Oral and Perioral Manifestations of the Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome (AIDS)

Background

Acquired Immunodeficiency Syndrome (AIDS) is a disease caused by retroviruses—the Human Immunodeficiency Virus (HIV). It’s mainly characterized by extreme immunosuppression associated with opportunistic infections, malignancies, wasting, and central nervous system (CNS) degeneration. “The Human Immunodeficiency Virus directly infects lymphocytes and, in particular, depresses the number of T-helper (CD4+) cells and reverses the ratio of helper to suppressor (CD8) lymphocytes” (Cawson, Binnie & Eveson, 1988). There are approximately 36.9 million people currently living with HIV/AIDS. Two forms of the virus have been identified: HIV type 1 (HIV-1) and HIV type 2 (HIV-2). HIV-1 is responsible for most of the infections worldwide and HIV-2 is endemic to many countries primarily in West Africa. The morbidity rates of AIDS-related deaths have been on the decline since the 1990’s, largely in part to the continual improvement of drug therapies and education. In fact, it is now considered a chronic illness.

Route of Transmission

There are various possible routes for transmission including sexual transmission, transmission via needles or from mother to fetus/child. HIV can reside in semen and vaginal fluids, and these fluids can transmit the virus onto mucous membranes of another person. Needles, syringes, and other drug injection paraphernalia are common because they increase the risk for blood-to-blood contacts. Blood donations are now screened for the virus, so blood transfusion recipients are no longer at risk. For children infected with HIV, the mode of transmission is most often directly from the mother to the infant. The virus can be transmitted during pregnancy, birth or while breastfeeding. HIV, however, is not spread via saliva or casual contact.

It’s important to consider that a patient infected with HIV is infectious even in the absence of symptoms. Seroconversion is the term used when an infected person’s blood converts from being negative for HIV antibodies to being positive. Seroconversion usually occurs within 1 to 3 months after exposure but can take up to 6 months. The time between infection and seroconversion is called the window period. Consequently, blood collection centers must screen potential donors to identify those with high risk behaviors who are potentially within this particular window period.

The Phases of HIV Progression

There are three distinct phases in the progression of HIV which occur over a 5-14 year period; the primary infection phase, the chronic asymptomatic (latent) phase and the overt phase. The primary phase is an acute illness stage similar to acute mononucleosis. This phase includes signs and symptoms such as fever, fatigue, headache, pharyngitis, night sweats, oral or genital ulcers and gastrointestinal problems. The latent phase is characterized by a period in which there are few signs or symptoms of the illness. Some patients may present with swollen or sore lymph nodes in two or more locations, not including the groin. The length of the latent phase is averaged at ~10 years. Patients who have entered the overt phase develop AIDS and the risk for opportunistic infections increase significantly.

Manifestations and Features of HIV/AIDS

Other manifestations include, but are not limited to rapidly progressive periodontitis, Addisonian pigmentation, angular cheilitis, herpes simplex or zoster, parotitis, myobacterial ulcers, facial palsy, trigeminal neuropathy and major aphthae.

Treatment

Candidosis: The Centers for Disease Control and Prevention has published guidelines for treatment of oropharyngeal candidosis (OPC) in patient with HIV (December 2004). Their guidelines are divided by age group; adults and adolescents vs. children and infants.

Recommended treatment of OPC in adults and adolescents:

Fluconazole 100 mg PO QD for 7-14 days
Itaconazole oral solution 200 mg PO QD for 7-14 days
Clotrimazole troches 10 mg PO 5x/d for 7-14 days
Nystatin suspension 4-6 mL QID or 1-2 flavored pastilles PO 4-5x/d for 7-14 days
Itraconazole oral solution 200 mg (or more) PO QD
Amphotericin B deoxycholate 0.3 mg/kg IV QD

Recommended treatment of OPC in children and infants:

Fluconazole 3-6 mg/kg body weight (max 400 mg/dose) PO for 7-14 days
Itraconazole cyclodextrin oral solution 2.5 mg/kg body weight (max 200-400 mg/d) for 7-14 days)
Clotrimazole troches 10 mg PO QID for 14 days
Nystatin suspension 4-6 mL PO QID or 1-2 flavored pastilles PO 4-5x/day for 7-14 days
Itraconazole cyclodextrin oral solution 2.5 mg/kg body weight PO BID (max 200-400 mg/day) for 7-14 days
Amphotericin B oral suspension 1 mL (100 mg/mL) PO QID for 14 days or less

Hairy Leukoplakia: There are both local and systemic treatment options for Oral Hairy Leukoplakia (OHL). Local treatments often include the use of topical podophyllum resin (POD) and/or surgery. POD is made from different plants such as American mandrake and Indian apple. POD must be used with caution to limit toxicity. Large amounts of POD may result in serious system adverse effects and fatalities (Baccaglini et al., 2007). Topical treatment is ideal for small, contained lesions and is impractical for very large lesions. Systemic antiviral treatments may include antivirals such as desciclovir, valacyclovir and acyclovir but recent studies show that they are not as effective as local treatments with topical drug application and/or surgical removal of the lesion.

Osteomyelitis of the Jaw: Osteomyelitis is most commonly affects the mandible compared to the maxilla. Treatment is dependent on various factors such as which stage in the Cierny-Mader Classification system it’s in, which pathogen is involved and what other comorbidities the patient may have. Treatment may involve sequestrectomy (removal of dead bone that is separated from the rest of the jaw), hyperbaric oxygen therapy, resection and reconstruction of the jaw, drainage of the infection, specific antibiotic prescription based on pathogen cultured, and debridement of the area.

Ulcerative Gingivitis: Treatment for ulcerative gingivitis includes debridement, antiseptic mouth rinse such as chlorhexidine or hydrogen peroxide, improved hygiene and antibiotics. Treatment should be divided into 4 stages:

Stage 1: Stop the disease process and control patient discomfort and pain
Stage 2: Treat the preexisting chronic gingivitis through professional prophylaxis and/or scaling and root planning
Stage 3: Corrective treatment of disease sequelae with procedures such as gingivoplasty and/or gigivectomy
Stage 4: Maintenance through compliance with oral hygiene practices and controlling predisposing factors

References

Baccaglini et al. (2007). Management of oral lesions in HIV-positive patients. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontology, v.103, S50.e1-S50.e23. https://doi.org/10.1016/j.tripleo.2006.11.002

Campbell-Yesufu, O. T., & Gandhi, R. T. (2011). Update on human immunodeficiency virus (HIV)-2 infection. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 52(6), 780–787. https://doi.org/10.1093/cid/ciq248

Cawson, R., Bonnie, W. & Eveson, J. (1994). Color atlas of oral disease: Clinical and pathological correlations. Wolfe Publishing.

