Botanical&NutritionalMedicineforWomen&Children

AvivaRomm,M.D.

ComplexPatients…Sigh...

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THECONVENTIONALRESPONSE?

FunctionalMedicineApproach

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RootCauses,RootSolutions

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RootsCauses

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46-year-oldWomanwithFATIGUE•  Day2mesomnolence

•  Hastonapforhoursduringtheday•  Evenifhasagoodnight'ssleeps2llneedsanapintheaCernoon

•  “Tiredallthe2me”•  Brainfog–can’tconcentrate•  Musclefa2gue

•  Withexercise

•  NightEa2ngSyndrome•  Insomnia

•  HasanxietyaboutgePngsleep•  Wakesupduringthenight-3am-7amthengoesbacktosleep

Let’sgoontoroo+ngoutthecause(s)offa+gue…

TheFatigueHistory

•  Understandingtheroleoffa2gueonyourpa2ent’sQOL•  Describingfa2gue

•  Onset(gradual,sudden,relatedtoanillness,exposure)•  Loca2on(muscleweakness,“inmyhead,”generalized).•  Type(heavinessinbody,brainfog,sleepy,deeplyfa2gued)•  Timing(morning,day2me,aCernoon,nighPme)•  Course(stable,improving,worsening)•  Frequency(daily,constantly,cyclic)•  Associatedsymptoms(sinusconges2on,bloa2ng,jointpain)•  Associatedbehaviors(exercise,postprandial)•  Allevia2ngbehaviors(sleep,ea2ngprotein)

•  Primarysymptomorsecondarysymptom(i.e.,2red,or2redofbeingsick)

TheFatigueFocusedPhysicalExam

•  Generalappearance:levelofalertness,psychomotoragita2onorretarda2on,grooming

•  Presenceoflymphadenopathy•  Thyroidfindings:Goiter,thyroidnodule,ophthalmologicchanges

•  Cardiopulmonaryexamina2on:signsofconges2veheartfailureandchroniclungdisease

•  Neurologicexamina2on:musclebulk,tone,andstrength;deeptendonreflexes;sensoryandcranialnerveevalua2on.

CommonFatigue-AssociatedConditions•  “Adrenalfa2gue”•  Anemia•  Autoimmunecondi2ons•  Caffeineuse•  Cancer•  ChronicFa2gueSyndrome•  CVD•  Depression•  Diabetes,Dysglycemia•  Fibromyalgia•  Foodallergies,intolerances•  Generalizedinflamma2on•  Hypothyroidism

•  Hyperthyroidism•  In2matepartnerviolence•  Lymedisease•  Medica2ons(pains,bloodpressure,an2depressants)

•  Obesity•  Restlesslegsyndrome•  Sleepapnea•  Sleepdisorders•  Stress,SESfactors•  “UNEXPLAINED”•  ViralInfec2ons(EBV,HSV,CMV)

RuleOuttheBigBadThings

•  CVD,cancer,i.e.,newonset/recentfa2gueinwomen>45•  MS,MG,etc.,Progressiveorrecurrentmuscleweakness•  HIV,i.e.,fa2guefrequentinfec2ons•  Leukemia,i.e.,Bruising

InQlammation:TheRootofFatigue

InitialConventionalLabsforFatigue

•  Completebloodcountwithdifferen2al•  Chemistryscreen(includingelectrolytes,glucose,renalandliverfunc2ontests)

•  Thyroids2mula2nghormone•  Crea2nekinase,ifpainormuscleweaknesspresent•  ConsiderESR

•  Addi2onallabsconven2onallyrecommendedonlyifhistoryorphysicalexamfindingssuggestaneed.

