Letters to the Editor

     The letter to the editor is a miniature literary form like the haiku, and one more transient than the blog post. I have written a great many over the years; no-one taught me, I believe that no university or technical college teaches the art that I have acquired "by doing".
     When you write to the editor you are constrained in time; your letter must be promptly relevant to a published letter or article. You are constrained in subject; you must rehearse the points raised and your own must be relevant to them. You are constrained in space to a paragraph or so, and you are equally constrained in style. Admittedly a smaller newspaper which I read in Tauranga has taken to publishing text messages with all their barbarous orthography intact, but a letter to an august organ such as the New Zealand Herald, with a circulation of over 500,000, must be a regular English prose composition (though if you can't quite manage that but still have something to say, the sub-editor may be generous with their aid).     
     Grandstanding, quirkiness, abuse, bare-faced flouting of logic, use of the word teh, substituting $ for S, multiplication of the letter K, obscenities, gratuitous offensiveness, and all the other tools of the blogger's trade will not be countenanced by the ladies and gentlemen of the press.
     My recently published letter was in response to one on the subject "Tackling Obesity" by one Peter Davis. It was reasonable enough and noted as I have done the sad decline in our once-great nation's health. The writer wondered if our armed forces might one day run out of healthy recruits. My first impulse was to respond that, obesity epidemic or not, the New Zealand defense forces will always be able to find the 18 or so recruits they need each year from a population of 4,405,200 at last count. However, I decided to drop the cheap joke to focus on a better target, a reference to eating too much and not exercising enough as causes of obesity. Really one can build a great deal around a light slap at this notion.
     This is my letter as it was published on Monday, May 13th:

    Peter Davis is right to insist that the social and health costs of the obesity epidemic require action. 

    Any measures taken should first increase research, while in the interim promoting the most successful overseas interventions, at present low-carb and ancestral diets, and developing them to suit New Zealand's needs. 

   It is presumptuous to say that obese people have eaten more and exercised less than others. First, such behaviour does not always result in obesity. Secondly, if I weighed an extra 45kg I would automatically be exercising a great deal harder than I do today just to go about my life, and this would probably require extra nutrition.
    Perhaps it is the declining quality of food - particularly the substituting of cheap starches, sugars and oils for nourishing fare - which is more than anything responsible for the declining quality of health in this area.

Yours Faithfully,

George Henderson

And this is the letter as I sent it. I am including this version so you can appreciate how lovingly the sub-editor refined and polished my points, erased my mistakes, and improved upon my style, still slightly imperfect after all these years.

Dear sir/ma'am,

Peter Davis is right to insist that the social and health costs of the obesity epidemic require action. To avoid making things worse any measures taken should first increase research, while in the interim promoting the most successful overseas interventions, at present low-carb and ancestral diets, and developing them to suit New Zealand's needs. It is presumptive to say that obese people have eaten more and exercised less than others. Firstly, such behaviour did not, and does not, always result in obesity. Secondly, if I weighed an extra 100 pounds I would automatically be exercising a great deal harder than I do today just to go abut my life, and this would probably require extra nutrition, especially if the food available was of poor nutritive quality.
Perhaps it is the declining quality of food, i.e. the substituting of cheap starches, sugars and oils for nourishing fare, that is more than anything responsible for the declining quality of New Zealanders' health in this area.

Yours Faithfully,

George Henderson

Notice that, as New Zealand went decimal in 1967, a fact I had forgotten due to my excessive reading of U.S. diet books and blogs, my reference to a round 100 pounds was converted to a rather clunky 45 kilos.

What I believe distinguishes this letter from my earlier published efforts is the sheer number of concepts I was able to address. Unintended consequences ended up on the cutting room floor, but I was able to retain

- scientific research as the proper basis for policy decisions

- the paramount effectiveness of low-carb and paleo (without claiming that current options are perfect)

- a subtle reference to "The Native Diet"* T.V. program and other local initiatives

- a Taubesian dig at CICO

- a reference to empty calories (food quality)

- a swipe at the 3 Paleo devils, grains, sugars and oils, ignoring the expected whipping boy, my buddy fat.

And really, that's enough to be going home with.