Hanley M., Hendriksen,S. & Cooper, J. (2020). Hyperbaric treatment of chronic refractory osteomyelitis. Treasure Island (FL): StatPearls Publishing. PMID: 28613536

Malek,R., Gharibi, A., Khlil, N. & Kissa, J. (2017). Necrotizing ulcerative gingivitis. Contemporary Clinical Dentistry, 8(3), 496-500. https://doi.org/10.4103/ccd.ccd_1181_16

Genetic Disorders: Wilson’s Disease

Medicine and Health

Introduction

Wilson’s disease (WD) is an uncommon autosomal recessive inherited disorder that is characterized by a copper imbalance in the body. Although copper is essential for the survival of living organisms, an excessive cellular copper load can lead to functional failure or death of the cell. WD impedes the normal biliary excretion of copper leading to itsaccumulation in various organs (Merle et al. 2007). Copper-transporting P-type ATPase (ATP7B) in hepatocytes transport copper from intracellular chaperone proteins to their designated secretory pathway. ATP7B is encoded by the WD gene, MIM 277900, hence its mutation results in a WD diagnosis (Ferenci, 2005). The accumulation of copper in organs such as the liver and brain results in the development of hepatic diseases such as liver cirrhosis and neuropsychological degeneration. The estimated frequency of WD is about 17 per million which translates to a carrier frequency of 1 in 122 (Lorincz, 2010).

Disease Inheritance

A study was conducted in the United Kingdom (2013) in an attempt to identify the rate of mutations in the WD gene ATP7B. 181 individuals with a confirmed WD diagnosis underwent genetic testing to determine the potential of non-ATP7B gene mutation causing the disease. According to the study, 116 different ATP7B mutations were identified and the overall chance of a mutation in a gene other than ATP7B causing a WD phenotype is very low due to the detection frequency of the specific mutation being 98% (Coffey et al, 2013). The study supplied strong confirmation for monogenic inheritance of WD, where traits for the disease are determined by single gene or allele expression and highlighted the need to consider rare genetic occurrences in clinical practice such as the presence of three mutations of the ATP7B gene or uniparental disomy.

Clinical Manifestations:

Patients with WD most commonly present with hepatic and neuropsychiatric symptoms. Considering clinical manifestations peak at around seventeen years of age, children often present asymptomatically. This means that accurate diagnosis is more difficult in children than in adults. Signs and symptoms of WD can be categorized into four categories: hepatic, neurologic, psychiatric and other. Hepatic symptoms include, but are not limited to, liver cirrhosis, active hepatitis with fibrosis andabnormal results on a liver function test. Neurologic and psychiatric symptoms include, but are not limited to, tremor, ataxia, dystonia, dysarthria epilepsy, cognitive impairment, dysphagia, mood and/or personality disorders, choreoathetosis, hallucinations and delusions (Loudianos et al, 2014). The most common symptoms relating to the eyes include Kayser-Fleischer ring and Sunflower cataracts, relating to fertility include infertility and amenorrhea, relating to the kidneys include tubular dysfunction, relating to the heart include cardiomyopathy and arrhythmias and relating to other organs include gallstones and endocrine disturbances (Loudianos et al, 2014).

Kayser-Fleischer rings are considered the hallmark of WD and are present in 95% of patients that present with neurological manifestations (Rodriguez-Castro et al, 2015). Dysarthria is present in relatively 85-97% of individuals with Wilson’s disease and is characterized as weakness, paralysis or damage to/in the muscles used for speech (Lorincz, 2010). WD tremors are also common and may be difficult to differentiate from essential tremors which can involve the arms, legs and head. Considering essential tremors often involve voice and symmetry, differentiating them from WD tremors can be easier when looking for asymmetric tremors in the extremities and voice tremors (Lorincz, 2010). Face of the panda is commonly found in midbrain MRI images of patients with WD which is due to a loss of intensity in the center of the midbrain. Liver disease is not as easily linked to WD as neurological manifestations. Manifestations of WD in the liver range from isolated biochemical abnormalities with no accompanying symptoms to cirrhosis of the liver. According to the European Association for the Study of the Liver (2012), Hepatic manifestations have an earlier onset than other types of symptoms and can precede neurological symptoms by as much as 10 years.

Diagnosis:

There are many ways in which a WD diagnosis can be made. Providers look for common manifestations—such as the ones presented above—and may perform diagnostic tests. Common diagnostic tests include serum ceruloplasmin, serum-free copper, 24-hour urinary copper, hepatic copper and slit lamp examination of Kayser-Fleischer rings (Bandmann et al, 2015).Ceruloplasmin carries copper in the blood and its levels are below the normal range in patients with active or neurological WD. The combination of liver disease and a decrease in ceruloplasmin levels in the blood may cause serum-free copper levels to rise. For this reason, the concentration of serum-free copper may be used as a diagnostic tool for WD (Bandmann et al, 2015). Urinalysis is perhaps the easiest of all tests to perform and it analyzes the quantity of copper excreted in a 24-hour period. Elevated levels, especially in patients without cholestatic liver disease, is an indication of WD.

Unfortunately, due to the potential for false positives, the diagnostic tests used for a WD diagnosis are not reliable in isolation. For example, low ceruloplasmin levels may indicate a WD diagnosis but may also present as a consequence of an alternate condition such as malabsorption (Lorincz, 2010). For these reasons, one test alone is unable to provide sufficient evidence to confidently diagnose WD. As a result, most providers use an amalgam of tests, signs and symptoms in the diagnostic workup process and consider the possibility of false positives. A less common, yet more accurate, type of diagnostic test is genetic testing. In the past, direct genetic testing for ATP7B was restricted due to the low detection of mutation and extended processing time (Bandmann et al, 2015). The advancement of technology has allowed for the reduction of both the turnaround time and the cost of genetic investigations making it highly likely for this type of testing to play a more critical role in the confirmation of a WD diagnosis in the future.

Disease Treatment and Management:

Early treatment (prior to symptom manifestations) can prevent liver and neurological deterioration as well as increase the life expectancy of an individual suffering from WD (Rodriguez-Castro et al, 2015). If treatment compliance is adequate, the prognosis of a WD diagnosis is highly favorable compared to the natural course of the disease which is characterized by an implacable deterioration of both neurological organs and the liver. Therefore, the main goals of treatment are to prevent the onset of symptoms and clinical deterioration. In severe cases, such as with acute-chronic liver failure or end-stage liver disease, treatment can be lifesaving and often involves a liver transplant.

