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Autonomic Nervous System

Breathing and Autonomic Nervous System








Breathing and Autonomic Nervous System hold a unique relationship:

Of all functions of the ANS, breathing is the only one we can consciously alter, offering us a backdoor 🚪 to the rest of the Nervous System.

Below is the list of some errands our body runs without our conscious participation:

Digestion of food
Detoxification of environmental toxins
Hormone production
Circadian rhythm cycling
Circulation of blood

Take a moment and think 💭, can you control any of the above? Breathing seems to be the easiest one to alter❗️


How is the respiratory system linked to the nervous system?

The components of Respiration

Our breath has 4 phases*: Inhalation “puraka”, Retention “kumbhaka”, Exhalation “rechaka” and 2nd Retention. Breathing exercises determine the:
1. pace: fast/slow
2. source: nose/mouth
3. volume of air: high/low

The components of the Nervous System

Our Nervous System (NS) consists of a network of neurons delivering signals to and from the brain and the peripheral parts of the body. The neurons in the brain and spinal cord belong to the Central Nervous System (CNS), while the neurons in the peripheral tissue belong to the Peripheral Nervous System. The ANS belongs to the Peripheral Nervous Systems and consists of 3 subparts. The:
1. Sympathetic
2. Parasympathetic
3. Enteric

How does the Autonomic Nervous System control Breathing?

Breathing and the Nervous SystemWhile a few regions in the brain contribute to the regulation of the breath all information is consolidated and decisions are made by the brainstem (made up of the midbrain, pons, and medulla oblongata). In order to regulate the breath according to our metabolic and psychological demands, the brainstem has established a 2-way communication with many areas in the body.

The inputs are derived from muscles and specialized sensory neuron receptor cells (called chemoreceptors). Chemoreceptors monitor our levels of CO2, O2, and pH. The brainstem after processing the inputs communicates to the diaphragm how fast to contract.

Image source: Aminoff’s Neurology and General Medicine

How does the Breath affect the Autonomic Nervous System?

A very compelling theory was put forward in 2006 proposing that voluntary breathing affects the ANS in 2 ways biomechanically (ref). Slow breathing:

  1. activates Slow Adapting Stretch Receptors (SARs) which subsequently cause the inhibition of neurons.
  2. stretches fibroblasts in the lungs leading to the slow down metabolic activity in the surrounding tissue.

Both actions, according to the authors, lead the ANS to a Parasympathetic dominant state. Biochemically though as well our slow breath holds and slow breathing activates the baroreflex receptors decreasing the basal Heart Rate (ref).

What is the fastest way to regulate the nervous system?

Many breathing exercises can help you regulate your nervous system. The following variation of box breathing, called “Empty State of Mind”, has worked wonders for many people.


To improve your breath though when you are not conscious of it check out the Breathe Right 2-week course.

CO2 Breathing Therapy

CO2 Breathing Therapy is breathing training for those with chronic or acute dysfunctional breathing aiming to reduce the associated physical, mental and psychological symptoms that accompany it. Due to the pivotal role Carbon Dioxide has in the use of Oxygen, CO2 Breathing Therapy can also improve patients’ metabolic function.


Most people know CO2 as a by-product of metabolism which can be toxic❗️ In reality CO2 has multiple functions in the body. If you want to learn:

• How does CO2 affect the way we breathe?

• Why CO2 is vital for metabolism?

• How to regulate CO2 levels with CO2 Breathing Therapy?

Read on…


Why is Carbon Dioxide important to humans?

Carbon Dioxide (CO2) allows us to regulate blood 🩸 pH, respiratory rate, and delivery of oxygen (O2) to our cells. Most of the CO2 in the body is produced during energy production [1] and in healthy individuals, it is maintained at 40 mmHg in the blood at all times.

If CO2 was non-essential, would our bodies ensure its constant presence in our bloodstream?

Why is CO2 important in metabolism?

Our body’s capacity to produce energy is dependent on oxygen. Our cells are capable of producing much more energy in the presence of oxygen compared to a non-aerobic state [2]. Approximately 90% of the oxygen in our cells is used for energy production [3]. So how can we ensure the delivery of adequate oxygen to our cells?

Oxygen circulates in our body through proteins called hemoglobin. Based on the Bohr effect, discovered in 1904 by Christian Bohr, hemoglobin in the blood requires CO2 in order to release oxygen (ref). Low levels of CO2 in the blood, increase the affinity of oxygen to hemoglobin, preventing it from moving to the cells [4].

