Autoimmune diseases and severe infections are risk factors for mood disorders overall and for schizophrenia. The immune system has also been recognized as playing a role in disorders including autism spectrum disorders, ADHD, obsessive-compulsive disorder, and post-traumatic stress disorder.
Diet and food selection, role of nutrition, does what we eat influence these
Does diet have a role in the etiology of rheumatoid arthritis?
Although dietary factors have been extensively studied in many chronic diseases, the role of diet in the epidemiology of rheumatoid arthritis (RA) has received little attention. Fish oil supplementation has consistently been shown to have a beneficial effect on the symptoms of established RA. There is evidence that RA is less severe in the southern Mediterranean countries, such as Italy and Greece, where oil-rich fish, fruit, vegetables and olive oil are consumed in greater amounts than in many other countries. Lower intakes of fruit and vegetables and dietary vitamin C are associated with an increased risk of developing inflammatory polyarthritis. These findings provide further evidence for a role of diet in the development of inflammatory arthritis. Proceedings Nutrition Soc. 2004.
Supplements and herbs that may be useful in autoimmune conditions
Research in this area has just started and my goal is to update you with information on dietary supplements that could be helpful in reducing the severity of an autoimmune disease. Please keep in mind that we know very little at this point and you should consult with your doctor before making any changes in your treatment plans.
Vitamin D, how big a role does it play?
Most people think of vitamin D in terms of bone strength. Vitamin D inhibits proinflammatory processes by suppressing the enhanced activity of immune cells that take part in the autoimmune reaction. Supplementation may be therapeutically beneficial particularly for Th1 mediated autoimmune disorders. Some reports imply that vitamin D may even be helpful in multiple sclerosis and diabetes type 1.
The co-existence of high prevalence of vitamin D inadequacy among Canadians and high prevalence of systematic autoimmune rheumatic diseases (SARDs) raise the question on relationship between the two situations.
Omega-3 fatty acids, flax seeds
Fish oils, or eating a diet that includes fish at least three times a week, may reduce symptoms. Another option is fish eggs, also called roe. Fish oils have anti-inflammatory fatty acids called EPA and DHA that could reduce the inflammation response.
Effects of eicosapentaenoic acid supplementation on
immunoglobulin A nephropathy.
Eicosapentaenoic acid (EPA), which is purified from fish oil, attenuates inflammatory responses by decreasing eicosanoid and cytokine production. EPA reportedly improves renal survival in patients with immunoglobulin (Ig)A nephropathy. Ther Apher Dial. 2010. Yoko Clinic, Kitakyushu, Fukuoka, Japan.
Effects of dietary omega3 and omega6 lipids and vitamin E on
proliferative response, lymphoid cell subsets, production of cytokines by spleen
cells, and splenic protein levels for cytokines and oncogenes in MRL/MpJ-lpr/lpr
Omega3 Fatty acid rich fish oil (FO) and vitamin E may delay the progress of certain autoimmune diseases. The observations from this study suggest that both FO and vitamin E modulate the levels of specific cytokines, decrease the levels of proinflammatory cytokines, inflammatory lipid mediators, and c-myc, and increase TGF-beta1 levels in spleens of MRL/lpr mice and thus may delay the progress of autoimmune diseases. J Nutr Biochem. 1999.
Green tea and EGCG
Green tea protects rats against autoimmune arthritis by modulating disease-related immune events.
Green tea, a product of the dried leaves of Camellia sinensis, is the most widely consumed beverage in the world. The polyphenolic compounds from green tea possess antiinflammatory properties. We investigated whether green tea extract can afford protection against autoimmune arthritis and also examined the immunological basis of this effect using the rat adjuvant arthritis (model of human rheumatoid arthritis. Green tea induced changes in arthritis-related immune responses. We suggest further systematic exploration of dietary supplementation with green tea extract as an adjunct nutritional strategy for the management of rheumatoid arthritis. J Nutrition. 2008.
The flavones luteolin and apigenin inhibit in vitro antigen-specific proliferation and interferon-gamma production by murine and human autoimmune T cells.
