Posts Tagged ‘fatigue’

Generic Name
Buspirone (bue-SPYE-rove) OG
Brand Name  BuSpar
Type of Drug
Minor sedative and antianxiety drug.
Prescribed For
Anxiety and generalized anxiety disorders; also prescribed for the aches, pains, fatigue, and cramps of premenstrual syndrome (pMS).
General Information
Buspirone hydrochloride has a potent antianxiety effect. It is approved by the Food and Drug Administration (FDA) for short-term relief of anxiety, but it may apparently be used safely for more than 4 weeks. The exact way in which buspirone works is not known, but it seems to lack the addiction dangers associated with other antianxiety drugs, including benzodiazepines. It neither severely depresses the nervous system nor acts as an anticonvulsant or muscle relaxant, as other antianxiety drugs do. Minor improvement will be apparent after only 7-10 days of drug treatment, but the maximum effect does not occur for 3 or 4 weeks.
Cautions and Warnings
Do not take buspirone if you are allergic or sensitive to any of its ingredients.
Buspirone should be used cautiously by people with timer or kidney disease.
Buspirone does not have any antipsychotic effect and should not be taken for symptoms of psychosis.
Although buspirone has not shown a potential for drug abuse, you should be aware of this possibility.
Buspirone should not be used with monamine oxidase inhibitor (MAGI) antidepressants.
Possible Side Effects
♦    Most common: dizziness, drowsiness, nausea, and head-
ache.
•    Common: fatigue, nervousness, lightheadedness, excite-
ment, dry mouth, and insomnia.
•    Less common: heart palpitations, muscle aches and pains, tremors, rash, sweating, clamminess, rapid heartbeat, dif-
ficulty concentrating, anger or hostility, depression, loss of interest, diarrhea, constipation, vomiting, and blurred vision.
♦    Rare: Rare side effects can occur in almost any part of the
body. Contact your doctor if you experience any side effect not listed above.
Drug Interactions
•    Combining buspirone with an MAGI antidepressant may produce severe hypertension and may be dangerous.
•    The effects of combining buspirone with other drugs that work in the central nervous system (CNS) are not known. Do not take other sedatives or antianxiety or psychoactive drugs with buspirone unless prescribed by a doctor familiar with your complete medical history.
•    Erythromycin, itraconazole, ketoconazole, clarithromycin, diltiazem, verapamil, fluvoxamine, and ritonavir may increase blood levels of buspirone. When used in combination, your buspirone dosage may need to be adjusted.
•    Buspirone may increase the side effects of haloperidol and diazepam.
•    Studies show that buspirone is not affected by alcohol, but this combination should still be used with caution because buspirone causes drowsiness and dizziness.
•    The combination of buspirone and trazodone may cause liver inflammation.
•    Combining rifampin with buspirone may decrease buspirone’s effectj\18″eSS.
Food Interactions
This drug may be taken either with or without food, but for the most consistent results, always take your dose at the same time of day in the same way—that is, with or without food. Avoid drinking large amounts of grapefruit juice with this drug.
Usual Dose
Adult: starting dosage-7.5 mg twice a day. Dosage may be increased gradually to 60 mg a day.
Overdosage
Symptoms of overdose are nausea, vomiting, dizziness, drowsiness, pinpointed pupils, and upset stomach. The overdose victim should be taken to a hospital emergency room. ALWAYS bring the prescription bottle or container.
Special Information
Buspirone may cause CNS depression, drowsiness, and dizziness. Be careful while driving or operating hazardous equipment. Avoid other CNS drugs and alcoholic beverages because they will enhance buspirone’s effects.
Contact your doctor if you become restless, develop uncontrolled or repeated movements of the head, face, or neck, or have any intolerable side effects.
If you forget a dose, take it as soon as you remember. If it is almost time for your next dose, skip the dose you forgot and go back to your regular schedule. Do not take a double dose.
Special Populations
Pregnancy/Breast-feeding: Though buspirone has not been found to cause birth defects, be sure to inform your doctor if you are or might be pregnant while taking this drug. When this drug is considered crucial by your doctor, its potential benefits must be carefully weighed against its risks.
It is not known how much buspirone passes into breast milk. Nursing mothers who must take this drug should use infant formula.
Seniors: Several hundred seniors participated in drug evaluation studies without any unusual problems. However, the effect of this drug in seniors is not well known, and special problems may surface, particularly in those with kidney or liver disease.

