Notes Re: Methylation, Homocysteine, Betaine, etc

Homocysteine & Methylation "Take Aways" 
Note: Methylation = Complex combination of actions whereby Homocysteine + “Certain B Vitamins” (i.e., b6, b9 (folate), b12) + Betaine, SAM-e, Adenosine etc etc = (recycled into) Methiones 

(Image from Wikipedia)

1. Homocysteine can be recycled into methionine or converted into cysteine with the aid of certain B-vitamins;
2. Normal homocysteine levels should be less than 13, with the ideal range being between 6-8, with hyperhomocysteinemia Dx at over 15;
3. Homocysteine levels are typically higher in men than women, and levels elevate with age;
4. MCV greater than 95 can indicate a methylation problem;
5. Blood or urine methylmalonic acid test for b12 deficiency (may be ordered as a follow up to a standard b12 test);
6. Daily diet should include one cup a day of dark green leafy vegetables, and daily protein intake should be between 80-120 gm;
7. Reducing AGE (advanced glycation end products) by diet and or supplementation can potentially lower homocysteine levels (and protect the kidneys);
8. Supplementation: All B vitamins, but IN PARTICULAR emphasis on b6 (up to 250 mg) & b12 (500 mcg), plus more than 400 mcg (RDA) folate (unless person has cancer), choline (precursor to betaine*);
9. NOTE: If one were considering supplementing with betaine to lower homocysteine levels, the IDEAL formulation appears to be BETAINE ANHYDROUS *NOT* betaine hydrochloride;
10. Digestive diseases, caffeine, some meds (i.e. acid blockers, methotrexate, or HCTZ), and no doubt, malabsorptive bariatric surgeries can impact levels of B vitamins in blood;  

Interesting articles:
Betaine supplementation decreases plasma homocysteine in healthy adult participants: a meta-analysis https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3610948/

Maximizing Methylation: The Key to Healthy Aging, by Mark Hyman MD http://drhyman.com/blog/2011/02/08/maximizing-methylation-the-key-to-healthy-aging-2/

Below the Radar: Advanced Glycation End Products that Detour “around the side” Is HbA1c not an accurate enough predictor of long term progression and glycaemic control in diabetes? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1320176/

Lowering homocysteine levels with folic acid and B-vitamins do not reduce early atherosclerosis, but could interfere with cognitive decline and Alzheimer's disease https://www.ncbi.nlm.nih.gov/pubmed/23224755

BEETS & GREEN LEAFY VEGGIES & METHYLATION 
CONFLICT #1: Green, leafy veggies, lowers homocysteine yet elevates oxylates 
CONFLICT #2: Green, leafy veggies lowers homocysteine (which would lower risks for DVT, clots, stroke) yet they contain Vitamin K which would increase risks for DVT, clots, stroke. 

BEETS: Despite the fact that beets are high in betaine, which helps lower homocysteine levels in blood, they are ALSO high in oxylates, which elevates purines in the blood, which then elevates uric acid and contributes to gout inflammation. 

GREEN LEAFY VEGGIES: People who have blood clotting disorders (Leiden varieties, in particular), like myself should be wary of ingesting too much in the way of green leafy veggies, as they are also high in Vitamin K (“klottenfactor”) and can have a potential negative impact (i.e. clots, stroke, dvt, etc), and it’s this reason (as well as having had a gastric bypass) that I use a variety of supplements to make sure my needs are met. ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬

Notes on Benfotiamine (fat soluable, B1): 

Below the Radar: Advanced Glycation End Products that Detour “around the side” Is HbA1c not an accurate enough predictor of long term progression and glycaemic control in diabetes? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1320176/ 

Effect of Benfotiamine on Advanced Glycation Endproducts and Markers of Endothelial Dysfunction and Inflammation in Diabetic Nephropathy

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3391239/

Lots To Process!

A while ago, I said how 2017 was going to be the year where I streamline the circus that has been my medical care, and eliminate redundancies, and try to pare down how many doctors/specialists I see.
 
LAST January, I saw my internist and had him arm chair quarterback my endocrinologist, who, at the time, sent me in for a 2 hour glucose tolerance test, even though most people know (I didn't!) that bypassers like me shouldn't have this test done for obvious reasons (a lot of bypassers end up with Reactive Hypoglycemia/Post-Prandial Hypoglycemia).  My internist didn't see much to be concerned about, though he did suggest to me that I find an endocrinologist closer to home and one who takes my medical insurance.

