Chinese medicine and IVF

How many failed IUI’s and IVF’s have you had? Four? Five? Seven? Have you heard this “you are producing beautiful embryos, your lining looks great and your husbands sperm is off the charts”? How many failed donor egg cycles have you had?

You may be a victim of poor diagnosis. For example, how many of you have had a fluid ultra sound? If you have not, raise your hand.  Did you know…one polyp residing in the uterine cavity can prevent implantation? Did you know that frequently a trans-vaginal ultra sound cannot detect a polyp but a fluid ultra sound always can?

Let’s look at a common scenario together. You are thirty-nine years old and you have an FSH of 17 and you have endometriosis. Your doctor thinks that you are not getting pregnant because you have an inflammatory disorder (endometriosis), and that you have poor egg quality, and low ovarian reserve indicated by your age and FSH levels respectively. But, if you have a regular period, the odds are that you still have some good eggs and may have a chance to conceive, else why would your doctor be willing to proceed with an IVF embryo transfer.

The fact that you have been diagnosed with endometriosis indicates that you have had it surgically addressed and so now its clinical relevance is diminished. Now its down to egg quality and ovarian reserve. If you still menstruate regularly, you still have some good eggs even if your FSH is 17.

So why are you not conceiving? Perhaps because of a physical obstruction, i.e., a polyp or worse, multiple polyps. Polyps are easily, painlessly and quickly removed via a hysteroscopy.  So, instead of continuing to have IVF after IVF and failure after failure why not rule out possible hidden causes of your problem with simple procedures?  I am not trying to insinuate that all infertility stems from improper diagnosis; sometimes woman can’t conceive for reasons which are beyond the scope of current diagnostic tools. I am, however, suggesting that many cases of infertility can be successfully treated where heretofore, they have not.

Did you know that day 3 embryos with less than 6 cells and more than 10 cells are often indicative of poor sperm quality?  Yes I know: your husband had a normal semen analysis. But, has he had a sperm DNA fragmentation assay? This test can reveal a  hidden sperm pathology that may be contributing to your inability to conceive?

If his sperm tests normal from the perspectives of volume, count, motility, and volume and you are producing day 3 embryos with less than 6 cells or more than 10 cells, he should have this test. Frequently this test is not performed because your doctor doesn’t believe in this test and wouldn’t know what to do with the results anyway. Doctors will tell you that the only challenge that sperm with fragmented DNA poses is their inability to penetrate an egg, so the answer is simple: do ICSI. ICSI is a process whereupon the sperm is injected into the egg enabling forced fertilization. So your egg is being fertilized with a sperm that couldn’t, on it’s own, have done this. Essentially, by default, you are ending up with a less than optimal embryo which may yield a pregnancy which may either result in miscarriage or produce a male child with the same problem as his dad with his future family planning requiring IVF with ICSI.

So, are we not, through these ‘band-aid’ procedures facilitating a nation of weakened children and actually contributing to a generation of infertile couples?

You’re wondering what the solution is.  Well that begets a question. If you had type 2 diabetes and were very overweight and had insulin resistance you could do two things to get better: 1) take Metformin and possible other medications or you could change your diet, lose weight, exercise and cure your-self.

One approach is a ‘band-aid’ approach and one approach is to address the problem at its root.  The solution lies ahead.

Back to sperm DNA fragmentation. Before we can hope to address a ‘root’ treatment we first need to know what causes the problem. Reactive oxidative species or ‘ROS’ causes fragmentation of the DNA in the sperm. ROS is caused by environmental assault such as exposure to certain chemicals, toxins, etc., which can come from smoking marijuana or cigarettes, testicular injury or testicular surgery allowing antibodies to enter the testicular environment and cause damage.

The severity of DNA fragmentation is determined by the amount of sperm that is affected. 0 to 15% is indicative of good outcomes in IVF procedures; 15% to 29% means that chances are fair to good; numbers above 29% usually do not result in live births.

In the idiopathic (no known cause) infertile couple, a full diagnosis has not been rendered without a sperm DNA fragmentation test. What is the cure? The eradication of free radicals which manifest as a result of ROS.

How? acupuncture (stimulates blood to the testis helping to send more oxygen and nutrients and dispel dead cells), herbs which have anti oxidant properties, vitamins C and E which have strong anti oxidant properties and daily intake of wheatgrass juice. There is no traditional Western medical approach to the successful treatment of sperm DNA fragmentation.

Is medical ego perhaps a contributing factor to the paucity of testing done for this significant pathology?  In other words: if the doctor doesn’t ‘believe’ in the test then it won’t be done.  Can you see air? Can you see microorganisms? Can you see God? Can you see energy? No, no, no and no. Do you believe in their existence?  Is your day to day behaviour not based upon your belief in these entities even though you have never seen even one of them?

There are some people that do not believe in the existence of God or microorganisms. Does their lack of belief indicate the lack of existence of these things? It is the wise person who, though belief may not be held, understands that there is a  possibility of existence nonetheless.

Did you know that endometriosis is an autoimmune disease than can cause infertility even in the absence of damaged fallopian tubes? Another interesting thing that you should be aware of is that when one has an autoimmune disease such as endometriosis there are often other autoimmune factors which can contribute to infertility which have not been diagnosed; but they should have been. I always recommend a full autoimmune evaluation when one of my patients presents with a known autoimmune disease to rule out the possibility of other, asymptomatic autoimmune disorders which can cause infertility.

The reason for the paucity of testing for autoimmune disorders which are known to contribute to infertility is that many doctors don’t believe that autoimmune disorders can contribute to infertility. The terms yin and yang according to traditional Chinese medicine, means, among other things balance. Balance, according to the traditions of Chinese medicine is required for health, and imbalance is what leads to sickness. Would you agree that an immune system which acts inappropriately against it’s host represents an imbalance? And, does it make clinical sense to try to rebalance the behaviour of organ/endocrine systems to re-institute health?

Let me tell you an interesting story: when the surgeon general first advised the nation  that there was a direct link between lung cancer and other cancers with cigarette smoking, most doctors who smoked (many, many did) continued to do so because they didn’t believe what the surgeon general said. Now, years later, most physicians don’t smoke because they became convinced of the validity of the surgeon general’s report. So, perhaps, years from now, many reproductive endocrinologists will finally understand the clinical significance of certain autoimmune disorders in so far as their role in infertility is concerned.

An example of an autoimmune disorder which can cause infertility is activated natural killer cells. These cells are meant to kill cancer in the uterus. They do so by spraying something called TNF-alpha or tumor necrosis factor on tumors, killing them, and in the best case scenario, saving the patient from endometrial cancer.

However, in one with an autoimmune mitigated hyperactivity of activated NK cells, these cells spray TNF-alpha on the embryos, instantly killing them causing infertility.  This again is a hidden pathology as it presents with no signs or symptoms.

The appropriate treatment is intralipid therapy or intravenous immunoglobulin therapy, both of which have been shown to positively affect pregnancy outcomes in patients presenting with highly activated NK cells.

Again, this is the band-aid approach and, in many cases a band-aid approach is not a bad thing; if it works, it works and at the end of the day that’s all we want.

To include a modality of medicine which can regulate immune function so that the body can behave normally again also makes sense. Acupuncture and herbal medicine can frequently manifest in this regulation of the immune system.  This is how acupuncture and herbal medicine helps patients who are HIV+ or in full blown AIDS to feel better and stronger – by immune function regulation to whatever extent possible.

Infertility treatment is still in its infancy stage. There have been more than three million babies born as a result of IVF. But this is similar to the concept that many people with cancer have been saved by medical intervention. Both are true, yet the fact remains many more people die from cancer than who are saved and many more IVF’s have been done without the production of a baby.

As time goes on, more and more research will yield better treatment approaches and perhaps one day  infertility will not exist.  In the mean time however it is my contention that all testing, even testing that may present a greater insight into the cause of a couples infertility should be rendered and, the root cause of the problem should simultaneously be treated with natural medicine such as acupuncture and herbs.

Western medicine is superior to Chinese medicine in treating the manifestation of an underlying disregulation or lack of harmony in the functioning of the body but traditional Chinese medicine is, in my opinion (based on clinical experience and three thousand years of data) superior in treating the human body and spirit at the deepest levels. Therefore, the best approach to treatment of the infertile couple is to employ both modalities of intervention. This is the solution!

Exterior or interior?

According to Chinese medicine theory, headache has two broad aetiologies: invasion by an exterior pathogen or internal disorder. A headache caused by an exterior pathogen has an acute onset with severe and continuous pain. It can often be accompanied by or follow cold and flu symptoms. Chronic, recurring or slow onset headaches on the other hand are generally due to internal disorders.

Acute and exterior headaches are usually associated with, or worsen after a recent history of infection by bacterial or viral pathogens, the most common being cold and flu. Chinese medicine further differentiates this type of headache according to its nature (wind-cold, wind-heat or wind-dampness) and location of pain.

• A Wind-Cold headache is continuous and aggravated by exposure to cold. The patient typically presents with a white tongue coating, floating and rapid pulse.
• A Wind-Heat headache is severe with a burning sensation. The patient may also be thirsty with a red tongue, yellow tongue coating and tight pulse.
• A Wind-Dampness headache is distending with a heavy sensation. The patient may feel their body or limbs are heavy, feel stuffy in the chest and present with a white and greasy tongue coating and soft pulse.

