IU vs RAE

Have you noticed a little change on nutrition labels?  Vitamin A used to be listed in IU’s (International Units), but is being changed to µg RAE (Retinol Activity Equivalents).

Apparently Vitamin A is more complex than initially thought. There’s so much more to it than eating carrots for good eyesight!  Vitamin A is still fat soluble. It’s still important for vision. It is also critical for things like immune function and modulating inflammation – especially important if you have an autoimmune disease!  What’s changed is what we know about how Vitamin A is metabolized.

• animal sources contain pre-formed Vitamin A (retinol & retinyl ester)
• plant sources contain many different kinds of pro-vitamin A carotenoids, including but not limited to:
  • alpha-carotene
  • beta-carotene
  • beta-cryptoxanthin

Our bodies bio-convert all of these nutrients so that we can use the active form of Vitamin A: retinal (and retinoic acid).  It turns out that what researchers have learned about this process led to the change in units from IU to RAE.  There’s a difference in how nutrients convert depending on their source. Confounding the researchers, when looking at IU’s, foods supposedly containing the same amount of Vitamin A can metabolize to vastly different amounts of usable retinal, which means that there isn’t a simple conversion factor to use to change all IU’s to RAE’s.¹ Although we absorb about 70-90 percent of pre-formed vitamin A from animal sources, carotenoids are a different story. Plant-based Vitamin A is not metabolized nearly as well.

Consider two foods that many people consider disgusting:  kale and liver.  Both are good sources of Vitamin A, yet the nutrients look quite different between the old and new units of measure.

Kale (1 C = 67 g)	10,302 IU	515 mcg RAE
Beef Liver (2 oz)	9,600 IU	2,805 mcg RAE

IU’s make it look like kale has more Vitamin A, but when we look at how much retinal our bodies get to use from these foods, a serving of liver has more than five times as much.

Vitamin A & Autoimmunity
For years, some people have suggested that autoimmune diseases are caused by nutrient deficiencies.  Nutrition is especially important to people with autoimmune diseases.  In the case of Vitamin A, we need sufficient amounts for our bodies to work correctly. Unfortunately, sometimes people think that they can just take a handful of vitamin pills instead of eating properly. It doesn’t work that way.  We need to consume plenty of Vitamin A-rich foods if we’re to be as healthy as possible.  Vitamin A is needed to do many things, including:

• form natural killer cells
• increase phagocytes to fight infection
• increase anti-inflammatory cytokines

Why the Change in Units?
The newer research about how bioconversion takes place indicates that some people are not getting nearly as much Vitamin A as they thought since not all IU’s are metabolized the same. Switching to RAE’s is better because it gives us a more accurate picture of the nutrients our bodies actually get to use.

One cup of kale provides 74% of the Recommended Daily Allowance for Vitamin A, while a two ounce serving of liver (because, honestly, who can stand to eat much more than that?) is well over the RDA and nearly to the tolerable upper limit (UL).

Yep, there’s an upper limit.  Just as it is important to get enough Vitamin A, it is also important not to get too much.  Toxicity can result from excessive intake.  Vitamin A toxicity is more common when people are taking supplements, but can happen through dietary intake, too, generally from excessive amounts of liver. I find it slightly ironic that eating too much liver can be harmful to our livers.

Symptoms of toxicity are numerous and can include headaches, dizziness, nausea, joint pain, peeling skin, and in extreme cases coma, or even death. Severity depends on how much Vitamin A was ingested, and how fast. This theory says that symptoms would be more severe for a person who eats 5,000 mcg in one sitting, compared to a person who eats 1,100 mcg three times a day. Am I a terrible person for thinking that anyone who eats 4 ounces of liver shouldn’t be surprised that it makes them sick?

Curiously, excess plant-based Vitamin A is not toxic. The most-reported symptom is orange skin. I know someone whose baby loved carrots and ate so many that his face turned orange.  Skin returns to its normal color when plant-sourced Vitamin A consumption is reduced.

