausea, anemia, and fatigue also are common. Crohn’s disease symptoms vary de-pending on which part of the intestine is affected and the severity of the disease, but usually include abdominal pain, diarrhea, and bloating. People with either type of IBD also can have symptoms outside the digestive system that may include joint inflamma-tion (arthritis), eye pain, ulcers or rashes on the skin, or liver and kidney problems.

Diagnosing Inflammatory Bowel Disease

The process of diagnosing IBD starts with a medical history, physical examination, and a series of tests that include blood tests and stool sample analysis. If ulcerative colitis is suspected, the next step will be a flexible sigmoidoscopy or colonoscopy, which allows the doctor to visualize the interior of the large intestine and take tissue samples for analysis. If Crohn’s disease is suspected, the doctor may perform an upper GI series to look at the small intestine, or recommend an MRI, endoscopy or capsule endoscopy, or colonoscopy.

Treating Inflammatory Bowel Disease

The emerging field of fecal microbiota transplantation has shown promise in treating people with ulcerative colitis (see “Fecal Transplant Can Help Treat Ulcerative Colitis”). However, the mainstay of Crohn’s treatment is medications and—for more severe cases—surgery. Lifestyle measures also may help, and include identifying which foods might be causing symptoms and eliminating them from your diet. The most common culprits include dairy products, high-fat foods, raw vegetables, spicy foods, and caffeine. Also try eating smaller meals, drinking plenty of liquids, and taking multivitamins, since Crohn’s disease impairs the ability to absorb nutrients from food. Limit your alcohol intake, as alcohol irritates the digestive tract and can cause flare-ups, and if you smoke, try to quit the habit, since smoking can aggravate the symptoms of Crohn’s and also can cause flare-ups. After surgery for Crohn’s, smokers of 10 or more cigarettes a day have twice the risk of flare-ups as nonsmokers, and may need repeat surgeries.

There are many medications for Crohn’s disease that can lead to relief of symptoms and, ultimately, remission. These drugs fall into the categories below:

Anti-Inflammatories

Anti-inflammatory drugs known as 5-aminosalicylates are used in the treatment of mild-to-moderate IBD confined to the colon. They include sulfasalazine (Azulfidine) and mesalamine (Apriso, Asacol, Delzicol, Lialda, Pentasa). Once considered first-line treatments, they have fallen out of favor as more effective drugs have been developed. Patients who fail to respond to mild drugs are often treated with corticosteroids to help induce remission. These powerful inflammation-fighters, such as prednisone (Del-tasone) or budesonide (Entocort EC), can induce remission but must be used for a short period of time (three to four months) to avoid serious side effects.

Immune System Suppressors

Drugs that blunt the immune response can be used to stop the body from attacking itself. They can be highly effective, but require the close supervision of a physician due to the potential for serious side effects caused by the drugs themselves, as well as their effect in weakening the immune system. They include:

• Azathioprine (Imuran) and 6-mercaptopurine (Purinethol)
• TNF inhibitors (“biologics”). These drugs neutralize an immune system protein, in the process reducing symptoms. The class of drugs includes infliximab (Remicade), infliximab-dyyb (Inflectra), adalimumab (Humira), certolizumab pegol (Cimzia), and go-limumab (Simponi)
• The interleukin-12/23 inhibitor ustekinumab (Stelara). In 2016, the Food and Drug Administration (FDA) approved this psoriasis drug for the treatment of moderate-to-severe Crohn’s disease in people who meet certain criteria. In the studies that led to FDA approval, one dose of ustekinumab produced symptom relief in 34 to 56 percent of patients in three to six weeks. Those who responded, and continued to receive doses every eight weeks, were in remission by 11 months after their first dose
• Methotrexate (Rheumatrex, Trexall), a drug used to treat cancer, rheumatoid arthritis, and psoriasis
• Cyclosporine and tacrolimus (Astagraf XL, Hecoria), which are primarily used in patients who have developed fistulas.
• Natalizumab (Tysabri) and vedolizumab (Entyvio), two integrin receptor antagonists.

