Aging Well with Naturopathic Medicine Jen Green Hallie Armstrong, Diana Quinn, Naturopathic Doctors Beaumont Integrative Medicine [email protected] Royal Oak 248-551-9990 Troy 248-964-9200 What is Naturopathic Medicine Licensed Naturopaths are the general practitioners of natural medicine. A licensed Naturopath has completed four years of pre-med, four years of graduate school at an accredited Naturopathic medical college, and has successfully passed North Americanwide licensing exams (NPLEX). Our scope includes nutrition, herbal medicine, homeopathy, lifestyle counseling and mind-body medicine. Training includes a Western medical understanding of the body eg. differential diagnosis, physical diagnosis, lab work, pathology, microbiology etc. We have a focus on evidence based complementary and alternative medicine (EBCAM). Goals with Healthy Aging Maintain healthy immune system, wound repair, stamina, mental wellness, tolerance to environmental stressors, sensory acuity, flexibility and nutrient absorption. Prevent and minimize the impact of cardiovascular disease, stroke, neurodegenerative disease, macular degeneration, osteoporosis, osteoarthritis, cancer and diabetes. And according to Robert Rountree MD: “Aging well means enjoying this emotional depth and experience that comes with time while keeping the body and mind healthy enough to do the things we want to do and maintaining the freedom to enjoy life.” Aging Aging is a breakdown in the ability to self repair Injuries include oxidative stress, inflammation, lipotoxicity, glucose toxicity and environmental toxins. Glucotoxicity According to Robert Rountree MD “Glucotoxicity is the longterm total burden of sugar . When we eat too much sugar, then the mitochondria leak a lot of free radicals that damage tissues. Some of those damaged tissues will go on to damage other tissues in what is called the propagation process. High levels of fructose are converted in the liver to triglycerides, and those triglycerides basically pack the liver with fat, which then interferes with insulin sensitivity. So, glucotoxicity contributes to lipotoxicity” Recommendation: Eat whole unprocessed foods. When indulging in alcohol or high sugar foods, combine with protein, fat and fiber to minimize the impact on blood sugar. Avoid fatfree foods high in sugar. Say no to candy and pop. Say yes to The Mediterranean Diet. Lipotoxicity Decrease trans-fatty acids which are found in processed food, baked goods and anything that has crackled when you fry it. Transfatty acids increase heart disease[i]. Decrease arachidonic acid in pork, red meat and peanuts. Arachidonic acid fuels inflammation, decreases efficacy of COX inhibitors (goes to LOX) and contributes to mucous, edema and lung constriction. Steam foods, stir-fry in water and add oil at the end, and olive oil to sauces after high heat cooking is complete. Fiber fiber fiber Include omega 3 oils which preferentially replace bad fats in cell membranes. Take fish oil, use cold-pressed olive oil liberally and eat walnuts. Use canola, organic butter or coconut oil for high heat cooking. [i] Association between trans fatty acid intake & 10-year risk of coronary heart disease in the Zutphen Elderly Study: a prospective population-based study. By Oomen CM, Lancet, 2001 Mar 10; Vol. 357 (9258), pp. 746-51 Environmental Exposures Persistent low level environmental toxins may have larger impacts than acute high level exposures with respect to aging The total toxic burden increases slowly over time Consider screening for heavy metals with a urinary heavy metal test following oral DMSA. Pesticides in well water increase risk of Parkinsons (NEUROLOGY TODAY January 21, 2010) Recommendation: Use a water filter, avoid heating in plastic, take shoes off at the door, avoid lawn pesticides, use green cleaning products, choose organic meat, dairy, eggs and oil (higher on the food chain so accumulate more toxins), avoid high mercury fish such as tuna. Water! Water! Water! to support elimination of toxins (early in the day to avoid night urination) . Conventional vs. Organic Water Necessary for all body functions eg. digestion, body-temperature maintenance, electrolyte balance, detoxification May benefit people with respiratory diseases (by