Category Archives: inflammation

Cartoon humor: A Prescription for Health!

 

prescription-for-exercise-cropped

Hat tip to Tommy Wood MD, PhD for introducing me to this great cartoon.

So what would happen if your doctor prescribed this? Would you be shocked? Would you follow the advice? Sadly few doctors make such recommendations as explicitly as this cartoon and fewer patients follow the advice.

How important are the elements in this advice?

They are essential. We too often focus on dietary concerns at the expense of ignoring other important low hanging fruit. Early morning  outdoor exercise with exposure to natural light in a green space, even on a cloudy or rainy day, is essential for health. Why? There are many reasons. Click the link above to read fitness expert Darryl Edward’s discussion with references. In fact outdoor exercise in a greenspace is more beneficial than the same exercise indoors. The reasons are many, including but not limited to Vitamin D production.

Early daytime exposure to natural outdoor light helps to maintain our Circadian rhythm and align the biologic clock in all of our cells and organs with the central biological Circadian clock in our brain. Most folks do not know that we have a biologic clock deep within our brain and that all the organs and cells of our body also have clocks. They all need to be synchronized with each other and with the sun for optimal health. When they are not synchronized bad things happen. Night shift workers and other folks with disturbed sleep have higher rates of cancer , depressionhypertension, heart attack and stroke.

Maintaining our circadian rhythm is vital to achieving adequate high quality restorative sleep. In turn, obtaining adequate restorative sleep contributes to lower cardiovascular disease risk in addition to four traditional lifestyle risk factors.

Exposure to artificial light at night disrupts our circadian rhythm and impairs the onset of sleep.

In medical school I learned that our retina has two cell types, rods and cones. But advances in science have revealed a  third cell type called retinal ganglionic cells. 

These cells are  particularly sensitive to blue light and directly connected to our central biological clock . Exposure to artificial light, especially from TV screens, computers, cell phones and other electronic devices after sunset disrupts our sleep cycle and delays the onset of sleep. That is why wearing blue light filtering glasses in the evening helps many folks to improve their sleep quality and duration.

Sleep deprivation for even one night causes elevation in interleukin 6 levels the following day. Interleukin 6 suppresses immune function and excessive levels cause bone and tissue damage (especially cardiovascular). Sleep deprivation  increases  Stress hormones (cortisol, adrenalin), decreases prolactin and Growth hormone , and decreases the nightly production of ATP .

Melatonin , often called the sleep hormone, is produced most abundantly during restorative sleep and essential for tissue healing, immune function, cancer prevention, and defense against tissue oxidation. These are just a few of the roles melatonin and sleep cycles play in determining our health..

So exercise outdoors in a green space daily to help synchronize your biologic clock with the sun, dim the lights in the evening and if you must watch TV or work on electronic devices before bed wear Blue Light filter glasses .

Of course eating an abundance of colorful fresh organic vegetables and fruits, and practicing some stress reduction techniques every day are equally important and essential to health and functional status.

Finally, not mentioned in the cartoon above is another healthy lifestyle choice, intermittent fasting (IF). IF will be discussed in the next post.

Until then, sleep well, exercise regularly out doors in a green space environment, eat clean, learn and practice some regular stress reduction techniques and read the next post about IF.

Bob Hansen MD

Functional Medicine: Getting to the Root Causes of Illness, A cure for Alzheimer’s

Today I watched a great TED talk by Dr. Rangan Chaterjee discussing his own journey in the discovery and implementation of a functional medicine approach to caring for his patients. The concept of using basic science and clinical science to diagnose and treat the root causes of illness, rather than treating symptoms, has been around for more than two decades.  This approach has recently started to attract more attention, especially within the community of younger physicians who have become more dissatisfied with the frustrations of traditional allopathic medicine.

Here is the talk. Dr. Chatterjee covers lots of ground in a passionate and informative talk.

Enjoy this talk. If you would like to learn about how a functional medicine approach can CURE ALZHEIMER’S DISEASE then watch this video of Dr. Bredesen who gave this lecture at a meeting of the American College of Nutrition.

Doctor Bredesen, an acclaimed neuroscientist, researcher, and more recently a brilliant clinician, has been criticized by the academic research community for implementing a clinical research protocol that addresses more than one variable at a time! Unfortunately, medical science has been handcuffed by the drug-model of clinical research wherein only one variable (drug vs. placebo for example) is studied. But if an illness has many potential contributing root causes, changing only one variable is doomed to failure, as Dr. Bredesen explains in this lecture.

Sleep well, eat clean, get outdoors every morning to help keep your circadian rhythm and biological clock in order.

Bob Hansen MD

Nutrition Journals and the influence of the food industry

Ever wonder why the public is so confused about nutrition recommendations? Just follow the money and you will understand that most of the professional societies that publish nutrition articles are funded by big food companies that are trying to sell more sugar, refined carbs and junk food. I recently read an excellent post about this topic here:

The Vilest Villain: American Society of Nutrition

This theme is repeated by medical journals that are “The Official Journal of the Society of >>>>>>” Just fill in the blanks for just about any medical society. Funding comes from big pharmaceutical companies the same way that funding in the nutrition Journals comes from large (junk) “food” manufacturers.

Don’t get me wrong, there are plenty of very valuable, life-saving drugs out there.

But most chronic human disease in developed societies is generated by various combinations of poor nutrition, lack of exercise, disruption of circadian rhythm, inadequate restorative sleep, stress and lack of social support systems.