So how much is enough, and how much is too much?
According to the current research, dietary needs increase as we grow.  Adult men tend to need more than adult women (probably because they tend to have larger bodies).

Do you ever wonder if people are just throwing darts at a dart board in making these recommendations?  At least 700 µg RAE every day?! Are they out of their ever-lovin’ minds?  People would have to quit their jobs and spend all their time menu planning & cooking in order to find a way to get that much Vitamin A on a regular basis!

How Do We Get Vitamin A?
We can get some Vitamin A from plants. The best plant sources are bright orange or leafy green.  Carrots and sweet potatoes (but not yams) have the most, followed by foods like kale, turnip greens, dandelion greens, radish leaves, and cantaloupe.

However, the Vitamin A from plants is in the carotenoid forms and isn’t metabolized very efficiently. We’re supposed to get animal sources, too.  If you don’t consume dairy or eggs (which is now recommended by many), that means liver. Beef liver. Chicken liver. Liverwurst. Foie Gras. Braunschweiger. Cod liver oil. Liver is an excellent source of Vitamin A.

Don’t eat too much, because toxicity – mentioned previously – is a real thing. One source recommends limiting liver to six ounces per week, maximum.

From a Vitamin A standpoint, it’s not even necessary to eat that much liver.  We could actually get our entire RDA of Vitamin A by eating half an ounce of beef liver daily.  Or bring back the practice of taking a daily spoonful of cod liver oil.

But don’t get stuck in a rut.  We’re actually supposed to get our nutrients from a variety of sources instead of eating the same thing every day.  The USDA’s FoodData Central website has nutrient information on pork liver, veal liver, lamb liver, turkey liver, goose liver, duck liver, sea lion liver, walrus liver, and even moose liver —  but not elk or deer, which are livers that I actually have access to. Go figure.  Anyhow, what it comes down to is that unless you’re eating a ton of vegetables, you should probably eat liver, but a little bit goes a long way.

If you’re curious about the actual amounts of Vitamin A in veggies:

 

By comparison, other veggies don’t have nearly as much Vitamin A². They do, however, contain other nutrients, so don’t neglect them:

So there you have it.  Switching the units from International Units to Retinol Activity Equivalents lets us look at nutrient information and know how much Vitamin A our bodies will actually be able to use.

* * * * * *

For Further Reading:

• Vitamin A (NIH)
• Vitamin A (Medline Plus)
• Vitamin A Fact Sheet for Health Professionals
• The Telltale Liver
• The Perils of Eating Polar Bear
• Hypervitaminosis A

___

¹Converting from IU’s to RAE’s:

• For meat and eggs (retinol sources), multiply IU by 0.3 to find mcg RAE
• For fruits and vegetables with beta-carotene, multiply IU by 0.05 to find mcg RAE
• For fruits and vegetables with alpha-carotene or beta-cryptoxanthin, multiply by 0.025 to find mcg RAE

²Nutrient info is from the US Department of Agriculture’s FoodData Central website, glycemic load information is from Self’s NutritionData database. Color groups shown are based on Dr. Terry Wahls‘ research, wherein she recommends eating 3C of leafy greens, 3C of brightly colored (try to hit more than one color), and 3C sulfur-rich foods daily. I have omitted nightshades and legumes because they are disallowed in the elimination portion of Wahls and AIP. Legumes didn’t make the re-intro cut for me (not a problem since I’m allergic to soy and probably peas and peanuts), and the only nightshade I really do okay with is tomatoes if they’re organic (but I react to standard store-bought tomatoes). More than you ever wanted to know, but that’s what determined what’s on the lists.

There’s always something new…

RA doesn’t just affect joints.  It can affect the lungs, kidneys, pancreas, and so on – all the body’s systems.  That’s a problem with a systemic disease.

Although I had thought my disease was fairly well controlled, it turns out that even though my joints seem to be okay, and my labs look fantastic, there’s hidden inflammation wreaking havoc internally.  In my ongoing learn-A&P-by-malfunction life-course, I now get to learn all about pericarditis.