thinning mucous secretions), urinary tract infections (by increasing their urine flow and removing bacteria), back, and may help reduce cancer risk of the colon, kidneys, bladder. Increased requirements with sweating, sun exposure, diarrhea or vomiting, certain medications An Environmental Working Group analysis of tap water tests from 1998 through 2003 for 1,446 communities across Michigan shows 69 pollutants were found in drinking water across the state. www.ewg.org/tapwater/statereports/statereport.php?state=MI Consider getting a carbon block or reverse osmosis filter system for drinking water. Oxidative Stress In a study of 20,000 participants, the mortality risk for people who are nonsmokers, who exercise regularly, have a moderate alcohol intake, and who have a plasma vitamin C level > 50 mmol/L (indicating fruit and vegetable intake of at least five servings a day), was the equivalent of being 14 years younger in chronologic age, compared with people who engaged in none of these behaviors. Don’t smoke and avoid second hand smoke Minimize alcohol use Exercise Regularly Khaw K-T, Wareham N, Bingham S, et al. Combined impact of health behaviours and mortality in men and women: The EPIC-Norfolk Prospective Population Study. PLoS Med 2008;5(1):e12;correction:2008;5(3)e70. Antioxidants- Eating the Rainbow Eat seven servings of fruit and vegetables daily Yellow-red-orange vegetables and fruits Red-purple-blue vegetables and fruits Broccoli, cauliflower, Brussels sprouts, cabbage, collard greens Allium Lycopene – tomatoes, guava Lutein – tomatoes, red peppers, green leafy vegetables Zeaxanthin Anthocyanidins – berries, grapes Dark leafy greens Cruciferous vegetables Carotenoids onion, garlic Green, white, red, black tea Curcumin/turmuric Bioflavinoids Quercetin, Hesperidin Antioxidants Drink organic green tea and eat blueberries If supplementing, consider food or herb-based antioxidants eg. New Chapter brand Supercritical Antioxidants, Green drinks eg. Enzymatic Therapies Earth’s Promise, New Chapter Berry Greens, Designs for Health Paleogreens. Extra vitamin C is helpful, but be aware that chewable vitamin C promotes tooth decay if you don’t brush after Antioxidants Antioxidant concentrations (Vitamin C, E and beta carotene) in the blood correlate positively with physical performance and strength in the elderly[i]. Vitamin C and E in combination decrease risk of Alzheimers disease[ii] Low vitamin C and E levels are also found in Parkinsons patients[iii]. Vitamin E has been shown to help with memory/cognition in elderly women (70-79 yrs)[iv]. The only concern with Vitamin E is that it can increase bleeding in high doses (so stop it 1 week before surgery), and it may also increase severity of respiratory infections[v] (so stop taking it during an acute cold or flu). Make sure patients are taking mixed tocopherols or vitamin E succinate rather than plain alpha tocopherol. Antioxidant References [i] Antioxidants and physical performance in elderly persons: the Invecchiare in Chianti (InCHIANTI) study. By Cesari M, Am J Clin Nutr, 2004 Feb; Vol. 79 (2), pp. 289-94 [ii] .Reduced risk of Alzheimer disease in users of antioxidant vitamin supplements: the Cache County Study. By Zandi PP, Cache County Study Group, Arch Neurol, 2004 Jan; Vol. 61 (1), pp. 82-8 [iii] Plasma levels of antioxidant vitamins C and E are decreased in vascular parkinsonim.By Paraskevas GP, J Neurol Sci, 2003 Nov 15; Vol. 215 (1-2), pp. 51-5 [iv] High-dose antioxidant supplements and cognitive function in communitydwelling elderly women By Grodstein F. AM J CLIN NUTR, Apr 1, 2003; 77(4): 975-84 [v] Vitamin E increases severity of respiratory infections. By: Gaby, Alan R.. Townsend Letter for Doctors & Patients, Feb/Mar2003 Issue 235/236, p32, Supplement Considerations in the Elderly • • • • Good quality multivitamin – capsule, powder or liquid instead of tablet because of absorption issues/possible low stomach acid Multivitamin should contain selenium 200mcg for glutathione support, chromium 200mcg for blood sugar stabilization, zinc for wound repair, and a B complex. Consider cancer risk when deciding whether to use natural or artificial folic acid. Do not supplement with iron unless iron deficiency is present because iron can increase