Author: David Wells, D.C., L.Ac.

Dr. David Wells has been licensed as a Chiropractor since 1979 and as an Acupuncturist since 1985. He also holds a Master's Degree in Psychology and a Master's in Clinical Nutrition. His clinical experience extends over 40 years of continuous practice. Along the way, he has been President of the California Acupuncture Association, President of the Council of Acupuncture and Oriental Medicine Associations, Bylaws Chair for the American Association of Acupuncture and Oriental Medicine, Founder of AcuNet (Acupuncture Provider Network) and Medical Director of Landmark Healthcare. In the latter capacity, he brought acupuncture as an insured benefit to 17 states. He wrote and presented for approval the CPT codes that allow acupuncturists to bill for their services and has taught numerous seminars around the country.

Blood Pressure

What Do The Numbers Mean?

Blood pressure is expressed as a fraction, as in 120/80. What do those two numbers represent? The top number is called “systolic”. It represents the force of contraction of the heart sending a pulse wave down the artery. The bottom number (diastolic) measures resistance of the artery to compression, either due to the amount of blood in the artery or the stiffness of the artery wall.

When I take your blood pressure using a stethoscope, I inflate the cuff on your arm until the blood vessel I am listening to is compressed and no blood is flowing through that artery. Then, I slowly let off the pressure until I first hear the sound of your pulse. I am watching the dial on the cuff and make mental note of the number (in millimeters of Mercury pressure) when I can first hear that pulse. This represents the force that your heart is pushing blood through your artery. It is pushing hard enough to get through the compressive force I am applying using the cuff.

I continue listening as I let air out of the cuff until I can no longer hear your pulse. This is the pressure at which compression from the cuff is equal or less than the stiffness of the artery. In other words, I am no longer compressing the artery so the pulse wave passes without resistance or noise.

Most offices (and of course home units) measure blood pressure without a stethoscope. The machine listens and records the numbers. Either way of measuring works fine. I just explained it (above) using a stethoscope because the process and it’s meaning is easier to understand that way. The first number (systolic) is the force of contraction of the heart. The second number (diastolic) is the amount of compression that no longer compresses the artery.

What Is Normal?

Most people know that a normal blood pressure is 120/80 and that healthy women often have a blood pressure ten points lower than men, i.e., 100/70. At one time, it was believed that blood pressure rises with age, but that the threshold for hypertension was 140/90 for people under age 65 and 150/90 for those 65 and older. The guidelines changed in 2017 to much stricter (lower) pressures.

These current guidelinesi are

Normal is a systolic lower than 120 and diastolic lower than 80.

Elevated is a systolic of 120 – 129 and diastolic less than 80

Stage One hypertension is a systolic of 130 – 139 and diastolic of 80 – 89

Stage Two hypertension is a systolic of 140 or higher and diastolic of 90 or higher

Hypertensive crisis is systolic higher than 180 and/or diastolic higher than 120

What changed?

The impetus for the 2017 guidelines was a study called SPRINT that included over 9,300 participants who were at high risk of cardiovascular events. (There was no group who were treated with diet, exercise and lifestyle interventions to lower their overall risk).

Participants were divided into two groups. One group was controlled with pharmaceuticals to a systolic of 130. The other to a systolic of 120. In the 130 systolic group, there were 8 deaths. In the 120 group, there were six deaths. This was reported as a 25% reduction in mortality risk. That makes it sound like 25 people out of 100 had their lives saved but it was actually only two people out of 4,550. Looked at this way, researchers needed to aggressively treat 4,550 patients to save two lives. In other words, the Number Needed to Treat (NNT) one patient is 2,275 patients. What was the cost both in dollars and side effects?

The dollar cost was estimated by the researchers as between $28,00 and $47,000 per “quality adjusted life year”, whatever that means. Using the lower number, it would cost ($28,000 times 2,275 patients) $63,700,000 to save one life. For that cost, you could hire a personal trainer and give healthy, organic food to all the participants.

As to side effects, researchers noted “higher risk of hypotension, syncope and accelerated reductions in GFR”. Hypotension is low blood pressure. Syncope is fainting. GFR or glomerular filtration rate is a measure of kidney disease. In other words, the intensive drug regimen advocated by the SPRINT study leads to fainting and a reduction in kidney function. Since the study was stopped early, there was no long-term assessment of reduced kidney function on morbidity and mortality.ii

Official Criticisms of the New Guidelines

A lot of physicians, particularly gerontologists were upset by the new guidelines. They pointed out that their elderly patients are at high risk of falling. Blood pressure rises with age to support normal perfusion (oxygen delivery) in the brain. Lowered blood pressure puts their patients at risk of falling, hitting their head and dying of a sub-dural hematoma, or falling and breaking a hip, leading to death by pneumonia.

The American College of Physicians wrote in the Annals of Internal Medicine, Are the harms, costs, and complexity of care associated with this new target justified by the presumed benefits of labeling nearly half the U.S. population as unwell and subjecting them to treatment? We think not and believe that many primary care providers and patients would agree iii

In the New England Journal of Medicine, Drs Bakris and Sorrentino concluded that, “The unintended consequence may be that many people, now labeled as patients with hypertension, receive pharmacologic therapy that’s unlikely to provide benefit given their low absolute risk, and they may therefore experience unnecessary adverse events.” They go onto say that while a “target of less than 130/80 mm Hg makes sense for high-risk patients, for everyone else it seems more reasonable to continue defining hypertension as a blood pressure of 140/90 mm Hg or higher.iv

There is also a risk that the lower blood pressure readings in the SPRINT study were artificially low because of the way they were measured. Patients in the study were measured after sitting alone in a room for five minutes. Then they were re-measured twice and the results averaged. How often has any doctor measured your blood pressure that way? Would those who measured 130 have measured 140 under normal conditions?

Like it or not, doctors will slowly conform to these new guidelines at risk of malpractice, or pressures from insurers and hospital administrators. As Dr Welch put it in a New York Times editorial, I suspect many primary-care practitioners will want to ignore this new target. They understand the downsides of the relentless expansion of medical care into the lives of more people. At the same time, I fear many will be coerced into compliance as the health care industry’s middle management translates the 130 target into a measure of physician performance. That will push doctors to meet the target using whatever means necessary — and that usually means more medications.”v

High Blood Pressure Is A Risk

Criticism of the new guidelines aside, high blood pressure is a serious risk. Cardiovascular disease is the leading cause of death worldwide. Elevated blood pressure accounts for 62% of stroke and 49% of coronary heart disease cases.vi Statistically, the risk of cardiovascular disease doubles for every 20 points of systolic increase and for every 10 points of diastolic increase (i.e., doubles at or above 140/90).vii Untreated hypertension can shorten life expectancy by 15 to 20 years due to heart attack, stroke and kidney disease. Bear in mind however, that until the SPRNT study, the increased risks have been associated with blood pressures above 140/90.

The Framingham study followed 5,200 individuals from age 28 through 62 for a period of 27.5 years. They divided participants into three groups; under 120/80 BP (normotensive), 120-139 BP (high normal) and greater than 140 BP. What researchers found was, “Significant increases in mortality were observed among hypertensives but not among participants with high-normal BP levels compared with viiinormotensives.”ix In other words, there was no significant increase in morbidly or mortality in the group with systolic blood pressures between 120 and 139.

I am not advocating that we ignore rising blood pressure. I am saying that we need to do everything we can to get our blood pressure to a normal range, but let’s focus first on diet, exercise and lifestyle change. Most of those recommendations can be found in https://drwells.net/cardiovascular-and-metabolic-disease/

What About Hypotension?

Low blood pressure is of course a serious problem as well. Without blood, our hearts, brains and every other organ quickly dies. We need Oxygen and other nutrients to be delivered constantly. Low blood pressure reduces that delivery. The usual first symptoms of low blood pressure include feeling lightheaded, difficulty concentrating, headaches, exhaustion, feeling out of breath and fainting. At very low pressures, the heart stops.

So How Low Is Low?

110/75 Is low normal. No treatment needed.

90/60 Borderline low end of functional. I evaluate patients in this range for hypoadrenia, hypothyroidism, eating disorders or other causes of low metabolic function.

60/40 Too low. This patient could become critical. I consult with the patient’s primary care provider or send my patient to an emergency room. I had a patient below this reading only once. She literally had to hold on to the walls while walking down the hall towards my office. She told me she came for nutritional advice. I asked what she usually eats. She replied, “Instant breakfast and candy.” I asked, “What else?” She said, “No, that’s it. Just the one glass of milk each day for my instant breakfast. The rest of the day I eat candy. Her history included multiple types of cancer, pneumonia and kidney disease. She was in her early 40’s. The only nutritional advice I could give her was to, “Eat food, a wide variety of real food and lot of it.” I also recommended she get psychological support.

Systolic-Diastolic Spread (Pulse Pressure)

The common normal blood pressure of 120/80 has a 40 point difference between the systolic and diastolic pressures. The same is true of 110/70. This is normal. So what does it mean when there is a 30 point difference as in 110/80? This is called a “narrow pulse pressure”. What about a 60 point difference as in 130/70? This is called a “wide pulse pressure.” A greater than 40 point spread between systolic and diastolic, such as 140/80 where the systolic number is out of normal range is called systolic hypertension. A wide pulse pressure within the normal range is generally ignored but as you will read, it shouldn’t be.

According to Anthony Dart, a Professor of Medicine in Melbourne, Classically, a wide (high) pulse pressure is a sign of aortic valve regurgitation and a narrow (low) pulse pressure is a sign of aortic stenosis. In the absence of valvular disease, a high pulse pressure may be a sign of stiffness in the arterial walls, and is a risk factor for coronary artery disease and myocardial infarction.” x

In addition to aortic stenosis, a narrow pulse pressure may also be due to congestive heart failure, particularly if the spread is 25 points or less. I should note that a pulse pressure of 30 points is the limit of normal variation and may simply be due to deconditioning. In a sedentary but otherwise healthy individual, regular walking may be all that is needed to correct this. If the spread is 25 points or less, you should see your primary care provider or a cardiologist.

A wide pulse pressure may also indicate valve regurgitation, hyperthyroidism or severe iron deficiency anemia. Having a wide pulse pressure also increases the risk of developing atrial fibrillation. The usual risk for atrial fibrillation is 6%. That goes up to 23% for those with a wide pulse pressure.xi

A wide pulse pressure where the diastolic is lower than 65 indicates an increased risk of myocardial infarction.xii Again quoting from Dr. Dart, The fall in diastolic pressure seen with pulse pressure widening may be particularly important for coronary perfusion since this occurs predominantly during diastole. In stenotic coronary arteries the reduced diastolic pressure could be expected to lead to impaired myocardial perfusion. He goes on to say, “Reduced perfusion is likely to be more relevant with a shortened diastolic duration (i.e. fast heart rate) and this may indicate the value of choosing therapy that will limit this reduction.” xiii What he is intimating here is that medication to reduce overall blood pressure that results in a diastolic below 65 while the pulse pressure is greater than 60 and the pulse rate is high (let’s say above 80) may put the patient at greater risk of heart attack.

As referenced in a JAMA network article, The Hypertension Detection and Follow-up Program reported that all-cause mortality increased by 11% per 10-mm Hg increment in pulse pressure but only by 8% and 5% for similar increases in systolic and diastolic blood pressures, respectively.”xiv In other words, we should all be paying more attention to the pulse pressure spread, instead of just the systolic and diastolic numbers. From what I can tell, this message has not reached most of the medical community, let alone the public. Or, as that JAMA article went on to say, In older hypertensive patients, pulse pressure, not mean pressure is the major determinant of cardiovascular risk.”xv

To paraphrase a study entitled, “Pulse Pressure, Not Mean Pressure Determines Cardiovascular Risk”, a wide pulse pressure 10 points greater than normal increases the risk of cardiovascular events and premature death by nearly 20%xvi

What About Athletes?

According to research cited in Wikipedia, For most individuals, during aerobic exercise, the systolic pressure progressively increases while the diastolic remains about the same. In some very aerobically athletic individuals, for example distance runners, the diastolic will progressively fall as the systolic increases. This behavior facilitates a much greater increase in stroke volume and cardiac output at a lower mean arterial pressure and enables much greater aerobic capacity and physical performance. The diastolic drop reflects a much greater fall in systemic vascular resistance of the muscle arterioles in response to the exercise (a greater proportion of red versus white muscle tissue). Individuals with larger BMIs due to increased muscle mass (bodybuilders) have also been shown to have lower diastolic pressures and larger pulse pressures.” xvii

So as we might expect, exercise conditions us to be better at exercise. Even our blood vessels adapt. According to an article in the American Hypertension Association Journal, In cross-sectional studies, aerobically trained athletes have a higher arterial compliance than sedentary individuals.” xviii The word “compliance’ in this context means that the aorta has greater elasticity. That’s a good thing. However, individuals doing strength training or other maximum exertion exercise (including high-intensity aerobics) increase the stiffness in their aorta and the arteries of their legs, widening the pulse pressure. The authors did not speculate if a wide pulse pressure in athletes might lead to increased risk of cardiovascular events, but did note that moderate aerobic exercise has multiple positive benefits without known adverse consequences. Personally, I think the risk of some stiffening of the aorta with high intensity exercise may not be significant. After all, Jack LaLanne (who among other things did 1,000 pushups in 20 minutes) lived a very full and active life up to his death from pneumonia at age 96. Other than being shot by a jealous husband at that age, I doesn’t get better than that.

Folic Acid

One of the possible causes of arterial stiffness is oxidative damage resulting from an excess of the amino acid Homocysteine. This amino acid is a byproduct of incomplete conversion of Methionine to Cysteine. That conversion is dependent on adequate Vitamin B6 and Folic acid, particularly the folic acid. The most common food source of folic acid is leafy greens. That’s why the name for folic acid or folate is from the same Latin root as “foliage.” Deficiency of these vitamins can cause homocysteinemia or an excessive level of homocysteine in the blood. Up to 40% of patients diagnosed with premature coronary artery disease, peripheral vascular disease, or recurrent venous thrombosis present with elevated levels of plasma homocysteine.xix

There are some people who are genetically unable to utilize folic acid because of an alteration of the gene that converts folic acid to methyltetrahydrofolate. These people are said to have the MTHFR genotype. This genotype is actually pretty common. According to Kaiser Permanente, “Between 10%-15% of the Caucasian population and more than 25% of the Latino population have variants in both copies of the MTHFR gene.”xx Numerous supplement companies sell methylated folate, which can bypass this genetic deficiency. We have it in a 5 mg dosage in our office.

A very interesting study found that, “Folic acid supplementation at 5 mg doses for three weeks reduced pulse pressure by 4.7 +/- 1.6 points.” xxi The authors of that study concluded that, “Folic acid is a safe and effective supplement that targets large artery stiffness and may prevent isolated systolic hypertension.” Interestingly, treatment did not correlate with plasma folate or homocysteine levels and it worked regardless of MTHFR genotype. This suggests that folate reduced arterial stiffness by some unknown mechanism.

Before going out to buy vitamins though, make sure you are getting regular, mild exercise like walking, eating a low-salt, heart-healthy diet and are also reducing stress, losing excess weight, avoiding nicotine, caffeine, excessive alcohol and recreational drugs. These diet and lifestyle modifications will make the biggest difference.

Three Position Blood Pressure

This is a test that is rarely performed but can reveal a lot. It is particularly indicated when the patient complains of feeling lightheaded or has recently suffered falling for an unknown reason. It should also be performed in geriatric patients and others at high risk of falling including patients with vomiting, diarrhea and blood loss. The classic presenting symptom is “feeling lightheaded on arising from a sitting or lying position.”

The procedure is to take blood pressure in a supine or semi recumbent position, then sitting and finally standing. We allow you to lie on the table for 3-5 minutes before taking the first pressure reading. Then let you sit for a minute before taking the sitting reading. We ask if you are feeling dizzy or light-headed and observe you for pallor or sweating. If you have these symptoms or signs associated with sitting up or a blood pressure less than 90/60, we let you lie down and do not proceed to the standing measurement. If it is safe to proceed, we measure your blood pressure as soon as you stand up, then repeat the standing measurement three minutes later.

How To Interpret The Results

According to the Agency for Healthcare Research and Quality. “A decline of ≥20mm Hg in systolic or ≥10 mm Hg in diastolic blood pressure after 3 minutes of standing = orthostatic hypotension.
A heart rate increase of at least 30 beats per minute after 3 minutes of standing may suggest hypovolemia, independent of whether the patient meets criteria for orthostatic hypotension.
A blood pressure drop immediately after standing that resolves at 3 minutes does not indicate orthostatic hypotension. However, this finding may be useful to confirm a patient’s complaint of feeling dizzy upon standing and may lead to patient education about using caution when arising from a lying or sitting position.”
xxii

This test can also be supporting evidence in identifying hypoadrenia or poor sympathetic tone. Normally, under the influence of the sympathetic nervous system and adrenals (which are themselves an extension of the sympathetic nervous system), blood vessels and muscles constrict slightly when we rise from lying to sitting or from sitting to standing. This constriction ensures adequate blood flow to the brain. Thin people (usually female) with poor muscle tone and chronic low blood pressure are more at risk. The evidence for adrenal insufficiency in people with postural hypotension is inferred from it’s presence in people with Addison’s Disease (adrenal failure).xxiii Postural hypotension in isolation does not confirm a diagnosis of hypoadrenia.

Those over age 65 should also be evaluated for carotid artery occlusion using sonography. The combination of postural hypotension and carotid artery occlusion is a common cause of falling in the elderly. Falls are the leading cause of fatal injury and the most common cause of nonfatal trauma-related hospital admissions among older adults.” xxiv

What Does It All Mean?

