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  • You Probably Do This Every Day- But Experts Warn It’s Harming Your Child’s Development

    You Probably Do This Every Day- But Experts Warn It’s Harming Your Child’s Development

    You ask your child to put the phone down, concerned about the effects of too much screen time on their developing brain. But what if the problem is not just their habits, but yours?

    New research suggests that it is not enough to simply limit a child’s screen time, but the way parents use technology around their children can influence a child’s cognitive development, emotional well-being, and even how much time kids themselves spend on screens.

    Many parents scroll through their phones during mealtime or playtime, often without thinking twice. But this seemingly harmless habit is creating a growing disruption known as “phubbing”, when technology gets in the way of face-to-face connection.

    Since young children rely on their parents’ attention and responsiveness to feel secure, explore their world, and develop emotionally, when this connection is interrupted, it can quietly affect their healthy development, suggests the researchers of the latest study published in the journal JAMA Network Open.

    The researchers evaluated over 6,000 studies on how parents use technology around their young children and further narrowed it down to include only studies that focused on healthy children from birth to about 5 years old. These studies explored how a parent’s use of phones or other devices in front of their child, called parental technology use (PTU), might be linked to factors such as the child’s brain development, emotional health, movement skills, screen time, sleep, and physical activity.

    The findings revealed that when parents use technology around their young children, it is linked to lower cognitive development, higher internalizing and externalizing behaviors, and weaker attachment. Children also spent more time on screens. The effects were consistent regardless of the type of technology used.

    “Parents’ use of technology in their child’s presence was negatively associated with cognitive and psychosocial outcomes and screen time among young children, although the effect sizes were small. Further research focusing on potential impacts on physical activity, sleep, and motor skills is needed,” the researchers concluded.

    The researchers stress that these findings do not mean technological devices are “inherently harmful,” as they can be useful tools for parents. However, managing how and when devices are used around children could help reduce possible negative effects. One helpful approach may be co-viewing or co-using devices with children, which has been “positively associated with cognitive outcomes” in early childhood.

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  • Treating Fatty Liver Disease with Diet 

    Treating Fatty Liver Disease with Diet 

    What are the three sources of liver fat in fatty liver disease, and how can we get rid of it?

    Nonalcoholic fatty liver disease (NAFLD) is now the most frequent chronic liver disease, thanks in part to our epidemic of obesity, and is even seen in children. “[N]early 70–80% of obese children may have NAFLD.” Why do we care? Because a fatty liver can progress into fatty hepatitis, which can cause scarring and liver cirrhosis, and cirrhosis is bad enough, but it may also cause the development of liver cancer.

    What is the source of the liver fat in fatty liver disease? There are three main sources: the excess sugar in our diet, the excess fat in our diet, and the fat spilling over from our excess body fat, as you can see at 0:51 in my video The Best Diet for Fatty Liver Disease Treatment. 

    How do we know excess dietary sugar is bad? Because it’s been put to the test. When teens with fatty liver disease were randomized to a diet low in free sugars (meaning a diet low in added sugar and sugary beverages), they experienced a significant improvement within eight weeks. Given these new data, a liver journal editorial read that “a strong argument can be made that we are beyond any period of uncertainty about the harmful effects of excess sugar consumption and that we must now act on the large body of available data to inform the public of the health risks of eating too much sugar.”

    And how do we know excess dietary fat is bad? Because it’s also been put to the test. When people were randomized to a low-fat diet or a high-fat diet with the same number of calories, within just two weeks, the liver fat of those on the low-fat diet decreased by 20 percent, whereas it increased by 35 percent in the participants getting the same number of calories but on a high-fat diet.

    On the low-fat diet, insulin levels went down about 15 percent, and on the high-fat diet, insulin levels went up about 15 percent. Low-carbohydrate and ketogenic diet advocates often talk about how we need to eat more fat and less carbs to keep our insulin levels down, but the exact opposite happens when it’s actually put to the test. A single high-fat meal not only increases liver fat but also insulin resistance. Within four hours, our whole-body insulin sensitivity can drop by 25 percent, so our body has to pump out that much more insulin. As the accompanying editorial put it: “A single fat bolus [dose] packs a punch.”

    So, to help prevent or treat fatty liver disease, patients should limit or avoid eating foods rich in fats. While more long-term clinical trials are always needed, “based on current evidence, we would recommend a diet low in fat, notably in saturated fatty acids, and low in refined carbohydrates, notably by reducing soft drinks consumption…as these nutritional factors may play a pivotal role in NAFLD.” So that means a diet low in meat, dairy, junk, and refined carbs, especially soda. Saturated fat is not only “more metabolically harmful for the human liver than unsaturated fat,” but saturated fat is more harmful than straight sugar. What happened when study participants were overfed with 1,000 calories of saturated fat (like cheese and coconut oil), unsaturated fat (like nuts and olive oil), or sugar (like soda and candy)? Overeating 1,000 calories a day of anything isn’t good for us, but the saturated fat increased liver fat by 55 percent, significantly more than the unsaturated fats, with the candy coming in between the two.

