Saturday, June 29, 2013

Really Cool!

Just got a REALLY nice email...

Dr. McCormick,

I saw you almost 3 years ago, when I was 26 and had just suffered a compression fracture and multiple rib fractures.  After following your advice and seeing a significant improvement in June 2011, I sent you my improved DEXA scan, and some updates about how I was back to running and started doing triathlons.

I just took another DEXA scan on Monday, attached, and the results are even better--I'm now in the normal range!  (At the low end, admittedly).  I'm still taking the supplements you had recommended and watching my diet (although still vegetarian), and I've kept my BMI in the healthy range.  And I've kept up the running and triathlons.

I hope I'm not bothering you with these updates.  My recovery has gone much better than I could have hoped in the summer of 2010, particularly since I decided not to take any drugs.  I remain incredibly grateful for the advice and inspiration you provided in your book and in my office visit.  Thanks so much, again.

Best,
Amy   

Really Cool!

Friday, June 28, 2013

How "Anabolic Resistance" can Derail Your Fight Against Age-related Muscle and Bone Loss

A recent article by Bouillanne et al. in Clinical Nutrition explains why optimal protein intake can help limit muscle loss during aging and why this is vital for maintaining health.

"Aging per se is responsible for a gradual loss of skeletal muscle mass (40% from 20 to 80 years of age) and muscle function, termed sarcopenia.  Sarcopenia is a major cause of the increased prevalence of disability, falls, morbidity and mortality in elderly people.  Malnutrition greatly accelerates sarcopenia in elderly subjects, in whom it preferentially induces a loss of lean muscle mass, unlike younger, similarly malnourished patients, in whom a loss of fat mass is preferentially induced.  The prevalence of malnutrition in the elderly is between 30% and 78% on hospital admission.  It is the most common cause of decreased skeletal muscle mass and strength and secondary immune dysfunction."

Preventing sarcopenia is more complex than simply engaging in an exercise program and eating a healthy, protein rich diet. Although these two factors are vital to successfully limiting muscle loss, to ensure an anabolic response we must also make sure that our body can metabolically respond to exercise and nutritional intake. If we are laden with inflammatory mediators from chronic systemic inflammation (which I have talked about numerous times in past blogs), then our body will not be able to utilize/metabolize this muscle stimulus/nourishment for anabolic rebuilding of muscle and bone.

This inability to respond to anabolic input has been referred to as "anabolic resistance" by Dardevet et al. in an article published in The Scientific World Journal. Here, the authors talk about the "anabolic threshold concept".

"These signaling alterations lead to an 'anabolic resistance' of muscle even if the anabolic factor requirements (amino acids e.g.) are theoretically covered, that is, with a normal nutrient availability fitting the recommended dietary protein allowances in healthy subjects."

 "This anabolic resistance may be in part explained by an increase of the muscle 'anabolic threshold' required to promote maximal anabolism and protein retention.  Because the muscle 'anabolic threshold' is higher, the anabolic stimuli (including aminoacidemia) cannot reach anabolic threshold anymore and by consequence, muscle anabolism is reduced with the usual nutrient intake."

"A possible nutritional therapy is then to increase the intake of anabolic factors (especially amino acids) to reach the new 'anabolic threshold.'  There are several ways to increase amino acid availability to skeletal muscle: increase protein intake, to supplement the diet with one or several free amino acids or to select the protein source on its amino acid composition and physicochemical properties when digested in the digestive tract."

The authors further explain that the amino acid leucine is key for stimulating protein synthesis for muscle growth. But they also caution that simply adding leucine supplements to a daily nutrient regime probably won't help to increase muscle mass.

"Studies with a synchronized leucine signal and amino acid availability have been performed by using leucine rich proteins that are rapidly digested (whey proteins).  With such proteins, leucine availability is increased simultaneously with the other amino acids to reach the increased muscle anabolic threshold.  However, as observed for free leucine supplementation, when such dietary proteins were given on the long term in elderly rodents, muscle anabolism was acutely improved but muscle mass remained unchanged." 