Like anything else, context is key. If you have a lot of risk factors, you may need to control your blood pressure more aggressively than someone with fewer risk factors. If your pressure is too high, the place to start is always with diet, exercise and other lifestyle choices like eliminating smoking, caffeine, alcohol and substance abuse. Medications should be a second line of defense (unless your blood pressure is critically high) but taking medication doesn’t eliminate the need to make the hard lifestyle changes. There is no substitute for good habits.

Like the other vital signs, we don’t just look at blood pressure in a vacuum. If you have a high BMI or waist to weight ratio, let’s address that. If you have low temperature and pulse, let’s address your low metabolism so you can lose weight. Low thyroid function is also implicated in elevated blood pressure because thyroid hormone is the main driver for producing Nitric Oxide in the endothelium (lining of the blood vessels). Nitric Oxide lowers blood pressure by relaxing blood vessels and increasing perfusion. Exercise also stimulates more nitric oxide production. The foundations of good health always come back to proper diet, exercise and lifestyle. We all know this but we don’t always follow what we know, instead reaching for a quick fix, whether it is a nutritional supplement or a drug. By monitoring vital signs, we can provide ourselves with accountability and knowledgable guidance on our path to recovery.

Recommendation

What I recommend is that you get a home blood pressure machine and take your blood pressure first thing in the morning and after other activities such as exercise. Keep a log of your blood pressures and associated activities. Find out what helps and what hurts. If your blood pressure is higher one morning, ask yourself, “What did I eat last night? Was it salty?” Measure your blood pressure after a stressful conversation. Measure it after whatever it is you do to relax. What you can measure, you can change. Just making these measurements and writing them down will provide the knowledge you need to improve. In my sixties, I found that salty food does indeed increase my systolic blood pressure and exercise reduces it. The generic advice, “Eat less salt” is not as actionable as knowing that every time I eat a particular dish from my favorite restaurant, my pressure is up the next morning. No one else could have told me to stop eating that and expect me to follow their advice. The generic advice of “Get regular exercise” is not as useful as knowing that my systolic pressure drops 20 – 30 points after intense exercise and stays down most of the day. Measurement can be motivational if you log the results and correlate blood pressure measurements with your activities and diet. To a great extent, you can be your own doctor. You can learn what works for you on a daily basis instead of just at your annual physical. We are happy to provide coaching, encouragement and advice, but no one else can fix it for you.

David Wells, D.C., L.Ac.

i https://www.health.harvard.edu/heart-health/reading-the-new-blood-pressure-guidelines

ii https://www.acc.org/latest-in-cardiology/clinical-trials/2015/09/23/10/40/sprint

v https://www.nytimes.com/2017/11/15/opinion/blood-pressure-guidelines.html

vi World Health Report 2002. Reducing Risks, Promoting Healthy Life. Geneva, Switzerland: World Health Organization. http://www.who.int/whr/2002. Accessed May 28, 2010.

vii https://www.ncbi.nlm.nih.gov/books/NBK9634/

viii https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5313243/

ix https://www.ahajournals.org/doi/full/10.1161/01.hyp.0000173433.67426.9b

x https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5313243/

xi https://www.health.harvard.edu/newsletter_article/heart-beat-high-pulse-pressure-poses-risk-for-atrial-fibrillation

xii Owens P, O’Brien E. Hypotension in patients with coronary disease: can profound hypotensive events cause myocardial ischaemic events? Heart 1999;82:477-81. 10.1136/hrt.82.4.477

xiii https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5313243/

xiv Abernethy  JBorhani  NOHawkins  CM  et al.  Systolic blood pressure as an independent predictor of mortality in the hypertension detection and follow-up program.  Am J Prev Med. 1986;2123- 132

xvhttps://jamanetwork.com/journals/jamainternalmedicine/fullarticle/485285

xvi Blacher J, Staessen JA, Girerd X, Gasowski J, Thijs L, Liu L, Wang JG, Fagard RH, Safar ME (Apr 2000). “Pulse pressure not mean pressure determines cardiovascular risk in older hypertensive patients”. Arch Intern Med. 160 (8): 1085–9.

xvii https://en.wikipedia.org/wiki/Pulse_pressure

xviiihttps://www.ahajournals.org/doi/full/10.1161/01.hyp.33.6.1385

xix https://www.nature.com/cdd/journal/v11/n1s/full/4401451a.html

xx https://mydoctor.kaiserpermanente.org/ncal/Images/GEN_MTHFR_tcm63-938252.pdf

xxi https://pubmed.ncbi.nlm.nih.gov/16002796/

xxiihttps://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3f.html

xxiii https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/547882

xxiv https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/

Get Out of Your Comfort Zone!

Dr. David Wells shirtless inside a glacier in Iceland, February 2019.

Since the dawn of time, humans have struggled to get enough to eat, to rest and to stay warm. Naturally, we continue on this path despite most of us being over-fed, sedentary and completely climate controlled. The point of this article is to show the upside of being a little uncomfortable. Don’t worry, I will not advocate in favor of misery. I am only suggesting a little challenge to the way we live and motivate ourselves. To that end, I suggest making friends with being a little bit hungry, a little bit sore and a little bit cold.

A Little Bit Hungry

The hungry lion runs fastest” anonymous

Intellectually, I know I will not starve to death if I don’t eat all the food on my plate, but part of me thinks I should eat it all just in case I never see food again. The self discipline of leaving some on the plate is hard but I actually feel better if I leave the table just a little bit unsatisfied. “Two bites short,” I call it. The alternative goes something like this; I order a large burrito at a restaurant. When it comes, I see that I really only need to eat half of it to be satisfied. If you think of your stomach as being about the size of your fist, it should be readily apparent that we over-stuff ourselves on a regular basis. If I am smart about it, I cut the burrito in half at that moment. If not, I soon find that I have become engrossed in conversation and eaten two thirds of the burrito before realizing that I am no longer hungry. This is because there is a lag between the time when I swallow my food and my brain gets enough nutrient to know that I have had enough. At that point, I have a third of a burrito remaining on my plate. Being a child of Depression era parents, I can’t waste it and it’s really too small to take home. What to do? Hmm? I guess I’ll just eat it. Does that sound familiar?

I once read an article in a small town newspaper in Oregon about a former cowboy who at the age of 103, rode a horse in the annual town parade. When asked to what he attributed his long and healthy life he said,” I have one rule and one rule only. I always leave the table a little bit hungry.” Damn. Why couldn’t he have said, “I always eat a little bit of chocolate,” or “I get a massage once a week,” or anything pleasant. No. He always leaves the table a little bit hungry. Despite not liking his answer, I gave the matter some thought. After all, the leading causes of death in this country are all related to our diet and lifestyle. Here is what I learned.

Hunger is an exquisitely tuned signaling system to keep our body about the same size as it was a couple of weeks ago. If I starve myself or exercise enough to lose a pound, I will be hungrier until I gain it back. On the other hand, barring interference from emotional signaling, I will stop eating if I am no longer hungry. Observing my kids and grandkids has taught me that kids stop eating when they are no longer hungry. The exception to this if the diet is too high in simple sugars and does not have sufficient nutritional value. Kids (and adults) keep eating to try to get the missing minerals, vitamins, amino acids, fatty acids, etc that they need. Empty calories are just that. They will not satisfy our hunger.

Rule Number One: Eat only high-quality, nutrient-dense foods.

What’s the practical application of this? What has worked for me and many of my patients is to eat just a little bit less than the amount I want. This is because I don’t usually know I have had enough until after I have eaten more than I need. This is one more reason to take time and savor your meal. As I said earlier, “just two bites short” is about the right amount. I tell myself that if I am still hungry in an hour, I can always have an apple or something. Usually, I am not hungry later. The trick is to keep this up for a couple of weeks. After a few weeks, my body adapts to this new normal. This is my new weight. This is my new hunger set point. Obviously, this does not produce dramatic weight loss. If you need a medically supervised fast, this is not for you. On the other hand, if you just want to lose 5 or 10 pounds – and you want it to stay off – this slow, steady physiological change really works.

When I say slow, you can expect to lose about 2 to 4 pounds per month. That may not sound like much but faster weight loss is commonly just water loss anyway. I once lost seven pounds in one day while working in the sun. In a couple of days it was back because I re-hydrated. A lot of “miracle” diets work by causing water and feces to leave. Sure the number on the scale is encouraging, but it is an illusion. Here’s the math for an average person; If you don’t eat for one day, you will lose about a half pound of fat. What about exercise? I will get to that shortly but in terms of weight loss, if you eat until you are satisfied, you will replace what you have burned with exercise. So my “two bites short” recommendation will create a calorie deficit that will enable you to burn one half to one pound of fat per week. Don’t even bother to weigh yourself more than once per week. The variables of water and fecal material make more frequent measurement irrelevant.

There are hundreds of strategies for losing weight from various forms of fasting various restricted diets. Theoretically, they all can work. Do whatever diet you like as long as it contains a variety of nutrient rich, whole foods. What won’t work (unless you are taking dangerous stimulant drugs) is losing weight without feeling hungry. Feeling hungry is the key to success. “Making friends with hungry” is what I call getting over the fear that hunger is a sign of something going wrong. It is a form of mild discomfort similar to feeling sore after exercise. Like breathing in and breathing out, hunger is the counterpoint to satiety.

By the way, you don’t have to be hungry after every meal. Be a little hungry or just reach the point of not hungry but don’t reach the feeling of being full unless you are trying to add muscle mass. For much of my life growing up, I thought that unless I felt full, I hadn’t eaten enough. That is simply not the case. If you are full, you are gaining weight. If you are hungry, you are losing weight. If you are not hungry or full, you are maintaining your weight. It is this simple. And when I say hungry, I am not talking about headache, irritability or other hypoglycemic symptoms. I am talking about an uncomfortable feeling in your stomach. A word of moderation here; if you are continuously hungry for two weeks, your thyroid will down-regulate your metabolism, sabotaging any effort to lose weight. My advice is to not be too strict about my advice. End your meals a little hungry most of the time, not all the time.

This technique works best if you are close to your healthy weight. The reason is because the sensation of satiety depends in part on the production of signaling hormones called “leptins”. These leptins tell your body you have eaten enough. The more fat you have stored, the less sensitive your body becomes to leptins, making you think you are hungry when you have in fact had enough. This is why your body may keep signaling you to eat more food, despite being overweight. BAs you lose weight, you gradually become more sensitive to leptins (making you less hungry) . You can also increase your sensitivity to leptins by cold exposure. Read on.

Rule Number Two: Eat Only Enough To Satisfy Your Hunger If You Want To Remain At Your Current Weight.

Rule Number Three: If You Want To Lose Weight, End Most Meals About Two Bites Short.

A Little Bit Sore

Most people who exercise regularly know that feeling a little sore after a workout is a good thing, so I won’t belabor the point. I do want to underscore the idea that we are talking about a little bit sore. Many people begin an exercise program a little too enthusiastically, leading to being way too sore the next day, which in turn leads to quitting the exercise program. Building muscle requires stressing the muscle with exercise, eating enough and sleeping enough to rebuild the muscle. Any time you start a new program, do about a third of what you think you can do and build on that. Take your time. Growing muscles is not a quick process. When I say do a third of what you think you can do, I am talking mostly about intensity as opposed to duration or repetitions.

You can think of this principle most easily in terms of weight lifting but it applies to any activity. So for example, if you think you can lift 30 pounds 10 times, try lifting 10 pounds 10 times on your first day. Note how you feel the next day. If you are not too sore, then build up the repetitions until you can lift 10 pounds for 3 sets of 10 times each without feeling more than a little bit sore. Now increase the weight and reduce the repetitions. For instance, lift 15 pounds 10 times, rest and repeat twice more. Most serious bodybuilders do around 10 to 15 repetitions, 3 to 4 times (sets) on any given muscle. Those repetitions are usually paired with alternatively working an opposite motion for the same number of reps and sets (as in biceps and triceps or chest and back). Eventually (or if you are already in very good condition), you can lift very few times at closer to your maximum resistance. You might for instance do 3 sets of 3 to 5 reps. The point is to have a very hard time completing the last set.

Most weight lifting programs are described in terms of sets and reps. You may wonder why they don’t prescribe how much weight to lift. This is because the amount of weight varies from person to person and is based how many reps and sets you can do before the muscle is unable to do another repetition. This is called muscle failure. Strength training is one endeavor where your goal is to reach failure. You can reach failure by doing a single rep or a hundred. Strength and muscle gains are achieved either way though if you are training for a specific activity, it’s best to do that activity. Training is specific because a lot of it happens in your nervous system. In a study where the subjects trained only one bicep muscle, researchers found that while the trained side increased in strength by 35%, the untrained side increased by 20%. This proves how much of strength training is actually neural facilitation.i

Try to avoid the temptation to lift more to boost your ego or social standing. That often results in injury and at the very least, results in poor form and consequent poor results. One of the best ways to gain muscle and strength is to lift light to moderate weights very slowly. Think Tai Chi speed. Perfect form, very slowly with a light to moderate weight will give the best results and also greatly reduce the risk of injury. For more on this, see my article on Super Slow, High Intensity Training.

If you really overdo it, you may get what is called Delayed Onset Muscle Soreness or DOMS. This is a condition in which proteins have leaked out of the muscle and cause a delayed inflammatory response. DOMS is characterized by appearing two days after the exercise (as opposed to the next day) and getting progressively worse over the next few days, taking about a week to subside. This is not a case of “if a little bit is good, more must be better.” DOMS is muscle damage that does not lead to muscle growth.

If you do it right, you will feel just a little thick and sore in the muscles you worked yesterday. People who do resistance training call that feeling “pumped” because the muscle feels bigger. It actually is a little bigger because the muscle slightly inflames during the healing process. Don’t work that same area until the feeling subsides. Work another body region or function. There are a multitude of programs to rotate through the major muscle groups on a weekly basis. After you have been doing one program for a month, change it up a little. As a body builder once told me, “The best program is the one you’re not doing.”

Rule Number Four: Do Resistance Training Sufficient to Feel Just A Little Bit Sore The Following Day.

If I’m not a little sore when I wake up in the morning, I figure I’m not trying hard enough. Or as one of my patients said, “If I wake up in the morning and absolutely nothing hurts, I’m dead.” Make friends with being a little bit sore.

If you are trying to build muscle mass, you will also have to eat more, particularly more protein. The minimum recommended amount of protein per day to maintain your weight is .8 grams of protein per kilogram of body weight. You will want to double that amount to gain muscle. You also need to consume more calories. This means eating a few bites more than you need to satisfy your hunger. Again, it’s not a good idea to stuff yourself at any one meal, so you may have to eat every few hours to get enough. If you find yourself producing intestinal gas, you are eating more than you can digest. If that gas smells like rotten eggs, you are eating more protein than you can digest. In addition to protein, you need to consume enough calories to support your desired muscle mass. To be sure that you are building muscle rather than fat, measure your waistline. You will want to gain weight without increasing your waistline.

Of course it is also important to do aerobic exercise. The same principle applies. Start with walking thirty minutes. If you want to take it another step (see what I did there), add a little intensity by going uphill for part of the walk. Of course, you can also walk farther and or faster. To challenge your heart, add intervals of race-walking or sprinting, mixed with walking. Go hiking up hills. You get the idea.

If you are moving at a comfortable pace, you will be mostly burning fat for energy. That means that you can go a long time without refueling. In fact, you can run a Marathon distance on about a half pound of fat. If you have been running or going uphill, you may feel muscle soreness related to breaking down and building muscle, but feeling sore after a long walk is most likely due to dehydration, rather than the effects of exertion. Nonetheless, for 24 hours after aerobic exercise, you will be burning energy at a higher rate. You will sleep better, digest better, feel better. It’s not exactly feeling sore, but there is a “spent but energized” feeling that comes after aerobic exercise.

Just A Little Bit Cold

Our bodies respond to cold by increasing our metabolism, and increased metabolism is what we want. Increased metabolism means more energy and faster fat burning. It also means less risk of killer diseases. So why do we avoid cold? For most of human history, we had to work very hard to get enough calories to sustain life. We know that being cold costs calories, so we avoid it, despite the limitless availability of restaurants and grocery stores. We try very hard to conserve energy.

How cold are we talking about? Just a little bit. If you are shivering, you are too cold. What we want to trigger is literally called, “non-shivering thermogenesis.” When we shiver, we burn glucose for energy. When we are cold but not shivering, we burn fat. Better yet, we train our bodies to keep burning fat preferentially, as if we were doing aerobic exercise. To explain this, I have to explain how different fat cells work.

We usually think of fat cells as passive storage depots but actually, they are metabolically active. They come in two basic types, white and brown. The white ones are primarily storage depots but they do make hormone-like molecules that send signals to increase hunger, blood pressure, risk of heart disease, etc. White fat is primarily stored in the trunk around the viscera. Too much white fat is not good. Brown fat cells on the other hand are brown because they are full of energy-producing, fat-burning mitochondria. You want more brown fat cells. Here is where it gets interesting. Exposure to cold stimulates brown fat cells to burn fat faster. That’s right. Your body starts burning fat at a faster rate to raise your temperature in response to cold. Better yet, exposure to cold causes white fat cells to become “beige” fat cells! These beige fat cells have more mitochondria and burn fat more efficiently. It all makes sense if you think about it. To stay warm in a cold environment, you need to burn more fat and make more energy.

So how do we use cold to our advantage? Be just “a little bit” cold. Not enough to shiver but enough to feel uncomfortable. The winter I first learned about this, we set our thermostat at 63 degrees Fahrenheit. I continued to wear short sleeve shirts despite feeling uncomfortably cool. I did wear thick socks. If I had been sitting still for awhile and was getting cold, I would get up and move around to warm myself. After a couple of months, my basal temperature went from it’s usual 97.6 (low end of normal) to a the ideal 98.6. My energy level increased and my TSH (a measure of thyroid function) went from slightly high (indicating a sluggish thyroid) to the ideal range. Some other symptoms and signs improved as well. In short, being cold kick-started my metabolism. During the summer months, swimming is a good way to get some cold exposure. I take cool showers all year. In the winter, I mix in some warm water with the cold. The rest of the year, my shower is at whatever temperature comes out of the cold tap. I actually shower outdoors most days but that’s another story.

