All Gender Cardiology

Posted on September 10, 2024 by Masina Wright ND

I am giving a webinar this week to a group of cardiologists on all gender cardiology. Spoiler alert, there is no difference between cis and trans gender heart health. The differences lay in access to health care, stereotypes about hormone therapy, and minority stress. For cardiology, once you have a sick heart, regular physician follow up is crucial to your care – multiple medications are sometimes needed to improve or preserve heart function and imaging is needed over a lifetime to track structure and function. If a person does not feel safe at their cardiologist’s office because they are constantly called the wrong name or experience microaggressions about their body, that person will avoid going back or drop out of care all together. Therefore, the first and most important point of all gender cardiology is creating a safe medical home with dedicated staff and physician training in transgender and gender diverse specific health care.

https://www.youtube.com/watch?v=S3eDKf3PFRo

Documentation matters. Medical charts are living documents of a patients experience and how we represent someone matters both for the patient and for all the people who read the document. Safety, Dignity and Respect are basic human rights which are not always upheld for gender diverse individuals, even in a doctors office. Do not be afraid to ask an individual what terms, names, pronouns they would like used in their chart. Asking is consent and consent is powerful. Some terms have fallen out of favor over the last 2 decades that I frequently hear used in the hospital such as Male-to-Female (MTF) and Female-to-Male (FTM). These have been replaced with assigned gender at birth attached to current gender presentation, or just gender presentation. Assigned gender at birth includes Assigned Female at Birth (AFAB) and Assigned Male at Birth (AMAB.) These can be helpful in a medical setting bc they may signify reproductive organs present ( or they may not depending on surgical interventions.) Some gender diverse folks feel passionately against AMAB/AFAB as well because they focus more on the assigned birth gender than the current gender. Therefore, in documentation, either ask the patient how they would like to be represented, or consider using a hybrid like AMAB transwoman, or just transwoman in your notes.

Cardiology and IM are frequently consulted for assessment prior to surgery. Treat gender diverse folks the same as you would anyone else. For a long time gender affirming hormones were stopped prior to surgery, especially estrogen for transfeminine patients due to the heightened risk of venous thromboembolism. This practice is no longer recommended. We would not put a cisgender person on hormone blocking agents for a surgery; therefore, stopping all hormone treatment for transgender individuals does not make sense. In fact, continuation of hormone treatment is beneficial for withdrawal prevention, mental health and for prevention of side effects of hypogonadism including osteoporosis. Continue the current therapy through surgery and risk stratify/ treat perioperatively as you would any other patient with RCRI, MINS screening and DVT prophylaxis.

For more on gender and plastic surgery see this collection of 11 special topics on gender surgery from the Journal of the American Society of Plastic surgeons.

“Hontscharuk and Schecter assemble the most
comprehensive review of literature from plastic sur-
gery, gynecology, and endocrinology to consider the
risk profile of transgender hormones and surgical
venous thromboembolism. One surprise of their
well-sourced study is that the risk of perioperative
estradiol may be lower than commonly thought.
High rates in early series are attributed to the use
of oral ethinyl estradiol and high doses, with newer
regimens showing lower rates. One area where the
literature is limited, however, is in quantifying cur-
rent practices in hormone cessation. In a survey of
six high-volume vaginaplasty centers (unpublished
data), all surgeons still stopped estradiol 2 to 4 weeks
before surgery.”

Ok, now we can finally start talking about the heart and gender affirming hormones, starting with testosterone. This topic applies to anyone who has testosterone including cisgender men but is specifically for transmen and nonbinary people using testosterone. As the rise of ‘andropause” or mens antiaging medicine came into the public eye, the medical assumption was that because men had more cardiovascular disease (CVD) and men had testosterone, therefore testosterone increased heart disease risk. This was pure conjecture and has not held up in any evidence based investigations. A 2014 JAMA article was published from VA data-mining that stated that hypogonadal men starting testosterone had increased risk of MI, with the declaration that therefore testosterone was not indicated in anyone with increased cardiac risk or cardiac disease. The article was quickly retracted and amended as the data was corrupted (multiple patients with MI’s had not started the testosterone, ciswomen not on testosterone were included in the MI population.) The damage was done, and many people still believe the false claims a decade later.

Testosterone therapy is vital for gender diverse patients who need masculinization. Even if it did carry a CVD risk, the beneficial effect of mental and physical wellness for gender congruence would be worth the possible risk. Because of its importance in transgender medicine, this is an ongoing hot topic of research to better understand the nuances and possible risks of testosterone therapy.

“A large 2018 case control study from several US centers that used 10:1 cisgender matched controls found no statistically significant difference in rates of MI or stroke between transgender women and cisgender men, a rates of MI, stroke, or venous thromboembolism (VTE) between transgender men and cisgender men or women. There was a statistically significant hazard ratio of 1.9 for VTE among transgender women when compared with cisgender men.” CH 15 WPATH SOC

The relationship between testosterone and trans health is important enough that the American Heart Association investigated and released a scientific statement in 2021, because trans and gender diverse folks of all genders HAVE consistently had worse cardiovascular morbidity and mortality than age matched peers.

The bottom line ” Mounting research has revealed that cardiovascular risk factors at the individual level likely do not fully account for increased risk in cardiovascular health disparities among people who are TGD. Excess cardiovascular morbidity and mortality is hypothesized to be driven in part by psychosocial stressors across the lifespan at multiple levels, including structural violence (eg, discrimination, affordable housing, access to health care). ”

However, in the anti-aging and cisgender mens health community the question of cardiac safety with testosterone hormone replacement lingered. In 2015 after the original data debacle, the FDA required companies making approved testosterone products to participate in clinical trials to elucidate the evidence. The Testosterone Replacement Therapy for Assessment of Longterm Vascular Events and Efficacy Response in Hypogonadal Men (TRAVERSE) trial was created and just published in 2023.

Bottom line? Testosterone repletion to biological levels for cisgender men did not increase cardiovascular risk, with primary endpoints of the study being **first occurrence of any component of a composite of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke**. A secondary cardiovascular end point was the first occurrence of any component of the composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or coronary revascularization, assessed in a time-to-event analysis.