"...a strategy to reverse the increase in the 'anabolic threshold' would restore the anabolic stimulation during the postprandial period with lower intake of dietary proteins or amino acid supplementation.  This requires the knowledge of the factors involved and responsible in the 'anabolic threshold' elevation.  The causes can be multiple and specific for each catabolic state.  However, most of these muscle loss situations have in common an increase of the inflammatory status.  Regarding aging, levels of inflammatory markers, such as interleukin-6 (IL6) and C reactive protein (CRP), increase slightly, and these higher levels are correlated with disability and mortality in humans.  Even if the increase is moderate, higher levels of cytokines and CRP increase the risk of muscle strength loss and are correlated with lower muscle mass in healthy older persons.  We have recently shown that the development of a low grade inflammation challenged negatively the anabolic effects of food intake on muscle protein metabolisms and that the pharmacologic prevention of this inflammatory state was able to preserve muscle mass in old rodents. A resensitization of muscle protein synthesis to amino acids could also be achieved with other nutrients such as antioxidants." 

The take home message from all of this is that if your body is inflamed--if it harbors chronic systemic inflammation--simply eating a "good" diet will not suffice. Muscle loss will continue as you age due to this increased anabolic threshold. The key to preventing muscle loss (which is directly connected to bone loss) is to ensure a diet that includes rich sources of quality protein with an emphasis on leucine intake, and address/eliminate factors that promote inflammation. I give lots of tips on how you can reduce inflammation and promote an anabolic body in my book The Whole-Body Approach to Osteoporosis. Check out Chapter 9 (starting on page 171), it's all about "How to Create an Anabolic Body."

Bouillanne O et al. Impact of protein pulse feeding on lean mass in malnourished and at-risk hospitalized elderly patients: A randomized controlled trial. Clin Nutr. 2013;32:186-92.

Dardevet D et al. Muscle wasting and resistance of muscle metabolism: The 'anabolic threshold concept' for adapted nutritional strategies during sarcopenia. The Scientific World Journal. 2012;2012(ID 269531).

Sunday, June 23, 2013

The pH Myth?

This is my response to Chris Kresser's blog post, The pH Myth.

Hi Chris, Yes, I agree the body “tightly regulates the pH of our blood” and yes, blood pH will consistently remain close to 7.4 unless a person is critically ill. But this does not mean that people don’t develop chronic low-grade metabolic acidosis and that this condition contributes to poor health. In fact, this catabolic condition is much more common than most realize. I also agree with you that there is no correlation between urine pH, metabolic acidosis, bone mineral density or fracture risk. I don’t think that there are many people out there who disagree with this..at least those who understand the pathophysiology of osteoporosis. But this does not mean that testing urine pH is bogus or that it has no place in the clinical setting. Testing urine pH can be extremely helpful especially for promoting patient compliance to a healthy high fruit and vegetable diet.
All patients are metabolically different and the causes of bone loss are complex—acid-base balance is only one aspect of osteoporosis. I describe osteoporosis as a collision between immunological dysfunction and the body’s energy regulatory mechanisms. This collision is then influenced by hormonal, mechanical, neuronal, and transcriptional regulatory arms of bone remodeling—and all of this is embedded in a pH and temperature sensitive environment.
If you notice, I mention body pH as only one part of the equation. For strong bones, an individual’s immune system must be in balance, their hormones effective, and their nerve flow optimal for osteoclasts and osteoblasts in bone remodeling to remain coupled. Immerse all of these factors in a suboptimal pH (or a system that struggles to maintain this pH) and it just may not function as well. Does this mean that an acidic pH will give a person osteoporosis? No. Does it mean that a diet high in acidic foods will cause bone loss….well, no, not directly. But it does mean that it may have a detrimental effect on the function of the “whole-body” and if a person’s immune system or hormone system or digestive tract is in any way compromised then in all probability pH and his or her dietary choices will create a greater impact on bone health.
I don’t think anyone would disagree that chronic systemic low-grade metabolic acidosis is destructive to bone and to health in general. The problem arises when advocates of the acid-ash hypothesis begin to oversimplify things by suggesting that we choose foods based on acidity or alkalinity and that this will determine the density of our bones. This creates a skewed view of what is healthy to eat and what is not. There are many “acidic” foods that are healthy. In fact certain amino acids from protein with their additional carboxyl groups are helpful for eliminating acids from the body. Adequate protein intake is important not only for building strong muscles but also for building bone matrix and for important blood buffering properties.
Testing first morning urine pH is not meant to determine if a person is alkaline or acidic. It is simply a tool to help monitor a person’s acid/alkaline contribution of food and how their body metabolizes it. If they eat a lot of greens with alkaline salts then urine alkalinity will increase. If they eat lots of meat, cheese, and ice cream, their urine will become more acidic. It isn’t that his or her blood pH is changing but rather by seeing this measurement in living color (pH strips) they are encouraged to eat the things that will provide them with the substrate (minerals, etc.) that their body will need to regulate pH.
I don’t believe that the acid-ash hypothesis is meant to refute the importance of buffering bicarbonate ions and the roll the kidneys and lungs play in regulating body pH. It only states that acid-ash intake is fundamentally important to health and the development of disease. Unfortunately, kidney dysfunction, even when mild, can reduce the body’s ability to eliminate acid. Any decrease in kidney function or any increase in metabolic acidosis for what ever reason (inflammation, stress, etc.) can have far reaching detrimental effects: elevated blood pressure, insulin resistance, and osteoporosis, to mention just a few. Encouraging a diet high in alkalinizing potassium salts, magnesium and sodium (not sodium chloride) from fruits and vegetables (and when necessary adding supplemental potassium salts) will ensure an effective potassium and sodium-rich bone membrane (another important buffering strategy developed by the body for maintaining normal body pH) as well as other numerous beneficial health effects. I explain this in more depth in my book The Whole-Body Approach to Osteoporosis but I hope this adds a bit to the discussion.