Pericard-itis is exactly what it sounds like it would be: inflammation of the pericardium.  And if you’ve ever taken Greek (thank you, Dr. Pecota), the pericardium is exactly what it sounds like it might be:  peri is a preposition meaning around, and cardion means heart, so the pericardium means something around the heart.  Thus pericarditis is inflammation of the thin, double-walled sac that surrounds the heart.  And let me tell you, it hurts!

There are many potential causes of pericarditis, and one is autoimmune diseases like RA.  Other causes include infection, heart attack/surgery, cancer, chest injury, HIV, and TB.  But with RA/SLE/PsA as a risk factor, this is something that the autoimmune community really ought to know more about.

The main symptom is chest pain.  This is most commonly sharp, stabbing pain – particularly in the center.  If you’re atypical like me, it could be more of a dull ache.  Think of your entire sternum hurting.  If you have a history of costochondritis (inflammation of the joints where the ribs attach to the sternum), you might be tempted to dismiss pericarditis symptoms as a costochondritis flare.  We’re talking about chest pain, though.  Go see your doctor!

Other symptoms can include:

• Fatigue
• Shortness of breath or difficulty breathing
• Coughing
• Palpitations
• Fever
• Pain when swallowing

It’s important to know the symptoms and seek help when warranted.  Don’t blow this off as a minor flare.  When we have chest pain, we need an accurate diagnosis and a good treatment plan!

Easier said than done.  I ignored things for a couple weeks, until finally my family members were concerned and insisted that I see our doctor.  Now, I like my doctor, but am not looking for extra excuses to see him.  I tend to figure that if I ignore things long enough, they’ll get better on their own.  After all, the body has a remarkable ability to heal itself!  Nonetheless, to get family members off my back, I went to see my doctor.  He is usually pretty good at the MD’s poker face. Nothing fazes him.  But when we discussed the “what makes it better/worse” question and I told him that it helps to lean forward, he looked at me like I’d lost my mind.  I smiled, “What can I say?  I just report the symptoms. You get to figure out what they mean.”  As it turns out, it’s pretty well documented that sitting up and leaning forward can ease the chest pain associated with pericarditis.  Once the doctors gave a name to my symptoms and I was able to read about it, I exclaimed, “HA! I’m not crazy!”  Well, maybe I am, but not about this!

Tests

When you see your doctor for chest pain, tests will be done.  Lots of tests.  Doctors don’t like their patients dying, so take complaints of chest pain quite seriously.  Even if you insist that it’s not your heart, it’s your lungs, they will ignore you and focus on your heart.  Expect to have an electrocardiogram (ECG/EKG) done almost immediately.  This not only tells the doctor what your heart is doing at that moment, but can show evidence of a past heart attack.¹

Stethoscopes are a great invention.  In the case of pericarditis, the layers of the pericardium can rub against one another, and doctors are often able to hear this rubbing.  It’s fascinating.  Painful, but fascinating.

Another test, but one that can’t be done in a lot of primary care offices, is an echocardiogram (echo). This is an ultrasound of the heart, and in addition to an ECG is one of the tests that can be used in diagnosing pericarditis.  Positive results are considered conclusive, however negative results are not.

A chest x-ray can show what’s going on with your lungs, and will also show if the heart is enlarged.

MRI can be done to check the thickness of the pericardium, but is not likely to be one of the tests ordered initially.

Labs might also be ordered.  This is especially true if you go to the ER from your doctor’s office.  They’ll completely ignore your pcp’s input and order a plethora of tests to measure inflammation and make sure you’re not having a heart attack.²

Types

• Acute pericarditis appears suddenly and lasts fewer than three weeks.
• Incessant pericarditis is continuous and usually lasts 4-6 weeks, but definitely less than 3 months.
• Recurrent pericarditis is when symptoms of acute pericarditis resolve completely, the patient is symptom-free, and then 4-6 weeks later the symptoms occur again.
• Chronic pericarditis lasts longer than 3 months.

