Thursday, January 11, 2018

A Simple Step to Improve Diet, Weight and Mental Health

Human behavior can be a funny thing.  At times it is so complex, yet some very seemingly simple things can change it in positive ways.  A new study looking at one simple logistical factor about eating has demonstrated this point well.  The complex part of human behavior examined was trying to change eating and activity behavior to a healthier pattern. 

Almost endless government and other organizational guidelines have had little success in that area.  The same for public service messages, public health programs and more.  
This is where a very simple answer has performed better.  The study looked at the relationship between eating meals as a family during adolescence and in those who became parents during the next 17 years.  Participants were from mixed socioeconomic and racially/ethnically diverse households.

Both those who had regular family meals as adolescents and maintained that as young parents, and those who began the practice as young parents ate healthier foods, participated in more healthy weight-related behaviors such as exercise and had higher psychological well-being scores compared to those who reported never eating family meals together.

It appears that the family mutual support group reinforced by the simple practice of eating meals as a family has profound positive effects on health behaviors that a mountain of guidelines and policies have not accomplished.  Human behavior has always tended to have a “tribal” nature which is highly influential on all parties.  Try regularly getting your tribe together for meals.  It is not just an old custom but also a healthy behavior.

Berge et al.  Intergenerational transmission of family meal patterns from adolescence to parenthood: longitudinal associations with parents’ dietary intake, weight-related behaviours and psychosocial well-being. Public Health Nutrition, 2018;21:299-308. 

Wednesday, January 3, 2018

Why We use Whole Food Nutritional Supplements

The vast majority of nutritional supplements available are synthetically made.  Only a small number of companies offer supplements made primarily from whole foods in spite of several advantages associated with them.  I thought it would be appropriate to discuss the differences and particularly how these differences translate into different health outcomes.

First, it may be surprising to many that most supplements are synthetic.  This practice actually originated several decades ago from concerns about whole food sourced nutrients, concerns that we now know were unfounded.  These concerns centered around the idea that plant nutrient content can vary according to the conditions the plants are grown in.  With reasonable varying growth conditions, plant nutrient levels remain within a reasonable range.

To eliminate this varying but reasonable nutrient range, the idea of making nutrients synthetically emerged.  Unfortunately, it generates far greater variability in nutrient content and health impact than what it was supposedly trying to avoid.  The variations from whole food nutrient content that synthetic supplements create include:
  •  They are incomplete micronutrients.
  • They are devoid of the phytonutrients that always appear with micronutrients in whole food.

Incomplete micronutrients

There are 28 essential micronutrients such as vitamins and minerals.  This means that humans cannot make them from other food substances and that they must be obtained directly from food.  However, different micronutrients are “complexes” containing multiple parts.  Vitamin E is an example containing 8 tocopherols.

Unfortunately the FDA decided since the biggest piece of this 8 piece complex was alpha tocopherol that for the purpose of making a supplement, only alpha tocopherol could be included and yet it could be called “vitamin E”.  A tipoff that a supplement is a synthetic is that there will be a second term in the name which describes the synthetic form such as “d-alpha tocopherol succinate”.  This is 1 piece of the 8-piece complex made synthetically.

The collective group of tocopherols generate the health effects.  For example, different tocopherols in the group have different antioxidant properties and different abilities to suppress HMG CoA reductase, the enzyme that increases cholesterol production in the liver.  The best balance of these effects appears to come from the whole complex of tocopherols.

Devoid of phytonutrients

Vitamins and minerals do not appear in nature by themselves but rather they always appear in complexes with several phytonutrients.  For example, ascorbic acid which is part of vitamin C complex always appears with the phytonutrients called phenolic compounds such as flavonoids.  Much of the benefit attributed to vitamin C is now thought to come from these phenolics.

The FDA has allowed synthetic ascorbic acid to now be called “vitamin C” even though it is devoid of this group of phenolics that always appear with it in whole food.  While there are 28 essential micronutrients in whole food, there are about 16,000 known phytonutrients all which impart health benefits.

Several of the large studies on the impact of nutritional supplements have suggested that they provide no significant health benefits.  Most notable were 2 different arms of the Physicians Health Study which look at many health outcomes related to several lifestyle factors.  The studies used 400 IUs of synthetic alpha-tocopherol and 500 mgs synthetic ascorbic acid over a 10-year period. The conclusions of these two studies were:

“In this large, long-term trial of male physicians, neither vitamin E nor vitamin C supplementation reduced the risk of major cardiovascular events.”