inflammation (eg joint pain). Use ferrous glycinate/Gentle Iron instead of ferrous sulfate if supplementing. "Ten-year trends in vitamin intake in free-living healthy elderly people: the risk of subclinical malnutrition," Toffanello ED, Inelmen EM, et al, J Nutr Health Aging, 2011; 15(2): 99-103. Fish Oil Fish oil decreases inflammation, lubricates the bowels, improves memory[i], decreases heart disease and stroke[ii][iii], helps address mild to moderate depression [v], lowers blood pressure[iv], improves bone density [vi] and helps prevent cancer. [i] Alzheimer's Disease is Largely Preventable. By: Grant, William B.. Townsend Letter for Doctors & Patients, May98 Issue 178, p72. Thirteen-Year Prospective Study between Fish Consumption, Long-Chain n-3 Fatty Acids Intakes and Cognitive Function," Jesse Guyot E, Peneau S, et al, J Nutr Health Aging, 2011; 15(2): 115-20. [ii] Changes in fatty acid composition, platelet aggregability and RBC function in elderly subjects with administration of low-dose fish oil concentrate and comparison with younger subjects By Terano T, Nippon Ronen Igakkai Zasshi, 1994 Aug; Vol. 31 (8), pp. 596-603) [iii] The effect of the short-term administration of fish oil on serum lipoproteins in old people. By Lehtonen A, Gerontology, 1989; Vol. 35 (5-6), pp. 311-4 [iv] A low-sodium diet supplemented with fish oil lowers blood pressure in the elderly. By Cobiac L, J Hypertens, 1992 Jan; Vol. 10 (1), pp. 87-92 [v] "The effect of low-dose omega 3 fatty acids on the treatment of mild to moderate depression in the elderly: a double-blind, randomized, placebo-controlled study," Tajalizadekhoob Y, Sharifi F, et al, Eur Arch Psychiatry Clin Neurosci, 2011 Feb 12 [vi] Protective effects of fish intake and interactive effects of long-chain polyunsaturated fatty acid intakes on hip bone mineral density in older adults: the Framingham Osteoporosis Study," Farina EK, Kiel DP, et al, Am J Clin Nutr, 2011 March 2 Omega 3 Fatty Acid Supplementation Fish Oil Considerations: Quality of Supplement Third-party testing eg. www.consumerlabs.com Hexane free Free of oxidative damage Free of heavy metals and impurities Good brands include Carlson Labs, Nordic Naturals, Designs for Health. Goal is at 900mg of EPA and 400 DHA. Algae EPA – EPA/DHA concentrations in fish are derived from the algae they consume; consider Algae EPA supplementation for vegetarians Eggs – chickens fed flax (ALA) Simonopoulos AP, Salem N. n-3 fatty acids in eggs from range-fed Greek chickens. N Engl J Med. 1989;331:1412. Dietary Fish • • • • • Wild caught vs. Farmed fish: Farmed fish has lower omega-3:omega-6 ratio than wild fish Good fish (low mercury fish that are high in omega 3 fatty acids) include anchovies, sardines, herring, wild Atlantic salmon, Sable fish, whitefish, flounder, haddock, farm-raised rainbow trout & catfish. Avoid tuna fish, shark, swordfish, tilefish and king mackerel because of mercury contamination. If pregnant or a young child, avoid grouper, marlin, orange roughy, bass (sea and large mouth), halibut, red snapper, spanish mackerel, bluefish, lobster, pike and walleye. Canned fish: Canned salmon EPA:AA ratio 25:1, EPA 5x higher than tuna • Ginsberg G., Toal B. Quantitative approach for incorporating methylmercury risks and omega-3 fatty acid benefits in developing species-specific fish consumption advice. Environ Health Perspect 117:267–275 (2009). See also www.healthychildhealthyworld.org http://www.hc-sc.gc.ca/english/protection/warnings/2001/2001_60e.htm van Vliet T, Katan MB. Lower ratio of n-3 fatty to n-6 fatty acids in cultured than wild fish. Am J Clin Nutr. 1990;51:1-2. Vitamin D Vitamin D is a common deficiency in the elderly community[i]. It is endemic in Michigan. Statins further decrease absorption of fat soluble vitamins (vitamin A,D,E, K). Supplementation with vitamin D 800 IU/day decreases falls[ii]. Vitamin D deficiency is linked with osteoporosis, hypertension, asthma, diabetes, seasonal depression, frequent viral infections, cancer, and autoimmune conditions. Evidence from epidemiologic studies and small clinical trials suggests an association between 25(OH)D concentrations and systolic blood pressure, risk for CV disease-related deaths, symptoms of depression, cognitive deficits, and