Which channel is affected?

Having differentiated the nature of the invading pathogen, it is then necessary to determine the location of the pain which indicates the channel that can be treated with acupuncture. The twelve primary acupuncture channels of the body can be divided into six pairs that meet at the head. When an external pathogenic factor invades any part of the body the resulting headache will be localised along the path that the channel runs in the head.

The following sites of pain are significant:

• The bridge of the nose and area between the eyebrows, back of the head (occipital region), nape of the neck and upper back represent the Greater Yang channel.
• The temporal and lateral side of the head indicates the Lesser Yang channel. The pain can be uni or bi-lateral.
• The forehead indicates the Yang Brightness channel.
• A heavy or distending pain around the upper head indicates the Greater Yin channel.
• Pain on the inside of the head radiating to the teeth indicates the Lesser Yin channel.
• Pain at the vertex/top of the head indicates the Terminal Yin channel.

For acute headaches, acupuncture points on the appropriate channels can then be selected according to the nature of the exterior pathogen and affected channel. For example BL-2 and BL-10 are suitable points on the Greater Yang channel for a wind-cold headache with pain between the eyes and a stiff neck. If the headache is accompanied by cold and flu symptoms, other additional points as well as herbal formulas are included in the treatment.

Which internal disorder?

When there is no evidence of exterior invasion, headaches of a chronic or recurring nature are symptoms of an underlying internal disorder, which may have a history of months, years or even decades. Internal disorders are more complicated and may involve one or more organs. Again, the precise pattern of internal disharmony can be ascertained by questioning the nature of the headache. Each of the following “syndromes” represents a unique combination of symptoms recognised by Chinese medicine diagnosis.

• A recurring distending or severe headache, often accompanied by dizziness or vertigo may be due to an Excess Yang syndrome. This type of headache is most commonly associated with stress, anger or other emotional changes and triggers. Its origin may be due to Liver Heat or Liver Yang Uprising which can be determined by further detailed questioning.
• Qi Deficiency headaches are mild and chronic, they may become more severe or triggered by physical fatigue or exercise. Spleen Qi deficiency syndrome is commonly associated with this type of headache.
• A heavy, foggy headache with dizziness may indicate a Dampness and Phlegm syndrome. This may co-exist with Spleen Qi deficiency symptoms such as fatigue, oedema, weight gain, poor appetite and digestive problems.
• Headache with a sharp, stabbing or throbbing pain may be indicative of Blood Stasis. This syndrome may arise from a history of physical trauma or surgery.
• A long-term, dull, empty headache with poor memory may indicate a Kidney Essence Deficiency syndrome especially in elderly patients. This may be accompanied by low back pain, weak knees, sexual or urinary dysfunction.

These are the main types of headache recognised by Chinese medicine diagnosis. Each type of headache may be caused by different underlying syndromes of disharmony which must be differentiated by further questioning of associated symptoms. Through detailed questioning of the nature of all symptoms, a rational diagnosis based on syndrome differentiation can be obtained.  The corresponding acupuncture points and/or herbal medicine formula is then chosen to treat the diagnosed syndrome which is causing the headache.

This is the principle by which Chinese medicine diagnoses and treats many disorders. To an experienced Chinese medicine practitioner, headache is not simply a disease to be cured but an important diagnostic clue which forms part of a holistic diagnosis process.

Acupuncture for the management of chronic headache: a systematic review

This systematic review demonstrated that traditional needling acupuncture is superior to sham acupuncture and pharmacological therapy for chronic headache treatment by improving headache intensity and frequency and increasing the response rate. The authors also found a lower incidence of side effects in the acupuncture group when compared with medications.

• Sun Y, Tong J. Acupuncture for the Management of Chronic Headache: A Systematic Review. Anesthesia & Analgesia. Dec 2008;107(6);2038-2047. [Fulltext]

Cochrane Reviews: Acupuncture for tension-type headache

Acupuncture in primary headache treatment

Abstract: Acupuncture has a long tradition of use for the treatment of many pain conditions, including headache. Its effectiveness has been studied mainly for primary headaches, particularly for migraine and tension-type headache (TTH). Traditional Chinese Medicine (TCM) has two diagnostic frameworks for headaches: meridian diagnoses, based on the location of the pain and on the meridians (or channels) that pass through it; syndrome diagnoses, dependent on external or internal factors and on the characteristics of the pain. The four meridians involved in headache are Shaoyang (TE-GB channels, on the temporal sides of the head); Taiyang (SI-BL channels, occiput); Yangming (LI-ST channels, forehead) and Jueyin (PC-LR channels, vertex). The syndromes may be due to excess or deficit. Very generally, the excess syndromes correspond in the majority of cases to migraine and the deficit syndromes to TTH. Acupuncture is a complex intervention, which is also characterized by a close interaction between patient and therapist. The complicated system of TCM classification of headaches has frequently generated great diversity among the various therapeutic approaches used in the different studies on acupuncture in headache treatment. Despite these differences, the recent Cochrane systematic reviews on acupuncture in migraine and in TTH suggest that acupuncture is an effective and valuable option for patients suffering from migraine or frequent TTH. Moreover, acupuncture seems to be a cost-effective treatment.

• Schiapparelli P, Allais G, Rolando S, Airola G, Borgogno P, Terzi MG, Benedetto C. Acupuncture in primary headache treatment. Neurological Sciences. 2011;32(1);15-18. [Abstract]

References

• Point location image copyright Carole & Cameron Rogers, ‘Point Location and Point Dynamics Manual’, University of Technology, Sydney.

“Green School in Bali, Indonesia is giving its students a relevant, holistic and green education in one of the most amazing environments on the planet.”
www.greenschool.org

Imagine beautiful bamboo classrooms without walls, lit by sunlight and cooled by the wind.

Imagine students who are motivated to learn from a hands-on curriculum; distracted only by frogs, mud, worms and nature.

Imagine fresh healthy lunches and students who are taught to understand and respect where their food comes from in a permaculture garden.

Sustainable education is vital to a healthier future and Green School is a truly inspirational project we can all learn from.

Green School is teaching today’s children how to take care of the world of tomorrow.

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A day in the life of a grade two Green Schooler.

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An inspiring TED talk by Green School founder John Hardy.

• Fu Zi and Wu Tou (Aconite Root)
• Gan Jiang (Dried Ginger)
• Rou Gui (Chinese Cinnamon Bark)
• Wu Zhu Yu (Evodia Fruit)
• Xi Xin (Chinese Wild Ginger)
• Hua Jiao (Sichuan Pepper)
• Gao Liang Jiang (Lesser Galangal Rhizome)
• Ding Xiang (Clove)
• Hu Jiao (Black Pepper)
• Bi Ba (Long Pepper)
• Xiao Hui Xiang (Fennel Seed)

Internal Cold Syndrome can develop in two ways: due to external invasion of pathogenic cold (acute), or deficiency of yang of the internal organs (chronic). The general actions of these herbs are to expel cold, warm the meridians and internal organs, promote qi and blood circulation, alleviate pain and cramp caused by cold.

Interior warming herbs are contraindicated for those with excess heat and yin deficiency syndromes. If you frequently eat spices such as ginger, cinnamon, pepper, clove or fennel seeds please pay attention to the contraindicated symptoms below.

Fu Zi and Wu Tou (Aconite Root)

Aconite (Aconitum carmichaelii) is a herbaceous, flowering plant species belonging to the buttercup family. It is native to the mountainous parts of north east Asia, particularly in China and Japan. Many species of aconite are cultivated in gardens, having either blue or yellow flowers. The plant is highly toxic and its roots contain the alkaloid aconitine which can cause numbness and tingling when touched to the lips and skin.

Aconite has long history of use in the traditional medicines of Asia, including traditional Chinese medicine and Ayurveda. Aconite was also described in Greek and Roman medicine. Several species of aconite have been used as arrow poisons for hunting and warfare. Also known as wolfsbane and monkshood, aconite has appeared in many popular literary works including Shakespeare, Dracula and Harry Potter.

Fu Zi and Wu Tou both come from the roots of the same plant. Fu Zi is the thin and long lateral root of the plant while Wu Tou is the main root. The root is harvested in autumn as the plant dies down and is then dried and specially processed with ginger to reduce its toxicity before use.

Fu Zi (Radix Aconiti Lateralis Praeparata) is an important herb in the Chinese materia medica because of its potency and versatility. If administered alone, it has a moderate cardiotonic effect, short duration and numerous side effects. Therefore it is generally combined with other herbs such as Gan Cao or Gan Jiang to synergistically increase the therapeutic effect of the formula and minimise its toxicity. It can also be combined with Da Huang to treat constipation, Huang Lian for epigastric distension, Yin Chen Hao for yin-jaundice, Long Dan Cao for liver damp-heat affecting the spleen and Sheng Di Huang to nourish blood.

Wu Tou (Radix Aconiti Carmichaeli) is better able to expel wind-cold, warm the meridians and relieve pain, while Fu Zi is regarded as more potent for its ability to warm Kidney-Yang (combined with Rou Gui) and rescue Yang from collapse (combined with Ren Shen). Both herbs are indicated for the treatment of arthritic cold bi-syndrome.

