The short-term effects of fasting on the neuroendocrine system in patients with chronic pain syndromes

Effects of Prolonged Medical Fasting during an Inpatient, Multimodal, Nature-Based Treatment on Pain, Physical Function, and Psychometric Parameters in Patients with Fibromyalgia: An Observational Study

Fibromyalgia syndrome (FMS) is a common chronic pain disorder and often occurs as a concomitant disease in rheumatological diseases. Managing FMS takes a complex approach and often involves various non-pharmacological therapies. Fasting interventions have not been in the focus of research until recently, but preliminary data have shown effects on short- and medium-term pain as well as on physical and psychosomatic outcomes in different chronic pain disorders. This single-arm observational study investigated the effects of prolonged fasting (3-12 days, <600 kcal/d) embedded in a multimodal treatment setting on inpatients with FMS. Patients who were treated at the Department of Internal Medicine and Nature-Based Therapies of the Immanuel Hospital Berlin, Germany, between 02/2018 and 12/2020 answered questionnaires at hospital admission (V0) and discharge (V1), and then again three (V2), six (V3), and 12 (V4) months later. Selected routine blood and anthropometric parameters were also assessed during the inpatient stay. A total of 176 patients with FMS were included in the study. The Fibromyalgia Impact Questionnaire (FIQ) total score dropped by 13.7 ± 13.9 (p < 0.001) by V1, suggesting an improvement in subjective disease impact. Pain (NRS: reduction by 1.1 ± 2.5 in V1, p < 0.001) and quality of life (WHO-5: +4.9 ± 12.3 in V1, p < 0.001) improved, with a sustainable effect across follow-up visits. In contrast, mindfulness (MAAS: +0.3 ± 0.7 in V1, p < 0.001), anxiety (HADS-A: reduction by 2.9 ± 3.5 in V1, p < 0.0001), and depression (HADS-D: reduction by 2.7 ± 3.0 in V1, p < 0.0001) improved during inpatient treatment, without longer-lasting effects thereafter. During the study period, no serious adverse events were reported. The results suggest that patients with FMS can profit from a prolonged therapeutic fasting intervention integrated into a complex multimodal inpatient treatment in terms of quality of life, pain, and disease-specific functional parameters. ClinicalTrials.gov Identifier: NCT03785197.

Effects of Fasting on the Physiological and Psychological Responses in Middle-Aged Men

Tracking changes in the body during fasting takes into account indicators of mental well-being and physiological parameters. The aim of the study was to measure psychological and physiological reactions, along with their mutual relations, caused by 8 days of water-only fasting. Fourteen men aged 35 to 60 participated in the study, divided into two groups, younger and elder. In addition to physiological parameters, psychological data were collected using four different tests. The obtained results confirmed reduction in body weight, systolic blood pressure, resting diastolic blood pressure and glucose level, and increase in resting heart rate, cortisol and β-hydroxybutyrate concentration. However, no significant psychological changes were observed under the influence of fasting intervention. A significant interaction effect occurred for the state anxiety variable determined before and after the fasting intervention for both groups. Moreover, negative correlations between physiological (cortisol) and psychological factors of subjectively assessed stress were revealed. The only effect on cognitive ability was seen when responding to simple tasks. The study confirmed the beneficial effect of 8 days of water-only fasting on physiological variables without affecting mental well-being. The relatively high level of well-being after fasting intervention was independent of the physiological indicators of stress.

Molecular Mechanisms and Pathophysiological Pathways of High-Fat Diets and Caloric Restriction Dietary Patterns on Pain

Pain perception provides evolutionary advantages by enhancing the probability of survival, but chronic pain continues to be a significant global health concern in modern society. Various factors are associated with pain alteration. Accumulating evidence has revealed that obesity correlates with enhanced pain perception, especially in chronic pain individuals. Existing dietary patterns related to obesity are primarily high-fat diets (HFD) and calorie restriction (CR) diets, which induce or alleviate obesity separately. HFD has been shown to enhance nociception while CR tends to alleviate pain when measuring pain outcomes. Herein, this review mainly summarizes the current knowledge of the effects of HFD and CR on pain responses and underlying molecular mechanisms of the immunological factors, metabolic regulation, inflammatory processes, Schwann cell (SC) autophagy, gut microbiome, and other pathophysiological signaling pathways involved. This review would help to provide insights on potential nonpharmacological strategies of dietary patterns in relieving pain.

Effects of Prolonged Fasting during Inpatient Multimodal Treatment on Pain and Functional Parameters in Knee and Hip Osteoarthritis: A Prospective Exploratory Observational Study