mortality. [i] High prevalence of vitamin D insufficiency in healthy elderly people living at home in Argentina. (eng; includes abstract) By Oliveri B, Eur J Clin Nutr, 2004 Feb; Vol. 58 (2), pp. 337-42 [ii] A randomised, controlled comparison of different calcium and vitamin D supplementation regimens in elderly women after hip fracture: The Nottingham Neck of Femur (NONOF) Study. (eng; includes abstract) By Harwood RH, The Nottingham Neck of Femur (NONOF) Study, Age Ageing, 2004 Jan; Vol. 33 (1), pp. 45-51 AND, Alfacalcidol reduces the number of fallers in a community-dwelling elderly population with a minimum calcium intake of more than 500 mg daily. By Dukas L, J Am Geriatr Soc, 2004 Feb; Vol. 52 (2), pp. 230-6 Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety. Am J Clin Nutr 1999;69:842–856. Extraskeletal effects of vitamin D in older adults: cardiovascular disease, mortality, mood, and cognition. Barnard K, ColónEmeric C. Am J Geriatr Pharmacother. 2010 Feb;8(1):4-33. Review. Vitamin D Recommendations Screen 25 OH Vitamin D routinely and aim for a serum level of 40-60. Any brand of D3 is fine, but taking it with a fatty meal or fish oil improves absorption. Use 2000 IU daily[v]. Watch for cumulative dosing between multivitamin, calcium supplements and plain vitamin D. Numerous brands now offer Vitamin D drops in 400, 1000 and 2000 IU/drop. Good to decrease number of pills and for anyone with swallowing issues. Vitamin D and Brain health According to Dr Perlmutter, Vitamin D supplementation is essential in Alzheimers and Parkinsons because it is a membrane-bound antioxidant that enhances neurotrophins, increases hippocampal density (rodent), supresses expression if inflammatory cytokines and is antimicrobial. Perlmutter links herpes simplex infection with AD Calcium/Magnesium Supplementation Supplementing calcium alone eg. Caltrate or CalciChews can create a magnesium deficiency!!! 2 g/day of calcium (citrate) decreased Mg absorption and plasma Mg levels in healthy volunteers. Clin Sci 1967;32:11-18 Calcium supplements should be balanced with magnesium in a 2:1 ratio and a maximum of 500mg calcium is absorbed at once. Forms of Calcium Calcium carbonate is mildly constipating Calcium citrate can encourage bowel movements Calcium glycinate and hydroxyappatite are bowel neutral and well-absorbed Coral calcium is a poor choice environmentally Dietary sources of calcium include dairy, tahini, seaweeds, almonds, calcium-enriched foods and green leafy vegetables. Magnesium Magnesium helps insomnia (if taken away from calcium), reduces heart palpitations, reduces blood pressure, supports cardiac & bone health, helps to normalize glucose metabolism & stabilize moods. According to Dr Alan Gaby, Magnesium is a cardioprotective nutrient that; inhibits platelet aggregation, dilates blood vessels, has anti-arrhythmic activity, is required for ATP synthesis, promotes intracellular potassium uptake, possibly lowers BP and increases HDL-C. Magnesium Deficiency is common: NHANES 1999-2000: 50% of Caucasians consumed < 75-80% of the RDA; Mg intake was about 25% lower in African Americans than in Caucasians. - J Nutr 2003;133:2879-82 Forms of Magnesium Magnesium oxide and magnesium hydroxide (milk of magnesia) are laxatives Magnesium glycinate/chelated magnesium is bowel neutral and helps with chronic pain and muscle stiffness Magnesium taurate has an affinity for the heart Dietary sources: soy, nuts, sunflower & pumpkin seeds, beans, avocados, leafy green vegetables, broccoli. Stomach Acid Antacids can wreak havoc on the acid barrier to infection and protein/mineral absorption. Dose vitamins/minerals away from antacids. Stomach acid naturally declines as we age, which can cause excess bloating and gas, poor protein digestion and poor mineral absorption (calcium, magnesium, zinc etc). Bitters: The esophageal sphincter can be re-educated to close properly by using herbal bitters for 2-3 weeks. Use Herbpharm “Digestive Bitters” or Nature’s Answer “Bitters with Ginger” 3-4 drops before meals. Discontinue immediately if heartburn is aggravated. Bitters often retrain the sphincter to close in response to stomach acid/food rather than staying lax. Careful with reducing stomach acid blockers because many