Two months ago, my husband and I were at the office where BOTH of our internists work, and we noticed there was an "In Memoriam" type book on the counter with a sign indicating that my internist had passed away. This saddened me greatly, and yet, oddly, it plays into the overall theme of what I verbally articulated 2017 to be, "The Year of Streamlining." Well, may he rest in peace, I was planning on acting on his guidance.

Monday was a regular appointment at the Endo for me, and I was steeling myself mentally to dispense the "It's Not You, It's Me" discussion wherein I let him know I can't financially sustain seeing him anymore. 

Right here is a perfect example of a nugget of advice my husband's grandmother used to share, "If you do nothing at all, in 75% of cases, your problems sort themselves out on their own."  

I walked into his office where we normally have a discussion before he examines me, and right off the bat, I noticed 2/3 of his books were off the shelves. And then HE gave me the news that he was selling his practice, and would no longer be seeing patients, and would be focusing his time on lecturing and teaching other doctors to do what he does.

I said, "Hey! You can't break up with ME! I was going to break up with YOU!"  

The examination went as it normally does; however, I refused to hop on the scale, since this is the last visit. And I blurted out, "Nope. Not this time. I refuse to hop on that metallic bastard! I want my last visit to end on a good note!"

While it would be nice for me, to go to whomever is buying his practice, it's just not feasible for an assortment of reasons--and really, WHAT do I know about this person? So, now I'm actively looking for a new endo, and my search is going Goldilocks style: one that isn't too old, and isn't too young, someone capable of monitoring my thyroid nodules, and someone local-ish, and takes my insurance, and basically gives me 2-3 days of my life back (not to mention, $$$ I won't be spending for a doctor who doesn't take my insurance).  Two of my co-workers go to an endo nearby, and speak highly of him, and he meets my criteria, so I need to get the new patient forms, and get things lined up so whatever medical records of mine can get transferred while my current Endo's office is still open and operating.

Even though I was planning on discontinuing, I wanted it to be my decision. And knowing my Endo, he's 85. I fully expected him to keep treating patients until the day he just ran out of steam and passed away, blissfully, at his desk in his office. Instead, there's THIS. And I know something must be going on with him for him to decide to go back to teaching and focus primarily on lecturing. And my hope for him is that whatever he's doing, I hope it brings him as much fulfillment as treating patients has.

It's wild to think he RETURNED to treating patients about 18 years ago, and of that 18 years, I have been seeing him 4x a year for 14 of those 18, so I've been there for the long haul as it were. And it was a good run. And he taught me a shitload about not just the assortment of things I need to stay on top of, but he's also taught me a lot about MYSELF.  

I plan on getting a birthday card and sending that off to him, as his day is coming up; and I plan on getting two lovely thank you cards and send them to his secretary and his clinician--both of whom I will miss interacting with them. Great, super sweet, friendly and professional women, both of whom I hope end up on their feet. 18 years is a long time, and this change will break up that little, happy, work place "family." 

Nothing lasts forever. 
Change can be a good thing for all involved.

It's still sad and a bit of an unexpected shock.

Supplement Comparison: Omega-3 vs Krill et al

Omega 3 vs Krill Oil vs Cod Liver Oil

On the Surface, both, Omega-3 and Krill oils, supply Omega-3 fatty acids, HOWEVER, the source fish are different, and more importantly, the potency of EPA and DHA differs MARKEDLY.  There are claims online that Krill oil “typically contains more EPA,” However, I did not find this to be true (see chart).

Krill oil contains fatty acids similar to fish oil, and these fats are thought to be beneficial in helping decrease swelling, lower cholesterol, and make blood platelets less sticky, and less likely to form clots.

Omega-3 and cod liver oil are two different oils even though they both come from fish and have a similar fatty acid profile. Fish oil is extracted from the flesh of tuna, herring, cod and other deep-sea oily fish species. Cod liver oil is a good source of omega-3 fatty acids such as EPA and DHA but doesn't have much (if any) in the way of omega-3 fatty acids.