Gan Jiang (Dried Ginger)

Gan Jiang (Rhizoma Zingiberis) is the dried rhizome of the plant Zingiber officinale. Garden ginger is widely used in many parts of the world because of its valuable medicinal and culinary uses. Ginger cultivation began in south-east Asia and is commercially grown in the tropical regions of east Africa, China, Jamaica and India, the latter being the world’s largest producer.

Around the world, ginger is mixed with mango tree sap as a panacea in Congo, to relieve nausea, headache, the common cold in India and Nepal, to relieve fatigue, prevent and cure rheumatism in Indonesia, as a throat lozenge in the Philippines, stomach aches in Peru and clinically proven for pregnancy-related nausea and vomiting in the United States.

Its active constituents have been shown to exert antioxidative, antitumorigenic, anti-inflammatory and immunomodulatory effects in vitro and it is an effective antimicrobial and antiviral agent.

In Chinese medicine, Gan Jiang targets the Spleen, Stomach, Heart and Lung meridians and is used in formulas to relieve symptoms of abdominal pain, asthmatic cough, indigestion, diarrhoea and constipation due to interior cold syndromes. Chinese medicine also uses the fresh ginger rhizome which has slightly different actions for the relief of acute nausea, vomiting and externally contracted colds.

According to the Chinese materia medica, Gan Jiang should be used with caution during pregnancy.

Rou Gui (Chinese Cinnamon Bark)

Rou Gui (Cinnamomi Chinensis Cortex) is the bark of the cassia tree (Cinnamomum Aromaticum) also known as Chinese cinnamon. It is a small evergreen tree native to southern China, Bangladesh, India and Vietnam. Medicinal Rou Gui is produced mainly in the areas of Guangdong, Guangxi and Yunnan.

Cassia is a close relative to, and often confused with Ceylon cinnamon (C. verum) which is the well-known culinary spice native to India and Sri Lanka. Cassia is also similar to Saigon cinnamon (C. loureiroi), camphor laurel (C. camphora) and Indonesian cinnamon (C. burmannii). Whole branches and small trees are harvested for cassia bark, which gives it a much thicker and rougher texture than the small shoots used to produce true cinnamon spice. Cassia sticks are extremely hard and usually made of one thick layer, whereas cinnamon sticks have many thin layers and can be easily ground.

Rou Gui is primarily indicated for Kidney-Yang deficiency syndrome displaying symptoms of sore and cold lower back and knees, abdominal pain, diarrhoea, impotence, infertility and menstrual disorders due to cold.

Wu Zhu Yu (Evodia Fruit)

Wu Zhu Yu (Fructus Evodiae Rutaecarpae) is the fruit of the evodia tree (Tetradium ruticarpum) which grows to 9m tall in temperate to tropical south east Asia. Also known as the beebee tree, tetradium is popular amongst beekeepers because it flowers in late summer when few other trees do and attracts large numbers of bees. The flowers produce clusters of red berries which ripen and expose tiny black seeds throughout autumn. The fruit is gathered in August or November and dried in the sun. The mildly toxic fruit is soaked in a decoction of Gan Cao (licorice root) before use.

Wu Zhu Yu is as pungent and hot as Fu Zi and can warm the liver meridian, disperse and descend liver qi. Indications for Wu Zhu Yu include vertex headache, cold cramping pain in the stomach or sides of the lower abdomen.

Xi Xin (Chinese Wild Ginger)

Xi Xin (Herba Asari Cum Radice) belongs to the Aristolochiaceae family of low-growing herbs found across the temperate zones of the northern hemisphere. In China, it thrives in the moist, humus-rich forest soils of Huayin at elevations above 1,200 metres.

Xi Xin has distinctive heart-shaped leaves which grow from the rhizome just beneath the soil surface. Two leaves emerge each year from the growing tip. The herb has fine roots and a very pungent taste. It is harvested in autumn and dried for later use. Xi Xin is traditionally indicated for the relief of wind-cold pain and can warm the lung to eliminate cold phlegm and fluids.

Safety warning: Xi Xin has similar names or appearance with other plants in the Aristolochia family. There is a risk that Xi Xin may be confused, substituted or adulterated with other botanicals that contain Aristolochic acid, which is a carcinogenic and nephrotoxic substance (refer to precautions below).

Hua Jiao (Sichuan Pepper)

The Chinese Prickly-ash (Zanthoxylum simulans) is a flowering plant native to eastern China and Taiwan. It is one of several species of Zanthoxylum from which Sichuan pepper is produced. Hua Jiao is the outer reddish brown husk of the small 3-4mm berry that splits open to release shiny black seeds. Only the husks are used.

Despite its name, Sichuan pepper is not related to black pepper, but is widely used as a spice in the cuisine of Sichuan, China from which it takes its name. It is also important in Tibetan, Bhutanese and Nepalese cuisine since few spices can grow in these regions. Hua Jiao has a unique aroma and flavour that is not hot or pungent like black pepper or chili. It has an alkaline pH and a numbing effect on the lips when eaten in large doses.

Since Hua Jiao is slightly toxic and moves quickly in the middle jiao, it is only used for acute excessive damp-cold syndrome for a short duration. It can relieve severe abdominal pain and cramp in the abdomen, frequent watery stools and urination due to cold.

Gao Liang Jiang (Lesser Galangal Rhizome)

Lesser galangal (Alpinia officinarum) is a plant belonging to the ginger family native to China. Although it resembles ginger, there is little similarity in taste. Lesser galangal has a reddish brown skin and flesh with a stronger, sweeter taste than greater galangal. Greater galangal (Alpinia galanga) which has a lighter yellow coloured flesh is more commonly used in Asian cuisines such as Thai tom yum soup and curries.

Lesser galangal was widely used in ancient and medieval Europe, and is still used as a spice and medicine in Lithuania and Estonia. In Chinese medicine, Gao Liang Jiang has a strong action in warming the Spleen and Stomach to treat epigastric symptoms such as cramping pain, vomiting and diarrhoea due to cold.

Ding Xiang (Clove)

Cloves are the strongly aromatic dried flower buds of Eugenia caryophyllata, a tree native to the Spice Islands of Indonesia. It is now cultivated in many tropical regions including Madagascar, Tanzania, South America, Indonesia, Malaysia and Sri Lanka.

The young flower buds change from a pale colour to green, then bright red which is when they are ready to be collected.

Cloves are used as a spice in cuisines all over the world, in the production of perfumes and incense, in Chinese medicine, Ayurveda and western herbalism. The essential oil is used as a painkiller in dental emergencies. Cloves can increase hydrochloric acid in the stomach and improve peristalsis.

Ding Xiang targets the stomach, spleen and kidney meridians to warm Kidney-Yang, direct rebellious qi downwards and warm the middle jiao to relieve epigastric and abdominal pain, vomiting and diarrhoea due to cold.

Hu Jiao (Black Pepper)

Black pepper (Piper nigrum) is a flowering vine native to India which has been prized for its fruit, the peppercorn, since at least 2000 BCE. It is extensively cultivated in tropical regions, with Vietnam being the world’s largest producer and exporter of pepper – the world’s most traded spice.

Black pepper is produced from the green unripe drupes of the pepper plant. Fully mature peppercorns turn dark red in colour. The drupes are blanched in hot water and dried during which the pepper around the seed shrinks and darkens giving black peppercorn its wrinkly appearance.

Hu Jiao is indicated for warming the middle jiao to relieve epigastric and abdominal pain, vomiting and diarrhoea due to cold.

Bi Ba (Long Pepper)

Long pepper (Piper longum) belongs to the same family as black pepper and has a similar but hotter taste. The pepper fruit consists of many minuscule fruits embedded in the surface of a flower spike. First discussed as a medicament by Hippocrates, it was an important spice to the ancient Greeks and Romans until it was displaced by black pepper in the fourteenth century. Long pepper is widely used Ayurvedic medicine (pippali) for its longevity enhancing effects. Bi Ba (Piperis longi fructus) also warms the middle jiao with similar effects as Hu Jiao.

Xiao Hui Xiang (Fennel Seed)

Fennel (Foeniculum vulgare) is a bulbous plant native to the shores of the Mediterranean and western Asia. It is a member of the celery family and well-known for its aromatic aniseed flavour which features in Mediterranean, Middle Eastern and Asian cooking. The entire plant is edible but only fennel seeds and extracts are used medicinally.

Xiao Hui Xiang (Foeniculi fructus) is not a true seed but the fruit of the fennel plant with the appearance of a dry seed 4–10 mm long. It is cultivated in all parts of China where the fruit is collected in autumn as it ripens and dried in the sun.

Xiao Hui Xiang can warm the middle jiao and enter the kidney and liver meridians to relieve abdominal and epigastric pain, hernia due to cold and improve the appetite.

Precautions and contraindications

Interior warming herbs are hot in nature and contraindicated for patients with existing Heat or Yin Deficiency syndromes. It is advisable to avoid interior warming herbs if you experience symptoms of excess heat, thirst, night sweating, red tongue with no coating, sore lower back and knees.

Fu Zi, Gan Jiang, Rou Gui, Wu Zhu Yu, Hua Jiao, Xiao Hui Xiang are contraindicated during pregnancy and should be used under careful supervision of a qualified Chinese medicine practitioner.