The Art of Medicine

Eventually I saw a cardiologist.  He’s a fantastic guy.  He read the history my family doctor sent, listened to my story, did an exam, and read the ECG.  Tired of waiting for the ultra-slow wifi to work, he said, “Let’s do this the old fashioned way,” and retrieved a couple tomes from his office – including one that he said used to be the Bible of cardiology.  It was kinda neat to watch him look things up just to confirm he was remembering things accurately, and he showed me in his books what it says about RA and pericarditis. Then he told me that he’d check up-to-date once he had a better internet connection.

After that, he showed me my ECG and explained that the machine was reading it as normal, but that’s not how he read it.  And he carefully showed me the exact places on all those wiggly lines that he thinks look like my readings are abnormal, as if I were able to read ECG’s.  I can’t, but he made it sound fascinating, didn’t treat me like an idiot, and I’m tempted to get a book to see if I can pick up the basics of reading ECG’s.

Medicine isn’t just feeding data into a computer that turns around and spits out a diagnosis and treatment plan.  There’s an art to listening to patients, asking the right questions to get all the assorted symptoms that the patient didn’t even think to mention, and putting everything together.  Then after determining a diagnosis, doctors still need to figure out a treatment plan.  Every patient is different.

Treatment

Since this is inflammation, it makes sense that anti-inflammatories would be the first line of treatment.  But RA patients already know to take ibuprofen before bothering their doctors with a little inflammation, which means my cardiologist jumped directly to the next step.

Colchicine is a gout medicine that works to reduce inflammation, and is one of the most common pericarditis treatments.  My insurance has this as a Tier II med, so be forewarned.  The most common side effect is needing frequent trips to the bathroom with lots of TP and air freshener, but if you’re already taking something like sulfasalazine, that is unlikely to be a problem 🙂

Steroids can also be prescribed to reduce the inflammation.  It’s nice to know there are options if the colchicine doesn’t work.  Frankly, given the cost difference, my personal preference would be to deal with prednisone, but there’s the usual love/hate issue when that medicine is prescribed.

Here’s hoping your life is less eventful!

_______

¹ If the ECG’s automated results say “inferior infarct, age undetermined” do not panic. It might mean that you had a small heart attack at some time in the past, but it also might mean that the machine isn’t particularly reliable and your results should be interpreted by a skilled cardiologist who will say, “don’t worry; you’re fine.”  If the doctor says, “Don’t worry; the machine doesn’t know what it’s talking about,” believe the doctor.

² If you go to the ER from your doctor’s office, they’ll repeat the ECG and also draw blood to run every test possible in an effort to discover whether or not you’re having a heart attack.  When they announce that you’re not having a heart attack, feel free to respond, “Nobody ever thought I was having a heart attack. I am here because my doctor told me to come here for an echocardiogram because none of the cardiologists can see me sooner than two weeks.”  Better yet, it might be appropriate to be proactive at the very beginning of the visit and insist that they enter “sent by pcp for an echo” as your chief complaint, or they’ll get it all wrong and think that you’re there for chest pain.  To tell the truth, the ER is a horrible experience and if I’m ever sent again, I will take with me the name of the ER doctor with whom my pcp spoke.  And if it’s the height of flu season, beg to be sent anywhere else.

Making Life Easier

RA can make it challenging to accomplish tasks that we once considered easy.  Rather than struggle and be frustrated, or give up activities we enjoy, it makes sense to adapt.

Opening Doors – Just say no to doorknobs.  Save your pennies, then swap out those pesky knobs for levers that work even when your hands don’t.

If you have significant issues with doorknobs and can’t afford levers, get creative. Occasionally a business will change out all the locks in their building – and will change all the levers, even those that don’t lock, so that everything matches.  They work perfectly well, but there isn’t much market for used commercial door hardware. If approached right, some locksmiths might give you a bargain (as long as you realize that it’s clunky, commercial hardware and not the lightweight stuff you normally find in houses).