New Crohn’s Disease Drugs

Because Crohn’s disease can be managed but not cured, investigators continue to test new drugs. Some are new drugs in existing classes, but others take a brand-new approach to the disease. Here are some of the more promising medications:

• Risankizumab (BI-655066). This mono­clonal antibody is designed to block the effects of interleukin-23, an already proven pathway for relieving the symptoms of moderate-to-severe Crohn’s disease. In phase-2 studies, researchers tested doses of 200 milli-grams (mg) and 600 mg against placebo, and found that 36.6 percent of those given 200 mg and 41.5 percent of those given 600 mg had a good response, compared with only 20.5 percent of those given placebo. After receiving risankizumab, 24.4 percent of patients given the 200 mg dose and 36.6 percent of patients given the 600 mg dose went into remission, compared with 15.4 percent of patients on placebo.
• Filgotinib (GLPG0634). In a phase-2 dosing study of this JAK1 blocker, 59 percent of patients with moderate-to-severe Crohn’s dis-ease had a favorable response, and 47 percent went into remission. This was at least double the number of patients given pla-cebo. Filgotinib is the first drug to target the JAK1 pathway to suppress inflammation.
• Ginger nanoparticles. In mouse studies, researchers at the Atlanta VA Hospital are evaluating the effects of refined juice extracted from fresh ginger root on Crohn’s and ulcerative colitis. When fed to mice, the nanoparticles were absorbed by the lining of the intestine, reduced acute colitis and prevented chronic colitis and cancer, and boosted the production of cells that make up the lining of the intestine. They also lowered the production of proteins that promote inflammation, and raised levels of pro-teins that fight inflammation. These same qualities are what make ginger effective against nausea and other digestive problems.

Other Drugs for Inflammatory Bowel Disease

Some patients with Crohn’s are given antibiotics to help heal fistulas: “tunnels” that lead from the intestine to another part of the body (such as the skin, bladder, and vagina). About 30 percent of Crohn’s patients develop fistulas, and they can become infected. Antibiotics also may be given to reduce harmful intestinal bacteria that may be aggravating inflammation. The most common antibiotics prescribed for Crohn’s are cirprofloxacin (Cipro) and metronidazole (Flagyl).

When diarrhea cannot be controlled, an anti-diarrheal may be prescribed. In cases of mild-to-moderate diarrhea, a stool-bulking agent such as psyllium (Metamucil or generic) or methylcellulose (Citrucel) may be effective. For more severe diarrhea, loperamide (Imodium) may be recommended.

Because Crohn’s interferes with the absorption of nutrients, doctors often recommend that patients take vitamin B12, calcium, and vitamin D. If you suffer from intestinal bleeding, iron supplements may be needed.

Be sure to check with your doctor before taking any OTC nonsteroidal anti-inflammatory drugs (NSAIDs), which include aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve). These products have the potential to make your disease worse, so use acetaminophen (Tylenol) instead.

Surgical Treatment for Inflammatory Bowel Disease

About 23 to 45 percent of people with ulcerative colitis and 75 percent of people with Crohn’s eventually have surgery to remove a portion of the diseased digestive tract. Surgery can relieve symptoms—some of them life threatening—and lower the likelihood of developing cancer.

The standard surgery for ulcerative colitis is removal of the entire colon and rectum (proctocolectomy), which cures the disease. Today, the recommended surgical procedure is a proctocolectomy with ileal pouch-anal anastomosis (IPAA), which eliminates the need for an external bag. In this procedure, the nerves and muscles necessary for a bowel movement are preserved, and stool is passed through the anus. When this is not possible, the end of the small intestine is attached to an opening in the abdomen (ostomy), where stool passes out of the body into a bag.

Unlike ulcerative colitis, Crohn’s disease cannot be cured by surgery: The disease can develop in any other portion of the GI tract. However, surgery may be necessary if adequate control of symptoms cannot be obtained with medications. In Crohn’s disease, the least amount of diseased intestine is removed, so as not to interfere with the proper absorption of nutrients. If the large intestine is affected, a proctocolectomy can be performed. In some patients, removal of the small intestine can be avoided with strictureplasty. In this technique, narrowed portions of the small intestine are widened to allow better function.

Blockage of the intestine is a common complication of Crohn’s disease, and may require surgery. Surgical repair also may be necessary for larger fistulas and smaller fistulas that do not respond to medication.

Rarely, ulcerative colitis patients develop severe bleeding in the intestine. Even more rare is a condition known as toxic megacolon. In this condition, the colon becomes severely inflamed and dilated, and is at risk of rupture. Symptoms include pain, swelling of the abdomen, fever, rapid heart rate, constipation, and dehydration. This potentially life-threatening complication requires immediate treatment and surgery.

Diverticulitis

Diverticulitis develops from a condition called diverticulosis, although the latter does not always progress.

In diverticulosis, diverticula (small pouches about the size of large peas) bulge outward from the colon. The condition is thought to result from a low-fiber diet—it occurs more commonly in industrialized countries, and is far less common in countries where people eat diets that are high in vegetable fiber. Fiber helps keep the stool soft, so it passes easily through the intestines. Hard stools cause constipation, and straining to move a hard stool puts pressure on the colon. Pressure causes weak spots in the colon to bulge out, creating diverticula.

