A Paleo physician’s journey through major surgery

At age 46 I had a total hip arthroplasty (THA). Metal and plastic components replaced my hip joint (the stem, ball and socket of the hip). I am convinced that if I had adopted a Paleo lifestyle at age twenty instead of age 58 I would have not needed that surgery. But more about that another time.

On Monday I underwent a revision of that surgery to replace some components, scrape out bad bone, remove inflamed joint lining, flush out plastic debris, and place some bone grafts into areas where bone cysts had formed. The surgery was necessary because the plastic debris from my first artificial joint had stimulated my immune system in a way that caused my macrophages (white blood cells) and osteoclasts (a special kind of bone cell) to start destroying the bone around my hip socket. This process is called osteolysis.

Our immune cells evolved to destroy and consume bacteria and viruses, not plastic powder. So as the plastic liner of my hip prosthesis wore down, the plastic debris provided a constant source of inflammation, stimulating my immune system to get rid of a foreign invader. The bone around my prosthesis got caught in friendly fire. This problem does not seem to occur since a newer form of plastic, having only 10% the wear rate of the old plastic has been introduced. Time will tell if that proves to be true.

To prepare for surgery I reviewed my Paleo behavior with respect to diet, sleep, exercise, stress reduction and outdoor time. My exercise routine was already very reasonable. I had been strictly avoiding grains (except for occasional white rice) and legumes but did include some fermented dairy (kefir and cheese) and wine. So I eliminated all dairy and all alcohol. Sleep has always been an issue because as a physician I take call and sometimes work through the night with emergency cases.

My last call night was 3 weeks before surgery and I was up all night. The next day I flew to NJ for two important events (a reunion and a wedding) both of which were definitely not Paleo environments. A flight cancelation required more sleep deprivation in order to reach my first event on time. That sleep deprivation in combination with the changes in time zone disrupted my circadian rhythm so upon returning home two weeks before surgery I knew I had to play catch-up to be ready for surgery. I avoided alcohol except for a few drinks at my brother’s wedding and violated the wheat prohibition once with a piece of wedding cake.

When I returned to California I was 6 pounds heavier and jet lagged. I promptly got an upper respiratory infection (probably acquired on my flight home) which started in my throat and nose and went to my lungs.

So now I am jet-lagged and infected just two weeks from surgery. Not a good situation.

Thereafter I was strictly Paleo in diet, sleep, and stress reduction (yoga and meditation) but had to limit exercise to yoga and walking in order to fight the infection and prepare for surgery. I spent as much time walking outdoors as was feasible and focused on eight hours sleep each night. After one week I was beating the URI so I decided to do two 30 minute sessions of resistance training during the last week before surgery.

By the day of surgery the URI was completely cleared and I was down 6 pounds to my baseline.

I self administered my own pre-operative medication protocol (designed to mitigate post operative pain) and received a spinal anesthetic from my friend and colleague using a combination of local anesthetic and a small dose of spinal morphine. The latter can provide pain reduction for up to 24 hours after surgery.

So here is the amazing result.

5 hours after surgery I walked without pain using a walker bearing full weight on the surgical leg. I walked again that evening without pain. I knew this was the honeymoon period because the spinal morphine was still protecting me.

The next morning the honeymoon was over but I was still able to walk with full weight bearing without any pain medications and subsequently walked several times up and down the hospital halls during the first three post operative days. Although I had pain with movement I had no pain at rest.

On the day after surgery my CRP (C reactive protein) was 0.2 mg/dl. CRP is a measure of inflammation in the body. Normal range is zero to 0.5. I was elated. One day after a major traumatic event which typically initiates an inflammatory cascade, I did not have excess inflammation throughout my body as measured by CRP. My WBC (white blood cell count) was also normal.

A paleo lifestyle will not prevent pain after surgery but being in a low inflammatory state before surgery certainly helped with recovery.

My walking ability immediately after surgery and during the next three days astounded the physical therapists and nurses. They all stated I had set records.