The obesity and diabetes epidemics continue to worsen yet the failed dietary advise of major health organizations is slow to respond to the data. Excess refined carbs (especially in the form of “food” made with flour) and added sugar (especially in the form of HFCS) are the major driving forces for obesity, diabetes and cardiovascular disease. Red meat is not the culprit, provided the meat is properly sourced (hormone and antibiotic free, grass fed) and cooked in a manner that does not create carcinogens and inflammatory mediators (cook with slow, low, moist heat, high temperature grilling and smoking cause problems, but that topic  is for another post).

Americans consume an average 130 pounds per year of added sugar and 140 pounds per year of refined flour. Those are averages so there are many people who consume more. The added sugar is not the white stuff people put in their coffee. It comes in all sorts of forms but is found in energy drinks, soda, lattes and mochas, salad dressing,  ketchup, canned soups, canned vegetables, white AND whole grain breads, pasta (even “whole grain”), crackers, breakfast cereal,  just about any packaged food that has more than one ingredient on the label. These foods represent 70% of the American diet. The problems created by this situation are enormous and will bankrupt our “healthcare system”. This is a cultural and economic problem.

The solutions are simple but largely ignored in our society. We are creatures of habit and convenience.

Eat whole foods, nothing from a package that has more than one ingredient. Eat meat, seafood, poultry, fresh organic vegetables (6-9 servings per day), fresh organic fruits, and nuts. Meat should be hormone and antibiotic free (free range, grass fed). Seafood should be wild. Poultry should be free range and the eggs should come from free range chickens, ducks, geese.

Do not worry about eating fat as long as it comes from healthy animals and sources such as coconut oil, extra-virgin olive oil, avocado oil and clarified butter (ghee).

Do not use any “vegetable” oils (corn, soy, and other oils from grains or seeds) The vegetable oils are highly refined and inflammatory. They contain easily oxidized omega 6 fats that feed the production of inflammatory mediators in your body and create oxidized LDL leading to atherosclerosis.

Exercise daily, preferably outside in a green space. Twice per week spend 20-30 minutes  doing resistance training (lift weights, work against the resistance of bands, use your own body weight doing pushups, pull-ups etc)

Reduce stress with mediation, yoga, tai chi, dancing, engaging in fun sports and social activities. Walk on the beach, by a lake, river or stream, in the woods, listen to music.

Get some sunshine regularly especially during the morning to get your circadian rhythm in order and to produce adequate amounts of vitamin D.

Spend time with family, friends and colleagues who are supportive and fun to be around.

Sleep in the dark.

Get at least 7 hours of sleep per night. Avoid TV, computer screens and other electronic devices for at least 2 hours before bedtime.

Unplug from the internet, email, etc on a regular basis.

We evolved as hunter-gatherers.

Peace

Bob Hansen MD

 

 

Chronic Pain: How does it occur and what can be done about it?

I have discussed the effects of nutrition, stress-reduction, sleep, and circadian rhythm on pain in previous posts . I have not yet discussed the theory of how chronic pain develops and persists. This post discusses some of the mechanisms involved in chronic pain as well as therapeutic approaches that have proven to be effective in addressing the root causes of chronic pain and suffering.

THE CENTRAL NERVOUS SYSTEM (BRAIN AND SPINAL CORD) CAN INDEPENDENTLY CAUSE PAIN AND OTHER PHYSICAL SYMPTOMS THROUGH THE DEVELOPMENT OF LEARNED NERVE PATHWAYS. THESE PATHWAYS INCLUDE CIRCUITS WITHIN THE BRAIN AND CIRCUITS CONNECTING THE SPINAL CORD TO VARIOUS PARTS OF THE BRAIN. THEY CAN PRODUCE PAIN EVEN IN THE ABSENCE OF ONGOING TISSUE DAMAGE.

THESE LEARNED NERVE PATHWAYS CAN DEVELOP AS A RESULT OF SEVERAL WEEKS OR MONTHS OF CONTINUOUS PAIN CAUSED BY AN INJURY OR DEGENERATIVE-INFLAMMATORY DISEASE. IF WE EXPERIENCE RELENTLESS PAINFUL IMPULSES COURSING THROUGH THE BODY THESE BOMBARD THE SPINAL CORD AND BRAIN WITH PAINFUL MESSAGES AND OUR BRAIN AND SPINAL CORD EXPERIENCE A CHANGE SIMILAR TO THE CHANGES THAT CAN OCCUR WITH PTSD CAUSED BY ONE OR MORE TRAUMATIC EVENTS.

THESE LEARNED NERVOUS SYSTEM PATHWAYS REPRESENT “NEUROPLASTICITY” MEANING CHANGES IN THE NERVOUS SYSTEM BROUGHT ABOUT BY EVENTS SUCH AS TRAUMA AND STRESS. THEY REPRESENT A “MEMORY” OF THE PAIN, TRAUMA AND STRESS IMPRINTED ON THE NERVOUS SYSTEM. THIS “MEMORY” INCLUDES NEWLY (AND OFTEN PERMANENTLY) FORMED CIRCUITS THAT OFTEN CONNECT VARIOUS PARTS OF THE BRAIN ASSOCIATED WITH PAIN, ANXIETY, DEPRESSION AND ANGER TO PARTS OF THE BRAIN AND SPINAL CORD THAT MEDIATE SENSATIONS OF LIGHT TOUCH AND PRESSURE. THESE CONNECTIONS PRODUCE “ALLODYNIA” WHICH IS A PAINFUL RESPONSE TO A STIMULUS WHICH IS USUALLY NOT PAINFUL. WE CAN ALSO EXPERIENCE “HYPERALGESIA” WHICH IS AN EXAGGERATED PAIN EXPERIENCE, OUT OF PROPORTION TO THE PAINFUL STIMULUS.