After age 80, almost everyone has diverticulosis (in fact, the condition is so common in older people that it isn’t considered a disease). However, 10 to 25 percent of people with diverticulosis progress to diverticulitis, in which the diverticula become in-flamed or infected. It’s not known exactly why diverticula become infected, but it may happen when stool or bacteria get caught in the pouches.

Diverticulitis Symptoms

The most common symptoms of diverticulitis are pain or tenderness on the lower left side of the abdomen, fever, a change in bowel function, and blood in the stool. Some people with diverticulitis develop complications including abscesses, fistulas, bowel obstructions, and peritonitis if a diverticulum bursts.

Diagnosing Diverticulitis

Diverticulitis symptoms can mimic those of other conditions, including inflammatory bowel disease or infectious gastroenteritis. Therefore, a CT scan with contrast (see Chapter 2) may be ordered to help make a diagnosis.

Treating Diverticulitis

Diverticulitis is treated with antibiotics, OTC pain relievers, and a few days on a liquid diet. If the attack is severe, a short stay in the hospital may be necessary to provide intravenous antibiotics and drain any abscesses that might have developed. You will likely need surgery—called bowel resection— if you continue to have episodes of diverticulitis, your immune system is compromised, or you develop a fistula, bowel obstruction, or peritonitis.

The best way to prevent diverticula from causing complications is to eat a diet high in fiber from fresh fruits, vegetables, beans, nuts, corn, and whole-grain foods. Wheat bran is often recommended, because it passes through the digestive system quickly, lowering pressure in the intestines. Cutting back or avoiding red meat also may lower your risk (see “Watch the Red Meat to Avoid Diverticulitis”). Excess weight and lack of exercise also may increase the risk of complications from diverticular disease, so take steps to address these if necessary.

Colorectal Cancer

Cancer is the second-leading cause of death in the United States, and colorectal cancer is the third most common cause of cancer deaths in both men and women. Changes in habits—primarily less smoking and more colon cancer screenings—have steadily lowered the incidence of colorectal cancer since the 1980s. Nevertheless, more than 95,000 cases of colon cancer and 40,000 cases of rectal cancer were projected to be diagnosed in 2016, and 49,000 deaths from the disease were expected. Perhaps most startling is that more young people are being diagnosed. Between 2004 and 2013, the number of colorectal cancers diag-nosed in people aged 50 and older dropped 2.5 percent—but the number of cases diagnosed in people younger than 50 rose 11.4 percent during the same period. Moreover, a larger number of these cancers were advanced at the time of diagnosis—30.6 percent, compared with 25.6 percent in the older age group.

Age increases the risk for the polyps that can develop into colorectal cancer. Other risk factors include eating a diet high in red or processed meat, low in calcium, and very low in fruits and vegetables. People who are obese and those with type 2 diabetes are also at greater risk, as are heavy drinkers of alcohol, and smokers (the latter appear to be at more risk for flat adenomas, a specific type of pre‑cancerous lesion).

Colorectal Cancer Symptoms

Colorectal cancer produces few or no symptoms until the disease is advanced, and the symptoms it does produce tend to be vague and easily overlooked. Symptoms that should prompt a visit to the doctor if they last longer than a week or two include:

• Rectal bleeding
• A change in typical bowel habits (such as the advent of diarrhea or constipation)
• A change in stool diameter
• Blood in the stool that may range from bright red to very dark red
• A feeling that the bowel has not completely emptied
• Cramping pain in the lower abdomen
• Decreased appetite
• Unexplained weight loss
• Weakness and fatigue.

Diagnosing Colorectal Cancer

Colorectal cancers caught early through screening tests have the highest likelihood of being cured. The five-year survival rate for colorectal cancer is 90 percent when the disease has not spread, but only 39 percent of cancers are diagnosed at this stage.

The American Cancer Society (ACS) recently updated its recommendations for first time colorectal cancer screening and now suggests that first time screening should begin at age 45. The U.S. Preventive Services Task Force (USPSTF) recommends that screening begin at age 50 and continue up to age 75, and advises people aged 75 and older to discuss with their doctor whether they should continue screening.

The ACS recommends the following colorectal cancer screening tests for people at average risk of colorectal cancer (see Chapter 2 for more information on these and other tests):

Colonoscopy: Every 10 Years

Colonoscopy is considered the gold-standard screening test, since it checks the entire colon.