Why am I short of breath if my oxygen saturation is good?

When you are out of breath your body has reached its limit of Carbon Dioxide tolerance. The urge to breathe harder (instead of an urge for more Oxygen) is an urge to get rid of Carbon Dioxide. When most people are out of breath, they tend to breathe faster or take bigger breaths. Both of these actions will offer a temporary release of the air-hunger sensation without affecting cellular oxygenation.

Strange as it may sound, the increase of air in the lungs, is not what is required for better oxygenation of our cells. Our body maintains high oxygen saturation.

By using an oximeter we can easily prove that our blood keeps 95-99% of its total oxygen capacity most of the time.

If our blood constantly maintains good levels of oxygen, why do we “run out of breath” at the end of a strenuous workout or when walking quickly upstairs? Because we have reached our tolerance to CO2 not because we are out of O2.

oxygen transport


In order to grasp how erroneous the idea of air hunger equating to lack of oxygen is, think of the following: During an asthma attack patients are advised to breathe through a brown bag. The reason is to re-inhale the CO2 they exhale so they maintain adequate levels of CO2 in their blood and oxygenate this way their cells.


How can I increase my CO2 levels naturally?

CO2 will naturally increase when you hold your breath or breathe less air than normal. While you can temporarily increase your CO2 levels this way, to establish a higher etCO2 level (the amount of CO2 your blood will maintain at a pH of 7.36) permanently, you need CO2 Breathing Therapy.

CO2 Breathing Therapy involves the daily practice of hypercapnic breathing exercises. Exposing the body to higher levels of CO2 will gradually desensitize the chemoreceptors that monitor respiratory rate → make breathing softer → increase levels of etCO2 & tolerance to CO2.

CO2 pH relationship

A simple exercise to start CO2 Breathing Therapy is the following:


How does CO2 Breathing Therapy improve metabolism?

In order to deliver oxygen to our cells efficiently, we need to prolong our urge for the next inhalation. The beneficial metabolic effect of temporary exposure to an elevated CO2 state has been demonstrated in one study, where the application of CO2 to transcutaneous tissue led to the proliferation of mitochondria, similar to the one observed during aerobic exercise (ref).

oxygen transport


Capnometry-Assisted Respiratory Training

Capnometry-Assisted Respiratory Training, or CART, is CO2 Breathing Training using a capnometer. This way the patient can measure exactly his levels of CO2, and has been shown to have beneficial effects in panic attacks (ref).


Take 🏡 message

Breathing affects many functions in your body and to the extent that CO2 regulation is the key determinant of your respiratory rate, it is worth training your CO2 tolerance. To start your training reach out to me via the contact page.



1. Carbon Dioxide (CO2) is a by-product of fat and carbohydrate metabolism (aerobic and anaerobic). It exists in the fresh air at concentrations of 0.036-0.041% (36-41ppm).

atmospheric oxygen and carbon dioxide levels

source: Cummins E et al., 2019

At 1% (10,000 ppm) concentration it can cause sleepiness and between 7 – 10% suffocation. In one study subjects were exposed to air containing 7-14% of CO2 for 10-20 mins. All subjects had a complete recovery of their physiology 10 mins after the end of the experiment (ref).

Carbon Dioxide (CO2), a natural-occurring product of metabolism, should not be confused with Carbon Monoxide (CO), a flammable gas that does not occur naturally in the atmosphere.

2. One molecule of glucose will produce two molecules of Adenosine Triphosphate (ATP – our body’s energy currency) in an anaerobic state, as opposed to thirty-six molecules of ATP in an aerobic state.

3. Bland, J., Costarella, L., Levin, B., Liska, D., Lukaczer, D., Schiltz, B. and Schmidt, M.A., 1999. Clinical nutrition: A functional approach. The Institute for Functional Medicine, Gig Harbor, Wash, USA.

4. That was 33 years before Han Krebs’ discovered the eponymous Krebs cycle.

Yoga for stress relief

9 ways yoga can help you with stress and anxiety

How much can you expect from yoga in periods of high stress and anxiety?

Yoga is often recommended as a stress relief strategy, but how much can you expect from it and how does it actually work? Let’s explore the benefits yoga can bring to help with stress and anxiety.

Feel Calmer

What is stress?