    So, “although weight loss is beneficial in NAFLD, certain diets known to induce weight loss can actually cause or exacerbate this disease, and therefore induce insulin resistance, such as very low carbohydrate, high fat diets.” In contrast, “healthy plant-based diets are associated with lower NAFLD risk and more favorable liver function tests profile.” The consumption of legumes (beans, split peas, chickpeas, and lentils), for example, is associated with a lower risk of fatty liver, up to 65 percent lower odds from eating more beans.

    In the earlier study, researchers weren’t looking at people eating strictly plant-based diets, just more or less so. It’s harder to study those eating completely meat-free diets since they currently represent just a small segment of the U.S. population. But what about Americans of Indian descent? South Asians, individuals originating from the Indian subcontinent, are “one of the fastest growing ethnic groups in the United States,” and they appear to largely retain their diets, with about the same percentage of vegetarians as in India—nearly 40 percent. We know that in India, meat eaters are at significantly higher risk of fatty liver disease. It is the same in Taiwan, with vegetarians at significantly lower risk of fatty liver. And even the vegetarians who were affected had significantly less liver scarring, as you can see below and at 4:35 in my video. Their data suggest that “replacing a serving of soy with a serving of meat or fish was associated with 12%-13 % increased risk”—having a single serving of meat instead of soy elevates the risk of fatty liver. 

    And in the United States? Eating a vegetarian diet was associated with being slimmer and having better blood sugars, better cholesterol, and less than half the odds of fatty liver disease. Is it cause and effect? We have to put it to the test. In an effort to reverse a fatty liver patient’s inflammatory bowel disease with a plant-based diet, researchers found that their liver inflammation was dramatically improved, but they also lost about nine pounds in the first 11 days, thanks to eating healthfully, so it’s hard to tease out the specific effects of the diet on its own. In fact, we have to be careful about rapid weight loss, because all that extra fat being broken down can flood into the bloodstream and sometimes make things worse. So, for individuals with fatty liver disease, losing about three pounds a week might be safer.

    Even though a plant-based diet has yet to be properly put to the test in a randomized clinical trial for fatty liver disease, I would submit that it is still the best diet for this disease, and that isn’t based on a single case report, but on the fact that cardiovascular disease, not liver failure, is the most common cause of death among patients with fatty liver disease. And we do have randomized controlled trials proving that a healthy plant-based diet and lifestyle programs can reverse heart disease and open up arteries without drugs, surgery, or stents. Yes, patients with fatty liver disease and fatty hepatitis “may eventually develop cirrhosis [of the liver], but only if they do not die of cardiovascular diseases first.”

    Doctor’s Note:

    There are some specific foods that may also help. See my videos in the related posts below.

    If excess sugar is so bad, what about fruit? Check out If Fructose Is Bad, What About Fruit? and How Much Fruit Is Too Much?. 



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  • RFK Jr Fails to Convince Users That a Database of People With Autism Would Be 'Protected': 'How Can He Be Trusted?'

    RFK Jr Fails to Convince Users That a Database of People With Autism Would Be 'Protected': 'How Can He Be Trusted?'

    Robert F. Kennedy Jr.’s plan to create a national autism database was met with doubt online as users questioned if those added would have their privacy protected.

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  • Type 2 diabetes – oral medicines: MedlinePlus Medical Encyclopedia

    Type 2 diabetes – oral medicines: MedlinePlus Medical Encyclopedia

    Different oral diabetes medicines work in different ways to help control diabetes:

    • Help the body produce insulin
    • Increase the sensitivity of body tissues to insulin
    • Help with carbohydrate digestion and absorption in the body

    There are eight major classes of oral medicines for diabetes:

    • Biguanides
    • SGLT2 inhibitors
    • Sulfonylureas
    • DPP-4 Inhibitors
    • Thiazolidinediones
    • Alpha-glucosidase inhibitors
    • Meglitinides
    • Bile acid sequestrants

    These medicines may be used alone or in combination.

    BIGUANIDES

    Metformin (Glucophage, Glumetza, Riomet, and Fortamet) is a biguanide. This is often the first oral medicine health care providers prescribe for type 2 diabetes.

    Metformin is a medicine that stops the liver from making glucose. It also makes body tissues more sensitive to insulin.