* "The Native Diet is a concept derived from traditional Māori eating, activity and the 1920′s research of Dr Weston Price, who after visiting 14 indigenous nations including Māori, concluded the western world must look back at the traditional diets of these people groups for the future health of the next generation. Price advocated prohibiting processed foods from diets of Americans, something that has not been followed up."

"The Truth was Still Putting on its Shoes", my first article to be published IRL

I haven't had my Diet Wars writing published before, unless you count my many letters to the editors of The Herald, Listener, and Otago Daily Times, letters which, I'm pleased to say, do often get published.
This is the first hard copy of an article that wasn't just a response to some piece of stupidity in the press.



It was commissioned for inclusion in the first edition of the free Café  Reader. This will hopefully be available in every café in New Zealand. Apart from my polemic, it also contains writing from the finest local talent. I opened it at random (after checking my piece for typos, phew!) and Simon Sweetman's party piece is the funniest thing I've read in ages. Put together by Phantom Billstickers, thanks to Jim and Kelly Wilson and no doubt other committed team members that I haven't had dealings with.



And there we have it. I will reprint the whole article in a few weeks for overseas readers.

Meanwhile, some exciting science news; expert scienticians have finally invented a high-fat diet that DOESN'T produce fatty liver in Wistar rats, even with prodigious overfeeding!

Long term highly saturated fat diet does not induce NASH in Wistar rats

Background

Understanding of nonalcoholic steatohepatitis (NASH) is hampered by the lack of a suitable model. Our aim was to investigate whether long term high saturated-fat feeding would induce NASH in rats.

Methods

21 day-old rats fed high fat diets for 14 weeks, with either coconut oil or butter, and were compared with rats feeding a standard diet or a methionine choline-deficient (MCD) diet, a non physiological model of NASH.

Results

MCDD fed rats rapidly lost weight and showed NASH features. Rats fed coconut (86% of saturated fatty acid) or butter (51% of saturated fatty acid) had an increased caloric intake (+143% and +30%). At the end of the study period, total lipid ingestion in term of percentage of energy intake was higher in both coconut (45%) and butter (42%) groups than in the standard (7%) diet group. No change in body mass was observed as compared with standard rats at the end of the experiment. However, high fat fed rats were fattier with enlarged white and brown adipose tissue (BAT) depots, but they showed no liver steatosis and no difference in triglyceride content in hepatocytes, as compared with standard rats. Absence of hepatic lipid accumulation with high fat diets was not related to a higher lipid oxidation by isolated hepatocytes (unchanged ketogenesis and oxygen consumption) or hepatic mitochondrial respiration but was rather associated with a rise in BAT uncoupling protein UCP1 (+25–28% vs standard).

Conclusion

Long term high saturated fat feeding led to increased "peripheral" fat storage and BAT thermogenesis but did not induce hepatic steatosis and NASH.

The full text paper is here. 

Can Spirulina Produce a Sustained Virological Response in Chronic Hep C? More Studies Here Please.

I was going to give the whole algae as immune stimulants theme a rest, until Silvia Hinojosa-Price sent me this paper.
Spirulina Platensis versus Silymarin in the treatment of chronic hepatitis C virus infection. A pilot randomized, comparative clinical trial.