How much fat is burned? That depends a lot on the individual and how much exposure to cold. One study of lean, young men who exercised for 45 minutes in 68 degree water found that they ate 41% more food compared to when they exercised in 91 degree water. This suggests but does not prove that they burned 41% more calories. If you think of how hungry you get after swimming in cold water, this makes sense. If you are trying to lose weight, the hard part would be not eating as much as you want to after the swim.

I can’t give you an exact number of calories burned per time in a particular temperature range but I know I lost eight pounds in a week when I was out photographing in Yellowstone in January. Despite being dressed for cold, I was cold all week (at one point the temperature got down to 27 degrees below zero). I didn’t have the option of just eating more food, so I lost weight.

If a little cold is good, is a lot better? In a word, “No”. As I mentioned above, cold to the point of shivering does not increase brown fat conversion or produce other changes leading to increased metabolism. You may have read about people like Wim Hof who swim in ice water or meditate naked in the snow, claiming to have found the fountain of youth. I don’t think extreme cold is an unqualified good. Many of the effects of exposure to extreme cold result from increased production of cortisol, an anti-inflammatory hormone. Suppressing inflammation in general is a good thing but cortisol also suppresses immune response so you don’t produce symptoms of illness even if the illness is continuing to spread. It does not make you free of infection and there is a rebound effect. Your adrenal glands can only produce cortisol for so long. Stress also causes in increase in cortisol but no one advocates more stress. If you feel an exhilarating rush from a cold shower or dip in the ocean, you are feeling the release of noradrenaline, another stress hormone that produces a kind of high. While this is a good thing if you have enough energy, adrenaline is also a stress on the body and should be avoided if you are feeling weak or are recovering from an illness. Adrenaline consumes a lot of glucose. If you feel tired later in the day after exposure to cold, you may want to dial it down. Cold, like exercise or hunger is a stressor. We want to challenge our bodies but not to an extreme.

I prefer just being in a slightly uncomfortable cool environment. When I feel like I need to shiver, I breathe deeply and try to relax more, bringing blood to all parts of my body. I am trying to get my body to produce heat without stressing or shivering. This is my way of calibrating my response.

Despite my cautious statement above, mild cold exposure can improve immune response. This is mediated in part by noradrenaline. A study of lean young men who sat in a cold bath for an hour found increases in their immune response, including an increase in natural killer cells.ii The immune enhancement was even better if they exercised prior to cold exposure. Personally, I hike or bike early in the morning when it is still cold outside. I under-dress for the occasion (shirtless while hiking), using exercise instead of clothing to warm myself.

If exposure to cold enhances immune response, why do we “catch cold” more frequently when in cold environments? This may be due to drying of mucus membranes in the upper respiratory tract, losing the protective benefits of a mucus coat, along with a withdrawal of blood (and therefore immune cells) from mucus membranes due to cold. I wear a buff or other facial covering when exercising in cold air. I do the same or put a little lubricant in my nostrils when flying because airplane cabin air is extremely dry.

One of the great things about cold exposure is that it can help your body repair telomeres. Those are the ends of your DNA that fray and degrade a little every time cells divide. The slow degradation of telomeres is how we age. Eventually, cells can’t divide properly and cells die. If enough critical cells die, so do we. Hunger, particularly fasting, also stimulates telomeres to repair.

Rule Number Five: Allow Yourself To Be Just A Little Bit Cold At Least Part Of The Time.

Conclusion

I am advocating living a richer sensory experience. As implied by the old saying “Hunger makes the best sauce”, we enjoy our food more when we are hungry. Feeling fully spent after exercise is a lovely mix of peaceful and vibrant. Diving into cool water feels exhilarating. Feeling the sun warm your skin afterwards is also delightful.

There is an emotional spinoff as well. We have greater confidence when we are not worried about being hungry, cold or facing the challenge of exercise. When I travel overseas on photography trips, people who know I am particular about what I eat ask, “What if you can’t find anything there to eat?” My reply is, “I’ll be hungry.” I know I will be uncomfortable but I won’t die. I have made friends with hunger. I do not fear it. There is a lot of freedom in that.

This embrace of life’s challenges and discomforts may even translate into more willingness to take social or emotional risks. Speaking up for what you want, even when it is uncomfortable may lead to actually getting what you want. At the very least, you will feel better about standing up for yourself. Telling truth to power isn’t comfortable, but that’s how the world gets better. As Chicago Tribune columnist Mary Schmich said, “Do one thing every day that scares you.”iii What I am saying is that courage to face some discomforts in life may lead to courage in other areas as well.

iNeural Factors vs. Hypertrophy in Time Course of Muscle Strength Gain,’ Am. J. Phys. Med. Rehabil., vol. 58, pp. 115-130, 1979

iihttps://journals.physiology.org/doi/full/10.1152/jappl.1999.87.2.699

iii1997 June 1, Chicago Tribune, “Advice, Like Youth, Probably Just Wasted on the Young” by Mary Schmich, Page 4C, Chicago, Illinois. (ProQuest

Covid 19 – Nutrition and Lifestyle Advice

 

First of all, follow the guidance of the Centers for Disease Control and the Safer at Home guidelines issued by the State off California and the City of Los Angeles. Practice social distancing, thorough hand washing, avoiding touching your face, etc. Everyone knows the drill by now. Nothing I say below in any way is a substitute for these procedures. I just want to add a little additional advice from a natural health perspective.

Next, try to stay focused, productive, calm and yes – happy. Your immune system works best when you are relaxed and happy. Doing something kind for a neighbor, reaching out by phone to friends, working in your garden, getting out your yoga mat or taking an online Tai Chi class – whatever makes you relaxed and happy – do it. You may feel that you can’t take the time for yourself in these uncertain economic times, but do it anyway.

Get eight hours of sleep per night. If you can’t sleep, try taking some magnesium before bed. We can provide magnesium and dosing information. Call us. Your immune system works best when you are well rested.

Limit consumption of sweets. Sugar is a favorite food of bacteria and yeasts. You don’t want to waste the resources of your immune system fighting bacteria when you need to save your strength for a possible encounter with a virus. We always see a flood of patients with a “cold” or “flu” right after Halloween and each of the subsequent holidays. Coincidence? We don’t think so.

Make sure you have enough of the following nutrients: Vitamin D3, Vitamin C and Zinc. If you need help getting a good source of these nutrients and advice on dosing, give us a call. Here is why they are important.

Vitamin D

The “Sunshine Vitamin” has been proven to reduce risk of illness from a variety of lipid coat (enveloped) viruses, including; Herpes Zoster, Epstein Barr, Ebola, Cytomegalovirus, HIV, Dengue Fever, Yellow Fever, Measles, Mumps, Smallpox, Influenza and the common cold.iCoronavirus is a lipid coat virus. The research isn’t in yet on the effect of Vitamin D on Covid 19 but having a normal level of Vitamin D seems prudent to me.

While it is possible to overdose on Vitamin D (The only case I have seen in the literature was a man who ate an entire polar bear liver), the RDA of 600 units is probably not sufficient. If you were naked in the tropics, your body would produce about 35,000 units per day. Low Vitamin D is associated with a wide range of illness, including osteoporosis and increased rates of breast and colon cancer.iiHaving enough is vital. There is no benefit to having too much, but the death rate from influenza is doubled for those who are severely deficient.iii

Vitamin C

The most severely ill Covid 19 patients die of what’s called a “cytokine storm.” This is an overactivity of the immune system that produces inflammation and tissue destruction. High doses of Vitamin C help to regulate the immune system, reducing the synthesis of pro-inflammatory cytokines.ivFurthermore, Vitamin C is a free-radical scavenger that reduces damage from inflammation, particularly damage to the immune system itself. v

Zinc

A classic symptom of Zinc deficiency is lack of the sense of smell and taste. As many as half of patients who have a mild or asymptomatic case of confirmed Covid 19 infection report loss of sense of smell.viCoincidence? Not likely. Zinc is an important part of the innate immune system and is commonly deficient in the elderly, increasing risk of infection and mortality from infection.viiZinc helps the immune system fight many kinds of bacteria and viruses and has been proven to reduce the incidence and duration of colds.viii

We recommend Zinc Gluconate or Zinc Piccolinate in doses ranging from 15 to 45 mg per day depending on age, size and symptoms. Too much Zinc can be harmful however. Food sources include meats and whole grains. Vegetarians are frequently deficient. Zinc can also be taken as a lozenge or nasal spray.

ihttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3308600/

iihttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470481/

iiihttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4463890/

ivhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3480897/

vhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783921/

vihttps://www.news-medical.net/news/20200323/COVID19-patients-describe-a-loss-of-smell-and-taste.aspx

viihttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279174/

viiihttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3273967/

Digestion – What You Need to Know

Digestion – What You Need to Know

 

About 600 million years ago, tube worms evolved and subsequently developed into every animal you can think of from dinosaurs to humans. The “tube” in tube worm is the digestive tract. That should tell us something about how important digestion is to us all. We all have a mouth at one end and an anus at the other with a continuous tube in between to digest our food. Without a digestive tract, we wouldn’t be alive. This article aims to help you understand how yours works and what to do if it isn’t working as well as you’d like. Please read on.

The essential thing to know about your digestive process is that it proceeds from top to bottom in an orderly sequence. You may have been diagnosed or know someone diagnosed with acid reflux or colitis, but to really understand what is happening, you have to take a global view of the entire digestive tract. If you or your doctor treat your stomach as if it was on a separate planet from your pancreas or intestines you will have a host of downstream problems. My first advice is to take a holistic approach.

That digestive sequence actually starts in our mind. We think about food. We see food. We smell food and we start making digestive juices. This is the way it is supposed to work. Far too many of us put food in our mouths while multi-tasking or otherwise distracted. Eating in this way is the start of most digestive problems, including obesity (If you don’t feel satisfied and nourished by your food, you will likely keep eating until your are overly full).

Imagine you are in Europe at a sidewalk cafe. You are with friends, the day is pleasant and you have plenty of time set aside for a relaxed meal. You enjoy an appetizer and then your plate arrives. Your food is beautifully prepared and smells delicious. The aroma wakens your hunger. You bring a bite to your mouth, close your eyes, put down your fork and savor the taste as you slowly chew. Ahh….

In contrast, most meals in America are eaten in the car.

Europeans think our obsession with fast food is ridiculous. Why would you want fast food? Do you want all your pleasures to be over with quickly? What’s the hurry? Eating is a physical and emotional pleasure that we get to enjoy several times per day. Why do we turn it into a quick re-fueling? Life is to be enjoyed.

Okay, okay, you have so much work to do. You don’t have time to enjoy your meals in a relaxed way. Here’s what you can do. At home when you are able, practice this; Make a colorful, flavorful meal with an enticing aroma. Sit down with your plate, close your eyes and relax your breathing. Feel your body relax. Feel your shoulders relax. Feel your abdomen expand as you inhale. Breath ten times. This is a traditional time to give thanks for all that is good in your life. You are shifting from your “fight or flight” nervous system to your “rest and digest” nervous system.

When you open your eyes, look at your food and appreciate the beauty and aliveness on your plate (if you are looking at a plate of mystery meat in greasy grey sauce with a slice of unripe tomato on limp iceberg lettuce, go back to the kitchen and start over. Food should look and smell enticing). Pick up your fork, bring a bite to your mouth, close your eyes and savor the flavor as you chew. After you have liquified and swallowed that bite, open your eyes and have another. A few bites in, you should be able to read or have a conversation without losing that sense of inner peace. I expect you will find that this is a delightful and relaxing experience, one you will want to repeat. I understand that you won’t be able to do this at work, but if you do this at home you may find that just a deep breath and a brief closing of your eyes on the first bite may be enough to trigger this relaxed state of eating while you are at work.

By the way, closing your eyes and putting down your fork is a way to break the habit of constantly searching for the next bite instead of enjoying the one in your mouth. This attitude of being present with your moment to moment experience can be transferred to your every conversation and interaction with the world. Eating can be your daily meditation practice. Fully receiving nourishment from your food can translate into fully receiving the gift of other people and experiences in your life. When someone gives you praise, do you breathe in that praise and own that you are worthy of those words or do you brush it off with, “Oh, that was nothing” or some similar avoidance. If you can’t receive food with grace, how can you say, “Yes I am good/kind/honest” or whatever the praise is about? Practice receiving the nourishment of food and deal with whatever self esteem issues arise. Then take what you have learned and apply it to your relationships.

Next stop – Your Stomach!

Anticipating, smelling and savoring your food increases saliva in your mouth and gastric juices in your stomach. Relaxing while you eat also brings blood to your digestive tract. Chewing your food breaks down cell walls in the food, making the nutrients inside available to be digested. An enzyme in your mouth called salivary amylase begins the process of breaking down starches.

When you swallow, the food travels down your esophagus, through a ring of muscle called the cardiac sphincter (called cardiac because it is close to the heart) and into the stomach. The esophagus is in the cavity containing your heart and lungs, the cardiac sphincter and stomach (and all subsequent digestive organs) are located below your diaphragm in your abdominal cavity. While the job of your teeth and saliva is to grind food into a digestible puree and begin breaking down starches, the job of your stomach is to continue churning and mixing the food with pepsin and hydrochloric acid to begin protein digestion.

The stomach of course, is just a specialized part of your digestive tube. It makes itself into a separate chamber by closing the cardiac sphincter at the upper end and the pyloric sphincter at the lower end. Both those rings of muscle close to trap the food with caustic, protein-digesting fluids in the stomach. The stomach lining isn’t injured by the acid and pepsin. Hydrochloric acid would burn other tissues (as it does in the case of acid reflux into the esophagus and duodenal ulcer in the upper small intestine). So as the stomach fills and the acid is released, the rings of muscle (sphincters) at the cardiac and duodenal ends close off the stomach so it can do its work.

In addition to beginning protein digestion, hydrochloric acid also kills bacteria that may have entered with your food. What if you don’t have enough stomach acid? An article in the Journal of the American Medical Association estimates that 33,000 Americans die every year from hospital acquired pneumonia because they are taking anti-acid medications.i ii Get that? Die from pneumonia. If they had normal stomach acid, the bacteria would have been killed rather than allowed to cause infections (including but not limited to pneumonia).

Many nutrients but most particularly Calcium require hydrochloric acid so that they may be absorbed. That’s why people who take proton pump inhibitors (a very strong class of anti acid) suffer higher rates of osteoporotic fractures. iii

If anti-acid medications are so dangerous, why are they prescribed? Well, they stop the pain of acid reflux (heartburn) and some doctors still think they prevent ulcers. Let’s start with the acid reflux.

It used to be that doctors and laypeople alike thought that the stomach produced too much acid in response to stress. I remember ads on television when I was a kid showing fire in the stomach of a stressed person being extinguished by anti-acids). Doctors however, should have known better. Stress causes a reduction in stomach acid. Remember, stress triggers a fight of flight response. You don’t make acid to digest food when you are fighting or running. Low acid in the stomach from “eating on the run” fails to fully close the cardiac sphincter. Muscular restriction and lack of blood flow in the stomach pushes the food back up the esophagus. The body wasn’t prepared to receive food. The stomach wasn’t relaxed and receptive. The stomach juices weren’t released. The sphincters weren’t closed. The top down, sequence of digestion wasn’t properly started in a person who didn’t take the time to slow down and relax while eating. So yes, eating on the run causes heartburn, but it is not because there is too much stomach acid. Quite the contrary.

So how to address acid reflux? First, eat consciously. Relax and enjoy your food. Second, avoid overeating. When the stomach is over full, the cardiac sphincter can’t contain the excess food. Third, avoid eating anything within four hours of going to bed. When you lie down, food pushes up against your cardiac sphincter in a way that it doesn’t when you are upright. You want your stomach to be empty when you lie down at night. Dinner should not be your heaviest meal of the day and it should not occur late in the day. I understand that for most people, dinner is when you finally relax and can eat a meal in peace. I don’t know how you can re-arrange your schedule to have a relaxed lunch and a light dinner. I just know that you will avoid a lot of digestive problems if you do.

As an example, one of my patients – a successful business man – had been on proton pump inhibitors (Nexium in this case) for about 10 years. It was no longer working. He had terrible stomach pain and acid reflux. My advice was to have only a low fat vegetable soup for dinner and to eat nothing after 6:00 PM. I told him he would continue to have pain for about a week and then it should start to improve. That is exactly what happened. The lining of his esophagus repaired and the pain subsided. He no longer had acid reflux and no longer needed the medication. In a couple of months, he also lost a lot of extra weight.

So what about ulcers? Don’t people need to take anti-acids to prevent ulcers? No. Ulcers are caused by low stomach acid.iv Yes, low stomach acid. This was first discovered in 1982. The mechanism of ulcers is that low stomach acid allows the overgrowth of a bacteria called Helicobacter Pylori (H-Pylori for short).v H-Pylori infection causes ulcers. The most effective treatment of stomach ulcers is antibiotics paired with bismuth (remember Pepto Bismol?). When Australian researchers Barry Marshall and Robin Warren first discovered and promoted the idea that ulcers were the result of H Pylori overgrowth, they were slandered and attacked in the press all around the world by gastroenterologists who saw their livelihoods at risk. Cutting out ulcers was good business. Prescribing antibiotics is not. At this point though, the confirming research is unassailable. In 2005, Marshall and Waren received the Nobel Prize in medicine for their discovery. Again, eating in a relaxed way promotes normal stomach acid. Normal stomach acid suppresses H Pylori and prevents ulcers.

