Targeted drugs to tackle hepatitis C.

But experts debate US screening recommendations.

John strains to recall the gap between learning that he had hepatitis C and deciding to get treated: it was either four years or five. His thinking is clouded by the combination of three drugs that he is taking to clear the infection. After the treatments’ other side effects set in — severe flu-like symptoms, depression and exhaustion — he took leave from his job as a chef in New York. John, whose name has been changed to protect his privacy, was at high risk of catching the virus, having once been addicted to crystal methamphetamine. But as a 51-year-old, he is also a baby boomer — a member of the generation born between 1945 and 1965 — millions of whom will face the disease and its sometimes harrowing treatment.

Better drugs are on the way. But the possibility of improved treatment is intensifying a debate about whether to screen a broad swathe of the US population for hepatitis C.

Last month, the pharmaceutical company Gilead, based in Foster City, California, submitted its hepatitis-C drug sofosbuvir to the US Food and Drug Administration for approval, after phase II trials showed a 100% success rate in a few patient groups when it was used in combination with existing drugs. Last week, the first phase III results showed similarly promising results (E. Lawitz et al. N. Engl. J. Med. http://doi.org/mcc; 2013).

The drug is one of at least ten in phase III trials in the United States that promise to improve results or reduce side effects. The first of these drugs could reach the market as early as 2014, and a recommendation from the US Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, to screen an entire generation for the disease could create vast demand for them.

John is a part of a demographic time bomb. Up to 4 million Americans are infected with hepatitis C, which can irreparably damage the liver and lead to liver cancer, but because it inflicts injury slowly over decades, as many as 85% of carriers do not know that they have it. Baby boomers account for about 27% of the US population, but up to 75% of those infected with hepatitis C, possibly because injecting drugs — one infection route — was more common during their youth than in other eras. Last August, the CDC recommended screening the entire generation of people born between 1945 and 1965, as well as people in high-risk populations such as intravenous-drug users. The CDC predicts that generational screening would find an extra 800,000 cases and prevent at least 120,000 deaths. “We have an opportunity to make a real dent in the impact of the disease,” says Kimberly Page, an epidemiologist at the University of California, San Francisco.

 

John’s doctor, infectious-disease specialist Kristen Marks of Weill Cornell Medical College in New York, says that screening is especially important for baby boomers because early symptoms of hepatitis C, such as fatigue and malaise, are difficult to distinguish from signs of ageing. People dismiss symptoms, says Marks, and some might not remember trying intravenous drugs in their youth. Even if they do, she adds, “they might not tell their doctor”. A peak in cases of liver scarring from untreated hepatitis C is expected in the next few years (see ‘An approaching burden’). But with the new drugs on the horizon, now is an optimistic time for treatment, says Marks. “Historically, not having good treatments was a disincentive for screening,” she says. “Now, I think there’s a renewed interest.”

But last November, the US Preventive Services Task Force (USPSTF), a panel of experts assembled by the US Department of Health and Human Services, released a draft statement giving the screening recommendation a ‘grade C’. That means that doctors should consider birth year when deciding whether to offer screening, but should take other factors into account. The mediocre grade could discourage many health-care providers — including Medicaid, the provider for people with low incomes — from pushing screenings.

As with its controversial recommendations in 2009 and 2012 to limit screening for breast and prostrate cancer, the USPSTF has tried to balance the benefits of screening against the risk of unnecessary treatment. The combination therapies used to combat hepatitis C can cost US$1,100 per week and last for up to a year, with severe side effects. Other treatments cost $4,100 per week. (Gilead declined to comment on the future price of sofosbuvir-based treatments.)

“We have an opportunity to make a real dent in the impact of the disease.”

Roger Chou, an internal-medicine specialist at Oregon Health and Science University in Portland and a scientific reviewer for the USPSTF, adds that in most patients, the disease is imperceptible: only 20% of people develop liver scarring in the first 20 years of infection, according to the CDC. Of the few baby boomers that might be caught through additional screening, says Chou, some will not need to be treated.