“In this large, long-term trial of male physicians, neither vitamin E nor C supplementation reduced the risk of prostate or total cancer.”

These results are in contrast to many studies that look at obtaining these nutrients in greater amounts from whole food diets which have shown consistent improved health outcomes, outcomes which have been attributed to their nutrient content.

So, what generated the stark difference in the clinical trials that have looked at the benefits of nutrients in disease prevention and treatment?  It appears to be the difference in the effects between whole food complexes and isolated synthetic nutrients.  Whole food supplements are natural, complete nutrient complexes with superior health benefits. 

Sesso et al.  Vitamins E and C in the prevention of cardiovascular disease in men: the Physicians' Health Study II randomized controlled trial.  JAMA, 2008;300(18):2123-33.

Gaziano et al.  Vitamins E and C in the prevention of prostate and total cancer in men: the Physicians' Health Study II randomized controlled trial.  JAMA, 2009;301(1):52-62

Wednesday, December 6, 2017

The Possible End to Increasing Life Expectancy

One of the more controversial papers ever to be published in the prestigious New England Journal of Medicine projected that “the steady rise in life expectancy which had occurred over the past 2 centuries may soon come to an end.”  They ended the conclusion commenting that the youth of today may live less healthy and shorter lives than their parents.   As would be expected this paper sparked a large volume of letters to the editor criticizing this projection.  

While the authors based their projection on some very sound data, the real validation could only come with time.  As my favorite philosopher, Yogi Berra once said when asked to predict on Thursday who would win a golf tournament which ended Sunday, “ask me Sunday night.  I am a lot better at predicting the past than I am the future.”

While “Sunday night” is not here on this striking prediction about our children’s longevity, the preliminary data appears to be supporting this grim projection.  The primary basis of this projection was the ever growing rate of obesity and its relationship to increased rates of the chronic diseases such as diabetes, heart disease, cancer and many others.

As projected, overweight and obesity trends have continued upward across all population groups.  Currently about 9% of children 5 years of age and under are obese, and this rises to 20.5% between 12 and 19 years.  The increasing trend continues throughout adulthood.  Currently 38% of U.S. adults are obese and 74% are overweight.

Diabetes is perhaps the best leading edge indicator of the disease trends that may accompany the overweight and obesity change.  It is now projected that the 14.3% of the U.S. population have diabetes an increase of approximately 300% since 1990.  The real emphasis comes from the fact that fully 38%, or about 1 of every 3 persons in the U.S., is pre-diabetic with a high percentage expected to convert to full diabetes over time.

Pre-diabetes is a misleading term in some ways. Normal fasting blood glucose is 70-99 mg/dL.  Diabetes is a fasting glucose of 140 or greater.  Pre-diabetes is that zone of abnormal glucose from 100-139.  My take on pre-diabetes is that just as the first trimester of pregnancy is not “pre-pregnant” but is early pregnancy, the better term is early diabetes.

These trends are fueled by the general belief by most that no matter what they do to themselves, some medical innovation will bail them out.  At least some knowledgeable healthcare scientists seem to accept that the rate at which we can become diseased is beginning to outpace the ability to maintain chronic disease.  One trend that supports this concept is another important statistic, healthy longevity.  It is defined as age of onset of the first chronic disease.

Even as longevity has increased over the past 60 years, healthy longevity has decreased more dramatically.  This is what the authors of the NEJM paper referred to as “our children living less healthy lives than their parents”. Many treatments for chronic disease do not completely prevent the complications that often shorten life but rather they delay them.  The diabetic today has their disease longer than previous generations.

The average onset of type II diabetes was 52 years of age 40 years ago.  It is now 41 years of age.  While improvements in diabetes treatment have delayed the onset of complications, the earlier ages of onset may begin to override treatment based complication delays. 

One of the most striking papers I have read was a commentary by an endocrinologist at the University of Texas.  He had been in practice 30 years and commented that in his early years they would see perhaps only a couple of new onset cases of type II diabetes in adolescents each year.  Now they see several new cases every week.  This phenomenon was why the terminology when I was in graduate school, adult onset diabetes, was changed to type II diabetes.