I’m not going to devote any more time to cod liver oil—as that wasn’t part of the original discussion (which I had with my chiropractor), but thought I didn’t want to exclude it from the entire discussion.

I found that the Mega Red Advanced 4-and-1 which contains both, fish oil and krill oil to be lacking, despite its high regard in its reviews (as well as great marketing); however, that might be related more to the antioxidant astaxanthin which is in the krill oil rather than than the EPA/DHA that their source fish, pollock, provides.

My theory/hunch is: whatever benefit people MIGHT get from a krill oil supplement isn’t due to the EPA/DHA, but actually from the astaxanthin.

• Marine Bioactives: Pharmacological Properties and Potential Applications against Inflammatory Diseases:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3366677/ 
•  A worthy mention regarding astaxanthin and cancer: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4515619/

To cover all bases, I’m ALSO going to contrast/compare that Omega XL supplement that Larry King promotes on TV into my analysis. 

Despite the fact it has “Omega” in the name, my theory/hunch is:  whatever benefit people might derive from that (VERY EXPENSIVE) supplement actually comes from the Green Lipped Mussel extract, which is high in boron.

SPOILER ALERT: At $1.11 per pill (PER PILL!), rather than buying the Omega XL, perhaps it would be more economical to consider buying a good quality omega-3 fatty acid supplement, and then buy a separate and less expensive boron supplement.

•  Nothing Boring About Boron:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4712861/

I *thought* I did a thorough contrast/compare, though I think I should have added how many pills make up the dose, as each manufacturer has different # of pills to make up the totals listed below.

Brand	# Pills	$ Per Pill	EPA (mg)	DHA (mg)	Total # Fish Oil (mg)	Source Fish	Notes:	Purified/Distilled
PacificCoast NutriLabs 2000mg Fish Oil	60	$0.17	800	600	2000	Herring, Mackerel, Salmon, Sardines		YES
Nordic Naturals - Ultimate Omega	90	$0.33	650	450	1280	Anchovies, sardines	"Other" Omegas: 180 mg	YES
Mega Red Advanced 4-in-1	80	$0.36	314                               (combined)		339	Krill, pollock	Total Fish Oil + Krill = 500 mg (Krill contains astaxanthin)	YES
Omega XL	60	$1.11	12	7		?	Green Lipped Mussel Extract (high in Boron)	?
Carlson Super Omega-3	120	$0.12	300	200	600	Macerel, sardines	"Norwegian Fish Oil 1,000 mg"	?
Carlson Lightly Lemon Cod Liver Oil	300	$0.07	85	100	1000	Cod liver	"Norwegian Cod Liver Oil, 1000 mg"     "Other" Omega-3: 45 mg	?

I, myself, have been on 3 mg of boron for a month or two now, and I originally started it out of concerns for bone density, as I'm getting older, plus I had gastric bypass six years ago. However, I might have a chat with my nephrologist (who treats me for hypertension), as the boron might impact my kidney function. I also started my husband on it due to his periodontal issues which have morphed into perio & endodontal issues. 

Astaxanthin tibit: From what I can find online, astaxanthin is derived from krill or shrimp or salmon.  And this site (while I don't know if it's credentialed) has some interesting information on the merits of consuming shrimp.  Cliffnotes: 4 oz of shrimp contains about 1-4 mg of astaxanthin--the true amount of astaxanthin in shrimp pretty much vascillates depending on if it's wild caught vs farmed, as the whatever farmed shrimp is fed impacts the astaxanthin levels, whereas wild caught shrimp feeds off of kelp and other sea vegetation.  Just a hunch here, but when buying shrimp or salmon, you want it to look as pinkish-orange as possible (I suppose this is why some farmed shrimp or salmon looks dull in comparison to wild caught).  

Just sharing my notes and take-away a-ha! information I've culled thus far, and by no means am I suggesting someone use my information INSTEAD of talking with their doctor FIRST before starting these supplements. I've made up my own mind with what information I have on hand, and making judgment calls for MY OWN health; however, I do think that someone interested in adding astaxanthin (or boron, for that matter), SHOULD run it by their doctor first, to see if it's a good fit for them.