    This medicine:

    • May help improve cholesterol levels
    • May help people with diabetes lose some weight
    • Has a low risk of low blood sugar

    There are two types of metformin:

    • Immediate-release: Taken 2 to 3 times a day
    • Sustained-release: Taken as a single dose every day, most often with an evening meal

    The most common side effect of metformin is diarrhea. Sometimes people taking metformin will become deficient in vitamin B12. If you have liver or kidney disease, tell your provider. People with liver or kidney disease or who are heavy drinkers should not take metformin.

    SGLT2 INHIBITORS

    SGLT2 inhibitors increase the amount of glucose that goes out in the urine. They may also lead to some weight loss and lower blood pressure in people with diabetes.

    SGLT2 inhibitors include:

    • Canagliflozin (Invokana)
    • Dapagliflozin (Farxiga)
    • Empagliflozin (Jardiance)

    If you have kidney disease, tell your provider before taking these medicines. Side effects include urinary tract infections and yeast infections due to the presence of more sugar in the urine.

    SULFONYLUREAS

    These medicines help the pancreas produce insulin and help the body use glucose (blood sugar) for energy. Sulfonylureas include:

    • Glipizide (Glucotrol)
    • Glyburide (Diabeta, Glynase)
    • Glimepiride (Amaryl)

    Glipizide is taken 30 minutes before a meal. Glyburide and glimepiride are taken with meals.

    In the beginning, your provider will:

    • Start you on a low dose, taken once a day.
    • Increase the dose every 1 to 2 weeks until your blood sugar level comes in range.

    When you take sulfonylureas:

    • Do not skip meals.
    • Limit alcohol (ask your provider how much is safe for you).
    • Always carry candy, juice, or sugar in case your blood sugar gets too low.

    The most common side effect of sulfonylureas is hypoglycemia. Other side effects include weight gain, irritability, stomach upset, and skin rashes.

    Tell your provider if your weight changes or if your blood sugar level is regularly low. Your provider will adjust the dosage of the medicine.

    DPP-4 INHIBITORS

    These medicines help the body release more insulin. They also lower the amount of glucose made by your body. DPP-4 inhibitors help lower blood sugar without causing hypoglycemia.

    DPP-4 inhibitors include:

    • Alogliptin (Nesina)
    • Linagliptin (Tradjenta)
    • Saxagliptin (Onglyza)
    • Sitagliptin (Januvia)

    These medicines are taken once a day. Common side effects are:

    • Muscle pain
    • Stuffy nose
    • Sore throat
    • Respiratory infection
    • Headache
    • Stomach ache

    These medicines can also cause severe joint pain. If you notice joint pain, contact your provider right away.

    THIAZOLIDINEDIONES (GLITAZONES)

    Pioglitazone (Actos) and rosiglitazone (Avandia) are in this group of medicines. They lower insulin resistance by making body tissues more sensitive to insulin. These medicines are taken 1 to 2 times a day with or without meals.

    Side effects include:

    • Weight gain
    • Water retention (edema)
    • Decreased bone density
    • Increased risk of heart failure
    • Increased risk for bladder cancer

    If you have heart disease or liver disease, and are prescribed a thiazolidinedione medicine, ask your provider if it is safe to take it. If you have side effects, stop taking the medicine right away and tell your provider.

    ALPHA-GLUCOSIDASE INHIBITORS

    These medicines delay the digestion of carbohydrates (starches and sugars) in the body. This helps lower blood sugar after a meal. Acarbose (Precose) and miglitol (Glyset) are alpha-glucosidase inhibitors.

    These medicines are taken with the first bite of each meal. Side effects include bloating, flatulence, and diarrhea.

    MEGLITINIDES

    Meglitinides such as repaglinide (Prandin) and nateglinide (Starlix) increase insulin production in the pancreas. Avoid alcohol when you are on these medicines.

    These medicines:

    • Are useful if you don’t eat meals at regular times
    • Can be taken anytime between 30 minutes before a meal up to mealtime

    Side effects can include low blood sugar and stomach upset.

    BILE ACID SEQUESTRANTS

    These medicines lower blood sugar and cholesterol in people with diabetes. Bile acid sequestrants were originally used to treat high LDL (bad) cholesterol. These medicines also help lower blood sugar.

    These medicines are often prescribed for people with type 2 diabetes who also have high cholesterol. They also may be used for people who have liver problems and can’t take other medicines.

    Cholestyramine (Prevalite, Questran) and colesevelam (Welchol) are bile acid sequestrants. Side effects include flatulence and constipation.