Asymptomatic patients are treated with zinc salts and chelators at a lower dosage than symptomatic patients. Chelators such as penicillamine, trientine or tetrathiomolybdate remove excess copper in the body and zinc salts prevent the absorption of copper in the intestines (Rodriguez-Castro et al, 2015). Due to the rare nature of WD, current pharmacological studies and clinical trials have not been performed on drugs used to treat the disease. As a result, most of the current drugs available to treat WD have not been adequately tested for their effectiveness and potential adverse effects, and they lack registered clinical trials, research projects or networks.

A multitude of drugs are available and used to treat WD. As mentioned, D-penicillamine, trientine, tetrathiomolybdate and dimercaprol are common chelators used to rid the body of excess copper, and zinc salts block intestinal absorption of copper. D-penicillamine and trientine both promote the excretion of copper through urine and their absorption is maximized when administered one to three hours prior to meals (Ferenci, 2005). Tetrathiomolybdate is a decoppering agent that prevents the absorption of copper in the GI tract (similar to zinc) and makes copper in circulation unavailable for uptake. Zinc increases metallothionein action in the gastrointestinal tract. Metallothionein is more sensitive to copper than it is to zinc; as a result, zinc increases the binding of copper to metallothionein and prevents its entrance into circulation (Ferenci, 2005).

The most important factor in determining the prognosis of a WD diagnosis is the time frame for onset of symptom manifestation. Patients with hepatic symptoms have earlier onset of symptoms and a faster diagnosis compared to patients that present with neuropsychiatric symptoms (Merle et al, 2007). In diagnosing asymptomatic or younger patients, family screening has shown evidence of being highly effective in early diagnosis—roughly 4 years sooner and a good long-term outcome. In addition to the onset of symptom manifestation, positive prognosis is dependent on patient access and compliance to treatment (Merle et al, 2007).

References

Bandmann, O., Weiss, K. H. & Kaler, S. G. (2015). Wilson’s disease and other neurological

copper disorders. The Lancet Neurology, vol. 14(1): 103-113. https://doi.org/10.1016/S1474-4422(14)70190-5

Coffey, A. J., Durkie, M., Hague, S., McLay, K., Emmerson, J., Lo, C., Klaffke, S., Joyce, C. J.,

Dhawan, A., Hadzic, N., Mieli-Vergani, G., Kirk, R., Allen, E., Nicholl, D., Wong, S.,

Griffiths, W., Smithson, A., Griffin, N., Taha, A., Connolly, S., Gillett, G. T., Tanner, S.,

Bonham, J., Sharrack, B., Palotie, A., Rattray, M., Dalton, A. & Bandmann, O. (2013). A genetic study of

Wilson’s disease in the United Kingdom. Brain, vol. 136(5): 1476-1478. https://doi.org/10.1093/brain/awt035

European Association for the Study of the Liver. (2012). EASL clinical practice guidelines:

Wilson’s disease. Journal of Hepatology, vol. 56(3): 671-685. https://doi.org/10.1016/j.jhep.2011.11.007

Ferenci, P. (2005). Wilson’s disease. Clinical Gastroenterology and Hepatology, vol. 3 (8): 726-

733. https://doi.org/10.1016/S1542-3565(05)00484-2

Lorincz, M. T. (2010). Neurologic Wilson’s disease. New York Academy of Sciences, vol.1184(1):

173-187. https://doi.org/10.1111/j.1749-6632.2009.05109.x

Loudianos, G., Lepori, M. B., Mameli, E., Dessi, V. & Zappu, A. (2014). Wilson’s Disease. Prilozi

(Makedonska akademija na naukite i umetnostite. Oddelenie za medicinski

nauki), vol.35(1), 93–98.

Merle, U., Schaefer, M., Ferenci, P. & Stremmel, W. (2007). Clinical presentation, diagnosis and

long-term outcome of Wilson’s disease: A cohort study. Gut, vol. 56(1): 115-120.

https://doi.org/10.1136/gut.2005.087262

Rodriguez-Castro, K. I., Hevia-Urrutia, F. J. & Sturniolo, G. C. (2015). Wilson’s disease: A review

of what we have learned. World Journal of Hepatology, vol. 7(29): 2859-2870.

https://doi.org/10.4254/wjh.v7.i29.2859

Kyphoplasty

Medicine and Health

As I’ve mentioned before, I am currently working as a medical assistant in pain management. It’s now been almost a month that I started my new job and I love it! I get to work alongside the best pain management doctors in my area and have learned so much in a short amount of time. Last week, I had the privilege of shadowing several Epidural Steroid procedures as well as a Kyphoplasty procedure. It was the coolest thing I’ve seen since tori removal back in my oral surgery days. If you don’t know what a Kyphoplasty is, keep reading because this post is all about it!

What’s a Kyphoplasty?

A Kyphoplasty is a procedure performed to correct vertebral compression fractures (VCF) through the use of polymethylmethacrylate (PMMA) aka bone cement. The leading cause of VCFs is osteoporosis (Cooper et al, 1992), but falling or high risk activities like lifting heavy weights could also lead to a fracture. Due to the nature of the fracture, VCFs can be very painful; the vertebral body collapses causing the patient to lose height in their spine. During the procedure, a hollow needle is inserted into the body of the vertebra through the pedicle. An inflatable balloon is then placed inside, inflated to restore the vertebral height and to create a working channel for the cement to flow into. The entire procedure is guided through a fluoroscope and contrast medium.

Why a Kyphoplasty?

Other treatment options for patients with painful VCFs include non-surgical management (NSM) and a Vertebroplasty procedure. A Vertebroplasty is very similar to a Kyphoplasty. The primary difference is that a balloon is not used to create a working space for the cement to flow into and the cement used tends to have a lower viscosity. Both of these factors increase the most pertinent risk associated with the procedure: bone cement extravasating into the epidural space. Without a working space, the physician doesn’t have as much control of where the cement is flowing into. Also, bone cement viscosity is identified as a decisive guideline influencing leakage in a Vertebroplasty, so using a cement with a higher viscosity reduces the risk of extravasation (Giannitsios et al, 2005). In fact, the incidence of leakage during a Vertebroplasty ranges between 2-67% compared to 0-13.5% for a Kyphoplasty (Denaro et al, 2009). Other risks to consider include heart attack, cardiac arrest and stroke. In addition to surgical procedures, there are also NSM options for patients with VCFs. These include bed rest, pain relief medication and back bracing. Compared to patients who undergo a Kyphoplasty procedure, patients following a NSM treatment plan for VCFs experience less pain relief and improvement (Meirhaeghe, 2013). For these reasons, if a non-surgical treatment is insufficient, a Kyphoplasty is often the preferred treatment option for VCFs.

What are the main indications for the procedure?