Stress is often an umbrella term for situations that are challenging. Of course, not every challenge is bad and I bet that in some areas of your life these stressful situations may even bring euphoria as opposed to negative emotions.

Let’s look at the following examples:

  • An athlete striving to improve performance and is under stress to exceed previous achievements.
  • A businessman trying to grow the company and is facing new challenges to help the company grow.

The examples above can be referred to as eustress and the opposite of which is distress often referred to as stress. One of the best definitions of distress/stress I have come across is the inability to adapt to a situation.

There are a few things that can help us deal with this type of scenario:

  • Understand what the issue is.
  • Understand how the stressful situation is affecting us (in a negative & positive way).
  • Receive support/help from our environment in our effort to deal with it.
  • Build the resilience necessary to endure its consequences.

Can yoga help with any of the above? Can yoga help reduce stress?


How can yoga help you manage stress and anxiety?


🪞 Yoga as a reflective practice

Yoga through all its components: meditation, asana, and pranayama improve our awareness of ourselves and this can be beneficial in managing stress and stressful situations in two ways:

  1. Understanding ourselves will help us understand others (situations/people).

    If every time I’m tired and practice yoga asanas (physical postures), I have less patience to hold the posture long enough. This may help me understand why a colleague has short temper later in the day after a series of demanding meetings.

  2. Understanding ourselves will help us see ourselves in others.

    If that happens, the stressful individual/situation – can now be seen as part of us as opposed to something foreign.

I might be patient during working hours but, like my colleague, short-tempered with my partner when I’m tired. Whatever we face which triggers us are parts of ourselves that manifest in some areas of our lives.

This aspect of yoga is critical when it comes to dealing with stressful situations. In the process of knowing ourselves, we will come to own all of our parts: some of which are often labeled positives or negatives.

Once I see my colleague’s reaction in me; getting stressed by her response will be the equivalent of getting stressed by myself. This happens all the time with aspects of ourselves we don’t own (we don’t acknowledge as ours). Once we own this quality, like in the example of lack of patience, the situation will no longer be as stressful.


🧠 🔗 🫀 Yoga: helping link mind & body – a reality check

Yoga has been credited with helping practitioners merge their minds and body. Though in reality, the mind and the body are inseparable. Here are two examples to help convince you (if you have any doubt)

  • When you’re in a jolly mood how different is the quality of your skin & hair?
  • How much is your cycle affected by your emotions?

The problem is that very often the mind & body are disconnected. Partly due to sociological pressure, partly due to the programming we have undergone (both during upbringing & later in life) we often feel obliged to conform to a behavior that might not necessarily serve us. Many people ignore the body’s signals of how to deal with this situation and end up disconnected.

How easy is it to deal with a stressor if you are not in tune with your body? In the most extreme cases – and I have been there myself – we may not even register the stress. I’ve had cases of clients who were convinced they were not affected by stress until they saw a messy 24h saliva cortisol test report.

When the mind & body are in synch we can easily pick up on the symptoms and act accordingly. Someone with a sensitive digestive system may want to adapt their diet accordingly when faced with stress. While someone dopamine-driven may want to schedule constructive activities during stressful periods and avoid the abuse of toxins. Of course, a mind-body connection is achievable through yoga, just not guaranteed.

I have observed practitioners focusing completely on their body (and how to perform a posture) and others obsessed about their emotions. Neither approach will achieve a mind-body connection.

Here are a few tips on how to improve your mind-body connection with yoga to reduce stress:

  1. Every time you start your yoga practice perform each exercise as if you are doing it for the first time.
  2. Try to remember what you do during the class: postures, alignment adjustments, breathing exercises, etc. At the end of the class, it’s worth reviewing what you went through.
  3. Maintain an inquisitive mind, questioning what effect each exercise has on you.
  4. Question if your current practice is serving you at this moment.


🛏 Yoga as a nurturing practice to reduce stress

This is by far the most common reason why people start yoga in the western world (alongside improving flexibility). Yoga offers numerous poses, that can calm the mind & the body. It’s hard to focus and make good decisions when overwhelmed, overthinking, or overworked.

Calming the nervous system with restorative yoga postures can help get more centered and ultimately deal with the task at hand.

While the nervous system can also calm down in passive ways, such as a Jacuzzi or massage, the fact that yoga requires active participation makes it even more beneficial. What’s interesting is that those that need restorative practice the most, are often the last ones to attend such a class. The more yang someone is the more need they have for yin. Usually, this individual will seek more yang practices to fight fire with fire.