people experience rebound hyperacidity Melatonin Deep phase sleep (high melatonin) is when the body repairs tissues Melatonin activates the immune system, helps to prevent and treat cancer and seems to increase HDL levels in peri and post menopausal women. Melatonin – 3-20mg half hour before bedtime to treat insomnia. Start with 3mg nightly and slowly increase every few days until you reach a dose where you sleep for seven hours and wake refreshed. Melatonin References Lissoni P, Chilelli M, Villa S, Cerizza L, Tancini G, Five years survival in metastatic non-small cell lung cancer patients treated with chemotherapy alone or chemotherapy and melatonin: a randomized trial. Journal Of Pineal Research, 2003 Aug; Vol. 35 (1), pp. 12-5 Tamura H, Nakamura Y, Narimatsu A, Yamagata Y, Takasaki A, Reiter RJ, Sugino N.Melatonin treatment in peri- and postmenopausal women elevates serum high-density lipoprotein cholesterol levels without influencing total cholesterol levels. J Pineal Res. 2008 Aug;45(1):101-5. Epub 2008 Feb 19. Vijayalaxmi; Thomas CR Jr; Reiter RJ; Herman TS. Melatonin: from basic research to cancer treatment clinics. Journal of clinical oncology : official journal of the American Society of Clinical Oncology [J Clin Oncol] 2002 May 15; 20 (10), pp.2575-601. Probiotics Treat both constipation and diarrhea in elderly patients Help prevent upper respiratory tract infections in the elderly Help prevent antibiotic associated diarrhea and yeast infections following antibiotic use Supplement Considerations; Single versus multiple strains Ability to colonize the gut Quality control is a huge issue! Trusted brands include Klaire Labs, Genestra, Orthomolecular Products. Must be stored correctly. Probiotics Improve Bowel Movements in Hospitalized Elderly Patients - The PROAGE Study," Zaharoni H, Rimon E, et al, J Nutr Health Aging, 2011; 15(3): 215-20. (Address: H. Zaharoni, Harzfeld Geriatric Medical Center, Gedera, 70750 Israel. 2004. Green, J. “Probiotics in Pediatric Health Conditions: A Systematic Review”. CAMLine.ca. Open access copy available at: http://www.camline.ca/professionalreview/pr.php?NHPID=43 Drug-NHP Interactions Basic steps to avoid interactions: Don’t take any medication or supplement with absorbent substances such as: Fiber, Bentonite or Charcoal Beware of caffeine, charbroiled food, St. John’s wort (Hypericum perforatum) and grapefruit because they effect liver clearance of medications Check drug induced nutrient depletions eg. Magnesium, CoQ10, melatonin. Drug-Induced Nutrient Depletion Handbook by Ross Pelton, James B. LaValle, and Ernest B. Hawkins Pharmacists are our friends!!!! Case Study: CoQ10 Interactions Oral Coenzyme Q10 with other anti-hypertensives can provide an additional blood pressure lowering effect. Hodgson JM, Watts GF, PlayfordDA, et al. Coenzyme Q10 improves blood pressure and glycaemiccontrol: a controlled trial in subjects with type 2 diabetes. EurJ ClinNutr.2002;56:1137-42. Singh RB, NiazMA, RastogiSS, et al. Effect of hydrosolublecoenzyme Q10 on blood pressures and insulin resistance in hypertensive patients with coronary arterydisease. J Hum Hypertens.1999; 13:203-8. Administration of coenzyme Q10 to heart transplant candidates led to a significant improvement in functional status, clinical symptoms, and quality of life. Study group showed significant improvement in the 6-min walk test and a decrease in dyspnea, New York Heart Association (NYHA) classification, nocturia, and fatigue. However, there were no objective changes in echo measurements. Berman M, ErmanA, Ben-Gal T, et al. Coenzyme Q10 in patients with end-stage heart failure awaiting cardiac transplantation: a randomized, placebo-controlled study. ClinCardiol.2004;27:2959. CoQ10 Interactions Statins can reduce serum coenzyme Q10 levels by blocking the synthesis of mevalonicacid, which is a precursor of coenzyme Q10. Statins' effect on coenzyme Q10 appear to be dose-related. Atorvastatin(Lipitor) 10 mg/day or pravastatin(Pravachol) 20 mg/day doesn't decrease levels of circulating coenzyme Q10 in healthy people Mortensen SA, LethA, AgnerE, et al. Dose-related decrease of serum coenzyme Q10 during treatment with HMGCoAreductaseinhibitors. Mol Aspects Med. 1997; 18:S137-44. BleskeBE, Willis RA, Anthony