Laundry – First, get a good sorter and train everyone in the house in its use.  I keep my three-bin sorter in my laundry room and taught the kids how to separate their clothes into whites/mediums/darks as soon as they were able to dress and undress themselves.  If I could do it over again, I’d get a fourth bin for denim. We do have a separate bin for clothes that require cold/delicate handling. This method makes things much easier because I don’t have to bend and reach and go through various contortions to retrieve everyone’s dirty clothes and sort them into their respective loads.  When a bin is full, I dump things into the washer. It’s that easy.

That said, there are different styles of sorters.  I highly recommend finding one that has separate bags that lift off the frame, not a single bag with multiple compartments. This will allow you to pick up the bag and empty it into the washer, rather than having to bend over multiple times to dig every last sock out of the bottom of the bag!

In an ideal world, only dry items would go into the sorter, but in the real world, children toss wet socks and washcloths into the sorter and eventually the bag mildews.  Therefore, I highly recommend getting the style that has bags which easily slide off their hangers.  This means that the bag can be tossed into the washing machine and dryer along with the clothes.

My other laundry tip has to do with detergent.  If your hands or shoulders get to the point that pouring detergent into the washer is difficult/painful, spend the extra money for individual pods.  I’m pretty frugal (I have five children, so can’t afford to throw away money), but have decided that these convenience packs are worth every penny.  It works out to 15 cents per pod; I use one in most loads, but two on socks and dirty jeans.  There is a similar option for dishwasher detergent.

Hanging Rods – Closets with rods that hang at (or above) eye level are poorly designed, in my opinion, and not a friend of anyone with shoulder issues. If you have trouble reaching up to hang your clothes, consider modifying things so that you can hang your clothes at waist height.  Fortunately, my closet has rods at two heights; when my shoulders started causing problems we swapped things around so that my husband had all the top rods, and I got all the lower ones that I could reach easily.

Berry Picking – There’s nothing like trekking up into the mountains to get huckleberries.  The peace and quiet, back-to-nature, time with the family… it’s heavenly. Months later you get to re-live the pleasant memories while enjoying the berries you’ve preserved. Unfortunately, huckleberries are tiny little things (half-the size of a blueberry), and not always easy to grasp.  This year I discovered two tools that I love.  While I used them for huckleberries, they’d also work on blueberries, gooseberries, and various other berries (not so great on wild blackberries, imo, but cultivated ones might be okay).  Do these tools work?  I have five gallons of huckleberries in my freezer for us to enjoy all year long. 🙂

The first tool I found is oh-so-imaginatively called a berry picker.  You just stick it under the branch, then gently comb along the branch from the center of the bush out. The berries fall into the picker, while the leaves (mostly) stay on the bush.  A little debris gets mixed in with the berries, but it’s quite easy to shake the container gently and get the leaves to fall out.

The second tool is made by the same company, and just as creatively named:  berry cleanup tray.  This was not something I planned to purchase, but it was suggested when I ordered my berry picker.  I don’t usually fall for those gimmicks designed to part you with your money, but this had very good reviews and my Raynauds-afflicted hands do not appreciate being immersed in cold water.  After some experimentation, I discovered that the most efficient method is to pour the dry berries into this tray and shake it gently.  Most of the debris will fall out of the tray (exactly as designed).  I then grab my blow-dryer and turn it on the low/cool setting; this blows the remaining debris off of the huckleberries. Note that this method is best used on dry berries.  Wet leaves stick to huckleberries and the tray.  It’s a pain.  First get rid of the debris, then rinse the berries after all the leaves and twigs have been removed.

Don’t struggle, making tasks harder than they need to be, and don’t give up things you enjoy.  Invest in tools that will allow you to do the things that you both need and want to do.  What are some gadgets you’ve discovered that make life easier?