TheMatrix&SymptomOrganization

FoodJournalReview

TheMatrix&Labs

LeakyGutandInQlammation

Matrix:OrganizeaRootCauseAssessment

Matrix:OrganizeTreatment

UsingtheMatrixtoTrendResults•  Mind/Mood

•  Sleepimproved,fallingasleepmoreeasily,nonightwaking•  NoNESonmelatoninand5-HTP•  Rarelyneedsmorethanabriefrestintheearlyevening•  Lavenderoilandadrenalsupportwithashwagandhabeforebed

•  Assimila+on•  SIBO–resolvedaCer1coursexifaxan,nauseaimprovedalsoonHCLnowandan2microbialbotanicalsforsupport•  4+yeast–clearedonrepeattes2ngs/pnysta2n,nogas,bloa2ng•  GERDsxresolved,offPPI,takingDGL,dietarychangesmade•  Offofdairy

•  Defense/Repair•  Takingcurcumin1000mgBID

•  Energy•  Anemiaresolved;Hct>30à37.4,ferri2nfrom14à23à53

•  Biotrans/Detox•  Taking5mgmethylfolate/day•  TorevisitHglevelsandamalgams

•  Transport•  LDL-P1817,LDL-C103,LDL-p1084•  A1Cà5.6•  GlucoseF93,1hr166,2hr.116•  Ins1hr127s

•  Communica+on•  VitaminDnow61s,reducedto2000units/day•  TSHàstartedonArmouràTSH1.0FT32.9•  Haslost20lbs,severalpantssizes

•  Structural•  Jointpainimproved,con2nuingcurcumin

GIFXPostTreatment

SIBO

WhatCanHappen…10monthslater…•  Lost25+LBSandhaskeptitoff.•  Says"Con2nuetofeelmuchbeserbecauseofyou”•  “Anxietyhascompletelydisappeared.”•  “Mystomachdoingsowell”-abletotakehersupplements•  “Armourhashelpedsomuch”sexdrivereturning!•  “Sleepisperfect”•  “Nojointpain”•  “Moodbeserthan[I]believedpossible”•  S2llget2redaround5pm•  Increasedself-awareness:Diet-for3mowassoreligiousandlostsomuchweight.Startedea2ngyogurtandglutenagain-aCeraweekstartedfeelingunwell,couldn'twalkproperly-sowentbackoffcompletelyandwithinaweektheinflamma2onisgone.

2yearoldgirloldw/JRA•  2yogirlold,dgwithpolyar2cularJRA•  Feverx1week,ATCtylenolandibuprofen•  àGastri2s,PPIx8months•  Developedpolyar2cularpainandswelling•  Diagnosedclinicallybyrheumatologistage18mo•  Chroniclimp,painàchronicNSAIDuse•  BornbyNSVD,motheroninsulinforpoorlycontrolledGDM•  Liverurally,?pes2cideexposure,heavymetalcontamina2onofwater,?arsenicexposure

•  RheumatologistreadytostartS.onmethotrexate

AdditionalAssessments&DiagnosesforSarah

•  Eczema•  Diges2vesymptoms,especiallybloa2ng,bellyaches•  An2bio2cUse•  GlutenIntolerant•  Irondeficiencyanemia•  Lead-ElevatedBodyBurden•  MTHFR+/-

THEGUTCONNECTION•  Immunologicaldysregula2onisthecauseofmanynon-infec2oushumandiseasessuchasautoimmunity,allergyandcancer.

•  Thegastrointes2naltractistheprimarysiteofinterac2onbetweenthehostimmunesystemandmicroorganisms,bothsymbio2candpathogenic.

•  Disturbancesinthehealthybacterialmicrobiotaofthehumangutduringcri2calwindows,andgenerally,resultsindysregula2onofadap2veimmunecelldevelopmentandresponse.

•  Increasedintes2nalpermeabilityleadstosensi2za2onoftheimmunesystemduetobreachofbarrierbetweenresponseto“self”and“other.”