Patients with Osteoporosis
Patients experiencing intense pain adjacent to the level of the fracture
Patients diagnosed with a fracture by an MRI, CT or X-Ray
Patients who failed non-surgical management for at least 4 weeks
Patients with lesion causing benign and metastatic tumors

Which patients are not candidates for the procedure?

Patients who did not fail non-surgical management for at least 4 weeks
Patients with asymptomatic vertebral compression fractures
Patients with allergies to materials used in the procedure such as PMMA or barium contrast
Patients with bleeding disorders that are unmanageable

How is the procedure performed?

The patient is placed on the table, face down with a gown open to the back. The patient’s skin where the needle will be inserted is prepped with an antiseptic solution. Most patients are sedated for comfort and since the procedure is minimally invasive, local anesthetic is primarily used.
The provider starts by inserting a bone access needle into the area affected to determine the trajectory of the working cannula. Once it’s confirmed through the fluoroscope that the access needle is at the correct location (on pedicle of vertebra), a bone drill is used to create a pathway through the pedicle into the vertebral body.
Once the pathway is created, a curved-tip osteotome is inserted into the vertebral body and manually curved/directed towards the fracture.
The balloon is inserted through the hollow needle and inflated to compact the soft porous bone inside of the vertebral body. Doing this not only restores the natural height of the vertebra but also creates a working channel for the cement to flow into. This decreases the chances of the cement flowing to places it shouldn’t flow into and gives the doctor more control of the cement’s trajectory. A contrast is used to visualize the inflation of the balloon and its location through the fluoroscope.
Finally, the balloon can be removed and cement is injected into the working channel under pressure using a special cement filler cannula. The pressure and quantity of cement being injected is strictly controlled to prevent leakage. The needle is removed slowly and carefully, ensuring the cement is not following the needle forming a “tail.” This is done by waiting for the cement to slightly harden and monitoring its progress through the fluoroscope.
The needle is removed and the incision is closed with either steri-strips or skin glue. Once the remaining cement on the table hardens, the patient is ready to be moved to the recovery room.

Pictures from the procedure I shadowed:

Works Cited

Giannitsios, D., Ferguson, S., Heini, P., Baroud, G. & Steffen, T. (2005). “High cement viscosity reduces leakage risk in vertebroplasty”. European Cells & Mat 10, Poster No. 314. http://www.ors.org/Transactions/5thCombinedMeeting/0314.pdf

McCall, T., Cole, C., Dailey, A. (2008). “Vertebroplasty and kyphoplasty: A comparative review of efficacy and adverse events.” Current Reviews in Musculoskeletal Medicine, Vol. 1: 17-23, doi: 10.1007/s12178-007-9013-0. https://link.springer.com/article/10.1007/s12178-007-9013-0

Meirhaeghe, J., Leonard, B., Steven, B., Jonas, R. & John, T. (2013). A randomized trial of balloon kyphoplasty and nonsurgical management for treating acute vertebral compression fractures. Spine, Vol. 38(12): 971-983, doi: 10.1097/BRS.0b013e31828e8e22. https://pubmed.ncbi.nlm.nih.gov/23446769/

Denaro, V., Longo, U., Nicola, M. & Denaro, L. (2009). Vertebroplasty and kyphoplasty. Clinical Cases in Mineral And Bone Metabolism: The Official Journal of the Italian Society of Osteoporosis, Mineral Metabolism, and Skeletal Diseases, Vol. 6(2): 125-130. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2781232/

Disparities in Health

Medicine and Health

The United States is known for having one of the most expensive and worst health care systems in the world.17.2% of our GDP is directed to health expenditures, compared to only 9.7% in the U.K, 10.9% in Japan, and 11.3% in Germany. Not only do we spend outrageously more than any other country, we don’t have a better system to show for it. Our death rate per 100,000 children aged 1-19 is 259 compared to 170 in the U.K, 147 in Japan and 166 in Germany. Even though we are one of the richest countries in the world, our people have one of the shortest life expectancies of any industrialized nation. Why in the world do we still have millions of Americans that don’t have access to basic preventative services and why do we pay so much?

The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health related societies to ladders. In this relationship, the rungs of the ladder are equivalent to the resources available for individuals in that “step” to live a healthy, secure, and prosperous life. This means that the individuals at the top of the ladder are the ones who possess college degrees, respected careers, and are financially prosperous. The individuals at the bottom of the ladder are not as privileged. They aren’t as educated, have lower income or unstable employment, and aren’t financially comfortable. Socioeconomic status contributes to disparities in health in that an individual’s place on the ladder directly affects how healthy they are or will be in their lifetime. For example, the risk of dying prematurely is 3 times greater for low socioeconomic individuals who fall on the lower rungs of the social ladder. When considering people in the middle, they are still 2 times as likely to die prematurely than the individuals at the top of the ladder. In addition to life expectancy, individuals at the bottom of the ladder are more likely to suffer from hypertension, obesity, diabetes, heart disease, HIV/AIDS, mental illness, and experience newborn health complications such as low birth weight, premature birth and birth defects.

The power that social status has over health and the quality of life we live is colossal and pervasive.

Individual Behavior vs. Genetics

There is a reason providers review family history with patients: genetics plays a role in the health of an individual, but behavior also largely contributes to health status. This doesn’t necessarily mean that the responsibility of health falls on the individual at 100%. The lower they are on the social ladder, the harder it is for them to practice healthy behaviors. An individual’s environment has the ability to expand or constrain the options and habits that improve health and prevent chronic diseases. For example, lower socioeconomic communities have fewer (or sometimes lack) fresh produce supermarkets, recreational facilities, libraries, and safety but have more liquor stores, fast food restaurants, and drug trafficking. to accompany this environment, stress levels are high in individuals who live in such communities. Stress directly impacts physical health, but also leads to individuals partaking in destructive behaviors such as smoking, abusing alcohol and consuming high levels of sugar and fat.

Social Determinants of Health by the Henry J Kaiser Family Foundation

Clearly, the relationship between behavior and the ladder isn’t as easy as scaling will-power. The issue with our medical model today is that many physicians look at patients and their diseases through only the biomedical model of health. Social and psychological factors are rarely accounted for. Appointment slots are 15-minutes for most practices and providers who feel compelled to do more simply don’t have the time. We can’t look at an obese patient and think “they have no moral fortitude and are lazy!” Alternately, we need to consider the patient’s position on the ladder to better understand their behaviors and properly formulate a treatment plan. Individuals on the bottom rungs of the ladder face environmental and social conditions that induce unhealthy behaviors. They are exposed heavier cigarette and alcohol marketing, they live with chronic high levels of stress, don’t have the same access to healthy food options due to location and price and have fewer educational and job opportunities. Motivational interviewing is new technique recommended for providers to help their patients practice healthier behaviors, but that discussion will have to be for another day.