This paper making these projections that received so much criticism in 2005 is being looked at as evolving reality in 2017.  Sad but true.

There is little disagreement that the primary driver of the chronic disease epidemic is diet based.  Likewise, the most effective solution will also be diet based.  Perhaps one of the best health investments we can make is to get some help from a nutritional health professional in understanding and optimizing our diet as well as that of our families.

Olshansky et al.  A Potential Decline in Life Expectancy in the United States in the 21st Century.  New England Journal of Medicine, 2005:352;11.

Thursday, November 30, 2017

If We Had This Drug, I Would Be on It

One of the largest studies on the reduction of chronic disease risk and mortality was recently published in The Lancet.  The study looked at the use of a particular treatment and the reduction of cardiovascular disease risk, stroke risk, as well as the risks of cardiovascular, non-cardiovascular and overall mortality.  The study was very comprehensive involving 135,335 individuals aged 35 to 70 years without cardiovascular disease from 613 communities in 18 low-income, middle-income, and high-income countries in seven geographical regions: North America and Europe, South America, The Middle East, South Asia, China, Southeast Asia, and Africa.

The results shown to the left were fairly striking with the treatment reducing the risks uniformly for all of the followed measures.  The vertical black line is the risk in the non-treatment group.  That is arbitrarily called “1” in a comparative study.

The graphic shows the risk reductions circled in red compared to those not taking the treatment regularly.  The red line shows the risk reduction to 0.7 which means a 30% reduction.  For cardiovascular events (CV disease) the reductions were all about 20%.  The mortality reductions were more dramatic, all being more than 30%.

The conclusion is that this treatment resulted in broad reductions in disease rates and deaths for the leading cause in developed and less developed countries.  The results occurred regardless of age, income status or country of residence.

Participation in this treatment would not take much persuasion if this drug existed, was widely available and relatively inexpensive.  While it meets all of those criteria, it has been and continues to be a hard sell to the population at large.  This is because the “drug” used in the study was actually “more than 3 servings per day of fruits, vegetables and legumes”. 

To give some perspective on these results, the results of similar clinical trials using statin drugs on total cardiovascular mortality have found risk reductions varying between 0 and 12%.  Seems like one could do twice as much just by eating enough fruits and vegetables daily.

The irony of all of this is that virtually every guideline out there supports this “therapy”, yet the minority of the population follow this in practice.  The breakdown seems to occur for many reasons.  Medical practice has become largely “this drug for that problem” with insufficient time spent or emphasis on implementing this very effective prevention.  This is driven by time restraints in patient care, patients preferring a pill over lifestyle change, and intense pharmaceutical advertising biasing opinions.

The bottom line is that you can’t fight data and in this case, it is convincing.  We are in the era of chronic lifestyle related disease and the biggest piece of lifestyle appears to be diet.

Wednesday, November 15, 2017

How Are Food Sensitivities and Depression Linked?

Food sensitivities or immune reactions to food have been linked to triggering several neurologic and psychiatric disorders.  This is caused by a couple of different mechanisms involving activation of the immune system.  The first is activation of a portion of the immune system called the innate immune system.  The system is the first part of the immune system to respond to challenge, and it activates systemic inflammation.  Much of how bad someone feels when they have the flu is inflammatory activation by the innate immune system.

About 1 in 10 persons will develop an innate immune response against a particular peptide in food, a problem called a foodsensitivity.  The immune system initiates an inflammatory response each time it detects the presence of that particular food peptide. 

Messengers called cytokines that activate inflammation also activate the more specialized part of the immune system called the acquired immune system.  One of its primary jobs is to produce antibodies against whatever has been perceived to be triggering the immune reaction.  Often this reaction can begin to make mistakes when it is chronically activated generating “cross-reactivity” where antibodies made against food molecules such as gluten begin to cause an attack against similarly appearing structures in the brain.

Studies have linked gluten triggered antibody reactions against brain structures in some seizures, neuropathy, migraine and cognitive impairment.  More recently the expanded knowledge of these reactions has suggested links between food reactions and two of the most common brain/mood disorders, anxiety and depression.