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  • A Meditation on Connecting Lands and Stories

    A Meditation on Connecting Lands and Stories

    Yuria Celidwen guides us to connect to the land, awakening gratitude and listening more deeply into the natural spaces around us.

    Many modern Western cultures don’t have a deep understanding of how we connect to the land as a source of collective identity, story, or purpose. There is a sense that, yes, land can be lovely—but it is mainly seen as a source of recreation or extraction, not necessarily as an integral part of what shapes us and future generations.

    In this guided practice, Indigenous scholar and teacher Yuria Celidwen, rooted in Nahua and Maya lineages, introduces a fresh way to consider our connection to the natural spaces around us. This is a practice that invites reverence, gratitude, and belonging, where our experience of the Earth moves from being strictly transactional to being interconnected and relational.

    A Meditation on Connecting Lands and Stories

    Read and practice the guided meditation script below, pausing after each paragraph. Or listen to the audio practice.

    1. If you haven’t done so already, turn off your devices or leave them in a different place from where you will do this practice. Find a place within easy reach where you may feel comfortable. If this place allows you to overlook the landscape, that’s fantastic. If you can sit outside, surrounded by the natural landscape, even better. Wherever you decide to sit, make it easy for you so your practice becomes accessible whenever and wherever in your daily life. 
    2. Let your body rest in a way that helps you stay relaxed but attentive. While you may know that some meditation practices engage in contemplation with eyes closed, in this practice, keep your gaze soft but open, taking in your surroundings with a soft, expansive, panoramic view. 
    3. Pause. Notice where your attention is. Just notice where your mind is wandering. Where is your mind wandering? When is your mind wandering? How is your mind wandering? Just notice. Gather your attention gently. And bring it back to this present place and moment. 
    4. Request permission to enter the lands, offering your gratitude for their welcoming. Open. Breath, anchor, presence. Notice the texture of the lands where you are. What are the smells, fragrances, scents? What are the forms, colors and shades? What are the tones,  resonances, timbres, rhythms? What is their touch, their temperature, their strokes? What are their subtle tastes? Even more subtle memories, imagination? 
    5. Breathe, acknowledge, recognize, welcome. Welcome the lands. Pause. Who are the lands? What are they? Where are they? Pause. The lands are telling stories. They have voices. They sing songs. With the utmost care, as you would to a precious elder or a newborn child, just pause to listen. What are the lands telling you right now? What are they singing about themselves? What is their story about you? 

    Pause to listen, as you would to a precious elder or a newborn child. What are the lands telling you right now? What are they singing about themselves? What is their story about you?

    1. Take a few moments to hold this experience. Embrace our first opening into our shared sacred space, our discovering of an open welcoming of the lands. Offer them your gratitude for that opening, for welcoming you. Take a deep breath and exhale, bowing to the lands. Now let this experience flow. 
    2. Here are a few cues to animate your experience. Feel each of these cues as they rise in your body, heart, mind, memory, imagination, and belonging. Let these inquiries connect you to the world. What emerges? How are the lands connecting with you? What are their languages? How are they arising? And how do you relate and reciprocate?



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  • Worried About Supplements Harming Your Liver? Doc Shares Tips

    Worried About Supplements Harming Your Liver? Doc Shares Tips

    Thinking of adding supplements to your wellness routine but worried about liver damage? It is good to be cautious as mindless supplement intake can harm your organs, but the good news is that you can still enjoy the benefits safely.

    Dr. Karan Rajan, a top U.K. surgeon, warns that this is because all kinds of supplements, even natural ones can affect the way the liver functions, Dr. Rajan explained in an Instagram video to more than 1.7 million viewers.

    Dr. Rajan admits that he is a fan of supplements and even takes a few himself, including omega-3, vitamin D, and fiber. But in response to a video of a woman who developed organ failure after using supplements for hair and nail growth, he offered a clear warning: “Just don’t turn your liver into a science fair project gone wrong.” “If you take supplements and want to avoid liver injury, there are a few things you should know,” he added.

    Know how it affects the liver:

    Before taking any supplement, Dr. Rajan advises checking a trusted source like LiverTox—a database that compiles case reports on how various drugs and supplements impact the liver.

    “If it’s listed under grade A,B or C, be extra cautious about the dose and what you’re taking. Even the natural ones involve liver metabolism, meaning they go through the liver’s biochemical sorting hat and get processed by liver enzymes. This can affect how hard your liver is working,” he said in the video.

    Ensure quality:

    With supplements so easily accessible, it is easy to get swept up by flashy marketing without knowing what you are really getting. That is why Dr. Rajan recommends looking for third-party certification labels on packaging, these indicate that the product has been independently tested for safety, quality, and performance. Although no testing can guarantee 100% protection from liver injury, it can at least help you know what is actually inside the capsule.

