Intermittent Starving vs Fasting

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 a hair trigger red flag signal for anorexia and eating disorders, I am triggered. As someone with a 20 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 anlot like the “don’t eat food after 7” rule that has quite a few generations of folks sleep binging and waking up covered in cookies.

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 spiritual 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 into 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 the special 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 by 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 your genome that get triggered by environmental circumstances.

The science is compelling though: 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.)

  1. 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.
  2. 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.
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Insulin Resistance

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.

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Rheumatology: Pain, Joints, and Autoimmunity

I just finished my final elective of medical school. I chose Rheumatology because I have such a strong genetic tendency towards this class of diseases, and because it was something I felt under-educated about heading into Internal Medicine.

Rheum itself means “a watery fluid that collects in or drips from the nose or eyes.” Whereas rheumatism is “any disease marked by inflammation and pain in the joints, muscles, or fibrous tissue, especially rheumatoid arthritis” according to online dictionaries. Clearly these two do not match up? Although perhaps one could argue it is the “watery fluid” of the joints that is attacked by immune system dysregulation in most of these conditions, resulting in pain, inflammation and joint destruction. Most of these conditions are also multisystemic, affecting the heart, lungs, kidneys, eyes, skin and more. The umbrella of rheumatology is large: conditions I saw in clinic included rheumatoid arthritis, lupus, scleroderma, psoriatic arthritis, polymyositis and dermatomyositis, pseudogout, gout, and polymyalgia rheumatica. There are of course more that I did not witness.

A large part of patient management involves managing and regulating pain. Opioids are now recognized as crutches inhibiting recovery for many people with long term pain rather than panaceas. Dr Clauw, a pain specialist from Michigan explains this way better than I could, and also addresses several prescription and over the counter medications as well as lifestyle management techniques for living your best life with chronic pain. Watch this YouTube video now, or listen to it while you drive: https://youtu.be/B0EhNajqkdU 

One conversation that came up several times was the use of topicals for pain. Many folks cannot take ibuprofen for pain due to stomach or kidney disease, or are already on long term therapy with prescription strength NSAIDS and still have pain. Voltarin, a topical NSAID was prescribed regularly, specifically for osteoarthritic pain at the base of the thumb with good success.

Many patients use CBD preparations for consistent pain reduction. Some people call cannabiboids “opioid sparing medications” as people can reduce the amount of narcotics needed on a daily basis with the concurrent use of CBD products. The doctors I was working with did not specifically endorse nor did they advise against medical marijuana as Maine is a state where purchase and possession is legal with certification. However, they did support individuals trying topical marijuana preparations of their own initiative for pain management.

The biochemistry of cannabinoids is super interesting if you are into psychoneuroimmunology. This recent article from Naturopathic Doctor News and Review does a pretty good job of outlining the basics of CBD oil as well as some of its politics in reference to mental health. Its use in pain management is multifactoral. There are two main cannabinoid receptors in the human body both of which are relevant to rheumatology and management of chronic inflammatory, neuropathic and mechanical pain. CB1 receptors are found throughout the brain and body and are responsible for most of the psychotropic effects; they are also found on osteocytes (bone) and chondrocytes (cartilage). CB2 receptors are primarily on immune cells  as well as osteo and chondrocytes. The underlying physiology is complex and still being researched extensively but one thing is clear: cannabis-based medications are effecting in reducing chronic pain via their effect on the the endocannabinoid system in humans and altering pain chemical signalling.

As aggressive autoimmune diseases, most of these conditions require sophisticated, high end medications to manage their progression. I saw many cases of men and women who had life changing benefits from DMARDS, or Disease Modifying AntiRheumatic Drugs. My main take home point from this rotation was if one of my patient is newly diagnosed with one of these conditions, REFER! to a rheumatologist as the medications are advanced and specific. My great-grandmother was bed-bound by 40yo with rheumatoid arthritis and she did not have the benefits of science to treat her disease progression. Even tho I am also a Naturopathic Doctor, I have respect for the powerful efficacy of these medications and do believe they improve and maintain quality of life in potentially destructive conditions like these.