Rou Gui may be toxic to the kidneys and cause haematuria if taken in large doses. Wu Zhu Yu should not be used in large doses or for long periods of time.

Xi Xin is a botanical product at risk of containing toxic Aristolochic acids. All species of Aristolochia are prohibited for supply, sale or use in therapeutic goods in Australia. Refer to the TGA Practitioner Alert about botanical products containing Aristolochia species and Aristolochic Acid [PDF].

References

• Chen JK, Chen TT. Chinese medical herbology and pharmacology, Art of Medicine Press, City of Industry CA.
• Yang, Y. 2010, Chinese herbal medicines: comparisons and characteristics, 2nd edn, Churchill Livingstone, Edinburgh.
• Unraveling the story of xi xin [http://asarumunfurled.wordpress.com/]

Fluoridation began in the United States in 1945 and has been introduced to varying degrees in many countries including Argentina, Australia, Brazil, Canada, Chile, Colombia, Hong Kong, Ireland, Israel, Korea, Malaysia, New Zealand, the Philippines, Singapore, Spain, the UK, and Vietnam. Continental Europe largely does not fluoridate water although some water supplies are naturally fluoridated and of its countries fluoridate salt. Worldwide, fluoridation is not unanimously supported with modernised countries such as Finland, Germany, Japan, the Netherlands, Sweden, and Switzerland having begun and discontinued their practice of fluoridation.

The following is a compilation of some key resources that unravel the scientific, medical and political controversies behind the practice of fluoridation. The concerns include the many toxicological dangers of excessive fluoride intake and our uncontrolled widespread exposure from many sources including processed foods, fluoride pesticides used in agriculture and its bioaccumulation in the environment and food chain.

“Since then our opposition to drinking water fluoridation has grown, based on the scientific literature documenting the increasingly out-of-control exposures to fluoride, the lack of benefit to dental health from ingestion of fluoride and the hazards to human health from such ingestion. These hazards include acute toxic hazard, such as to people with impaired kidney function, as well as chronic toxic hazards of gene mutations, cancer, reproductive effects, neurotoxicity, bone pathology and dental fluorosis.” – NTEU Chapter 280

There is no way to measure or control the daily fluoride intake by individuals and thus fluoridation violates the most basic principles of modern pharmacology. As with many endocrine disruptors, infants, children, pregnant women, the elderly and individuals with impaired renal function are most vulnerable to the health effects of fluoride ingestion. The general public is largely under-educated about fluoride, that it can prevent tooth decay in the mouth but is not effective in the body, its toxicity, that fluoride accumulates in bone, that bottled water can contain fluoride and it cannot be easily filtered out of tap water. Many clinicians may not be aware of the latest research in order to recommend a reduction in fluoride intake among their most vulnerable patients.

We hope our readers will take the time to evaluate the current evidence against fluoridation and decide whether its continued practice is really worth the risks. How much fluoride are we actually consuming and how much is too much? Until we can reliably measure our total exposure, it may be wise to exercise the precautionary principle with fluoride as we should with pesticides.

Professional perspectives on fluoride

Dr. Bill Osmunson explains in this brief introductory video the concerns about fluoride and water fluoridation. You can also watch the full-length version of this presentation online (28 mins, highly recommended).

Why I changed my mind about water fluoridation

Dr John Colquhoun was Principal Dental Officer for Auckland, New Zealand, and a staunch supporter of fluoridation until he evaluated national and worldwide data on its effectiveness. This paper explains why an ethical health professional was compelled to reverse his support for fluoridation.

http://www.fluoride-journal.com/98-31-2/312103.htm

Why the EPA headquarters’ union of scientists opposes fluoridation

Chapter 280 of the National Treasury Employees Union represents approximately 1,500 scientists, lawyers, engineers and other professional employees at the US Environmental Protection Agency. Read their position statement on why the views of these EPA employees oppose that of their employer.

http://www.nteu280.org/Issues/Fluoride/NTEU280-Fluoride.htm

The case against fluoride: how hazardous waste ended up in our drinking water and the bad science and powerful politics that keep it there (2010)

“Sweden rejected fluoridation in the 1970s and, in this excellent book, these three scientists have confirmed the wisdom of that decision. Our children have not suffered greater tooth decay, as World Health Organization figures attest, and in turn our citizens have not borne the other hazards fluoride may cause. In any case, since fluoride is readily available in toothpaste, you don’t have to force it on people.” - Arvid Carlsson, Nobel Laureate in Medicine or Physiology (2000) and Emeritus Professor of Pharmacology, University of Gothenburg

http://www.amazon.com/Case-Against-Fluoride-Hazardous-Drinking/dp/1603582878

The fluoride deception by Christopher Bryson (2006)

“Bryson marshals an impressive amount of research to demonstrate fluoride’s harmfulness, the ties between leading fluoride researchers and the corporations who funded and benefited from their research, and what he says is the duplicity with which fluoridation was sold to the people. The result is a compelling challenge to the reigning dental orthodoxy, which should provoke renewed scientific scrutiny and public debate.” – PUBLISHERS WEEKLY

http://www.amazon.com/Fluoride-Deception-Christopher-Bryson/dp/1583225269

Professionals’ statement calling for an end to water fluoridation

The Fluoride Action Network is an international coalition seeking to broaden public awareness about the toxicity of fluoride compounds and the health impacts of current fluoride exposures. Over 2,700 international science and health professionals have signed its Professionals’ Statement to end fluoridation of drinking water.

http://www.fluoridealert.org/professionals.statement.html

Patricia Cochran, an Inupiat from Northwestern Alaska describes her food culture:

Our meat was seal and walrus, marine mammals that live in cold water and have lots of fat. We used seal oil for our cooking and as a dipping sauce for food. We had moose, caribou, and reindeer. We hunted ducks, geese, and little land birds like quail called ptarmigan. We caught crab and lots of fish – salmon, whitefish, tomcod, pike, and char. Our fish were cooked, dried, smoked, or frozen. We ate frozen raw whitefish, sliced thin. The elders liked stinkfish, fish buried in seal bags or cans in the tundra and left to ferment. And fermented seal flipper, they liked that too.

These foods hardly make up the “balanced” diet most of us grew up with, and they look nothing like the mix of grains, fruits, vegetables, meat, eggs, and dairy we’re accustomed to seeing in conventional food pyramid diagrams. Yet how can people who gorge on fat and animal protein be healthier than we are?

The micronutrient mystery

What the diet of the far north illustrates is that there are no essential foods – only essential nutrients. One might imagine gross vitamin deficiencies from a diet with scarcely any fruits and vegetables, but humans can get these nutrients from diverse and eye-opening sources.

For example, vitamin A, which is fat soluble, is also plentiful in the oils of cold-water fishes and sea mammals, as well as in the animals’ livers, where fat is processed.

These dietary staples also provide vitamin D, another fat-soluble vitamin needed for bones. Those of us living in temperate and tropical climates on the other hand usually make vitamin D indirectly from exposure to the strong sun, and by consuming fortified cow’s milk which the indigenous northern groups had little access to and don’t tolerate very well.

As for vitamin C, the source in the Eskimo diet was long a mystery. Most animals can synthesise their own vitamin C in their livers, but humans are among the exceptions along with other primates and oddballs like guinea pigs and bats. Scurvy – joint pain, rotting gums, leaky blood vessels, physical and mental degeneration – plagued European and US expeditions even in the 20th century. However, Arctic peoples living on fresh fish and meat were free of the disease. Native foods easily supply enough vitamin C especially when organ meats – preferably raw – are on the menu.

In a study comparing the vitamin C content of 100 gram samples of foods eaten by Inuit women in the Canadian arctic: raw caribou liver supplied 24 mg, seal brain 15 mg and raw kelp more than 28 mg. Still higher levels were found in frozen whale skin and blubber. Wherever collagen is made, you can expect vitamin C. Thick skinned, chewy, and collagen rich, raw muktuk can serve up an impressive 36 mg of vitamin C in a 100g piece. Traditional Inuit practices like freezing meat and fish and frequently eating them raw conserve vitamin C, which is easily cooked off and lost in food processing.

Not often in our industrial society do we hear someone speak so familiarly about “our” food animals. We don’t talk of “our pig” and “our beef.” We’ve lost that creature feeling, that sense of kinship with food sources. You’re taught to think in boxes. In our culture the connectivity between humans, plants, the land they live on, and the air they share is ingrained in us from birth.

The ethnographic diet

The Ethnographic Atlas is a database on 1,167 societies coded by George P. Murdock and published in 29 successive installments in the journal Ethnology, 1962-1980. Dr Loren Cordain, professor of evolutionary nutrition at Colorado State University reviewed the macronutrient content (protein, carbohydrates, fat) in the diets of 229 hunter-gatherer groups from the Ethnographic Atlas, including some of the oldest surviving human diets. In general, hunter-gatherers tend to eat more animal protein than we do in the standard Western diet, with its reliance on agriculture and carbohydrates derived from grains and starchy plants. Lowest of all in carbohydrate, and highest in combined fat and protein, are the diets of peoples living in the Far North, where they make up for fewer plant foods with extra fish.