    Be mindful of dosage and interactions:

    When it comes to the dosage of supplements, Dr. Rajan emphasizes that more is not always better so it is crucial to stick to clinically recommended amounts.

    “If you’re on prescription medications like statins, blood thinners, anti-epileptics and anti-depressants, check for drug interactions with your pharmacist or doctor before starting any supplement,” he said.

    “If you are taking multiple herbal supplements, make sure there isn’t significant overlap between the active ingredients of each one. You’re creating a pharmacological cocktail with unknown synergy,” he added.



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  • Post-Travel Diarrhea | Yellow Book

    Post-Travel Diarrhea | Yellow Book

    Introduction

    While most travelers will have onset and resolution of diarrhea during their trip, some will present with symptoms after return. Although most cases of travelers’ diarrhea (TD) are acute and self-limited, some people develop persistent (>14 days) gastrointestinal (GI) symptoms. Details on the management of TD during travel are available in the Travelers’ Diarrhea chapter.

    Pathogenesis

    While acute travelers’ diarrhea (i.e., diarrhea lasting less than 2 weeks) is usually self-limited and the etiologies are mostly infectious pathogens (see Travelers’ Diarrhea chapter), the pathogenesis of persistent diarrhea (i.e., diarrhea lasting 2 weeks or longer) in returned travelers generally falls into 1 of the following broad categories: ongoing infection or co-infection with a second organism not targeted by initial therapy; previously undiagnosed GI disease unmasked by the enteric infection; or a post-infectious phenomenon.

    Ongoing infection

    Most cases of TD are the result of bacterial or viral infection and are short-lived and self-limited. In addition to prolonged symptoms of typical pathogens among immunosuppressed persons and sequential infection with different pathogens, ongoing infection with parasites can cause prolonged diarrheal symptoms. Table 10.4.1 lists common bacterial, viral, and protozoal pathogens causing TD.

    Table 10.4.1: Common bacterial, viral, and protozoal pathogens causing travelers’ diarrhea

    Common Bacterial, Viral, and Protozoal Pathogens Causing Travelers’ Diarrhea – Table 10.4.1 – Bacteria
    Bacteria
    Organism Epidemiologic Association Antimicrobial Treatment Options
    Aeromonas spp. Waterborne Fluoroquinolone1

    Third-generation cephalosporin
    Campylobacter spp. Foodborne (poultry, milk), waterborne Azithromycin
    Clostridioides difficile Fecal-oral, surfaces Oral vancomycin Fidaxomicin
    Escherichia coli (ETEC, EAEC, EPEC) Foodborne, waterborne Azithromycin

    Fluoroquinolone1

     
    Escherichia coli

    (EHEC, STEC)

    		 Avoid antimicrobials2
    Plesiomonas spp. Waterborne, contaminated seafood Fluoroquinolone1
    Salmonella, non-typhoidal (see Typhoid and Paratyphoid Fever chapter) Foodborne (poultry, milk products), contact with poultry/reptiles Fluoroquinolone1

    (see note3)

     
    Shigella spp. (Enteroinvasive Escherichia coli) Fecal-oral: close/household contacts, anal-genital/oral/digital contact Azithromycin

    Fluoroquinolone1

    (see note4)

     
    Vibrio spp. Waterborne, contaminated seafood Fluoroquinolone1

    Doxycycline

    Azithromycin
    Yersinia enterocolitica Foodborne (pork) Fluoroquinolone1

    Third-generation cephalosporin5
    Common Bacterial, Viral, and Protozoal Pathogens Causing Travelers’ Diarrhea – Table 10.4.1 – Viruses
    Viruses
    Organism Epidemiologic Association Antimicrobial Treatment Options
    Norovirus (see Norovirus chapter) Fecal-oral, foodborne, waterborne household contacts, facilities/schools/ships No antimicrobial indicated
    Rotavirus Fecal-oral No antimicrobial indicated
    Sapovirus Fecal-oral No antimicrobial indicated
    Common Bacterial, Viral, and Protozoal Pathogens Causing Travelers’ Diarrhea – Table 10.4.1 – Protozoans
    Protozoans
    Organism Epidemiologic Association Antimicrobial Treatment Options
    Cryptosporidium parvum and hominis Recreational water Nitazoxanide
    Cyclospora cayetanensis Foodborne (vegetables, fruits) Trimethoprim-sulfamethoxazole
    Dientamoeba fragilis Fecal-oral Nitroimidazole6

    Paromomycin
    Entamoeba histolytica Foodborne, waterborne, fecal-oral Nitroimidazole6 plus an intraluminal agent7
    Giardia duodenalis Waterborne Nitroimidazole5 Nitazoxanide

    Notes

    Abbreviations: ETEC, enterotoxigenic Escherichia coli; EAEC, enteroaggregative Escherichia coli; EPEC, enteropathogenic Escherichia coli; EHEC, enterohemorrhagic Escherichia coli; STEC, shiga toxin-producing Escherichia coli.