Preliminary clinical data suggest that pain reduction through fasting may be effective for different diagnoses. This uncontrolled observational clinical study examined the effects of prolonged modified fasting on pain and functional parameters in hip and knee osteoarthritis. Patients admitted to the inpatient department of Internal Medicine and Nature-based Therapies of the Immanuel Hospital Berlin between February 2018 and December 2020 answered questionnaires at the beginning and end of inpatient treatment, as well as at 3, 6, and 12 months after discharge. Additionally, selected blood and anthropometric parameters, as well as subjective pain ratings, were routinely assessed during the inpatient stay. Fasting was the only common intervention for all patients, being performed as part of a multimodal integrative treatment program, with a daily caloric intake of <600 kcal for 7.7 ± 1.7 days. N = 125 consecutive patients were included. The results revealed an amelioration of overall symptomatology (WOMAC Index score: -14.8 ± 13.31; p < 0.001; d = 0.78) and pain alleviation (NRS Pain: -2.7 ± 1.98, p < 0.001, d = 1.48). Pain medication was reduced, stopped, or replaced by herbal remedies in 36% of patients. Improvements were also observed in secondary outcome parameters, including increased quality of life (WHO-5: +4.5 ± 4.94, p < 0.001, d = 0.94), reduced anxiety (HADS-A: -2.1 ± 2.91, p < 0001, d = 0.55) and depression (HADS-D: -2.3 ± 3.01, p < 0.001, d = 0.65), and decreases in body weight (-3.6 kg ± 1.65, p < 0.001, d = 0.21) and blood pressure (systolic: -6.2 ± 15.93, p < 0.001, d = 0.43; diastolic: -3.7 ± 10.55, p < 0.001, d = 0.43). The results suggest that patients with osteoarthritis of the lower extremities may benefit from prolonged fasting as part of a multimodal integrative treatment to improve quality of life, pain, and disease-specific functional parameters. Confirmatory randomized controlled trials are warranted to further investigate these hypotheses.

Intermittent Fasting: Potential Utility in the Treatment of Chronic Pain across the Clinical Spectrum

Dietary behavior can have a consequential and wide-ranging influence on human health. Intermittent fasting, which involves intermittent restriction in energy intake, has been shown to have beneficial cellular, physiological, and system-wide effects in animal and human studies. Despite the potential utility in preventing, slowing, and reversing disease processes, the clinical application of intermittent fasting remains limited. The health benefits associated with the simple implementation of a 12 to 16 h fast suggest a promising role in the treatment of chronic pain. A literature review was completed to characterize the physiologic benefits of intermittent fasting and to relate the evidence to the mechanisms underlying chronic pain. Research on different fasting regimens is outlined and an overview of research demonstrating the benefits of intermittent fasting across diverse health conditions is provided. Data on the physiologic effects of intermittent fasting are summarized. The physiology of different pain states is reviewed and the possible implications for intermittent fasting in the treatment of chronic pain through non-invasive management, prehabilitation, and rehabilitation following injury and invasive procedures are presented. Evidence indicates the potential utility of intermittent fasting in the comprehensive management of chronic pain and warrants further investigation.

Ten days of complete fasting affected subjective sensations but not cognitive abilities in healthy adults

PURPOSE

People may be unable to obtain anything edible for days under some circumstances, but they must maintain their calmness and cognition to navigate solutions. Our aim was to study changes in subjective sensations and cognition in healthy adults during a 10-day complete fasting experiment.

METHODS

Thirteen healthy male volunteers voluntarily participated in the 22-day experiment comprising 4 phases: 3 days of baseline consumption, 10 days of complete fasting (only water ad libitum), 4 days of calorie restriction, and a 5-day recovery period. The volunteers' subjective sensations, cognitive performance, and serum energy substances were measured at 6 time points.

RESULTS

Across the 6 time points, the trajectories of subjective sensations in response to fasting were "U"- or " ∩ "-shaped curves instead of progressive discomfort or mood enhancement. A significant fasting time effect was found on depression-dejection (baseline: 16.85 ± 2.88; highest score on the third day of completing fasting: 17.69 ± 3.97, P = 0.04) and self-rated anxiety (baseline: 26.23 ± 4.75; highest score on the sixth day of completing fasting: 30.85 ± 5.58, P = 0.01), and the change curves were consistent with the inflection point of the energy substrates shifting from serum glucose to ketone. In addition, basic cognitive functions appeared to be unaffected during the 10-day fast.

CONCLUSIONS

Our study showed strong influences on the sensations from the third to sixth days of the prolonged fasting period but no significant effects on basic cognitive abilities associated with the energy substance switch. These findings could contribute to the development and understanding of survival strategies in food-shortage emergencies or of intermittent fasting programmes.

Short-term fasting accompanying chemotherapy as a supportive therapy in gynecological cancer: protocol for a multicenter randomized controlled clinical trial

Background/objectives

A few preliminary studies have documented the safety and feasibility of repeated short-term fasting in patients undergoing chemotherapy. However, there is a lack of data from larger randomized trials on the effects of short-term fasting on quality of life, reduction of side effects during chemotherapy, and a possible reduction of tumor progression. Moreover, no data is available on the effectiveness of fasting approaches compared to so-called healthy diets. We aim to investigate whether the potentially beneficial effects of short-term fasting can be confirmed in a larger randomized trial and can compare favorably to a plant-based wholefood diet.

Methods

This is a multicenter, randomized, controlled, two-armed interventional study with a parallel group assignment. One hundred fifty patients, including 120 breast cancer patients and 30 patients with ovarian cancer, are to be randomized to one of two nutritional interventions accompanying chemotherapy: (1) repeated short-term fasting with a maximum energy supply of 350–400 kcal on fasting days or (2) repeated short-term normocaloric plant-based diet with restriction of refined carbohydrates. The primary outcome is disease-related quality of life, as assessed by the functional assessment of the chronic illness therapy measurement system. Secondary outcomes include changes in the Hospital Anxiety and Depression Score and as well as frequency and severity of chemotherapy-induced side effects based on the Common Terminology Criteria of Adverse Events. Explorative analysis in a subpopulation will compare histological complete remissions in patients with neoadjuvant treatments.