CommensalBacteriaandImmuneDevelopment

TheTimeline

THEMODERNTIMELINE

SampleTriggerData•  Infan2lecolicaharbingerofatopyinchildren.•  Posi2veassocia2onbetweenthelactulosetomannitolra2oandtheseverityoftheeczemaaCerac2vetreatmentwithprobio2cs.Impairmentoftheintes2nalmucosalbarrierappearstobeinvolvedinthepathogenesisofatopicderma22s.

•  Meta-analysisof8studiesexaminingrela2onshipbetweenexposuretoan2bio2csanddevelopmentofchildhoodasthmacomparedexposuretoatleastonecourseofan2bio2csinfirstyearvs.noexposure(12,082children,1,817asthmacases).Riskofasthmawassignificantlyincreasedinchildrenreceivingoneormorecoursesofan2bio2csduringfirstyearoflife:ORwas2.05(95%CI1.41-2.99).Dose-responseanalysisshowedincreaseinORof1.16(95%CI1.05-1.28)foreachaddi2onalcourseofan2bio2cs.

•  Cesareansec2onposi2velycorrelatedwithdevelopmentofobesityandautoimmunityinchildren.

3KEYAREASOFGUTPERTURBATION

•  Dysbiosis•  Hyperpermeability•  Chronicinflamma2on

WhatisDYSBIOSIS?•  Dysbiosisislossofbiodiversity,species,andreserves,“Lossofancestraldefenses.”

•  Changesinspeciesdominancefromphysiologictopathologic

•  Bacterialresistanceofpathogenicspeciesandevencommensalspecies

•  Lackofproperimmunologicdevelopmentandresponse

WhatisLEAKYGUT?

BarrierProtection•  Anextremelyimportantfunc2onoftheintes2neisitsabilitytoregulatethetraffickingofmacromoleculesbetweentheenvironmentandthehostthroughabarriermechanism.

•  Togetherwiththegut-associatedlymphoid2ssueandtheneuroendocrinenetwork,theintes2nalepithelialbarrier,withitsintercellular2ghtjunc2ons,controlstheequilibriumbetweentoleranceandimmunitytonon-selfan2gens.

•  Zonulinisthephysiologicalmodulatorofintercellular2ghtjunc2onsinvolvedintraffickingofmacromoleculesand,therefore,intolerance/immuneresponsebalance.

•  Glutenisaknownup-regulatorofzonulinac2vitywhichleadstodown-regula2onoftheproteinoccludinandresultsinincreasedgutpermeability.

TheHealthyEpithelium•  Commensalbacteriaplayaroleinmaintainingtheintegrityoftheintes2nalepithelium.

•  Intes2nalepithelialcells(IECs)provideaphysicalbarrierbetweenluminalmicrobesandunderlyingintes2nal2ssuestocontroldefenseandtolerance.

•  IECsexpresspasernrecogni2onreceptors(PRRs)andcanrecognizemicrobialpathogen-associatedmolecularpaserns(PAMPs)andrespondtointes2nalmicrobesthroughsecre2onofcytokinesandan2microbialproteinsandup-regula2onofsurfacemoleculesthatmediateintercellularinterac2ons.

•  SecretoryIgAreducesintes2nalproinflammatorysignalsanddrivesdiversityingutmicrobiota.StressreducesSIgA.

•  Adefec2vebarrierallowstransloca2onofforeignproteins,LPSs,andcanleadtoendotoxemia,an2bodyforma2onandfoodsensi2vi2es,allergic,andautoimmuneresponses.Inaviciouscycleitalsoperpetuatesdisorderedgutflora.

•  Disrup2onsleadtodisrup2onsinnutri2on–manychildrenendupanemic,lowinvitaminD,depletedan2oxidantstatus(ieglutathione).

•  Endotheliumalsoimportantforproduc2onofsystemicallyimportantan2oxidantsreduc2onofwhichincreasesoxida2vestress,asdoesthechronicgutinflamma2onsooverallburdenofoxida2vestressincreases.