On the other hand, medications alone are often not enough to manage and maintain the best health possible. The 2017 textbook I was given for the elective had a small section at the back for complementary and alternative therapies that have good evidence for rheumatology.

  • Vitamin C is an essential component of cartilage and collagen. Supplementation reduced progression of joint and cartilage destruction over time. My Note: Vitamin C is naturally occurring in high levels in many raw fruits and vegetables. This is a great reason to eat fresh raw foods as part of your every day diet with any kind of inflammation or joint disease.
  • Vitamin D is for more than strong bones; it is also a hormone that effects immune health. Countries that have less sunlight year round have higher occurrences of autoimmune disease. Get outside 20 minutes daily minimum all year round, and supplement vitamin D every winter. Have your blood levels tested every fall to ensure optimal levels of this hormone and nutrient.
  • Fish Oil has known anti-inflammatory properties in its EPA component and many brain benefits in its DHA. This rich omega 3 essential fat is best eaten as a meal at least 3 times per week – a tin of sardines, mackerel or herring has way more nutritional value than a couple of fish oil pills and costs so much less. Any seafood will contain fish oil  – the littler the fish, the higher the benefit when it comes to these healthy oils. If you do go for the fish oil pills know that you get what you pay for. Evidence shows you need about 3000mg of fish oil via pills daily for benefit, or at least 450 mg DHA and 750mg EPA. I like Nordic Naturals Brand for best quality and efficacy if you are going to go the pill route. For tinned fish, there are lots of brands, but this is my fave and it’s easy to find in regular grocery stores.
  • Omega 3 oil is also available in vegetarian form as flax seed oil or marine algae oils.

The evidence for a specific kind of diet for autoimmune disease is variable. Dr Jackson referenced the Mediterranean Diet as the best foundational nutritional plan for Lupus specifically. This makes sense as it is a low inflammatory, high fruit, fiber and vegetable diet with known benefits for heart health and longevity.

Many people choose to go paleo, or follow the whole 30 autoimmune diet plan. Phoenix Helix is a podcast dedicated to autoimmune health and paleo nutrition. During my rotation I listened to a great episode with Dr. Aly Cohen, an integrative rheumatologist who spoke on scleroderma and integrative medical management. In addition to reviewing some specific suggestions for scleroderma, Dr. Cohen spoke on the importance of reducing processed food chemicals, pesticides and additives and choosing clean drinking water, not from plastic bottles. As she said, over 90,000 chemicals have been introduced to the ecosystem and therefore the human body in less than 100 years. Autoimmune disease is linked to this toxic burden and inability to process the chemicals. Find out more about her work @thesmarthuman on Twitter and Facebook.

Three weeks of rheumatology clinic was only enough to learn the basics of diagnosis and management, and gave me great respect for my fellow Rheumatologicial internists. Each of the conditions under the Rheumatology umbrella have advanced immune dysregulation and multisystemic consequences with potentially dire outcomes. Fortunately, pharmacology has a class of exceptional medications that work quite well, especially when paired with nutritional initiatives and long term pain management strategies that focus on quality of life. I am grateful to Dr. Stanhope and Dr. Jackson at Central Maine Medical Center Rheumatology Associates for letting me ask too many questions while they were trying to write notes during their busy clinic days – and for the freedom to enjoy afternoon sunshine on my last medical school rotation!

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A Habit is Harder to Break than a Heart

Ugh. New Years Resolutions. Worst idea ever! And yet – I had a tough end of 2018 personally so I decided to make some resolutions in an effort to bring structure and more wellness to my life.

Well, it is 13 days in and I have already failed all of my official resolutions. In fact I failed my first one in the first two days of the year:

1. spend less time on my phone, especially in the company of people I love

Excuses are bountiful. However, If you are in the same boat as me with lofty goals and a complex life, I encourage you to think about resolutions as a year long goal, not something to be abandonded by week 3. It could take even 3 years to build the structure that you need to support the foundation of your bigger dreams/resolutions like an art or writing studio and time to produce new work.