But new drugs, however expensive, could change the calculus for doctors and patients, says Mark Eckman, a physician at the University of Cincinnati in Ohio, who has calculated that even screening the entire US population would be cost effective given the financial and personal burdens of living with liver diseases (M. H. Eckman et al. Clin. Infect. Dis. 56, 1382–1393; 2013).

For example, sofosbuvir, which is one of a set of new antiviral drugs that specifically target hepatitis C rather than viruses in general, can achieve success rates above 90% in combination treatments of just three months. The drug inhibits the virus’s RNA polymerase, preventing viral replication. It is also being tested without the classic combination drug of pegylated interferon, which boosts the immune system but causes harsh side effects.

The USPSTF is still reviewing its draft recommendations, but it is likely to make a final decision in the next few months, well before approval of sofosbuvir or other new drugs could alter the calculations.

That is too bad, says David Thomas, a viral-hepatitis specialist at Johns Hopkins University in Baltimore, Maryland, who argues that the next generation of drugs helps to justify wide-scale screening. “It makes a pretty easy case for doing something different,” he says.

Source: Nature

 

Memory Loss, Confusion Noted by Many Older Adults.

One in eight noninstitutionalized adults aged 60 and older reported an increase in memory problems during the preceding year, according to a CDC analysis of 2011 data from the Behavioral Risk Factor Surveillance System survey published in MMWR.

Of 60,000 respondents, 13% reported having confusion or memory loss that had gotten worse or more frequent during the past year; of those with memory problems, 35% reported interference with work, social, volunteer, or household activities. People with these functional difficulties were more likely to report needing or getting help from family or friends. Only about one in three people with memory problems reported discussing them with a healthcare provider.

MMWR’s editors say these findings provide baseline estimates of the scope of the problem and “underscore the need to facilitate timely discussions with healthcare and service providers so that linkages can be made to accurate information and needed services.”

Source:MMWR

Coccidioidomycosis on the Rise in the U.S.

The incidence of coccidioidomycosis, or “valley fever,” increased eightfold in the endemic area of the U.S. from 1998 through 2011, according to MMWR. The endemic area comprises Arizona, California, Nevada, New Mexico, and Utah.

Analyzing data from the National Notifiable Diseases Surveillance System, CDC researchers found that the incidence in this region rose from 5.3 to 42.6 cases per 100,000 population over the study period. The increase was seen among all age groups, but those aged 60 and older were most affected.

Speculating on the reasons for the increase, MMWR‘s editors note thatCoccidioides spores, which live in the soil, might have spread readily because of drought, rainfall, temperatures, or construction activity. They also acknowledge that changes in disease surveillance might have affected the numbers. Nonetheless, they conclude that clinicians “should be aware of this increasingly common infection when treating persons with influenza-like illness or pneumonia who live in or have traveled to endemic areas.”

Source: MMWR

 

Patient Caught Rabies Through Organ Transplant, CDC Says.

A patient who recently died of rabies in Maryland contracted the illness from a kidney transplant received over a year ago, the CDC reported on Friday. The lengthy incubation period, while longer than the typical 1 to 3 months, is unusual but not unprecedented.

Tests on tissue samples from the patient and donor confirmed that they were both infected with raccoon-type rabies. The three other patients who received organs from the donor have been identified and are receiving anti-rabies shots.

The CDC notes: “If rabies is not clinically suspected [in a potential donor], laboratory testing for rabies is not routinely performed, as it is difficult for doctors to confirm results in the short window of time they have to keep the organs viable for the recipient.”

Source: CDC

Pertussis Immunity Drops Soon After the Last Vaccine Dose Is Given.

The incidence of pertussis in children rises steadily in the years immediately following receipt of the fifth dose of the diphtheria-tetanus-acellular pertussis (DTaP) vaccine, according to a study in Pediatrics.

Researchers examined the incidence of pertussis among more than 400,000 children in Minnesota and Oregon who’d received all five doses of DTaP, with the fifth dose given between ages 4 and 6 years. In the 6 years after the last dose was received, some 550 pertussis cases were identified. The incidence rose steadily with each passing year.

The authors say their findings “strongly [suggest] waning of vaccine-induced immunity,” which “helps to explain the emergence of an increased burden of disease among 7- to 10-year-olds.” (Currently, the adolescent booster is recommended at ages 11 to 12 years.)