Minorities and Health

The inequalities in health status shared among minorities in the United States is shocking. Not only are minorities more likely to be at the bottom of the social ladder, they have a much higher risk of developing various diseases compared to non-minorities in the same position on the ladder. Racial health disparities are due (mostly) to an unjust distribution of socioeconomic resources and not genetics. Minorities are more likely to live at or below 200% of the Federal Poverty Line, be less educated, and live in low socioeconomic communities. These are a few of many social factors that determine the health of an individual. Instead of being considered separate entities, they are a reflection of one another. Low education leads to low paying jobs. Low paying jobs leads to living in low-income communities. Low-income communities lack social resources (recreational facilities, libraries, fresh produce supermarkets) and have high crime rates. This environment influences health damaging behaviors like smoking, drinking alcohol, and abusing recreational drugs. Although Medicaid is available to low-income individuals, people who have a job and make more than the limit, don’t qualify for Medicaid but also can’t afford private insurance. This lands them in the insurance gap position, with little to no access to preventative services. This means they seek health care services when they are very ill or in life threatening situations.

In 2016, 40% of people living in the United States were people of color. By 2050, that number is projected to increase to over half of the population. Given that people of color make a disproportionate share of the low-income and the uninsured relative to their size in the population, addressing health care disparities is extremely important. Disparities not only affect the groups directly suffering, but also hinders improvement in the quality of care and health for the broader population and leads to unnecessary costs.

Why Address Inequality in Health and How to Do It

Not only are we improving individual health, we are decreasing health care expenditures because healthy people require less medical services. Pinpointing the underlying determinants of disease and successfully addressing it is the first step in reducing health care expenditures. The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health identified two policies that are required to reduce premature death and eliminate the increase in disparities as you move down the social ladder:

Policies that affect the length of the ladder and the distance between it’s rungs.
Policies that buffer the damaging conditions of living below the top rungs.

Changing the Ladder

To alter the length of the social ladder in the United States, we need to advocate for policies that improve access to quality education and impact income distribution. There is no reason for a qualified student to not attend college in the United States of America because of financial barriers. Also, public education should be of high and equivalent quality throughout all K-12 levels. In terms of income and wealth distribution, we need policies that increase saving incentives in family households and offer opportunities for job training and community colleges to lower socioeconomic individuals.

Limiting Consequences

To ameliorate the risks linked to an individual’s socioeconomic status, we need policies that improve the environment and limit bad behaviors. Such policies should reduce violence and crime, increase affordable housing, improve access to drug and alcohol abuse programs as well as smoking cessation programs, increase taxes on cigarettes, fast food and alcohol, make school lunches more nutritional, and support green markets and fresh produce grocery stores. These are some examples of many policies that would improve the quality of life that individuals on the bottom of the ladder live.

What You Can Do to Help

You don’t have to start a non-profit or get into politics. Although those are great things to do, you can help in many other ways. Here are five things you can do right now, regardless of your financial situation, to help bring health care access to people in your community.

Become a mentor to a minority student at your local high school. Help them find their passion and motivate them to pursue a higher education. Educate them on requirements to get into college and how to finance the costs.
Create a book drive to provide a mini public library to a neighborhood in your area that doesn’t have one. Books can be donated to the local school or could be handed out to students at an event.
Volunteer your skills. If you are a nutritionist or maybe a personal trainer, consider offering free services on the weekend to people in your community who need it most. Educate them on how to make better food choices and teach them exercises they can do at home.
Donate to smoking cessation or alcohol abuse programs in your community.
Help a neighbor plant a garden. Motivate your peers to eat healthier and make better health choices.

Remember: a little goes a long way. Just because you don’t see the results of your efforts immediately, doesn’t mean you aren’t making a difference! Keep pushing towards a better future for our generation and the next.

Works Cited

Orgera, K., Artiga, S. (2018). Disparities in Health and Health Care: Five Key Questions and Answers. 2020 Kaiser Family Foundation.

Adler, N., Stewart, J. (2010). Reaching for a Healthier Life: Facts on Socioeconomic Status and Health in the U.S. The John D. and Catherine T. MacArthur Foundation Research Network on Socioeconomic Status and Health.

Fiscella, K., Williams, D. (2004). Health Disparities Based on Socioeconomic Inequities: Implications for Urban Health Care. Academic Medicine, Vol 79, No. 12.

Pampel, F., Krueger, P., Denny, J. (2010). Socioeconomic Disparities in Health Behaviors. National Institute of Health Annual Review Social, 36: 349-370, doi: 10.1146.

Cohen, S., Janicki-Deverts, D., Chen, E., Matthews, K. (2010). Childhood Socioeconomic Status and Adult Health. Annals of the New York Academy of Sciences: The Biology of Disadvantage, doi: 10.1111.

The Basics of an Anti-Inflammatory Diet

Medicine and Health

The Basics:

In an over simplified definition of inflammation, you could say it is your body’s way of fighting off something that could potentially harm it. Inflammation is actually necessary for you to have a healthful life. When you cut your finger or scrape your knee, your body turns on its acute inflammation response to heal the area. The same idea can be translated into your diet. Every meal you eat triggers inflammation in your gut. This isn’t necessarily a bad thing. When you eat a meal, although you are (hopefully) taking in lots of good nutrients, you are also consuming bacteria. Your body is responsible for taking in all of the good stuff you feed it, fighting off the bacteria and discarding the bad stuff. In a recent study, scientists have discovered that the efficiency of your immune system and metabolism is highly dependent on the ratio of nutrients and bacteria that you are eating. The less nutrients you consume, the harder it is for your body to fight off bad bacteria in your gut and you’re stuck in a constant state of inflammation.

Unfortunately, due to the nature of industrial agriculture today, we are seeing a steady decline in the nutritional value of the foods we eat. Our soil is poisoned with chemicals used to improve plant growth and kill certain organisms that harm it. The bad news is that these chemicals tend to remain in the soil for long periods of time, killing communities of organisms in the soil that are beneficial to us and the quality of the food we eat. The food we eat today, even the organic ones, are less nutritious than the food our parents and grandparents ate. You can imagine how hard it can be to consume the right ratio of nutrients to ensure our body is not in a constant state of alert.

This leads me to my next point: what effects does chronic inflammation have on our bodies? The human body is very smart. It learns to adjust and adapt for survival. When your body goes from an acute state of inflammation to a chronic one, it knows that it needs to make adjustments to keep going. These adjustments can lead to acute, as well as chronic, diseases.