Testosterone HAS been repeatedly shown to decrease HDL, the protective scavenging cholesterol and increase triglycerides. It evidences variable effects on total cholesterol and LDL . This could be a piece of the puzzle for increased CVD risk in trans men, but has not been definitively proven yet. Regardless, exercise is the best way to increase HDL in all genders, so as health care providers we need to continue motivational interviewing for active lifestyles, 150minutes of exercise weekly and lipid-conscious nutrition for all our patients including trans men.

So why are transmen more likely to have cardiovascular disease? The the answer is multifactoral and boils down to lifestyle and and health care access which crosses many intersections of class, and race, minority stress and more (which is another important conversation). Heart disease is a cumulative pathology. Unless one has a congenital heart condition, it takes decades of uncontrolled alcohol use, dysregulated blood sugar, nicotine toxicity, low nutrient and high fat foods and sedentary lifestyle to generate atherosclerotic coronary disease. Prevention is the best medicine for a healthy heart and vasculature, but prevention also means having a doctor to work with for things like blood work and blood pressure measurement. If you are someone who has a bad experience in the medical world, or worse, someone who is denied care due to your gender or sexuality, that person will often have worse outcomes with age.

TBC in the next post – ESTRADIOL! – because this one is getting long!

To Sleep or Not to Sleep

Posted on September 28, 2022 by Masina Wright ND

I love falling asleep quickly and easily and waking up 9 hours later.

When this doesnt happen, the work of unpacking the complex architecture of sleep and our associated subconscious and unconscious patterning begins. This post will provide a brief overview of sleep-wake cycle circadian dysregulation as well as nutraceuticals and botanical medicines to help fall asleep. Botanicals to stay asleep or address eearly waking will be in the following sleep post. I will not discuss prescription medications for sleep. Some people with trauma, PTSD, significant depression and anxiety, and persistent insomnia and/or sleep apnea may need pharmaceutical medications for sleep and/or sleep studies to better understand what is happening. Psychiatry, therapy and counselling can also be helpful to do a deep dive into childhood and adult patterning related to sleep or preventing sleep including hypervigilance as well as cognitive behavioral therapy to work with thought patterns preventing sleep.

Everyone agrees that sleep is worse in periods of stress, and sometimes in periods of excitement too. Disturbed sleep is also part of major depressive order for many people with either inability to sleep or desire to sleep too much. And, anyone with a significant grief experience knows that early mornings can be very tough times for waking up and experiencing sorrow. For these reasons and more, treating insomnia is far from simple as sleep is deeply entwined with the conscious and subconscious mind.

There have been many studies on sleep and health outcomes. This 2020 study by Hackett et al states: “Poor sleep quality has been linked with negative health outcomes. Adults who report sleep problems are more likely to have hypertension, obesity and coronary heart disease (CHD) than their counterparts without sleep problems (Koyanagi et al., 2014). Meta-analytic evidence has detected a relationship between short sleep duration and incident hypertension (Itani et al., 2017). However, studies investigating the prospective link between poor sleep quality and hypertension have produced mixed results (St-Onge et al., 2016). Pooled evidence indicates that short sleep duration is a risk factor for obesity (Itani et al., 2017). While poor sleep quality has been linked with the development of the metabolic syndrome in middle-aged and older adults (Troxel et al., 2010).”

Our bodies hormonal clock may originate in the suprachiasmatic nucleus, but many organs have their own biological rhythms that are regulated independently. This concept has been proven in modern science but orginated in Chinese Medicine more than 5ooo years ago

There is a reason we go to sleep at night and wake up in the morning. This is called the circadian rhythm and provides a skeletal structure for many of our hormonal biorhythms. Cortisol and ACTH levels are pulsing throughout the day and night, roughly every 60 minutes. The pulse is generated from within the HPA axis in a dynamic feedback loop. There is a threshold for a negative setpoint that is predetermined by the suprachiasmatic nucleus where ACTH pulses, stimulates cortisol production into the vasculature, which diffuses into the IC space of the brain and stops ACTH production which then retriggers the negative threshold and restarts this ULTRADEIAN cycle. At night (or during sleep hours) the circadean set point is set at a lower free cortisol level in a diurnal pattern.

Living with chronic stress can alter this rhythm. Living with depression can alter this rhythm. Substance use can alter this rhythm. Grief can alter this rhythm. PTSD can alter this rhythm. Changing time zones can alter this rhythm. Shift work can alter this rhythm. Parenting will alter this rhythm. And kids need to develop this rhythm as part of learned sleep patterns coming out of infancy.

So, once ones sleep is dysregulated, what can be done? So-called sleep hygeine is the first step. This is a basic series of actions designed to minimize sleep interruption and maximize comfort and melatonin production. I often tell patients to treat themselves like a 5 years old with a bedtime routine. This creates patterning in the mind and body (those ultradeian clocks) that signals sleep time is coming.

Insomnia falls into to big categories – falling asleep and staying asleep. We will discuss these seperately as they require different medicine.

Falling asleep. What a gift it is to drift into effortless sleep. How many times have i lain awake, unable to relax enough to let that sleep veil drift across my consciousness? Falling asleep medicine is often in the form of sedatives in an acute setting. Melatonin + a sedative botanical is a good combination for short or long term difficulty falling asleep. As you can see from the image below, melatonin production has an inverse relationship to plasma levels of cortisol. If your circadian rhythm is dysregulated, melatonin supplementation can help recreate a new pattern (which is why it is used in changing time zones.) In our “more is more” culture people sometimes think taking higher doses of melatonin will work better. In actuality, this pineal gland hormone is naturally microdosed and 1mg is often the best dose. Combining melatonin with an app to provide guided relaxation meditations or sleep-inducing music like binaural beats can increase theta waves at the level of the brain simulating deep relaxation and promoting sleep. (I use the Insight Timer free app almost every night!)

The amino acid tryptophan is converted into 5HTP which is concerted into serotonin which is converted into melatonin. This is the biochemical reason why serotonin deficiency (depression) can lead to insomnia. Increasing foods rich in tryptophan, or taking either SSRI medications or 5HTP supplement can also increase endogenous melatonin production. Do not take 5HTP and prescription mood medications unless prescribed and followed by a health care provider.

My favorite sedative botanicals are valerian (valeriana officionale) and california poppy (Eschscholzia californica). Both are decidedly yucky tasting, with california poppy being super disgusting! However, it is one of the few things that consistently works for me so I choke down the earthy swampy tincture with a juice chaser.