I've been reading these Hep C natural therapy papers for many years now and this is the first to record SVR. Essentially, this means that the treatment (Spirulina, a simple dried extract at 500mg 3x daily) was associated with undetectable virus levels after 6 months treatment. Only in 13.3% of the subjects (4 of 30, with another 2, or 6.7% having a significant drop of over 2 log) but still - this NEVER happens in clinical trials of "natural" or "alternative" therapies. The best will often lower viral load, but not to undetectable levels. HCV researchers never use the word "cure", but having no virus is as close as it gets. There are a few caveats I'll add later, but this is an impressive paper. I don't often see papers of this sort so well written or with the data so well presented. There's not much left to the imagination, which is how it should be. The authors are coming from a conventional, standard of care background and have had their interest piqued by patients reporting beneficial effects from Spirulina supplements; so they ran this clinical trial. 
The motivation to conduct this study, "apart from the theoretically convincing background", was the unintended data coming from some of our patients who took Spirulina as nutritional supplement and reported to us marked improvement of the general well being and sexual activity. From this probing experience, as well as from the results of Danoff A, et al. [44] and Soykan A, et al. [45] who reported an association of chronic HCV with depressed sexual functions independent of depression, we opted to compare the effect of both treatments on sexual functions beside the other efficacy parameters in such patients. We assumed that improvement in sexual appetite; frequency and performance are logical indicators for the improvement in the overall wellbeing. Our results went in agreement with this assumption.
This is how it should be done, respecting the patients' anecdote as a hypothesis generator, yet these kinds of trials often end in disappointment. But not this time. Yakoot and Salem were smart enough to allow the trial to last 6 months. They made the logical assumption that the time needed for any response to Spirulina would be at least as long as that needed for a response to Interferon-based therapies.
We hypothesized that there must be a time needed to establish and solidify the immune mechanisms behind the activation, release and action of endogenous interferons and other interplaying cells and mediators. Even the parenterally administered high dose of interferon alpha took some months to manifest its maximal virological response, that is why we wait at least 3 months to predict the sustained virological response through the early complete or even partial virological response.

Silymarin was used as an "active placebo". In other words, Spirulina was compared to extract of Milk Thistle seeds (140mg 3x daily), the supplement most likely to be used by chronic Hep C sufferers, but one that has only a small objectively measurable effect (at least, in this basic dosage form: but you can see here that other, more bioavailable forms might be worth testing).
Lo and behold, one of the Silymarin group (1 of 29) had an SVR. This reduced the significance of the 4 Spirulina SVRs and doesn't seem to be commented on. For what it's worth, Silymarin does have inhibitory effects on HCV replication, but these should be mild at the levels attained in a 140mg 3x daily dosing, and it's the first I've ever heard of SVR from Silymarin. However, there is a natural rate of spontaneous clearance in chronic Hep C, estimated at 1% per year, though no-one really knows and most clinicians would rather not follow up such cases. Lazarus was a disappointment to his doctor.
The patients with the lowest viral loads were the most likely to have an SVR in response to Spirulina. In those patients with viral loads below 100,000 the difference between Spirulina and Silymarin was statistically significant.
Our results showed significantly greater effects of Spirulina than Silymarin on most studied parameters including the significantly greater reduction of serum ALT and the greater improvement in both disease specific health related quality of life and sexual functions scores. Though the virological response rates were not statistically significantly different between the 2 treatment groups, yet it reached the level of significance with the one sided Z test for proportions in those who presented with low or intermediate baseline viremia.

One limitation was the absence of post-treatment follow-up. 
It is the main limitation of our study that we did not follow up patients for one year treatment followed by 6 months off-treatment period as the case in the protocols for the study of interferon alpha based therapy. We designed this relatively short term pilot study to answer a simple research question; is there any therapeutically feasible potential for Spirulina in chronic HCV patients, worthy to conduct a larger study with longer follow up period.
I would expect that some of the SVR cases would relapse once they stopped taking Spirulina; after all, this happens with conventional drugs. But why should anyone stop taking Spirulina? It would be no imposition at all to keep taking it for the rest of one's life, indeed it probably be a good idea even if the sustained viral response didn't depend on it.
This study was mainly focusing to help a considerable percentage of chronic HCV patients who are facing the situation of contraindication, intolerability or non-response to the current gold standard therapy. They usually become feeling hopeless and unsecure with deterioration in their overall wellbeing, functional status and quality of life. If further studies confirm our results with reproducibility, this could be an alternative treatment in such situations if at least it can improve quality of life, physical activity and performance. We did not focus on the luxury of sustained virological response at this exploratory stage, but it will be our objective in the coming planned study.

Where to from here?
The raised issues from the already discussed in-vitro and preclinical data about the potential immune stimulation and virus entry blocking also urged us to plan to test a new hypothesis; could the complementary therapy with Spirulina improve the response to the current gold standard antiviral therapy?. This will be tried to answer in our next study; through testing the effect of combining Spirulina with the current gold standard therapy, or the effect of offering a lead-in course for those who have high baseline virus load.

I would like to see a longer study of constant treatment, similar to the long-running Japanese zinc carnosinate (Polaprezinc) study. And there is no reason why the dose couldn't be increased. The nutrients that support Interferon - B12, D3 and retinol - could be optimized. And so on.