M, et al. The effect of pravastatinand atorvastatinon coenzyme Q10. Am Heart J. 2001;142:E2. Statin-induced myopathy: Coenzyme Q10 might lessen muscular adverse effects caused by high-dose HMGCoAreductaseinhibitors ThibaultA, SamidD, Tompkins AC, et al. Phase I study of lovastatin, an inhibitor of the mevalonatepathway, in patients with cancer. ClinCancer Res.1996;2:483-91. CoQ10 Negative Interactions CoQ10 / Warfarin Interactions: Concomitant use might reduce anticoagulation effects. Coenzyme Q10 is chemically similar to menaquinoneand may have vitamin K-like procoagulant effects Four cases exist of decreased warfarin efficacy likely due to coenzyme Q10 Preliminary clinical research suggests coenzyme Q10 might not significantly decrease the effects of warfarin in patients that have a stable INR Warfarin-induced hair loss There is some preliminary evidence that coenzyme Q10 might be helpful for preventing warfarininduced hair loss Heck AM, DeWitt BA, LukesAL. Potential interactions between alternative therapies and warfarin. Am J Health SystPharm. 2000;57:1221-7. SpigsetO. Reduced effect of warfarincaused by ubidecarenone. Lancet. 1994;334:1372-3. EngelsenJ, Nielsen JD, WintherK. Effect of coenzyme Q10 and Ginkgo bilobaon warfarindosage in stable, long-term warfarintreated outpatients. A randomized, double blind, placebo-crossover trial. ThrombHaemost. 2002;87:1075-6. Nagao T, IbayashiS, FujiK, et al. Treatment of warfarin-induced hair loss with ubidecarenone. Lancet.i 1995;346:1104-5. Putting it all Together: Assessment & Screening Quality of sleep (sleep hygeine, deep breathing before bed, melatonin supplementation if needed) Emotional fluidity and expression (screen for depression – then check for hypothyroidism, B12 deficiency, folate deficiency, add fish oil) Optimal nutrition with appropriate caloric intake (dentition and food issues, social vs solo eating, avoiding empty calories, screening for zinc deficiency if low appetite, use digestive bitters if low stomach acid) Appropriate dietary supplementation as indicated (multivitamin, vitamin D, fish oil, calcium/magnesium, melatonin, probiotic if needed) Best Medicine = Individualized Medicine Two patients of mine, Betty and Philip – both 82 yrs old Betty – Diagnosed with senile dementia, history of angina with stent, frequent night waking, high cholesterol, low HDL, anemia, high uric acid, chronic constipation, morning headaches, loss of appetite with low caloric intake, mild depression, cared for by loving husband. Philip – Hypertension, gout, gas, breast cancer in 1984, polynephritis (incomplete bladder emptying) with chronic kidney failure, kidney stones, headed for dialysis, poor balance, constipation, recent fatigue, recent anxiety with early night sleep disturbance since wife passed away, lives in FoxRun Naturopathic Recommendations for Betty Cardiac rehab three times weekly for heart health and to improve memory Increase water early in the day, try juice on waking to see if low blood sugar is causing headaches Switch iron to ferrous bisglycinate Nutrient-rich smoothies: Coconut milk (medium chain triglycerides), Whey Cool protein powder, Fish Oil 1 TBSP, ¼ cup cherry juice for uric acid, Calcium magnesium liquid 1 TBSP, frozen or fresh fruit (especially organic blueberries, raspberries) Chocolate chewable CoQ10 100mg by ITI Designs for Health Twice Daily Multi Vitamin D3 2000IU Digestive Bitters 4 drops before meals for 2 weeks to try to stimulate appetite and proper digestive function Naturopathic Recommendations for Philip Balance calcium with magnesium, add extra magnesium glycinate 200mg for kidney function Nettle seed tincture 1 dropper twice daily to improve kidney function. BUN and Creatinine gradually improving so dialysis unnecessary. Switched iron to ferrous bisglycinate, constipation resolved Eliminated daily cabbage and gas resolved Replace flax oil with fish oil 3000mg/3 capsules Theanine 200mg before bed eliminated night disturbance and calms down anxiety. (Patient added melatonin of his own accord) Increased thyroid dosage after detailed testing (TSH was normal, fT4 was not). Fatigue better with new thyroid dose. Amalgamate and streamlined many supplements, especially with high doses possibly effecting kidney function.