Source: Pediatrics

Cervical Cancer Screening Rates Encouraging, but Show Some Inappropriate Use .

Declining rates of cervical cancer screening over the past decade are bringing clinical practice more in line with current guidelines; however, many women who’ve undergone hysterectomy are being screened unnecessarily, according to articles in MMWR.

A CDC analysis of young women‘s Papanicolaou screening histories based on telephone interviews found that in the 18–21 age group (a group not recommended to undergo screening) the proportion reporting never having undergone screening rose from 26% to 48% between 2000 and 2010. However, in the 22–30 group (which should undergo screening every 3 years) the proportion reporting never being screened rose from 6.6% to 9.0% over the decade.

A similar study among women aged 30 and older found a similar trend toward guideline goals. The exceptions were the estimated 20 million women who had undergone hysterectomy for benign causes but who nonetheless underwent unneeded screening over the course of the decade.

Source: MMWR

What’s Preventing Us from Preventing Type 2 Diabetes?

The Diabetes Prevention Program (DPP) clinical trial and its 10-year outcomes study (DPPOS), both sponsored by the National Institutes of Health (NIH), showed that certain interventions could prevent or substantially delay the onset of type 2 diabetes both safely and cost-effectively.1,2 Yet diabetes prevention is not widely practiced in the United States, and the disease’s staggering human and financial costs continue to grow. It is therefore essential to identify the factors impeding the full realization of the DPP interventions’ potential for preventing diabetes.

The DPP was a comparative effectiveness trial involving 3234 overweight or obese adults with impaired glucose tolerance (prediabetes). Forty-five percent of the participants belonged to racial or ethnic minority groups that have an increased risk of type 2 diabetes. Participants were assigned to receive one of three interventions: lifestyle intervention aimed at modest weight loss through diet and exercise, treatment with generic metformin, or a placebo control. DPP findings published in 2002 indicated that, relative to placebo, lifestyle intervention and metformin reduced the rate of conversion to diabetes by 58% and 31%, respectively, over 3 years.1 Subgroup analyses showed that lifestyle intervention was effective in both sexes, across all racial and ethnic groups, and in people with a genetic predisposition to diabetes. Lifestyle intervention worked best in participants 60 years of age or older, a group in which metformin did not provide a significant benefit. Metformin worked well among younger participants and was particularly effective in women with a history of gestational diabetes. Most DPP participants (88%) enrolled in the DPPOS, in which continued follow-up demonstrated that the 10-year risk reduction for type 2 diabetes was 31% for lifestyle intervention and 18% for metformin.2

Beyond reducing diabetes risk, lifestyle intervention led to substantial health benefits and health care cost savings. Even though these interventions were initially delivered by highly trained professionals who conducted individual sessions, the net 10-year cost was quite modest; although metformin conferred fewer benefits and prevented fewer cases of diabetes, thanks to its lower cost it yielded net savings.2

To translate clinical research into practice, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) established a program to adapt efficacious diabetes and obesity interventions, including the DPP’s lifestyle intervention, to real-world settings. In one promising trial, lifestyle intervention delivered by YMCA fitness trainers in a group setting greatly reduced per-patient costs and validated one practical approach for reaching many of the estimated 79 million Americans with prediabetes.

Building on NIDDK research, which we sponsored, the Centers for Disease Control and Prevention (CDC) created the National Diabetes Prevention Program (NDPP) to assemble a sizable workforce well-trained in the methods pioneered through the DPP and YMCA–DPP studies. Quality assurance and credentialing provide payers with confidence that interventions are safe and effective, and the program is increasing the number of intervention sites and employing marketing strategies that highlight program availability. Through cooperation with public and private partners, including the YMCA and UnitedHealth Group, group-based lifestyle intervention is now available at more than 100 CDC-recognized sites in 25 states.3

Despite the strong evidence of benefit and the increasing capacity for delivering group-based lifestyle intervention, most payers do not cover services for preventing type 2 diabetes. The Affordable Care Act requires the Centers for Medicare and Medicaid Services (CMS) and private insurers to cover preventive medical services that receive a grade of B or better from the U.S. Preventive Services Task Force (USPSTF). Since the USPSTF has not issued a recommendation on diabetes-prevention services, lifestyle intervention is not covered. CMS recently began covering intensive behavioral therapy for obesity, which is a risk factor for diabetes. But this coverage has limited efficacy for diabetes prevention, since overweight, nonobese persons with prediabetes are not covered, and few primary care physicians who provide obesity counseling are trained in lifestyle intervention.