The Winter Solstice (12/21/18) is when we annually rekindle the spark of the year ahead. This tiny flame grows to a raging bonfire at Summer Solstice with our culling and tending and then dwindles down to the blue flames of Halloween and Nov-Embers. Then the cycle begins anew with the next Winter Solstice.

If you looked at your resolutions as a fire you were to tend for a 12-36 month duration, would that change your approach? Your commitment to your Self or Visions?

I have things about my lifestyle I need to adjust, and those are built on deeply entrenched habits that function as crutches that allow me to perform in my hugely challenging day to day life. I cannot just pull the supports from my foundational Activities of Daily Living; I CAN build new supports/habits to relieve the not-so-functional structures.

Building a new wellness foundation takes a team or at the very least a multifaceted approach. I failed my New Years Resolutions the first week because I did not have my new structures in place to support them. I now see who and what I could rely on to make this reality functional, and this second week of the year I was 50% more successful in my goals.

What are your NYR? What changes do you need to make this happen?

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I Always Bring My Lunch

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!

 

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Gall Bags, Spring, and Other Mysteries

Has Spring come to your part of the world? Because it is slow to arrive in Maine. Most of our world here is still a monotonous palate of gray, brown, pine green, white, dirty white and cold blue. April has promise, because today the sun felt warm even with the cool wind. And little shoots of yellow-green things are growing in the dirt!

Naturopathic Medicine heralds spring as the season of the liver – like trees stagnant over the winter our saps start to flow too. And our sap in this case in not blood, but bile. The ancient Greeks separated bilious humors into yellow, and black. Yellow bile is what we now call bile, stored in the gall bladder and useful in digestion. Black bile is a far more mysterious, melancholic and deadly humour, and one that I will have to investigate further when I am not studying for surgery exams.

So far this clerkship has been “general surgery” which has been primarily cholecystectomys and hernia repairs. The standard of care is to electively – or emergently – remove every gall bladder that presents with symptoms and evidence of stones or sludge. This makes sense because once one stone has caused problems, its pretty likely another will eventually. Complications can be pretty intense – gallstone pancreatitis with or without ileus is nasty, as is choledocolithiasis and ascending cholangitis. I am on board with this plan.

The best plan of action to avoid having gall bladder surgery is prevention. Inspired, committed lifestyle and nutritional prevention years before the problem starts. Not many people are willing, or have access to the knowledge to practice the kind of prevention that is required to avoidgallstones. By this I mean, too many people are never educated about the impact of food choices on health,  or just dont care enough to make the choices to eat an every day diet with good quality oils, moderate animal proteins and high fiber, high antioxidant, high phytonutrient grains and fruits/vegetables. (This is a whole other conversation about class, nutrition, education, access and economics.) Individuals also need to have the spark of interest to learn about plants as medicine and botanical therapies for liver health, as well as the initiative to either track down someone to act as a herbalist or dabble in self care. Because, once gallstones are formed there are some treatment options but…. not many. And IMHO, not many that are truly effective.

For those out there looking for guidance, herbal medicine combined with nutrition is the best way to maintain long term liver and gall bladder health. According to a PubMed Physiology text, bile is formulated in liver cells and modified by cholangiocytes as it travels through the bile canalicula. It is essentially a watery mix of cholesterol, bilirubin, phospholipids (fats), bile salts (broken down cholesterol bound to amino acids), proteins, bicarbonate, salts, and enzymes like alkaline phosphatase. Bile is classified as a mechanism to eliminate waste from the body, and I suspect it carries dubious products from the CYP enzymes that are not fully metabolized by an overburdened liver as well.