My colleagues in the Anesthesia Department could not believe that I received no opiate or NSAID pain medications during my recovery. It is now five days since surgery. I have taken no opiate pain killers or NSAIDs except for low dose aspirin (starting yesterday) to help prevent blood clots

I avoided NSAIDs because NSAIDs increase intestinal permeability (which leads to an inflammatory response) and also because NSAIDs increase risk of cardiovascular events (heart attack, stroke, blood clots in the legs which can travel to the lungs and cause death in severe cases)

I can attribute my success to many factors including an excellent anesthetic, a great surgeon, an optimal pre-operative medication protocol, the superb nursing and therapy staffs and the Paleo lifestyle. In preparing for surgery I was able to make an effective come back from a stressful travel week, two successive nights of sleep deprivation and an upper respiratory infection only because of the Paleo approach.

As I walked my laps around the orthopedic unit I noticed that most patients spent the entire day in bed except for a few laps each day with PT. Many factors contribute to that problem. Our PT department is very aggressive but post operative pain, obesity, inflammatory diets and sedentary lifestyles all contribute to slow recovery. The hospital menu is highly inflammatory thick with processed-carbohydrates, pro-inflammatory grains, legumes, and refined vegetable oils, and yes,  even some trans fats. A strictly Paleo menu would be very helpful. But most of those patients have been living the Standard American Lifestyle (inflammatory diet, chronic sleep deprivation, inadequate exercise, poor stress management, etc.)  for a lifetime prior to surgery and it can take months to years of a Paleo lifestyle to mitigate a lifetime of self abuse. Even then some damage is permanent (like my hip).

I ate the hospital’s fresh fruit, vegetables and wild seafood, the rest was delivered from home by my loving spouse. Kathie is my anchor in the storm and my guiding light when I become lost. The importance of love and human physical contact is well recognized by the Paleo community so it is appropriate that I end with an expression of gratitude to Kathie and the host of friends who visited me during recovery. Hugs and kisses are as important as an anti-inflammatory diet.

Live clean and prosper.

Bob Hansen MD

13 thoughts on “A Paleo physician’s journey through major surgery

  1. laurip

    You mention your “pre-operative medication protocol”. What does that consist of? I have always refused post-op pain killers, but in the near future, when I have foot surgery, I would love to be able to avoid the NSAIDS, too.

    Reply
    1. Bob Hansen MD Post author

      Lyrica (pre-gabalin) 150 mg oral 2 hours before surgery, in the evening on day of surgery, then twice daily for 3 days. Alternative would be gabapentin 900-1200 mg 2 hours before surgery, 600-900 mg in the evening on the day of surgery, then 600-900 mg oral three times daily, three days.
      Acetaminophen 1000 mg orally 2 hours before surgery.
      tramadol extended release 200 mg 2 hours before surgery.
      Consult with your anesthesiologist. All but acetaminophen are prescription medications. Let your anesthesiologist and surgeon know if you take acetaminophen or any medication or supplement before surgery. Get their approval first.

      Reply
    1. Bob Hansen MD Post author

      Thanks Phillip. You raise a good point about the importance of the inflammatory response with regards to healing, but you seem to have missed the main points. I had no pain for the first 24 hours. I attributed that to pre-emptive analgesia (although I did not use that terminology) combined with a spinal anesthetic and spinal morphine as well as optimizing my physiology as much as possible pre-op (exercise, sleep, stress reduction, diet). After the effects of spinal morphine had dissipated, getting out of bed was very difficult but tolerable with assistance and after one lap of walking, I had minimal pain. The first lap was tough but with each lap after that the stiffness and pain diminished. Of course inflammation is a natural response to trauma and necessary for healing. MY point was that my inflammatory markers were not sky high. If you think a low inflammatory state impairs healing then you must think NSAIDs are “bad” after surgery. The anesthesia literature is replete with studies in which various anesthetic protocols are employed with the goal of decreasing the stress response (as measured by serum catecholamines and cortisol levels) and decreasing inflammatory markers. There will be plenty enough inflammation after surgery to produce healing even with the theoretical “best” anesthetic and surgical technique. You also missed my point about Lyrica and pre-emptive analgesia, which inhibits central sensitization and decreases post op pain. When spinal or regional anesthesia is combined with multiple pre-operative medications that affect different neurotransmitters the “pre-emptive analgesia” produced decreases post operative opiate requirements.That is clear in the anesthesia literature. I also forgot to mention in the post that I received a gram of Magnesium Sulfate in the operating room. IV magnesium also decreases post op opiate requirements by blocking NMDA receptors. But since you have raised concern about the plausibility of my scenario my next post will discuss the pain inhibiting effects of all the modalities that were employed in my case. As an anesthesiologist with a particular interest in preventing chronic post surgical pain I have about 150 lecture slides on the topic and will share some of that data in lay-person’s terms in my next one or two posts. Also, although my CRP of 0.2 mg/dl was in the “normal” range it was still high enough to increase my risk for heart attack and stroke. The lowest risk category for cardiovascular risk is less than 0.1 mg/dl (do not confuse this with the low sensitivity CRP which is measured as mg/L). By the way, I have seen “normal” CRPs in the range of 0.2-0.3 mg/dl in patients with ongoing infections, including osteomyelitis. Normal CRPs are also found in several auto-immune diseases with active arthritis symptoms. So CRP does not pick up all inflammatory states.