THE NERVOUS SYSTEM HAS A BUILT IN “MUFFLER” DESIGNED TO DAMPEN DOWN PAIN MESSAGES BUT IN CHRONIC PAIN THIS MUFFLER BECOMES AN AMPLIFIER THAT NOT ONLY AMPLIFIES THE TRANSMISSION OF PAIN BUT ALSO CONNECTS THIS AMPLIFIED PAIN SYSTEM TO PARTS OF THE BRAIN ASSOCIATED WITH ANXIETY, ANGER, AND DEPRESSION.

ONCE THESE CIRCUITS OR PATHWAYS ARE IN PLACE (“LEARNED”) THEY CAN NOT BE ELIMINATED (“UNLEARNED”). EFFECTIVE PAIN REDUCTION REQUIRES ACTIVATING ON A REGULAR BASIS ALTERNATIVE PATHWAYS THAT ALREADY EXIST SUCH AS THOSE ASSOCIATED WITH PLAY, MUSIC, DANCE, HUMOR, LAUGHING. ACTIVATING OTHER PATHWAYS CAN ALLOW THE PAIN PATHWAYS TO BE “TURNED OFF” OR MUFFLED. AS CHILDREN WE LEARN TO PLAY AND THOSE LEARNED PATHWAYS STAY WITH US FOR LIFE. WITH PRACTICE WE CAN REGULARLY ACTIVATE THOSE BRAIN PATHWAYS AND MAKE THEM AND OTHER PATHWAYS THE PREDOMINANT PATHWAYS OF OUR BRAIN ACTIVITY.

BUT BEFORE WE CAN UTILIZE THE PLEASANT ALREADY-LEARNED PATHWAYS IN THE BRAIN TO CIRCUMVENT THE PAINFUL-ANXIOUS PATHWAYS WE MUST FIRST DEAL WITH OUR ANGER. DEALING WITH OUR NATURAL AND JUSTIFIABLE ANGER REQUIRES FORGIVENESS. UNTIL THE ANGER IS RELEASED AND FORGIVENESS ACHIEVED WE CANNOT MAKE USE OF THE THERAPIES AND STRATEGIES AVAILABLE TO DECREASE AND MANAGE OUR PAIN. ANGER BLOCKS THE PATH TO HEALING AND PAIN REDUCTION.

The brain processes an emotional insult in exactly the same way that the brain processes a physical insult. Stressful life events and our emotional reactions to them may cause pain that is severe. This is why chronic pain becomes worse when we experience a stressful event. Vicious cycles develop as multiple circuits connecting pain pathways to areas of the brain associated with anxiety and depression become activated and stay activated.

COGNITIVE BEHAVIORAL THERAPY: Over the course of months and years, our reaction to chronic pain often includes repetitive negative thoughts. Cognitive behavioral therapy helps us learn techniques to avoid repetitive negative thoughts.

Mindfulness Based Stress Reduction is another technique that can help mitigate the suffering associated with pain. Mindful Meditation practiced 30 minutes per day produces measurable changes in brain activity that can be seen on Functional MRI scans of the brain within 90 days. These changes demonstrate decreased brain activity in areas associated with pain, depression, anxiety and anger. Scientific studies have also demonstrated that MBSR produces improved immune function, reduces blood pressure, reduces heart rate, improves sleep and provides other beneficial physiologic changes associated with healing and wellness. Yoga and meditation are essential components of an MBSR program.

SLEEP: Pain cannot be managed or successfully treated unless an individual gets 8-9 hours of restorative sleep per night. Sleep hygiene recommendations are an essential part of the path to wellness. Daily exposure to sunlight outdoors and restoring normal circadian rhythm are essential for pain management. Going to bed at the same time every evening and sticking to a regular schedule is the most important part of improving sleep. Daytime exposure to sunlight and dimming the lights in the evening are also required. Regular exercise (daily walking) is essential. Wearing blue-light blocking glasses for 2-3 hours before bedtime can facilitate sleep. When blue light wavelengths (light bulbs, computer screens, TV screens) hit the retina of the eye a message is immediately relayed to the “internal clock” of the brain that tells the brain there is still daylight. This inhibits the production of melatonin (the “sleep hormone”). Avoiding bright light (especially from TV or computer screens) for 2-3 hours before bedtime is important. If you must watch TV or work on the computer in the evening that blue light blocking glasses or goggles are a must. There are free software programs that will eliminate the blue light from your computer screen as an alternative to blue light blockers.

NUTRITION: Pain involves inflammatory pathways. An anti-inflammatory diet is essential for treating pain and providing the nutritional components necessary for healing tissue and establishing better brain chemistry. Paleo Diet removes potential sources of inflammation from the diet. If a patient suffers from an auto-immune disorder the more restrictive Autoimmune Protocol version of the Paleo-diet can help put the disease into remission and decrease the inflammation associated with the auto-immune process.