CMS lacks statutory authority to reimburse nontraditional care providers, such as lifestyle coaches. Private payers, on the other hand, have fewer constraints. Recognizing the health and financial benefits of lifestyle intervention for participants with prediabetes, UnitedHealth Group and Medica do cover these preventive services, and other private payers are considering doing the same. Recently, the YMCA received a CMS Health Care Innovation Award to pilot diabetes-prevention services for 10,000 Medicare beneficiaries with prediabetes in 17 communities. Such a program could be a model for more widespread intervention coverage. Unfortunately, the great majority of Americans with prediabetes remain undiagnosed or unaware of their condition, and few have access to an accredited lifestyle-intervention provider.3

Given its efficacy, potential for cost savings, and excellent safety profile, metformin offers another approach to diabetes prevention, particularly in people less than 60 years of age and in women with a history of gestational diabetes. It is difficult, however, to know how often the drug is prescribed off-label for diabetes prevention. Lack of Food and Drug Administration (FDA) approval for this indication hampers education about its potential benefits: it is unlawful for industry to advertise drugs for unapproved indications, and professional societies and insurers are reluctant to recommend unapproved agents in guidelines and educational materials. Only holders of an original new drug application (NDA) may file for FDA approval of new indications. From a business perspective, a pharmaceutical company may have difficulty justifying the cost of a supplemental NDA if a medication is available in generic form.

One important and unavoidable consideration is that the deadly, debilitating, and costly complications of diabetes do not appear immediately after disease onset. Although the peak incidence of the disease occurs between 50 and 60 years of age, complications typically emerge a decade or more later (with enormous implications for Medicare). The duration and extent of hyperglycemia predict complications, and controlling diabetes becomes more difficult over time. Thus, it may take decades to fully realize the health and financial benefits of diabetes prevention. Even the substantial benefits achieved through glycemic control in the NIH’s landmark Diabetes Control and Complications Trial and the Epidemiology of Diabetes Interventions and Complications studies were not immediate: an average of 6.5 years of intensive blood-glucose management dramatically reduced early signs of microvascular complications of diabetes, but effects on clinical events such as myocardial infarction and kidney failure emerged over decades.4

Such results demonstrate the importance of following patients to assess long-term outcomes in key clinical trials, particularly for chronic diseases such as diabetes. Since the effects of interventions on the most serious consequences of diabetes are not immediate, the health and financial benefits of preventing or delaying diabetes are expected to accrue slowly at first, then accelerate over time. Achieving modest cost savings with metformin within a decade and the near cost neutrality of even the original, individually administered lifestyle intervention over that same period are therefore remarkable. Under the Congressional Budget Office’s standard scoring of policy proposals on the basis of their 10-year budgetary impact, diabetes prevention appears to be on the cusp of fiscal benefit, in addition to being of enormous health benefit.5 Given a longer-term perspective, however, the value of applying DPP results to diabetes prevention is clear cut.

Although research has provided tools for preventing or delaying type 2 diabetes, health policies limit their application. Industry needs incentives for obtaining FDA approval of new uses of generic drugs, or we must design alternative pathways for approval. Benefits and costs must be assessed over meaningful timelines for diseases that stretch across decades. Finally, instituting mechanisms for compensating NDPP-certified ancillary health care providers and integrating them into the broader public health infrastructure may cost-effectively stem the tide of diabetes and improve our nation’s health.