A protein ceiling

Equally striking, these meat-and-fish diets also exhibit a natural “protein ceiling”. Protein accounts for no more than 35-40 percent of their total calories, which suggests that’s all the protein humans can comfortably handle. Cordain thinks this ceiling could be imposed by the way we process protein for energy.

The simplest, fastest way to make energy is to convert carbohydrates into glucose, our body’s primary fuel. But if the body is out of carbohydrates, it can burn fat, or if necessary, break down protein from muscle. On a truly traditional diet, Arctic people had plenty of protein but little carbohydrate, so they often relied on gluconeogenesis. Gluconeogenesis is our body’s way of making glucose from protein and takes place in the liver. It uses a dizzying slew of enzymes and creates nitrogen waste that has to be converted in to urea and disposed of through the kidneys. Not only did the Inuit have bigger livers to handle the additional work but their urine volumes were also typically larger to get rid of the extra urea.

Nonetheless, there appears to be a limit on how much protein the human liver can safely cope with. Too much overwhelms the liver’s waste-disposal system, leading to protein poisoning – nausea, diarrhoea, wasting and death. Plenty of evidence shows that hunters through the ages avoided protein excesses, discarding fat-depleted animals even when food was scarce. Early pioneers and trappers in North America encountered what looks like a similar affliction, sometimes referred to as rabbit starvation because rabbit meat is notoriously lean. Forced to subsist on fat-deficient meat, the men would gorge themselves, yet wither away.

Protein can’t be the sole source of energy for humans, anyone eating a meaty diet that is low in carbohydrates must have fat as well. Furthermore, a normal meat diet is not a high-protein diet. In the traditional Inuit diet, three-quarters of the calories was coming from fat. However, numerous researchers point out that there are profound differences between the Inuit diet and our modern farm-raised meats and processed fats.

You truthfully can’t separate the way we get our food from the way we live. How we get our food is intrinsic to our culture. It’s how we pass on our values and knowledge to the young. When you go out with your aunts and uncles to hunt or to gather, you learn to smell the air, watch the wind, understand the way the ice moves, know the land. You get to know where to pick which plant and what animal to take.

All fats are not created equal

Fats have been demonised in the United States, says Eric Dewailly, professor of preventive medicine at Laval University in Quebec. In the Nunavik villages in northern Quebec, adults over 40 get almost half their calories from native foods and their cardiac death rate is about half of other Canadians or Americans. The heart of the Inuit paradox is that all fats are not created equal, more importantly the fats in Inuit native foods come from wild animals.

Farm animals, cooped up and stuffed with agricultural grains (carbohydrates) typically have lots of solid, highly saturated fat. Much of our processed food is also riddled with solid fats, or trans-fats, such as the re-engineered vegetable oils and shortenings hidden in baked goods and snacks. A lot of the packaged food on supermarket shelves contains them. So do commercial french fries.

Wild animals that range freely and eat what nature intended have fat that is far more healthful. Less of their fat is saturated, and more of it is in the monounsaturated form (like olive oil). Also, cold-water fishes and sea mammals are particularly rich in polyunsaturated omega-3 fatty acids. The polyunsaturated fats in most American diets are the omega-6 fatty acids supplied by vegetable oils. By contrast, whale blubber consists of 70 percent monounsaturated fat and close to 30 percent omega-3s.

It’s part, too, of your development as a person. You share food with your community. You show respect to your elders by offering them the first catch. You give thanks to the animal that gave up its life for your sustenance. So you get all the physical activity of harvesting your own food, all the social activity of sharing and preparing it, and all the spiritual aspects as well. You certainly don’t get all that, do you, when you buy prepackaged food from a store.

Food is a culture, not a diet

The subsistence diets of the Far North are not “dieting”. Dieting is the price we pay for too little exercise and too much mass-produced food. Northern diets were a way of life in places too cold for agriculture, where food, whether hunted, fished, or foraged, could not be taken for granted. They were about keeping weight on. Subsistence living requires hard physical work. The native diet and lifestyle provides a hedge against obesity, type 2 diabetes and heart disease, but the well-being of the northern food chain is coming under threat from globalisation, global warming and industrial pollution of the marine environment.

Prof Stephen Palumbi shows how toxins at the bottom of the ocean food chain find their way into our bodies. It has disrupted the food ways of the Inuit such that mothers can no longer breastfeed their own children.

No one, not even residents of the northernmost villages on Earth, eats an entirely traditional northern diet anymore. The Inuits have probably seen more changes in their diet in a lifetime than their ancestors did over thousands of  years. And with westernisation, comes processed foods and cheap carbohydrates, as well as type 2 diabetes, obesity and other diseases of the Standard American Diet.

That’s why some of us here in Anchorage are working to protect what’s ours, so that others can continue to live back home in the villages. Because if we don’t take care of our food, it won’t be there for us in the future. And if we lose our foods, we lose who we are. The word Inupiat means “the real people”. That’s who we are. – Patricia Cochran

References

• Gadsby P. The Inuit paradox. Discover Magazine, August 2002, pp. 12-14. [PDF]

The complexity of living systems

Although the principle of homeostasis has been a cornerstone of western physiology for more than a century, the enormous complexity of biological systems has often driven pharmaceutical research towards trying to identify and influence single targets that make the difference between health and disease. This approach has yielded many potent drugs, especially for the treatment of acute conditions such as infectious diseases, but also revealed major drawbacks.

In fact, it involves trying to influence a system by interacting with a single protein that is often part of a complex pathway, and involved in a cascade of reactions and feedback loops. The reality is that most diseases are multi-factorial which means that treating a single target provides a partial treatment, and no cure in the majority of cases. In the case of chronic diseases, serious side effects can occur particularly in the long term. Although this awareness is not new, it has been very difficult to find alternative routes given the complexity of the living system, which is almost impossible to reveal.

Chinese medicine treats the system

The therapeutic principles and goals of traditional Chinese medicine (TCM) are different from those in western medicine. In western medicine, drugs are developed to antagonise pathological targets or eliminate pathogenetic factors, whereas in TCM the therapy is aimed at a specific response which reflects changes on multi-system and multi-organ levels. This is an approach unique to TCM that also distinguishes it from most other folk medicines in the world which usually treat symptoms or diseases.

TCM does not focus solely on the disease defined by specific pathological changes, but instead concentrates on the overall functional state of the patient.

In western medicine, a disease is thought to develop as a result of one of more crucial pathogenic factors, whereas in TCM a disease is a common product of both pathogenetic factors and maladjustments in the body. The diagnosis proposed by TCM focuses more on the body’s response to pathogenetic factors than the pathological mechanisms.

The number of potential different stimulants (eg. microorganisms, environmental changes) is enormous but the number of reaction types elicited by the body (eg. fever, cough) is limited. The absence of knowledge about the pathological changes that occur inside the body does not hinder diagnosis by TCM. In TCM diagnosis, all of the visible signs and symptoms of patients are analysed to identify the type of internal maladjustments. This systematic classification of functional states, or patterns of disharmony, is called syndrome differentiation and forms the foundation of all TCM diagnosis and treatment.

The pharmacological basis of Chinese medicine

Synergistic and complementary effects

Because the ‘target’ of TCM treatment is the pattern that reflects multi-system changes, benefits produced by herbal medication include not only the regulation of several crucial targets but, more importantly, the modulation of other associated general changes that delay the healing process. The huge number of active ingredients in one formula makes it suitable for multi-target actions. For example, TCM heat-clearing herbs are often used to treat infection but their pharmacological mechanisms are not limited to antibiotic actions.

Microorganisms are not the only important factors involved in infection. In addition to the presence of fever and local inflammation and infection, toxins and their induced cytokines and mediators such as interleukin 1 and histamine can excite the CNS and sympathetic-adrenomedullary system, increase the levels of metabolites of proteins and sugars and capillary permeability, and cause the dysfunction of blood coagulation and the digestive system.

In turn, these effects could do harm to the body, such as inhibit immune function and cause arteriolar constriction, leading to a disturbance of the microcirculation. Antibiotics alone would not be able to solve all these problems.

In another example, TCM cold-dissipating herbs can promote thermogenesis and diaphoresis, dilate constricted superficial blood vessels, and even excite the HPA axis. Thermogenesis helps the body to stimulate the defense system: dilation of blood vessels and sweating can increase heat loss to keep the body’s temperature balanced. These herbs do not aim to inhibit the thermogenic centre or kill the pathogens, although they might contain some anti-organism ingredients. No medicine could be more efficient than improving the self-healing mechanism of the body, which are formed during evolution.

Except in the presence of a genetic defect in self-regulation, drugs should not be designed to replace or interfere with the self-healing process of the body. The role of the drug in TCM is merely to either improve the body’s regulatory mechanisms or remove factors that impair the self-healing ability of the body. It should also be pointed out that chemical compounds such as those used in ‘cocktail’ therapies for AIDS, although multi-targeted, are conceptually and methodologically different from TCM therapy because their design is still based on internal pathological targets and not the general response of the body.

Individualised treatment

Although different diseases have common pathological mechanisms, the mechanism of one disease might not be identical in different people. Another aspect challenging the validation of the efficacy of herbal medicine is individualised therapy.