Tuesday, June 18, 2013

Silicon plays an essential role in bone health

The mineral silicon (silica) is essential for quality bone formation. Increased silica intake has been associated with higher bone mineral density and improved bone strength. Unfortunately, most Americans do not obtain sufficient silica from their diets to promote optimal bone health.

For a short summary of what we know about the bone-specific benefits of silica and a review of the research, check out this article published in the International Journal of Endocrinology. Although further research is clearly needed, there is little doubt that silica is an important ingredient for bone health. The average American diet provides less than 20 mg/day of silica whereas 40 mg/day is considered optimal for promoting strong bones. Since most silica comes from whole grains and cereals, individuals on a gluten-free diet may find it even more difficult to obtain adequate levels from diet alone. For these reasons, we have included 21 mg natural silica from Horsetail extract in our comprehensive, bone-specific vitamin/mineral supplement, OsteoSustain.

Price, C.T., et al. 2013. Silicon: a review of its potential role in the prevention and treatment of postmenopausal osteoporosis. Int J Endocrinol, Article ID 316783.


Sunday, June 16, 2013

Webinar: Chiropractic Care for Patients with Osteoporosis

As a chiropractic physician specializing in helping patients achieve optimal health through improved skeletal mechanics, it makes perfect sense that I extend this expertise to improving skeletal metabolic health. After all, recent research shows us that bone metabolism is intricately and inseparably related to the health of the rest of the body. There is no separation.

When a person develops osteoporosis it is typically not due to some type of isolated bone issue. Osteoporosis is a whole-body issue. Specifically, osteoporosis develops when immune system dysfunction collides with the body's energy regulatory mechanisms. By improving whole-body health and paying specific attention to improving the body's immune system and energy regulation, bone health improves. And, as bone health improves so too does the health of the rest of the body.

If you want a better understanding of the most recent scientific research underlying bone loss, check out the webinar I presented to the Association of New Jersey Chiropractors. Chiropractors are often light years ahead of the traditional medical model in understanding how everything in the body fits together and how it is all related. We understand that body dysfunction leads to disease and through improving function we reduce disease. In the words of Thomas Edison..."The doctor of the future will give no medicines but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease." He was a smart guy.

Tuesday, June 11, 2013

On a Quest

I've been a competitive athlete all my life and my body has experienced MORE than its fair share of tissue damage: concussions, torn muscles, broken bones. Getting back in shape after an injury was never easy, but I always managed to bounce back...until I reached my 40's and was, well, slowed down somewhat by my diagnosis of  severe osteoporosis. Regaining competitive-level strength after that setback was quite an ordeal. I attributed the uphill battle to the long period of inactivity while I healed myself. I was half right. I forgot about age. Aging also has a lot to do with the difficulties of trying to regain muscle mass and strength after a period of inactivity.

This past winter I came down with a nasty persistent cough, courtesy of the flu. Absolutely zero exercise for almost three months (plus a few months before that when I was just lazy) resulted in a completely deconditioned and flabby sorry-state of a body. Then my son called me a few weeks after the Boston Marathon bombing. "Dad, we have to run Boston next year. It's just something we HAVE to do...it's REALLY important! You need to find a marathon to run so you can qualify." "And quick, the dead-line for qualifying is in September!"

Hmmm....

I knew what my son was saying. It would be such an important demonstration of solidarity by the running community to return to Boston even stronger. No terrorists were going to stop us...not us runners...not all of the passionate spectators that cheer us on...not us tough-as-nails Bostonians/New Englanders/Americans...  NO WAY!