Plant-derived flavonoids are inhibitors of various intracellular processes, notably phosphorylation pathways, and potential inhibitors of cellular autoimmunity. In this study, the inhibiting effects of various flavonoids on antigen-specific proliferation and interferon-gamma (IFN-gamma) production by human and murine autoreactive T cells were evaluated in vitro. T-cell responses were evaluated for the human autoantigen alpha B-crystallin, a candidate autoantigen in multiple sclerosis, and for the murine encephalitogen proteolipid protein peptide PLP. The flavones apigenin and luteolin were found to be strong inhibitors of both murine and human T-cell responses while fisitin, quercetin, morin and hesperitin, members of the subclasses of flavonoles and flavanones, were ineffective. Antigen-specific IFN-gamma production was reduced more effectively by flavones than T-cell proliferation, suggesting that the intracellular pathway for IFN-gamma production in T cells is particularly sensitive to flavone inhibition. These results indicate that flavones but not flavanoles or flavanones are effective inhibitors of the potentially pathogenic function of autoreactive T cells. The effects of flavones were the same for human and murine autoreactive T cells, stressing the usefulness of animal models of autoimmunity for further studies on the effects of flavonones on autoimmune diseases. Biochem Pharmacol. 2004.
Int Immunopharmacol. 2015. Melatonin enhances interleukin-10 expression and suppresses chemotaxis to inhibit inflammation in situ and reduce the severity of experimental autoimmune encephalomyelitis.
Quercetin ameliorates experimental autoimmune myocarditis
Experimental autoimmune myocarditis (EAM) in rats is an animal model of human giant cell myocarditis and post-myocarditis dilated cardiomyopathy. The pathogenesis of EAM has not been elucidated, but there is accumulating evidence that cytokines secreted from monocytes/macrophages and T cells play a crucial role in the induction and progression of disease. Flavonoids are a large group of polyphenolic compounds abundantly present in the human diet, which scavenge oxygen radicals and have anti-inflammatory activities. The present study suggests that quercetin ameliorates EAM, at least in part, by interfering production of proinflammatory (TNF-α and IL-17) and/or anti-inflammatory (IL-10) cytokines. J Pharm Pharm Sci. 2010.
Rose hip herbal remedy in patients with
rheumatoid arthritis - a randomised controlled trial.
In a double-blind placebo-controlled trial, patients with rheumatoid arthritis according to ARA/ACR criteria were randomised to treatment with capsulated rose-hip powder 5g daily or matching placebo for 6 months. The results indicate that patients with RA may benefit from additional treatment with rose hip powder. Phytomedicine. 2010.
Efficacy of an Andrographis paniculata composition for the relief of rheumatoid arthritis symptoms: a prospective randomized placebo-controlled trial.Clin Andrographis paniculata possesses anti-inflammatory effects, attributed to the main constituent andrographolide proposed as alternative in the treatment of autoimmune disease. Rheumatol. 2009 Aug9 .Burgos RA, Hancke JL, Bertoglio JC, Aguirre V, Arriagada S, Calvo M, Cáceres DD.Institute of Pharmacology and Morphophysiology, Universidad Austral de Chile, Valdivia, Chile.
Alpha-lipoic acid is effective in prevention and treatment of experimental autoimmune encephalomyelitis.
Alpha-lipoic acid (alpha-LA) is a neuroprotective metabolic antioxidant that has been shown to cross the blood brain barrier. We tested whether alpha-LA is capable to prevent MOG35-55-induced experimental autoimmune encephalomyelitis (EAE), an established model of multiple sclerosis (MS). Daily oral administration of alpha-LA, starting at the time of immunization, significantly prevented EAE progression as compared to control mice. This was associated with a reduction of CNS infiltrating T cells and macrophages as well as decreased demyelination. We then tested alpha-LA in a therapeutic protocol aimed at suppressing EAE after its onset. Intraperitoneal, but not oral, administration of alpha-LA significantly prevented disease progression when compared to vehicle-treated controls. Our data indicate that alpha-LA can effectively interfere with the autoimmune reaction associated with EAE through mechanisms other than its antioxidant activity and supports further studies on the use of alpha-LA as a potential therapy for MS. J Neuroimmunol. 2004.
What are some types
of autoimmune disease?
Scientific World Journal. 2013. Possible role of human herpesvirus 6 as a trigger of autoimmune disease. Human herpesvirus 6 (HHV-6) infection is common and has a worldwide distribution. Recently, HHV-6A and HHV-6B have been reclassified into two distinct species based on different biological features (genetic, antigenic, and cell tropism) and disease associations. A role for HHV-6A/B has been proposed in several autoimmune disorders (AD), including multiple sclerosis (MS), autoimmune connective tissue diseases, and Hashimoto's thyroiditis.