      Reply
    2. Bob Hansen MD Post author

      Thanks Kate. Legumes have a few issues. They are high in phytic acid which binds iron, magnesium, zinc, calcium, iodine and other important minerals and they are high in saponins, which increase intestinal permeability. In third world nations that have low levels of iodine in the soil, soy based infant formula increases the risk of goiter. Soaking legumes overnight decreases phytic acid content and fermenting legumes enhances their nutritional value but does not eliminate saponins. I do not see the point in consuming anti-nutrients and saponins and although many people seem to do fine with legumes chronic gut permeability issues (sub-clinical, asymptomatic) remain.
      Of all the grains, white rice is the most benign. It is gluten free. I prefer to consume nutrient dense foods like vegetables, fruits, pastured meat, wild seafood and offal. To minimize undesirable effects of legumes and maximize nutritional value they should be overnight soaked and fermented.

      Reply
      1. Adam

        Though legumes are high-er in phytic acid, like grains, does not mean that the nutrients don’t exist in them. Specifically, magnesium and zinc are like 40% reduced i believe, but calcium (though initially lowered by a diet high in phytic acid) returns to baseline after a few weeks. Soy sucks, i agree with that. As for legumes’ other anti-nutrients, see: http://chriskresser.com/are-legumes-paleo Also: http://www.ncbi.nlm.nih.gov/pubmed/21206508

        Sweet potatoes contain glycoalkaloids, but they’re quite healthy.

        People say a lot about chronic gut permeability, but I haven’t seen a study that pinpoints how this could occur – zonulin response to gluten is transient. And saponins were commented thusly upon by Matt Lalonde: “The saponin and glycoalkaloid story is slightly different. The activity of the compounds varies enormously depending on the nature of the sugars attached to the alkaloid or terpene. It has been shown that changing one single stereogenic center on the carbohydrate can completely alter the activity of the saponin or glycoalkaloid. The carbohydrates attached to the alkaloids or terpenes have been shown to be easily cleaved or modified during digestion. In addition, saponins and glycoalkaloids have many different types of activities, some of which are beneficial. The studies that have shown saponins or glycoalkaloids to be detrimental to the gut are animal studies where massive amounts of the compounds were fed to the critters. The studies are simply not physiologically relevant. There is currently no convincing evidence that cooked and ingested glycoalkaloids and saponins are harmful.”

        I’d say legumes can be eaten just like those middle-eastern men – right after cooking, no long soaking or fermenting processes needed (but those would be a bonus!)

        Just some added food for thought.

        I love the post, though – I want to become a pro-paleo doctor (currently applying) 🙂