Individualised therapy in TCM originated from the ancient physicians’ concern with constitutional differences and different reactions to one pathogenetic factor among individuals. Even when treating the same pathological change (eg. myocardial ischemia), TCM practitioners still give individualised therapy based on the symptoms and the patient’s constitution. The different mechanisms that cause ischemia validate the scientific basis of such individualised treatment.

Preliminary work supports the viewpoint that the efficacy and toxicity of herbs are associated with syndromes in TCM (ie, pharmacokinetics of a formula correlated with the specific pattern). The idea behind pattern-based individualised medication is in accordance with the future point that pharmacogenetics hopes to reach.

Finding synergy

The western pharmaceutical industry often tends to approach Chinese medicine from a non-holistic perspective, by searching for single bioactive compounds. This is the standard approach used for exploring natural products. However, this approach for bioactivity screening removes the important basis of multiple component intervention, including synergy, being the basis of TCM’s holistic approach.

Synergy is an aspect that will be lost in a target driven, single lead discovery programme with TCM. For example, the US National Cancer Institute and US Department of Agriculture screened 35,000 samples from different tissues from 12,000 plant species and only three new drugs were discovered. Nevertheless, the ancient Oriental pharmacopoeias contain thousands of therapeutic formulations, indicating that the biological activity of these preparations might result from the synergy of active compounds rather than from a single chemical entity.

For example, the antimicrobial activity of the alkaloid berberine is 100 times enhanced by 5′ MHC, a compound found in the same plant as the alkaloid but has no antimicrobial effect itself.

Even the antiproliferative activity of pomegranate juice extract is enhanced by both peel and seed extracts.

Another example from nature comes from the traditional use of bark of Salix to treat pain and headaches. Interestingly, acetylsalicylate (aspirin) is not found in the bark. The bark contains salicin which is hydrolysed to saligenin and finally oxidised to yield salicylic acid in the gut. The medicinal plant itself doesn’t contain an active compound in this case, but a pro-drug, which would be very unlikely to be selected by conventional screening methods.

The nascent use of systems biology and metabolomics can study the effect of complex mixtures such as those used in traditional Chinese medicines as well as the foods we eat. It offers a more holistic approach to the study of complex biological systems such as plants and humans which cannot be adequately described by a reductionist approach. These techniques are promising but also represent one of the most complex challenges today in life sciences research.

A better understanding of plants

In TCM more than 80% of the constituents of preparations are derived from plants. Like any other organism, plants are constantly interacting with their changing, and often harsh, environment during the several phases of their life cycle. Many plant secondary metabolites have biological effects because these compounds confer many benefits to the plant such as chemical protection against invading pathogens and predators, or the attraction of pollinators. Plants can make several thousands of these secondary metabolites. This has resulted in a natural treasure house with highly diverse and often very potent compounds with a wide diversity of application in human health. It is also a strong argument for the protection of the biodiversity of our natural environment, upon which we depend for our health and our medicines.

Plants must also be regarded as living systems and not merely a collection of compounds to be harvested and extracted.

The production of plant secondary metabolites is highly dynamic and responsive to their environment. For example, harvesting ginkgo leaves after a light period dramatically increases both the ginkgolide and bilobalide content. Not only the quantity but also the qualitative composition of the secondary metabolites is affected by the time of harvesting.

In many studies of the activity of medicinal plants, and in particular clinical studies, the plant material was not properly defined, making the results very doubtful and difficult to evaluate. Researchers studying plant metabolites would be well rewarded with the additional study of plants themselves.

Beyond reductionism

China’s experience has shown that methodologically it is not appropriate to apply reductionism to TCM research.

It may be relatively cheap and convenient to trial single herbs and their active constituents, but we can now understand why the result will fall short of the true potential and efficacy of TCM.

It is evident that as western medicine begins to explore the benefits of complementary medicines such as TCM, it must also take the further step of learning the therapeutic wisdom with which to understand its methodology and evaluate its efficacy. All life belongs to a system and we will never truly understand it unless we begin to study the sum of the parts.

Ed: a large part of this article is paraphrased from the excellent paper by Wen-Yue Jiang. We encourage interested readers to pursue the original article referenced below which contains even more detail.

References

• Jiang WY. Therapeutic wisdom in traditional Chinese medicine: a perspective from modern science. Trends in Pharmacological Sciences. 2005:26(11);558-563. [PDF]
• Wang M, Lamers R-JAN, Korthout HAAJ, van Nesselrooij JHJ, Witkamp RF, van der Heijden R, Voshol PJ, Havekes LM, Verpoorte R, van der Greef J. Metabolomics in the context of systems biology: bridging traditional Chinese medicine and molecular pharmacology. Phytotherapy Research. 2005:19;173–182. doi: 10.1002/ptr.1624 [PDF]

A paper submitted by Pauling to the Proceedings of the National Academy of Sciences and accepted for publication on June 11, 1991 was later revoked by the editor under questionable circumstances: “We are aware that this pullback was not the decision of an individual. It happened in the interest of those who are personally or economically dependent on the present dogma of human cardiovascular disease.”

In the mid-1930s, Pauling shifted his interest towards biological molecules and protein structures, although it was his work on vitamin C which generated much controversy. Pauling popularised vitamin C as an effective therapy for terminal cancer patients and the common cold. However, the failure of randomised trials by the Mayo Clinic to demonstrate any benefit and the public debate that ensued resulted in the medical establishment eventually rejecting his claims as quackery.

In his last years, Pauling continued to research vitamin C and became especially interested in its possible role in preventing atherosclerosis and heart disease. It is this forgotten work by Pauling and Matthias Rath at the Linus Pauling Institute which presents a compelling case for re-examining atherosclerosis research, prevention and treatment.

Our evolutionary loss of endogenous vitamin C production

Almost all animals are capable of synthesising their own ascorbate (vitamin C is the common name for ascorbate) by conversion from glucose, except humans who lost this ability about 40 million years ago. Our ancestors at that time lived in tropical regions and their diet provided an abundant ascorbate supply from several hundred milligrams to several grams per day (by comparison, modern government recommended intakes are set at 40-95 mg/day). When our ancestors eventually settled other regions of the world with less availability of dietary ascorbate, they became prone to scurvy.

After the loss of endogenous ascorbate production, lipoprotein(a)/Lp(a) and apolipoprotein(a)/apo(a) became greatly favoured by evolution. The frequency of occurence of elevated Lp(a) plasma levels in species that had lost the ability to synthesise ascorbate is so great that it is hypothesised that apo(a) functions as a surrogate for ascorbate.

The primary cause is ascorbate deficiency and lipoprotein(a) deposition

“Human CVD is multifactorial. Ascorbate deficiency, however, is the common denominator of this disease.”

In the course of their work, Pauling and Rath discovered that virtually every patho-mechanism for human cardiovascular disease (CVD) can be induced by ascorbate deficiency, as a consequence of the inability of humans to synthesise endogenous ascorbate combined with insufficient dietary intake.

To summarise their theory:

1. Ascorbate deficiency leads to increased permeability of the vascular (blood vessel) wall because ascorbate is essential for the optimal production and hydroxylation of collagen and elastin.
2. The physiological response to this blood loss results in vasoconstriction and haemostasis (blood vessel constriction and clotting), with the deposition of Lp(a) and fibrinogen being the most effective, specific and frequent of these countermeasures.
3. In ascorbate deficiency, Lp(a) is selectively retained in the vascular wall. Apo(a) compensates for collagen by binding to fibrin. Lp(a) also has functions in the containment of diseases and the repair of tissues. Lp(a) can inhibit both free-radical induced and plasmin-induced tissue degradation.
4. Chronic ascorbate deficiency leads to a sustained accumulation of Lp(a) in the vascular wall, which leads to the localised development of atherosclerotic plaques, premature CVD, heart attack and stroke.

The extracellular accumulation of Lp(a) in the vascular wall is an independent pathomechanism of human CVD which is at variance with concepts suggesting that the cellular uptake and degradation of lipoproteins by scavenger cells is a prerequisite for atherogenesis.

Cigarette smoking also damages the vascular endothelium directly or via oxidation of lipoproteins. Ascorbate, being the strongest antioxidant normally present in the body is a potent inhibitor of these pathomechanisms.

Other genetic and metabolic disorders associated with CVD

Inherited disorders of lipoprotein metabolism such as familial hypercholesterolaemia (elevated LDL), hypertriglyceridemia (elevated triglyceride) and hyperhomocysteinuria (elevated homocysteine) are frequently associated with CVD.

Ascorbate deficiency unmasks these underlying genetic defects and leads to an increased blood concentration of lipids (cholesterol, triglycerides) and lipoproteins (LDL, VLDL) and their deposition in the impaired vascular wall.

The deposition of these lipoproteins other than Lp(a) is a less specific defense mechanism and frequently follows Lp(a) deposition. With sustained ascorbate deficiency the continued deposition of lipids and lipoproteins leads to atherosclerotic plaque development and CVD.

Peripheral vascular disease

Lp(a) is predominantly deposited at predisposition sites and is therefore found to be significantly correlated with coronary, cervical and cerebral atherosclerosis but not with peripheral vascular disease (PVD). In about half of the CVD patients the mechanism of Lp(a) deposition contributes significantly to the development of atherosclerotic plaques.