While we’re on the topic of H pylori, it’s worth noting that H. pylori infection is also the cause of gastric and gastroesophageal cancer. Another good reason to take time and enjoy your food.

Where does the food go next?

When the food is sufficiently mixed, churned and exposed to pepsin and hydrochloric acid, the valve at the lower end of the stomach (pyloric sphincter) opens to let a little food at a time move on to the first part of the small intestine known as the duodenum. The beginning part of the duodenum is also where the pancreas and gallbladder contribute their juices to the mix. The valve that releases bile and pancreatic enzymes into the duodenum is triggered to open by contact with acidity in the food leaving the stomach. Again, reduced acid means reduced release of bile and pancreatic enzymes. Each step in digestion is triggered by the preceding step.

Pancreatic enzymes actually do most of the work of digestion. These enzymes digest protein, carbohydrates and fats. The pancreas also releases bicarbonate to neutralize stomach acid. This prevents damage to the small intestine. If there isn’t enough acid to trigger the release of bicarbonate (or if there is a blocage in the pancreatic duct) the excess acid could cause a duodenal ulcer.

From here on down the small intestine, the enzymes break down the food and the nutrients are absorbed into the bloodstream. From there, the nutrients go to your liver and on to the rest of your body.

Speaking of the liver, that is where you produce bile. You can think of bile as a soap. Bile emulsifies fats. In other words, it allows fat to break up into small particles and mix more easily with water. This in turn creates more surface area for the fats to be broken down by pancreatic enzymes. Between meals, bile accumulates in your gallbladder. When food hits your small intestine, the gallbladder contracts and pushes bile out the same tube (common bile duct) as your pancreas and through the same valve (pancreatic sphincter) into your duodenum.

One of the components of bile is cholesterol. Your liver gets rid of excess cholesterol by making it into bile and excreting it into your intestines where it binds with fiber and is carried out to the toilet. If you do not have good digestion and adequate fiber, the cholesterol reabsorbs back into your bloodstream, where it can increase your risk of cardiovascular disease.

In addition to breaking down and absorbing nutrients in your food, the small intestine also produces serotonin, the hormone that makes you feel relaxed and happy after a good meal. This is the same hormone that is potentiated by drugs known as SSRI’s or selective serotonin re-uptake inhibitors. Examples include prozac, celexa and lexapro. As a society, we are heavy consumers of SSRI’s, anti-acids, osteoporosis drugs and fast food. Are you seeing a pattern here?

After most of the nutrition is absorbed in the small intestine, the food moves on through the ileocecal valve to your large intestine. The job of the large intestine is primarily to absorb water and minerals. Most of the good stuff has already been absorbed. I should note that if digestion wasn’t good upstream, there will be too much nutrient available for bacteria in your intestines, leading to inflammation and infection in the colon (colitis/irritable bowel). The bacteria that you want in your large intestine thrives primarily on soluble fiber, the stuff you get from eating your whole grains, beans, fruits and vegetables. Flax meal is also a terrific source of fiber and is effective in lowering your serum cholesterol. Healthy “probiotic” bacteria in your intestines can protect against a host of diseases and help us to digest our food. Taking antibiotics kills those healthy bacteria. Eating too much refined carbohydrate feeds yeasts and unhealthy bacteria. If you have yeast infections, sore throats, etc., you may want to cut down on your consumption of refined carbohydrates.

A side note on that topic is sinus infections. The sinuses are part of the same tube as the digestive tract. Chronic sinusitis is a sign of chronic inflammation in your large intestine. For many of my patients, not eating within four hours of going to bed cures their chronic sinus problems.

So how do you know if your digestion is working well? Here are a few clues:

Pain – There shouldn’t be any. If there is, note the location and what triggers the pain. Tell us or your primary care physician.

Gas – The digestive process produces gas – a lot of it – though most is reabsorbed in your intestine. If you are belching or burping, you are either swallowing air or you don’t have sufficient stomach acid. Slow down, chew well and enjoy your food.

If you are passing intestinal gas, note the smell. If it smells like a rotten egg, that indicates a problem digesting protein. Either you are eating too much or too fast (see above).

If you have copious amounts of odorless intestinal gas, you have consumed too much carbohydrate, particularly a combination of starch and a simpler sugar. Think bread and jam, pastries, cookies, etc. Odorless gas is a result of yeast fermentation. The gas bubbles in beer come from yeast fermentation.

Transit time – Food should pass from your mouth to the toilet in 24 to 36 hours. The average American transit time is 72 hours, meaning the average person is constipated. You can test your transit time by having a meal that includes a lot of beets. Beets will retain much of their color as they pass through your system. The problems associated with constipation are numerous, ranging from acne and hemorrhoids to colon and liver cancer.

Look at your bowel movements – An ideal bowel movement is 12 to 18 inches long, 1 to 1.5 inches thick and comes out easily in one piece. Not too hard or too soft. This should happen at least once per day. It can happen after every meal. Frequent soft bowel movements are diarrhea and can result in malabsorption. If you have diarrhea, try having foods that are warm and soft like soup rather than cold and chewy like salad. Ginger and cinnamon can calm and bring blood to the stomach. If diarrhea persists, talk to your health provider.

Infrequent, hard bowel movements are associated with constipation. If you have constipation, try drinking more water and eating more high fiber foods. Most importantly, try establishing good bowel habits. What that means is setting aside time to defecate. Ideally, sit down on the toilet after breakfast and allow yourself 5-10 minutes to relax and empty your colon. Nothing may happen for several days but if you persist, your body will get that you are serious. I understand you have to get to work or get the kids ready for school, but if you can establish this habit, you will feel better every day. If after breakfast doesn’t work for your schedule, try after dinner. Eating and defecating at regular times helps your whole system.

Normal stool ranges in color from light to dark brown. On any given day the color may be affected by what you ate the day before so some variation in color is not a cause for alarm, particularly if you have no pain or other symptoms.

If your stool is black and sticky like tar, you may have a bleeding ulcer (Digested blood looks black. hemorrhoidal blood is red). A black non-sticky stool may just indicate that you have consumed iron tablets or bismuth (Pepto Bismol). A bleeding ulcer generally includes nausea and stomach pain plus weakness and light-headedness.

If your toilet water has an oily sheen to it, or your stool is grey or clay colored you may have a gallbladder problem. Obstruction of the bile duct is often accompanied by yellowing of the whites of the eyes. Gallstones cause intermittent, cramping pain in the right upper abdomen.

Persistently yellowish stool in an adult may indicate obstructive disease of the pancreas such as pancreatitis or pancreatic cancer but may also indicate a malabsorption syndrome such as celiac disease.

I am not trying to make you obsessive about all this, just trying to give you some tools so you can monitor and report to your doctor any changes you might notice.

Many patients are embarrassed or dismissive about their digestive complaints and fail to mention them but digestion is an important part of your overall health. Remember, we are all just specialized tube worms. Poor digestion means poor quality of life. If you have a problem or question about your digestion, please bring it up next time you are in the office. We want you to feel well. Chiropractic offers manipulative techniques to restore normal position and function to digestive organs. Acupuncture has a wealth of treatment protocols designed to help all kinds of digestive issues. Let us know what we can do to help.

Best,

David Wells, D.C., L.Ac., MS (Nutrition)

 

 

i JAMA. 2009 May 27;301(20):2120-8. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. Herzig SJ, Howell MD, Ngo LH, Marcantonio ER.

ii Chun-Sick Eom, Christie Y. Jeon, Ju-Won Lim, Eun-Geol Cho, Sang Min Park and Kang-Sook Lee. Use of acid-suppressive drugs and risk of pneumonia: systematic review and meta-analysis. CMAJ, December 20, 2010 DOI: 10.1503/cmaj.092129

iii Laura E. Targownik, MD MSHS, Lisa M. Lix, PhD, Colleen J. Metge, PhD, Heather J. Prior, MSc, Stella Leung, Msc. and William D. Leslie MD
Use of proton pump inhibitors and risk of osteoporosis-related fractures CMAJ August 12, 2008 179:319-326; doi:10.1503/cmaj.071330

iv Kusters JG, van Vliet AH, Kuipers EJ (July 2006). “Pathogenesis of Helicobacter pylori Infection”. Clin Microbiol Rev 19 (3): 449–90.

v Therapeurtic Advances in Gastroenterology. Helge Waldum, per Kleveland and Oystein Sordal. Helicobacter pylori and gastric acid: an intimate and reciprocal relationship. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5076771/

Take Care of Your Thyroid – Part 1 – Hypothyroidism

Marsha is tired all the time. She wakes up with a dull headache and needs coffee before she can be civil with her husband and kids. Her skin is dry despite practically soaking in lotion. Her hair is getting thinner and more brittle. She has gained a lot of weight and feels cold much of the time, so much so that she wears socks to bed.

Janet also feels tired but in her case, she feels wired and tired. Her pulse is fast and her skin is moist. She feels anxious and irritable. She has a hard time sleeping. What do these two women have in common? They both have thyroid problems.

Of course, men can have thyroid problems too. It’s just a lot more common in women. According to the American Thyroid Association, “Women are five to eight times more likely than men to have thyroid problems.” They go on to say, “One woman in eight will develop a thyroid disorder during her lifetime.”i

The following article will help you understand how your thyroid works, what the lab tests mean and what you can do to improve your thyroid function. I have included enough detail to make you an expert. I suggest you read the whole article, skimming any sections that seem too technical. Take what information you need and can use. You can always come back to this article to answer any questions that may arise.

Please note – I am not an endocrinologist or even a medical doctor.  Use this article as a resource while working with your physician.

Where is my thyroid?

The thyroid gland is located just above the sternum. It is a butterfly shaped gland, wrapped around the trachea. Inside the thyroid are the parathyroid glands. The thyroid is part of the “fight or flight” nerve and hormone system. Thyroid hormones increase energy, speed and body heat. The parathyroids are part of the “rest and digest” system. Parthyroid hormone helps the body to nourish and repair itself, primarily by directing calcium back to the bones when it is not needed elsewhere. The function of the parathyroids has to be replaced in the case of thyroidectomy (removal of the thyroid) because the parathyroids are embedded in the thyroid gland.

What is thyroid hormone made of?

The thyroid gland produces thyroid hormones, primarily T4, though also smaller amounts of T3 and T2 respectively. T4 is made of an amino acid called Tyrosine plus four molecules of the mineral Iodine (Hence the name, T4). T4 is the transport form of the hormone. T3 is Tyrosine plus three Iodine molecules and T2 has two molecules of Iodine. T3 is the active form of the hormone.

One of the causes of hypothyroidism is insufficient Iodine in the diet. Many parts of the world don’t have sufficient Iodine in the soil, so the foods grown in that soil or the animals that depend on that food are deficient in Iodine. People eating those grains, vegetables and animals therefor don’t get enough Iodine. A severe form of mental retardation called Cretinism was common before Iodine was added to salt. Subclinical Iodine deficiency is still common.

The amino acid Tyrosine is a normal component of the diet and should not need to be supplemented, though there are some people with insufficient enzymatic ability to split Tyrosine molecules off from the rest of the protein in their food and thus do have a need for Tyrosine supplementation. These people are the exception and can be identified by testing serum amino acids. Clues that helped me to find Tyrosine deficiency in a few patients were the failure to produce endorphin in response to acupuncture, general lack of zest for life and extreme sensitivity to air pollution. The poor response to acupuncture and lack of joy is because Tyrosine is also needed to make endorphin, dopamine and norepinephrine – hormones that cause pain relief, reward and excitement. The exagerated response to air pollution (extreme fatigue) is because certain pollutants block the conversion of Phenylaline (another amino acid) into Tyrosine, resulting in low levels of the substrate needed to make endorphin, dopamine and norepinephrine as well as thyroxine.

What does thyroid hormone do?

In brief, thyroid hormone raises the metabolic rate of the cells, that is, the rate at which cells burn fat and oxygen to make energy. Thyroid hormone does this by making the cell sensitive to adrenal hormones. Adrenal hormones in turn, speed the metabolic rate.

You might wonder why thyroid hormone is needed since adrenal hormones actually control the burn rate of fat and oxygen. The answer is that adrenal hormones come and go in little spurts that would make your energy level rise and fall like someone driving a car by pumping the gas pedal up and down. Thyroid hormone smoothes and regulates the overall rate of metabolism. If there is not enough thyroid hormone, the “gas” doesn’t reach the “engine”. You can think of thyroid hormone as the “cruise control”, setting the overall rate of energy production.

In general, men have larger adrenal glands and more muscle mass than women and thus can tolerate a lower functioning thyroid and not have symptoms.

How does thyroid hormone get where it needs to go?

Most of the hormone produced by the thyroid gland is in the form of T4 (In fact, fourteen times more T4 than T3). T4 is a very stable form of the hormone, but because T3 is the active form of the hormone, T4 must be converted to T3 in the tissues.

Ninety-nine point five (99.5) percent of the T4 and T3 are bound to proteins called thyroid-binding globulin (TBG), transthyretin (TTR) and albumen. Of these, TBG binds 75% of the thyroid hormone, TTR 20% and 5% is bound to albumin. These are very stable molecules that serve as a reservoir of thyroid hormone outside the thyroid gland itself. If there were no pool of circulating protein-bound thyroid hormones, depletion of the hormones could occur within hours of the thyroid ceasing production. As it is, the thyroid could stop making hormone for 24 hours and amount in the blood would only decrease by 10% and 40% for T4 and T3 respectively. This allows thyroid production to fluctuate without affecting available levels of the hormones. Another advantage to being bound to large protein molecules is that there is less loss of the hormone in the urine than there would otherwise be.

The different carrier proteins also direct the delivery of thyroid hormone to particular parts of the body. Most notably, transthyretin (TTR) delivers thyroid hormone across the blood-brain barrier to the brain and nervous system, and across the placenta to the fetus.

As noted earlier, there is a small amount (0.5%) of unbound T4 and T3 in the bloodstream. The T4 and T3 must become free of the transport protein in order to enter the cells of the target tissues. In lab tests, the free T4 and T3 fractions can be measured separately from total T4 or total T3.

Once at the cell membrane, T4 and T3 must cross the cell membrane with the help of cellular thyroid hormone transporters and then bind to the nuclear thyroid receptors in the nucleus of the cell. Thyroid disruptors like PCB’s, BPA, dioxin and flame-retardants can block crossing the cell membrane.,

Conversion of T4 to T3.

Once inside the cell, T4 must be converted to T3. This occurs with the help of enzymes called deiodinases. There are three types of deiodinase, designated as Type I, II and II Regardless of which type is involved, for deiodination to result in metabolically active T3, one molecule of iodine must be removed from the outer ring of the T4. Removal of an iodine molecule from the inner ring produces an inactive form of T3 called “reverse T3” or rT3. Types I and II produce metabolically active T3. Type III produces rT3. Type III is used to reduce excess levels of T3 in the brain and in the placenta and fetus. Excess T3 could stimulate abnormal cellular differentiation, particularly in the fetus.

Type I deiodinase is produced in the liver, kidney, thyroid, pituitary and heart but primarily in the liver. The liver is thought to be the main source of peripheral T3 production and also the main location for clearance of plasma reverse T3. Type I is the most dependent on adequate selenium levels of the three types.

Type II is produced in the central nervous system, pituitary, skeletal muscle, cardiac muscle and brown adipose tissue. Both Types I and II are blocked by the presence of mercury, arsenic, cadmium, lead, PCB’s, FD&C red dye #3, the pesticide methoxychlor and a UV agent used in sunscreens called octylmethoxycinnamate. Blocking the action of Type I or II deiodinase results in less T3 and thus lowered metabolism.

How does thyroid hormone raise energy level?

T3 increases transcription of beta-adrenergic receptors and decreases transcription of alpha-adrenergic receptors on the cell membrane. Beta-adrenergic receptors bind with circulating catacholamines such as norepinephrine (adrenal hormone), stimulating glycolysis and glycogenolysis (the burning of glucose and glycogen to make energy). In contrast, when catacholamines bind with alpha-adrenergic hormones, metabolism is reduced. Thyroid hormone is also an insulin antagonist. It stimulates lipid turnover, free fatty acid release and cholesterol synthesis. In short, T3 encourages converting both fat and glycogen into energy.

Additionally, thyroid hormone maintains calcium mobilization and is necessary for the contractility of mysosin filaments in the muscles. It is necessary for central nervous system, skeletal and sexual maturation and is also required for protein synthesis and the formation of apoenzymes.

From this it is easy to understand how lack of thyroid hormone activity causes poor muscle and ligament development, low energy, cold body temperature, inability to think clearly, accumulation of fat, etc. Beyond the obvious, energy is required to power every metabolic process. Low energy equals reduced health in every respect.

How is the production of thyroid hormone regulated?

The short answer is that the pituitary produces a hormone called thyroid-stimulating hormone or TSH, which in turn stimulates the thyroid to produce more thyroid hormones. The production of TSH is in turn regulated by hypothalamus. The hypothalamus makes thyroid-releasing hormone (TRH). TRH causes the pituitary to produce TSH.

The hypothalamus is in turn influenced by the weather (prolonged cold causes increases in TRH production), the amount of circulating iodine in the blood, fasting (lowers metabolism to conserve energy) and other factors. Think of the hypothalamus as a little lab in your head, constantly measuring blood chemistry and other information and deciding what hormones are needed. The hypothalamus sends this information to the pituitary. In turn, the pituitary issues the orders to the glands to make appropriate amounts of hormones needed to deal with current environmental conditions.

With such a beautifully balanced system, what can possibly go wrong?