      2. Bob Hansen MD Post author

        Thanks Adam for your thoughtful comments. Matt Lalonde is a very bright guy but the evidence that eliminating saponins from legumes and gluten (wheat) has benefit comes via many avenues. First, as in my response to Kate below, there is an increased frequency of goiter in infants fed primarily soy based formula in areas where iodine content of soil is low. Second, there have been multiple case reports of bringing auto-immune disease into remission through a paleo diet both with and without the more restrictive components of the auto-immune protocol (see ThePaleoMom.com and see her book The Paleo Approach, also see Dr. Terry Wahl’s book “The Wahls Protocol, How I beat Progressive MS…) Third, In an RCT of Rheumatoid Arthritis, gluten free diets reduced RA symptoms in 15% of patients. IN addition, a transient increase in gut permeability can kill people depending on the load of bacterial endotoxin and the degree of permeability (as in septic shock). Just a few hours can do it. It is a matter of degree, duration and the load of undesirable toxins that can cross the gut. Chronic inflammation is a major component of many diseases. The topic is too great to discuss in a few paragraphs. That is why many books have been written in this area. Intestinal permeability is increased in many situations, IBS, fibromyalgia, Crohn’s, Ulcerative Colitis, the list goes on and on. Fasano discusses the data in a great review article.Go to PubMed and search “intestinal permeability AND auto-immune disease”, “Fasano AND intestinal permeability” to start. Then see Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double-blind randomized placebo-controlled trial. Am J Gastroenterol. 2011 Mar;106(3):508-14 Here are a few more articles Anticancer drug-loaded gliadin nanoparticles induce apoptosis in breast cancer cells.
        Then there is the issue of how certain foods affect gut flora and how the gut flora in turn affect IP.
        Take a look at Scand J Gastroenterol. 2006 Apr;41(4):408-19.
        Gliadin, zonulin and gut permeability: Effects on celiac and non-celiac intestinal mucosa and intestinal cell lines.
        OR PLoS One. 2011 Jan 13;6(1):e16169. doi: 10.1371/journal.pone.0016169.
        Role of intestinal bacteria in gliadin-induced changes in intestinal mucosa: study in germ-free rats.
        Am J Gastroenterol. 2011 Mar;106(3):516-8. doi: 10.1038/ajg.2010.490.
        Editorial: Can gluten contribute to irritable bowel syndrome?
        There are many studies that demonstrate the basic science relative to IP as a contributing factor and perhaps an essential component to the pathogenesis of many illnesses. it is difficult to respond to your statement that you have not seen any convincing evidence….without writing a book. I have accumulated a file of more than 2000 articles and many of these are part of the footnotes in the two books I recommended above. Every month new studies are published on the relationship between IP and chronic disease.
        I have also seen benefit in many patients with various inflammatory diseases including RA and post traumatic arthritis by eliminating grains and legumes. We need more RCTs but in the meantime the preponderance of evidence speaks for the potential clinical benefit of a Paleo diet in addition to the benefit of other Paleo lifestyle interventions relative to stress reduction, sleep and exercise.

        http://www.ncbi.nlm.nih.gov/pubmed/22119716 Paracellular versus transcellular intestinal permeability to gliadin peptides in active celiac disease.

        What causes type 1 diabetes? Lessons from animal models.

        Role of intestinal bacteria in gliadin-induced changes in intestinal mucosa: study in germ-free rats.

        Tight junctions, intestinal permeability, and autoimmunity: celiac disease and type 1 diabetes paradigms.

        The significance of coeliac disease antibodies in patients with ankylosing spondylitis: a case-controlled study.

        Live probiotic Bifidobacterium lactis bacteria inhibit the toxic effects induced by wheat gliadin in epithelial cell culture.

        [Relationship between intestinal permeability and antibodies against food antigens in IgA nephropathy].

        Elevated IgA anti-gliadin antibodies in juvenile chronic arthritis.

        Small intestinal function and dietary status in dermatitis herpetiformis.

        Elevated level of IgA gliadin antibodies in patients with rheumatoid arthritis.

        Gliadin, zonulin and gut permeability: Effects on celiac and non-celiac intestinal mucosa and intestinal cell lines.

  2. Phillip

    Don’t buy it. Sorry. He might have gotten by ok with a spinal and then grinned and bared it but paleo or not that surgery would hurt like f% $! That low of an inflammatory state is actually bad after having a surgery of that size… What do you think stimulates the fibroblasts and wound healing mechanisms. ..

    Reply
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  5. Tiffani

    Thanks Dr. Hansen for sharing. I recently bought the book The Paleo Approach and I have been reading it. I’m going back on the Paleo completely. I’m going to push myself to do different exercise stuff. I’m also going to talk to my wonderful doctor on our next visit about stopping and or changing my medications on next visit.

    Reply

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