Some Diseases Linked to Chronic Inflammation:

• Obesity
• Type 2 Diabetes
• Hypertension
• Rheumatoid Arthritis
• Crohn’s Disease
• Pancreatitis
• Some cancers
• Fatty liver
• Metabolic syndrome
• Heart disease

Some Symptoms of Chronic Inflammation:

• Fatigue
• Body aches
• Depression
• Anxiety
• Frequent infections
• Weight gain/loss
• Insomnia
• GI complications (diarrhea, acid reflux, constipation)

Although not all inflammation is related to diet, following a healthful anti-inflammatory diet is a great way to decrease symptoms associated with chronic inflammation. After all, your gut and your immune system are closely related. Your gut health is the captain leading the direction of your overall health. I recently purchased an amazing book which I will recommend in the books section of my blog this week. It has tasteful anti-inflammatory recipes and includes a lot of great information for beginners.

Now, let’s get to the point

Foods that Worsen Inflammation:

1. Processed and Red Meat

Ideally, you want to decrease your meat consumption. If you want to savor meat here and there, make sure you are buying organic, grass-fed meat. The quality of the meat you eat is very important. Skip out on the processed options. A good brand to look into is Nature’s Rancher.

2. Sugar

For decades we have been blaming fat for obesity. The real threat has always been sugar! We need good fats for our brain to function properly. Ditch sugar (even brown sugar) or any form of sugar substitute like Aspartame, Saccharin, Sucralose, and for the love of everything that is good in this world STAY AWAY FROM HIGH FRUCTOSE CORN SYRUP! Consider sweetening your coffee with honey.

3. Processed Foods

This one is the hardest. In reality, the options of foods you can eat is a lot greater than what you can’t eat. The issue is that every supermarket you walk into is selling primarily processed foods. You probably have been eating processed foods your entire life. A good way to know if what you’re buying is processed or not is to check the label. If the ingredients list is full of junk that you can’t even pronounce, drop it! Also, try to buy foods that aren’t pre-packaged and full of sodium, saturated fats and added sugars.

4. Refined Grains

This is the stuff we all hold so close to our hearts and have a hard time letting go of. Some examples of refined grains are white rice, flour, white bread, pasta, cookies, and cereal. These grains are modified from their natural form. They are literally stripped of all of their vitamins, fiber, and pretty much anything that is good for you. A delicious substitute for pasta is lentil pasta and for rice is quinoa.

5. Dairy

Cutting dairy out of my life has changed me in ways I can’t even begin to describe. Dairy is a huge food allergen and it’s no surprise that a lot of people are considering alternatives. There is a common misconception that drinking milk leads to having strong bones. A 1997 study that investigated the effects of milk on bone strength discovered that drinking milk actually has the opposite effect than what is considered popular belief today. In fact, the women in the study that drank 2 glasses of milk per day for 12 years, had a 50% higher chance of suffering from a bone fracture compared to the women who consumed 1 glass or less of milk per week. Don’t panic if you love milk, yogurt, cheese, and butter. There are various delicious vegan substitutes for dairy products. Some of my favorite alternatives include Violife cheese, Califia Farms butter and almond milk, and Forager yogurt.

6. Plant-Based Oils

Some oils to avoid include corn, sunflower and soy oils. These oils contain very high levels of pro-inflammatory omega-6s. Coconut oil is a good substitute but it is high in saturated fats, so you should consume it with moderation. The best substitute is olive oil.

Foods that Fight Inflammation:

1. Fruits and Vegetables

When buying fruits and vegetables, keep the Environmental Working Group’s (EWG) Dirty Dozen and Clean Fifteen guidelines in mind. Try to buy organic if you can. If you have to chose which produce to buy organic, follow the list. Specifically, berries, watermelon, apples, and pineapple have high levels of phytonutrients making them strong anti-inflammatory options. Try to consume fruits that have high-antioxidant vitamin C such as citrus fruits. Also, season your dishes with garlic and onions because they are beneficial to your immune system.

2. Whole Grains

Examples include quinoa, brown rice, popcorn, oatmeal, amaranth, millet, buckwheat and teff. These grains are rich in fiber, micronutrients, protein and antioxidants. Don’t be fooled, they are also flavorful!

3. Omega-3 Fatty Acids

Dorothy Calimeris, RDN calls these “All Star Anti-Inflammatoriy Agents” in her book The Complete Anti-Inflammatory Diet for Beginners. Foods that contain this type of unsaturated fat include salmon, sardines, walnuts, pine nuts, and seeds like hemp, chia & flax.

4. Pre/Probiotics

These kinds of foods are good for your digestive and immune health. Examples include pickles and sauerkraut. They are abundant in good gut bacteria. These are bacteria that your digestive system needs to properly function. Due to the overuse of antibiotics in our foods and healthcare system, many of us suffer from a gut microbial deficiency. These foods help in balancing the microbial communities in your gut. The good guys vs. bad guys ratio.

5. Herbs and Spices

Of course, I won’t leave you without telling you what to season your delicious meals with. Eating healthy doesn’t mean sacrifice flavor. Great spices and herbs to add to your kitchen are turmeric, ginger, saffron, thyme, rosemary, and basil. These options smell and taste great!

Wrapping Up:

I know this all seems like a lot to take in. It can be at first. Take it one day at a time and embrace the trial and error phase. Purchase anti-inflammatory recipe books or downloads similar apps. You will realize that the hassle of readjusting and retraining your brain is well worth the benefits you will experience. You will notice that your meals won’t drag you down. You will be satisfied for longer and feel energized after you eat. Food isn’t meant to make you tired. You are providing your body with nutrients that it craves to survive. If you feel sluggish or tired after a meal, it’s a good indication that you aren’t feeding your body what it needs. You may also experience weight loss, a decrease in anxiety levels and a boost in your health.

I challenge you to try an anti-inflammatory diet for one month and see how it changes your body and the way you feel!

Organic Stew Recipe

Medicine and Health

Okay, let’s be real: eating healthy is hard. It’s hard because we have spent most, if not all, of our lives eating crap. Western culture and the modern world we live in today has normalized a restless lifestyle. We feel bad when we stop to rest. We feel guilty if we are not being productive with our time. We must keep pushing, working, drinking caffeine and borrowing energy to keep-up.

With all of the pressures and responsibilities in the modern world (bills, mortgage, college, deadlines), cooking is not our priority. We grab a protein bar in the morning as we rush our the door for work, we skip lunch because we have a deadline to reach and we buy take-out dinner because cooking takes way too long. Not to mention the sheer thought of cleaning up after. Let’s face it: after a long day of running against the clock, we don’t want to cook.