Rosacea in women is linked with an increased risk for a wide variety of autoimmune disorders including type 1 diabetes, celiac disease, multiple sclerosis, and rheumatoid arthritis
There are several recognized conditions that are considered autoimmune disease. Here they are in alphabetical order:
leads to hair loss
Alpha lipoic acid may be helpful.
β-Lapachone is a naturally occurring quinine, originally isolated from the bark of the lapacho tree (Tabebuia avellanedae) which is currently being evaluated in clinical trials for the treatment of cancer. J Neuroimmunol. 2013. Beta-Lapachone ameliorization of experimental autoimmune encephalomyelitis.
The Zika virus may be linked to another brain disorder, this one similar to multiple sclerosis. The mosquito-borne virus is already suspected of causing a birth defect called microcephaly -- characterized by an abnormally small head and brain -- and a nervous system disorder called Guillain-Barre syndrome. A study reports a possible link between Zika and an autoimmune disorder known as acute disseminated encephalomyelitis (ADEM). In this disease, the immune system attacks the coating (myelin) around nerve fibers in the brain and spinal cord, much like multiple sclerosis.
Sci Rep. 2015. Kirenol Attenuates Experimental Autoimmune
Encephalomyelitis by Inhibiting Differentiation of Th1 and Th17 Cells and
Inducing Apoptosis of Effector T Cells.fg
Autoimmune hemolytic anemia (AIHA) and immune mediated hemolytic anemia (IMHA).
Autoimmune hepatitis is a condition in which the body’s
immune system attacks liver cells. This immune response causes inflammation of
the liver. A genetic factor may make some people more susceptible to autoimmune
diseases. About 70 percent of those with autoimmune hepatitis are female.
My wife was diagnosed with autoimmune hepatitis a few years ago and now her liver enzymes elevated again. Do you have any recommendation as far as her diet? Anything that you recommend as far as herbal medication.
I have not studied the natural, herbal or dietary treatment of this condition.
Autoimmune myositis is usually divided between polymyositis and masticatory muscle myositis.
Would natural products benefit someone with
the condition of polymyositis? My daughter is in her late 30's, and was
diagnosed less than two years ago. She has tried prednisone, methotrexate, IVIG
(couldn't tolerate), cellcept, Immune Matrix products and testing, chinese
medical remedies, and at almost six feet tall, she is losing muscle mass and
weight. She is down to less than 118 pounds, and is so debilitated she cannot
work any longer. She is off of gluten, dairy and eats mostly organic and raw
foods. She suffered with asthma and lichen planus as a child, and had mono as a
teenager. Her Polymyositis started as Dermatomyositis, two months after she
married. Any links, tips, resources, or potential remedies you might suggest
would be greatly appreciated.
Oral creatine supplements combined with home exercises improve functional performance without significant adverse effects in patients with polymyositis or dermatomyositis. They appear safe, effective, and inexpensive. Arthritis Rheum. 2007 May 15. Creatine supplements in patients with idiopathic inflammatory myopathies who are clinically weak after conventional pharmacologic treatment: Six-month, double-blind, randomized, placebo-controlled trial.
Dermatomyositis is an uncommon disease marked by muscle weakness and a distinctive skin rash.
Diabetes type I
Among children who are genetically predisposed to develop type 1 diabetes, dietary consumption of omega-3 fatty acids appears to reduce the risk of becoming diabetic. Type 1 diabetes has a strong hereditary component, and it occurs when the immune system mistakenly attacks the islet cells in the pancreas that produce insulin. This islet "autoimmunity" is decreased by high dietary levels of omega-3's in children with a family history of type 1 diabetes or who have a genetic pattern linked to the condition.
Autoimmune thyroiditis (hypothyroidism) - Autoimmune thyroid disease
Q. I have found your site to be an extremely helpful reference for the most current studies on supplements. Thank you. I have an unusual autoimmune disorder (Hashimoto’s Encephalopathy) which I have helped to stabilize great deal through use of supplements and diets (under the supervision of a M.D. Naturopath). Although this is prescription medication not a supplement, I’m wondering about what data you may have collected on low dose naltrexone. There seems to be a lot of anecdotal information about its beneficial impact on a broad range of autoimmune disorders.