Discussion/planned outcomes

Preclinical data and a small number of clinical studies suggest that repeated short-term fasting may reduce the side effects of chemotherapy, enhance quality of life, and eventually slow down tumor progression. Experimental research suggests that the effects of fasting may partly be caused by the restriction of animal protein and refined carbohydrates. This study is the first confirmatory, randomized controlled, clinical study, comparing the effects of short-term fasting to a short-term, plant-based, low-sugar diet during chemotherapy on quality of life and histological tumor remission.

Trial registration

ClinicalTrials.gov NCT03162289. Registered on 22 May 2017

Raising burden of non-communicable diseases: importance of integrating Yoga and Naturopathy at primary care level

Primary health care is a vital component in health care delivery. Non-communicable diseases (NCD's) are rising like a major threat to human survival, which is expected to account for 75% of the total mortality by 2030. Lifestyle and behavioural changes are reckoned as the way ahead. Yoga and Naturopathy, a drugless system of medicine has intersecting paradigms which addresses all planes of health effectively. Yoga and Naturopathy through its holistic approach educate and make the people responsible for their own health. It has shown its efficacy in alleviating and preventing various NCD's. A systematic approach should be initiated, which can channelize the integration of Yoga and Naturopathy at the primary care level considering its cost-effectiveness and efficacy over NCD's.

SIRT3 mediates hippocampal synaptic adaptations to intermittent fasting and ameliorates deficits in APP mutant mice

Intermittent food deprivation (fasting, IF) improves mood and cognition and protects neurons against excitotoxic degeneration in animal models of epilepsy and Alzheimer’s disease (AD). The mechanisms by which neuronal networks adapt to IF and how such adaptations impact neuropathological processes are unknown. We show that hippocampal neuronal networks adapt to IF by enhancing GABAergic tone, which is associated with reduced anxiety-like behaviors and improved hippocampus-dependent memory. These neuronal network and behavioral adaptations require the mitochondrial protein deacetylase SIRT3 as they are abolished in SIRT3-deficient mice and wild type mice in which SIRT3 is selectively depleted from hippocampal neurons. In the App^NL-G-F mouse model of AD, IF reduces neuronal network hyperexcitability and ameliorates deficits in hippocampal synaptic plasticity in a SIRT3-dependent manner. These findings demonstrate a role for a mitochondrial protein deacetylase in hippocampal neurons in behavioral and GABAergic synaptic adaptations to IF.

Intermittent fasting has been shown to have beneficial effects on hippocampal function in rodents, but the underlying mechanism is not fully understood. Here the authors show that the mitochondrial protein SIRT3 contributes to the beneficial cognitive and synaptic effects of intermittent fasting in mice.

Safety, health improvement and well-being during a 4 to 21-day fasting period in an observational study including 1422 subjects

Only few studies document longer periods of fasting in large cohorts including non-obese participants. The aim of this study was to document prospectively the safety and any changes in basic health and well-being indicators during Buchinger periodic fasting within a specialised clinic. In a one-year observational study 1422 subjects participated in a fasting program consisting of fasting periods of between 4 and 21 days. Subjects were grouped in fasting period lengths of 5, 10, 15 and 20±2 days. The participants fasted according to the Buchinger guidelines with a daily caloric intake of 200-250 kcal accompanied by a moderate-intensity lifestyle program. Clinical parameters as well as adverse effects and well-being were documented daily. Blood examinations before and at the end of the fasting period complemented the pre-post analysis using mixed-effects linear models. Significant reductions in weight, abdominal circumference and blood pressure were observed in the whole group (each p<0.001). A beneficial modulating effect of fasting on blood lipids, glucoregulation and further general health-related blood parameters was shown. In all groups, fasting led to a decrease in blood glucose levels to low norm range and to an increase in ketone bodies levels (each p<0.001), documenting the metabolic switch. An increase in physical and emotional well-being (each p<0.001) and an absence of hunger feeling in 93.2% of the subjects supported the feasibility of prolonged fasting. Among the 404 subjects with pre-existing health-complaints, 341 (84.4%) reported an improvement. Adverse effects were reported in less than 1% of the participants. The results from 1422 subjects showed for the first time that Buchinger periodic fasting lasting from 4 to 21 days is safe and well tolerated. It led to enhancement of emotional and physical well-being and improvements in relevant cardiovascular and general risk factors, as well as subjective health complaints.

The effects of short-term fasting on quality of life and tolerance to chemotherapy in patients with breast and ovarian cancer: a randomized cross-over pilot study

Background

This pilot trial aimed to study the feasibility and effects on quality of life (QOL) and well-being of short-term fasting (STF) during chemotherapy in patients with gynecological cancer.