The European union has a formal scientific herbal monograph compendium listing the scientific and traditional uses of 167+ commonly used botanicals. This was originally created to standardize information about commonly used herbal medicines for providers and consumers in an upgradeable format as new evidence develops. I personally prefer the Alt Med review for botanical monographs which is North American but not government regulated like the European compendium. In general herbal medications come in dry form used as teas, preserved in alcohol called tinctures or preserved in glycerine for children or people who cannot tolerate alcohol, capsules of prepared herbs or standardized extract capsules with prespecified amounts of active ingredients in each capsule. The strength of the medicine increases from raw herb/ tea –> glycerite –> tincture –> capsule –> standardized extract as the most potent form.

Valerian is a natural sedative. The active phytochemicals are bicyclic monterpenes, free amino acids, and valepotriates. Valerian is very safe and can be used in pediatrics and pregnancy. I do not reccomend it in late stage kidney disease. If anyone is taking multiple medications with severe illness, please only use any herbal medication under the advice of a naturopathic doctor, experienced herbalist or physician. This plant has stinky volatile oils that are also part of why it works. The herbal chemicals are sedating and calming, they can help both to initiate sleep and to maintain sleep. Start with the lowest possible doses as a tea or low dose tincture (10-30 drops) and increase as needed up to 3 capsules before bed. The primary side effect of valerian is morning grogginess from oversedation. This can be avoided by using lower doses and less potent forms. The smell of valerian could be a factor in ones decision of which to use with glycerite and tincture the least pungent forms.

valerian plant botanical monograph — Valerian (Valeriana officinalis) illustration. Digitally enhanced from our own book, Medical Botany (1836) by John Stephenson and James Morss Churchill.

California poppy is the other sedative plant that I frequently use for my own sleep. I use it in combination with melatonin for shift work and during times of significant stress where I really need something to “knock me out.” It tastes so terrible, but some days that is a small price to pay. I have only found this plant in tincture form. It can be added to a small amount of warm water to evaporate off the alcohol. This medicinal plant is listed in the European compendium as safe for use for adults only with over 30 years of safety. It is not to be used in pregnancy or breastfeeding or for pediatrics as it is in the poppy plant family. It does not have narcotic effects but it does have many chemical alkaloids to induce sedation. It is recommended to be used for up to 2 weeks and then stopping use for at least 2 weeks.

references

Oster H, Challet E, Ott V, Arvat E, de Kloet ER, Dijk DJ, Lightman S, Vgontzas A, Van Cauter E. The Functional and Clinical Significance of the 24-Hour Rhythm of Circulating Glucocorticoids. Endocr Rev. 2017 Feb 1;38(1):3-45. doi: 10.1210/er.2015-1080. PMID: 27749086; PMCID: PMC5563520.
Ruth A. Hackett, Zeynep Dal, Andrew Steptoe. The relationship between sleep problems and cortisol in people with type 2 diabetes, Psychoneuroendocrinology. Volume 117,2020,104688, ISSN 0306-4530, https://doi.org/10.1016/j.psyneuen.2020.104688.

Intermittent Starving vs Fasting

Posted on March 13, 2020 by Masina Wright ND

My IG and twitter feeds keep sending me promoted ads for intermittent fasting and young thin women in my Internal Medicine residency program keep telling me they are doing it. As someone with an inherent red flag signal for anorexia and eating disorders, I am triggered. As someone with a 4 year nutrition degree and as a gal raised with a spiritual practice of fasting, I do understand the value behind the concept. The problems start when restriction/binging/restriction patterns are overlayed on the foundational evidence.

This is the best nutritional protocol and evidence I found to implement intermittent fasting into a food plan for weight loss or for longevity. There is good reasoning and practice behind the idea that the liver stores glycogen for storage, and that this “immediate use” supply needs to be used up before the body creates new glucose from adipose cells and muscle. This is reasonable: fasting uses up the supplies . Then fasting decreases fat or muscle from stores.

Some fasting articles I’ve read suggest 16 hours between eating every day. This sounds alot like the “don’t eat food after 7” rule that has quite a few generations of folks waking up covered in cookies from night eating.

Some articles suggest 16 hours between meals twice a week. This seems more reasonable to me as it allows for some pre-planning to have restful, quiet time during the fasting period. Our human bodies are not designed to “run on empty.” I grew up in a yoga community where fasting was part of the practice towards enlightenment, but work was not done during the fast. One’s time in the fasting state is to be spent meditating, reflecting, and processing (like while we sleep.) Yoga is also an acceptable practice during this time as it stimulates glands and organs as well as the musculoskeletal body to return to homeostasis. Fasting is designed as a parasympathetic state to rebalance CYP liver enzymes and clear the intestines. Pushing through fasting with sympathetic, highly motivated activity like mental or physical labor requires the adrenal glands to overachieve and drive metabolism through adrenaline and sheer will aka cortisol.

The one place where hard work on a fasting belly IS indicated is for anyone looking to lower insulin resistance by using the biochemistry of exercise. This could be someone requiring huge doses of insulin for only moderate blood glucose control, or someone trying to beat type 2 diabetes in the pre-diabetic state. Exercising on an empty stomach is one of the few ways to upregulate cellular receptors called GLUT_4 for insulin to bring blood sugar into cells. I have tried this and its oddly satisfying. Nerd out on biochemistry and GLUT-4 here.

I don’t intermittent fast intentionally myself. Some weekend days I wont eat food until 2-3 in the afternoon, just based on my natural appetite; however, I do have black coffee and water and sometimes juice during that time. To be my best self, I need frequent and regular fuel to keep this brain and body going for the intense work weeks I do. Not allowing myself to eat when I am hungry in not helpful for my mental health either – not only do I get edgy or feel anxious, my own disordered eating and body dysmorphia can easily be motivated towards restrictive eating patterns.

Aside from mental health, some people also have genetic metabolic imbalances if their lineage experienced a traumatic food restriction. This has been researched in Irish descendants as well as Jewish folks. Caloric restriction can actually trigger a survival metabolism where minimal resources are burned and every morsel of fat possible is stored. This is ancestral trauma that has caused permanent alterations in the genome that get triggered by environmental circumstances.

The science is compelling: improved metabolism, destruction of cancer cells, immune regulation, cortisol balancing, cellular rejuvenation…. benefits are numerous!