A. I have not studied this medication well enough.
Hypoadrenocorticism (Addison’s disease)
Immune-mediated thrombocytopenia (ITP)
bowel disease (IBD)
Myasthenia gravis --The muscle building supplement creatine may help increase muscle strength.
Mixed connective tissue disease features signs and symptoms of a combination of disorders — primarily of lupus, scleroderma and polymyositis. For this reason, it is at times referred to as an overlap disease.
Optic Neuritis is an inflammation of the optic nerve. The condition
usually develops from an autoimmune disorder. Major symptoms are sudden loss of
vision (partial or complete), or sudden blurred or "foggy" vision, and pain on
movement of the affected eye. In most cases, visual functions return to near
normal within eight to ten weeks, but they may also advance to a complete and
permanent state of visual loss. Up to 50% of patients with MS will develop an
episode of optic neuritis, and 20-30% of the time optic neuritis is the
presenting sign of MS. There is a higher incidence of optic neuritis during the
spring months. Balashov KE, Pal G, Rosenberg ML. Optic neuritis incidence is
increased in spring months in patients with asymptomatic demyelinating lesions.
Multiple Sclerosis. Feb2010;16(2):252-4.
Comments: Is it because of low vitamin D levels having gone through winter and decreased sun exposure?
Primary biliary cirrhosis information
Relapsing polychondritis is an inflammatory and destructive disorder
involving primarily cartilage of the ear and nose but also potentially affecting
the eyes, the trachea, bronchi tree, heart valves, kidneys, joints, skin, and
blood vessels. Diagnosis is by a combination of clinical, laboratory, imaging,
and sometimes biopsy findings. Medical treatment usually involves prednisone and
drugs that suppress the immune system.
SLE, systemic lupus erythematosus information and natural ways to treat it.
arthritis is an autoimmune disease in which joints,
usually including those of the hands and feet, are symmetrically inflamed, resulting in
swelling, pain, and often the eventual destruction of the joint's interior.
Rheumatoid arthritis is the most common inflammatory joint disease and
a major cause of disability, morbidity, and mortality. It occurs
worldwide, affecting approximately one per cent of adults. Rheumatoid
arthritis may be accompanied by fatigue, weight loss, anxiety, and
depression. some natural options are worth a try. Smoking cigarettes can
worsen the symptoms of rheumatoid arthritis.
The risk of lymphoma is higher in people with inflammatory polyarthritis relative to that seen in the general population. Inflammatory polyarthritis is a form of rheumatoid arthritis involving two or more joints. The incidence is higher in patients with rheumatoid arthritis and those who take disease modifying anti-rheumatic drugs. The highest risk is seen in patients treated with methotrexate.
The co-existence of high prevalence of vitamin D inadequacy among Canadians and high prevalence of systematic autoimmune rheumatic diseases raise the question on relationship between the two situations.
Scleroderma is an autoimmune skin condition
Q. My mom was recently diagnosed with Takayasu's Arteritis. She is 68 years old. I know this disease normally presents itself in young Asian females ages 18-40. My Mom was put on 75 mgs of Prednisone in May and has been tapered to 20 mgs as of this past week. She has severe muscle weakness, fatigue, moon face, thin skin etc. What makes this whole thing worse is that she recently had to undergo emergency surgery for diverticulitis.She was healthy until this diagnosis in May. What can we do naturally to alleviate the symptoms so she doesn't have to take the Prednisone? She can't live with all these symptoms. The goal, as I understand it, is to taper her down to 10 mgs or less over the next 6 months.Any help you could provide would be greatly appreciated.
A. I am not sure how to treat this condition, but perhaps some of the information on this anti-inflammatory article could be of benefit.
Autoimmune disease symptom
These vary widely depending on the disease as well as from patient to patient. It is difficult to say that any particular set of symptoms is indicative of an autoimmune condition. Inflammation is a common autoimmune disease symptom. Dizziness, fatigue, malaise and a low-grade fever are among autoimmune disease symptoms associated with collagen vascular–type of autoimmune diseases. The symptoms mentioned earlier can be caused by a variety of other medical conditions unrelated to autoimmunity.
People with immune-related disorders such as rheumatoid arthritis and lupus may be at increased risk for developing potentially deadly blood clots during hospital stays.