😤 Breath as the backdoor to our Autonomic Nervous System (ANS)

Our body has been engineered to adapt to our environment. If it was not for our ancestors’ ability to adapt we would not be where we are now. Our body’s adaptation system is called the Autonomic Nervous System (ANS) and it orchestrates the function of numerous organs so that we will improve our chances for surviving and procreating.

The ANS controls the endocrine system (hormones), heart rate, and breathing. The different parts of the ANS are linked with each other, somewhat through a very famous nerve called the vagus nerve. Of all the components of the ANS, the breath is the one we have easier control over, and thus by changing our breath we can manipulate the state of the entire ANS.

In a state of distress, we feel that we have no control over the situation. While this may hold true, we do have control of our response to it, and there is no more apt way to prove that than by altering the state of our nervous system through breathing.

It is worth pointing out that breathing can be used to activate both the sympathetic (fight or flight) or parasympathetic (rest & digest) parts of our ANS. This can be useful in periods of stress, as a stressful situation may also demand us to be in a state of alertness at times. The video below is from my 5 videos series #freebreathing mini-course showing participants how they can gain control of the nervous system through their breath.

Don’t forget that you can sign up for free now by clicking here: #freebreathing mini-course


The breath as a metronome

When holding yoga poses for long periods (ie. more than 10 seconds) lactic acid builds up in the muscles we recruit, which we often experience as muscular fatigue. In the process of holding these postures, we learn how to breathe accordingly to endure the “pain”. Sequentially we learn how to use our breath in other states of discomfort such as situations of distress. One key aspect of breath which allows us to endure these situations is rhythm. Establishing a slow, rhythmic pattern not only can help us maintain an optimal supply of oxygen to our organs but also stay centered.

The easiest way to establish a rhythm is to count each of the four stages of the breathing cycle. Inhalation, pause, exhalation, and pause for a set period of time. Some individuals are not able to pause while breathing, due to low tolerance & poor chemo-sensitivity to CO2, in which case it is best to set a breathing pattern involving inhalations & exhalations only.

This is a simple introductory exercise to help you establish a rhythm.


🌞 🔗 🌙 Yoga a circadian rhythm regulator

When we are in distress for prolonged periods our body will be adjusting to the new situation. The adaptation process will involve altering hormone production, metabolism, and excretion which will sequentially affect our appetite, sleep, and sex hormones. Do you eat better, sleep better or have the same sex drive when you’re stressed or relaxed?

Physical exercise as well as breathwork, especially when performed at the same time of the day can help us regain control of our hormonal cycle and sequentially our circadian rhythm, our body’s biological clock. By restoring our circadian rhythm we’re able to reverse the vicious cycle of stress stimulus; feeling distressed, being oversensitive to stress stimulus, and feeling more distressed.

Rhythm is one of the five qualities of good breathing. My course “Breathe Right” has been developed specifically to help reprogram our everyday breathing patterns. The video below is from my Breathe Right 2-week course and covers an exercise to help establish a breathing rhythm.



🏋🏽‍♀️ Breathwork: a workout for your respiratory system

The demands on the breath during a yoga asana class can be high as the biomechanics of the respiratory system can be challenged. No wonder free divers perform numerous stretches to improve their respiratory capacity.

Aside from the physical postures, yoga offers a plethora of breathing techniques that will help improve respiratory capacity. Altering the levels of blood gases, like nitric oxide (the molecule behind viagra), oxygen, and carbon dioxide can help achieve this. The 2 pillars of breathwork are hypercapnia (increased levels of CO2) & hypoxia (low levels of Oxygen).

Individuals with low tolerance to CO2 are more susceptible to anxiety & panic attacks. Knowing this allows us, to improve our resilience to stress and response to it, by training our respiratory capacity.

If you are interested in finding out what your tolerance to CO2 is, you can perform the test described in the video below.


💨 Better oxygenation of our brain

Do you ever hold your breath unconsciously when you’re stressed? While this is less worrying than most people think, it is still an indication of being in an uncentered state. A yoga and breathing practice can help train our respiratory system to maintain regular/slow inhalations and exhalations and thus provide a continuous supply of oxygen to our lungs and peripheral organs (including the brain).