A preliminary caution on astaxanthin (in supplement form) can be found on this site.  Again, that, too, is just a website, and not a replacement for talking to a doctor, but I think reading and thinking and wanting to be an advocate for your own medical care is KEY to optimal health. At best, the doctor might agree it should be included in your daily regimen, and at worst, the doctor would say to avoid it entirely (and hopefully provide a couple of reasons, too).  

Physician Fatigue Part 7: Overwhelmed

Here's the quick and dirty inventory of doctors I see, and with what frequency:

Add to this mix the annual sonogram & potential biopsy of my thyroid nodules, too, and it's a formula for disaster, regarding time, time off from office to accommodate all these appointments, plus the added STRESS. 

It's pretty overwhelming, especially on days like tomorrow, where I have to get up at 6 a.m., to drive to Greenwich CT, to sit and wait 15-30 minutes for my physiatrist, have an hour with the massage therapist (to maximize the trigger point injections I no doubt will get), possibly have an X-ray of my shoulder, and I somehow STUPIDLY scheduled this appointment on the same day when I have occupational therapy on my elbow during  my lunch hour.

UNCLE!  

The end of March brought with it SURPRISE! His and Hers Root Canals! I has the first step on 4/22 and on 5/11, I will hopefully have it finished. Normal people's root canals take about 45 minutes for the first step. Mine took 2 hours and 15 minutes. 

So with this, as well as the added worry about my husband's root canal (which is now a TREND, as he had to get the tooth that is immediately ADJACENT to the  tooth he had previously root canaled two years ago done, too. And now, it appears as if this has now evolved into periodontal-endodontal disease for him.

So between the scheduling, worry, and COSTS of TWO root canals, I've now hit my limit. This month is a rough month, time-wise. No chiropractor or physical therapy appointments can be scheduled on Saturdays--due to other scheduling obligations on my part. That there throws every single week into a dizzying game of BEAT THE CLOCK, and just adds to my stress and anxiety. 

 

Breaks my heart to discontinue physical therapy--but my once a week treatments aren't really helping me. And as much as I adore being on the traction table for my neck and low back, I am experiencing minimal effect, and it's very short lived at that. This is no indication of the talents of the physical therapist--he's great. It's just a sign that there's not much to be done to help.

I am now well over six months deep into my relationship with the physiatrist, who, seems to be keeping me in a holding pattern with trigger point injections, the occasional cortisone injection (which I'm really philosophically not supporting), as well as Synvisc (or was it Euffexa?) injections. The synvisc injections HAVE helped with the knee, but to a point, and it has by extension helped the referred pain in my hip, TO A POINT, but I am still experiencing pain, and just would rather explore the idea of a knee replacement already and quit pussy footing around. I'm giving this 1-3 more visits, which will bring me to the first 1-2 weeks of June, and then I'm just going to call it quits.  I can't sustain this much longer, either. 

The one care provider that I feel my most marked benefit from is my chiropractor, of whom, just now, I scheduled an appointment for tomorrow night, and I'm going to run this by him, ditching who I can, and saving my sanity--to a degree.  I. Just. Can't. Even. Anymore.

Additionally: I dumped an account on FB, and haven't gotten so much as a text from anyone saying, "Gee, what happened?" And for the remaining account, I cannot tell if I am being ignored, if I'm getting minimal interaction due to the never-ending fuckery that is the FB algorithm, or if I actually DID something to warrant being/feeling shunned--especially by long term, IRL friends, and TBH, I don't see anyone anymore, and given that online is the only real venue for interaction (see also: no texts on phone, no emails no nothing anymore), I'm wondering if I am just too obtuse to realize that I'm a snooze or I'm offensive, and what friends I have/had are just phasing me out--yet inexplicably, aren't unfriending me on FB. I am so anxious and depressed and overwhelmed, I cannot decipher it all anymore. And given that one IRL friend of mine seems to have dumped me (it's been six weeks and no contact since) after I let it be known that I don't feel important enough or interesting enough to warrant one hour during lunch without her being glued to her cell phone. Fifteen year friendship down the shitter due to being honest.  So, whatever. Thereygao. I better hit "publish." Fuck it.

*ETA: I dumped that last FB account in August 2018 and I haven't looked back.

A Glimmer

Good news: No changes on my thyroid sonogram--so that means no need for a biopsy! I just wish that I could have had a repeat of last year where one of my nodules just up and disappeared! We can't have it all, I guess.