Here is what I would do if I was either doing a period of cleansing/detox and intentionally working on restoring health or if I was committed to a defined period of intentional weight loss (8 months from this algorithm.)

Style 1: two mornings a week, fast until 12-1pm depending on your 16 hour window. On these mornings drink warm water, organic green tea or herbal tea, stretch and do yoga or go for a gentle walk, get into nature, rest/ meditate, write or reflect. Eat a Mediterranean style diet the remainder of the time.
Style 2: For a more intensive weight loss experience, follow the algorithm for 2 days a week of restricted caloric intake from the JAMA article referenced at the beginning of this post. I would not also follow the time restricted feeding patterns myself as I find this too rigid for modern life and overrides the natural appetite instincts which are essential. Eat a Mediterranean type diet or Paleo. Consider pairing this with the Whole 30 protocol or an elimination diet for true restorative food as medicine. Follow the above guidelines for your calorie restricted days with rest, nature, reflection, massage, acupuncture or other healing practices, whole organic foods, teas and water. Once you have completed month 4, return back up the protocol until you are back at full weekly caloric intake and reassess.

Insulin Resistance

Posted on February 9, 2020 by Masina Wright ND

Insulin is a hormone that is produced by the pancreas that helps cells to absorb glucose in the blood. When we eat a lot of sugar or carbs, there is a rush of glucose (sugar) absorbed into the bloodstream and the pancreas responds by releasing insulin, signaling the cells to allow the sugar in. When blood sugars dip low from chronic hunger or lack of food, there is very little insulin produced.

A lifetime of sugar rushes and sugar deficits can lead to Type II Diabetes, a blood sugar disorder that is characterized by insulin resistance. Insulin resistance happens when your cells stop being able to efficiently respond to the presence of insulin. Imagine you live next to a train track, or by a fire station. Eventually the constant trains or sirens become background noise – we stop hearing them out of habituation. Insulin resistance is kind of like this – chronically elevated blood glucose results in cellular apathy. Each little cell stops posting the GLUT4 receptors in the presence of insulin and the glucose cannot be absorbed. This results in a starvation state for the cells with an overabundant state in the blood, with resulting nerve damage from high blood sugar and cellular aging from nutritional deficit. Can you imagine how this could be improved with nutritional regulation of blood glucose?

The good news is it is possible to improve insulin sensitivity at a cellular level, especially at the pre-diabetes stage. The first step is to adjust your eating habits and diet. The chronically elevated blood glucose needs to stop happening as it is the flooding of the system and causing the habitual “resistance.” This can be achieved with high protein and vegetable meals with abundant healthy fats eaten every 6 hours or so.

Our cells like a slow, steady amount of glucose and insulin in the blood. The logic is as follows: protiens and fats and high fiber carbs like vegetables and grains break down slowly in the digestion, giving a slow steady stream of nutrients and building blocks. Processed carbs, sugar and fruits are broken down quickly and result in a rush of glucose. Therefore, to slow the rush of blood sugar one needs fiber, fat and protien present with each meal. This makes sense – it is always easier to handle any situation in life when things come at us in a moderate, orderly fashion. The microcosm is the macrocosm.

look up healthy fats and high protein foods!

The ginseng family including Panax Ginseng and American Ginseng are also used to lower blood sugar while increasing the ability to adapt to stress. This adaptogenic action exhibits effects across multiple endocrine organs including reproductive, adrenal and pancreas, making it a great herb for modern medicine. The ginsengs work at the plasma membrane level as well as improving steroid hormone receptor sites, which may explain their benefit and use in improving insulin resistance. http://www.ncbi.nlm.nih.gov/pubmed/10571242. There are many other botanicals that have a history of use in blood sugar management including bilberry, cinnamon, gymnemna and more.

Vitamin and mineral deficiency can also worsen existing insulin resistance and exacerbate high blood sugar. The trace minerals chromium and vanadium are both cofactors in the glucose-insulin complex and deficiencies in either of these will worsen blood sugar issues. Chronic magnesium deficiency is also commonly found in people with insulin resistance. This could be due to a deficient dietary intake as magnesium is found in leafy green vegetables and broccoli as well as fish, raw nuts and seeds, avocados, bananas and dark chocolate.

Finally, high intensity, short-term exercise is essential for improving insulin resistance. This kind of exercise shifts metabolism into fuel-burning mode, instead of fuel saving mode. Being active multiple times a day is even better for shifting into glucose utilization mode and improving cell receptor activity. http://www.thebloodcode.com/type-2-diabetes-recovery-needs-daily-exercise/ . Exercise is the only thing that will independently stimulate individual cells to produce those Glut 4 insulin-regulated glucose transporters found primarily in fat and muscle cells, instantly improving insulin resistance and decreasing blood sugar.

In summary, insulin resistance is a complicated condition that is essential to address in the treatment of diabetes. Fundamental nutritional changes and lifestyle basics are essential starting points for anyone interested in improving blood sugar parameters and taking an empowered stance towards metabolic recovery.

I Always Bring My Lunch

Posted on October 6, 2018 by Masina Wright ND

I was in NYC in August this summer, doing a short 4th year medical elective at the Center for Transgender Medicine and Surgery. I did some couch surfing, and stayed at an Air BnB in Williamsburg my last week. Medically it was an outstanding experience, and in my dream future, I will get to be a physician working at this clinic in Manhatten. Being away from home, I realized how much I rely on having my own kitchen! Making my lunch is I keep my body feeling good despite spending most of my time working in a hospital or relaxing in bed.

What do you do for lunch every day? By lunchtime every day, I will eat basically anything. I sometimes eats my lunch at 10:30 AM I am so hungry. The more glucose my brain is burning, the more I need that hit of fat, phytonutrients and fiber.

Therefore, my cunning plan is to eat super healthy sometimes boring basics for lunch – lots of veggies, good quality fats, high fiber fruits, raw vegetables and very few processed carbs. Then, I dont have to think as hard about what’s for dinner and still maintain a good nutrient balance.

So, what do I actually eat? Greens and grains, with cheese, avocado or nuts/seeds and random chopped veggies like carrots, cucumber, tomato, radish. In summer I love to put flowers in my food. A grain free diet is popular with the keto crowd, but I advocate to have at least a few cups of whole grains in the diet per week. The fiber, magnesium, B vitamins and serotonin release metabolically help keep the mind-gut axis regulated. We rotate our grains between short grain brown rice, wild rice, quinoa, and millet to maintain variety of flavor and nutrient profiles.