About the Physician Authors; AA Salem has authored 420 medical papers (well not all of those, possibly a common name, but certainly including 5 based on clinical experience of HCV cases. M Yakoot has authored 13 papers, mostly clinical trials of dietary supplements or reviews of OTC drugs. He appeared on Egyptian TV during the swine flu outbreak there.)
Dr Yakoot presents the results of the Spirulina paper in the last 2 minutes of this video, which also features some cool animations of HCV, LDL and LDL-R interaction:

http://www.youtube.com/embed/4kdnaxiZew4

The competing interests: 
Beovita-Safe Pharma, a Joint German Egyptian Company, Katzbachstr. 29, D-10965 Berlin, had supplied the drugs and partly the costs of the laboratory tests.

There seems to be nothing unique or patentable about Beovita-Safe Pharma's Spirulina or Silymarin products that would prevent the results being replicated with another company's products. I suspect Beovita-Safe Pharma's motivation was to have the use of their products accepted as safe and justified by the clinicians treating their customers. I wonder what Beovita-Safe Pharma will do with this additional information. They'll certainly be motivated to support other trials.
We opted to use the whole herbal extract and not any one of the fractionated bioactive molecules presuming that the whole natural multi-components as previously discussed in introduction could offer not only antiviral activity but also other immune enhancing activities that might be summated together to produce therapeutic effects on this state of chronic viral infection that evades the immune system.

Update: I looked at Spirulina products while shopping today. Most are whole dried Spirulina 500mg tablets, but I found one product that was a "herbal extract" of 2,300mg Spirulina in an approximately 500mg cap (I suspect) together with 50mcg selenium from selenomethionine. It had been made in New Zealand for the Japanese market.
This may be close to the Beovita product. I hope to find out more - including, what is the iron content of the Beovita tabs? 1g of Spirulina can supply 3mg iron and a standard dose of whole dried spirulina is 9g daily.


 

Spirulina and LPS; and, Maybe Trans Fats are Not the Devil?

One of the very minor controversies in Paleo-land is whether algal foods or supplements are healthful. For what it's worth, pond algae appeared in the Paleolithic menu (according to the 2008 book Feast: why humans share food by Martin Jones). Spirulina and Chlorella supplements have both been used in the treatment of Hepatitis C with interesting results:
(music - Free Kim Dotcom by The Puddle featuring Matthew Bannister)


Efficacy and safety of Chlorella supplementation in adults with chronic hepatitis C virus infection http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3581996/

Eighteen adults with chronic infection by HCV genotype 1 received daily oral supplementation of Chlorella for 12 wk. Changes in the RNA levels of HCV, as well as those of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were evaluated following this treatment period. Paired t tests were conducted to compare the means of the different variables at the beginning and end of the study. Side effects and quality of life aspects were also compared between weeks 0 and 12 of the study period.

RESULTS: A majority 84.61% of the patients had a significant decrease in their ALT levels from week 0 to week 12. Evaluation of side effects showed that Chlorella was well tolerated. Quality of life assessment showed that 76.9 of the participants reported an improvement in their energy levels and 46.1% reported an improvement in their perception of general health. Although 69.23% also showed a decrease in their AST levels, this was not statistically significant. Most patients that exhibited an improvement in their ALT and AST levels also showed a tendency toward a decreased HCV viral load. The HCV RNA levels showed a decrease in 69.23% of the patients, which along with changes in AST/ALT ratios from week 0 to week 12, these results were not statistically significant.

One very interesting outcome, not captured in the abstract was that those subjects who had not undergone previous treatment with interferon almost all (5/6) saw significant drops in viral load, whereas the 7 subjects that had previously used, and failed to respond to, interferon had no such reaction (see Table 1). 

What effect of algae could account for these results? Both spirulina and chlorella express PAMPs (Braun polysaccharides in the case of spirulina, and glycoprotein in the case of chlorella) that possess activity at TLR2. TLR2 is interesting because, as well as its immune system signalling role, it also promotes the intestinal detoxification of benzopyrene carcinogens. But that curious fact need not concern us here.