LEAKYGUT&IMMUNEDYSREGULATION

STRESS&THEGUT•  “Ifeelitinmygut,”“Ican’tstomachthis,”“Thismakesmesicktomystomach”…

•  StressreducesSIgA•  Stressdivertsbloodflowfromawayfromthegut•  Knownimpactonpredominantspecieswithchangesseeninreduc2oninLactobacillusandBifidobacteriumspptowardColiformandEcoli.

•  Stresschangesthechemicalmilieuwhichchangesthefoodresourcesavailableforgutflora.

•  Changesinneuro-immunesystemnowknowntobeubiquitousandcompletelyinterconnectedandnotreallyseparatesystems.

GUTHEALTHYDIET•  Smartstarttosolids;nofoodavoidanceunlessnecessary+/-dairyproducts

•  Fooddiversity•  REALfood•  Fiber•  Fermentedfoods•  Lowsugar•  Avoidan2bio2cexposuresinfoods•  Healthydaily(orageappropriate)evacua2on

THE4RPROGRAM

•  Remove:Triggersandirritants•  Replace:Diges2veenzymesandhydrochloricacid,forexample,arereplacedinthisphase.LowBcomplexassociatedwithlowstomachHCL.

•  Repair:Providenutrientsthatnourishandhealtheintes2nalmembranesandhealthyflora.ConsiderL-glutamine,turmeric,licoricerootextract(orDGL),marshmallowroot,zinc,querce2n,andlarch-arabinogalactans.

•  Reinoculate:Prebio2csandprobio2cs,alongwithgoodqualityfiber

Remove Replace Repair Reinoculate

REMOVE:THEELIMINATIONDIET•  Elimina2onphase:“classicalapproach”and“goldstandard”•  2-6weeks•  Highlysimplifieddiet•  Avoidingcommoncausesoffoodsensi2vity•  Dailysymptommonitoring•  Screenforea2ngdisorder•  Prosandconsof“all-in”vs.stagedelimina2on

•  Studyfindingsareequivocalbutsomestudiesfinddefiniteimprovementwithuseofelimina2ondiet

•  Mostcommonfoodsinproducingallergysymptomsaremilk,eggs,chocolate,soy,citrus,nuts,wheatandcorn

•  Skintes2ngforallergensdoesnotusuallycorrelatewithclinicalsymptoms

EliminationDiet• Provoca2on/”Tes2ng”phase

• Addonenewfoodevery3-5days•  Startwithfoodseatenmostfrequently• Con2nuedailysymptommonitoring•  Ifnochangeinsymptoms,foodcanstayindiet;ifsymptomsworse,foodshouldbeavoidedasapossiblecause

• Useof“rota2ondiet”concept

REPLACE•  Nutrients–gutpermeabilityreducesnutri2on•  Enzymes•  BetaineHCL•  B-6

REINOCULATE•  Probio2cs,prebio2cs,symbio2cs

•  S.Boulaardi•  Bifidospp,Lactobacillusspp.•  VSL#3(Bifidobacteriumbreve,Bifidobacteriumlongum,Bifidobacteriuminfan2s,Lactobacillusacidophilus,Lactobacillusplantarum,Lactobacillusparacasei,LactobacillusbulgaricusandStreptococcusthermophilus)

•  KlareTherbio2cInfant

ProbioticBeneQits•  Double-blinded,placebo-controlled,cross-overstudy,probio2clactobacilli(Lactobacillusrhamnosus19070-2andLreuteriDSM12246)wereadministeredfor6weeksto41childrenwithmoderateandsevereatopicderma++s.Significantdecreaseinthefrequencyofgastrointes+nalsymptomsduringac2vetreatment(39%duringtheplaceboperiodversus10%duringac2vetreatment,P=.002).