OBESITY AND OVERWEIGHT: Extra fat around the belly and internal organs causes chronic inflammation throughout the body. The fat cells around internal organs and the immune cells that reside alongside the fat cells both produce a steady stream of chemicals that circulate throughout the body stimulating inflammation everywhere. These circulating chemicals are called cytokines and chemokines. Certain cytokines and chemokines cause fatigue, brain fog, and sensitize the nerves, increasing pain. They also interfere with sleep. Weight loss is an essential component to pain reduction for overweight and obese patients. The best nutritional approach to weight loss includes a Paleo Diet with carbohydrate restriction (low carbohydrate, high-healthy-fat whole food diet). Adding medically supervised intermittent fasting (such as an 18- 24 hour fast every 1-2 weeks, consuming only water for 18-24 hours) can also be effective especially combined with a carbohydrate restricted Paleo Diet and lifestyle.

Exercise and Physical Conditioning: Chronic pain causes sedentary behavior which results in physical de-conditioning. This process involves loss of muscle, decreased bone density, shortening of ligaments and tendons and shrinkage of the tissues that envelope muscle. This leads to more pain when physical activity is increased and a vicious cycle is created. This cycle must be broken with a graduated daily exercise and physical conditioning program. If you follow a medically prescribed exercise program you will not damage your body even though it may be painful during the first several days. Exercise also helps to convert the “amplifier” back to a “muffler” in the nervous system.

Below are some links to articles related to this discussion.

Eat clean, live clean.

Bob Hansen MD

Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain.

Central sensitization and altered central pain processing in chronic low back pain: fact or myth?

How to explain central sensitization to patients with ‘unexplained’ chronic musculoskeletal pain: practice guidelines.

Addressing sleep problems and cognitive dysfunctions in comprehensive rehabilitation for chronic musculoskeletal pain.

Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories.

Efficacy of a modern neuroscience approach versus usual care evidence-based physiotherapy on pain, disability and brain characteristics in chronic spinal pain patients: protocol of a randomized clinical trial.

The effect of relaxation therapy on autonomic functioning, symptoms and daily functioning, in patients with chronic fatigue syndrome or fibromyalgia: a systematic review.

Pro-nociceptive and anti-nociceptive effects of a conditioned pain modulation protocol in participants with chronic low back pain and healthy control subjects.

Vagal modulation and symptomatology following a 6-month aerobic exercise program for women with fibromyalgia.

Brain-derived neurotrophic factor as a driving force behind neuroplasticity in neuropathic and central sensitization pain: a new therapeutic target?

The role of central sensitization in shoulder pain: A systematic literature review.

Chronic whiplash-associated disorders: to exercise or not?

Exercise, not to exercise, or how to exercise in patients with chronic pain? Applying science to practice.

Evidence for central sensitization in patients with osteoarthritis pain: a systematic literature review.

Malfunctioning of the autonomic nervous system in patients with chronic fatigue syndrome: a systematic literature review.

Endogenous pain modulation in response to exercise in patients with rheumatoid arthritis, patients with chronic fatigue syndrome and comorbid fibromyalgia, and healthy controls: a double-blind randomized controlled trial.

You may need a nerve to treat pain: the neurobiological rationale for vagal nerve activation in pain management.

Avoidance behavior towards physical activity in chronic fatigue syndrome and fibromyalgia: the fear for post-exertional malaise.

The role of mitochondrial dysfunctions due to oxidative and nitrosative stress in the chronic pain or chronic fatigue syndromes and fibromyalgia patients: peripheral and central mechanisms as therapeutic targets?

Thinking beyond muscles and joints: therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment.

Evidence for central sensitization in chronic whiplash: a systematic literature review.

Pain in patients with chronic fatigue syndrome: time for specific pain treatment?

Kinesiophobia, catastrophizing and anticipated symptoms before stair climbing in chronic fatigue syndrome: an experimental study.

Central sensitization in patients with rheumatoid arthritis: a systematic literature review.

 

Why do our tax dollars continue to subsidize death, disability and disease?

Yesterday I posted a comment on Medscape after reading an article Longtime Dietary Fat Advice Unsupported by Data: Analysis . Medscape is a website with articles and news written for physicians and other health professionals. Anyone can access this information by creating a user name and password, there is no fee.

Here is my comment. It is long and technical. I will provide an explanation in lay terms after quoting myself.