Coeliac Disease
During World War 11, there was no bread to be had in the Netherlands and people were forced to eat tulip bulbs. ‘My mother roasted them,’ one survivor recalls, ‘and they tasted delicious then, because we were so hungry I suppose. I cooked some years later, just to taste them again, and they were absolutely disgusting.’
While most of the population was thin and unwell on this starvation diet, a few children were actually healthier than before. An observant Dutch doctor noted that these were the children who, before the war, had suffered from constant diarrhoea, fatigue, poor growth and muscle wasting. They were suddenly stronger and, his enquiries revealed, their diarrhoea had vanished. But when the food situation improved at the end of the war, all their old problems returned. By carefully experimenting with the diet of these patients, the doctor discovered that eating wheat and rye caused the symptoms. Subsequent research has revealed that both contain a collection of proteins, referred to as gluten, which are the source of coeliac disease.
Belly disease
Coeliac disease (or celiac disease) is an old name which simply means ‘belly disease’. It is derived from the Greek word for’belly’ — koilia. Once the cause of the symptoms became understood, a new name was devised — gluten-sensitivity enteropathy — but it has not really caught on. Other terms that you may come across are non-tropical sprue and coeliac sprue, based on the close resemblance of the symptoms to those of tropical sprue. This disease, found in those who live or have lived in the tropics, is probably caused by bacterial infection. There is no causal link with coeliac disease.
Symptoms
The symptoms of coeliac disease are:
• diarrhoea, with pale, bad-smelling stools
• in a few patients, constipation rather than diarrhoea, but this is very rare
• bloating and wind
• damage to the lining of the intestine. This is of a characteristic type: the complex folded structures (the villi) of the intestinal lining are destroyed. Additionally, huge numbers of immune cells are present.
• the loss of the villi results in failure to absorb nutrients from food (malabsorption) causing poor growth in babies, and weakness and weight-loss in adults.
• poor appetite, especially in babies. This can greatly reduce the diarrhoea.
Coeliac disease usually appears in babies during weaning, a few weeks after cereals are introduced, but it can also begin for the first time in adults. The tendency to coeliac disease is genetically inherited, so it runs in families.
Where coeliac disease runs in the family, another disease, dermatitis herpetiformis, is also likely to occur. Dermatitis herpetiformis has the same basic mechanism as coeliac disease but very different symptoms:
• an intensely itchy rash, sometimes with tiny blisters; the rash is symmetrically distributed on the buttocks, shoulders, scalp, and the outer surfaces of the knees and elbows
• the same characteristic damage to the lining of the intestine as seen in tests for coeliac disease, though generally less severe
• diarrhoea, in some cases, but not all. About 5% of those with coeliac disease actually go on to develop dermatitis herpetiformis. Most people have either one or the other.
Both diseases are caused by the same gene, which results in sufferers developing antibodies against one of their own proteins, an enzyme called tissue-transglutaminase. The job of this enzyme, which is found in the intestines, is to assist with the breakdown of gluten.
If no gluten is present, the enzyme does not arouse the interest of the immune system. It is the process of gluten digestion, in which a particular peptide is produced from gluten, that provokes the autoimmune reaction. (A peptide is any short length of protein chain, obtained from the complete protein chain by digestion.)
What seems to trigger the autoimmune reaction is this enzyme–peptide combination: the offending peptide, newly produced and still attached physically to the enzyme. There is something about the particular ‘chemical picture’ that this combination makes which outrages the immune system of individuals with a particular genetic make-up.
The impact of this autoimmune reaction on the intestinal lining is severe in coeliac disease, less so in dermatitis herpetiformis. What causes dermatitis herpetiformis is a particular type of antibody, called dimeric IgA, which is transported by the bloodstream from the gut to the skin. It is deposited in the skin all over the body, but for some reason only provokes inflammation in certain areas.
In rare cases, an IgE-mediated food allergy to wheat can co-exist with coeliac disease, making reactions more severe.
Secondary problems
Paradoxically, while the damaged gut lining of untreated coeliac disease makes a poor job of absorbing specific nutrients (e.g. iron and vitamins) in a form that the body can use, it also lets through far more intact, or partially digested, food molecules. These get into the bloodstream in such numbers that they can lead to idiopathic food intolerance (see p.74). Sensitivity to soya is a common problem, because it is so heavily used in gluten-free bread and other prepared food. Those with coeliac disease who have not improved fully, despite a strict gluten-free diet, often benefit from an elimination diet (see p. 194). This must be done under medical supervision.
Another possible effect of the intestinal damage is lactose intolerance (see p.79), producing a sensitivity to milk.
The frequency of schizophrenia is higher among those with coeliac disease than among the general population. Coeliacs not following a strict gluten-free diet are also vulnerable to other psychological problems. These might be linked to the effects of food-derived exorphins (see pp. 76-7) and other peptides on the brain. The increased permeability of the gut could play a part in this, allowing more exorphins to reach the bloodstream.
Diagnosis
A biopsy (see p. 92) is the only really reliable form of diagnosis. It is crucial that this is done before removing gluten from the diet, because the damage is repaired if gluten is avoided and the healing process is fairly rapid for some people (though in others it takes many months). If the intestinal lining reverts to a normal appearance quite quickly, an accurate diagnosis is never obtained, which can have serious consequences: if you or your child are coeliac, you need to know.
New blood tests can also be helpful in diagnosis, but they do not give the unequivocal result obtained with a biopsy.
Research from the United States suggests that coeliac disease is under-diagnosed in some countries compared to others – for example, Italy screens children routinely but the States does not. Some authorities suspect that there is a great deal of ‘hidden’ coeliac disease in the States, and this could be true in other countries as well. There is no routine screening of children in Britain.
The symptoms of coeliac disease are not always distinctive. Many cases are first detected when patients with rather non-specific symptoms are discovered, by a blood test, to be anaemic.
Treatment
There are no drug treatments for coeliac disease and avoiding gluten religiously is the only way to remain well. Those who are lax about their gluten-free diet may be more vulnerable to certain cancers of the digestive tract.
A strict gluten-free diet is not easy to follow (see p. 177). The most severely affected coeliacs are so sensitive to gluten that they react violently to even a tiny amount: this is known as coeliac shock and can be fatal.
A gluten-free diet is also the treatment for dermatitis herpetiformis, but at the outset the rash can be controlled with the highly effective drug dapsone.