    1Due to its narrower spectrum of activity, ciprofloxacin is slightly preferred over levofloxacin.

    2Given the risk for hemolytic uremic syndrome, for patients with confirmed or suspected EHEC/STEC infection, hospitalization for aggressive fluid management and avoidance of antibiotics are recommended.

    3Given risks of prolonged carriage associated with antibiotic use, antibiotics are recommended only for non-typhoidal Salmonella infection in infants, the elderly (>50 years), the immunocompromised, or those with severe disease.

    4Given emergence of extensively drug-resistant strains, for patients with Shigella infection who have severe disease (e.g., bacteremia, hospitalized) or who are immunocompromised, empiric treatment with a carbapenem is recommended while awaiting results of drug susceptibility testing.

    5Antibiotics are only indicated for moderate to severe illness.

    6Tinidazole is preferred over metronidazole due to lower frequency of dosing and higher efficacy for some organisms.

    7Intraluminal agents include paromomycin, iodoquinol, and diloxanide furoate.

    Bacterial

    While individual bacterial infections rarely cause persistent symptoms, travelers infected with bacteria known to cause mucosal inflammation, such as Campylobacter spp., Shigella spp., or Salmonella spp., as well as diarrheagenic Escherichia coli, can experience persistent diarrhea, including cases where the organism may be resistant against antibiotics commonly used for empiric treatment of TD (see Typhoid and Paratyphoid Fever chapter). A rare cause of post-travel persistent diarrhea is Yersinia spp., a foodborne bacterial infection which can present as a subacute febrile gastroenteritis.

    Clostridioides difficile-associated diarrhea can occur after or during antibiotic use, including malaria chemoprophylaxis. The association between C. difficile and antimicrobial treatment is especially important to consider in patients with persistent TD that seems refractory to multiple courses of empiric antibiotic therapy. The initial workup of persistent TD should always include C. difficile testing. Healthcare professionals can prescribe oral vancomycin, fidaxomicin, or, less optimally, metronidazole, to treat C. difficile. Recurrent cases may be treated with fecal microbiota transplantation, now available by the oral route or as a retention enema. The monoclonal antibody bezlotoxumab is also an option.

    Parasitic

    As a group, parasites are the pathogens most likely to be isolated from patients with persistent diarrhea. Most parasitic infections have a less acute onset of symptoms than those caused by bacteria or viruses, and the probability of a traveler having a parasitic infection increases with increasing duration of symptoms. Parasites might also be the cause of persistent diarrhea in patients already treated for a bacterial pathogen.

    Giardiasis

    Giardia duodenalis is the most likely parasitic pathogen to cause persistent diarrhea. Suspect giardiasis particularly in patients with fatty stools, flatulence, or upper GI-predominant symptoms. When giardiasis is left untreated, symptoms can last for months, even in immunocompetent hosts. Diagnosis can be made by stool polymerase chain reaction (PCR), microscopy, enzyme immunoassay, or immunofluorescence (see Evaluation section below). In the absence of diagnostics (given the high prevalence of Giardia duodenalis as a cause for persistent TD), empiric therapy is a reasonable option in the appropriate clinical setting.

    Amebiasis

    Infection with Entamoeba histolytica, or amebiasis, can result in intestinal symptoms ranging from mild diarrhea to dysentery. Diagnosis can be made by stool PCR, microscopy, or enzyme immunoassay. Microscopy cannot distinguish between the pathogen E. histolytica and some non-pathogenic Entamoeba species such as Entamoeba dispar. Treatment is with metronidazole, followed by an intraluminal agent such as paromomycin or iodoquinol. Antibody testing for E. histolytica should be used for extra-intestinal infection only.

    Cryptosporidiosis

    Cryptosporidium spp. are emerging as common protozoans causing persistent diarrhea in both returning travelers and U.S. residents. Transmitted through contaminated food and water (including recreational water), most infections are asymptomatic or are self-limited. Symptoms may include watery diarrhea, nausea, or abdominal cramping. Disease may be more severe and prolonged in immunocompromised individuals. Diagnosis can be made by stool PCR, microscopy (modified acid-fast stain), immunofluorescence, or enzyme immunoassay. While most immunocompetent individuals recover with oral rehydration alone, in those with persistent symptoms, nitazoxanide may be used.