[One hundred years ago the birth of immunology was made official by the Nobel Prize award to Elie Metchnikoff and Paul Ehrlich. Metchnikoff discovered phagocytosis by macrophages and microphages as a critical host-defense mechanism and thus is considered the father of cellular innate immunity. He also was interested in the impact of normal flora on well-being and in pre- and probiotic diet and their influence on the normal flora. Ehrlich described the side-chain theory of antibody formation and the mechanisms of how antibodies neutralize toxins and induce bacterial lysis with the help of complement and thus is considered one of the fathers of humoral adaptive immunity.]

TLR2 activation by algal ligands activates elements of the innate immune system; natural killer T cells (NKT) and interferon (PDF). This will be responsible for the drops in viral load (in people whose immune systems are not already either unresponsive to interferons, or damaged by exposure to the supraphysiological levels of interferon-alpha used in HCV therapy). 

HCV core protein is a pro-inflammatory TLR2 ligand; this allows the immune system to recognise the virus and respond appropriately. Most HCV exposures (antibody+) will be cleared in the first 6 months, but chronic infection means that the virus has managed to subvert these responses. So supplying algal TLR2 ligands is a way of switching back on (or turning up) responses that the virus has managed to dim.
But TLR2 is also expressed on Treg cells (regulatory T Cells), able to induce immune tolerance (less Th17 inflammation, lower antibody production) to specific immune triggers, so HCV core protein's interaction with Treg TLR2 could be a way of numbing the immune system to the presence of HCV. This can be a good thing in some ways; sometimes "fighting the dragon" aggressively is just too destructive a strategy to be sustainable.

Another way in which HCV is able to reduce the host immune response is by the binding of HCV core protein to the C1q complement receptor; this inhibits complement activation, resulting in depletion of the C3 complement factor, and inhibits proliferation of T cells. 

Strikingly, this inhibitory effect of core on lymphocyte proliferation was observed at a concentration of core protein as low as 1.3 nM. 

This (I hypothesise) may result in compensatory increase in uptake of, and sensitivity to, LPS, as activation of both TLR4 and the alternate complement pathway by LPS are default ways for the immune system to maintain adequate activity (uptake of LPS from the intestine is not normally an accident, but a regulated and pseudo-hormonal activity). Thus restoring immune activation through TLR2 may decrease the LPS sensitivity which drives liver inflammation, as well as improving immune surveillance of and response to the ongoing HCV infection. As well as spirulina, probiotic bacteria such as Lactobacillus Rhamnosus also have TLR2 activity (PDF). 

My own suggestion would be to combine live Rhamnosus and/or Del-immune V with sprirulina or chlorella. The quantity of chlorella consumed in that paper seems rather daunting, and spirulina is a rich source of iron, so it will be good if lower intakes are effective. My own experience is that spirulina and probiotics go well together. Spirulina is also a very good source of mixed carotenoids, and high carotenoid intakes are (independently of retinol) associated with lower rates of hepatocellular cancer in chronic hep C populations; it is also a source of vitamin K2. (It is important to buy algal products from reputable suppliers who will test them for hepatotoxic contaminants).

Fatty liver, or steatosis, is a metabolic phenomenon and mainly diet driven and is a virtual precondition for hepatic fibrosis. Fibrosis itself, on the other hand, seems to be an immunological phenomenon, with the aspects of diet that have most influence being concerned with the microbiota (probiotics, prebiotics, parasites, pathogens, spices, and active foods like algae), the movement of LPS into the liver (polyunsaturated vs saturated fats), and the immune response to these (vitamins A and D, niacinamide and herbal medicines), as well as glucose and insulin regulation. 

(Note: in this neural stem cell paper http://www.plosone.org/article/info:doi/10.1371/journal.pone.0010496 "the diet supplemented with spirulina was able to negate ...an acute systemic inflammatory insult of lipopolysaccharide")

(More Music: Sketches of Spain by Miles Davis)

Maybe Trans Fats are Not the Devil

Trans-palmitoleic acid isn't a special trans-fat like CLA (which everyone agrees is good). It's found in both dairy fat and partially hydrogenated vegetable oil. So why do people with the highest levels of TPA have a halved risk of developing diabetes?