What we don’t realize is that the take-out food we are buying and the lunch we are skipping is the reason we are tired, depressed, anxious and feel like complete crap half of the time. Food is meant to give your body energy to keep going. The protein bar you think is going to hold you off until lunch isn’t food. It’s processed junk and no matter how busy you are, if you don’t make time to fuel your body with the nutrients it needs, you will never feel better. It doesn’t matter how many deadlifts you do at the gym or how many yoga classes you go to…

Health starts with your diet!

I was just like most people in America. I skipped meals, ate processed junk and convinced myself I was healthy as long as I was going to gym. If you want to try and transition into a healthier lifestyle, try out this great stew recipe that I started out with when I decided to finally stop making excuses and take care of myself. Here’s the best part: it’s Crock Pot friendly. You just throw everything into your Crock-Pot and go about your day. Do your yoga, walk your dog and take a shower because dinner will be ready in no time.

I know eating healthy is intimating because first, you may not know a thing about what BPA, GMO or organic even means. It may feel like you don’t know where to start. Second, everyone talks about how expensive organic foods are. Don’t worry, this recipe is affordable and if you don’t have time to go to Whole Foods or the super market, you can purchase all of the ingredients above on Amazon. If you didn’t know, Amazon has partnered with Whole Foods, so everything you want to buy at Whole Foods is available online. Plus, you get a discount when you do go buy your groceries in store.

These seasonings are optional. You can mix it up if you’d like. These are seasonings my husband and I love to use. You don’t have to buy them at any fancy organic store. Get them wherever you’d like or use what you have at home. Like a true Latina woman, I don’t measure any of these seasonings. As my mother would say, we season with heart, so add the seasonings to taste. I personally use one whole onion and one whole garlic in my soup because I love how they taste. If you can, do purchase an organic onion and garlic. Organic vegetables contain more nutrients than regular ones. You are doing yourself a favor by spending the extra $0.20 on a clean and natural vegetable versus not.

How to prepare:

Dice the garlic and onion and cook it over medium heat on a regular stove. Cook until they brown. After, place them inside of the Crock Pot.
Drain the organic kidney beans, garbanzo beans, and pinto beans from the can and place them inside with the garlic and onion.
Add 2 full cartons of beef bone broth and 1 box of the red lentil penne pasta.
Add the organic frozen vegetables and cauliflower.
Add seasonings to taste.
- Salt & Pepper
- Paprika
- Ground Cumin
- Ground Coriander
Let the soup cook in the Crock Pot for as long as necessary. Usually, I leave mine on high for about 3 hours, and then reduce it to low. I like my pasta very soft as well as the vegetables, so you may cook your stew for less time than me.
When I think it’s done, I add in chopped parsley to taste. If you don’t want to add it to the entire soup batch, you can add it to the individual bowl when you are ready to eat or serve.

That’s it! Seriously, that is actually it.

If you have the seasonings already and only need to purchase the ingredients, you will spend about $25.00. If you need to buy onion and garlic, you may spend about $27.00-$28.00 depending on if you buy organic or not.

There it is. An easy, Crock Pot friendly, and affordable healthy recipe for you to kick-start your diet and lifestyle change. Let me know how it tastes once you try it. I’m super excited to see what you all think.

The Many Benefits of a Daily Yoga Routine

Medicine and Health

You don’t need to be a yoga master to know that practicing yoga offers various health benefits. We read posts on social media, we see ads at the gym, and we hear people talk about it all of time. In the fast-paced society we have all become subjected to, staying behind your breathe is hard. It’s why so many of us are anxious and depressed. We are feeding our bodies junk on the daily and taking no time to reconnect with nature or our health. I get it, you might be a science person and you may harbor some skepticism about the benefits of yoga practice. If that’s you, I have good news: modern research is available to solidify and back-up everything I’m about to tell you. Seriously, look it up! Although a lot of research costs money, there are free research articles on google or at a University library. Don’t take this from me, look it up, or better yet, practice yoga and see the benefits for yourself.

Before adopting a daily yoga routine, you need to understand the amazing things yoga can provide you. The benefits aren’t only physical, they are psychological as well. You will become more confident/motivated and less anxious/depressed. Here is a list provided by Susan Hollister in her book “The Top 100 Best Yoga Poses” regarding some of many (and I really mean many) benefits that yoga can offer you:

Improves flexibility.
Opposes food cravings.
Promotes better blood circulation.
Enhances fertility.
Decreases blood pressure.
Enhances mood.
Boosts your immune system.
Supports heart health.
Eases chronic back pain.
Speeds hangover recovery.
Eases asthma symptoms.
Decreases blood sugar.
Boosts your memory.
Encourages focus.
Delays signs of aging.
Relaxes your nervous system.
Boosts your energy levels.
Enhances your balance.
Reduces your body’s sodium levels.
Releases tension.
Increases your red blood cell count.
Facilitates sleep.
Increases and maintains hand-eye coordination skills.
Promotes proper breathing techniques.
Protects your digestive system.
Boosts self-esteem.

If you are still not sold on yoga and are not motivated to start RIGHT NOW… here are some fast facts that may help you decide:

People have been practicing yoga for over 5,000 years. Seriously, 5,000 years!
There are more than 100 different yoga poses that range from slow and gentle to fast and intense. This means that anyone can practice yoga. Don’t be intimidated from starting. We all have to start somewhere and the sooner you start, the sooner you will become your best self.
Yoga can target nearly every muscle and part of your body. It stimulates and massages internal organs that aren’t accessible through traditional massage.
If you need to start taking on some cardiovascular exercise, yoga can help. Research suggests that it can provide as much of a cardiovascular workout as aerobic exercise.
It’s fun for team-bonding and group activities. Schedule a weekly yoga session with your friends instead of the usual coffee house hangout.
You can practice yoga anywhere. You don’t need to have a gym membership or any fancy equipment. You can do it from home, outside at a park or during your lunch break at work.

Yoga is easy to learn and master. It can be practiced alone or with friends. It’s easily accessible and doesn’t cost any money. The health benefits mentioned are some of many and there’s research out there to back it up. If you work long hours and don’t want to invest in a gym membership, consider buying Susan Hollister’s “100 Top Best Yoga Poses” book and giving this thing a try. I promise, you won’t regret it, neither will you look back! From my home to yours, namaste.

Follow the link below to purchase Hollister’s book and start practicing yoga!