    Cyclosporiasis

    Cyclospora spp. may cause protozoal infection generally acquired by ingestion of contaminated food. It has been an increasingly recognized cause of persistent diarrhea in both U.S. residents and returning travelers. The oocyst of Cyclospora is resistant to chlorine disinfection. Diagnosis is through stool PCR or microscopy (modified acid-fast stain or wet mount confirmed by ultraviolet autofluorescence). Treatment is with trimethoprim-sulfamethoxazole.

    Cystoisosporosis

    Infection with Cystoisospora belli results in sudden onset of watery diarrhea that is self-resolving, although it may cause persistent diarrhea in immunocompromised individuals. Diagnosis can be made through detection of oocysts by stool microscopy (modified acid-fast stain). Most cases are self-resolving. Trimethoprim-sulfamethoxazole can be used if symptoms persist or if a patient is immunocompromised.

    Dientamoeba fragilis infection

    Dientamoeba fragilis is a protozoan that may be found in stools of both healthy individuals and in persons with abdominal symptoms. While it can be associated with diarrhea in returning travelers, its role as an intestinal pathogen is unclear. Diagnosis can be made by stool PCR or microscopy of permanently stained stool smears. Treatment options, none of which have been assessed in randomized controlled trials, include metronidazole and paromomycin.

    Fungal

    Microsporidiosis

    Microsporidia are a group of fungi that can cause a self-limited watery diarrhea in travelers. In people living with HIV and rarely in immunocompetent persons, microsporidia can cause a chronic diarrhea. The route of transmission is not well known, and foodborne, waterborne, and animal-contact transmission have been reported. Diagnosis can be made by stool PCR or microscopy. Treatment depends on the species and includes albendazole.

    Tropical sprue and brainerd diarrhea

    Persistent TD also has been associated with tropical sprue and Brainerd diarrhea, both of which are believed to be caused by an infectious agent, although their culprit pathogens have yet to be identified. Tropical sprue is associated with deficiencies of vitamins absorbed in the proximal and distal small bowel and most commonly affects long-term travelers to tropical areas, as the name implies. The incidence of tropical sprue appears to have declined dramatically over the past 3 decades. Brainerd diarrhea is a syndrome of acute onset watery diarrhea lasting ≥4 weeks. Symptoms include 10–20 episodes of explosive, watery diarrhea per day, as well as fecal incontinence, abdominal cramping, gas, and fatigue. Nausea, vomiting, and fever are rare.

    Underlying gastrointestinal disease

    Celiac disease

    In some cases, persistent symptoms relate to chronic underlying GI disease or to a susceptibility unmasked by the enteric infection. Most prominent among these is celiac disease, a systemic disease manifesting primarily with small bowel changes. In genetically susceptible people, exposure to antigens found in wheat causes villous atrophy, crypt hyperplasia, and malabsorption. Serologic tests, including tissue transglutaminase antibody testing, support the diagnosis; a small bowel biopsy showing villous atrophy confirms the diagnosis. Patients can be treated with a gluten-free diet.

    Colorectal cancer

    Depending on the clinical setting and age group, healthcare professionals might need to conduct a comprehensive search for other underlying causes of persistent diarrhea. Consider colorectal cancer in the differential diagnosis of patients passing occult or gross blood rectally or in patients with new-onset iron-deficiency anemia.

    Inflammatory bowel disease

    Idiopathic inflammatory bowel disease, including Crohn’s disease, microscopic colitis, and ulcerative colitis, can occur after acute bouts of TD. One prevailing hypothesis is that in genetically susceptible people, an initiating exogenous pathogen changes the microbiota of the gut, thereby triggering inflammatory bowel disease.

    Lactose intolerance

    Lactose intolerance is a syndrome caused by deficiency of lactase. Its prevalence varies across racial and ethnic groups, with the highest in Asian, African, and Native Americans, and increases with age. Symptoms include abdominal pain, flatulence, bloating, nausea, or diarrhea within hours after ingestion of lactose-containing foods.

    Post-infectious phenomena

    In some patients who present with persistent GI symptoms, healthcare professionals will not find a specific cause. After an acute diarrheal infection, patients might experience a temporary enteropathy characterized by villous atrophy, decreased absorptive surface area, and disaccharidase deficiencies, which can lead to osmotic diarrhea, particularly after consuming large amounts of fructose, lactose, sorbitol, or sucrose. Use of antimicrobial medications during the initial days of diarrhea might also lead to alterations in intestinal flora and diarrhea symptoms.