Typically, celiac disease is used as the model to test cross-reactivity between a food peptide and molecules in the nervous system.  Celiac disease is a cross-reactivity where antibodies against gluten begin to react with a peptide in the small intestinal lining destroying that structure.  This cross-reactivity can expand to structures in skin, glands and other areas including the nervous system.

A new study used this celiac disease model to look at nervous system involvement that may be associated with depression.  Patients with established celiac disease were examined with transcranial magnetic stimulation (TMS) which allows accurate measurement of the excitability of the brain.  All patients also completed a standardized test for depression, the Hamilton Depression Rating Scale (HDRS).  At the beginning of the trial 60% of the patients had positive depression scales.

A previous study performed by these researchers using TMS demonstrated that the celiac patients had abnormal balance between brain activation and inhibition.  The “balance” in brain response comes from the signal from one neuron to the next being “toned” by both inhibitory and excitatory interneurons.  These interneurons express neurotransmitters that turn up (excitatory) or turn down (inhibitory) the amount of signaling between neurons much like dimmer switches.

Normal information processing in the brain involves excitatory signals involved in the desired process at any moment combined with the inhibition of others that would take the desired function “off track”.

All subjects were asked to follow a gluten free diet.  Sixteen months later the TMS and the HDRS were redone.  There was actually a small reduction in the imbalance in brain activation.  In contrast, the depression scale showed active depression in only 8%, down from the original 60%.

The altered pattern of brain activation was the result of improved control of the inhibiting neurons that used the neurotransmitter GABA to produce the inhibition.  Research has indicated a high rate of cross-reactivity between gluten and casein, a peptide in dairy, antibodies with the enzyme GAD which is responsible for the production of GABA in the brain.  The antibody destruction of that enzyme appears to result in the abnormal pattern of brain activation.

This study brings up several points about the relationship between food sensitivities and depression.  The first is that once the food sensitivity is diagnosed, avoiding the triggering food improves the depression.  The second point is that the brain does not recover a normal activation pattern simply from avoiding the initial food trigger. 

The researchers discussed the failure of the brain to completely normalize its activation pattern.  The subjects were an average of 39 years of age.  Their immune reaction against gluten had been present for many years.  While the chemical stimulus to the brain which altered its activation pattern was removed, the abnormal brain pattern had likely become “learned”.

All learning comes through repeated stimuli to the brain resulting in neurons developing preferred connections and activation patterns.  We now know that when this has occurred with an abnormal activation pattern such as stress, the brain eventually “learns” that preferred pattern.  At this point in time techniques such as neurofeedback which is EEG guided brain training must be used to re-train the brain back into a more normal pattern.

For many the best outcome with depression will result from finding the original trigger such as a food sensitivity but then restoring normal brain activation patterns with neurofeedback.

Thursday, October 26, 2017

Irritable Bowel Syndrome

The What, Why and How

Irritable bowel syndrome, or IBS, is the most common functional digestive disorder.  Generally, digestive problems fall under two categories, functional and pathological.  Pathological disorders are basically those that can be seen and/or measured such as tumors, ulcers and others.  The vast majority of testing that is done for digestive complaints is done to look for pathologies.

Functional disorders, in contrast, are diagnosed by the presence of symptoms combined with the absence of pathology.  Generally, they can be described as some phase of the digestive process simply not “functioning correctly”.  They are often diagnosed by ruling out pathology in the presence of symptoms rather than demonstrating some abnormality.  As with many “rule out” diagnoses, the patient is often left only knowing that they have no pathology but without getting answers about what needs to be done to resolve the symptoms.

It is estimated that 80% of digestive disorders are functional and only 20% are pathologic. IBS is the most common functional digestive disorder.  Between 10-15% of the population experiences IBS.  The typical symptoms include abdominal pain, bloating, and often constipation and/or diarrhea. They may vary from episode to episode. 

The most important point to appreciate regarding IBS is that it is a heterogeneous disorder.  This simply means that it is not caused by one thing but rather can be caused by several problems.  The most important point in resolving any individual case is to find all of the triggers in that circumstance.  IBS is also typically “multifactorial” which means it is caused by several contributing factors.

Occasionally, it will be just one factor such as a food sensitivity.  Most often, however, it results from the co-existence of multiple factors in the same person. Appreciating this relationship is the most important factor in obtaining resolution of the problem.