The vascular defense mechanisms associated with most genetic disorders are non-specific. These mechanisms can aggravate the development of atherosclerotic plaques at predisposition sites. Other nonspecific mechanisms lead to peripheral forms of atherosclerosis by causing a thickening of the vascular wall throughout the arterial system. PVD is characteristic for angiopathies associated with type 3 hyperlipidemia, diabetes mellitus, hyperhomocysteinuria and many other inherited metabolic diseases.

In general, inherited metabolic disorders resulting in an elevated concentration of noxious plasma constituents, such as hyperhomocysteinuria, are frequently associated with peripheral vascular disease.

Evolutionary conservation

After the loss of endogenous ascorbate production, scurvy and fatal blood loss rendered our ancestors in danger of extinction. Under this evolutionary pressure, genetic and metabolic countermeasures that could counteract the increased permeability of the vascular wall were favoured. By favouring these “disorders”, nature decided for the lesser of two evils: the death from CVD after the reproduction age rather than death from scurvy at a much earlier age.

These genetic disorders were conserved during evolution largely because of their association with mechanisms that lead to the thickening of the vascular wall. Inherited disorders associated with CVD became the most frequent among all genetic predispositions, lipid and lipoprotein disorders occuring particularly often. The more effective and specific a certain generic feature conteracted the increasing vascular permeability in scurvy, the more advantageous it became during evolution and the more frequently this genetic feature occurs today.

Familial hypercholesterolaemia

Familial hypercholesterolaemia (FH) increases the risk for premature CVD primarily when combined with elevated plasma levels of Lp(a) or triglycerides. The incidence of CVD was shown to be significantly determined by the Lp(a) plasma concentration, with total cholesterol and LDL cholesterol in the plasma not related to the clinical manifestations of CVD.

Ascorbate supplementation prevents the exacerbation of hypercholesterolaemia and related CVD by increased catabolism of cholesterol, stimulating 7-a-hydroxylase, a key enzyme in the conversion of cholesterol to bile acids and increasing the expression of LDL receptors on the cell surface. Furthermore, ascorbate is known to inhibit endogenous cholesterol synthesis as well as oxidative modification of LDL.

Hypertriglyceridemia

Triglyceride rich lipoproteins are particularly subject to oxidative modification, cellular lipoprotein uptake and foam cell formation. Ascorbate supplementation prevents the exacerbation of CVD by stimulating lipoprotein lipases and thereby enabling a normal catabolism of triglyceride rich lipoproteins. Ascorbate prevents the oxidative modification of these lipoproteins, their uptake by scavenger cells and foam cell formation.

Hypoalphalipoproteinemia (low HDL)

Hypoalphalipoproteinemia (HA) is a frequent lipoprotein disorder (reflecting its evolutionary usefulness) characterised by a decreased synthesis of HDL particles. HDL is part of the reverse-cholesterol-transport pathway and is critical for the transport of cholesterol and other lipids from the body periphery to the liver. Ascorbate supplementation can increase HDL production, leading to an increased uptake of lipids deposited in the vascular wall and to a decrease of the atherosclerotic lesion.

This mechanism was important during evolution. During the winter seasons, with low ascorbate intake, our ancestors became dependent on protecting their vascular wall by the deposition of lipoproteins and other constituents. During spring and summer, the ascorbate content in the diet increased significantly and mechanisms were favoured that decreased the vascular deposits.

In an earlier clinical study it was shown that 500 mg of daily dietary ascorbate can lead to a reduction of atherosclerotic deposits within 2 to 6 months. This concept also explains why heart attack and stroke occur today with a much higher frequency in winter than during spring and summer, seasons with increased ascorbate intake.

Diabetes mellitus

The glucose and ascorbate molecule share structural similarities and compete for the same transport system for cellular uptake. Elevated blood glucose levels prevent many cellular systems in the human body, including endothelial cells, from optimum ascorbate uptake, leading to the chronic depletion of ascorbate. Ascorbate supplementation prevents diabetic angiopathy by optimising the ascorbate concentration in the vascular wall and also by lowering the need for insulin.

Hyperhomocysteinuria

Hyperhomocysteinuria is characterised by the accumulation of homocysteine and its metabolic derivatives in the blood plasma, tissues and urine as a result of decreased homocysteine catabolism. Elevated concentrations of homocysteine damage the endothelial cells throughout the arterial and venous system, leading to peripheral vascular disease and thromboembolism. These clinical manifestions have been estimated to occur in 30 percent of patients before age 20 and in 60 percent of patients before age 40. Ascorbate supplementation prevents homocysteinuric angiopathy and other clinical complications by increasing the rate of homocysteine catabolism.

Ascorbate supplementation may be a universal treatment

The overall rate of ascorbic depletion in an individual is largely determined by the polygenic pattern of disorders. The earlier the ascorbate reserves in the body are depleted without resupplementation, the earlier CVD develops.

Optimum ascorbate supplementation prevents the development of CVD independently of the individual predisposition or pathomechanism. Ascorbate reduces existing atherosclerotic deposits and thereby decreases the risk for myocardial infarction and stroke. Moreover, ascorbate can prevent blindness and organ failure in diabetic patients, thromboembolism in homocystinuric patients, and many other manifestations of CVD.

What is to become of a lost legacy?

“Fifty years ago ascorbate deficiency was established as a prominent risk factor in CVD, 37 years ago ascorbate was shown in preliminary angiographic studies to reduce atherosclerotic plaques in man. There is no rational explanation why these early observations of the therapeutic value of ascorbate were ignored and did not become common knowledge in the medical profession long ago.”

Pauling and Rath also believed that the significance of their discovery was not limited to CVD; Lp(a) and ascorbate are involved in cancer, inflammatory diseases, and other diseases including the process of aging. Abolition of ascorbate deficiency may profoundly improve human health and increase the life expectancy of human beings.

Lessons learned from randomised controlled trials

In the last two decades, several randomised controlled trials have shown no effect of antioxidant supplements on hard endpoints such as morbidity and mortality. Lykkesfeldt and Poulsen (2010) reviewed the literature on vitamin C and were disappointed that at present we do not have the necessary scientific evidence to judge the effect on health – be that beneficial or deleterious – from vitamin C supplementation as a single substance.

They found that no study has used vitamin C deficiency as an inclusion criterion. No dose-response relationships for pharmacodynamic evaluation are available. For most of the available studies, the population status at entry with regard to vitamin C is unclear and may have been severely or marginally deficient, suboptimal or optimal. Major confounders are, for example, dietary vitamin C and smoking status, and these factors need to taken into account in the study design.

The authors regard that there is a dire need for high-quality trials to examine the effect of vitamin C as a single supplement in populations which have been carefully defined with inclusion criteria of different levels of vitamin C status and with variable demand for vitamin C, for example, smokers v. non-smokers.

Ed: given the significance of the claims, we sincerely hope our readers will further investigate and scrutinise this theory. How does vitamin C supplementation compare with statin treatment? More clinical trials are needed to support this profound hypothesis, which may yet prove to be Pauling’s last legacy.

References

• Rath M, Pauling L. Solution to the puzzle of human cardiovascular disease: it’s primary cause is ascorbate deficiency leading to the deposition of lipoprotein(a) and fibrinogen/fibrin in the vascular wall. J Orthomol Med. 1991;6(3&4):125-134. [Fulltext]
• Rath M, Pauling L. A unified theory of human cardiovascular disease leading the way to abolition of this disease as a cause for human mortality. J Orthomol Med. 1992;7(1):5-12. [PDF]
• Lykkesfeldt J, Poulsen HE. Is vitamin C supplementation beneficial? Lessons learned from randomised controlled trials. Br J Nutr. 2010 May;103(9):1251-9. Epub 2009 Dec 15. Review. [PDF]
• Li Y, Schellhorn HE. New developments and novel therapeutic perspectives for vitamin C. J Nutr. 2007;137: 2171–2184. [Fulltext]

“Worldwide, more than 1.3 billion people are overweight, whereas only 800 million are underweight – and these statistics are diverging rapidly.” – Barry M Popkin

For most developing nations, obesity has emerged as a more serious health threat than hunger. Although under-nutrition and famine remain significant problems in sub-Saharan Africa and South Asia, even desperately poor countries such as Nigeria and Uganda are wrestling with the dilemma of obesity.

Globalisation over the past 20 years has contributed to the increased consumption of sweetened beverages, vegetable oils and animal-source foods by poor people in developing countries, as they also adopt sedentary Western lifestyles. This combination of lifestyle and dietary changes is paving way for a global public health catastrophe.

Obesity is a burden on the poor

In 1989 fewer than 10% of Mexicans were overweight, nobody talked about obesity and diabetes were almost nonexistent. National surveys in 2006 found that 71% of Mexican women and 66% of Mexican men were now overweight or obese, with almost 1/7th of the country bearing the burden of type 2 diabetes. Incidentally, Mexicans have since surpassed the US as the world’s number 1 Coca-Cola drinkers per capita.

In the developing world, obesity has become predominantly a problem of the poor, just as it is in the US. In all countries with a GDP greater than US$2,500 per capita (which includes most developing nations outside of sub-Saharan Africa) obesity rates are higher for poor women than for those with higher socioeconomic status.

As average incomes have risen, farm labourers and the urban poor have adopted modern habits associated with obesity such as watching television and shopping in supermarkets, but lack access to education, healthier foods and recreational opportunities.