With this in mind, increasing bile flow with bitter alkaloids and other phytochemicals inherent in plant medicine are a logical way to improve gall bladder health. There is one botanical I know that have specific use for stones in the body called peumos baldo, but most of the hepatophillic herbs simply increase bile flow thereby decreasing stagnation and thus stone formation. One well-known liver loving botanicals is milk thistle (silybum marianum), which is insanely hepatoprotective and has multiple studies on it for chemical insults. This will not likely help with bile health directly, but it does protect hepatocytes from repeat insults from drugs metabolized by the CYP enzyme system such as antidepressants, anti-epilepsy drugs, birth control, alcohol, narcotics, and some antibiotics.

Dandilion (Taraxacum officionalis) and artichoke (Cynara scolymus) are often paired for their cholegogue effects. Its very common to see these three together in standardized formulations as they are probably the most well known players – and for good reason because they are safe for most healthy people and have a very long historical use for all sorts of “bilious” afflictions including gall stones. Of note, if you have lots of gall stones sitting in your gall bladder or have already had gall stone attacks,  taking high doses of cholegogues could precipitate an attack of acute cholecystitis. However, if you have already had your gall bladder removed they would be safe. There are many other plant medicines for bilious health employed by Naturopathic Doctors and herbalists world-wide, from many indigenous systems of medicine. Seeing an expert for individualized medicine is always the best choice for safe, effective and appropriate treatment as the liver, like all organs in the body rarely acts in isolation. Thus, the best medicine takes your whole health into account.

Finally, we think of natures medicine as extracted herbal “drugs”, but plain old water is so therapeutic for liver health. If bile is an aqueous solution, then chronic dehydration from caffeine/alcohol soda/sodium must lead to a concentrated and hypersoluble solution, right?

Vegetables are also medicinal plants. Spicy and bitter greens have the same cholegogue activity as dandilion and artichoke and are very safe to consume. Cruciferous vegetables like cauliflower, broccoli, kale and brussel sprouts have documented chemical constituents that improve estrogen metabolism, thereby improving bile flow. The fiber binds excess cholesterol and maintains bowel health, and they have documented anti-cancer properties. Eat your broccoli!  Beets and carrots are rich in carotenoids which give their vibrant colors. These have traditionally been used as healing foods for the liver and although I do not know the exact reason why, can they hurt? Only if you hate beets, I suppose.

I have to stop writing this post, because I have to be up at the crack of dawn for another laproscopic cholecystectomy tomorrow. Its a surgery that definitely needs to be done – the woman has had some significant blockage from a stone that miraculously moved on its own but caused an elevated bilirubin as well as weeks of abdomninal pain and distress. It would be unsafe for her to just wait around for that to happen again, because where there is one stone, there are probably two. And where there is a chronically dehydrated American taking multiple pharmaceuticals and eating the SAD, there will always be another gall bag to take out.

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The Pain Conundrum: Options & Alternatives

I’m a woman with chronic pain. It waxes and wanes, but I have been on flourbiprofen, a prescription-strength NSAID for about 20 years. I take it about a week before and the week of my menses. That is two weeks a month of strong NSAID use. Plus, ibuprofen for occasional headaches or other pains.

After spending a week observing a nephrology office in January, I started thinking about my own NSAID use and  kidney health. After getting some lab evaluation (creatinine, BUN and GFR) it turns out I have stage 2 kidney disease. WHAT!! I consider myself an extremely healthy woman, and no doctor has ever mentioned kidney issues, much less had a conversation with me about the well known, scientifically proven ways that NSAIDS like ibuprofen, alleve, midol, and aspirin damage kidneys.

Here is the science: The kidneys receive about 25% of the blood flow from the heart, and filter blood through their delicate & intricate filter and tube mechanisms.

 It is prostaglandins that increase pain and inflammation. All NSAID medications work by inhibiting the cyclooxygenase (COX) enzyme, thus decreasing prostaglandin synthesis.However, ibuprofen and all NSAIDs also interfere with the body’s natural blood vessel constriction and dilation hormones through this system, ultimately affecting the kidneys. In the long term, this damages the delicate kidney structures from irregular blood flow. It can also lead to chronic high blood pressure.