Am J Clin Nutr. 2013 Apr;97(4):854-61. doi: 10.3945/ajcn.112.045468. Epub 2013 Feb 13.

trans-Palmitoleic acid, other dairy fat biomarkers, and incident diabetes: the Multi-Ethnic Study of Atherosclerosis (MESA).

Mozaffarian D, de Oliveira Otto MC, Lemaitre RN, Fretts AM, Hotamisligil G, Tsai MY, Siscovick DS, Nettleton JA.

Source

Division of Cardiovascular Medicine and Channing Laboratory, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, Harvard School of Public Health, Boston, MA.

Abstract

BACKGROUND:

Dairy consumption is linked to a lower risk of type 2 diabetes, but constituents responsible for this relation are not established. Emerging evidence suggests that trans-palmitoleate (trans 16:1n-7), a fatty acid in dairy and also partially hydrogenated oils, may be associated with a more favorable metabolic profile and less incident diabetes.

OBJECTIVE:

We investigated the association of trans-palmitoleate with metabolic risk and incident diabetes in a multiethnic US cohort.

DESIGN:

Phospholipid fatty acids and metabolic risk factors were measured in 2000-2002 among 2617 adults in the Multi-Ethnic Study of Atherosclerosis (MESA), a cohort of white, black, Hispanic, and Chinese Americans. In 2281 participants free of baseline diabetes, we also prospectively assessed the risk of new-onset diabetes (205 cases) from baseline to 2005-2007.

RESULTS:

trans-Palmitoleate concentrations correlated positively with self-reported consumption of whole-fat dairy, butter, margarine, and baked desserts and with other circulating biomarkers of both dairy fat and partially hydrogenated oil consumption, which suggested mixed dietary sources. After multivariable adjustment, trans-palmitoleate concentrations were associated with higher LDL cholesterol (quintile 5 compared with quintile 1: +6.4%; P-trend = 0.005), lower triglycerides (-19.1%; P-trend < 0.001), lower fasting insulin (-9.1%; P-trend = 0.002), and lower systolic blood pressure (-2.4 mm Hg; P-trend = 0.01). In prospective analyses, trans-palmitoleate was independently associated with lower incident diabetes (P-trend = 0.02), including a 48% lower risk in quintile 5 compared with quintile 1 (HR: 0.52; 95% CI: 0.32, 0.85). All findings were similar between men and women and between different race-ethnic subgroups.

CONCLUSIONS:

Circulating trans-palmitoleate is associated with higher LDL cholesterol but also with lower triglycerides, fasting insulin, blood pressure, and incident diabetes in a multiethnic US cohort. Our findings support the need for further experimental and dietary intervention studies that target circulating trans-palmitoleate. The MESA trial was registered at clinicaltrials.gov as NCT000054

see also: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3056495/

Trans-palmitoleate was associated with substantially lower incidence of diabetes, with multivariable-hazard-ratios=0.41 (95%CI=0.27–0.64) and 0.38 (95%CI=0.24–0.62) in quintile-4 and quintile-5, versus quintile-1.

One might surmise that in this case either the health benefits of increased fat intake override any negatives from hydrogenated vegetable oils (backed up by the finding that palmitoleate from DNL is associated with negative effects that are the inverse of those associated with trans-palmitoleate), or the health benefits of dairy fat are so profound that the negative effects of hydrogenated oils are swallowed up by them.

P.S. A few thoughts on the MESA trans-palmitoleate and palmitoleate studies.
I've looked at some of the other MESA research (there is a great deal of it) and this group's epidemiological work stands out for these reasons:
1) They are measuring an accurately quantifiable factor that is diet-dependent, not relying on food frequency questionaires.
2) They have verified that that factor does correlate with reported dietary intake
3) They are using an actual disease diagnosis (DM2) as the end-point, as well as differences in serum markers.
4) These are prospective studies.
5) Given the short follow-up period (5 years) the odds ratios for DM2 incidence are striking. 
6) There is little in the way of a priori assumptions to colour the interpretation of the data.

More lessons from Naltrexone and TLR4; Astragalus

The naltrexone story I covered in the last post has turned up other insights into its mode of action in Hepatitis C.