COMMENT: I generally do not post such long narratives, but I have made an exception in this case because of the lesions it brings to the discussion of the community implementation of clinical trials.  Here we have demonstrated effectiveness of interventions that will reduce or delay the onset of diabetes with an effectiveness of at least 10 years.  We also have data that the intervention is cost effective and in the case of the metformin intervention in certain subgroups, cost saving.  We also have data from my colleagues at Indiana University that less costly interventions associated with the YMCAs are effective.  Given all of this and in the face of a worldwide diabetes epidemic, why are we not implementing these strategies widely?  This article answers in part this question:  At least for the US physicians and the US health care system prevention is just not our thing!  The Affordable Care Act will help some in paying for preventative services, but it still works within the traditional health care system.  The lifestyle interventions are mostly within the expertise of non-traditional providers, personal trainers, for example; and located in non-traditional settings, health clubs and YMCAs.  As the cliché would have us do, we need to think outside of the box.  If we can pay more for physicians and clinical setting on the basis of outcomes, why can’t we pay for health club or YMCA programs that can demonstrate effectiveness of their programs?  Food for thought.  My question is: “Is your country doing a better job of imprementing diabetes provention programs than the US or, if so, how?”

Source: BMJ doc2doc

Hepatitis C Screening: USPSTF Readies New Recommendations.

The U.S. Preventive Services Task Force is about to update its 2004 recommendations on screening for hepatitis C. Evidence reviews on screening adults, reducing mother-to-infant transmission, and antiviral treatments are available in the Annals of Internal Medicine.

The 2004 statement recommended against routine screening in adults not at increased risk and found no evidence for or against screening those at high risk.

The USPSTF’s evidence review on adult screening points out that the CDC‘s recent recommendation to screen all baby-boomers was based on cost-effectiveness analyses and that information on the clinical outcomes of such strategies is needed. Targeting screening of high-risk patients will miss some patients with infection, they observe.

The review on preventing mother-child transmission finds that no intervention has been shown to reduce risk — including the avoidance of breast-feeding.

Also included is a systematic review on antiviral treatments.

 

Rapid Influenza Diagnostic Tests: Negative Results Might Not Exclude Infection.

Rapid diagnostic tests for influenza provide variable results and might not detect virus at low concentrations, according to a CDC analysis in MMWR.

Researchers evaluated the performance of 11 FDA-approved rapid influenza diagnostic tests for detecting 23 recently circulating influenza viruses, each at 5 concentrations. Most tests detected virus at the highest concentration, but detection at lower concentrations varied by test and virus type.

“Negative RIDT test results might not exclude influenza virus infection in patients with signs and symptoms suggestive of influenza,” MMWR‘s editors write. They advise clinicians not to use a negative test result as a reason to withhold indicated antiviral treatment from patients with suspected influenza. In addition, they recommend collecting respiratory specimens within 24 to 72 hours after symptom onset, when virus concentrations are highest.

Source: MMWR

 

In Emergency Situations, a Fecal Transplant May Be a Lifesaving Option .

Probiotics, i.e. beneficial gut bacteria have been heavily featured in the media lately, and for good reason. Researchers are increasingly realizing just how essential your intestinal microflora really is to your health.

The easiest way to improve the makeup of bacteria in your gut is to include traditionally fermented foods in your diet, but in an emergency situation, a novel procedure called fecal microbiota transplant may be the difference between life and death.

Who Knew a Fecal Transplant Could Be a Life Saving Procedure?

Such was the case with Kaitlin Hunter, a California woman who developed a potentially lethal bacterial infection in her colon after spending a month in the hospital recuperating from a serious car accident.

As reported by CNN Health:¹

“In the hospital after her accident, doctors followed standard care and put Hunter on antibiotics to prevent an infection. In spite of the antibiotics – or possibly because of them – Clostrium difficile (C. diff) infected her colon, causing severe stomach pain, diarrhea and vomiting…

It’s believed that antibiotics, which kill harmful infection-causing bacteria, also weaken the beneficial, healthy bacteria percolating in the colon. With the colon’s defenses down, C. diff grows rampant, releasing a toxin and inflaming the colon.

C. diff infections kill about 14,000 people in the United States every year, according to the Centers for Disease Control and Prevention, and the number and severity of total cases have increased dramatically over the past decade.”

A fecal microbiota transplant (FMT) involves taking donor feces (the donor is typically a spouse or relative; in the Kaitlin’s case, it was her mother) and transferring it to the patient during a colonoscopy. In this way, the patient receives a transplanted population of healthy bacteria that can combat the overgrowth of pathogenic bacteria.