Optimal levels of oxygen, nitric oxide, and carbon dioxide are essential in order to secure oxygen delivery to the organs. All organs are necessary for dealing with stressful situations (including adrenals, brain, kidneys) and they need to operate optimally.


🔬 Concentration = Mental strength

Our ability to perform physical tasks depends, to a large extent, on our ability to recruit our muscles. Similarly, our ability to think depends on our ability to recruit our brain. Being mentally sharp 24/7 is not possible and neither necessary. When faced with challenging situations maintaining a clear mind is critical in making the best decisions.

Unquestionably all the exercises we covered until now can support brain health. Meditation however is the most direct way to train our brain. Meditation, a component of yoga, helps us gain control of our brain by teaching us how to stop thinking which can reduce stress. Once we learn how to do that, we can then direct our thoughts at will. Wouldn’t that be beneficial when faced with a stressful situation and not having emotions run our brain?



Challenges are part of life, if not synonymous with it. We refer to challenges as eustress when it’s related to things that we enjoy and inspire us. We refer to challenges as distress when we see no value in them.

Yoga & breathwork can help us in stressful situations so that we:

  • Understand the challenge at hand.
  • See the impact it has on us.
  • Find the resources we need.
  • Become more resilient.

All the above though are likely to take time. Do not expect the benefits after one class. By practicing the techniques over time, yoga helps with stress and anxiety. Be confident that thousands of practitioners have experienced these benefits before you. To schedule an appointment, send me a message via the contact page.


Ice baths

Cold exposure : 3 benefits

The popularity of cold exposure has increased since 2017 in continental Europe, US & Australia through the work of Wim Hof. Whether it is through cryotherapy or cold water immersion more and more people practice and hashtag: #coldexposure. Cold therapy has its roots back in South East Asian yogic traditions and Eastern European-Scandinavian cultures. In this article, I will cover 3 benefits training with cold has for those of us living a modern lifestyle.


How old is cold therapy?

The moment you ask this question you realize that cold has been accompanying humans from the very start of our existence. As temperatures in nature constantly fluctuate, humans have been exposed to cold: voluntarily or not for a long time.


From a therapy standpoint, cold exposure is listed in “The Edwin Smith Papyrus” dated 3,500 BC (Wang H et al., 2006). In certain parts of the globe (ie. Russia, Bulgaria, Scandinavian countries) cold training has been part of the culture, practiced in banya or plunge pools, as well as a standard procedure in hospitals to prevent further damage in patients with cardiovascular (Ref) and neurological conditions (Ref).


In recent years Wim Hof (a dutchman Guinness record holder) popularised cold training through his workshops across the globe. It was my training with Wim in 2016 that initiated my journey in cold exposure.


1. Cold exposure improves Circulation & Cardiovascular Function

Think of cold exposure as a workout for the circulatory system.

Most people think of cardio when it comes to improving their cardiovascular function. Cold exposure though offers a unique way to strengthen one’s cardiovascular system (cvs).

Our cardiovascular system is surrounded by epithelial muscles which facilitate the circulation of the blood. At low temperatures, the epithelial muscles surrounding the veins and arteries of our extremities constrict – preserving the blood and the nutrients carried in it for the more vital organs in the trunk and the head. When the body returns to higher temperatures the epithelial muscles in our extremities dilate again allowing for the blood to flow freely there. In a similar way that our biceps get stronger as they contract during bicep curls (or chaturangas) our cardiovascular system can get stronger through cold exposure.



Good circulation means no athlete’s foot, no cold extremities, better cognitive function, ability to heal/recover faster, and perform better in sports.


2. Cold exposure as a meditation technique

Those that practice cold water immersions for some time report a sensation of stillness in mind (usually 30 seconds to a minute after the initial exposure). A friend of mine Luke Wills (founder of the Optimal Health Method) said he reached a similar state of mind in his 2nd ice bath, with that on the 7th day of a vipassana meditation retreat. Anecdotal evidence like this were confirmed to be valid in a study published in May 2018 titled “Brain over Body“.  In this study participants with no previous experience in cold exposure and Wim Hof, were interchangeably exposed to cold and neutral temperatures. One of the most striking differences between the inexperienced subjects and Wim was the Dutchman’s ability to reduce activity in the insular cortex part of the brain during cold exposure. Insular cortex is an area involved in emotional attachment to external stimuli and self-reflection. Activity in this part of the brain has been shown to be linked with meditation and control in emotional eating.