Sugar, especially HFCS (high fructose corn syrup), used in so many foods is more inflammatory than saturated fat. Grass fed meat from ruminants has a fatty acid mix that is exactly the same as wild game, which we evolved to eat, along with tubers, green leafy vegetables, and fruit in season. Excess refined fructose intake AND use of modern refined “vegetable oils” along with non-healthy grains combine to cause excess caloric intake, NAFLD (non-alcoholic fatty liver disease), obesity, metabolic syndrome and CAD (coronary artery disease). N6 PUFA (omega six polyunsaturated fatty acids) are easily oxidized. N3 PUFA (omega 3 fatty acids) despite greater number of double bonds are protected from oxidation in cell and Lipoprotein membranes by plasmalogens as opposed to linoleic acid which is not easily  incorporated into plasmalogens. The PUFA in vegetable oils (linoleic acid) is the FA (fatty acid) that is oxidized on LDL particles and remnant particles, stimulating monocytes to transform to macrophages and then foam cells. The USDA, ADA and AHA have had it upside down for decades and they still fail to admit folly. We evolved for > 1 million years without grains and they have contributed to disease. Per calorie fresh vegetables have five times the amount of fiber compared to whole grains. We do not need grains and would be better without them. They contain anti-nutrients and wheat, hybridized in the 1980s to a storm resistant dwarf plant, now has 50 times more gluten/gliadin than the old wheat. This has generated more gluten intolerance and celiac. Our greatest nutritional threats to public health include refined sugar, carbohydrates predominantly from grains and refined vegetable oils. Vegetable oils are not healthy, we did not evolve to eat them. N3 FAs are anti-inflammatory but have been competing in our diets with a sea of inflammatory N6 PUFA from unnatural refined and easily oxidized “vegetable oils”. Even though PUFA can reduce LDL-C they wreak havoc by creating ox-LDL particles which initiate the cascade of atherosclerosis. Substituting SFA (saturated fatty acids) with PUFA results in increased levels of Lp(a) and oxLDL in humans, not a good thing. Close the feed lots, stop government subsidy of corn, wheat, dairy and soy, eat meat from grass fed ruminants, wild seafood, fresh organic vegetables and fruits in season. Nibble on tree nuts. Stop creating carcinogens with high dry heat cooking methods and we will watch obesity, insulin resistance, metabolic syndrome and atherosclerosis melt away.

That was my comment. Here is some explanation.

I have previously discussed the pro-inflammatory nature of refined “vegetable oils”. “Vegetable oils” are actually not from vegetables, they are from grains, seeds and legumes. The two major sources of excess omega six polyunsaturated fats in the American diet are corn oil and soy oil marketed by various brand names such as Wesson. They are major components of margarine and other butter substitutes and are present in most salad dressings. Most salad dressings sold in our supermarkets contain high levels of easily oxidized unhealthy refined “vegetable oils” and HFCS. The use of these salad dressings converts a healthy salad into a vector for disease.

The major source of caloric sweeteners in our food and beverages is high fructose corn syrup. Both corn (oil and sugar) and soy predominate our processed food supply because they are cheap. They are cheap because our tax dollars subsidize their production. This subsidy started during the Nixon administration. Once a food subsidy is put in place it is very difficult to eliminate, Big Agriculture provides a deep pocket for lobby money and our elected officials from the mid-west bread-basket respond to $$.

Another major source of disease causing elements in the standard American diet is highly refined flour from wheat. Doctors Davis and Perlmutter discuss the problems associated with wheat-flour foods in their books Wheat Belly and Grain Brain respectively. The production of wheat has also been subsidized since the Nixon administration.

Wheat is not what it used to be. A new dwarf hybrid wheat has predominated the US market since the 1980s. Bread and pasta are not what they used to be when great grand-mother made her own bread and pasta in the kitchen from coarsely ground whole flour. But even if we all went back to making our own whole-grain bread and pasta from locally ground pre-1980s wheat, bread, pasta and pastry would still present a health risk because of issues related to intestinal permeability, auto-immune disease (now epidemic in the USA), and the presence of nasty lectins and phytates (discussed in my manifesto and previous posts).

The Medscape comment quoted above describes  adverse consequences caused by replacing saturated fat in the diet with “vegetable oils”. This is a complex subject and I will try to be brief for now but promise to expand on this in a future post.

Many factors contribute to atherosclerosis, heart attack and stroke. Sedentary lifestyle, stress, inadequate restorative sleep, smoking and poor dietary choices top the list. These factors also contribute to obesity, diabetes, metabolic syndrome, insulin resistance and many cancers.

DIETARY FACTORS:

The combination of sugared foods and beverages (predominantly sweetened with HFCS), refined flour foods, and excess consumption of the PUFA in “vegetable oils” TOGETHER  contribute to the formation of plaque in the walls of our arteries (atherosclerosis).

How does this happen?

LDL (low density lipoprotein) is a particle that transports cholesterol and triglycerides through our blood to our organs. This particle is comprised of a core and a surrounding membrane.  Here is a picture.

LDL 2

The core contains cholesterol in a storage form (esters) and triglycerides. The outer membrane includes a large protein called apoprotein B-100, “free” cholesterol molecules and phospholipids. The phospholipids contain fatty acids, including PUFA.

LDL has been demonized as “the bad cholesterol” and that demonization has mislead the public.

hdl_ldl good guy bad guy

LDL is the major lipoprotein in our blood but there are others that have different names.

Cholesterol is cholesterol, whether it is carried in LDL or HDL. When carried in the core of a lipoprotein it is carried as a cholesterol ester. 80% of the cholesterol in an LDL particle is carried as an ester in the core. 20% is carried as “free” cholesterol on the outer surface or membrane.

LDLand cholesterol molecule

HDL (high density lipoprotein) is smaller and denser. HDL has been called “the good cholesterol”, another misnomer.

HDL particles, when they are functioning correctly can protect us from atherosclerosis but in patients with diabetes, obesity, and insulin resistance, HDL particles do not function well and in fact probably contribute to disease. (More about that in a future post)

But back to LDL.

Although the risk of cardiovascular disease is correlated with the amount of cholesterol carried by LDL in our blood (referred to as LDL-C), the total amount of cholesterol shuttled by LDL particles is much less relevant than one would be led to believe given the great use of statin drugs to lower LDL-C.

The short version is as follows.