    Occasionally, onset of irritable bowel syndrome (IBS) symptoms occurs after a bout of acute gastroenteritis, known as post-infectious IBS (PI-IBS). PI-IBS symptoms can occur after an episode of gastroenteritis or TD. The clinical workup for microbial pathogens and underlying GI disease in patients with PI-IBS will be negative. Whether using antibiotics to treat acute TD increases or decreases the likelihood of PI-IBS is unknown.

    Small intestinal bacterial overgrowth is characterized by an excess of bacteria in the small intestine and is associated with intestinal motility disorders. Symptoms may include IBS-type symptoms such as abdominal discomfort, persistent diarrhea, or flatulence, and, in some cases, manifestations of nutrient malabsorption. Diagnosis is by carbohydrate breath testing, and treatment is with antibiotics.

    Evaluation

    Traditional methods of microbial diagnosis of diarrheal illness include stool culture, antigen detection using enzyme immunoassays, and microscopy. For detection of bacteria, routine stool culture will identify Campylobacter, Shigella, Salmonella, Aeromonas, and Plesiomonas. Special culture methods are required for Yersinia and Vibrio species. Diagnosis of C. difficile can be made by antigen detection and PCR. Identification of STEC/EHEC (E. coli O157:H7) is by culture and detection of Shiga-like toxin. Giardia and Cryptosporidium can be detected by antigen testing, and examination of serial stool specimens collected over 3 or more days for ova and parasites is appropriate for evaluation of persistent diarrhea when parasites are suspected, including the use of acid-fast staining for Cryptosporidium, Cyclospora, or Cystoisospora. In addition, a D-xylose absorption test can determine whether patients are properly absorbing nutrients. If underlying GI disease is suspected, include serologic testing for celiac disease and consider inflammatory bowel disease during initial evaluation. Subsequently, studies to visualize both the upper and lower GI tracts, with biopsies, might be indicated.

    Diagnostic tests to determine specific microbial etiologies in cases of post-travel diarrhea have advanced in the past number of years. While culture, microscopy, and antigen detection have been the mainstay of diagnostics, PCR-based diagnostics (including as part of multiplex panels, which uses a single stool specimen to detect multiple enteropathogens simultaneously) are becoming increasingly available for detection of bacterial, viral, fungal, and protozoal pathogens. While these assays have high sensitivity and specificity, the clinical utility and economic impact of these diagnostic molecular panels have not been determined fully. In some cases, molecular testing detects colonization rather than infection, potentially making it difficult for healthcare professionals to interpret and apply the results properly. For persistent diarrhea, the use of a protozoa-dedicated multiplex panel would be most appropriate because bacteria and viruses are unlikely causes.

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  • This Common Supplement Could Impact How Your Medicines Work

    This Common Supplement Could Impact How Your Medicines Work

    If you are someone taking a cinnamon supplement for its health perks, you might want to think twice. New research suggests it might be time to go back to getting nutrients from your plate, not a pill. Researchers now found that a compound in cinnamon supplements could interfere with how your body processes medications, something plain old cinnamon in food does not seem to do.

    Cinnamon is an age-old spice that has long been used as a flavoring agent in foods like breakfast cereals, snacks, bagels, teas, and hot chocolate. In recent years, cinnamon supplements have gained popularity among health enthusiasts, praised for their potential anti-inflammatory benefits and blood sugar-lowering effects.

    The latest study, published in the journal Food Chemistry: Molecular Sciences, uncovers a surprising twist for supplement users. Researchers found that cinnamaldehyde, the compound responsible for cinnamon’s distinctive flavor and many of its medicinal properties, can interfere with how the body processes certain medications when taken in concentrated supplement form. This interference could either reduce the effectiveness of common drugs or amplify their side effects, posing unexpected risks for people who rely on regular medications.

    However, adding a dash of cinnamon to your coffee or oatmeal is harmless and might even offer small health perks. But when cinnamon is taken in concentrated supplement form, the story changes.

    The new findings are a reminder that more is not always better, especially for those who turn to supplements as a shortcut for nutrition. “Health concerns could arise if excessive amounts of supplements are consumed without the knowledge of health care provider or prescriber of the medications. Overconsumption of supplements could lead to a rapid clearance of the prescription medicine from the body, and that could result in making the medicine less effective,” Shabana Khan, a principal scientist at the National Center for Natural Products Research in a news release.

    “People who suffer from chronic diseases – like hypertension, diabetes, cancer, arthritis, asthma, obesity, HIV, AIDS or depression – should be cautious when using cinnamon or any other supplements. Our best advice is to talk to a healthcare provider before using any supplements along with the prescription medicine. By definition, supplements are not meant to treat, cure or mitigate any disease,” Khan added.

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  • Natural Neuropathy Relief

    Natural Neuropathy Relief

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