TNF blocker prescription drugs
TNF blocker prescription drugs to treat rheumatoid arthritis, Crohn's disease and other conditions may cause serious and deadly fungal infections. The so-called TNF blocker medications include Johnson & Johnson's Remicade, Abbott Laboratories Inc's Humira, UCB's Cimzia, and Amgen Inc and Wyeth's Enbrel. Humira, Cimzia, Enbrel and Remicade work by suppressing the immune system. This can expose some patients to serious, even fatal, fungal infections.
Activation of autoimmunity following use of immunostimulatory herbal supplements.
Arch Dermatol. 2004. Section of Dermatology, University of Chicago, IL, USA.
Evidence for the scientific basis of purported therapeutic effects and adverse effects of herbal supplements continues to grow. Many herbal supplements are touted for their immunostimulatory properties, and both in vitro and in vivo experiments have supported this claim. Although this explains their beneficial effects in preventing or curtailing disease, to our knowledge, no immunostimulatory herbal supplements have been reported to exacerbate disorders of immune system overactivity. We describe 3 patients whose autoimmune disease onset and/or flares correlated with ingestion of herbal supplements with proven immunostimulatory effects. Echinacea and the alga Spirulina platensis are implicated in 2 patients' flares of pemphigus vulgaris, and a supplement containing the algae Spirulina platensis and Aphanizomenon flos-aquae was ingested by a third patient days before both onset and a severe flare of dermatomyositis. The third patient showed heterozygosity for a tumor necrosis factor alpha (TNF-alpha) promoter polymorphism, leading to increased production of TNF-alpha, which may have predisposed her to developing dermatomyositis. Immunostimulatory herbal supplements may exacerbate preexisting autoimmune disease or precipitate autoimmune disease in persons genetically predisposed to such disorders. Increased production of TNF-alpha may play a role, although more research is needed to clarify the mechanisms of such phenomena.
I noticed that spirulina has
a warning for those with autoimmune disease. How about chlorella?
I have not seen such studies, so I don't know if chlorella pills would have a similar effect.
World J Gastroenterol. 2014. Helicobacter pylori and autoimmune disease: cause or bystander. Helicobacter pylori (H. pylori) is the main cause of chronic gastritis and a major risk factor for gastric cancer. This pathogen has also been considered a potential trigger of gastric autoimmunity, and in particular of autoimmune gastritis. However, a considerable number of reports have attempted to link H. pylori infection with the development of extra-gastrointestinal autoimmune disorders, affecting organs not immediately relevant to the stomach. This review discusses the current evidence in support or against the role of H. pylori as a potential trigger of autoimmune rheumatic and skin diseases, as well as organ specific autoimmune diseases. We discuss epidemiological, serological, immunological and experimental evidence associating this pathogen with autoimmune diseases. Although over one hundred autoimmune diseases have been investigated in relation to H. pylori, we discuss a select number of papers with a larger literature base, and include Sjögrens syndrome, rheumatoid arthritis, systemic lupus erythematosus, vasculitides, autoimmune skin conditions, idiopathic thrombocytopenic purpura, autoimmune thyroid disease, multiple sclerosis, neuromyelitis optica and autoimmune liver diseases.
Autoimmune natural treatment questions
Q. I am also a physician in practice residing in Connecticut who is grateful to you for all your insight and contribution to the field of Complementary / Alternative Medicine. I have read some of your writings on hormonal therapy and autoimmmune disease and i find them very informative and interesting. I also routinely use supplements in my practice and take pride in practicing Integrative medicine which i hope one day will be ubiquitous. My question to you relates to what you consider are adequate hormone holidays for patients with autoimmune disease who are placed initially on Pregnenolone 25mg and DHEA 25mg or higher. In practice I may start with higher doses initially and then taper down to maintenance dosing of about 5 mg depending on response for the long term. Also on a more personal note i have family members who would like to see a physician experienced in the these areas of hormonal therapy ( As family members i would rather they see someone other than myself) within the greater New York area is there someone here you recommend. I don't have to tell you that it is hard to find physicians knowledgeable in this area. Dr. Sahelian once again thank you. I respect you as a mentor and look forward to your thoughts on these questions.