Colonoscopies are recommended every 10 years, yet some research has suggested that the test may not be as beneficial in people aged 70 and older. A 2016 study looked at more than 1,355,000 Medicare beneficiaries age 70 to 79, at average risk of colorectal cancer. They found that screening colonoscopy had a modest benefit in preventing colorectal cancer in those aged 70 to 74, and a smaller benefit in those aged 75 to 79. The benefit of colonoscopy was thought to be linked to each person’s life ex-pectancy based on their medical problems and functional status. Moreover, screening colonoscopy was associated with excess risk of adverse events requiring hospitalization or visit to the emergency department within 30 days of the procedure.

This finding does not mean that people age 70 and older should not have screening colonoscopies. However, it does mean that if you are in your 70s, you and your doctor should discuss whether the benefits of a screening colonoscopy are likely to outweigh the risks.

People who have had precancerous polyps removed from a colonoscopy, and are still at intermediate risk for colon cancer, may benefit from follow-up procedures (see “Follow-Up Colonoscopies Offer Further Protection Against Colon Cancer”).

Colonoscopy requires that you avoid solid food and drink just clear liquids in the 24 hours before the test. You also will need to take laxatives in liquid form (referred to as ‘bowel preparation”).

Recent developments in colonoscopy emphasize the importance of using split-dose bowel preparation for enhancing the quality of colonoscopy. This involves taking the laxative the day before the procedure and then again the morning of. A 2016 study found that split-dose prep more than triples the rate that sessile serrated polyps (which are flatter and harder to detect) are found, from 2.4 percent with single-dose prep to 9.9 percent with split-dose prep. New research also has found that taking a blue dye tablet during the bowel prep can help identify more polyps, especially smaller, hard-to-detect ones (see “Blue Dye Tablet Identifies More Polyps During Colonoscopy”).

Unfortunately, many people refuse to drink the bowel prep because they do not like the taste. Others say a clear liquid diet leaves them hungry and fatigued. For these reasons, researchers are actively searching for more acceptable ways to screen for colon polyps. Research suggests that eating a low-residue diet instead of a clear-liquid diet might be an option for some people. A low-residue diet is designed to reduce the frequency and volume of stools. It includes small portions of foods like eggs, yogurt, bread, rice, chicken breast, and ice cream. Studies have found that people who followed this diet felt less hungry the night before a colonoscopy, and less fatigued the morning of. Moreover, gastroenterologists were able to visualize the colon just as well as they could following a traditional bowel prep.

Sigmoidoscopy: Every Five Years

This test checks only about one-third of the colon, meaning that any polyps or potentially cancerous growths higher up may be missed. As with colonoscopy, a restricted diet and bowel prep are needed.

CT Colonography: Every Five Years

Computed tomographic colonography (CTC, or virtual colonoscopy) is a less-invasive alternative to colonoscopy, although bowel prep is still required. However, CTC can miss very small polyps, and any polyps it does find must be confirmed and removed during a conventional colonoscopy. Medicare covers traditional colonoscopy, but not CTC.

Barium Enema: Every Five Years

This involves an x-ray, and if polyps or cancers are detected, colonoscopy will be recommended. As with colonoscopy and sig-moidoscopy, bowel preparation is needed.

Stool DNA Test: Every Three Years

The cells in a stool sample are analyzed for DNA changes that could indicate cancer. This is a noninvasive test, but if the results show a change in DNA then a colonoscopy will be recommended.

Fecal Occult Blood Test/Fecal Immunochemical Test: Every Year

These are the simplest methods of screening for colorectal cancer: you simply collect a stool sample on a test card or in a collection container, and give it to your doctor or mail it to a laboratory for testing. If blood is found, a follow-up colonoscopy is needed.

Colorectal Cancer Screening for High-Risk Groups

Certain people are at particularly high risk for colorectal cancer, and may be advised to get screened for the disease at a younger age and more frequently than people at average risk. These groups include:

• African-Americans, who have the highest incidence of colorectal cancer of any racial or ethnic group—12 percent higher than whites. They also tend to be diagnosed with colorectal cancer at a younger age than whites, and have lower survival rates. The American College of Gastroenterology (ACG) recommends that African-Americans begin screening for colorectal cancer at age 45.
• People with inflammatory bowel disease. Due to years of irritation to the mucosal lining of the colon, people with ulcerative colitis or Crohn’s disease are at increased risk for colon cancer. Those with ulcerative colitis are at particular risk. According to guide-lines formulated by several physician groups and societies, patients with IBD involving the entire colon for eight years or more should have a colonoscopy every year, with tissue biopsies taken to look for evidence of cancer or precancerous changes. Patients who have IBD only in the left descending section of the colon (and not in the ascending section) should be checked for colorectal cancer every year or two after they’ve had the disease for 12 to 15 years.
• People with a strong family history of colorectal cancer or colon polyps in a first-degree relative (a parent or sibling) are at high risk, particularly if their relative developed the disease before age 60, or two first-degree relatives had the disease at any age. For these individuals, the ACG recommends colonoscopy every five years beginning at age 40, or 10 years before the youngest age at which a person in your family developed the disease.
• People with a genetic risk for colorectal cancer. Two genetic conditions—called familial adenomatous polyposis (FAP) and hered-itary non-polyposis colon cancer (HNPCC)—can greatly increase colon cancer risk beginning in adolescence or young adult-hood, and require early and frequent colonoscopies.
• Diabetics. In one study, diabetics aged 40 to 49 had the same number of malignant polyps as healthy patients a decade older. This suggests that people with diabetes should begin screening colonoscopies a decade earlier than age 50. As yet, no national body has made specific screening recommendations for diabetics, but it is especially important that they stay up-to-date with screening.
• Smokers appear to be at higher risk for flat adenomas, a specific type of pre-cancerous lesion. Again, the ACG does not make specific screening recommendations for smokers, but it does suggest that individual patients should be evaluated to determine whether they should consider beginning colorectal cancer screening earlier than age 50.

Treating Colorectal Cancer

In the very early stages of colorectal cancer, removing the cancerous polyp can cure the disease. Removal often is carried during a screening colonoscopy, or during a second procedure. More advanced colon cancer requires surgical removal of the cancerous section of colon and the nearby lymph nodes. The surgeon may perform traditional open surgery or less-invasive laparo-scopic surgery. Either way, the outcome will be similar.

Chemotherapy may be given before surgery (sometimes with radiation) to shrink the tumor, or after surgery to eliminate any remaining cancer cells or cancer cells that have spread to other organs.

The risk of getting colorectal cancer can be reduced through a healthy diet and regular exercise (see “More Whole Grains and Exercise Protects Against Colon Cancer”). If you have been treated for colorectal cancer, the same combination will help lower the risk that your cancer will recur.

Consuming a Mediterranean-style diet that includes plenty of plant foods, including whole grains, legumes, fruits, vegetables, nuts, and seeds, may reduce the risk of colorectal cancer as well as many other diseases. In fact, eating a few servings of nuts per week also may benefit people who have been treated for colon cancer (see “Nuts May Help People With Stage III Colon Cancer”). Replacing red meat with fish is also advised, since red meat—especially processed versions—has been linked with an increased risk of colorectal cancer.

An abundance of omega-3 fatty acids from such foods as salmon, tofu, walnuts, and soybeans can lower the risk of colorectal cancer, and may even increase the likelihood of surviving after diagnosis, according to a 2016 study. Researchers examined the outcomes of two large, long-term population studies involving more than 172,000 people. Of these participants, 1,659 developed colorectal cancer—but those whose diets were higher in omega-3 fatty acids from oily fish had a 41 percent lower risk of dying from the disease. Increasing the daily intake of omega-3s by 0.15 grams after diagnosis was associated with a 70 percent lower risk of dying from colorectal cancer, while reducing omega-3 intake increased the risk.

Adequate intake of calcium is important, along with vitamin D. Daily exposure to the sun for 15 to 20 minutes (without sunscreen) during the summer months provides adequate vitamin D for some people. Those who live in northern climes or are confined to the indoors may not get enough vitamin D at any time of the year, and should top up with foods and supplements. Foods that contain vitamin D include fortified milk, salmon, herring, mackerel, tuna, sardines, oysters, shrimp, eggs, and beef liver. If you are going to take a vitamin D supplement, choose a product that contains vitamin D3 (cholecalciferol), since this variant is more active than vitamin D2 (ergocalciferol).

Finally, if you are between the ages of 50 and 59, you should ask your physician whether taking a low-dose daily aspirin might be beneficial. In 2016, the USPSTF recommended low-dose aspirin for the primary prevention of colorectal cancer as well as cardiovascular disease in adults aged 50 to 59 with a 10 percent or greater risk of developing cardiovascular disease within 10 years. However, the ACS advises against the routine use of aspirin for colorectal cancer prevention, noting that the potential risks of aspirin (such as gastrointestinal bleeding and stroke) may outweigh its benefits in the general public. The best approach is to dis-cuss it with your doctor.

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