I heard once in a conference lecture that nutritional studies were done evaluating T4 –> T3 conversion activation (active thyroid hormone.) Subjects were fed fat based diets, protein based diets or carbohydrate (CHO) based diets. Only the diets with carbohydrates evidenced thyroid hormone conversion. Since I am a huge fan of having optimized T3 production for an effective metabolic mileau, I advocate for having a moderate amount of whole grains in ones basic nutritional foundation.I wish I had the study in-hand to back this up but I dont; maybe once I am out of medical school I will have time to research these things more fully. The bottom line is that whole grains are good for health and tasty and I like them in my lunch. They are filling and delicious and beneficial.

I like to layer the grains on the bottom, then a huge handful of greens – whatever has the latest expiry date when I am shopping! We rotate spring mix with herbs, arugula, baby spinach, crispy green leaf lettuce, and occasional kale salad (leftover.) I need fat with my lunch to feel satisfied, so I douse the whole thing with yummy olive oil and a delicious vinegar like balsamic or umeboshi or fire cider vinegar. Then, I add some protein: cheese is the easiest and I love cheese. Tuna, egg or chicken salads are always a win too.

I also love toasted walnuts, pecans, pumpkin seeds or sunflower seeds. I buy them raw, and toast them in a dry cast iron pan until they are warm and smell nutty but not burnt. Make sure to stir! I store these in glass jars in the cupboard. The pumpkin seeds are best toasted with some Chalula hot sauce and cumin! Yum. These add a crunch, some richness, protein, and delicious essential fats. Finish the lunch with 2 chopped veggies for color, fiber, and variety: an organic carrot, cucumber spears with pepper, pepper slices, whatever floats your boat.

If you are a hard paleo and refuse grains, or if you are like me and sometimes need a second lunch or a hearty snack then organic nitrite free salami is a good addition. It is filling, savory, and works well with olives, carrot rounds and other veggies for finger snacks. Just veggies is not enough for me.

Lunch Plan B: huge leftovers fan here. If I go out to dinner, I almost always save half for lunch the next day. This is a win-win, because I stop eating when I am full (or save room for dessert) AND I have a pre-made meal to go. I hate waking up extra early to deal with lunch, so I usually get lunch ready the night before. We generally also cook for more than two, planning a lunch or two and maybe even a supper into every meal we co-create. Leftovers are exciting to me because these are usually rich yummy comfort foods like pasta, steak, curries and other “real meals”.

Finally, making lunch saves me money. The first day of my August rotation I went to the nearby Whole Foods for lunch. I wasted 15 minutes wandering around the hot and cold bars, trying to figure out what to eat. My $15 salad ended up being an awkward mish-mash of flavors that did not blend well. That day after work I went and bought $40 worth of groceries (almond flour crackers, apples, greens, cheese, nuts, yogurts and paleo granola for breakfast) and brought my lunch to work every day for the next week, supplementing with enchilada leftovers.

Bringing your lunch ensures you know exactly what you are eating. It keeps you committed to your intentions with food, and lines up the healthy choices for you in moments of “Im Starving” brain meltdowns that would otherwise allow for easy Trash. It is also a great way to plan your daily insulin for diabetics! Finally, it frees up dinner for more social food activities that may be less greens and grainy.

Oh, and bring a snack, maybe two. For Fall and Winter I find an apple is the hardiest fruit. Combined with nuts and raisins, it’s a great choice. Someone once said, if you dont want to eat an apple, you are not actually hungry. This holds true as long as your teeth are in good shape. In winter and summer, cut up fruit like citrus or stone fruits an berries are refreshing and delightful. I also love dried mango slices from Trader Joe’s. If you crave yogurt and aren’t having it for breakfast, it’s a good option too. I love the dairy-free yogurts too like soy, almond and coconut singles, which are far better choices than anything a vending machine or a cafeteria might offer.

My basic formula is eating good quality food 65% of the time. Then I can easily process about 35% cheeseburgers, nachos, pizza, sweets, and other junk. To change your body composition this may need to become more like 75:25 and exercise has to be added in. I eat at least 60% of my daily food at work between 9-5pm. If I make sure these foods are healthy, wholesome and invigorating to my brain and bowels, my nutritional work is done for the day. Yay!

Balancing with Ayruvedic Medicine – from Womens Power to Heal

Posted on January 1, 2017 by Masina Wright ND

I am doing an Integrative Medicine Scholars program through the AMSA and we have to do a project to explore some aspect of Integrative Health. Ayurveda is a practice of medicine I don’t know much about, so I decided to do a personal practice incorporating lifestyle, nutrition and herbal medicine principles for the month of January. My friend Cathleen Miller helped me to figure out what my Dosha is (constitutional type) and lent me this amazing book, and …. here we go! Below is an outline taken directly from this text for (my) Pitta-Vata type.

Balancing Pitta-Vata Rhythms –

Rise with the sun and go to bed by 10 pm – maintain steady eating and sleeping routines
Ease yourself out of all stressful activities and maintain only those projects that create ease – allow adequate time to complete projects
Take ample rest
East wholesome, fresh, moderately warm, moist substantial and calming foods.
Avoid bitter, cold, raw, hot, spicy, oily, salty, fermented or stale foods and stimulants.
Shield against hot, wet, humid, cold, damp, or stressful environments.
Embrace serenity, love, warmth, healthy rituals and calmness.

Nutrition Principles

AVOID: caffeine, refined sweets, alcohol, saturated fats, excess salt, oily and spicy foods, and commercial dairy projects, as well as highly processed junk foods, meats, additives, frozen, canned, commercially grown, bioengineered, transgenic refined salts, sugars, flours and hydrogenated oils.