The two diagrams show the concepts of multifactorial and heterogeneous. Patient "A" has 4 contributing factors causing their IBS. While different ones are contributing more or less to the problem, resolution is unlikely to occur unless all are addressed.

In contrast to patient "A" the second example, patient "B" has a different grouping of factors causing their IBS (multifactorial), and they are not the same as patient "A's" triggers (heterogeneous).

These different triggers of IBS are not equally common.  Food sensitivities, or immune inflammatory food reactions, are perhaps the most common.  These are delayed food immune reactions with symptoms beginning from several hours to 1-2 days after the food exposure.  Typically, the person has eaten multiple times in between obscuring the relationship.

Dysbiosis is another common contributing trigger to IBS.  This is an imbalance in the bacterial population living in the digestive tract.  Certain species help with the regulation of inflammation in the digestive tract.  These species should make up the dominance of the population of the 100 trillion bacteria in the human microbiome.  Many factors may cause the favored species to diminish allowing less desirable “opportunistic” bacteria to populate.  This often causes a low grade inflammatory response instead of the inflammatory preventing response created by the preferred bacterial population.

Stress often is the most difficult for most to understand the relationship with IBS.  The autonomic nervous system that governs all function in the digestive tract has two divisions, the sympathetic which controls “fight or flight” and the parasympathetic which controls “rest and repair”.  Digestive function is shut down during fight or flight and activated when in rest and repair. 

Ongoing stress tends to train the nervous system to stay in sympathetic dominance inhibiting function in the digestive tract.  IBS cannot be fully understood without a look at the balance in the autonomic nervous system.  This can be done with a test called heart rate variability which shows the sympathetic/parasympathetic balance.  Once the problem is understood, autonomic training can be successfully used to retrain balance in sympathetic/parasympathetic tone.

IBS is truly multifactorial, heterogeneous.  Only approaching its diagnosis and treatment with this understanding will consistently yield good results.

Tuesday, August 22, 2017

Are Herbs All the Same?

I get asked some version of this question frequently.  A recent interaction triggered this blog post.  A patient had chosen to use an herb product she bought online versus the one that I recommended from the Standard Process herb line, MediHerb.  The follow-up test didn’t look any better, and there wasn’t much change in symptoms.  The dilemma it presented was that there could be 2 reasons.  The first is that the protocol we arrived at wasn’t what was needed, and the second was that the product she took wasn’t adequate to produce good clinical effect.

Shortly after that interaction information arrived from Standard Process with a detailed analysis comparing the content of several Echinacea products.  There are different forms of Echinacea, and different companies also use different qualities of herbal material. 

Echinacea is noted for its immune enhancing properties.  The effect comes from constituents in the herb called alkylmides and there are two types of these, 2-ene and 2,4-diene.  They must appear together for the herb to have good clinical effect.  The 2,4-diene alkymides generate much of the clinical effect, but they tend to be broken down quickly by human liver enzymes.  When they occur together with the 2-ene alkymides, they prevent the excessively quick liver breakdown and generate the good immune enhancing effect.

So what difference does which Echinacea used make?  Plenty.  It seems that Echinacea augustifolia doesn’t contain much of the 2-ene alkymides so the 2,4-diene alkymides get broken down too fast to generate much effect.  Echinacea purpurea contains a lot of the 2-ene form allowing better clinical effect.

MediHerb goes to great length to balance the two forms of Echinacea to generate optimal effect.  In an independent lab study MediHerb Echinacea Premium alkymide content was compared to 9 other commercial products. The chart shows the results.  The MediHerb product contained about 2 1/2 times as much alkymides as the next highest product and many times greater than most of the others.  The comparison chart at the bottom of how many tablets of each other product would have to be taken to equal the alkymides in a single Echinacea Premium.  So, are all herbs the same?  No, not at all.  As Paul Harvey used to say, “now you know the rest of the story”.

PS  -  As I was correcting the final proof of this post, I received a new 6-minute video from MediHerb showing the extent of their efforts to produce the best quality herbs.  So fitting!!
Click Here To See The MediHerb Video!

A Simple Step to Improve Diet, Weight and Mental Health

Human behavior can be a funny thing.  At times it is so complex, yet some very seemingly simple things can change it in positive ways.  A n...