PreventionofAtopicDiseasewithProbiotics

•  Doubleblindrandomizedplacebo-controlledtrial(n=132)ofchildrenwithastrongfamilyhistoryofatopicdisease

•  LactobacillusGG(1X1010CFUs)tomothersfor2-4weeksprenatallyandthentoinfantspostnatallyforsixmonths

•  Atopiceczemadxbyage2in23%(15/64)ofprobio+cgroupvs.46%(31/68)inplacebogroup(RR0.5195%CI0.32-0.84)

•  Numberneededtotreat4.5

ReductioninAllergicRhinitiswithProbioticTreatment•  Nineof12RCTsreviewedbyCochranethatevaluatedclinicaloutcomesinARshowedanimprovement(lowerreportedARscoresandlessmedica2onuse)duetotheuseofprobio2cs.comparedwithplacebo.

•  Also,5ofthe8RCTsthatreferredtoseasonalARsuggestedanimprovementinclinicaloutcomes.

•  NineRCTsthatreportedvariousimmunologicmeasurementsofallergyfoundnosignificantprobio2ceffectsandnoclearimprovementinasthma.

PreventionofAtopicDiseasewithProbiotics

•  Perinataladministra+onoftheprobio+cLactobacillusrhamnosusstrainGG(ATCC53103),reducesincidenceofatopiceczemainat-riskchildrenduringthefirst2yearsoflife(infancy).

•  Atage4,14of53childrenreceivingLactobacillushaddevelopedatopiceczema,comparedwith25of54receivingplacebo(rela2verisk0.57,95%CI0.33-0.97).

•  Skinpricktestreac2vitywasthesameinbothgroups:tenof50childrenpreviouslygivenLactobacilluscomparedwithnineof50givenplacebotestedposi2ve.

PreventionofAtopicDiseasewithProbiotics

•  7-yearfollow-upconfirmedthatthecumula2veriskofdevelopingeczemaduringthefirst7yearsoflifewassignificantlylowerintheprobio2cgroupthanintheplacebogroup.

•  However,atopicsensi2za2onwassimilarbetweenthegroups,sugges2ngthatthepreven2veeffectoneczemawasnotIgE-mediated.

PreventionofAtopicDiseasewithProbiotics

•  Abrahamsson:cumula2veincidenceofeczemawassimilarinbabiesreceivingLactobacillusreuteribeforedeliveryandupto12monthsoldandthecontrolgroup.TheL.reuterigroupdidhavelesserIgE-associatedeczemaduringthesecondyear

•  Kuitunen:1223motherswithinfantsathighriskforallergywererandomizedtoreceiveprobio2corplaceboduringthelastmonthofpregnancyandtheirinfantstoaddi2onallyreceiveprebio2cgalactoligosaccharidefrombirthun2l6months.Nodifferencesinthefrequencyofallergicdiseasesandsensi2za2onaCer5yearsoffollow-up.

•  BUT…LessIgE-associatedallergicdiseaseoccurredincesarean-deliveredchildrenreceivingaprobio2csmixture.

AlteredStates•  GutmicrobiotaofchildrenwithatopycharacterizedbyapredominanceinC.difficile,Coliformspecies,andS.aureuscomparedwithnon-allergicchildren

Physiologicmechanismsforprobioticsinatopicdisorders•  TH1vs.TH2regula2on:mayhelpdowngradeTH2responseswhichleadtoatopy(hygienehypothesis)

•  Systemicdown-regula2onofinflammatoryprocessesbybalancingthegenera2onofproandan2-inflammatorycytokines

• Capacitytoreducethedietaryan2genloadbydegradingandmodifyingmacromoleculesinthegut

• Reversetheincreasedintes2nalpermeabilitycharacteris2cofchildrenwithfoodallergy

•  EnhancespecificIgAresponsesfrequentlydefec2veinchildrenwithfoodallergy

REPAIR•  Reduceinflamma2onfromdiettoallowhealingdiet•  AppropriatesupplementsespeciallyzincandL-glutamine.•  Botanicals

L-glutamine•  Aminoacid•  S2mulatesenterocyterepairandprolifera2on.•  Increasesintes2nalvillousheight,s2mulatesgutmucosalcellularprolifera2on,andmaintainsmucosalintegrity.