Compared to LDL-C, a much better predictor of cardiovascular disease is the amount of “modified” LDL particles circulating in the blood. Oxidized LDL particles are one form of “modified LDL”. LDL can also  be modified by excess blood sugar levels (especially from HFCS). This modification is referred to as glycosylated or glycated LDL. In this latter form of modification, the major protein on the outer membrane of the LDL particle (apo B 100 in the picture above) becomes attached to a sugar and the result is an LDL particle that is not easily cleared by normal processes. The modified LDL is not “recognized” by the LDL receptors that act as entry points into our cells for proper processing. The result is that the glycated LDL particles circulate longer and are more likely to use up their anti-oxidants (Vitamin E and  Co-enzyme Q 10).

As a result glycated LDL are more likely to become oxidized. That is not good because oxidized LDL sets up a cascade of unhealthy events.

The portion of the LDL particle that becomes oxidized is the fat (fatty acid) from “vegetable oil”, specifically the fatty acid called linoleic acid. This fatty acid has two double bonds making it more likely to be oxidized than for example oleic acid, the major fatty acid in extra virgin olive oil which has only one double bond.

The double bonds between the carbons in the fatty acids are unstable and easily oxidized. The single bonds in saturated fat do not get oxidized.

All other things being equal (and you will see that they are not), the more double bonds in a fatty acid the greater chance for oxidation.

Here is a picture showing the linoleic acid, also called linoleate, on the outer membrane of the LDL particle.

LDL with linoleate

And here is a picture that shows the phospholipids that contain the linoleic acid.

LDL 3

Let’s say it again. The fatty acid found in “vegetable” oil, linoleic acid, is easily oxidized because it has two double bonds.

Saturated fats are not oxidized because they contain no double bonds.

The part of the LDL particle that becomes oxidized is the fatty acid that comes from “vegetable oils”.

A particular kind of immune cell (white blood cells called monocytes) have  special receptors for oxidized LDL particles. When ox-LDL are “seen” by these monocytes, the monocytes become transformed into macrophages. Macrophages are designed to destroy bacteria that invade our bodies. The oxidized LDL particles resemble the structures of invading bacteria. The macrophages, with very specialized receptors for oxidized LDL, “swallow” the LDL particles and release toxic chemicals to destroy “the invader”.  The macrophages then become “foam cells” in the walls of our arteries, initiating the creation of plaque. Here is a picture.

ldl_mechanisms oxidation in vessel wall

This picture depicts the oxidation occurring in the wall of the artery after LDL particles have penetrated the wall. However LDL particles can and do become oxidized while still circulating in the blood and these oxidized particles can stimulate monocytes to transform into macrophages and gobble up the oxidized or modified LDL while these particles are still circulating in the blood.

How and whether unmodified LDL particles cross the wall of arteries into the “sub-endothelial” area remains an unsolved complex issue. The picture above implies that LDL particles simply move across the endothelial cells that line the wall of the artery but that is a presumption.

Clearly, macrophages that have “swallowed” modified LDL particles have mechanisms to work their way between the junctions formed by adjacent endothelial cells.

This is an important distinction because many cardiologists believe that what drives atherosclerosis is a mass effect. The greater the number of LDL particles, the more likely they are to cross the endothelial barrier, get oxidized and retained and start the process of plaque formation. However the process is much more complex and not clearly understood.

We do not yet know or understand completely the factors that influence the permeability of the endothelium to Lipoprotein particles. We do know that modified (oxidized and glycated LDL) disrupt the protective surface of endothelial cells which is called the glyocalyx. Other factors that disrupt the glyocalyx include high blood sugars, dramatic fluctuations in blood pressure (too high or too low), oxidative stress, infections, and circulating endotoxin (which is governed by intestinal permeability).

It is clear from several studies that modified (oxidized) LDL as a single variable predicts cardiovascular disease and heart attacks with much greater accuracy than LDL-C (total cholesterol content of LDL particles). It is also clear that monocyte receptors are specific for modified LDL and that the  process that initiates the cascade of events that leads to plaque formation involves the interaction between modified lipoprotein particles and the immune system (monocytes).

Now here is another twist.

Omega 3 fatty acids in fish oil are considered “heart healthy”. They help prevent heart attacks and strokes. They also decrease inflammation throughout the body thereby producing many health benefits.

BUT OMEGA 3 FAT HAS MORE DOUBLE BONDS THAN OMEGA 6 FAT (LINOLEIC ACID) YET THEY HELP PROTECT THE HEART. HOW CAN THAT BE?

How do they avoid contributing to atherosclerosis? Are they not even more readily oxidized than linoleic acid?

The simple answer is no.

The major reason is that the omega three fatty acids are protected by “plasmalogens” which are important components of our LDL particle outer membranes. Plasmalogens are found in the membranes of lipoprotein particles and in the membranes of human cells. Because of their chemical structures, omega three fats are easily incorporated into plasmalogens which protect the double bonds of omega three fats from oxidation. Linoleic acid, the predominant component of “vegetable oils” is not easily incorporated into the protective arms of plasmalogens.

This selective protection is well described on pages 141-142 of  “The Fats of Life”, written by Dr. Glen Lawrence and published in paperback in 2013. (link below)

I asked Dr. Lawrence about this issue in an email and here was his response.