Candidal Spores of the Fungus, Candida Albicans.
`As a small child Jason was plagued with ear infections which led to many courses of antibiotics,’ Hannah Mitchell recalls. ‘Eventually he started to get symptoms such as an upset stomach, itchy bottom, flu-like symptoms and extremely itchy eyes. The GP prescribed eye drops and when I put them in Jason screamed his head off. In the morning every single eyelash had fallen out. Jason’s health deteriorated and a few months later his eyebrows started to itch. Within two days every single eyebrow hair had fallen out. His eyes were worse and I was offered steroid eye drops again. Reluctantly I accepted.’
‘Putting the drops in caused Jason extreme pain. The red patches of skin around his eyes spread and the itching increased. I was at the end of my tether when I came across a book in the library about food-related illness…
What Hannah discovered from her reading was that, for many with diarrhoea, bloating, wind and an itchy bottom, the cause can be an overgrowth of yeasts in the gut, caused in part by repeated courses of antibiotics which kill off friendly gut bacteria in the gut flora (see p. 204) and allow yeasts to flourish. This is not mainstream medicine, which is why none of the doctors who had seen Jason mentioned the possibility of yeast overgrowth.
Yeasts are microscopic fungi, so anti-fungal drugs are needed to kill them. However, reducing the intake of sugar in the diet is also very effective because yeasts living in the gut thrive on sugar. Hannah took matters into her own hands, and tried out a diet containing no sugar and no yeast. (The reason for avoiding yeast in food is discussed below.) There was some improvement and, encouraged, she went back to the doctor and asked for anti-fungal drugs.
The doctor agreed, and to Hannah’s immense relief, the combination of diet and drug treatment worked for Jason – it cleared the diarrhoea, wind and itching, and eventually allowed his eyelashes and eyebrows to grow back. (Note that few other patients with yeast problems suffer hair-loss – this is a very exotic symptom – but yeast overgrowth can produce some other quite unusual reactions.)
The elusive culprit
So far, you will notice, I have not mentioned Candida. Among those doctors who study and treat this condition, this particular yeast was once considered the prime suspect. Indeed, the disease itself was called ‘candidiasis’. But the role of Candida is now considered doubtful by many.
Researchers such as Dr John Hunter, of Addenbrooke’s Hospital in Cambridge, have tried to find Candida in their patients without success. ‘I think now we have to reject the idea of Candida causing the symptoms,’ says Dr Hunter. ‘But I do believe that there is an imbalance in the gut flora – the micro-organisms that live in the gut. I believe that’s at the root of so-called “candidiasis”.’ This new evidence has not yet affected beliefs about candidiasis’ and ‘Candida’ in the complementary health field.
The fact remains that anti-fungal drugs have proved very helpful to many patients with the typical cluster of symptoms –diarrhoea, wind, bloating and an itchy anus – that were previously attributed to Candida. Given the effectiveness of these drugs, it seems probable that yeasts of some kind are playing a large part in this condition. So the term ‘yeast overgrowth’ is being used, rather tentatively at the moment, as a label for this condition. The yeasts concerned have not, as yet, been identified.
The facts about Candida
This box is about Candida as understood by conventional medicine, rather than ‘Candida’ and ‘candidiasis’ as understood by alternative medicine.
The yeast known as Candida lives naturally in the gut, usually causing no trouble. Problems are usually caused by Candida only when it sets up home in the throat, vagina or penis (’thrush’ infections). Such localised infections have well-defined symptoms and, in most cases, are easily treated with anti-fungal drugs. Patients with damaged immune systems, caused by anti-cancer drugs or AIDS, often develop more widespread Candida infections, but this never happens to people with a normal immune system.