A. I truly appreciate the positive feedback and hope you continue helping your patients heal. It is very difficult to know which patients will respond to hormonal therapy. I personally prefer the cautious approach and would not use a dosage greater than 10 mg. I have seen too many people with serious side effects on high doses, including cardiac rhythm disturbances. You may be fine treating quite a large number of people with higher dosages with no apparent side effects, but eventually you will come across a patient who will have a serious untoward response. I prefer trying less risky options first, such as diet with high amount of fish and lower amounts of omega 6 oils, fish oil supplements, flavonoids, and perhaps certain herbs. Hormones are a last resort. And even if DHEA and pregnenolone work initially, continuing their use is not practical due to eventual side effects. There's still much we need to learn about the use of nutrients and herbs for autoimmune conditions and hopefully more info will be published in the future regarding the natural approach to these conditions.
Q. Is it okay to take
saw palmetto or
lipoic acid for someone
with an autoimmune condition?
A. It's really difficult to predict how herbs and supplements interact with an autoimmune condition or the medicines a person is taking to treat the autoimmune condition. I would suspect small amounts would be fine, but I can't be sure.
Q. I have found your site through researching my illness.
I have autoimmune urticaria and rheumatoid arthritis. After struggling for 8
years with harsh steroids and immune suppressants i think i finally found a
decent treatment. I have begun taking superoxide dismutase and cordyceps. I have
followed the bottles directions for dosage. I have seen a dramatic improvement
with both of my conditions. However I still am getting symptoms. I would like to
increase the dosage of both the cordyceps and superoxide dismutase to see if i
can completely control my illness. I am totally amazed at how well these
supplements work for my autoimmune disease. I would recomend them for anyone
looking to go the natural route for autoimmune disorders.
A. Please keep us updated.
Q. Are EGCG,
the green tea extract, and
resveratrol helpful in autoimmune disease?
A. Perhaps, but we need lots more studies.
an autoimmune disease?
A. It is not classified as an autoimmune disease.
I have some interesting autoimmune issues: autoimmune
thyroiditis, Raynaud's and erythromalalgia. For about 20 years I had consistent,
elevated liver enzymes (althought for the last 4 years or so they have been
normal). I added the NAC after reading one of Sherri Roger's books on
detoxification and found that I noticed a clearer head, less pain and overall
improved energy. (However, I have been taking many other nutritional supplements
and have made some dramatic changes in my diet over the years.) But now I am
wondering if pairing the NAC with food becomes irrelevant if the dose is
reasonably high enough to allow for a therapeutic effect.
It is difficult to predict in any one individual whether taking N acetyl cysteine would be more beneficial if taken with or without food. A good way to find out is, for a period of one to three weeks, to take the pills with food and another 1 to 3 weeks without food to see if there is any difference in reduction of symptoms or signs. That is the best way to find out in your particular case which option is better.
I've been using anti-opiates to treat autoimmune diseases for years now, with a good percentage of patients responding very positively. In fact some are near miracles. Of course you won't hear a lot about this treatment because most antiopiates have lost patent protection.
I am a college professor and MD who has been doing
research online for a holistic protocol for an autoimmune condition called cutaneous histiocytosis (also the possibility of systemic histiocytosis) that
has afflicted my precious furkid Basset Hound for two years now (we did not get
the actual diagnosis until now). This is where the body is making too many
histiocytes and I am being told that his immune system needs to be supressed (So I was curious if you knew of any holistic products that help modulate the
immune system when it is in overdrive such as with histiocytosis (knows as
Langerhans histiocytosis in humans). I am sure there must be some herbs or other
holistic supplements that help modulate the immune system as well as some herbs
that have a strong inflammatory response as well? Since this disease also had a
strong inflammatory component associated with it as well.
The whole issue of the effects of different herbs on the immune system is complicated since there are times when some herbs are initially immunostimulants and then after a few days or weeks or months they become immunosuppressive and vice versa. I have not studied this topic enough to have a good suggestion. Since long term studies with herbal products are not common, it is difficult to know, plus the whole thing becomes more complicated since different herbal extraction processes, dosages, length of use, interactions with other supplements, medications, substances in the diet, alcohol, coffee, sleep patterns, etc, all make it quite complex, along with each person's unique immune system function.
Does the herb maca stimulate the immune system and if so--can
it be used if you have an autoimmune disorder?
I have not seen research with maca involving those with such conditions.