Meditation is the 5th of the 8 limbs of yoga. Cold exposure is one of the many ways to enter into a state of meditation.


3. Cold exposure helps overcome fears

Cold exposure is demanding on many levels:

• the adrenal glands

• musculoskeletal system

• circulation and

• the brown fat tissue are activated at low temperatures.

Aside though the multiple biochemical adaptations in the rest of the body:

our brain also changes when we are exposed to cold.

The initial response is that of: “fight or flight”. A small area of the brain called amygdala (Greek word for almond) – activates the HPA (Hypothalamic Pituitary Adrenal) axis – signalling a stress response to the rest of the body. While this initial stage is universal the way one deals with cold thereafter depends on his/her experience and ability to use her breath.

By training the body to deal with a stressful situation (ie. a cold immersion) in a controlled environment (such as a shower or a bath) we can reprogram our mind to deal with stressful situations which are out of our control. Our main tool is our breath. Dealing with fear was the focus of a workshop I gave in 2017 to a group of actors.



The list above is not exhaustive of the benefits one can get from cold exposure :

• Controlling pain perception [Ref]

• Generation of Brown Fat [Ref]

• Strengthening of the immune system [Ref]
• Improved tolerance to cold [Ref]

are also good reasons for modern “over-civilised” humans to train with cold.


supplements for vitiligo

Supplements for Vitiligo

Vitiligo is an autoimmune condition and as such certain dietary protocols as well as supplements can be used to support the immune system for those that experience the characteristic skin depigmentation. The scope of this article however is to discuss the supplements that have been shown in clinical trials to help the repigmentation of the skin.

In most cases supplementation was accompanied by the use of light therapy.


For thousand of years the treatment of “leukoderma” (vitiligo) involved the topical application or ingestion of seeds or plant extracts and the subsequent exposure to sunlight. supplements for vitiligoKhellin is an extract from the seeds of the plant khella found in the eastern Meditteranean area. Supplementation of Khellin has been repeatedly shown (Abdel-Fattah, A. et al., 1982, Orecchia, G. et al., 1998, de LEEUW, J. et al., 2003) to improve the repigmentation of the skin.


There have been cases though (Ortel, B. et al., 1988) that after 4-6 weeks of khellin supplementation the elevation of transaminases was observed and for these individuals had to discontinue the treatment.



In search for re-pigmentation solutions for vitiligo, a group of scientists in Amsterdam – NL (Cormane R et al., 1985), noted that patients with phenylketonuria (who among other symptoms have lighter than normal skin) when administrated tyrosine and were incubated with UV-light had normal melanin production. Cormane’s team initially tried the tyrosine & UV-A protocol in a pilot study of 5 without any success. Sequentially they tried phenylalanine (a precursor of tyrosine) seeing improvement in 95% of the subjects after 6 to 8 months. The theory put forward on why phenylalanine benefits vitiligo patches was that it stops antibodies and allows sun radiation to stimulate melanocytes from other areas to migrate to the damaged ones (Camacho, F. and Mazuecos, J., 1999).


50 mg/kg of body weight per day of phenylalanine was administered 1 hour prior to UV A irradiation (twice per week). Of the 19 participants:

i. 5 noted dense re-pigmentation in 6 to 8 months

ii. 13 saw sparse re-pigmentation in the same period

iii. and 1 had no re-pigmentation even after 8 months.

supplements for vitiligo

Since the 1980’s there has been no more research examining the benefits of phenylalanine for vitiligo. All 3 studies combining the administration of the amino acid & UVA exposure as well as the 1 that used just the amino acid reported positive outcomes (Szczurko, O. and Boon, H.S., 2008).


Additional Supplements

PABA is an ingredient often used in sunscreen lotions. One study showed PABA to support repigmentation (Sieve B F, 1942) but currently there is limited research to confirm these findings. An 8 years old girl developed hemolytic anemia and hepatotoxicity after administration of PABA for 4 months. Symptoms were reversed 2 months after discontinuing the supplement (Tootoonchi, P., 2018). PABA has also been reported to cause depigmentation (Hughes, C. G., 1983)


Vitamin E (Szczurko, O. and Boon, H.S., 2008) and vitamin C have also been shown to support re-pigmentation potentially due to their antioxidant properties.



The results in the above studies are very promising. However, as I mentioned already, in certain cases there have been adverse effects such as the development of cirrhosis which highlights the importance of complementary testing and supervision.