Inhaling steroids and not rinsing out the mouth afterwards can make asthma sufferers more susceptible to Candida infections in the throat (see p. 145).
Other symptoms that have been linked to yeast overgrowth are:
• fatigue
• poor concentration
• irritability, depression and confusion
• headache or migraine
• severe premenstrual problems
• recurrent cystitis
• skin rashes
• aching muscles
• chronic urticaria.
Sometimes there is constipation rather than diarrhoea. Recurrent thrush – a genuine Candida infection in the vagina – can also be a feature of this problem. Occasionally allergic symptoms such as asthma seem to get worse with yeast overgrowth.
Is there an allergic reaction to the yeast?
Those with symptoms typical of yeast overgrowth may give a positive skin-prick test to Candida, but what this means is debatable. For one thing, not everyone with this condition gives a positive test. For another, some entirely healthy people give a positive skin-prick test to Candida. To complicate matters, there are a lot of cross-reactions (see p. 14) between different kinds of yeasts and moulds, due to similarities in their chemical constituents. So the positive skin-prick test does not mean that Candida itself triggered the original IgE-response.
The question of whether some kind of sensitivity reaction to yeasts is occurring in those with yeast overgrowth, and contributing to their symptoms, is an interesting one. The benefits from avoiding yeast in food (see Diagnosis and treatment) suggest that it may be – but this is a question that cannot be answered at present.
Diagnosis and treatment
Unfortunately, this is one of those ’suck-it-and-see’ conditions, where diagnosis and treatment are the same – you try the treatment for yeast overgrowth, and if it works you assume that the disease is, or was, yeast overgrowth. This is far from satisfactory, but is the best that can be done at present.
It is only worth trying this treatment if you have quite a number of the symptoms listed. Bowel problems and an itchy anus are characteristic, and if you have neither of these it is unlikely the treatment will help you.
A key part of the treatment is a no-yeast-no-sugar diet (see p. 205). This diet has been developed on a largely pragmatic basis, and seems to work – but why? The rationale for cutting out sugar is clear – it feeds yeasts in the gut. But why avoiding foods containing yeast should help is uncertain. Possibly the yeasty food supplies some special nutrient that benefits the yeasts living in the gut. Alternatively, there might, for some people, be a sensitivity reaction to the yeast in food (see left).
If it seems that you are on the right track, because there is some improvement with this diet, ask your doctor for anti-fungal drugs. You should take these in addition to the diet. Nystatin (see box below) is very safe for most people, since it is not absorbed from the gut. Bacterial replacers (see p. 205) may also be useful.
You may need a referral to a doctor who is knowledgeable about yeast overgrowth but try to avoid those doctors and alternative therapists who are part of the ‘Candida’ craze, and think that ‘candidiasis’ explains a huge variety of illnesses. You may not have yeast overgrowth at all, so you need someone with an open mind.
Eczema and yeasts?
Doctors have found that some children whose eczema looks very red, and is not responding to treatment, have IgE in the blood against a range of yeasts and other fungi (Candida, Trichophyton, Saccharomyces and Pityrosporum). Given the tendency to cross-reactions among fungi (see main text) it is not clear exactly what these reactions indicate. A proportion of these children get much better on anti-fungal drugs, including a drug called nystatin, which is not absorbed through the gut wall – so cannot reach the skin. The eczema improves, and at the same time there is a fall in levels of anti-fungal IgE in the blood. In other words, a treatment that can only affect fungi living in the gut benefits the skin. Exactly what is going on here is unknown, but the important point is that the treatment seems to work. This is a controversial topic, but since nystatin is an extremely safe drug, your doctor may be prepared to try it out. A course of 3-4 weeks is the minimum needed.

