Hi, Freddd.
Thanks for sharing your insights about the symptoms people have reported on the simplified treatment approach. (I especially like all the colors!)
You have clearly been a very keen observer of your own experience, and I take your word on it that what you are reporting also represents the experiences of some others.
As I've also written before, I think we do have to acknowledge that people are unique to some degree, inheriting different sets of genomic polymorphisms, which impact how they respond to treatments. And we also have to deal with the issue of having a fairly heterogeneous population in terms of the disorders that they actually have. I think that the new international criteria for M.E. that have recently been published are a step in the right direction toward tightening the specifications on the diagnosis of M.E., so that we can know that we are dealing with a more homogeneous group when we try to apply the results of a study group to others who have M.E.
In view of this heterogeneity, I remain cautious in applying the results I see, as well as those you report, to everyone who has M.E. I think the data you present are interesting, but I have to apply a critical eye to it, just as I do to data that I or anyone else generate.
I know that you have taken a dim view of the possibility that mobilization of stored toxins can account for some of the symptoms reported. I would like to suggest the possibility that indeed, some of the symptoms can be attributed to the deficiencies you have suggested, but that others may be due to mobilization of toxins, and perhaps some can be caused by either, since they are not all very well defined, as you noted.
I think this is suggested both by observations and by what we know of biochemistry and physiology. I take your word, for example, on the symptoms you have been able to correct by adding potassium, and I think this lines up well with the biochemistry and physiology and what we think is going on during the methylation-type treatments.
In particular, it is known that folate is needed to produce purines and thymidine, which in turn are needed to make RNA and DNA, and that these in turn are needed to make new cells. If a person is depleted in intracellular folate, it should be expected that their bodies have not been able to produce new cells as rapidly as is needed. One piece of evidence for this is the elevated value of mean corpuscular volume (MCV) that many have on the complete blood count (CBC). When the erythropoietic cells in the bone marrow do not have enough folate, they are not able to make new cells fast enough, and in the case of the red blood cells, they stuff more hemoglobin into the ones they are able to make, causing them to be larger. We should expect that the same problem must exist for other cell types that are rapidly turned over, such as those lining the intestine. I think it is probable that part of the cause of the "leaky gut" experienced by so many as multiple food sensitivities can be traced back to the inability to make new cells to line the gut rapidly enough.
Given this situation, we should expect that when the intracellular folate levels are raised by treatment that includes both folates and vitamin B12 (the latter being necessary to promote the methionine synthase reaction to use methylfolate and convert it tetrahydrofolate, thus preventing draining of methylfolate from the cells via the "methyl trap" mechanism), the body will now be able to start making new cells at a faster rate to make up for the deficiency of new cells that has existed during the illness.
As you know, new cells require more than RNA and DNA alone. They need ionic species, amino acids, and fatty acids in particular. The main ionic species they need is potassium ions. There are reservoirs elsewhere in the body for most of the species needed to make new cells. For examples, the muscles are a reservoir for amino acids in the form of protein, and the bones store a great deal of phosphate. But potassium is found mainly inside cells (98%), which are likely in short supply in this illness because of the longstanding intracellular folate deficiency, so this potassium would likely not be very available for making new cells.
It is therefore to be expected that a potassium deficiency would appear if the rate of production of new cells were suddenly increased, as from a protocol including both high-dose B12 and folate. The known symptoms of potassium deficiency, which shows up as low levels of potassium in the blood (hypokalemia) depend on the individual and the severity of the potassium deficiency. These symptoms involve the heart, the skeletal muscles, the smooth muscles, and kidney function.
The heart exhibits arrhythmias, and in severe potassium deficiency develops ventricular tachycardia which can lead to death. The skeletal muscles exhibit weakness, fatigue, cramps, fasciculations and rhabdomyolysis (breakdown of muscle tissue). Breathing can become difficult because of effects on the muscles involved in breathing. Smooth muscle problems include constipation and ileus (a paralytic blockage of intestinal transport). Severe potassium deficiency affects the nervous system, causing flaccid paralysis, hyporeflexia, and tetany. Kidney-related symptoms are excessive urination and thirst.