Recent research has shown the procedure to be very effective against recurrent Clostridium difficile infections. In a study² published earlier this summer, FMT had a 91 percent primary cure rate, meaning resolution of symptoms without recurrence within 90 days of FMT. The secondary cure rate was 98 percent. Here, resolution of symptoms occurred after one additional course of vanomycin either with or without probiotics and/or a repeat FMT.

Antibiotics Without Probiotics Can Be a Dangerous Proposition

Kaitlin had received nine rounds of antibiotics, so it’s no wonder such a dangerous infection could get foothold in her colon. In this particular case, the fecal transplant likely saved her life.

However, I would dissuade you from thinking this procedure is a magical route to fix less than life threatening conditions. Furthermore, it’s important to understand that you have the power to prevent such a dangerous condition from occurring in the first place. It would certainly be nice if more doctors understood the importance of reseeding the gut with probiotics during and after a course of antibiotics, to reduce the health risks to their patients. However, as in so many other instances, many doctors still overlook this critical step, and this is where knowledge and self-responsibility comes into play.

Any time you take an antibiotic, it is important to take probiotics to repopulate the beneficial bacteria in your gut that are killed by the antibiotic along with the pathogenic bacteria. And you certainly don’t need a doctor’s prescription or permission for this.

If you’re in a hospital setting, you’re not likely to be served fermented foods, but you could have a family member or friend bring some in, or ask your doctor to sign off on a probiotics supplement. Outside a hospital setting, your best bet is to incorporate traditionally fermented foods in your diet, so you’re constantly maintaining a healthy bacterial balance.

Other Infections that Can Be Treated with Probiotics

Clostridium difficile infections are very serious, and since the cure rate with beneficial bacteria is so high for this type of infection, it can give you an idea of the power of probiotics for other, far less lethal ailments. For example, another type of infection that is far more common than C. diff. is Candida albicans.

An overgrowth of Candida, a type of yeast, can cause a variety of chronic health problems in both men and women. Under normal circumstances Candida albicans is a harmless part of your skin, intestines, and for women, your vagina. But Candida cells develop rapidly, and if your system is out of balance from eating unhealthy foods, taking certain prescription drugs, or fighting an illness for example, Candida can quickly grow out of control.

Vaginal yeast infections tend to occur when the normal acidity of a woman’s vagina changes, allowing the yeast to multiply. It’s estimated that up to 75 percent of women have had at least one vaginal yeast infection in their lifetime, which typically is accompanied by intense itching, burning with urination and sometimes a thick, white discharge. Up to 80 million Americans – 70 percent of them women – suffer from yeast-related problems, and if you suffer from yeast infections (especially if they’re recurrent) you should also be on the watch for other symptoms of Candida overgrowth, such as:

Chronic fatigue	Weight gain
Food allergies	Irritable bowel syndrome
Migraines	PMS

 

As with all yeast-related problems, the infection occurs because your system has become run down or out of balance, allowing the Candida that already exists in your body to multiply out of control, causing illness. You may also fall into the trap of treating the infection with an over-the-counter anti-fungal cream, and then assuming that when the symptoms disappear the problem is cured. However, these creams only treat the symptoms and do nothing about the underlying yeast overgrowth that caused the problem to begin with.

How to Harness Your Gut Bacteria for Better Health

Do you suffer from gas and bloating? Constipation or diarrhea? Fatigue? Headaches? Sugar cravings? All of these are signs that unhealthy bacteria of one type or another have taken over too much real estate in your gut, which is actually quite common considering how vulnerable your gut bacteria are to environmental insults. It’s important to realize that your lifestyle can and does influence your gut flora on a daily basis. Therefore, to protect your microflora, you’ll want to avoid:

• Antibiotics
• Chlorinated water
• Antibacterial soap
• Agricultural chemicals
• Pollution

Poor diet is another enemy to healthy gut bacteria. Sugar is enemy number one, as it actually nourishes the bad or pathogenic bacteria, yeast, and fungi in your gut. Hence, dramatically limiting or eliminating sugar and fructose is an essential step to optimize your gut health. Processed foods also promote bad bacteria – partly due to the high fructose content in most processed foods, but also because of the processing, which essentially “kills” the food.