Hmm, let me count the ways…

Excluding pathology such as tumors of the pituitary, genetic abnormalities, infectious disease, etc., the most common conditions of the thyroid are hypothyroidism and hyperthyroidism. Let’s start with hypothyroidism.

Hypothyroidism

Hypothyroid means low-functioning thyroid. Remember, a low functioning thyroid results in low energy production. Hypothyroidism can be caused by

  1. Inadequate stimulation by the pituitary.
  2. Inadequate production of T4 by the thyroid gland (Primary hypothyroidism).
  3. Inadequate conversion of T4 to T3 in the tissues (Peripheral thyroid resistance).
  4. Auto-immune destruction of the thyroid gland or its hormones (covered in a following section).

Let’s take these one at a time.

Inadequate stimulation by the pituitary.

The pituitary produces thyroid-stimulating hormone (TSH). The normal range for TSH in the blood is .4 – 4.5 mlU/L. Symptoms of hypothyroidism in patients whose blood levels of TSH are under .4 indicate under-production of TSH by the pituitary. Blood levels of TSH over 4.5 in persons with symptoms of hypothyroidism indicate that the patient’s thyroid gland is not responding to the TSH.

It should be noted that the current lab standard of up to 4.5 mU/L may be missing many people who are clinically hypothyroid. The National Academy of Clinical Endocrinology recommended in 2002 that the target TSH level for thyroxine replacement should be between 0.3 and 3.0 mU/L. Adopting this new guideline would bring the number of people with abnormal thyroid function to as much as 20 percent of all adults, up from 4.6 percent under the current guidelines. In guidelines published by the National Academy of Clinical Biochemistry the report states, “In the future, it is likely that the upper limit of the serum TSH euthyroid reference range will be reduced to 2.5 because 95 percent of rigorously screened normal euthyroid volunteers have serum TSH values between 0.4 and 2.5 mU/L”.

What does TSH do?

TSH stimulates a plasma membrane transport system called NIS that allows sodium to be pumped out of the cell and iodine pumped in to the cell. This allows the cell to concentrate iodine 20 to 40 times more than the level found in the plasma. A number of thyroid disruptors, chiefly perchlorate, thiocyanate, bromate and nitrate, compete with iodine for binding to the NIS protein. This competition results in less iodine getting into the follicular thyroid cell and thus less production of thyroid hormones.

Inadequate production of T4 by the thyroid gland.

To produce thyroid hormones, the thyroid gland must have adequate supplies of iodine, protein (chiefly Tyrosine) and several co-factors, including selenium, zinc, Vitamins C, A, E, B12 and alpha-lipoic acid (also known as ALA or Thioctic Acid). The most common limiting factor is Iodine.

Iodine

For over fifty years, iodine deficiency has been known to be the primary cause of hypothyroidism. While most people believe that iodized salt has solved the problem of iodine deficiency in this country, many researchers do not believe this to be the case. For one thing, only about half the population uses iodized salt. For another, many people are on low-salt diets. More importantly, iodization of salt assumes the standard need for iodine to be 150 micrograms per dilution for adults. Compare this to the average ingestion of 13.8 mg Iodine consumed in Japan. Best case, the average American is getting 1 percent of the Iodine as the average Japanese person.

Bromine

A further problem with Iodine is that we are no longer getting Iodine in all our baked goods. Up until the 1980’s, Iodine was added to flour to strengthen the dough and allow for greater rise. So for example, in the 1960’s a slice of bread contained 150 micrograms of Iodine. Since the 1980’s, Iodine has largley been replaced with Bromine. The National Health and Nutrition Survey (NHANES) found that Iodine levels have declined 50% in the United States during the period from 1971 to 2000. Worse, Bromine binds to the same receptor sites as Iodine but Bromine is a carcinogen. Since the breasts, ovaries and prostate (in addition to the thyroid gland) concentrate Iodine or Bromine, this may be at least partially responsible for the increased rates of cancer in these organs since the 1980’s. Fortunately, England and Canada ban the use of Bromate in flour and California lists it as a carcinogen. For this reason, many bakers and millers (such as King Arthur Flour) only use iodated flour.ii

Halogens

Bromine is one of a group of similar chemicals. Iodine, Bromine, Fluorine and Chlorine are collectively known as halogens (Latin for “Salt formers”). These molecules share characteristics that make them able to interact with the same receptor sites in the body. What this means is that in place of Iodine, one of these other molecules can bind to that spot, preventing Iodine from doing it’s job.

Bromine (also bromate or bromide) is not only found in breadstuffs, it is in flame-retardants and thus is found in most furniture fabrics, carpeting, etc. It is used as a fumigant on crops and also a disinfectant in swimming pools. It can also be found in sodas and many prescription items.

Fluoride is added to the water supply and to toothpaste. In addition to interfering with thyroid hormone function, fluoride is implicated in causing rickets, hip fractures, bone cancer and death. Sodium fluoride is used as rat poison.

Chlorine is a widely used disinfectant (also added to our water supply), is in many cleaning products (such as Cloroxtm) and is found in many pesticides and other environmental pollutants. These pollutants are ubiquitous. One study of 5,994 Texans found that 99.5% of those tested had significant levels of organochlorine pesticide (DDE) residues in their blood. An Environmental Working Group study tested cord blood from 10 infants born in US hospitals in 2004. A total of 287 toxic compounds were found, including 147 PCB’s (polychlorinated biphenyls) and 212 chlorinated pesticides. These toxins bio-accumulate in the fat stores of the body, becoming increasingly concentrated with age.

Thiocyanates

Thiocyanate inhibits Iodine uptake into the thyroid by interfering with the NIS. The half-life of thiocyanate is around six days. Brassica family vegetables (broccoli cauliflower) contain thiocyanate. Thiocyanate is reduced by cooking and only about half of it is absorbed in the GI tract. Cigarettes on the other hand are a greater source of thiocyanate. The breast milk of smokers has been found to have four times more thiocyanate than that of non-smokers and half as much Iodine. The take-home message is to avoid smoking and second-hand smoke, and to cook brassica family vegetables.

Nitrates

Nitrates are found in many good foods such as lettuce, beans, squash, beets and carrots. Nitrites are added as a preservative to prepared meats and fish, and nitrate runoff from agriculture is in the water supply. Nitrates also interfere with Iodine uptake by the thyroid but their half-life is about five hours. Cooking also reduces the nitrate content of vegetables. Using a water filter and cooking vegetables can reduce nitrate load. Consuming additional Iodine can counter the effects of thiocyanates and nitrates.

Inadequate conversion of T4 to T3 in the tissues.

As discussed earlier, conversion of T4 to T3 requires a selenium-dependent enzyme called I 5’ deiodinase (Type I). Deficiency of selenium can result in a lack of this enzyme and as a result, a lack of T3 despite normal circulating levels of T4. Besides selenium deficiency, many other substances can block the activity of I 5’ deiodinase, including cigarette smoke, pesticides, plastics, heavy metals and even some foods.

Of the factors listed above, the most important blockers are the heavy metals, mercury, cadmium and arsenic). This is because these heavy metals bind with the enzyme I 5’ deiodinase and prevent it from removing one iodine from the appropriate ring of the Tyrosine-Iodine complex (T4). While healthy foods like tofu and broccoli weakly bind with the enzyme, heavy metals form very tight bonds that are slow to release. The half time of mercury excretion from the body is over two years. That means if you are exposed to mercury today, in two years, half of it will still be in your body. In four years, one quarter of that mercury will still be in your body!

After iodine deficiency, the most important nutrient deficiency is selenium. This is because the enzyme I 5’ deoiodinase is made from selenium. Deficiency can cause a “14-fold decrease” in T4 to T3 conversion.iii Though Selenium deficiency must be severe to cause a deficiency of I 5’ deiodinase,iv insufficient Selenium increases risk of auto-immune thyroiditis because Selenium is needed to make the protective anti-oxidant enzyme glutathione peroxidase.

The next most important group of thyroid disrupters is plastics and pesticides such as DDE, BPA, Dioxin, bromates, etc. These also have a very long life. For example, DDE, a breakdown product of DDT (which was banned in 1972) has been found in samples of breast milk around the world, sometimes at levels exceeding what would be allowed on the market in a commercial milk product. These toxins accumulate in fat stores and concentrate up the food chain, ultimately in animal products that we consume.

There is some evidence that elevated levels of the stress hormone cortisol and also of insulin can inhibit the conversion of T4 to T3.v

Auto-immune destruction of the thyroid gland or its hormones.

Hypothyroidism is frequently the result of auto-immune destruction of the thyroid gland or it’s products. The auto-immune diseases of the thyroid are Grave’s disease and Hashimoto’s thyroiditis. The lab tests to detect and monitor these conditions are anti-thyroglobin antibodies and antimicrosomal antibodies.

What are the symptoms of hypothyroidism?

Since thyroid hormone is necessary to make energy, the primary symptoms are fatigue and cold. However, thyroid hormones have many other direct effects and also affect activity of other hormones.

I created a symptom survey to use with my patients. The way I use this survey is to total the answers in the “Yes” column. A total score over 10 is suggestive of hypothyroidism. Count the number of “Yes” answers. A number greater than 10 suggests further investigation is warranted.

I am tired much of the time Yes No
I often have headaches in the morning that wear off during the day Yes No
My skin is dry Yes No
My hair is thin Yes No
I feel stiff and achy in the morning Yes No
I waer socks to bed to keep my feet warm Yes No
I use moisturizing lotion on my arms, legs or body Yes No
I have difficulty losing weight or avoiding weight gain Yes No
I tend towards constipation (less than one bowel movement a day) Yes No
My fingernails are brittle Yes No
I am not very interested in sex Yes No
My hair seems thin and breaks easily Yes No
I feel depressed Yes No
I have difficulty thinking quickly Yes No
My reaction time seems slow Yes No
Moderate exercise makes me short of breath Yes No
I feel achy and stiff unless I exercise or take a hot shower or bath Yes No
My skin feels puffy or swollen Yes No
I feel best with more than 8 hours of sleep per night Yes No
I feel heart palpitations or have been told I have mitral vale prolapse Yes No
I have to urinate frequently (more than 6 times per day) Yes No
I have difficulty remembering things Yes No
The outer third of my eyebrows has thinned or disappeared Yes No
My pulse rate is below 65 even though I don’t exercise extensively Yes No
I feel sleepy during the day Yes No
I need coffee, cola or tea to think clearly in the morning Yes No
My feet and ankles appear puffy or swollen Yes No
My knees lock when I stand (rather than being slightly flexed) Yes No
I feel light-headed if I stand up too quickly Yes No
I am double jointed (such as bend my thumb back towards my wrist or do the splits) Yes No
(Men only) I have difficulty achieving or maintaining an erection Yes No
(Women only) I have very painful menstrual cramps Yes No

Beyond symptoms, how do we test for it?

Blood work

The most commonly used test is Thyroid Stimulating Hormone or TSH. This test measures the amount of TSH produced by your pituitary gland because presumably, the pituitary knows how much thyroid hormone you need. Doctors use this test to determine the correct dose of thyroid hormone to prescribe. If the TSH is high, this means that your pituitary is trying to raise your thyroid hormone production. If it is low, this means the pituitary is trying to reduce the amount of thyroid hormone production. As noted above, the ideal range of TSH is around .4 to 3.0 (not the upper limit of 4.5 recommended by most labs). In fact, for women wishing to become pregnant, a TSH greater than 2.5 is associated with implantation failure and early pregnancy loss.vi,vii

Most medical doctors begin by ordering a TSH. If that is normal, they generally look no further because the indication for prescribing replacement hormone is a high TSH. If the TSH is high (indicating that the pituitary thinks that thyroid hormone levels are low), then the doctor will likely order a T4 test next.

A more comprehensive panel may include; Free T4, Free T3, Thyroid Binding Globulin (TBG) and reverse T3 ( rT3). This gives a much fuller picture of where the dysfunction exists. Remember, T4 is the transport form of the hormone while T3 is the active form. While they are each bound to globulin (protein) they are not metabolically available. That’s why testing Free T4 and Free T3 gives a picture of the levels of hormone actually interacting with cells. Even this picture can be misleading because some of the T3 may be the inactive, reverse T3 (rT3) form because the deiodinase enzyme was disrupted by exposure to heavy metals, plastics or other pollutants. If rT3 is elevated, hair Mercury levels (Doctors Data) and serum GSH are additional tests that may be employed.

If auto-immune thyroid disease is suspected, these additional tests may be ordered;

Anti-Thyroperoxidase (TPO) Antibodies, TSH receptor antibodies (TRAb) and antithyrogobulin antibodies (Tg). particularly if the patient has hypothyroid symptoms despite normal TSH, Free T4 and T3 tests.

Physical exam

  • The single most distinguishing sign of advanced hypothyroidism is thinning or loss of the lateral third of the eyebrows. This can advance to the point that only the medial third of the eyebrow remains.
  • Thinning of head hair, both in terms of the number of hairs and the thickness of each individual hair is another strong indication.
  • Dry skin is most readily seen on the calves and forearms, though frequently, the earliest indicator is dry, cracked heels.
  • Obesity is another possible indicator, particularly if accompanied by fluid swelling in the feet and legs.
  • Ligamentous laxity is another sign. You can test the tone of the ligaments by asking the patient to bend their thumb backwards or touch their palms to the floor.
  • When testing reflexes, you may note slow reflexes in hypothyroid individuals.
  • Low blood pressure is another sign. This can be felt in the pulse but can be quantified with a blood pressure cuff. A further test is to take blood pressure lying down, then standing. In a normal person, the blood pressure will not fall when rising from a lying to standing position and may in fact rise 5 mm Hg. In someone with adrenal fatigue/hypothyroidism/poor sympathetic tone (or a number of other medical conditions) the blood pressure will drop when rising to a standing position. A systolic drop of 20 points or a diastolic drop of 10 points is defined as orthostatic hypotension.viii (A drop of 20 points may indicate Cushing’s Syndrome (excessive cortisol production). Additional signs associated with Cushings Syndrome include a round or “moon” face, fat deposited above the collarbone and in the upper back “dowager’s hump”, dark pigmentation in the creases of the hands, purple stretch marks, obesity in the trunk but muscle loss in the arms and legs).ix
  • Heart palpitations. More than two “skipped beats” per minute is abnormal and may be due to hypothyroidism.
  • Multiple areas of point tenderness. Hypothyroidism is essentially the same as chronic fatigue syndrome and fibromyalgia.x

Basal Temperature

By far the most important test of all is to take your temperature every morning when you wake up and write down the number. Do this every morning for at least a week.

Normal temperature is 98.6 degrees. The range of normal is a full degree plus or minus 98.6. If the your temperature is consistently below 97.6, a hypo-metabolic condition is present. After a few days or weeks of intervention, this test can be repeated to get an indication of whether or not the treatment is working.

This test is cheap, effective and empowers you to track your progress. The importance of this test is that, regardless of blood test results to the contrary, if the temperature is low, the metabolism is low. An analogy I use is that, “You can measure the gas or oil in your car but if the engine is cold, it isn’t running”. If the temperature is low and you don’t feel good, keep looking until you find the problem.

(In the 1970’s, the basal temperature test was popularized by Broda Barnes MD, whose books, “Hypothyroidism – the Unsuspected Illness” and “The Riddle of Heart Attacks Solved” posited that as much as 40% of the US population was suffering from hypothyroidism and that cardiovascular disease, including high cholesterol is a result of hypothyroidism.)

Differential nutritional diagnosis

To treat the hypothyroidism nutritionally, we need to understand thyroid hormone deficiency from a biochemical point of view. That understanding allows us to diagnose and intervene in a more holistic way. The main nutritional interventions are to screen for and treat iodine deficiency and/or halogen excess, to screen for and treat problems with conversion of T4 to T3, chiefly heavy metal intoxication, and to screen for and treat organochlorine toxicity. We should also determine if the hypothyroidism is due to auto-immune thyroid disease such as Grave’s or Hashimoto’s.

Iodine deficiency/Halogen excess

Iodine deficiency can be screened using hair or whole blood trace-mineral analysis. These are also useful tests to screen for selenium and zinc deficiency as well as toxic amounts of mercury, arsenic, cadmium and lead. A more specific test for Iodine deficiency and halogen excess is the Urine Halides test. In this test (available through Doctor’s Data in Chicago), patients take 50 mg of Iodine by mouth, then collect their urine for 24 hours and send a sample to the lab. This test assumes that if the patient has all the Iodine needed, he or she will excrete 90% of the ingested Iodine in the urine. Greater percentages of iodine retained by the body suggest greater levels of Iodine deficiency.

T4 to T3 conversion

If T4 is not being converted to T3 by Type I or II deiodinases, Type III deiodinase will convert T4 to reverse T3 (rT3). A blood test for rT3 can be ordered from many labs.

Remember, converting T4 to T3 requires a selenium-dependent enzyme (Type II or II deiodinase). Tissue samples (hair or blood) can be examined by atomic absorption mass spectrometry to determine levels of normal nutrients such as selenium and also toxic elements such as mercury. These tests are also performed by Doctor’s Data. You can order test kits by calling 800-323-2784.

GSH

An indirect way to measure the level of organochlorine burden (from pesticides, plastics, flame retardants, etc.) is to measure GSH (Glutathione). GSH is the most abundant and most important intracellular antioxidant. GSH is involved in the detoxification of heavy metals, toxic halides and organochlorines. A low level of GSH implicates a high body burden of these toxins and predicts a difficult detoxification process. Doctor’s Data offers a blood test to accurately assess GSH levels. If levels are found to be low, supplementation with whey protein, alpha lipoic acid, curcumin, magnesium and N-Acetyl Cysteine (NAC) have been found to effectively increase GSH levels.