Methods

In an individually-randomized cross-over trial patients with gynecological cancer, 4 to 6 planned chemotherapy cycles were included. Thirty-four patients were randomized to STF in the first half of chemotherapies followed by normocaloric diet (group A;n = 18) or vice versa (group B;n = 16). Fasting started 36 h before and ended 24 h after chemotherapy (60 h-fasting period). QOL was assessed by the FACIT-measurement system.

Results

The chemotherapy-induced reduction of QOL was less than the Minimally Important Difference (MID; FACT-G = 5) with STF but greater than the MID for non-fasted periods. The mean chemotherapy-induced deterioration of total FACIT-F was 10.4 ± 5.3 for fasted and 27.0 ± 6.3 for non-fasted cycles in group A and 14.1 ± 5.6 for non-fasted and 11.0 ± 5.6 for fasted cycles in group B. There were no serious adverse effects.

Conclusion

STF during chemotherapy is well tolerated and appears to improve QOL and fatigue during chemotherapy. Larger studies should prove the effect of STF as an adjunct to chemotherapy.

Trial registration

This trial was registered at clinicaltrials.gov: NCT01954836.

The Role of Leptin in Maintaining Plasma Glucose During Starvation

For 20 years it has been known that concentrations of leptin, a hormone produced by the white adipose tissue (WAT) largely in proportion to body fat, drops precipitously with starvation, particularly in lean humans and animals. The role of leptin to suppress the thyroid and reproductive axes during a prolonged fast has been well defined; however, the impact of leptin on metabolic regulation has been incompletely understood. However emerging evidence suggests that, in starvation, hypoleptinemia increases activity of the hypothalamic-pituitary-adrenal axis, promoting WAT lipolysis, increasing hepatic acetyl-CoA concentrations, and maintaining euglycemia. In addition, leptin may be largely responsible for mediating a shift from a reliance upon glucose metabolism (absorption and glycogenolysis) to fat metabolism (lipolysis increasing gluconeogenesis) which preserves substrates for the brain, heart, and other critical organs. In this way a leptin-mediated glucose-fatty acid cycle appears to maintain glycemia and permit survival in starvation.

AGE-RAGE Interaction Does Not Explain the Clinical Improvements after Therapeutic Fasting in Osteoarthritis

BACKGROUND

Therapeutic fasting improves joint pain in patients with osteoarthritis (OA), but the underlying mechanisms are unknown. Interactions of advanced glycation end products (AGEs) and their receptors (RAGE) play a role in OA pathogenesis. This study aimed to investigate whether the benefits of fasting in OA can be explained by changes in AGEs or RAGE.

PATIENTS AND METHODS

37 patients with OA underwent fasting for 8 days. Serum levels of an AGE (N-ε-(carboxymethyl)-lysine; CML) and the soluble RAGE (sRAGE) as well as clinical outcome parameters such pain characteristics (measured by visual analogue scale; VAS), joint function (determined by the Western Ontario and McMaster Universities Arthritis Index; WOMAC), and quality of life (via the 36-Item Short-Form Health Survey (SF-36) questionnaire) were assessed. The variables were measured at baseline, the end of fasting, and at follow-up at 4 weeks.

RESULTS

The CML levels did not significantly change from baseline to the end of intervention (Δ = -25.6 ± 92.2 ng/ml; p = 0.10). In contrast, the sRAGE levels (Δ = -182.7 ± 171.4 ng/ml; p < 0.0001) and the sRAGE/CML ratio (Δ = -0.4 ± 0.6; p < 0.001) significantly decreased, but they returned to baseline levels 4 weeks after the end of fasting. The scores for pain, WOMAC, and the physical subscale of the SF-36 significantly improved during fasting. There was no correlation between the clinical outcomes and changes in serum levels of CML, sRAGE, or the sRAGE/CML ratio.

CONCLUSIONS

Fasting resulted in a significant but non-sustained reduction of sRAGE levels and the sRAGE/CML ratio in OA, while the CML levels did not change. Improvement in clinical endpoints of OA does not correlate with changes in CML or sRAGE.

Impact of neonatal iron deficiency on hippocampal DNA methylation and gene transcription in a porcine biomedical model of cognitive development

BACKGROUND

Iron deficiency is a common childhood micronutrient deficiency that results in altered hippocampal function and cognitive disorders. However, little is known about the mechanisms through which neonatal iron deficiency results in long lasting alterations in hippocampal gene expression and function. DNA methylation is an epigenetic mark involved in gene regulation and altered by environmental factors. In this study, hippocampal DNA methylation and gene expression were assessed via reduced representation bisulfite sequencing and RNA-seq on samples from a previous study reporting reduced hippocampal-based learning and memory in a porcine biomedical model of neonatal iron deficiency.

RESULTS

In total 192 differentially expressed genes (DEGs) were identified between the iron deficient and control groups. GO term and pathway enrichment analysis identified DEGs associated with hypoxia, angiogenesis, increased blood brain barrier (BBB) permeability, and altered neurodevelopment and function. Of particular interest are genes previously implicated in cognitive deficits and behavioral disorders in humans and mice, including HTR2A, HTR2C, PAK3, PRSS12, and NETO1. Altered genome-wide DNA methylation was observed across 0.5 million CpG and 2.4 million non-CpG sites. In total 853 differentially methylated (DM) CpG and 99 DM non-CpG sites were identified between groups. Samples clustered by group when comparing DM non-CpG sites, suggesting high conservation of non-CpG methylation in response to neonatal environment. In total 12 DM sites were associated with 9 DEGs, including genes involved in angiogenesis, neurodevelopment, and neuronal function.