“The omega-3 fatty acids are preferentially incorporated into plasmalogens, which act as antioxidants due to the double bond adjacent to the ether linkage of these phospholipids. This structure would tend to scavenge free radicals or reactive oxygen species near the surface of the membrane, rather than allowing them to penetrate deeper in the membrane where the double bonds of PUFA are located. This makes any polyunsaturated fatty acids attached to the plasmalogens more resistant to oxidation than they would be in a regular phospholipid. See pp 141-142 of The Fats of Life. The shorter chain and less unsaturated linoleic acid does not tend to be incorporated into plasmalogens.”

In summary:

  1. “Vegetable oil” is actually not oil from vegetables but rather a highly processed and refined oil. This oil contains primarily the easily oxidized omega 6 PUFA (polyunsaturated fatty acid) linoleic acid. Oxidation can occur during manufacture,  before consumption while sitting in the bottle, but especially during high heat cooking (fried foods). Oxidation can also in your body as this fat circulates in your blood on the membrane of lipoprotein particles.
  2.  LDL particles are the major lipoprotein particles that shuttle cholesterol and fatty acids (in in the form of triglycerides) through our bodies in our bloodstream.
  3. Modified LDL particles (glycated and/or oxidized LDL) stimulate monocytes (immune cells) to transform into macrophages and gobble up the modified LDL. In addition, glycated LDL particles are more easily oxidized because they circulate longer in our blood.
  4. Macrophages become filled with modified LDL. These are called foam cells. Foam cells  initiate a cascade of events that lead to the formation of plaque in the walls of our arteries.
  5. The part of the LDL particle membrane that becomes oxidized is the phospholipid that contains linoleic acid which comes from “vegetable oils”
  6. High amounts of sugar, especially HFCS, and highly refined flour foods in our diets cause larger blood sugar fluctuations than whole foods and therefore contribute to the glycation of LDL particles. This glycation leads to more oxidation of LDL. In this manner HFCS and refined flour foods contribute to the process of atherosclerosis.
  7. High amounts of sugar, HFCS and refined flour foods also contribute to obesity, insulin resistance and diabetes which then increase the risk of heart attack and stroke.
  8. Several factors contribute to the disruption of the glycocalyx which is the protective surface of the endothelial cells that line our arteries. These include but are not limited to modified LDL, inflammation, high blood sugars, abnormal fluctuations in blood pressure, circulating endotoxin (associated with increased intestinal permeability), infections. Disruption of the glycocalyx contributes to the formation of plaque (atherosclerosis).
  9. Modified LDL particles might also migrate through the junctions that connect adjacent endothelial cells either inside macrophages or on their own. Many factors, known and unknown likely determine the susceptibility or permeability of these junctions to this migration.

These are the major points, but there is allot more to discuss. Substituting “vegetable oils” for saturated fat in our diets not only increases the amount of oxidized LDL but also increases a dangerous lipoprotein called Lp(a). On third of Americans have an amount of Lp(a) that is considered “high risk” for heart attack and stroke. More about that in a future post.

Then there is the process of an actual heart attack or stroke which involves disruption of plaque and the creation of a blood clot that ultimately disrupts the flow of blood and the death of heart or brain tissue. The susceptibility of plaque to disruption is a huge topic that involves high blood pressure, diabetes, insulin resistance, oxidative stress, inadequate sleep, and stress to name a few. So much more to discuss.

But getting back to the title of this post, why don’t you ask your elected representatives why our tax dollars continue to subsidize nutritional root causes of death, disability and disease?

Here are some links to papers and books that support the discussion above.

Circulating Oxidized LDL Is a Useful Marker for Identifying Patients With Coronary Artery Disease

Cholesterol deposition in macrophages: foam cell formation mediated by cholesterol-enriched oxidized low density lipoprotein.

Erythrocyte fatty acid profiles can predict acute non-fatal myocard… – PubMed – NCBI

Changes in Dietary Fat Intake Alter Plasma Levels of Oxidized Low-Density Lipoprotein and Lipoprotein(a)

Low-density lipoprotein subclass patterns and risk of myocardial in… – PubMed – NCBI

Subendothelial Lipoprotein Retention as the Initiating Process in Atherosclerosis

Oxidative susceptibility of low density lipoprotein subfractions is… – PubMed – NCBI

Effects of linoleate-enriched and oleate-enriched diets in combinat… – PubMed – NCBI

Enhanced oxidative susceptibility and reduced antioxidant content o… – PubMed – NCBI

Susceptibility of small, dense, low-density lipoproteins to oxidati… – PubMed – NCBI

Modulation of Endothelial Glycocalyx Structure under Inflammatory Conditions

Oxidized Lipoproteins Degrade the Endothelial Surface Layer

S1P Control of Endothelial Integrity

Mechanical control of the endothelial barrier. – PubMed – NCBI

Therole of actin-binding proteins in the control of endothelial bar… – PubMed – NCBI

The Fats of Life, Dr. Glen Lawrence

Functions of plasmalogen lipids in health and disease

Grain Brain: The Surprising Truth about Wheat, Carbs, and Sugar–Your Brain’s Silent Killers: David Perlmutter, Kristin Loberg: 9780316234801: Amazon.com: Books

Finally a quote from the Dali Lama (thanks to my cousin Diane for bringing this to my attention).

“Man. Because he sacrifices his health in order to make money. Then he sacrifices money to recuperate his health. And then he is so anxious about the future that he does not enjoy the present, the result being that he does not live in the present or the future, he lives as if he is never going to die, and dies having never really lived.”