Scientists have also long hypothesised that Latin American, African and South Asian populations carry more “thrifty genes” that may predispose the obese in these developing countries to develop diabetes or high blood pressure than obese individuals of European descent. In China, where obesity levels are climbing rapidly, nearly one third of the population suffers from high blood pressure.

A sickly sweet disaster

One of the biggest contributors to the obesity epidemic in the Third World is the recent popularity of sweetened beverages. The proportion of calories coming from beverages has been relatively small until the past 50 years, when Coca-Cola, Pepsi and other soft drinks began spreading across the globe. The human body did not evolve to reduce food intake to compensate for beverage consumption, therefore people continue to eat the same amount of food and their total calorie consumption increases.

Research has estimated sweeteners in beverages added about 137 kcal to the average American diet between 1977 and 2006, which translates to an average weight gain of 6.4 kgs over a year. The average Mexican now consumes more than 350 kcal from beverages every day.

The expansion of supermarkets in the developing world has greatly increased the availability of cheap sweetened beverages and processed foods. Technological advances in production and processing have made vegetable oil a relatively cheap option for poor families. The consumption of energy-dense vegetable oils (soybean oil, palm oil, corn oil and their variations) has recently skyrocketed in the developing world. In China, the average daily vegetable oil intake rose from 14.8 grams per person in 1989 to 35.1 grams per person in 2004, adding an extra 183 kcals to the daily diet; the poor spend a larger share of their food expenditures on vegetable oil than the rich.

The globalisation of obesity

The overarching trend that is encouraging all these detrimental changes in diet and lifestyle is globalisation. Global food retailers are opening cheap megastores, global media companies have enhanced the attraction of television and the marketing of sugar-loaded foods and beverages. Many governments and industries are contributing to the growth in obesity by flooding developing countries with cheap sweeteners, oils and meat while doing nothing to promote the consumption of fruits and vegetables. Furthermore, international agencies such as the World Bank have promoted agricultural changes that have encouraged the proliferation of unhealthy diets in the developing world.

The long-held philosophy of agricultural experts is that once a country produces enough grains and tubers, it should massively subsidise its livestock, poultry and fish industries. The result has been a major reduction in the prices of animal-source foods.

Over the past 20 years most of the growth in the world’s production of meat, poultry, fish, eggs and milk has come from developing nations. Latin Americans are eating more beef, Chinese are eating more pork, and Indians consuming more dairy products. By 2020 developing countries are expected to produce nearly two thirds of the world’s meat and half its milk.

People are rapidly abandoning their traditional low-fat, high-fibre diets and switching to meals of calorie-rich fats, sweeteners and refined carbohydrates.

The need for a globalised solution

Representatives of the food industry insist that governments should not restrict an individual’s dietary choices, their solution is to teach people how to control their diets and become more physically active (ed: ironically these companies spend billions of advertising dollars on television). Even most health professionals in the US and abroad focus on the narrow, short-term need to educate children and their parents. But this strategy ignores the vast social, technological and structural changes that are pushing millions of people into debilitating lives of obesity. If left unchecked, the momentum of these changes will cause horrendous increases in chronic illness and reductions in life expectancy worldwide.

Government and private aid programs in developing countries can also backfire if national hunger programs do not consider the consequences of transitioning their populations to unhealthy and overweight lifestyles.

The need for healthier, sustainable agriculture

We could begin by restructuring the massive agricultural subsidies that encourage the production of meat, poultry and dairy products. Instead of giving billions of dollars to giant agribusinesses growing grain for livestock, the US and other high-income nations could direct some of that money to farmers cultivating fruits and vegetables.

Reforms are needed to make healthier diets available and affordable for poor people in developing countries (and developed countries). Current food prices do not take into account the health and environmental costs of their production and consumption. Making meat more expensive and vegetables cheaper would provide an incentive for healthier food choices. New farm policies should also promote the global consumption of whole grains, which have more fibre, vitamins and minerals than refined carbohydrates.

Government responsibility is our responsibility

Revamping farm subsidies will not be as effective for discouraging the consumption of sweetened foods and beverages, because the cost of sweeteners represent just a small fraction of their price. The author of this research, professor Barry M Popkin, is working with the Ministry of Health in Mexico to devise taxes on caloric sweeteners and other high-calorie beverages. Working with the Chinese government in testing a tax on vegetable oil, he has found that taxing dietary fat can cut the total calorie intake while increasing protein consumption among the poor in China, because they substitute healthier foods for the fats.

Understanding the wider global, socioeconomic, environmental and agricultural issues driving the obesity epidemic will help all health professionals to design more effective weight-loss programs. No country in modern times has succeeded in reducing the number of its citizens who are overweight or obese and the obesity epidemic is accelerating. Gathering political support for a fight against obesity remains difficult when obesity is still viewed as a sigh of sloth and gluttony rather than as a consequence of global changes. With this knowledge, we all have the responsibility to support policies that can stem this truly globalised epidemic.

References

• Popkin BM. 2007. The world is fat. Scientific American Magazine, 88-94, Sept. [PDF]
• Monteiro CA, Moura EC, Conde WL, Popkin BM. Socioeconomic status and obesity in developing countries: a review. Bulletin of the World Health Organisation. 2004;82:940-946. [PDF]
• The Nutrition Transition [http://www.nutrans.org]

The Tsimane’ are a population of some 9,000 forager-horticulturalists inhabiting a vast area of lowland forests, and savannas east of the Andes in the Bolivian Amazon. They live in about 80 small villages without running water or electricity, and make a living through swidden agriculture, hunting, fishing, gathering, and occasional wage labor.

The Tsimane’ offer some of the last remaining opportunities to study the effects of kin, culture, and ecology on aging in a small-scale, natural fertility, kin-based, subsistence society, and for this reason have been the focus of study by the UNM-UCSB Tsimane’ Health and Life History Project which began in 2001.

This joint health and anthropology project aims to understand the impacts of ecology and evolution on the shaping of the human life course. It focuses on health, growth and development, aging, economics and biodemography of small-scale populations of hunter-gatherers and horticulturalists, combining biomedical and anthropological research with medical attention.

The following study by Gurven et al. supports the mounting evidence that chronic vascular disease had little impact on adult mortality for most of human evolutionary history.

Inflammation and infection do not promote arterial aging and cardiovascular disease risk factors among lean horticulturalists

The general health of the Tsimane’ is characterised by their short life expectancy at birth of 54 years (from 1990-2000), high infectious loads and inflammation, with half of documented deaths due to infectious and parasitic disease. Anemia is prevalent and physical growth is stunted, however, they are physically fit and consume a lean diet.

Chronic inflammation is associated with all stages of cardiovascular disease (CVD) in modern, sedentary societies. For the Tsimane’ however, their risk of CVD due to higher lifetime infection and inflammation exposure is expected to be offset by their physical fitness, low adiposity and lean diet.

The study found no evidence of advanced atherosclerosis, with an absence of peripheral arterial disease (PAD) among the entire sample of 258 Tsimane’ adults. Furthermore, PAD increases with age in every investigated population except the Tsimane’, including rural and urban settings in both developed and developing countries. The Tsmiane’ also have low rates of hypertension, increasing with age and peaking at 23.5% for adults >70 years.

These results are consistent with previous reports of low CVD among traditional foraging and small-scale farming populations. Traditional populations often show negligible CVD prior to the adoption of western diets and sedentary lifestyles. Australian Aborigines and Pima Indians now have the highest prevalence of obesity and type 2 diabetes in the world.

Interestingly, obesity, blood lipids, cigarette smoking, disease history and cardiovascular indicators were not significantly associated with Tsimane’ PAD after controlling for age and sex. Over half of Tsimane’ adults show unfavourable HDL levels by American Heart Association standards. Also contrary to expectations, higher WBC and ESR associate with lower blood pressure among the Tsimane’ and CRP is not significant, whereas CRP is a positive predictor of high blood pressure in the US.

A possible hypothesis for these findings may be due to the physically demanding Tsimane’ lifestyle. It is estimated that Tsimane’ men and women age 40-49 expend 850 and 450 kcals/day more, respectively, in physical activity than US adults. Exercise reduces oxidative load in muscle, levels of inflammatory cytokines, systolic blood pressure, macrophage-rich fat and improves insulin sensitivity. In comparison with the Tsimane’, physical activity is extremely low among industrialised populations.

Alternative explanations which merit future investigation include genetic variability, the influence of diet (eg. flavonol-rich citrus fruits) and hypothesised cardioprotective effects of helminthic infection.

This study provides preliminary evidence that the presence of chronic infection and inflammation in a subsistence population does not necessarily predict CVD. The risk factors applicable to westernised populations may not accelerate atherosclerosis in the context of a restricted caloric diet, parasitism, and daily physical activity that maintains low BMI.

References

• Gurven M, Kaplan H, Winking J, Eid Rodriguez D, Vasunilashorn S, et al. 2009 Inflammation and Infection Do Not Promote Arterial Aging and Cardiovascular Disease Risk Factors among Lean Horticulturalists. PLoS ONE 4(8): e6590. doi:10.1371/journal.pone.0006590 [Fulltext]
• Tsimane’ photo by M. Gurven.