Yoga: The top 100 best yoga poses

Foods Your Daily Smoothie is Lacking

Medicine and Health

If you are anything like me, you don’t have a large appetite in the morning. In fact, I have a hard time getting any solid food down until at least 10 am. For years, I simply skipped breakfast and went about my day, having my first meal at or after lunch. Recently, I decided to try the breakfast smoothie lifestyle and I LOVE IT! It fills me up, tastes amazing and I feel energized throughout my morning. If you are always on-the-go or don’t feel hungry in the morning, blend yourself a liquid breakfast and drop the processed protein bar aka Frankenfood. Super food smoothies are delicious and can help you improve your health. The basis behind liquid nutrition is that the nutrients are made available for complete absorption without decreasing the nutrient level (which happens when you heat or process it). Also, your body doesn’t have to spend any extra time and energy breaking it down. It’s fast, convenient and efficient!

Before we start, understand that non-organic fruits and veggies lack essential nutrients because the are sprayed with toxic pesticides and are grown in soil that is overused. Not only are GMOs harmful to your health, they make the fruits and vegetables you’re buying useless! For starters, buy organic. Second, learn about super foods. These are foods made and grown in other parts of the world that are studied for their health benefits. So, what foods and nutrients are a must in your to-go breakfast? To give you the best answer, I turned to Dr. Alan Gruning, author of “Prescription For Health” and a CIRS specialist in Southwest Florida.

HEMP (4 tablespoons)

Did you know that George Washington and Thomas Jefferson were hemp farmers? Hemp is widely grown all over the world and hemp products used for consumption (free of THC) are available is various forms. You can buy hemp powder, seeds and oils. Hemp seeds are abundant in protein, fiber, chlorophyll, iron, omega 6 and 3 fatty acids and other nutrients. Hemp is one of the only complete proteins in the plant kingdom. Dr. Gruning recommends the Hi-fiber Nutivia for organic hemp protein powder. 4 tablespoons of hemp powder is plenty for your morning smoothie.

Bone Broth (2.5-3 tablespoons)

Bone broth is an anti-inflammatory source of omega 3 and protein. It can aid in correcting Leaky Gut and reduces joint and other inflammation. Use organic bone broth made directly from U.S grass fed cows. A good company to consider is Pure Protein Organics. Pure Protein Organics make their broth from scratch and it’s delicious.

Chia and Flax Seeds (1 tablespoon of each)

Chia seeds are high in omega 3 fatty acids, fiber, iron, easily digestible protein and other nutrients. They were commonly used amongst the Aztecs, Mayans and Incas. Flax seeds are a good source of healthy omega 3 fats, fiber and protein. You can buy both in powder or seed form but make sure to opt for organic. If you purchase the seed form of chia seeds, soak them for 5-10 minutes to allow them to turn into a gel and not get stuck in your teeth.

Cacao (1-2 tablespoons)

Cacao beans are the highest antioxidant containing food on earth! It’s a vegetable and contains compounds that neutralize free radicals. It has fiber, magnesium, iron, calcium and protein. The high nutrient levels in cacao are only retained when it is cold pressed. Heating it destroys many beneficial nutrients. Unfortunately, most of the chocolate you see in store today contains cacao, but they are heated, killed and combined with sugar and fat. So drop the Hershey’s chocolate and pick up some organic cacao chocolate powder. Dr. Gruning recommends Viva Naturals Organic Cacao Powder. It is made from Criollo beans grown in the Andes Mountains, which are highly prized, and it has a very rich, dark color.

Açaí

Açaí berry is one of the highest antioxidant fruits on earth. It is grown in the Amazon rain forest and is loaded with vitamins, minerals, omega fatty acids, and other health promoting nutrients. Use only organic Açaí powder in your smoothie. If you don’t want to purchase the organic powder, a small amount of the juice (available at Costco) will also suffice.

Pomegranate (1 tablespoon)

Pomegranate is frequently mentioned in the Bible. It is high in antioxidants, vitamins, minerals and fiber. You can eat the seeds raw or they can be freeze dried into powder.

Maca (1 tablespoon)

Maca is a root grown in the Andes Mountains. It helps balance Adrenal function during stress and is rich in nutrients and fiber. Dr. Gruning recommends Food to Live Organic gelatinized Maca because it removes some substances that can upset your gut.

Wheatgrass (1 teaspoon)

Wheatgrass has lots of chlorophyll, vitamins, minerals and nutrients. It is great as an alkalizing and detoxifying agent as well as an energy source. When purchasing wheatgrass powder, avoid any products from China due to quality concerns. Stick with organic and U.S made.

Turmeric (1/2 teaspoon)

Turmeric is an orange spice that is loaded with antioxidants and is a powerful anti-inflammatory agent. It can help your immune system and joints. The great thing about turmeric is that if you use a small amount, you won’t taste it in your smoothie.

Aloe Vera (2 ounces)

Aloe Vera can help in healing your gut lining. The biggest con with aloe vera juice is that it’s often bitter. Dr. Gruning recommends George’s Aloe, which is made from the Aloe plant and isn’t as bitter as other options.

Alan Gruning, D.O

Dr.Gruning is a Christian physician in Southwest Florida who seeks to heal the whole person-body, mind and spirit-because that is what provides the greatest long term success for patients. He is the author of Prescription for Health, a comprehensive guide to living a balanced life in a toxic world, and was the host of his own TV program of the same name, still visible on his YouTube channel. He is the founder, Executive and Medical Director of the Southwest Florida Free Pain Clinic, the only free medical clinic in the US specializing in the comprehensive treatment of low income, uninsured patients with acute and chronic pain. Dr. Gruning speaks frequently about numerous topics to many different groups around SW Florida.

Dr. Gruning’s smoothie recipe:

1/2 cup vanilla coconut milk or almond milk + 1/2 cup George’s Aloe + 1 cup water
4 tbsp organic Hi-Fiber Hemp protein powder or 2.5-3 tbsp organic grass fed bone broth protein
1 tbsp organic Flax powder
1 tbsp organic Chia Seeds (soak for 5-10 minutes before blending to make a gel)
2 tbsp organic Cacao powder
1 tbsp organic Baobab powder or 1 tsp Açaí or Pomegranate powder or 1-2 ozs Açaí juice
1 tbsp Maca powder
1/2 tsp organic Turmeric powder
1/2 Banana
1/2-1 cup frozen organic berries

Combine in blender or Ninja. Add a little organic cane sugar or stevia if it is not sweet enough. Add less Cacao if you like less chocolate. Use a frozen banana if you want it colder. This provides about 16 ozs.

Total nutrition:

24+g protein
37g fiber
450 calories (if no sugar added)
8,000+mg Omega 3 (converted to EPA/DHA at 20-25% in the body)

This smoothie has so many vitamins, minerals and antioxidants in their raw form that one a day will improve your overall health! In-between meals, eat organic nuts, dried organic berries, and raw cacao nibs. Eat more raw organic fruits and vegetables and watch the new you come to life!