Supplementation and detoxification

In addition to drinking more water, consuming more fiber, getting aerobic exercise and taking the GSH supporting nutrients listed above, there are other nutritional interventions that may help protect and repair your thyroid funciton.

Iodine

If Iodine levels are sub-optimal and other halides are high, the best treatment is to supplement with Iodine, either as tablets or as Lugol’s Solution. Lugol’s is potassium iodide in water. It was first compounded in 1829 and has been used as an antibiotic and disinfectant ever since. One drop of 5% Lugol’s Solution contains about 6.25 mg of Iodine. It is available over the counter in Canada and Mexico or online. Tablets equivalent to two drops of Lugol’s Solution are available under the trade name Iodoraltm. Dr David Brownstein MD uses between one and four tablets of Iodoral with his patients, dosed according to results of the Urine Halides test. I never use more than one per day.

Many people consume seaweeds (nori, kelp, hijiki, wakame) to get Iodine. These are available in Japanese restaurants, grocery stores and as powdered supplements. Seaweeds are a source of Iodine and other nutrients, including compounds that aid in detoxification. Unfortunately, they also contain Bromine. For that reason, I don’t recommend them as a treatment or preventative for hypothyroidism.

Unrefined salt such as sea salt is also helpful in eliminating toxic halides. Salt is mostly Sodium Chloride. The chloride portion can displace other toxic Chlorine compounds in the body. Sea salt contains all 72 minerals found in the sea and in your bloodstream in roughly the same proportions as are found in your blood. Traditional Asian foods that utilize sea salt are Miso and Tamari. These foods are made by combining beans, grains and sea salt in a jar and allowing them to ferment. The fermentation process forms complexes of the salts with the proteins of the beans and grains. Excess salt can cause high blood pressure, so again, I don’t think salt is as good as taking Iodine. With both salt and seaweeds, use them to taste, not as a medicine.

Heavy metal detox

Similar to the way halides like Bromine bind to receptors meant for Iodine, the heavy metals, Mercury, Arsenic and Cadmium bind to receptors meant for Selenium and Zinc. Raising levels of Selenium and Zinc helps to displace heavy metals. GSH precursors like whey protein and alpha lipoic acid can allow metal detoxification with minimal side effects.

Supportive strategies include increasing dietary fiber, exercise, drinking water and sweating. Increasing dietary fiber traps toxins excreted by the liver through the bile. Exercise mobilizes fats, increasing turnover and release of stored toxins. Water dilutes toxins, facilitating elimination through the kidneys and skin. Sweating is a great way to eliminate toxins. Many holistic practitioners use far infrared saunas and other means to increase sweating.

Caffeine and Caffeine Substitutes.

As noted earlier, caffeine acts in a manner similar to thyroid hormone. Many undiagnosed hypometabolic people depend on coffee to wake up and do their work. In a perfect world, they might instead get 8 hours of sleep or reduce their stress, though I understand that is very unlikely to happen. I suggest that we think of coffee as a drug to palliate the effects of high stress and not enough sleep. Like all drugs, coffee has it’s side effects. Many people rely on coffee, caffeinated soft drinks, etc. to get through their day. If you need caffeine, I recommend green tea or chocolate instead of coffee or colas. Also, for people with intact thyroid glands that are just not performing up to par, the less we rely on taking thyroid hormone substitutes like caffeine, the less we are asking our thyroid glands to do on their own. Your thyroid will produce less thyroxine if you are drinking coffee or colas. This is not to say that anyone should quit drinking coffee suddenly. I am only suggesting that we take the lowest effective dose to maintain healthy function and that we choose the stimulant with the least side effects.

Green Tea

Other strategies include using chlorophyll and foods that contain chlorophyll to increase excretion of fat-soluble toxins in the feces. Additionally, polyphenols in white and green tea have been shown to increase the excretion of fecal fat, carrying those toxins out of the body. Green tea has a long history of safe use in Asian cuisine and medicine. In addition to helping to excrete toxins, the caffeine in tea acts like T3. This is because caffeine increases the circulating levels of the catacholamines epinephrine and norepinephrine and increases their intracellular effects. The intracellular effect occurs because caffeine inhibits the intracellular enzyme (phosphodiesterase) that inactivates cAMP (cyclic adenosine monophosphate). Less inhibition means less breakdown of cAMP. The resulting increase in cAMP prolongs the effects of catacholamines.

This means tea can be a helpful transition to a healthy metabolic state. You can use green tea to help you feel better while working to improve your thyroid function. However, any form of caffeine, including chocolate, can lose its beneficial functions when used regularly because the body adapts and becomes dependent. For that reason, I suggest only using caffeine as needed.

Green tea raises metabolic rate in an amount greater than can be attributed to its caffeine content. This may be due to the epigallocatechin gallate found in green tea. That compound plus theoflavins in green tea are thought to be responsible for reported anti-cancer effects.

Green or white tea is a far better source of caffeine than coffee for a variety of reasons. For one, the caffeine in tea is bound in a double molecule that has to disassociate before it can interact with your body. This makes the caffeine in green tea hit your system in a time-released manner compared to coffee. Coffee is not bound as a double molecule. Furthermore, coffee has a number of additional compounds that cause other health problems, everything from bladder irritation to irregular heartbeats.

Chocolate

Chocolate is in my opinion, even better. While the caffeine in coffee reaches peak levels in 30-60 and has a half-life of 2.5 to 5 hours, the half life of theobromine (the caffeine like substance in chocolate) reaches peak levels in 2-3 hours and has a half life of 7-12 hours. This is in part because it is fat-soluble rather than water soluble like coffee. Chocolate is also about a tenth as potent as coffee.

Additionally, very dark chocolate has many health benefits. A Canadian study of 44,500 people found that those who ate one serving of chocolate per week were 22% less likely to have a stroke than people who ate none.xi Even eating up to 100 grams of chocolate per day is linked to a lower risk of heart disease and stroke.xii Also, consuming chocolate also improves athletic performance in cyclists, probably due to the flavenoids in chocolate that enhance the release of nitric oxide in the blood vessels.xiii Nitric oxide dilates blood vessels and reduces oxidative damage in the blood vessels.

Prevention

Avoiding tobacco smoke, using a water filter for all drinking and cooking water, using only organic fruits, vegetables and grains wherever possible, using iodinated bakery products can help prevent ingestion of thyroid disruptors. Goitrogenic foods should be eaten with moderation. These include soy, flax, kale, canola oil, and raw cruciferous vegetables such as broccoli, bok choy, cauliflower, cabbage, brussels sprouts, mustard greens and others. The cruciferous vegetables are healthy foods but should be eaten cooked rather than raw. Ground flax seed can be very effective in lowering your serum choleterol and reducing the risk of hormone dependent cancers, but I wouldn’t recommend more than 1 TBS per day. There is no reason to consume Canola oil other than it is added to so many prepared foods and is thus very hard to avoid. Additional measures include avoiding toxic chemicals like cleaning products and pesticides and using a sauna or exercise to increase sweating.

Acupuncture and Chinese herbs

Acupuncture is known to normalize neurotransmitters, cytokines, hormones and thus most bodily functions.xiv Traditional Chinese methods of point selection customized according to patient syndrome are the best guide in this regard. Moxa (a hot coal of Artemesia Vulgaris) is traditionally applied near REN4-6, ST36, SP6 and on the back at UB23 and GV4, with additional points added based on syndrome differentiation.

Many tonic formulas raise metabolic activity. In traditional Chinese medicine, symptoms and signs are the basis for prescribing, not lab tests. My favorite formula for hypometabolism (thyroid and/or adrenal insufficiency) is Ginseng and Astragalus (Bu Zhong Yi Chi Tang). It was traditionally used for weakness and fatigue after an illness.xv One of it’s indications is faintness upon rising from a recumbant or sitting position (blood pressure drop). The Astragalus in this formula also provides a lot of Selenium. Glutathione Peroxidase is a Selenium dependent enzyme that protects the thyroid gland from oxidative damage, reducing the risk of auto-immune thyroid disease. The whole formula is as follows:

Huang Qi (Radix Astragali)

Zhi Gan Cao (Radix and Rhizoma Glycyrrhizae Prep)

Bai Zhu (Rhizoma Atractylodis Macro)

Ren Shen (Radix and Rhizoma Ginseng)

Dang Gui (Radix Angelica Sinensis)

Chen Pi (Pericarpium Citri Reticulatae)

Sheng Ma (Rhizoma Cimicifugae)

Chai Hu (Radix Buplerui)

Shen Jiang (Rhizoma Zingiberis Recens)

Da Zhao (Fructus Jujubae)

The licorice (Glycyrrhizae) in this formula slows the breakdown of cortisol, delaying the onset of fatigue.

From a Chinese medicine perspective, thyroid hormone insufficiency is functionally equivalent to Chi Xu (energy deficiency) and Yang Xu (heat deficiency) with further diferentiation possible according to affected organ systems, i.e., Spleen Qi Xu would include digestive symptoms such as bloating, loose stools, hemorroids, poor appetite/craving for sweets in addition to the other symptoms associated with hypothyroidism.

Summary

The best way to get started is to take the symptom survey above and if your score suggests a problem, start measuring your basal temperature. If your temperature is consistently below 97.6, schedule a meeting with your doctor and bring the results of your basal temperature and symptom survey. You can then discuss whether lab testing would be appropriate.

In terms of labs, a TSH is helpful, but a panel including TSH, T4, T3, rT3, would give a fuller picture. If rT3 is elevated, consider the Hair Mineral Analysis (includes heavy metals) and Urine Iodine tests, both from Doctor’s Data. Adding GSH to the blood testing would quantify the ability of the body to deal with toxic load. Auto antibody tests could be added if auto-immune thyroid disease is suspected.

Nutritional treatment strategies including hair sample testing for deficiency of Iodine, Selenium, and Zinc, as well s testing for excess of the heavy metals Mercury, Arsenic and Cadmium. Iodine sufficiency can be tested more reliably with a provoked urine test. If mineral deficiencies are noted, supplementation can then be taken with re-testing six to twelve months later.

If heavy metals were found or if GSH blood levels were found to be low, detoxification with water, fiber, supplementation with whey protein, alpha lipoic acid, curcumin, magnesium and N-Acetyl Cysteine (NAC) may be helpful.

In all cases, mild aerobic exercise is recommended, starting slow and building up gradually. If you feel exhausted the day after exercise, you did too much. Cut your exercise level to the point that you feel better the next day, but by all means, don’t stop exercising.

Small amounts of coffee, tea or chocolate may be needed to get you through your day while your thyroid is getting stronger, but the ultimate goal is to minimize dependency. Chinese herbs may also provide a bridge to wellness, but again should not be used long term.

Getting 8 hours of sleep will cure many people of mild hypothyroidism.

If you are reasonably healthy and want to raise your metabolic rate, exposure to cold can be helpful. Like exercise, this has to be started slow and increased slowly.

Continue measuring your temperature and pulse rate to evaluate your progress. The goal is to get your temperature to 98.6 when you awake in the morning, without raising your pulse rate above 72 bmp. You will be able to track the effects of any changes you make in your daily routine, sleep, exercise, caffeine, supplements, etc. My goal in writing this article is to empower you to do the things you can do and assist your doctor in helping you to recover.

Best,

David Wells, D.C., L.Ac. MS (Nutrition).

 

 

 

 

 

ihttps://www.thyroid.org/media-main/press-room/

iihttps://www.kingarthurflour.com/professional/bromate.html

iiihttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC1148561/

ivhttps://www.ncbi.nlm.nih.gov/pubmed/10875250

vhttps://www.ncbi.nlm.nih.gov/pubmed/2838733

vi Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum.

Stagnaro-Green A, Abalovich M, Alexander E, Azizi F, Mestman J, Negro R, Nixon A, Pearce EN, Soldin OP, Sullivan S, Wiersinga W, American Thyroid Association Taskforce on Thyroid Disease During Pregnancy and P ostpartum.

Thyroid. 2011 Oct; 21(10):1081-125.

vii Subclinical hypothyroidism and pregnancy outcomes.

Casey BM, Dashe JS, Wells CE, McIntire DD, Byrd W, Leveno KJ, Cunningham FG

Obstet Gynecol. 2005 Feb; 105(2):239-45.

viiihttps://www.aafp.org/afp/2011/0901/p527.html

ixhttps://www.niddk.nih.gov/health-information/endocrine-diseases/cushings-syndrome

xMetabolic Treatment of Fibromyalgia John Lowe, D.C. 2000

xihttps://www.aan.com/PressRoom/Home/PressRelease/799

xiihttps://heart.bmj.com/content/101/16/1279

xiiihttps://jissn.biomedcentral.com/articles/10.1186/s12970-015-0106-7

xivhttps://www.evidencebasedacupuncture.org/present-research/acupuncture-scientific-evidence/

xvhttp://www.acupuncture.com/herbs/buzhongyi.htm

Aerobics

Aerobic Exercise

The most exercise common mistake I see in my clinic is people who try too hard to lose weight through exercise. Most people know that aerobic exercise is the best way to lose weight. Unfortunately, many people think that if they push harder, they will lose weight faster. This is not the case. The “aer” in Aerobic refers to “air”. To exercise aerobically is to exercise at a pace that allows air to reach the muscles. For instance, if while you are exercising, you can talk without huffing and puffing, you are exercising aerobically. You know this because you have more than enough air to perform the activity. When you are gasping and panting, you are exercising anaerobically, or “without air”.

How does aerobic exercise help lose weight?
Fat burns in the presence of oxygen. Fat and oxygen together burn slowly, steadily and cleanly. An example of fat burning is a candle. With the right mixture of fat and oxygen, a candle can burn slowly and steadily for many hours without smoke. By contrast, paper (a carbohydrate) burns hotter, faster, and produces smoke and ash (byproducts of incomplete combustion).

When the demand for energy exceeds your oxygen supply, your body burns carbohydrate instead or in addition to fat. Burning carbohydrate produces a waste product called lactic acid (The waste product is like the smoke from burning paper). This acid is what makes your muscles “burn” during intense exercise. Lactic acid is also what makes your muscles feels sore and achy the day after intense exercise. Burning carbohydrate can also make you feel light-headed, exhausted and hungry after a workout. An aerobic workout like a brisk walk, is apt to make you feel invigorated and refreshed. You may be hungrier later, but immediately after the walk you are likely to feel energized by the increase in your metabolism.

Fat is a very efficient fuel. You can run a marathon on a half pound of fat. So how are you going to shed all those pounds by going for a half-hour walk each day? The beauty of aerobic exercise is that once you get your metabolism going, you will continue burning fat at an accelerated rate for the next 24 hours. You will burn extra fat while you sit, move, eat or sleep on the days you do aerobic exercise.

How hard should I exercise?

The simplest measure of intensity is to observe your breathing. If you are able to carry on a conversation while exercising, you are in your aerobic zone. If you are getting out of breath and your muscles are burning, you are moving out of your aerobic zone and into anaerobic territory. This method of evaluation is called “perceived exertion”. Frankly, if you’re not a competitive athlete, this is good enough.

How fast should my heart beat while doing aerobic exercise?

The following recommendation comes from the fact that for most people, your maximum heart rate equals 220 minus your age in years. So if your age is 20, then 220 – 20 = 200 beats per minute. If you are 70 years old, then 220 – 70 = 150 bpm. Remember, that’s maximum heart rate. Your training rate should between 50% and 85% of your maximum rate. So again, if you are 20 years old, your training rate will be between 100 and 170 beats per minute. To see your training rate (as endorsed by the American Heart Association), enter your age in the calculator below:

 

What if I’m new to aerobic exercise?

The American Heart Association recommends that you begin exercising at the low end of the training rate for your age. Use the Perceived Exertion Method to determine if you are exercising too hard or not hard enough. If you are getting light-headed, out of breath or feeling burning in your muscles, slow down. If it feels too easy, speed up. The only right intensity is what works for you. If you have a heart condition or are uncertain of the status of your heart, check with your physician before beginning any new exercise program. Also, if you are on blood pressure medications, your training rate will be lower.

How fast should my heart beat at rest?

For anyone over the age of 10, the normal range according to the American Heart Association is 60 to 100 beats per minute (the average is 72 beats per minute). Trained athletes normally have lower heart rates, typically in the range of 40 to 60  beats per minute. Tour de France winner, Miguel Indurain had a resting rate of 28 beats per minute.

Despite the American Heart Association guideline above, I recommend that your resting heart rate should not exceed 65 beats per minute. Why? Because studies have shown that there is a 10 – 20% rise in death rate for every 10 beats per minute over 65 bpm.(1) That same meta analysis found that “men with resting heart rates of over 90 beats per minute had an almost two-fold increase in risk for cardiovascular disease mortality; in women it was associated with a three-fold increase.”

One study of men with no evidence of heart disease but with a resting heart rate of more than 90 beats per minute had five times greater risk of sudden cardiac death.(2)

What if my resting pulse rate is abnormal?

First of all, check with your physician to find out why. In the meantime, let me provide a little information on possible reasons; Low pulse rate in non-athletes occurs in hypothyroidism, high blood pressure, weakness of the heart, inflammatory and autoimmune conditions and as the result of some medications. Low pulse rate in the elderly may be a sign of heart failure, particularly if it occurs in association with fainting, fatigue, cognitive issues and light-headedness. Coenzyme Q10 may be helpful for age-related slow heart rate because CoQ10 strengthens heart muscle by improving cellular utilization of oxygen. Note that statin drugs decrease production of CoQ10. For more on that, read my article on Cardiovascular and Metabolic Disease.

High pulse rate occurs in fever and hyperthyroidism.  I have seen pulse rates over 120 beats per minute at rest in acute hyperthyroidism. Rapid pulse rate can also occur as a result of lack of oxygen to the heart due to heart failure, atherosclerosis, pneumonia or other infections. Stress can raise heart rate temporarily, but it should not remain high for long.