CHOOSE:

VEGETABLES	Broccoli	Brussel sprouts	cabbage	Cauliflower
Artichokes	Asparagus	Bamboo	Bitter greens	Black olives
Celery	Cucumber	Green beans	Dark greens	Parsnips
Peas	Potatoes	Sprouts	Summer squash	Sweet potato
Winter squash	yams	Watercress	Bok choy	Carrots
Daikon	Beets	Leeks

FRUITS	Apples	Apricots	Coconuts	Dates
Fresh figs	Oranges	Pears	Pomegranate	Tangerines
Mango	Plums	Raisins	Quinces	Limes
pineapple	Avocado	Banana	Grapefruit	Kiwi
Lemon	Peaches	Tamarind	Rhubarb

LEGUMES	Aduki beans	Mung beans	Kidney	Lima
Lentil	Navy	Pinto	Chickpeas	Tofu
Black beans

NUTS	Coconut	Roasted sunflower seeds	Roasted pumpkin seeds	Poppy seeds
Water chestnuts	Macadamia nuts	Sesame seeds	Pecans	Walnuts
Pine nuts	Pistachios

DAIRY	Unsalted butter	Cows milk	Cottage cheese	Sweetened yogurt
Buttermilk	Whole cows milk cheese	Cream	Ghee	Sour cream

OILS	Sunflower	Almond	Olive	Coconut
Dark sesame	Light sesame

SWEETENERS

Maple syrup

Dates

Sucanat

SPICES	Coriander	Cumin	Cardamom	Cilantro
Curry leaves	Dill	Fresh basil	Fennel	Turmeric
Saffron	Peppermint	Spearmint	Ginger	Anise
Mustard seeds	Sage	Nutmeg	Thyme	Ginger
Cloves	Rosemary	Tarragon	Oregano	parsely

Practices

New moon journalling with saraswati mantra – Aim Sarasvatyai Namaha
Ginger compress one week before the new moon (unless bleeding)

1 gallon water

1 handful grated fresh ginger

1 lg stainless steel pot with cover

2 stainless bowls

Bring water to a boil, and add ginger secured in a ouch with a drawstring. Squeeze the pouch to release the ginger juice and drop into the water. Simmer 30 minutes. Let sit 5 minutes before uncovering when taken off the heat. Create a compress towel and apply to lower back for 4-5 minutes or until lukewarm. For full instructions, see text p. 264.

Rose Oil Pichu – for headaches, hair loss, pain in the eyes, poor vision, mental fatigue and nose bleeds. Pichu: a powerful lubricating and loving therapy that helps maintain mental calm, emotional equanimity and helps balance the doshas. Best time: waxing moon phase. C/I bleeding. Best time: morning or early evening.

¼ cup dried roses

1 c sesame oil

Bring to boil over low heat and remove from heat, Add rose flower, cover and let steep 4-6 hours. Strain and use.

PICHU instructions: need pottery bowl, 12 “ clean cotton square and cotton hand towel.

Wash hair a few hours before
Release all stressful thoughts and details from the mind
Assemble the supplies on the floor close by
Soak the cloth in oil and lie down; place the cloth ear to ear. Press down on the cloth and wipe away excess oil
Rest quietly for 30 minutes and rise slowly, use hand towel to wipe away excess oil and maintain a peaceful attitude for the rest of the day.

Shakti Mudra – should be daily but 3 times per week seems doable – enhances sense of self, reinforces femininity, self esteem and restores vital energy to the womb.

Sit facing east

Bring palms together and separate slowly

Form the Shakti mudra hand position – see p. 192 text

Breathe deeply into pelvis and breathe out slowly, tracing the exhalation from the base 0f the perineum, circulating through the uterus and belly

Maintain for 15 minutes

Take a deep breath and make a commitment to a life of non-hurting

Yoni Mudra – 3 days before the new moon and full moon to revise Shakti prana.Not when bleeding.

Sit in meditative practice with palms facing up

Create the yoni mudra hand positions – see p. 155 text

Hold the hand gesture for 5 minutes

Allow breath to flow freely throughout the body, keeping the mind centered

HERBAL MEDICINE

Herbal Teas for PMS – Vata type predominant – take for 3 days of the new moon as well as the 5 days before menses

Helpful herbs: nutmeg, valerian, triphala, ashwaganda, shatavari, cinnamon, turmeric, fennel, dill and wild yam.

CINNAMON, CLOVE AND CARDAMOM DECOCTION (VATA) for PMS

2 c water

2 c organic milk

1 tbsp cloves

1 tsp cinnamon

1 tsp cardamom

½ tsp ginger

1 pinch saffron

LAVENDER FENNEL GINGER TEA DECOCTION (PITTA) for PMS

I c water

1 c organic cows milk

1 tso roasted fennel seeds

1 tbsp lavender petals

1 tbsp hops

½ tsp ginger powder

1 pinch saffron

bring water and milk to a boil. Toast the fennel seeds, then add all herbs and spices and simmer on medium for 15 minutes. Remove from heat, add saffron and stand 3-5 min before drinking.

Heartbreak and Heart Failure

Posted on November 25, 2016 by Masina Wright ND

Sometimes life, work and study all seem to dovetail and everything makes sense for just a few glorious moments. Cardiology was like that for me, in between the Frank Starling curves.

Last year we had a case study of a woman with congestive heart failure (CHF.) Her husband had renal failure and needed dialysis, and she worked at a job she didnt love. She slowly developed worsening heart failure over the course of the case, with shortness of breath, edema, high blood pressure, and poor circulation, eventually dying from it. I was impacted by the apathy she displayed in her efforts to recover – unwilling to eat more grains and greens, decrease salt, get outside, exercise regularly, investigate psychotherapy, or better her personal life in any way. Instead, she just declined in health, adding a new prescription per year to mange her symptoms until she – drowned. In her grief. Of heart disease.

This. Story. Happens. Every Day.

And not only in the US, or Canada or Europe. World-Wide.

The multitudes of meta-analysis risk factor evaluations like the Framingham, Whitehall and Rekjavic studeis have concretely illustrated important evidence about the facts of heart disease: atherosclerotic fatty streaks in arteries, high blood sugar, and inflammation are the undeniable Holy Trinity of heart disease. What is not being avidly reported is the rate of divorce, or mood disorders in these same subjects. The sexual dissatisfaction. The childhood trauma. Socioeconomics and race are sometimes studied, and African Americans and Latinos have higher rates of heart disease. Nobody is surprised. Russia has the highest rate of ischemic heart disease in the world, along with some African nations and Indonesia. These countries also have horrible human rights records, with well documented transphobia, homophobia and police brutality.

If we are going to turn around heart disease, do we not need to acknowledge the humanity of the heart? The same epidemiological study quoted deep within the content:

“Additional reports from this study have shown inverse associations between fair and respectful treatment at work and CHD [Congestive Heart Disease],and job control with future CHD risk.“

Similarly, hypertension, which is the harbinger of heart disease through its effect on cardiac structure and function, is hugely mediated by the stress response.