(music: Steely Dan live from 1974)

Most importantly, naltrexone is antifibrotic. TLR4 agonism stimulates the activation of hepatic stellate cells (HSC) into myofibroblasts that lay down collagen-rich matrix all over the place like a one-armed plasterer on meth. A little of this is part of the repair process but excess is like DIY repairs gone bad. Sooner or later there's so much plaster you can't get in or out of your own cells. Hilarity doesn't ensue.

Mechanisms of Hepatic Fibrogenesis

Among the most compelling pathways of injury are those recently uncovered for innate immune signaling in liver. Specifically, the discovery of TLRs has led to major advances in understanding how the human organism responds to pathogens. The identification of TLR4, the receptor for bacterial lipopolysaccharide, on Kupffer cells, was therefore not a surprise, but its expression on stellate cells was unexpected. Moreover, although TLR4 signaling in macrophages may be essential for inflammatory responses, recent studies have indicated that signaling by stellate cells in response to lipopolysaccharide and possibly endogenous ligands of TLR4 (eg, high-mobility group box 1, biglycan, and heparan sulfate) may be more important than in Kupffer cells in eliciting a fibrogenic response by down-regulating bone morphogenic protein (BMP) and activin membrane-bound inhibitor, a transmembrane suppressor of transforming growth factor β1 (TGFβ1), which is the major fibrogenic cytokine in the liver. This finding has converged with evidence that specific single-nucleotide polymorphisms of TLR4 contribute to the rate of fibrosis progression in HCV infection, thereby linking a genetic risk marker to disease pathogenesis.

Naltrexone prevents gliosis (inflammation of neuroglial cells) caused by opiates through TLR4 agonism. HSCs are hepatic glial cells. Glial cells are "caretaker" cells that protect and repair nerves, blood vessels and the like and maintain the appropriate spaces between cells and the extra-cellular matrix. So this link between gliosis and fibrosis doesn't surprise me. Even in the dizzying and scarcely ever linear world of immunology, sometimes the correct answer can be the simplest.

What are the relevant TLR4 agonists in liver fibrosis? Lipopolysaccharide (LPS) from gram-negative bacteria, and alcohol. Opiates too maybe (methadone use is associated with fibrosis in Whites Only in this study, but methadone can always be either substituting for, or encouraging the use of, something worse).

Naltrexone antagonizes TLR4 and increases receptor numbers (decreasing sensitivity).

Naltrexone, an opioid receptor antagonist, attenuates liver fibrosis in bile duct ligated rats

This is the first study to demonstrate that administration of an opioid antagonist prevents the development of hepatic fibrosis in cirrhosis. Opioids can influence liver fibrogenesis directly via the effect on HSCs and regulation of the redox sensitive mechanisms in the liver.

Comparative Study between the Effect of Atorvastatin and Naltrexone on Hepatic Fibrosis Induced by Bile Duct Ligation in Rats (pdf)

Another TLR4 antagonist seems to be the polysaccharide-A from astragalus root. Astragalus is a common Chinese herb which is well-tolerated and used in many anti-inflammatory preparations including liver-protecting and immune-boosting formulas. I like it myself and have had good results with either astragalus alone, or a mixture of astragalus and the super-weird cordyceps fungus, which also contains an active polysaccharide but much else besides.

TLR4 expression in chronic UTI patients after astragalus treatment was higher than pre-treatment.

The pattern with these agents seems to be that sensitivity to "bad" LPS is reduced, but that macrophage activity is enhanced. This should see some clearing of the immune complexes (cryoglobulinaemia) associated with hepatitis C and a reduction in the various extra-hepatic autoimmune symptoms they cause. Hepatic LPS sensitivity is also reduced by the presence of highly-saturated fats in the diet (beef tallow, coconut oil, etc) and the restriction of polyunsaturated fatty acids.

Probiotics (such as the anti-inflammatory Rhamnosus LGG) have a comparable  effect on TLR4: activation after LPS exposure is decreased.

LGG attenuates LPS induced inflammation, and this may be associated with TLR4/NF-κB down-regulation.

Lactobacillus GG Treatment Ameliorates Alcohol-induced Intestinal Oxidative Stress, Gut Leakiness, and Liver Injury in a Rat Model of Alcoholic Steatohepatitis

I think it's a good idea to take probiotics if you have hepatitis C, and the L. Rhamnosus plus Reuterii combination was my favourite long before I knew this TLR immunology stuff.