Abdel-Fattah, A., Aboul-Enein, M. N., Wasset, G. M., & El-Menshawi, B. S. (1982). An approach to the treatment of vitiligo by khellin. Dermatology165(2), 136-140.


Camacho, F. and Mazuecos, J., 1999. Treatment of vitiligo with oral and topical phenylalanine: 6 years of experience. Archives of dermatology, 135(2), pp.216-217.


Cormane, R.H., Siddiqui, A.H., Westerhof, W. and Schutgens, R.B.H., 1985. Phenylalanine and UVA light for the treatment of vitiligo. Archives of Dermatological Research, 277(2), pp.126-130.


de LEEUW, J., MAIERHOFER, G., & NEUGEBAUER, W. D. (2003). A case study to evaluate the treatment of vitiligo with khellin encapsulated in L‐phenylalanin stabilized phosphatidylcholine liposomes in combination with ultraviolet light therapy. European Journal of Dermatology13(5), 474-477.


Hughes, C. G. (1983). Oral PABA and vitiligo. Journal of the American Academy of Dermatology9(5), 770.


Szczurko, O. and Boon, H.S., 2008. A systematic review of natural health product treatment for vitiligo. BMC dermatology, 8(1), p.2.


Sieve, B. F. (1942). The clinical effects of a new B-complex factor, para-aminobenzoic acid, on pigmentation and fertility. South Med Surg104(135), 9.


Orecchia, G., Sangalli, M. E., Gazzaniga, A., & Giordano, F. (1998). Topical photochemotherapy of vitiligo with a new khellin formulation: preliminary clinical results. Journal of dermatological treatment9(2), 65-69.


Ortel, B., Tanew, A., & Hönigsmann, H. (1988). Treatment of vitiligo with khellin and ultraviolet A. Journal of the American Academy of Dermatology18(4), 693-701.


Tootoonchi, P. (2018). Hemolytic Anemia and Other Side Effects of Para-amino Benzoic Acid in an 8-Year-Old Girl. Iranian Journal of Pediatric Hematology & Oncology8(3).

How to test for Celiac Disease?

The only way you can get a definite YES or a NO for Celiac Disease (CD) is by doing an intestinal biopsy. As this is an invasive and expensive procedure, many prefer measuring serum antibodies as an initial screening process. When someone decides to test for antibodies against gluten it is necessary to keep in mind:

a) that the gluten protein is fairly complex and thus all antibodies need to be tested

b) that the blood test is not a substitute for the biopsy.

Whichever assessment method one decides to use it is important to know that:

For CD, early diagnosis means early intervention with treatment and prevention of long-term complications, including the development of severe and irreversible phenotypes and of other autoimmune disorders.” (Ventura A et al., 2010)


Intestinal biopsy is the golden standard for diagnosing Celiac Disease.


An individual is classified as celiac when a biopsy of the duodenal mucosa is taken which detects:

a) a reduction or disappearance of intestinal villi &

b) intraepithelial lymphocytes (IELs) higher than 25/100 enterocytes (Sapone A. et al., 2012).

Individuals presenting with significant villous atrophy are classified as CD March stage III, whereas normal villi but increased number of intraepithelial lymphocytes are classified as Marsh I or II (Hill ID et al., 2005). Marsh type II may also suffer from CD but positive serological tests is needed to strengthen the diagnosis (Hill ID et al., 2005). When only elevated IELs are observed but no damage of the intestinal lining, it is difficult to diagnose CD (Kakar eta l., 200). In literature this state is usually referred to as latent CD (Dewar et al., 2005) and further testing is required.


Can elevated IELs be due to a different cause other than Celiac Disease?

The presence of IELs can be due to gastrointestinal inflammation caused by H. pylori (Memeo et al., 2005) or tropical sprue (Ross et al., 1981). Unexplained neurological or psychiatric disorders such as autism, schizophrenia, and cerebellar ataxia (Cascella N et al., 2009, Burk K et al., 2009, Genuis S and Bouchard T, 2010) are also linked with elevated IELs and no mucosal damage.


Can a blood test confirm Celiac Disease?