To make matters worse, there is a second way that ibuprofen, aspirin and other NSAIDs damage the kidneys. The immune system can react against these drugs and cause an inflammatory reaction right in the matrix of the kidneys. This is called Acute Interstitial Nephritis and can happen after only one week of use. It can also become a chronic, simmering problem that is definitely underdiagnosed.

So, what to do? We cant use opioid pain medication like we used to because it is extremely addicting, and now ibuprofen, aspirin and products like Motrin or Alleve are also harmful. Sadly, acetaminophen, or Tylenol is a centrally acting medication with little anti-inflammatory action and it doesn’t work well for most pain although it is great for fever.

First of all, I would argue we as a culture need to become a little more tolerant to living with some discomfort. Pain is often a sign that something else needs to be addressed: like, hydration, nutrition, posture, or drug/alcohol overuse.

Second, the practice of prevention goes a long way to decreasing the duration and quantity of pain medications needed. WE ARE LAZY!! Simple stretching and at-home exercises can do wonders for back and body pain as can weekly yoga. People who don’t know basic stretches can be referred to physical therapy for individual assessment; this is covered by most private and federal insurances. The newest guidelines from the American Academy of Family Physicians recommend:

“Nonpharmacologic treatment, including exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, biofeedback, low-level laser therapy, cognitive behavioral therapy, or spinal manipulation, should be used initially for most patients who have chronic low back pain.”

Finally, botanical medicine has an evidenced role in combating pain. Most herbs are better used proactively for prevention of pain and inflammation than acutely when symptoms are already present. Turmeric, ginger, black pepper and boswellia all have a long history of use for muscle and joint issues. New Chapter has a herbal Zyflammend product line that specifically addresses pain and/or age-related joint disease that is worth trying. Take as directed on the label, 2 tabs daily for at least 6 weeks to assess your response.

DLPA is a less used supplement for chronic pain and depression. This is DL-phenylalanine, an amino acid that gets converted into tyrosine. Rather than directly addressing pain, DLPA slows endorphin breakdown by decreasing enzymatic function. This results in higher endorphin levels for pain control as well as increased adrenal hormones such as norepinephrine. The dosage varies from 1500mg on an empty stomach each morning to 200mg twice daily. For gynecological pain like mine, cramp bark is another option. This needs to be taken in moderately high doses (3 caps 2-3 times per day)  just before menstrual pains begin, and continued throughout the pain window.

These are all good options for all kinds of pain, not just back pain. If we as a consumers were willing to put the same effort into treating & preventing our various pains proactively instead of just popping 3 Advil every 4 hours, we may live longer and healthier. The effect on the kidney is also real, and needs to be talked about more. I see patients dying of kidney failure in the hospital every day, and it is not pretty. I know that I am forcing myself to be more tolerant of the low grade pains I live with, and I just started using herbs (Vitanica’s cramp bark) and (walking and stretching) exercises in an attempt to minimize the pain medications I may really need in a few days. I am hoping it makes a difference, because my kidneys aren’t really up for another 10 years of this.

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Balancing with Ayruvedic Medicine – from Womens Power to Heal

510fafgjdbl-_sx336_bo1204203200_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.

 

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The Pitfall of Alcohol

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.

gait-ataxiaThe cerebellum is one of the parts of the brain most affected by alcohol cell death; this is why people become unsteady and clumsy anterior-vermiswhen 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.

confusionThe 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. nrhpth08

 

 

 

 

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:)

screen-shot-2016-09-26-at-12-32-00-pmEthanol/ 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.

screen-shot-2016-09-26-at-12-36-56-pmFinally, 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).

screen-shot-2016-10-08-at-4-29-14-pmWhen 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!)

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Eat, Sleep, Wait, Repeat.

glycogen-and-intermittent-fastingI 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.

blackHint: 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.

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