The days when doctors wanted their patients to obey orders and ask no questions are largely gone. Patients with allergies and other forms of sensitivity - or their parents -

have to play a key role in managing the disease. Most doctors now recognise this, and encourage their patients to learn about their illness, its diagnosis and treatment, and to

be partners in their own medical care.
Quite apart from this, there are aspects of allergy management where few doctors can afford the time to become experts. The nitty-gritty details of dust-mite avoidance or food

labelling practices are good examples. You can usefully supplement your doctor’s treatment here, by informing yourself.
But where should this process stop? That is a difficult question which doctors are increasingly forced to consider. One modern phenomenon, being discussed in many medical

journals at present, is the abundance of medical information on the Internet. Some doctors dread the arrival of patients who have logged on the night before their appointment

and are armed with a huge number of facts about their illness -some accurate, some utterly wrong and some highly debatable. But other doctors welcome the fact that patients are

actively interested in their health problems.
The reactions of doctors to ‘Internet patients’ highlight an issue that also runs right through this
book - that of medical orthodoxy. Who decides what is true and what is false in medicine, and how do they do it? Make no mistake - this is a deep and abiding problem which

afflicts not just scientific medicine, but science in general.
If a doctor, confronted with a web-page claiming that allergies are caused by space aliens intent on
destroying Western civilisation, snorts ‘Rubbish!’, he or she is not, strictly speaking, taking a scientific approach. In science, you should consider all the different

hypotheses.
In theory, science works by questioning everything and taking nothing on trust - but you can’t make much practical progress if you stick rigorously to that approach. Neither

scientists nor doctors start their careers by running experiments to establish the truth of everything they were ever taught. At some point in science, and in scientific

medicine, you have to assume that certain things are probably true, and proceed accordingly. If you make significant progress working on those assumptions, then the chances are

they were correct. But a good scientist always remembers that they are only assumptions.
Scientific medicine rests on a huge number of assumptions. Some of these are clearly accurate - for example, that eating wheat triggers coeliac disease -and it would be

time-wasting to argue about them. But this ‘fact’ about coeliac disease began as just a theory (see p. 70), and a highly debatable one. It has taken time for it to become

substantiated by more and more evidence.
Some medical assumptions become enshrined as facts rather too quickly. Fifty years ago, orthodox medicine accepted as a ‘fact’ that many asthmatic children had ‘intrinsic

asthma’, which was psychological in origin. Research since then has shown that there is almost always an allergy underlying childhood asthma. Many other examples could be given

of medical ‘facts’ that are overturned by subsequent research.
Doctors thirst for certainty, something that is quite understandable when they are faced with so much human need. A significant part of the healing power of medicine comes from

placebo effect (see p. 233), and that relies on patients having faith in the doctor. The traditional way for doctors to cultivate that faith was by assuming an air of absolute

certainty - about their diagnosis of the patient’s illness, about the treatment, and about medicine in general. This need for certainty has always hastened the transformation of

assumptions into facts.
The fatherly authoritarian attitude of old-fashioned doctors was, in large part, a reflection of how little they had in the way of useful treatments, and how much they relied on

placebo effect. Modern doctors have far more genuinely effective remedies to offer and can afford to take a different approach. Many now rely on a different kind of authority,

one based on intelligence, good information, flexibility, curiosity and openness. It’s a form of authority that allows a doctor to say ‘I could be wrong…’ or, ‘Let’s try this

and see what happens…’ without losing face.
Unfortunately, there is another powerful force at work in this complex situation, and that is quackery -the age-old business of selling phoney cures (see p. 209). Official

bodies within the medical community try to curb quackery by weighing the evidence about novel treatments and coming to decisions on their validity. This can be very useful. But

in deciding what is, and what is not, good scientific medicine, medical organizations always run the risk of mistaking their own unverified assumptions for facts.
Establishing criteria for good treatment is essential in medicine, but when this develops into dogmatism, that is decidedly unhealthy. Among the treatments that are being

dismissed as valueless today, there are
several that deserve a fairer hearing.
Some of these treatments have been shown to work by the most excellent of scientific methods. The use of elimination diets in Crohn’s disease is a good example - for some

patients, there is a huge and sustained improvement, suggesting that their disease was caused, at least in part, by food sensitivity. The tactic used by those who want to reject

this evidence is simply to ignore it. When scientific review papers (summaries of all the current knowledge and latest research) are written about Crohn’s disease, the research

on diet is usually not mentioned. Evidence that is routinely ignored in this way slips into oblivion because most doctors only have time to read the review papers, not the

original research reports.
Occasionally - and this is even more shameful -good scientific evidence that goes against the grain of current orthodoxy is actually misreported in review papers. This happened

with an impeccable scientific study showing the benefits of an elimination diet for some patients with rheumatoid arthritis. By missing out certain key facts, a review author

managed to give the impression that the results of this study supported the conventional view on the subject (that diet makes no difference to rheumatoid arthritis), whereas

they actually disputed the conventional view.
Unthinking rejection of new treatments often occurs with currently untreatable diseases such as autism and Chronic Fatigue Syndrome (CFS). Such medical problems always attract

experimental treatments, just as they always attract sheer quackery, and sorting out one from the other is not easy - it takes time, and a clear-headed approach, not knee-jerk

dismissal.