A few clicks on the computer told me I would need to run at least a 3:40 marathon and probably a 3:30 to guarantee a qualifying spot. "That's do-able" I said to myself with some doubt. "Now, find a marathon that still has entry spots left in it..." Planning and training to run a marathon should be a year-long venture. Six months is pushing it. Oh, did I mention I'm approaching age 60? The ONLY marathon I could find after my search, the Around the Lake Marathon in Wakefield, MA, was in just 12 weeks (well, 11+...but who's counting). Hmmm.... "Better get started..."

In a study published in The Journal of Physiology, Suetta et al. investigated what types of cellular mechanisms may be involved in muscle mass recovery after a period of immobilization and how these may change as we age. They found that muscle re-growth after a period of inactivity is diminished as we age due to a failure of quiescent immature muscle cells to activate into mature muscle. Instead of developing into contracting muscle cells in response to re-instating an exercise program, these satellite precursor cells remain dormant. They just don't wake up. Even after 4 weeks of resistive exercise, the study found that regrowth of muscle mass in elderly individuals was diminished compared to younger males.

("Great...just what I wanted to hear...")

In addition to reduced muscle cell development, aging is also associated with elevated levels of a protein called myostatin. This protein is a signaling molecule secreted by muscle cells and is important for limiting muscle growth. Myostatin ensures that you don't inadvertently end up looking like Arnold Schwarzenegger. Now I certainly don't want to look like Arnold but I do need some muscle strength (in addition to aerobic capacity) to run a marathon. The problem is that as we age, myostatin levels increase and this makes it increasingly difficult to gain or even maintain muscle mass and strength. When muscle cells waste away it is called sarcopenia, a wasting condition often seen in the sick or elderly. Even higher levels of myostatin are found in these people. Unfortunately, sarcopenia (and excessively elevated levels of myostatin) is also commonly seen in patients with osteoporosis. Muscle and bone actually "talk" to each other by way of signaling molecules such as myostatin. When an individual has osteoporosis, this "cross-talk" between muscle and bone can create an even greater barrier to re-gaining muscle mass once it is lost.

I devote an entire chapter in my book, The Whole-Body Approach to Osteoporosis, to explaining how muscle wasting correlates with osteoporosis and vice versa, and what to do about it. Reducing inflammation, creating a more-neutral body pH, limiting oxidative stress, ensuring adequate protein intake, and adding a few key supplements can help maintain an anabolic physiology and stave off muscle and bone loss. Exercise itself is of utmost importance. In fact, exercise helps not only increase IGF-1  production (the most powerful anabolic agent naturally produced in the body) but it also increases GASP-1, a myostatin binding protein that lowers myostatin levels.

Yes, these past 5 weeks of training seem slower to stimulate muscle tone than I remember. With only 7 weeks remaining to race day I'm certainly beginning to wonder about reaching that 3:30 cut-off time to qualify for Boston. I guess illness and injury are unavoidable but there is no doubt that sticking to a regular exercise program (when possible) is your best bet for retaining muscle mass and strength. For those of you who are exercising, stick with it! And for those of you who have let it slide...the sooner you can re-boot your program, the better. (Stay tuned for an update on the marathon (July 26th) and my run for Boston.)

Suetta, C., 2013. Aging is associated with diminished muscle re-growth and myogenic precursor cell expansion in the early recovery phase after immobility-induced atrophy in human skeletal muscle. The Journal of Physiology. June 3 [Published online].

Wednesday, June 5, 2013

Physically Fit Kids Have Less Fractures Later in Life

In a study published in the Journal of Bone and Mineral Research, Nordstrm et al. evaluated the association of being physically fit as a young man with the incidence of fracturing later in life. What they found is that exercise DOES pay off! Being aerobically fit and strong as a young adult helps prevent fractures decades later.

But then again... It's never too late.

Results of this Swedish study showed that young men with poor aerobic capacity would have twice the risk of fracturing and the highest risk of breaking a hip later on in life. On the other hand, men with higher aerobic capacity and muscle strength had a substantial reduction in fracture risk. This demonstrates that regular exercise as a young adult "has potential to reduce fracture risk later in life at least by one-third, or that a fracture is postponed by several years."

"Our data provide the first evidence that objective measures of physical fitness in young adulthood convey an important risk factor for fracture more than 30 years later."

Nordstrom, P, et al. 2013. High physical fitness in young adulthood reduces the risk of fractures later in life in men: A nationwide cohort study. JBMR 28(5):1061-1067.
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