You have suggested that the two cases of constipation (or perhaps ileus) that were reported on the simplified treatment approach may have been due to temporary potassium deficiency. I think you may be correct about this. I note that additional fatigue as well as weakness was also reported on this treatment, and perhaps they were also due at least in part to temporary potassium deficiency. The transient increased muscle pain that was reported may also have been due to temporarily low potassium. There were two cases of difficulty breathing. One was apparently due to swelling of an existing goiter, but the other may have been at least partly due to temporary potassium deficiency. Perhaps the temporarily increased urination, transiently increased thirst and clear urine that were reported can also be attributed to low potassium. I think it is notable that arrhythmia was not reported. As I have posted in the past, I think that problems with potassium deficiency are likely to be less severe if lower dosages of B12 and the folates are used, as in the simplified treatment approach, so that the body is able to respond more gradually, and potassium intake from food is more likely to be able to keep up with the demand. Nevertheless, there do seem to be some symptoms that can be attributed to potassium deficiency even with a "low and slow" methylation treatment.
What about the evidence that mobilization of toxins may be responsible for some symptoms on this type of treatment? From the biochemical point of view, it is known that the body's detoxication system relies to a large extent on sulfur-containing substances, including glutathione, cysteine, taurine, and sulfate. We know that the methylation cycle lies at the beginning of the body's sulfur metabolism and that it normally exercises control over the sulfur metabolism. We also know that in M.E. there is a partial block in the methylation cycle and that the sulfur metabolism is dysregulated. In particular, glutathione is depleted in most cases, and often the levels of cysteine and/or sulfate are low. Under these circumstances, we should expect that the detox system will not be operating properly, and toxins will therefore build up in the body. Indeed, many people with M.E. have taken a detoxication profile panel and have typically found low Phase II glutathionation, and sometimes low sulfation as well. Lab measurements in many cases have found elevated levels of toxic heavy metals, in particular, and analysis of the mitochondria have shown elevated levels of both toxic metals and organic toxins in cases of M.E.
We should also expect that when the operation of the methylation cycle is restored and glutathione is brought up to normal, that the detoxication system would begin to operate more normally, and would start to work down the backlog of stored toxins. The action of the detox system in various cells, tissues and organs is known to first move toxins into the bloodstream. There is a time lag before these toxins are removed from the blood by the kidneys, liver and sweat glands,and are excreted. If the digestive system is not functioning well, more of the toxins excreted into the gut in the bile from the liver will be reabsorbed and can stay in the blood longer. It can be expected that the higher levels of toxins temporarily in the blood will affect the cells of the body in general, and that this might lead to a variety of temporary symptoms.
There is evidence that toxins are mobilized and excreted when methylation treatment is given. In autism. which shares the partial methylation cycle block with M.E., Dr. Amy Yasko has compiled large amounts of data showing increased excretion of heavy metals during this type of treatment. Some who have M.E. have also observed this in urine toxic metals testing. Repeat mitochondrial analysis in some has shown clearance of toxins formerly found in the mitochondria after being on methylation treatment for a few months.
Reports of the benefit for ameliorating symptoms of adding substances known to bind toxins in the gut, such as activated charcoal, or substances known to promote increased excretion of certain toxins (weak acid type) by the kidneys, such as lemon juice, are further evidence that toxins are being mobilized during methylation-type treatment.
Considering symptoms that would be likely to result from increased mobilization and excretion of toxins, it seems that the most direct connection could be made with those that involve the main known routes of excretion of toxins, i.e. the urine, stools and perspiration. Transient changes in the amounts, smell, or appearance of these substances would be very suspect of being caused by excretion of toxins, in my opinion. The metallic taste in the mouth would also be suspected of being due to mobilization of toxins, in my opinion. I think that skin-related issues such as temporary rashes and itching could be caused by mobilized toxins as well.
I realize that you have attributed several of the reported symptoms to folate deficiency, based on your experience, and I have no reason to doubt your interpretations in your own case.
However, as I've noted before, I am not sure how widespread this "paradoxical folate deficiency" that you've reported to be caused by taking folic or folinic acid or glutathione-related substances actually is in the M.E. population. It does appear, though, that there are some others who do share your experience. I think it's also possible that some symptoms that are not very specifically defined could be produced by more than one cause in different people.
So in conclusion, you have convinced me of the importance of potassium deficiency in producing symptoms during methylation-type treatment, even treatment that is more "low and slow" than the protocol you advocate. I am also willing to believe that in your case, and in some others, some symptoms may be caused by induced folate deficiency caused by some substances in some of the methylation protocols. As I've noted in the past, I agree with you that the folic acid form of folate is best minimized. However, I continue to believe, based on the evidence I've cited, that mobilization of toxins is likely to account for some of the reported symptoms as well. So that's where it currently stands as far as I'm concerned, but I am continuing to keep an open mind for more evidence one way or the other, and I very much appreciate your sharing your experience and insights.
Best regards,
Rich