•  Preventsintes2nalhyperpermeabilityandbacterialtransloca2on.

•  Ininflammatorycondi2ons,theavailabilityofglutamineasanenterocytefuelsubstrateisessen2alforthepreserva2onofafunc2onalbarriertomicroorganisms.

Zinc•  Consideredtobeakeyfactorforthepreserva2onofstructuralintegrityoftheintes2nalbarrier

•  Improvesenterocyterepair,aidsinrepairofcellswithrapidturnover–espmucosaandimmunesystem.

•  Correc2onofzincdeficiencyleadstoafasterregenera2onofthegutepitheliumandincreasesthelevelsofenterocytebrush-borderenzymes

•  Alsoan2oxidant•  Zincabsorp2onisinhibitedbysomenon-diges2bleplantligands,suchascontainedincorn,cereals,rice,legumes,whichforminsolublecomplexeswithzincionsthatareexcretedinthestool.

•  Theamountofproteinsisposi2velycorrelatedwithzincbioavailability.

•  Someproteins,suchascaseininmilkandsoyprotein,havebeenreportedtohaveaninhibitoryeffectonzincabsorp2on

IgGAntibodies•  Bovineorserumderived•  Colostrumisthefirstnaturalfoodproducedbyfemalemammalsduringthefirst24–36hdirectlyaCergivingbirth.

•  Chemically,colostrumisaverycomplexfluidrichinnutrients,an2bodiesandgrowthfactors.Incowsthean2bodiesprovidepassiveimmunitytothenewborncalf,whereasthegrowthfactorsespeciallys2mulatethegrowthofthegut.

•  Theotheran2microbialcomponentsofcolostrumincludelactoferrin,lysozymeandlactoperoxidase.

•  Bovinecolostrumhasalsobeenusedasarawmaterialforimmunonoglubulin-richcommercialproducts(immunemilkprepara2ons).

•  Theseproductscanbegivenorallytopa2entswhoaresufferinginfec2onsofthegastrointes2altractorinordertopreventtheseinfec2ons.

•  Severalanimalstudieshaveshownthatthegrowthfactorsinbovinecolostrum,especiallyinsulin-likegrowthfactors,s2mulatecellgrowthinthegut.

Stewagen,Ketal.Immunecomponentsofbovinecolostrumandmilk.JournalofAnimalScience[2009,87(13Suppl):3-9]Playforda,RJ.BovinecolostrumisahealthfoodsupplementwhichpreventsNSAIDinducedgutdamage.Gut1999;44:653-658.

Quercetin •  Flavonoidinredwine,tea,onions,kale,tomatoes,broccoli,greenbeans,asparagus,apples,andberries

•  An2-inflammatory•  Mayinfluenceimmunesystemfunc2on

•  Demonstratesac2vityagainstretroviruses,parainfluenza,andrespiratorysyncy2alviruses.

Dose:Typicaldietaryintakesarebetween5mgand40mg/day--250-500mg/daywithhighconsump2onoffruitsandvegetables,especiallyifea2ngpeel.Supplement250-500mg1-2xdaily.(Ques2onofnephrotoxicity>722mg/day)

Stoner,G,Wang,LS.(2013).NaturalProductsasAn2-inflammatoryAgents.InObesity,Inflamma2onandCancer(pp.341-361).SpringerNewYork.