I was talking to Dr. Stein, an internist specializing in HIV and also our OMS II course director, about this theory that heart failure is so rampant because we have no real medicine for soul-problems like dissatisfaction, grief, sorrow, envy, loneliness and such. He said the links between depression, elevated cortisol, hypertension and CHF are well documented and clearly evidenced.

He reiterated that it is known that People of Color have higher blood pressures because their lives are more stressful due to systemic and personally experienced racism aka “stress.” It is also well evidenced that African Americans with CHF respond better to different medications than other races – Hydralazine, a vasodilator that decreases resistance, improves survival with isosorbide dinitrate rather than the ACE inhibitors and Beta Blockers commonly used. Ha, decreasing [systemic institutionalized] resistance as a keystone in improving survival? I need to know more about the MOA of these drugs to understand why decreasing the catecholamines isnt enough for this population; maybe its because of the deleterious and constant push and pull the sympathetic blockers have on the heart receptors of someone living in the actual adrenergic rut of an unsafe society.

Our cardiologist professor Dr. Glass stated that the average person with hypertension is on 3.4 medications to manage it. These are usually layers of diuretics to decrease the blood volume and drain edema (decreasing preload), and beta blockers to decrease cardiac work and improve cardiac output, and/or other meds like diphydropyridines and nitrates. But guess what – it just came out recently that hypertensive medications may be CAUSING depression/ mood disorders while working to decrease blood pressure. What a double whammy. This was a big study from a database of a single hospital containing 525,046 patients over 5 years. This 2016 article stated:

“Major depressive and bipolar disorders predispose to atherosclerosis, and there is accruing data from animal model, epidemiological, and genomic studies that commonly used antihypertensive drugs may have a role in the pathogenesis or course of mood disorders.”

Patients on angiotensin converting enzyme inhibitors or angiotensin receptor blockers had the lowest risk for mood disorder admissions
those on β-blockers (hazard ratio=2.11; [95% confidence interval, 1.12–3.98]; P=0.02) and calcium antagonists (2.28 [95% confidence interval, 1.13–4.58]; P=0.02) showed higher risk
those on no antihypertensives (1.63 [95% confidence interval, 0.94–2.82]; P=0.08) and thiazide diuretics (1.56 [95% confidence interval, 0.65–3.73]; P=0.32) showed no significant difference.

To summarize the findings, calcium antagonists and β-blockers may be associated with increased risk, whereas angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may be associated with a decreased risk of mood disorders. (Hypertension. 2016;68:1132-1138. DOI: 10.1161/HYPERTENSIONA HA.116.08188.)

It appears, the drugs that most directly affect the heart muscle itself are thus linked to more mood disorders, while those that work indirectly and decrease the work for the heart seem to have less impact on mood.

This is such a broad topic and there are so many layers to heart failure – blood pressure, kidney regulation of blood pressure, nutritional effects, blood lipids, blood volume, inflammatory mediators, free radicals and antioxidants, sleep quality and more – but I think that too often we lose sight of some of the most basic truths of happiness and heart health. And we also forget the deeply sensitive creatures that most of us are and fool ourselves that pharmacy could possibly be enough to cure a heart that is systemically broken, or the effects of a chronically hypervigilant nervous system.

I am going to need to become proficient at cardiology as an Internal Medicine doc. But without a degree in psychiatry, or soul medicine, or archangel intervention, how can I possibly hope to help people recover their failing hearts when the intersections cut so deep? I am scared of all of those people that have no willingness, or ability, to look deep within and make the simple and profound choices towards life. This is the part of being a physician I most fear. The medical failures; the broken hearts.

The Pitfall of Alcohol

Posted on September 26, 2016 by Masina Wright ND

I’ve been avoiding writing this post for at least a week, probably two. Mostly because it has personal meaning to me as alcoholism runs in my family on both sides – My mothers father was one of the “Mad Men” of the 50’s, worked in advertising and died of liver failure due to alcoholism. I guess he got pretty ugly in the end. My paternal grandparents didnt drink at all (which leads me to wonder if their parents were alcoholic) but all of their children have a penchant for the sauce.

Before I was a medical student, I thought the damaging effects of alcohol could be traced directly by measuring liver enzymes – and as long as those harbingers of hepatic cell death stayed within a reasonable limit, one was “getting away” with whatever one was doing. Enter: neurology. Boy was I wrong. Oh and Ps. Dead liver cells cant release ALT or AST, so good liver enzymes in the face of chronic alcoholism is actually a pretty bad sign.

The blood brain barrier is an effective barrier to most things except: nonpolar and lipid soluble molecules. Enter: CO2, O2, and ETOH (alcohol.) This means that as soon as alcohol is in your blood, it is seeping into your brain. And brain cells/ neurons are permanent cells – they don’t have the ability to divide, so they don’t replicate. You get what you started with – some axons can be regenerated, but once the cell body dies, your numbers start to decrease.

The cerebellum is one of the parts of the brain most affected by alcohol cell death; this is why people become unsteady and clumsy when drunk – inhibition of cerebellar function! There are multiple and complex inputs to this lower brain region from almost every aspect of the nervous system, so it can compensate for loss of neurons (when sober) for a long time. Up to 80% of cell death can happen before symptoms become noticeable! Unfortunately, once this is happening in the sober state, the cells are dead and there is no ability to recover balance or coordination.

I didn’t know that memory loss is also a component of chronic alcoholism. There are two halves to the cognitive decline that will happen eventually called Wernicke-Korsakoff syndrome, and these are from alcohol related destruction to two more areas of the brain.

The first set of symptoms is reversible, and is related to a deficiency of vitamin B1 aka thiamine. The mammillary bodies are wee nubs on the underside of the brain that are part of the social and emotional brain. They take information from the hypothalamus and hippocampus, and run it to the anterior nucleus of the thalamus.

This is a critical loop in emotional and social behavior integration at a cognitive level. I guess this is partially where the numbing effect of alcohol on the emotions could occur? With a deficiency of B1, the mammillary bodies hemorrhage and cause Wernickes encephalopathy, characterized by confusion and your eyes not tracking properly, as well as the unsteadiness from the damaged cerebellum. This is why in hospital treatments, alcoholics are first given thiamine/ B1 to see if it can reverse the symptoms. From a prevention standpoint, taking a good quality capsule (not tablet) daily multivitamin seems like a good idea for anyone drinking on a regular basis.