Eat clean, live clean, sleep well, exercise wisely, rest often, enjoy the company of loved ones, spend time outdoors and live in the present.

BOB

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

Low Carb Beats Low Fat Again, Annals of Internal Medicine article

Once again, a randomized trial demonstrates that a carbohydrate restricted approach is superior to a low fat diet with regards to weight loss, inflammation, body composition and cardiovascular risk factors. This study was recently published in the Annals of Internal Medicine, the official journal for the American College of Physicians.

Men and women aged 22 to 75 years with a body mass index of 30 to 45 kg/m2 (obesity defined as BMI > 30, morbid obesity defined as BMI >35) were recruited from the general public by using mailing lists, fliers, work site and community screenings, and television advertisements.

Neither diet included a specific calorie or energy goal. Participants in each group were asked to refrain from changing their physical activity levels during the intervention

Here is the summary cut and pasted from the abstract.

Objective: To examine the effects of a low-carbohydrate diet compared with a low-fat diet on body weight and cardiovascular risk factors.

Design: A randomized, parallel-group trial. (ClinicalTrials.gov: NCT00609271)

Setting: A large academic medical center.

Participants: 148 men and women without clinical cardiovascular disease and diabetes.

Intervention: A low-carbohydrate (<40 g/d) or low-fat (<30% of daily energy intake from total fat [<7% saturated fat]) diet. Both groups received dietary counseling at regular intervals throughout the trial.

Measurements: Data on weight, cardiovascular risk factors, and dietary composition were collected at 0, 3, 6, and 12 months.

Results: Sixty participants (82%) in the low-fat group and 59 (79%) in the low-carbohydrate group completed the intervention. At 12 months, participants on the low-carbohydrate diet had greater decreases in weight (mean difference in change, −3.5 kg [95% CI, −5.6 to −1.4 kg]; P = 0.002), fat mass (mean difference in change, −1.5% [CI, −2.6% to −0.4%]; P = 0.011), ratio of total–high-density lipoprotein (HDL) cholesterol (mean difference in change, −0.44 [CI, −0.71 to −0.16]; P = 0.002), and triglyceride level (mean difference in change, −0.16 mmol/L [−14.1 mg/dL] [CI, −0.31 to −0.01 mmol/L {−27.4 to −0.8 mg/dL}]; P = 0.038) and greater increases in HDL cholesterol level (mean difference in change, 0.18 mmol/L [7.0 mg/dL] [CI, 0.08 to 0.28 mmol/L {3.0 to 11.0 mg/dL}]; P < 0.001) than those on the low-fat diet.

Limitation: Lack of clinical cardiovascular disease end points.

Conclusion: The low-carbohydrate diet was more effective for weight loss and cardiovascular risk factor reduction than the low-fat diet.

Primary Funding Source: National Institutes of Health.

Let’s go through those results again: At 12 months, participants on the low-carbohydrate diet had

  1.  greater decreases in weight. This has been demonstrated in multiple previously published studies.
  2.  greater decreases in  fat mass. This is an important distinction, the low carb group lost more fat, not muscle.
  3.  greater decreases in the ratio of total to high-density lipoprotein (HDL) cholesterol. This ratio is a measure of cardiovascular risk (risk for heart attack and stroke). It improved more on low carb than on low fat diets.
  4.  greater decreases in triglyceride level. Triglyceride level is also an important cardiovascular risk factor. It went down significantly more as compared to the low fat diet.
  5.  greater increases in HDL cholesterol level. This result is considered to be protective against heart attack and stroke.
  6. greater decreases in CRP level than those in the low-fat group. CRP (C-reactive protein) is a blood test for inflammation and is also a cardiovascular risk factor.
  7. significant decreases in estimated 10-year risk for coronary heart disease as measured by the Framingham risk analysis at 6 and 12 months, whereas those in the low-fat group did not. Say again, the low fat group did not decrease their Framingham risk analysis but the low carb group did.

All of these differences were “statistically significant”, meaning they were unlikely caused by accident.
And what about side-effects?

The number of participants who had symptoms, including constipation, fatigue, thirst, polyuria, diarrhea, heartburn, gas, nausea, vomiting, appetite changes, or headache, did not differ significantly between the low-carbohydrate and low-fat groups, except significantly more participants on the low-fat diet reported headaches at 3 months

The authors concluded:

Our study found that a low-carbohydrate diet induced greater weight loss and reductions in cardiovascular risk factors at 12 months than a low-fat diet among black and white obese adults who did not have diabetes, CVD, or kidney disease at baseline. Compared with a low-fat diet, a low-carbohydrate diet resulted in greater improvements in body composition, HDL cholesterol level, ratio of total–HDL cholesterol, triglyceride level, CRP level, and estimated 10-year CHD risk. Because CVD is the most common cause of death in the United States and obesity is a particularly prevalent risk factor, our study has important clinical and public health implications

Effects of Low-Carbohydrate and Low-Fat Diets: A Randomized Trial, A. Bazzano, MD, PhD, MPH et. al., Ann Intern Med. 2014;161(5):309-318. doi:10.7326/M14-0180

Get rid of the sugar-added foods, processed and refined flour foods and vegetable oils. Send a message to corporate America that crap-in-a bag and crap-in-a-box is no longer in demand. Eat only grass-fed meat, wild seafood, fresh vegetables, fresh fruit and tree nuts. Enjoy better health and better food.

 

Bob Hansen MD.