Food Intolerance
The comments of those who have recovered from food intolerance after many years of ill-health are always memorable. ‘It’s like getting my life back again,’ said one woman. ‘I had actually forgotten what it felt like to be well,’ said another, ‘the effect of cutting out certain foods was just amazing.’
For most of those with food intolerance, the disease begins very subtly and gradually – first one symptom (persistent and unexplained diarrhoea, perhaps) then, some years later, another (migraine or headaches) and then, when a few more years have passed, another symptom (such as joint pain or muscle aches). Steadily increasing levels of irritability, `fuzzy-headedness’ or inexplicable tiredness may accompany this decline in health.
Most patients have no idea that all these symptoms are connected until they try an elimination diet, and everything clears up at once, quite dramatically. As one former sufferer described it: `Some of the stuff that got better – well, I’d been like that so long I thought it was just the way I was –grumpy and exhausted, and feeling terrible if I didn’t eat meals on time. It was an absolute revelation to feel completely OK again.’
What does ‘food intolerance’ mean?
In this book, food intolerance means any reaction to food where the immune system has no proven central role.
All the people I have described so far have idiopathic food intolerance, which means, food intolerance with no established mechanism – in other words, doctors can’t say exactly how it is caused. This is a highly controversial area.
The definition of food intolerance used in this book means that it also includes metabolic abnormalities, which do have a well-established cause. These are due to defective enzymes (see upper box on p. 75).
The question of what words mean is a key part of the debate over idiopathic food intolerance. At one extreme, you may come across doctors who call this problem ‘food allergy’, using the original meaning of the word ‘allergy’ (see p. 6). (Some of these doctors use terms such as delayed food allergy and masked food allergy, to point up the distinction from true food allergy, but not all do.) Using the word ‘allergy’ in this context causes a lot of aggravation and confusion, so the term ‘food intolerance’ has, for a long time, been widely accepted as a useful one that avoids unnecessary conflict.
You will also hear the term ‘food intolerance’ used to mean idiopathic food intolerance only – this is probably the most common usage. When the term is used in this way, metabolic abnormalities are being thought of as a separate entity altogether.
A new twist has recently been added to this long-standing wrangle over meanings. When mentioning food intolerance in their literature, some of the major medical organisations (those who dispute the very existence of idiopathic food intolerance) now say simply ‘food intolerance e.g. lactase deficiency’. To anyone familiar with this field, it looks suspiciously like an attempt to redefine ‘food intolerance’ so that it means nothing more than ‘metabolic abnormalities’. The idea seems to be that, if you deny a disease a name, it will go away!
In the medical wilderness
The main text of this article is about idiopathic food intolerance, a disease with a distinctly dubious reputation among doctors. Because it is so controversial, few doctors actually look at the evidence that it exists – which is in fact quite strong (see box on p. 77). Such evidence is simply ignored in most of what is written by the major medical organisations debunking idiopathic food intolerance.
This lack of medical recognition is very unfortunate for patients with idiopathic food intolerance, whose debilitating symptoms could be eliminated, rather than simply being treated (usually to little effect) with drugs.
This prejudiced attitude to idiopathic food intolerance also plays into the hands of those offering bogus diagnostic tests and phoney treatments, often at a very high price. These practitioners
– who have moved in to fill the gap left by conventional medicine
– are a considerable part of the problem, helping to give idiopathic food intolerance a bad name.
The waters are muddied even more by the fact that some people who believe themselves to have food intolerance are actually suffering from psychological problems, which they prefer to attribute to food. Many more have picked up on food intolerance as something rather glamorous to suffer from, inspired by all the media reports about food intolerance among celebrities. All these patients are a good source of revenue for the less scrupulous fringe practitioners and are unlikely, therefore, to be discouraged from their beliefs.
Fortunately there are enough conventional but open-minded doctors, often GPs, who have come to realise, through experience with their own patients, that elimination diets have a remarkable curative effect for some people. The ones who benefit are often the doctor’s ‘old faithfuls’ – those with long-term multiple symptoms, who have been referred to innumerable specialists and treated with all kinds of drugs, but who never get much better. The conventional view of such patients is that they have psychological problems that are being expressed as physical symptoms. This may well be true for some – but others have idiopathic food intolerance.
One of our enzymes is missing
Metabolic abnormalities are a distinct type of food intolerance. Unlike other kinds of food intolerance, metabolic abnormalities have a clearly understood cause: an enzyme that carries out a crucial task in the body’s metabolism is either missing or inept. The problem is generally caused by a defective gene and is therefore inherited.
The most common metabolic abnormality is lactase deficiency leading to lactose intolerance (see p. 79) — this may or may not be inherited. Other metabolic abnormalities include:
trehalase deficiency, lack of the enzyme which breaks down a substance in mushrooms and most other fungi, including yeast. galactosaemia, a defect in the enzyme which processes galactose, one of the sugars found in milk (cow’s or human). This is a serious disease and sufferers must avoid milk scrupulously.
fructose intolerance, which is extremely rare. Those affected have an unpleasant taste in the mouth on eating fruit and other sources of fructose, so avoidance is no particular problem.
phenylketonuria, also very rare. Those affected are usually identified early in life, by a routine blood test.
Is it just placebo effect?
Doctors who doubt the very existence of idiopathic food intolerance will say that people who recover on an elimination diet are just experiencing placebo effect — a psychological response that operates with any treatment, whether effective or ineffective, simply because people believe that the treatment will work. But this is to ignore certain facts:
• Placebo effect produces a fairly small improvement in most people — you have to be very suggestible to feel enormously better. By contrast, when people respond to an elimination diet (the standard method for diagnosing idiopathic food intolerance —see p. 194) they usually have a sudden and dramatic improvement.
• Most of those with idiopathic food intolerance have had it for years and tried all sorts of treatments. They have often experienced some small benefit from these, probably placebo effect. When they try an elimination diet, they have a response that is in a completely different league.
• The idea that all the different symptoms are linked has never occurred to many people who try an elimination diet — they are often trying it for just one symptom, and are staggered when everything clears up. Placebo effect relies on expectation.
• Placebo effect doesn’t last very long — it fades over the ensuing weeks and months. Avoiding the culprit food usually produces a lasting improvement for those with idiopathic food intolerance.
Symptoms
The symptoms of idiopathic food intolerance come on slowly after eating the offending food, and the foods to blame are often those eaten very regularly, such as wheat or milk. Consequently, the symptoms from one meal tend to overlap with those from the previous meal and people with idiopathic food intolerance are more-or-less unwell for most of the time. It Is usually not obvious that food is at fault.
All the symptoms of idiopathic food intolerance are common ones that can be caused in other ways. And no two patients have exactly the same set of symptoms.
(As far as doctors are concerned, neither of these attributes gives the disease a respectable air.)
These are some of the symptoms commonly reported:
• headache or migraine
•diarrhoea, sometimes with bloating and wind; this is often diagnosed as irritable bowel syndrome (IBS)
• in children, stomach aches
• occasionally constipation
• nausea and indigestion
• joint pain
• aching muscles
• a constantly runny or blocked nose (this could be perennial allergic rhinitis linked to food – see p. 68)
• glue ear (see p. 29)
• fatigue and a general feeling of vague ill-health.
Asthma and eczema, triggered by specific foods (see p. 68), can also be part of the picture.
In babies, colic is often caused by food intolerance, including foods the mother is eating which come through into the breast milk in tiny amounts (see p. 202).
Less common symptoms include:
• recurrent mouth ulcers
• stomach or duodenal ulcers
• chronic urticaria (see pp. 50-53)
• swelling (angioedema).
The following diseases have also been linked to idiopathic food intolerance in some patients:
• Crohn’s disease
• palindromic rheumatism (intermittent episodes of joint inflammation)
• rheumatoid arthritis.
Psychological problems such as depression, anxiety, or hyperactivity in children can sometimes be due to food (see p. 80) but it is rare for such psychological effects to occur without any physical symptoms.
Remember that every single one of these symptoms and conditions can be caused in some other way. However, the constellation of migraine/headache, joint pain and diarrhoea is highly characteristic of idiopathic food intolerance.
How might intolerance be caused?
No one knows how idiopathic food intolerance is caused. There are probably many factors involved, with a slightly different mix of factors in each patient. This would help to explain why the symptoms are so extraordinarily varied, with no two sufferers exactly alike.
Although symptoms accumulate over the years, some people can in fact pinpoint the moment when their problems began. ‘I had this terrible bout of diarrhoea from eating too much melon. I lived near a farm and they were free, because of a glut, so I just gorged myself on them. Although I was over the diarrhoea in a couple of days, I was never what you’d call “regular” after that, and the least thing would upset me. Eventually the doctor said it was irritable bowel syndrome. When the other problems began, ages afterwards – headaches and hypoglycaemia and fatigue – it seemed like something quite separate. I never associated them in my mind with the diarrhoea.’
Bad diarrhoea can clear the intestines of their beneficial bacteria, known collectively as the gut flora (see p. 204), and this is probably what initiates food intolerance in such cases. Large doses of antibiotics (as are sometimes given before an operation, e.g. a hysterectomy), or prolonged and repeated courses of antibiotics, given for glue ear or acne, can also disrupt the gut flora and lead to food intolerance. A study of hysterectomy patients has shown that antibiotic treatment before the operation tends to result in irritable bowel syndrome – a common symptom of idiopathic food intolerance – afterwards.