This condition can progress to irreversible memory loss for the past, with an inability to make new memories, plus psychotic symptoms. This is called Korsakoff psychosis. As people lose their ability to remember, they start making things up to fill in the blanks called confabulation. This can be really depressing for friends and family members as it becomes clearly evident that the damage is permanent.

and THEN, there is the metabolic damage that is occurring below the neck. (This next section is biochemical mumbo jumbo, but since this is my review exercise, I’m going to include it for my medical interest:)

Ethanol/ your drinks/ are 80% broken down by cells (cytosol) of the liver. 15% of alcohol is broken down by microsomes in the brain and liver, and this pathway is upregulated in chronic alcoholism. The remaining 5% are converted to fatty acids and phospholipids that are thought to play a role in tissue damage. Both primary pathways break down ethanol to acetaldehyde, which is metabolized down to acetate…..Acetate, where have you heard that before? yes, NAIL POLISH REMOVER, flooding your liver and brain.

The major metabolic consequence is from the elevation of NADH that occurs in the cell and in the mitochondria in steps one and two with excessive and continual amounts of alcohol intake, because this NADH will inhibit the TCA cycle from running. No TCA = no glucose metabolism = no fuel for the cells. The brain will still need fuel, so the liver cleverly shifts the glucose from the alcohol (which can no longer be metabolized) to ketone production + free fatty acid synthesis (aka fat storage.) This explains, in painful detail, why alcohol makes you gain weight and affects blood sugar levels.

Finally, I wanted to add this last slide for an important prevention note. This is the process of the 15% microsomal pathway that is upregulated with chronic high alcohol intake. Note the second step produces ROS – this is reactive oxygen species aka free radicals which are known to cause cell damage and cell death. Higher levels of ROS are bad in general and associated with greater inflammation and cellular damage across the board. This points to another potential place for prevention – with use of high dose antioxidants like CoQ10 200-300mg, resveratrol (500mg), alpha lipoic acid (200mg) and vitamins C (1000mg) and mixed tocopherol E (400IU).

When alcohol intake gets high enough to start causing brain damage, obviously the primary treatment goal is to reduce the intake. Our first case study had a 37 yo male drinking 12-16 beers PER DAY. How many drinks, realistically speaking, are you having per day? How many does that add up to per week? Does that seem reasonable to you?

I don’t know enough about addiction to know how to address real chronic alcoholism. I imagine it is incredibly hard to quit, and even to reduce daily intake without a pure and strong internal directive to do so – no one can be told to do it, the drive Must Come from Within. Treating underlying depression, anxiety, or life stressors are surely part of the picture, but what if you just drink to have fun? Sometimes, the party needs to stop, or gets out of control. I guess we all need to grow up sometime and learn to tolerate whatever it is we harbor inside our minds (before they get destroyed.)

Alcohol is a depressant, so withdrawal symptoms are the opposite – agitation, irritation, worse case scenario people can have seizures. Benzodiazapines, some sleep drugs and alcohol all work on the GABA-A receptor in the brain. Chronic alcohol use downregulates the expression the neurotransmitter GABA, one of the “off switches.” Once high levels of alcohol start to lower, it takes time for the brain to start making enough GABA again, resulting in foul moods, irritability and general unpleasantness.

There are medications like naltrexone and acamprosate that can help reduce the cravings for alcohol, and medications to treat the side effects of withdrawal, mostly aimed at these same parts of the brain. These are definitely worth exploring with a psychiatrist or addiction specialist to figure out what approach will work best for you. Complete abstinence does not need to be the goal. GABA as a supplement is not absorbed well, but is readily available and might be worth a try for someone who is just cutting down on daily intake, and has addictive enough a personality that switching to benzos instead of alcohol could exacerbate rather than relieve the problems. However, it is unlikely GABA alone would be enough to support sobriety. Making the very personal and often terrifying choice to look at one’s habits and face trauma/addiction is the place to begin. A comprehensive medical assessment with an empathetic and respectful health professional who has experience in addiction is next step. (if you are in Maine, I highly recommend Dr. Merideth Norris!)

Eat, Sleep, Wait, Repeat.

Posted on October 6, 2015 by Masina Wright ND

I recently read an article that most Americans eat for 15 hours a day. Apparently, the body needs a 12 hour fast daily to clear liver glycogen, thus switching metabolism to utilize the body’s stores (fat) to fuel the basic metabolic rate. Without this 12 hour fast, the liver does not get to ever fully utilize glycogen stores, and food/fuel aka glucose gets stored as fat.

Ive been tracking myself, as I always do when I am trying out a new metabolic theory, and I usually get about a 9 hour fast in. I’m one of those people that likes to eat at night, and with my new academic schedule, I need my 7am morning toast to soak up the coffee that makes my 6am wake-up call possible. Also, beverages counts as food/fuel in this context. Therefore, the last drink of alcohol, milk or juice you have before bed also counts towards the fasting timeline.

The 12 hour fast biochemistry is probably the source of the “dont eat after 7pm” dogma. That, and most of the snacking that occurs after dinner is high calorie and high deliciousness.But what if, like me, you are someone who likes to graze after 7am, eat dinner late, and/or cant sleep with an empty belly?

The moral of the story is: if you are trying to lose weight, make it a priority to fit in a 12 hour fast that includes your hours of sleep (hopefully 8+. Read how more sleep helps you lose weight here.)

For example: If you snack until 10pm, don’t have breakfast, coffee with sugar or cream/milk, juice, or anything over 5 calories or sweet tasting until 10am. (Ps. Even artifical low calories sweeteners may be linked to weight gain says Harvard med.) This will allow your body to “empty” its reserves, making room for a day of metabolic synergy and a delicious, satisfying 12 hours of food after your overnight fast.

Hint: learn to love black tea or coffee, green tea, and/or hot lemon water before your 12 hour fast is over if you are honestly wanting to lose weight. If, like me, you are too busy to make changes right now, just think about it, watch your patterns, and see if you can do it every once in awhile or on weekends.

The Wright Doctor

Modern Medicine, Old Fashioned Care

Category Archives: Metabolism