CONCLUSIONS

Neonatal iron deficiency leads to altered hippocampal DNA methylation and gene regulation involved in hypoxia, angiogenesis, increased BBB permeability, and altered neurodevelopment and function. Together, these results provide new insights into the mechanisms through which neonatal iron deficiency results in long lasting reductions in cognitive development in humans.

Cross-cultural gene- environment interactions in depression, post-traumatic stress disorder, and the cortisol awakening response: FKBP5 polymorphisms and childhood trauma in South Asia

Despite increased attention to global mental health, psychiatric genetic research has been dominated by studies in high-income countries, especially with populations of European descent. The objective of this study was to assess single nucleotide polymorphisms (SNPs) in the FKBP5 gene in a population living in South Asia. Among adults in Nepal, depression was assessed with the Beck Depression Inventory (BDI), post-traumatic stress disorder (PTSD) with the PTSD Checklist-Civilian Version (PCL-C), and childhood maltreatment with the Childhood Trauma Questionnaire (CTQ). FKBP5 SNPs were genotyped for 682 participants. Cortisol awakening response (CAR) was assessed in a subsample of 118 participants over 3 days. The FKBP5 tag-SNP rs9296158 showed a main effect on depressive symptoms (p = 0.03). Interaction of rs9296158 and childhood maltreatment predicted adult depressive symptoms (p = 0.02) but not PTSD. Childhood maltreatment associated with endocrine response in individuals homozygous for the A allele, demonstrated by a negative CAR and overall hypocortisolaemia in the rs9296158 AA genotype and childhood maltreatment group (p < 0.001). This study replicated findings related to FKBP5 and depression but not PTSD. Gene-environment studies should take differences in prevalence and cultural significance of phenotypes and exposures into account when interpreting cross-cultural findings.

Fasting in mood disorders: neurobiology and effectiveness. A review of the literature

Clinicians have found that fasting was frequently accompanied by an increased level of vigilance and a mood improvement, a subjective feeling of well-being, and sometimes of euphoria. Therapeutic fasting, following an established protocol, is safe and well tolerated. We aim in this article to explore the biological mechanisms activated during fasting that could have an effect on brain function with particular focus on mood (we do not discuss here the mechanisms regulating eating behavior) and to provide a comprehensive review on the potential positive impact of therapeutic fasting on mood. We explored Medline, Web of Science and PsycInfo according to the PRISMA criteria (Preferred Reporting Items for Systematic reviews and Meta-Analysis). The initial research paradigm was: [(fasting OR caloric restriction) AND (mental health OR depressive disorders OR mood OR anxiety)]. Many neurobiological mechanisms have been proposed to explain fasting effects on mood, such as changes in neurotransmitters, quality of sleep, and synthesis of neurotrophic factors. Many clinical observations relate an early (between day 2 and day 7) effect of fasting on depressive symptoms with an improvement in mood, alertness and a sense of tranquility reported by patients. The persistence of mood improvement over time remains to be determined.

Prolonged fasting in patients with chronic pain syndromes leads to late mood-enhancement not related to weight loss and fasting-induced leptin depletion

Periods of fasting are practiced worldwide on a cultural/religious background, and related mood-enhancing effects are postulated. We aimed to assess the effect of fasting on mood and to explore the interaction with neuroendocrine activation and leptin depletion in a controlled explorative study on consecutive inpatients (BMI < 35 kg/m2) of a nutritional ward. 36 subjects (38.9 +/- 7.0 years; 29 female, BMI 26.7 +/- 4.1 kg/m2) participated in an 8-day modified fast (300 kcal/day), 19 patients (38.1 +/- 5.9 years; 18 female, 23.5 +/- 4.1 kg/m2) received a mild low calorie diet. Measurements included daily ratings of mood (VAS), weight and levels of leptin and cortisol at four time-points of the 2-week study period. Weight loss was 4.8 +/- 1.2 and 1.6 +/- 0.9 kg in fasters and controls, respectively. Fasters showed a more pronounced decrease of leptin (58% vs. 20%; P < 0.001) and a 17% increase of cortisol levels (P < 0.001). Mood ratings increased significantly in the late phase of fasting (P < 0.01) but were not related to weight-loss, leptin-depletion or cortisol increase. Our findings suggest that fasting induces specific mood-enhancement. The physiological mediator appears to be neither leptin nor cortisol, the role of other mechanisms has to be further studied.