Turmeric WhattheScienceSays§  NIH:posi2vestudiesforUC,Crohn’s,

rheumatoidd/o§  Invitroandanimalstudiesshowit

increasesphaseIIenzymesandinhibitsphaseICYP1A

§  An2oxidanteffects:DownregulatesCOX2,LOX,NFkB,AP-1,TNF

Safety§  Warfarininterac2on,bleedingriskat

highdosesDose(Adult)§  1200-2400mg/dcurcuminforIBD§  India:averagedailyintake=60mg

curcumin(2.5gm/dofturmeric)§  20mgblackpepper/1kgcurcumin->

approx2000%absorp2onincrease

ChandranB,GoelA.Arandomized,pilotstudytoassesstheefficacyandsafetyofcurcumininpa2entswithac2verheumatoidarthri2s.PhytotherRes2012;26:1719-25.TaylorRA,LeonardMC.Curcuminforinflammatoryboweldisease:areviewofhumanstudies.AlternMedRev.2011Jun;16(2):152-6.

Chamomile •  Tradi2onallywidelyused•  Evidencebasedusesincluded

•  Anxiety/GAD•  Colic(w/fennel,lemonbalm)•  Pediatric“stomachaches”•  Diarrhea(w/applepec2n)•  Dyspepsia(inIberogast)•  Oralmucosi2s

Dose:1mlTIDSafety•  Maycauseallergicreac2oninsomeindividuals(rare).

McKayDL,BlumbergJB.Areviewofthebioac2vityandpoten2alhealthbenefitsofchamomiletea(Matricariarecu2taL.).PhytotherRes.2006Jul;20(7):519-30.RossSM.Generalizedanxietydisorder(GAD):efficacyofstandardizedMatricariarecu2ta(Germanchamomile)extractinthetreatmentofgeneralizedanxietydisorder.HolistNursPract.2013Nov-Dec;27(6):366-8.

Ginger WhattheScienceSays•  Clinicalresearchshowsthattaking

gingerextractscanmodestlyimprovepaininsomepa2entswithosteoarthri2s

•  Maybecomparabletoibuprofeninadoseof500mgtwicedaily

•  Alsocomparedfavorablytodiclofenac+glucosaminesulfate

•  Thereissomepreliminaryevidencethatgingermightbehelpfulfordecreasingjointpaininpa2entswithRA

Dose(Adult):250mggingerextractfour2mesdaily,dosingmayvaryaccordingtotheprepara2on

Licorice •  Tradi2onaluses:cough,colds,sorethroat,GERD,gastri2s

• Compoundsinlicoriceincreaselocalprostaglandinlevelsthatpromotemucussecre2onandcellprolifera2oninthestomach

• Prepara2onswithoutglycyrrhizinarecalledDGL

Dose•  700-800mg(760mg)• ChewabletabletsSafety:AvoidinptswithHTN,hyperaldo,onsteroid.Likelysafeinhealthyadultswhenusedatdosesnotexceeding3grams/dforperiodsupto3-4weeks.

Sarah’sSupplements•  Mul2vitamin•  Proprietarylicoriceblendcontaininglicorice,ashwagandha,rehmannia,andwildyam.

•  Chamomiletea•  ProEFAJr-NordicNaturals,1,twicedaily•  VitaminD3•  Curcuminconcentratewithgingerandboswellia•  L-Glutamine•  Zinc•  Probio2ccontainingLactobacillusandBifidostrains

Evaluation&Testing•  Historyrevealsthecure•  Diet&nutri2onreview•  Diges2onevalua2on•  (Known)toxicorinfec2ousexposures

•  CBC,ironstudies,ANA,ESRLyme(WB)

•  CeliacHLA,GlutenAbs•  EFAtes2ng(omega3,6)•  Leakygutvialactulose:mannitol

•  Stooltes2ng•  Detoxstudies

•  CanconsiderIgGandIgMtes2ngthruspecialtylabs

SarahGetsHerLifeBack!•  8monthsnoneedforNSAIDs,methotrexatenolongerindicated

•  Hashad1(prescheduled)jointinjec2on

•  Perrheumatologist,only1joint(indexfinger)remainsslightlyswollencomparedto8jointsbeforestar2ngcare

•  Abletorun,play,dancewithoutpain,justlikeotherkidsinfamily!

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