One of the major side benefits of eating a healthy diet like the one described in my nutrition plan is that it helps your beneficial gut bacteria to flourish. A critical part of a healthful diet is fermented foods, as they will actively “reseed” your body with good bacteria, and can do so far more effectively and inexpensively than a probiotic supplement. It’s unusual to find a probiotic supplement containing more than 10 billion colony-forming units.

But when my team tested fermented vegetables produced by probiotic starter cultures, they had 10 trillion colony-forming units of bacteria. Literally, one serving of vegetables was equal to an entire bottle of a high potency probiotic! So clearly, you’re far better off using fermented foods. Again, when choosing fermented foods, steer clear of pasteurized versions, as pasteurization will destroy many of the naturally-occurring probiotics. Examples of traditionally fermented foods include:

• Fermented vegetables
• Lassi (an Indian yoghurt drink, traditionally enjoyed before dinner)
• Fermented milk, such as kefir (like fermented vegetables, a quart of unpasteurized kefir also has far more active bacteria than you can get from a probiotic supplement)
• Natto (fermented soy)

Learn to Make Your Own Fermented Vegetables

Fermented vegetables are my favorite as they’re both easy to make, and one of the tastiest types of fermented food. To learn how to inexpensively make your own, review the following interview with Caroline Barringer, a Nutritional Therapy Practitioner (NTP) and an expert in the preparation of the foods prescribed in Dr. Natasha Campbell-McBride’s Gut and Psychology Syndrome (GAPS) Nutritional Program. In addition to the wealth of information shared in this interview, I highly recommend getting the book Gut and Psychology Syndrome, which provides all the necessary details for Dr. McBride’s GAPS protocol.

Although you can use the native bacteria on cabbage and other vegetables, it is typically easier to get consistent results by using a starter culture. Caroline prepares hundreds of quarts of fermented vegetables a week and has found that she gets great results by using three to four high quality probiotic capsules to jump start the fermentation process. If you’re not quite ready to make your own, Caroline also prepares the vegetables commercially. I used hers for a month before I started making my own batches. You can find her products on www.CulturedVegetables.net or www.CulturedNutrition.com.

How to Reduce Chances of “Healing Crisis”

There is one precaution that needs to be discussed here, and that is the potential for a so-called “healing crisis,” provoked by the massive die-off of pathogenic bacteria, viruses, fungi, and other harmful pathogens by the reintroduction of massive quantities of probiotics. It can significantly worsen whatever health problem you’re experiencing, before you get better.

The reason for this is because when the probiotics kill off the pathogens, those pathogenic microbes release toxins. These toxins are what’s causing your problem to begin with; be it depression, panic attacks, rheumatoid arthritis, multiple sclerosis, or any other symptom. When a large amount of toxin is suddenly released, your symptoms will also suddenly increase. So, if you’ve never had fermented foods before, you need to introduce them very gradually.

Dr. Campbell-McBride recommends starting off with just ONE TEASPOON of fermented vegetable, such as sauerkraut, with ONE of your meals, and then wait for a couple of days to see how you react. If it’s manageable, you can have another helping, and gradually increase your portion. If you feel worse, stop. Let the side effects subside, and then have just a tiny amount again. Some may even need to start with just a teaspoon of the juice ferment to start. Then move on to two teaspoons per day, and so on.

It’s important to realize that besides containing massive amounts of beneficial bacteria, fermented foods also contain many active enzymes, which act as extremely potent detoxifiers. As Dr. Cambell-McBride explains:

“Healing goes through two steps forward, one step back, two steps forward, and one step back. But you will find that the next layer is smaller. The die off and the detox will not last as long as the previous one… We live in a toxic world, and many of us have accumulated layers and layers of toxicity in our bodies. The body will clean them out, but you will find that each layer will last shorter and not be as severe… Eventually, you will come to complete, radiant health. You will feel 100 percent healthy, no matter how ill you were before.”

Source: Dr. Mercola