In-Patient Treatment of Fibromyalgia: A Controlled Nonrandomized Comparison of Conventional Medicine versus Integrative Medicine including Fasting Therapy

Fibromyalgia poses a challenge for therapy. Recent guidelines suggest that fibromyalgia should be treated within a multidisciplinary therapy approach. No data are available that evaluated multimodal treatment strategies of Integrative Medicine (IM). We conducted a controlled, nonrandomized pilot study that compared two inpatient treatment strategies, an IM approach that included fasting therapy and a conventional rheumatology (CM) approach. IM used fasting cure and Mind-Body-Medicine as specific methods. Of 48 included consecutive patients, 28 were treated with IM, 20 with CM. Primary outcome was change in the Fibromyalgia Impact Questionnaire (FIQ) score after the 2-week hospital stay. Secondary outcomes included scores of pain, depression, anxiety, and well being. Assessments were repeated after 12 weeks. At 2 weeks, there were significant improvements in the FIQ (P < 0.014) and for most of secondary outcomes for the IM group compared to the CM group. The beneficial effects for the IM approach were reduced after 12 weeks and no longer statistically significant with the exception of anxiety. Findings indicate that a multimodal IM treatment with fasting therapy might be superior to CM in the short term and not inferior in the mid term. Longer-term studies are warranted to assess the clinical impact of integrative multimodal treatment in fibromyalgia.

Prolonged fasting as a method of mood enhancement in chronic pain syndromes: a review of clinical evidence and mechanisms

Periods of deliberate fasting with restriction to intake of solid food are practiced worldwide, mostly based on a traditional, cultural, or religious background. Recent evidence from clinical trials shows that medically supervised modified fasting (200-500 kcal nutritional intake/day) with periods from 7 to 21 days is efficacious in the treatment of rheumatic diseases and chronic pain syndromes. Here, fasting is frequently accompanied by increased alertness and mood enhancement. The beneficial claims of fasting are supported by experimental research, which has found fasting to be associated with increased brain availability of serotonin, endogenous opioids, and endocannabinoids. Fasting-induced neuroendocrine activation and mild cellular stress response with increased production of neurotrophic factors may also contribute to the mood enhancement of fasting. Fasting treatments may be useful as an adjunctive therapeutic approach in chronic pain patients. The mood-enhancing and pain-relieving effect of therapeutic fasting should be further evaluated in randomized clinical trials.

Leptin-mediated neuroendocrine alterations in anorexia nervosa: somatic and behavioral implications

Hypoleptinemia is a key endocrinological feature of anorexia nervosa (AN). Several symptoms in acute AN are related to the low circulating leptin levels including amenorrhea and semi-starvation-induced hyperactivity. The drop in leptin levels results from the loss of fat mass; once leptin levels fall below specific thresholds the hypothalamic-pituitary-gonadal and -thyroid axes are down-regulated; in contrast, the hypothalamic-pituitary-adrenal axis is up-regulated. Hypoleptinemia is the major signal underlying both somatic and behavioral adaptations to starvation. Because the mechanisms involved in this adaptation are similar in rodents and humans, rodent models can be used to investigate the relevant central pathways which underly the respective starvation-induced symptoms. During therapeutically induced weight gain, leptin levels can intermittently increase above normal concentrations. This hyperleptinemia could predispose to renewed weight loss.

[Glycotoxins and cellular dysfunction. A new mechanism for understanding the preventive effects of lifestyle modifications]

Recently the AGE-RAGE interaction was identified as a potential mechanism underlying chronic and inflammatory diseases like atherosclerosis, diabetes mellitus and kidney disease. Advanced glycation end products (AGEs) are the derivatives of glucose-protein or glucose-lipid reactions and are mainly generated from the diet (depending on intensity of heating, cooking time and oxygenation). Binding of AGEs or other ligands to the AGE receptor (RAGE) results in cellular activation, i.e. increased expression of inflammatory mediators and oxidative stress. Diet-derived AGEs thus induce deleterious effects on tissues and the cardiovascular system. Recent research also found that other lifestyle factors are associated with pronounced inflammatory activation, e.g. psychosocial stress and smoking. In addition, each intake of meals is associated with proinflammatory cellular changes. The AGE-RAGE model and investigations of the underlying cellular mechanisms thus may lead to a better understanding of the health benefits of diets (Mediterranean diet, uncooked vegetarian diets), caloric restriction and intermittent fasting. The clinical impact of low-AGE diets and fasting and the interaction between stress and food intake should be further investigated in controlled trials.

Alterations in intracerebral hemorrhage-induced brain injury in the iron deficient rat

BACKGROUND

Iron contributes to brain edema and cellular toxicity after intracerebral hemorrhage (ICH). Knowledge regarding ICH in the context of iron deficiency anemia (IDA), a common nutritional disorder, is limited.

OBJECTIVE

To determine the effect of IDA on brain and behavioral outcome after ICH in rats.

METHODS

Six-week-old male rats (n = 75) were randomized to non-IDA or IDA groups. After 1 month of iron sufficient or deficient diets, 100 microl autologous blood was infused into the right basal ganglia (BG). Brains were assessed for iron concentration, regional water content, BG transferrin, and transferrin receptor concentrations after ICH. Recovery of upper extremity sensorimotor function was assessed. Brain and behavioral variables were compared by diet group. Significance was set at p < 0.05.

RESULTS

Whole brain iron was decreased and water content was increased for IDA rats in injured cortex and BG at day 3 (p < 0.05) compared with non-IDA rats. Transferrin and transferrin receptor content were increased in injured BG for IDA compared to non-IDA in the first week after ICH (p < 0.05). IDA rats had greater left vibrissae-stimulated forelimb-placing deficits and forelimb-use asymmetry than non-IDA after ICH (p < 0.05).