Irregular heart rate can be caused by heart valve conditions such as mitral valve prolapse, over consumption of caffeine or prolonged stress, or imbalances in electrolytes (the minerals sodium, potassium, calcium and magnesium). Most Americans consume too much calcium and sodium, and not enough magnesium and potassium. The DASH diet recommended by the American Heart Association is designed to provide normal levels of electrolytes.

If your heart is beating too slow, too fast or irregularly, check with your primary care physician. When our hearts stop, so do we.

How do I measure my heart rate?

The best way to learn to measure your heart rate manually is to place two fingers on your opposite wrist, palm up, on the thumb side of the wrist. Alternately, you can place your fingers in the groove in the front of your throat, next to your windpipe. Feel for the pulse. When you are comfortable that you have found it, count while looking at the second hand of a clock so you can count all the beats in a full minute. With a little practice, try counting for 30 seconds and multiply by 2, or count for 15 seconds and multiply by 4. Ultimately, you will want to be able to get a good estimate by measuring for 6 seconds and multiplying by 10. To measure more conveniently, get a pulse measuring wristband or watch.

How long should I exercise?
A minimum of 20 minutes at your ideal pulse rate is sufficient to obtain the aerobic effect of burning calories at a higher rate for the next 24 hours. The longer you exercise, the more calories you burn but the most important factor is to exercise at least those 20 minutes every day. Be aware that it will very likely take you a little time to warm up to that heart rate and also to cool down with a milder version of your exercise. Therefor, it is best to allow at 30 minutes to do your daily minimum. You can always do more than the minimum to lose fat faster. Bear in mind that fitness is lost if you exercise 2 days or less per week. Fitness is maintained at 3 days per week and improved at 6 days a week.

What kind of exercise?
Walking, swimming, cycling, jogging, skating, skiing, jumping rope, rowing, running in place or on a trampoline, dancing or hiking are all good exercises because they require continuous, steady effort. Activities such as tennis, baseball or golf should be considered recreation rather than aerobic exercise because the effort is intermittent, characterized by bursts of anaerobic activity interspersed with periods of rest.

How do I know if I’m getting stronger?
The best way to measure your cardiovascular fitness is to monitor your pulse recovery rate. The way to do this is to take a six-second pulse immediately when you finish exercising and again exactly one minute later. The faster your heart is able to slow down after exercise, the greater your cardiac fitness. The formula to determine your recovery rate is to subtract your one-minute pulse from your end of exercise pulse and divide the result by 10. For example; if your heart rate as you finish exercising is 140 and your pulse one minute later is 100, 140 minus 100 = 40 divided by 10 = a recovery rate of 4. How does 4 rate? The following chart can be used as a guide:

Less than 2 Poor
2-3 Fair
3-4 Good
4-6 Excellent
More than 6 Super!

How do I know if I’m losing fat?
Muscle weighs more than fat, so the scale won’t tell you the full story. As you exercise, you increase your muscle mass. The more muscle you have, the more places you have to burn fat. You will know that you are losing fat by the way your clothes fit. If your waist is getting smaller, you are losing fat. To learn more about this read Take Charge of Your Waistline.

Conclusion:
Even if you don’t learn to measure your six-second pulse and you don’t care about your cardiac recovery rate, just get out and do at least 20 minutes a day of vigorous walking. If you can carry on a conversation, you have enough air. The benefits of exercise are tremendous. You will be feeling and looking better soon.

 

(1) The association between resting heart rate, cardiovascular disease and mortality: evidence from 112,680 men and women in 12 cohorts”. European Journal of Preventive Cardiology. 21 (6): 719–726.

(2)  Resting heart rate and risk of sudden cardiac death in the general population: influence of left ventricular systolic dysfunction and heart rate-modulating drugs”. Heart Rhythm: The Official Journal of the Heart Rhythm Society. 10 (8): 1153–1158

Take Charge of your Waistline

Measuring your waistline is a lot easier and cheaper to do (not to mention less painful) than getting your cholesterol tested, but it reveals much the same information. As a consumer of health care, I’ve always wanted to have simple, do it at home tests and treatments for health conditions. Here is one I want to share with you.

As an absolute measure, the waistline for women should not exceed 35 inches. For men, the upper limit is 40 inches. Why is that? The Nurses Health Study was one of the largest and longest studies that looked at the relationship between waist size and death from heart disease in middle aged women. This 16 year study of 44,000 women found that women with waist sizes of 35 inches or higher had nearly double the risk of dying from heart disease compared to women who reported the lowest waist sizes (28 inches or less). Double.i

Furthermore, women with the largest waists had a similarly high risk of death from cancer and from any cause compared to women with the smallest waists. The risks increased steadily with every added inch around the waist.

Having normal weight and a large waistline doesn’t help. In fact, normal weight women with a waist of 35 inches or higher had three times the risk of death from heart disease compared to normal weight women whose waists were smaller than 35 inches. Triple.

As long as you have your tape measure out, let’s talk about waist to hip ratio. If you measure your waist and your hips, you can compare the numbers and come up with your waist to hip ratio.

Waist/Hip Ratio

The World Health Organization states that abdominal obesity is defined as a waist to hip ratio above .90 for males and above .85 for females. The gender difference is because women normally have larger hips than men.

The ratio is: Waist in inches divided by Hips in inches.

As an example, a woman with a 28 inch waist and 36 inch hips would have a ratio of 28/36 = .77 (well below .85). As you can imagine, she would be considered attractive. This is because we are wired to see that fertility and better health outcomes are expected with a healthy waist to hip ratio. If a larger woman had measurements of a 32 inch waist and 44 inch hips, the ratio would be 32/44 = .72  (an even better ratio). As you can see, a ratio accounts for various sized people. It’s only when the ratio approaches equal, or that the waist is larger than the hips that we get into trouble. In the first example above, suppose the woman with the 36 inch hips gained weight to where her waist was 34 inches and her hips were 37 inches. 34/37 = .92 (This is above the safe limit of .85).

 

Despite the angst many women feel about having large hips, they represent no adverse health outcomes. Hips (under the influence of progesterone) store water and fat because childbirth and nursing require a lot of both. Big hips aren’t a problem for your health and in most cultures are considered sexy (for good reason because again, they signal fertility).

After smoking, abdominal obesity is the single greatest modifiable risk factor for all the major killer diseases of modern times. Most premature deaths are related to metabolic syndrome. Waist measurement and waist to hip ratio are the easiest ways to monitor these risks.

So how do we measure?

You will need a cloth tape measure (Metal tape measures just don’t conform well enough to your shape). To measure your waist, slide your hands down your sides to reach your last rib. This should be the narrowest part of your waist. Note that this is above the level of your navel, not at the waistline of your jeans. Wrap the tape around at this circumference and take your measurement.

To measure your hips, find the bones at the sides of your hips and wrap the tape around at that level. Keeping the tape level will include much of the muscular part of your butt. The fattier part of your butt (if you have that) will be below this level.

The fact that you will always use bony landmarks to measure yourself means that your measurements can be consistent over time. I wouldn’t recommend measuring yourself more than once a week as changes happen very slowly. As you can read from the statistics above, these are very important measurements for a long life and good health.

Body Mass Index.

Another commonly used measure is Body Mass Index (BMI). This is the measure used by the government and life insurance companies use to determine whether you are underweight, normal, obese or morbidly obese. The formula compares your height and weight. This method has advantages and disadvantages. A disadvantage is that very muscular individuals like weightlifters are classified as obese using this method, even though they may have very low body fat. They just have more muscle than most people. Not a problem. Muscle is like money in your metabolic bank.

BMI does however have a couple of advantages. One is that it is easy to get the information. The average person usually knows their height and weight. The big advantage though is that it is more accurate for the morbidly obese compared to measuring waist and hips. This is because as individuals get fatter, their abdomen sags below the belt line. To learn your BMI, fill in the fields below:

 

The normal BMI for men and women is between 18.5 and 24.9. If you fall into this range, congratulations – keep up the healthy lifestyle.

If your BMI is below 18.5, you are considered underweight. This is not good. There are increased risks of premature death associated with being underweight. Sometimes underweight is caused by other conditions such as anorexia, malnutrition/malabsorption syndromes, smoking, cancer, lung or gastrointestinal disease. There is such a thing as being too thin.

If your BMI is between 25 and 30, you are considered to be overweight. Health risks increase with increasing weight. A BMI of 25 to 27.5 is associated with a 7% increase in the risk of premature death. A BMI of 27.5 to 30 correlates with a 20% higher risk.

If your BMI is between 30 and 39.5, you are classified as obese. A BMI between 30 and 35 equals a 45% increase in risk of premature death. A BMI of 35 to 40 is associated with a 94% increased risk of premature death!

If your BMI is over 40, you are classified as morbidly obese. BMI in the range of 40 to 60 equals a nearly three fold increase in the risk of premature death.ii

Body Composition

Perhaps the best measure of fitness is found by looking at the ratio between your weight and your waistline. This is particularly important for people who begin exercising and find that though their “clothes fit better”, they haven’t lost much if any weight. The reason this frequently happens is because muscle weighs more than fat. If exercise helps you to gain muscle while losing fat, your weight on the bathroom scale will not reflect your fat loss. This can be discouraging.

The most important measure of fat loss is reduction in waistline. Muscle gain will be reflected in increases in the chest, arms, back, butt and legs – not in the waist. In fact, increasing muscle tone in the abdomen will make the waist a little smaller. You can measure the girth of your arms and legs to track specific increases in muscle size if you are a bodybuilder, but for most of us, the simplest measure is overall weight compared to waistline. That way, we can know our percentage of body fat and our percentage of lean mass.  Let’s try this out;

 

Most people rely on the bathroom scale to measure success in getting to a healthy weight. This can be dangerous. If you lose weight without reducing your waistline, you are losing muscle mass. Muscle is what burns fat. The less muscle you have, the less fat you burn. This is why people who go on starvation diets generally end up fatter than they started once they start eating normally. Their burn rate has decreased.

I suggest you enter a target weight (such as from when you felt your best or from the BMI calculator) into the Body Composition calculator above and see what that does to your body fat percent. Then enter progressively lower waistlines until you get to a healthy percentage of body fat. The calculator will show you how much muscle you have to gain and how much fat you have to lose. Remember, your target waistline is the most important part of this equation. This knowledge can help you to plan a good diet and exercise program and also help you to track how well you are reaching your goals.

So what is a good level of  body fat? The answer is different for men and women. The following ranges are suggested by the American Council on Fitness.

First, there is an essential amount of body fat, without which your body would not function well. For men, that amount is between 2 and 5%. For women, it is between 10 to 13%.

Competitive athletes aim for a body fat range of 6 – 13% in men and 14 – 20% for women.

Fit individuals range from 14 – 17% body fat in men and 21 – 24% in women.

The average persons body fat  ranges from 18 – 24% in men and 25 – 31% in women.

Obese men have greater than 25% body fat and obese women have greater than 32% body fat.

Some authorities suggest that the percentage of body fat normally goes up as we age. I’m sure it does, just as surely as tree rings add girth to trees with every passing year, but I don’t know that it’s helpful. Every extra pound of fat adds 3 to 7 miles of blood vessels that our hearts have to push against. That can’t be good.

Come back to this site as often as you like to track your progress. Changing your body composition is challenging. All of us at Wells Chiropractic wish you the best in achieving your health goals.

David Wells, D.C., L.Ac., MS (Nutrition)

i Zhang C, Rexrode KM, van Dam RM, Li TY, Hu FB. Abdominal obesity and the risk of all-cause, cardiovascular, and cancer mortality: sixteen years of follow-up in US women.

ii  https://www.hsph.harvard.edu/news/press-releases/overweight-obesity-mortality-risk/

 

A New Theory of Acupuncture

Why Are Acupuncture Points Located Where They Are?

Patient’s often ask, “Why are you needling my hand when the problem is in my sinuses, or needling my foot to treat tooth pain? Why are the points always somewhere other than where my problem is?” The quick answer is that these are the most effective points for that condition. A slightly longer explanation might include that acupuncturists have been refining and passing on this knowledge for over two thousand years.

None of these responses answer the question of why the points are where they are. Sure, you can say, “That’s where the meridian is”, but then why is the meridian there and not somewhere else? Every acupuncturist knows that the classic points are by no means all of the possible points, and that just because the knowledge was codified over two thousand years ago doesn’t mean that no more knowledge is possible.

Historical roots

The Nei Jing is the foundational book of Chinese Medicine. Scholars generally agree that the written work is dated to somewhere in the late Warring States Period (475 – 221 BC) and the Han dynasty BCE 220 to CE). The Nei Jing consists of of two parts, the Suwen and the Ling Shu. The format of the Nei Jing is a conversation between the semi mythical  Yellow Emperor, Huang Di (黃帝) and his court physician, Chi Bo. Though there were no surviving written records from the time of the Yellow Emperor, oral tradition suggests that he lived approximately 2,600 years ago. Due to the Chinese cultural reverence for ancestors and their high regard for the Nei Jing, later authors and innovators in Chinese medicine generally describe their discoveries as commentary on the Nei Jing, rather than taking a fresh look at the underlying theories.

Not being content with re-interpreting the classics, I (with the help of my son Michael) have developed a theory that integrates classical acupuncture knowledge with modern science, particularly embryology. This has helped us in our clinical practice to find dozens of novel points. The purpose of this article is to outline that theory so that you too, can predict and discover additional effective acupuncture points.

Embryology

To explain our theory requires a review of embryology. Sperm and ovum meet. The two cell nuclei combine, forming the basis of a new body with genetic material from each parent. This combined cell is called a zygote. The zygote then divides in two. The two resulting cells divide in two and so it goes as two becomes four becomes sixteen, becomes thirty-two. At this point, the 32 cells are still the same size as the original zygote. The zygote takes on the shape of a hollow ball and attaches to the uterine wall.

During the third week after fertilization, the continually dividing cells begin to organize themselves into three layers. These are known as the Ectoderm (which will become the skin, hair, nails, brain, spinal cord and peripheral nervous system), the Mesoderm (which will become muscle, bone, connective tissue, kidney, gonads and circulatory system) and the Endoderm (which will become the digestive tract, liver, pancreas, bladder and lung). At around this same time (day 16), the beginnings of the brain and spinal cord appear as a “neural streak”. This is the first visible structure in the developing embryo.

This is important to our theory. The brain and spinal cord are already forming and developing an “image” of the body while the body is just three interconnected layers of cells that link future internal organs with cells that will become muscles and skin. Think about that for a moment. Acupuncture points in skin and muscle stimulate effects in internal organs.

Then think about this; the nervous system is creating an image of the body while it is still a ball. Right and left, top and bottom are still undifferentiated. It is the neural streak that becomes the dividing line between the right and left sides of the body and also defines top from bottom. In other words, the neural streak is present at the beginning and likely is involved in directing the further development of the embryo.

The neural streak forms a thick, flat plate of cells called the neural plate, which then bends to form a tube the length of the body. This is called the neural tube. It will become the brain and spinal cord. The outer layer of the neural tube forms the neural crest, which will become the sympathetic and parasympathetic nervous systems.

At the same time, the mesoderm is forming into multi-layered tube. The paraxial layer of the mesoderm will give rise to muscle, cartilage, bone and dermis. The intermediate mesoderm will become kidneys, gonads, adrenal glands and the rest of the urogenital system. The lateral plate mesoderm will become the heart, blood vessels, the body wall and the muscles in our internal organs.

Concurrently, the endoderm is also rolling into a tube. That tube will become the digestive tract. The upper part of this tube forms pouches that will become the esophagus, stomach, part of the duodenum and a bud that will develop into the lungs. The midsection develops into the rest of the duodenum, small intestine, ascending and transverse colon. The final section becomes the remainder of the transverse colon, descending and sigmoid colon, and the rectum.

All the time that these cell layers are forming into tubes, budding and developing into muscles, organs and bones, the early nervous system is wiring everything together. We hypothesize that the effectiveness of distal acupuncture points is a remnant in the mature brain’s memory of the original developmental plan in the embryo.

What does this have to do with meridians?

In Chinese medicine, the kidneys, adrenals and gonads are all lumped together as “Kidney”. Anatomically and functionally they are quite different structures but embryologically, they derive from the same tissue. Presumably, the linear distribution of associated muscle and skin that we needle to affect those organs arose from adjacent tissue during the process of differentiation. In other words, the “meridians” of acupuncture are tissues that are neurologically related because of their proximity to each other during embryological development.

Similarly, the lung and large intestine are considered to be paired organs in Chinese Medicine. There is no obvious special relationship between those two organs in Western Medicine. It’s possible though, that they do share some common signaling pathways because they both derive from the endoderm. No one knows at this time what neural connections are present in the developing zygote and embryo, but it is clear that the nervous system is already present as the organs and other structures are forming.

The unique contribution of Chinese Medicine is its recognition that the body is organized in lines of associated tissues that run from head to toe. For example, the Yang Ming meridian runs from the eye to the second toe. Points along that pathway are used to treat stomach conditions, shoulder bursitis, eye or jaw pain, etc. What do all these areas have in common? I suspect it is that they arise from common or adjacent tissues in the developing embryo.

Misconceptions

It’s very confusing for Westerners to try and wrap our heads around a pathway that relates so many disparate tissues. It’s made worse by the unfortunate naming of these pathways by Jesuit missionaries in the 1700’s. They named the pathways after organs, as in the case above, the stomach. That sort of reductionistic thinking makes it hard to explain to patients because needling a stomach or liver or kidney point doesn’t mean that there is anything wrong with the named organ.

Worse, the Jesuits understanding of organs was still rooted in Hippocratic medicine. So for example, they would conceive of blood rushing to the head causing anger, headache or even stroke due to an over active liver. Many discredited ideas from Hippocratic medicine are hung around the neck of Chinese medicine, making it seem all the more outdated to Western science.