No. However, a lot of the time serum antibody testing is used in the screening process. The ones necessary are: anti-DGP IgG & anti-tTG IgA


Antibodies for the diagnosis of Celiac Disease



Not affected by IgA deficiency

Not prone to interpretation


Appropriate for children <2 years old






Anti-Actin IgA



classic Anti-gliadin (AGA) antibody IgA


1. relatively cheap


1. found in healthy individuals (Bizzaro N et al., 2012)

2. May fluctuate within the first 2 years of age (Simell et al., 2007)

3. relatively insensitive (Fasano A, 2013)




1. useful for pediatric patients with CD who test negative for anti-tTG (Carlsson A et al. 2001, Lagerqvist C et al., 2008).

2. useful in patients with IgA deficiency (Villalta D et al., 2007).

3. reasonably cheap

3. Same results where obtained with the DGP IgG test (Liu E et al., 2007, Agardh D 2007, Basso D et al., 2009, Naiyer A et al., 2009).

4. Remains constant the first 2 years of age (Simell et al., 2007)


1. relatively insensitive (Fasano A, 2013)


EmA (Endomysial Antibodies – antigliadin) IgA (unless IgG requested)


1. It is equally specific with the anti-tTG antibodies, meaning it recognizes the same antigens (Hill 2005)


1. It is prone to subjective interpretation

2. It is less sensitive than the anti-tTG (Biagi F et al., 2001, Baudon J et al., 2004, Lock et al., 2004, Kaukinen K et al., 2007).

3. Not accurate in patients with selective IgA deficiency.

4. May fluctuate within the first 2 years of age (Simell et al., 2007)

5 *The IgG version has inferior sensitivity (Fasano A, 2013)


anti-tTG (antihuman tissue transglutaminase) IgA (unless IgG requested)


1. As it is quantitative, automated and not prone to subjective interpretation

2. high diagnostic sensitivity (95%) specificity (97%) (Tozzoli et al., 2010)


1. Anti-tTG IgA is not sensitive enough to be used alone and the addition of the anti-DGP IgG test would increase the accuracy for CD especially in children (Niveloni S et al., 2007, Villalta D et al., 2007, Volta U et al., 2010, Tonutti E et al., 2009, Villalta et al., 2010, Maglio M et al., 2010)

2. May fluctuate within the first 2 years of age (Simell et al., 2007)

3 *The IgG version has inferior sensitivity (Fasano A, 2013)


DGP antibodies IgG (deamidated gliadin peptide)


1. antibodies comparable sensitivity and specificity to anti-tTG and EMA (Sugai E et al., 2006)

2. Remains constant the first 2 years of age (Simell et al., 2007)

3. DGP IgG test positive in 80% of cases of CD patients with IgA deficiency as compared to 40% for AGA IgG ( Villalta et al., 2010)



Pros: can evaluate the severity as it is related to the severity of intestinal damage (Granito A et al., 2004, Carroccio A et al., 2005)

Cons: limited usefulness for diagnosis


In monitoring of patients on a gluten-free diet, positivity with a low titer of anti-DGP antibodies suggests that the diet should be reassessed, even if the anti-tTG test is negative” (Tursi et al., 2006)


Interpretation of serological and biopsy test results






Absence of CD and possible false-positive blood test. A negative genetic test can strengthen the negative diagnosis.

This result is treated as CD. However, inflammation in the lining can be due to other causes, including intolerances to other foods.

No CD. However, in the presence of other autoimmune conditions or genetic predisposition, future monitoring may be appropriate.


Which other blood biomarkers are available?

While the tests above are the ones most commonly done there is evidence that more thorough testing may be needed for those with negative results and positive symptoms. A complete antibody screening should include: Alpha gliadin, Omega gliadin, Gamma gliadin, Deamidated gliadin, TG2, TG3, TG6.


Deamidation is an acid or enzymatic treatment used by the food processing industry to make wheat, water-soluble so it mixes with other foods. It has been shown to cause severe immune responses to people (Leduc V et al., 2003).

Gliadin is broken down to alpha, omega and gamma fractions. If a lab tests only for alpha gliadin antibodies the results may be misleading (Quartesn H et al. 2001).

Elevated antibodies of TG2 indicated a reaction against the intestinal track (Thomas H et al., 2011). Transglutaminase 3 (TG3) is found in the skin. An autoimmune reaction to skin may lead to skin disorder known as dermatitis herpetidormis, which presents as itchy red blisters found usually in the knees, elbows, buttocks but can appear anywhere on the body (Stamnaes I et al., 2010). Elevated antibodies to transglutaminase 6 indicate an immune response against the nervous system (Alessio et al., 2012).