CONCLUSIONS

Brain iron status may be an important determinant of injury severity and recovery after ICH.

Mediterranean diet or extended fasting's influence on changing the intestinal microflora, immunoglobulin A secretion and clinical outcome in patients with rheumatoid arthritis and fibromyalgia: an observational study

BACKGROUND

Alterations in the intestinal bacterial flora are believed to be contributing factors to many chronic inflammatory and degenerative diseases including rheumatic diseases. While microbiological fecal culture analysis is now increasingly used, little is known about the relationship of changes in intestinal flora, dietary patterns and clinical outcome in specific diseases. To clarify the role of microbiological culture analysis we aimed to evaluate whether in patients with rheumatoid arthritis (RA) or fibromyalgia (FM) a Mediterranean diet or an 8-day fasting period are associated with changes in fecal flora and whether changes in fecal flora are associated with clinical outcome.

METHODS

During a two-months-period 51 consecutive patients from an Integrative Medicine hospital department with an established diagnosis of RA (n = 16) or FM (n = 35) were included in the study. According to predefined clinical criteria and the subjects' choice the patients received a mostly vegetarian Mediterranean diet (n = 21; mean age 50.9 +/-13.3 y) or participated in an intermittent modified 8-day fasting therapy (n = 30; mean age 53.7 +/- 9.4 y). Quantitative aerob and anaerob bacterial flora, stool pH and concentrations of secretory immunoglobulin A (sIgA) were analysed from stool samples at the beginning, at the end of the 2-week hospital stay and at a 3-months follow-up. Clinical outcome was assessed with the DAS 28 for RA patients and with a disease severity rating scale in FM patients.

RESULTS

We found no significant changes in the fecal bacterial counts following the two dietary interventions within and between groups, nor were significant differences found in the analysis of sIgA and stool ph. Clinical improvement at the end of the hospital stay tended to be greater in fasting vs. non-fasting patients with RA (p = 0.09). Clinical outcome was not related to alterations in the intestinal flora.

CONCLUSION

Neither Mediterranean diet nor fasting treatments affect the microbiologically assessed intestinal flora and sIgA levels in patients with RA and FM. The impact of dietary interventions on the human intestinal flora and the role of the fecal flora in rheumatic diseases have to be clarified with newer molecular analysis techniques. The potential benefit of fasting treatment in RA and FM should be further tested in randomised trials.

Incorporation of Fasting Therapy in an Integrative Medicine Ward: Evaluation of Outcome, Safety, and Effects on Lifestyle Adherence in a Large Prospective Cohort Study

OBJECTIVES

The aim of this study was to implement fasting therapy in an inpatient integrative medicine ward and to evaluate safety, acceptance, and effects on health-related outcomes and lifestyle adherence.

DESIGN

This was a prospective observational study with consecutive inpatients over 3 [corrected] years. Inclusion and exclusion criteria for fasting therapy were checked by treating physicians and recommendations given. After receiving full information patients decided whether they would participate in fasting. Outcomes were assessed on admission, at discharge, and 3 and 6 months after discharge.

SETTING

The study took place in an integrative medicine department of an academic teaching hospital.

SUBJECTS

Subjects were newly admitted inpatients with chronic internal diseases and chronic pain syndromes, with lengths of hospital stay of >3 days.

INTERVENTIONS

All patients received intensive integrative treatments including Mind/Body Medicine, acupuncture, nutritional/lifestyle education, and hydrotherapy. Fasting patients participated in a 7-day juice fast (intake <350 kcal/day) with accompanying bowel cleansing, 2 prefasting relief days, and 3 days with stepwise reintroduction of food.

OUTCOME MEASURES

Outcomes were assessed based on rate of participation in fasting, severity of main complaint, quality of life (QOL, MOS 36-Item Short-Form Health Survey), safety, lifestyle adherence to recommendations given (relaxation, diet, exercise).

RESULTS

Of 2121 patients with complete discharge questionnaires, 952 patients participated in fasting, 873 had a normocaloric vegetarian diet, and 296 patients had other diets and were excluded. Response rates were 71% and 56% at 3- and 6-month follow-up. The main disease-related complaint at discharge was significantly greater improved in fasters versus nonfasters (p < 0.01). Patient QOL increased significantly and comparably from baseline to discharge in both groups. Fasting was well tolerated and no serious fasting-related adverse effects were reported. In all, 743 (78%) of fasting patients reported improvement of their health through fasting. Descriptors of lifestyle adherence showed higher levels of related activities in the 3 and 6 months of follow-up.

CONCLUSIONS

Fasting can safely and successfully be implemented in an inpatient integrative medicine concept and is perceived as a health-promoting method by the majority of patients. Potential effects on disease-related complaints and lifestyle adherence should be further evaluated in randomized trials.