A few interesting observations suggest that minor metabolic abnormalities – a defect in certain detoxification enzymes – may sometimes play a part in idiopathic food intolerance. This is especially likely where there is intolerance to food additives, or where there are behavioural symptoms (such as hyperactivity) or symptoms involving the nervous system (such as migraine).
A third factor that could play a part for some patients are food-derived exorphins. These are fragments of proteins (called peptides) produced by the digestion of food proteins. They happen, probably by pure coincidence, to resemble the substances called endorphins that we all produce for ourselves. Endorphins
are our internal painkillers. They modify nerve impulses in the body and brain, reducing sensations of pain, and improving the sense of well-being. The receptors to which they bind are the same receptors that bind morphine and heroin - it is the intensive stimulation of these receptors that makes these drugs so effective.
Food-derived exorphins may sound like the stuff of science fiction, but they have actually been demonstrated in the digestion products of wheat and milk. They may exist for other foods as well. They are nowhere near as strong as morphine, but do seem to improve mood.
These exorphins may explain the strange observation (made repeatedly, by a great number of initially sceptical doctors) that patients with idiopathic food intolerance often eat huge amounts of their offending food, and ‘can’t live without it’. Often they eat the food several times day, sometimes at every meal. With a ubiquitous ingredient like wheat or milk, this is not particularly difficult - wheat cereal and milk for breakfast, a cheese sandwich at lunchtime, pasta with a creamy sauce for supper, a milky drink and biscuits at bedtime.
Any of these abnormalities is likely to be just one factor in a multi-factorial disease.
Diagnosis
Unfortunately there are no simple accurate tests for idiopathic food intolerance. The kind of tests you may see offered commercially (in advertisements in health magazines for example) are very inaccurate, and a waste of money. Consequently, the only way to diagnose idiopathic food intolerance is through an elimination diet, in which you cut out all the foods you commonly eat, and then -if you get better - test them one by one.
It sounds easy but it isn’t, so make sure you read all the instructions for doing the diet before you start (see pp. 194-7). You should also see your doctor and get his or her approval. Some symptoms - such as severe diarrhoea or headaches -should be investigated by conventional methods first, in case there is some serious underlying cause.
The first step in diagnosis is to decide if a food really is the cause of the symptoms, and the second step is to identify the food or foods concerned.
The first step is crucial. One of the problems with the diagnostic tests that are advertised - such as those using samples of hair or blood - is that they begin with the second step. In other words they assume that food is the problem (see p. 93).
When it comes to the second step, remember that although common foods are often the culprits, almost anything that is eaten can cause idiopathic food intolerance. Every patient with this problem is different in the foods they react to.
Treatment
Avoidance of the food is usually the best treatment for idiopathic food intolerance - however most people do not have to avoid their problem foods for ever. After a while - it could be six months or it could be three years - you can usually go back to eating it again, but in moderation. You must never start eating the food in large amounts again, and it is best not to eat it every day - certainly not at almost every meal, which is the usual pattern for cow’s milk and wheat in the Western diet.
If you find the restrictive diet too difficult, you could try desensitisation treatment (see pp. 210-13). This can work very well.
The patients who should avoid the culprit food indefinitely are those with Crohn’s disease and rheumatoid arthritis: a severe and irreversible relapse can occur otherwise.
The evidence
The evidence for idiopathic food intolerance is more substantial than its opponents would have you believe.
One very well-conducted and interesting study involved children with severe migraine who were investigated by a research team at Great Ormond Street Hospital in London. These are children who are very difficult to treat successfully by normal means. On an elimination diet, 88% of those children got better — an astonishing number. Not just their migraine, but all sorts of other symptoms as well, including aching limbs, runny noses, asthma, eczema, diarrhoea, wind, mouth ulcers and hyperactivity. Some of these children also had epileptic fits, and even this symptom cleared up on the diet, recurring when culprit foods were tested.
A notable feature of this study is that, of the five researchers involved, four were deeply sceptical at the outset. Their report notes that they ‘embarked on this study believing that any favourable response, such as that claimed to substantiate the dietary hypothesis, could be explained as a placebo response. The positive double-blind controlled trial… provides clear evidence that a placebo response was not the explanation.’
Other studies with good scientific credentials have demonstrated a role for idiopathic food intolerance in adults with migraine, and for sufferers from irritable bowel syndrome and Crohn’s disease. There are also good studies of individual patients with rheumatoid arthritis and palindromic rheumatism (an episodic form of inflammatory arthritis) who have responded dramatically to avoidance of a particular food. Some of these patients were given several double-blind challenges and showed changes in certain immunological tests, as well as joint symptoms, when challenged with the offending food. This suggests that the immune system could be playing some part in these food reactions.