It gets worse…

The widespread belief that acupuncture is a pseudo-science was compounded by Georges Soulie, a translator in China in 1910, who was forced out of China and sent back to France during the Boxer Rebellion in 1911. Unemployed in France, Soulie began writing books about Chinese culture. While it is not known if he ever actually witnessed acupuncture being performed, in 1939 (28 years after leaving China) he wrote a book about acupuncture that described meridians as invisible pathways of vital energy circulating in the body. This idea was very popular to people in the West who were looking for a “vitalist” explanation of health that connected the individual to cosmic, spiritual forces. In other words, it presented a pseudo scientific explanation that appealed to people looking for spiritual solace.

Contrast this with the Chinese, who were dissecting nerves and blood vessels while my ancestors were throwing spears and painting their faces blue. Soulie did all of us a disservice. His translation of “Chi” as vital force for instance, misses the mark. To the Chinese, “chi” means “air”, “weather” and “metabolism” as in aerobic metabolism (which is dependent on air). Yes, metabolism means energy in the sense of electromagnetic forces involved in ATP production or other chemical reactions in the body but it does not mean mysterious, cosmic energy or life force, independent of biological processes.

The cosmic aspect of Chi arose because Chinese used weather metaphors to describe moods and bodily conditions, i.e., “her face clouded over with sadness”, or, “she had a sunny disposition”. That does not mean that various types of cosmic chi are creating a disturbance in our minds and bodies. The Chinese also related weather to physical conditions as in “he caught a cold” or, “had heat exhaustion” or, “his arthritis feels worse in cold, damp weather”. To read or hear acupuncturists talk about “cold”, “damp” or “heat”, you get the impression that these actual environmental factors are abstract, metaphysical archetypes with a life of their own. But I digress….

Homologous structures

Getting back to embryology, our bodies are organized as bilaterally symmetrical, segmented tubes, divided by a spine. This is a basic organizational principle going back to flatworms, over 500 million years ago. It makes sense that we can needle the right elbow to treat the left elbow and as noted above, there is also a linear organization of related tissues following the axis of those tubes in the developing embryo. Here comes a trickier thought; The segments are also related to similar structures further up or down the tube. How does that work?

Think of this. Your thumb looks and functions a lot like your big toe. Your elbow divides your upper limb the way your knee divides your lower limb. Your shoulder and hip are the attachments of your upper and lower limbs to your trunk. We are not only symmetrical from right to left. We are symmetrical from top to bottom. Imagine your body folded up in a ball, so your head and hands were touching your feet. Your wrists would overlap your ankles. Your elbows would be next to knees, etc.

If you think of it this way, many acupuncture point locations are explained. Better yet, you can predict the location of acupuncture points just by knowing anatomy.

How I arrived at this theory

I had been looking for more effective distal points for several years. I knew a handful of distal points that could work what can only be described as miracles; Yao Tang Xue for sciatica. St 38 for shoulder bursitis. SJ 5 for acute sore throat… Instantaneous, complete relief. Nothing in Western medicine could compete with these results and nothing in Western medicine could explain them. I reasoned if there were a few of these points, there must be hundreds.

I attended a class with Dr. Richard Tan. His work and that of Dr. Tung before him pointed to the kind of instantaneous success from distal points that I was seeking. I found however, that their rationale for point selection didn’t fit for me in the hurry of clinical practice. Should I select points based on the Mother-Son relationship, Midday-Midnight, 5-Elements, mirror image, reverse mirror image, etc. There were too many choices. Also, There were so many overlapping rationales for so many points it seemed that one could justify just about any point with one rule or another. In short, I felt it lacked specificity and was cumbersome for me to use. (I wish to be clear that this is not an indictment of an excellent system of point selection. It just didn’t work for me).

I did feel that mirroring was a correct concept. I had been experimenting with mirroring with some success prior to taking that class. I also felt that the points had to derive from embryological development. I was guided to this thought in part by a book I had read in the early 1970’s by Felix Mann, MD. i

Well as they say, necessity is the mother of invention. One busy Summer day, all five treatment tables were loaded with patients and I had two more in the waiting room. One room opened up and I brought in the next patient. She was a middle aged woman with right buttock pain. She wore a spaghetti strap top with a girdle under her skirt. I had no time to wait for her to change into a gown to get access to her hip. I noticed that her right foot was turning out as she walked into the room. I asked to to turn her right foot inward towards the left foot. That immediately caused a sharp increase in her right buttock pain. As I suspected, her right piriformis muscle was tight and painful. How to release it quickly? I thought for just a moment and realized that the piriformis muscle externally rotates the lower limb. What muscle externally rotates the upper limb? Aha! The infraspinatus muscle. I quickly needled the most tender point in the belly of that muscle (SI.11) and asked her to rotate her right foot medially and laterally. Within seconds, the pain was gone! I told her to keep walking and testing her leg to be sure the buttock pain was gone until I came back.

I quickly went to the next woman. She too was wearing an outfit that exposed her shoulders and she too had a pain in her hip. In her case, she pointed to the side of her hip. I palpated and found tenderness at the greater trochanteric bursa. Again visualizing the anatomy, I thought, “What’s the bursa that reduces friction when abducting the shoulder which is similar to the bursa that eases abduction for the hip?” I needled a non-classic point in the sub-deltoid bursa and her pain immediately disappeared! Success! I removed the needle from the first patient and was soon able to get back on schedule.

Principles of Point Selection

What I came to was a set of principles for selecting distal points, namely that I look for;

1. Homologous structures.

2. Of the same tissue type.

3. With a similar function.

I think numbers 2 and 3 are self explanatory but just to be sure this is clear; If the problem is in a muscle, needle a distal muscle. If the problem is in a bursa, needle a distal bursa (as above). These are the same tissue type. Similar functions are illustrated in the examples above, i.e., muscles that externally rotate the limbs relative to the trunk and bursa that ease abduction of the upper and lower limbs. The first principle however, needs a little clarification.

I use the term homologous which the dictionary defines as “having the same relation, relative position, or structure” to describe anatomically similar structures. Going back to what I was saying about embryology; your hand is like your foot, your knee is like to your elbow, your hip is like your shoulder. Obviously, your thumb is similar to your big toe, but what part of the elbow is paired with what part of your knee. Think of this. Your radius aligns with your thumb and your tibia is aligned with your big toe. If you lay your palm down over your foot, the relationship is clear. You may notice that in this position, your knee flexes backward while your elbows flex laterally. Think of the hollow of the elbow (antecubital fossa) and the hollow the knee (popliteal fossa) as mirroring one another. This makes even more sense if you think of how these joints function in a quadruped. That means if you were treating a Baker’s Cyst (popliteal bursitis), you would needle the center of the antecubital fossa (LU5) in the bursa of the elbow. If you were treating a medial meniscus sprain, you would needle LI12. The lateral meniscus would be treated near HT3. You might treat the anterior tibialis muscle by treating LI10, or the quadracep femoris by needling the tricep (near LI13). Get the idea?

A less obvious relationship is between the scapula and the pelvic (innominate) bones. Following this logic, you can needle SJ 15 to treat the quadratus lumborum or HT 1 to treat the psoas. I will detail some of these relationships below.

I should mention a few other principles at this point;

1. Distal points are most effective for reducing pain and inflammation while local points are best for releasing muscle tension and attracting an immune response to the area. The reason that local points are more effective for releasing muscle tension and attracting an immune response is because the release of Substance P in the cells that are pierced causes local muscle relaxation and immune cell chemotaxis (the attraction of immune cells to the site of the injury). Distal points create a greater impression of injury in the brain, stimulating more endorphin and steroid release. Distal points may also create a greater neural blocking effect (Melzack-Wall Gate Theory).

2. For best effect, needle distal areas with a high density of pain fibers compared with the area of complaint. So for example, you’ll get a better result needling the shoulder for the hip and the elbow for the knee than the other way around. Hand to foot is the same either way. You will get some benefit needling a knee to help the elbow, but will likely need to treat local points in the elbow for best results.

3. Move the area of complaint while the distal points are inserted and painful. This increases the effectiveness of treatment and helps the patient get over their fear of moving the injured area. I used to ask patients to walk around when I needled Yao Tang Xue for sciatica. I have a large room in my office that has three treatment tables. I also have two private rooms. One morning, I had two patients in the large room. Both of them had sciatica from disc lesions. One was a dancer, the other a film producer. When I had them both walking around with needles in their hands, the dancer said, “Now that we can walk without pain, we should dance!” She then proceeded to teach all of us the samba. Since then (late 1990’s) I have been teaching the samba or encouraging other dance forms while the patient is retaining the needles. The psychological benefit of the patient shifting from thinking they may never walk again to dancing pain-free cannot be overstated. Similarly, the family members who assisted the patient as he or she limped in are delighted to see them dancing out under their own power.

4. This should be obvious, but the distal points must cause a deep ache (da qi) to be most effective. A deep ache is necessary because we are trying to trick the brain into thinking that a far worse injury has occurred. The greater the ache, the larger the area of representation in the brain and subsequent recruitment of healing resources.

In addition to the homologous joints, there are areas that form a homunculus and can treat the whole body. The best known homunculi are the ear, hand and foot, though there may well be others. We have noticed that needling distal to Yao Tang Xue in the grooves adjacent to the third metacarpal progressively treats spinal areas up through the lower lumbar, to thoracic to the cervical spine at Ba Xie (metacarpal phalangeal joint).

The exciting lesson to learn from all of this is that there is more to discover. As practicing acupuncturists, we can continue to add to the literature, rather simply try to better understand the lessons our acupuncture “ancestors” left for us. I hope this article inspires you to continue the search for better ways to serve our patients, rather than becoming the basis of a new dogma.

Warmest regards,

David Wells, D.C. L.Ac.

 

Acupuncture: The Ancient Chinese Art of Healing and How it Works Scientifically by Felix Mann, MD.

Ice or Heat? Rest or Move?

Some of the most common questions we hear after an injury are, “Should I use ice or heat? Movement or rest?”. While all rules have variations to account for individual circumstances, more often than not the answer will be ice and movement. Let’s break that down.

Immediately after an injury, there is inflammation. Like the name suggests, this is a hot condition and is helped by using ice. The hallmarks of inflammation are heat, swelling and tenderness to the touch. Ice helps all of that.  Normally, we recommend using ice 2 -3 times per day for the first few days after an injury. The upper limit of frequency for using ice is ten minutes per hour. Continuous ice can cause frostbite. Another risk for frostbite occurs with using ice directly on the skin. Normally, a cold pack is separated from the skin by a layer of cloth. If your ice pack stings to the touch, use a thicker piece of cloth. Your ice pack can be kept in the refrigerator section, not the freezer. That way it will be soft and conform better to your injury. Most refrigerators keep food around 38 degrees. That is plenty cold!

In a severe injury, the acute inflammatory stage can last for 3 to 5 days. This is the time for ice and also the time for rest. After that, the body shifts focus to repairing the injury with less inflammation. This sub-acute stage is probably still a good time for ice but it is also the time to begin moving the injured area. The way to tell if the injured area is still inflamed is to check for tenderness to pressure. Another way to tell is that pain from inflammation is present even when you are not moving. So if your sprained knee is aching while you are lying in bed and it is tender and puffy to the touch, it is inflamed and would benefit from ice.

Movement during this time prevents the injured area from filling in with scar tissue. The most common mistake we see is people who wait until there is no pain to begin moving. This results in decreased range of motion and often, permanent disability. Early mobilization is the key to a full recovery. In the case of our hypothetical sprained knee, this means performing range of motion activity such as using a stationary bike, not activities with high forces like playing tennis or basketball. Let common sense and pain guide you as you return to full function.

After 4 to 6 weeks, you enter the chronic or remodeling phase. During this phase, emphasis should be on obtaining full range of motion and developing strength. At this point, there should be no pain at rest, no redness and no palpable swelling or tenderness. There is likely to be some pain when you attempt to stretch the muscles. This is the phase where heat is often recommended, but the best form of heat is actually exercise, not a hot pack. Why is this? Heat applied to the surface only penetrates about a half inch. Your problem is usually much deeper than that. Another reason is that heat applied externally usually only gives relief for a short time, often a half hour or less. Heat generated by muscle activity will last for 24 hours. Finally, exercise is not only warming the muscles, it is strengthening the muscles and restoring normal range of motion. As a result, we rarely recommend or use heat to help recover from an injury.

To illustrate, I’ll tell a story about one of my injuries. One Sunday evening, I fell hard onto my driveway, smashing my left palm and right knee onto the cement. After my wife helped me up and into the house, we applied ice to my knee and my left elbow. I didn’t hit the elbow but I could see it was swelling. After about a half hour, I couldn’t move my elbow at all and I realized it was fractured. I decided to go to the local hospital and get it X-rayed. Sure enough, there were signs of fracture, so the doctor put my elbow in a cast and offered pain medications (which I declined). Back at home a few hours later, I developed a burning pain and numbness running down my forearm to my little and ring fingers. I realized that I should never have let them cast me, because the cast was trapping the swelling in my elbow and crushing my ulnar nerve. Good thing I didn’t take pain meds or I would have woken up in the morning without the use of my hand.

I went back to the hospital and had them cut off the cast. The next morning, I went to a radiology lab I use and got an MRI of my elbow. The fracture was much more clearly visualized. The bone was split lengthwise at the elbow and there was a lot of swelling. I then went to an orthopedist I know and asked for his advice. He asked if it hurt, probably because I didn’t look to be in obvious distress. So he put a syringe in my elbow to draw out blood that had leaked into the space between the separated sections of bone. The syringe completely filled with blood. So put another syringe on the needle and it too filled with blood. His eyebrows raised. Then he put another and another and finally, blood stopped coming out of my elbow. It was such a relief, I told him it felt like my elbow gave birth. I asked the doctor what I could and could not do during recovery. He said I couldn’t externally rotate my forearm for six weeks, but I could begin moving it as I felt able.

I wore a sling for four weeks to prevent accidental movement. All I did the first week was wiggle my fingers and gently make a fist. I used ice, acupuncture and a little massage on the forearm to reduce inflammation and muscle spasm. I increased my range of motion during the second week. By the third week, I began doing isometric resistance exercises with my forearm and increasing my range of motion. By the fourth week, I was lifting light weights and doing deep massage in the muscles to prevent scar tissue build up. By the fifth week, I had regained full range of motion and the ability to make a strong fist. I increased the weights. By the sixth week, I was doing bicep and tricep exercises with 30 pound dumbbells. When I returned to the orthopedist, he said there were two ranges of motion I would not get back after an injury like mine. To his surprise, I could do those motions with ease.

If I had worn the cast or even the sling without doing any exercises or treatments during those six weeks, I would indeed have lost the full function of my elbow. This is one example among many of the value of early mobilization.

Super Slow High Intensity Strength Training

The safest way to build muscle quickly is to do resistance exercise very slowly. When I say slow, I mean 2 – 3 repetitions per minute. That’s why it’s called Super Slow. This kind of exercise makes Tai Chi look fast.

Which exercises? Really any normal strength move. Let’s say you like to do bicep curls with a dumbbell. First thing to know is that any exercise you select is much harder to do when you go slow. Because of that, you will want to start with about half the weight you are used to lifting.

Why is it harder? Because the way a muscle works uses energy at three stages: First, energy is used to release the bonds between the hundreds of individual muscle fibers. Then, energy is used to shorten those muscles fibers. Next, the fibers have to bond again to one another in a shortened position. This cycle repeats until the movement is completed. When you lift at a normal speed, these energy-intensive bondings, contractions and un-bondings happen just a few times as the muscle contracts through the full range of motion. The slower you contract your muscle, the more times the muscle has to un-bond, contract and re-bond to go through the full range of motion. A single, super-slow bicep curl is much more work that several quicker ones because you get no benefit from momentum or speed. It can be the same effort as ten “normal” repetitions.

Why is this better than just lifting heavier or more repetitions? Because injuries happen when connective tissue is rapidly stretched. It’s hard to hurt yourself when you go slow. Compare a very smooth, slow lift with jerking the dumbbell up using momentum from hip movement to get started. That sudden acceleration can tear tendons and ligaments. The initial acceleration also gets the weight up into the mid range of the bicep contraction where the muscle is strongest. Lifting slowly from a dead hang forces the muscle to work in a disadvantageous position.

Another benefit of slow is that it gives you time to focus on your form. As noted above, going slow encourages you to go through the full range of motion, working on the more difficult parts of your exercise. Another element I try to create in strength training is to add some kind of instability. This trains balance, coordination and almost always recruits the abdominal muscles. In the case of a bicep curl while standing and holding the dumbbell in your right hand, bend and lift your left leg so that your foot is resting on a stability ball. The resulting instability will require you to recruit a lot of other postural muscles.

You can understand now why it’s important to start out with a lighter weight that you usually lift. So what if your preferred exercise is pushups? How do you lift less weight? You can start by doing your pushups against a counter. As you get better, try lifting one foot off the ground to create instability. As your strength improves, you may end up doing pushups in a standard plank position on the floor, but with one foot resting on a soccer ball to create instability. Try doing two of those per minute. Trust me, it’s a challenge.

That brings me to the high intensity part of this type of training. When you are comfortable with the form of your exercise, you want to make it increasingly more difficult until you reach your desired level of fitness. My strategy is to only do any one exercise for a minute. That’s all, one minute. I don’t have a lot of time to devote to exercise, so I want to make the most of the time I have. To get the most out of exercise, I do what’s called “one minute to failure”, meaning that I am giving my maximum effort to the point that I can just barely finish the minute without collapsing.

So there you have it. Super slow, high-intensity strength training. Safe, quick and effective.