Rat brain iron concentration is lower following perinatal copper deficiency

Experiments performed with Holtzman rats demonstrated that brain iron (Fe) was lower by postnatal day 13 (P13) in pups born and nursed by dams that began copper-deficient (-Cu) treatment at embryonic day 7. Transcardial perfusion of P24-P26 males and females to remove blood Fe contamination revealed that brain Fe was still 20% lower in -Cu than +Cu rats. Estimated blood content of brain for -Cu rats was greater than for +Cu rats; for all groups, values ranged between 0.43 and 1.03%. Using group-specific data and regression analyses, r = 0.99, relating blood Fe to hemoglobin, brain Fe in non-perfused rats in a replicate study was lower by 33% at P13 and 39% at P24 in -Cu rats. Brain extracts from these rats and from P50 rats from a post-weaning model were compared by immunoblotting for transferrin receptor (TfR1). P24 brain -Cu/+Cu TfR1 was 3.08, suggesting that brains of -Cu rats were indeed Fe deficient. This ratio in P13 rats was 1.44, p < 0.05. No change in P50 -Cu rat brain TfR1 or Fe content was detected despite a 50% reduction in plasma Fe. The results suggest that brain Fe accumulation depends on adequate Cu nutriture during perinatal development.

Kognitive Veränderungen beim Fasten

Zusammenfassung. Theoretischer Hintergrund: Auf Grund der extrem eingeschränkten Kalorienzufuhr beim Fasten kommt es zu verschiedenen hormonellen- und Stoffwechselveränderungen. Fragestellung: Sind kognitive Funktionen bei einer Fastendauer von 72 Stunden beeinträchtigt? Methode: Es wurden 15 Teilnehmer eines Buchinger-Fastenkurses und eine nach Geschlecht, Alter und höchstem Schulabschluss parallelisierte Kontrollgruppe an zwei Untersuchungszeitpunkten neuropsychologisch getestet (Aufmerksamkeit, visuo-konstruktive Fähigkeiten, konditional-assoziative Lernfähigkeit, Befindlichkeit). Ergebnisse: In der Fastengruppe ergaben sich nach 72 Stunden signifikant schlechtere Leistungen in Aufmerksamkeitstests und im konditional-assoziativen Lernen. Das allgemeine Befinden war jedoch deutlich besser ausgeprägt als in der nicht fastenden Kontrollgruppe. Das verbale Lernen, die verbale und visuo-räumliche Merkfähigkeit sowie die Visuokonstruktion waren dagegen unbeeinträchtigt. Schlussfolgerung: Bereits nach einer extremen Nahrungseinschränkung von 72 Stunden zeigen sich selektive Beeinträchtigungen der kognitiven Funktionen, welche in milder Ausprägungen denen von Anorexiepatientinnen entsprechen.

Decreased transferrin receptor expression by neuromelanin cells in restless legs syndrome

BACKGROUND

Restless legs syndrome (RLS) is a sensory-movement disorder affecting 5 to 10% of the population. Its etiology is unknown, but MRI analyses and immunohistochemical studies on autopsy tissue suggest the substantia nigra (SN) of patients with RLS has subnormal amounts of iron.

METHODS

Neuromelanin cells from the SN of four RLS and four control brains were isolated by laser capture microdissection, and a profile of iron-management protein expression was obtained by immunoblot analysis. Binding assays for iron regulatory protein activity were performed on cell homogenates.

RESULTS

Ferritin, divalent metal transporter 1, ferroportin, and transferrin receptor (TfR) were decreased in RLS neuromelanin cells compared with control. Transferrin was increased in RLS neuromelanin cells. This protein profile in RLS neuromelanin cells is consistent with iron deficiency with the exception that TfR expression was decreased rather than increased. The concentration and activity of the iron regulatory proteins (IRP1 and IRP2) were analyzed to determine whether there was a functional deficit in the post-transcriptional regulatory mechanism for TfR expression. Total IRP activity, IRP1 activity, and IRP1 protein levels were decreased in RLS, but total IRP2 protein levels were not decreased in RLS.

CONCLUSION

Restless legs syndrome may result from a defect in iron regulatory protein 1 in neuromelanin cells that promotes destabilization of the transferrin receptor mRNA, leading to cellular iron deficiency.

Pre- and Postweaning Iron Deficiency Alters Myelination in Sprague-Dawley Rats

Iron deficiency in early life is associated with hypomyelination; however, the role which iron plays in myelinogenesis is not clearly established. In this study, we examined the effect of preweaning [postnatal days (PND) 4-14 and PND 4-21] and postweaning (PND 21-63) iron deficiency on hindbrain 2',3'-cyclic nucleotide 3'-phosphohydrolase (CNPase) activity (marker of oligodendrocyte metabolic activity) and myelin basic protein (MBP) concentrations. Both CNPase activity and concentrations in the cerebrum and hindbrain were significantly lower in pre- and postweaning iron-deficient rats. Similarly, MBP concentrations were also reduced (25-35%) in all three groups of iron-deficient animals. Iron-deficient animals also had significant alterations in the fatty acid composition of individual phospholipids within the hindbrain as well as changes in cytochrome oxidase activities. These studies show that postnatal iron deficiency, for as little as 10 days, can significantly alter the production of myelin and oligodendrocyte functioning. Importantly, postweaning iron deficiency was still associated with a decrease in CNPase activity and MBP concentrations despite occurring well past a likely key sensitive period of peak myelinogenesis at PND 8-12. This suggests that iron deficiency in later life, as well as during early postnatal growth, can effect the production and maintenance of myelin.