J Am Coll Nutr. 2012 Feb;31(1):14-23.
Probiotics in the treatment of the liver diseases.

Kirpich IA, McClain CJ.

Source

Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville, KY 40202, USA.

Abstract

The concept that interactions between the gut, the liver, and the immune system play an important role in liver diseases is an old concept that has recently seen a resurgence in interest. Altered intestinal bacterial flora and gut-associated endotoxemia are increasingly recognized as critical components in both nonalcoholic fatty liver disease (NAFLD) and alcoholic liver disease (ALD). Probiotics have been proposed in the treatment and prevention of many conditions, including the liver diseases. Probiotics are live microorganisms that, when consumed in adequate amounts, confer a health benefit to the host. There are many mechanisms by which probiotics enhance intestinal health and influence the gut-liver axis, including modulation of the intestinal microflora, modification of intestinal barrier function, and immunomodulation. The present review summarizes the recent studies highlighting the role of the intestinal microflora in the development of NAFLD and ALD and the potential efficacy of probiotics as a therapeutic strategy for liver diseases.

Oh, BTW, what's another TLR4 antagonist? Niacinamide (nicotinamide). I've told you that's antifibrotic in an earlier post, for quite different reasons.
I could go on all day, all year maybe, but I have stuff to do now.

 

Cordyceps in action (The one in this video is a relative of C. Sinensis, the herbal one, which parasitizes Tibetan moth larvae):

 

 

Naltrexone has TLR-4 activity - is it an "Old Friends" mimic?

(Our first song for today is appropriately Junk by The Puddle, a early post on this topic from 1985.)


Naltrexone is a mu-endorphin antgonist that is used as an opioid antagonist. It will reverse intoxication from opioid analgesics and has a longer duration of action than naloxone. Naloxone is preferred in emergency settings because of its faster onset of action, but naltrexone, unlike naloxone, is effective given by mouth, and its long duration of action (10 hrs) makes it a safer treatment for overdose with long-acting opioids such as methadone (24 hrs, but the half-life of methadone can be significantly decreased by urinary acidifiers such as ascorbic acid or citric acid, and is increased by urinary alkalizers such as sodium bicarbonate as methadone has low solubility at high urinary pH). Naltrexone's most common clinical use is in doses of 50mg daily as a maintenance treatment to blockade the addictive effects of both opiates and alcohol. Recently I spoke to an AOD patient using naltrexone in this way and was surprised that they reported that the drug had an anti-depressant effect. This isn't what would we'd expect under the old endorphin receptor model from a full-time blockade; dysphoria would be the predicted side-effect.

 

A clue lies in the popular off-label use of naltrexone at low doses (3-4.5 mg nocte) as an immune-modulating agent. The Low Dose Naltrexone homepage claims

"FDA-approved naltrexone, in a low dose, can normalize the immune system — helping those with HIV/AIDS, cancer, autoimmune diseases, and central nervous system disorders."

This is not quackery; read the NOLA Hepper blog in the blogroll to your right for a case study of LDN in the treatment of hepatitis C. Naltrexone is some potent juju, but the results have been hard to explain till recently. The mechanism that was originally stated is as followed; endorphin synthesis is highest at night. Blocking receptors for a few hours while the patient sleeps has the effect of elevating endorphin levels; these elevated endorphins have mood and immune-modulating effects. Hormesis in other words.

"The brief blockade of opioid receptors between 2 a.m. and 4 a.m. that is caused by taking LDN at bedtime each night is believed to produce a prolonged up-regulation of vital elements of the immune system by causing an increase in endorphin and enkephalin production. Normal volunteers who have taken LDN in this fashion have been found to have much higher levels of beta-endorphins circulating in their blood in the following days. Animal research by I. Zagon PhD. and his colleagues has shown a marked increase in metenkephalin levels as well."

The endorphin effects of naltrexone are significant of course, but the much higher dose taken by the patient I spoke to could not work in this way; also, both opioid drugs like morphine, and morphine withdrawal states have been found to stimulate HCV replication in vitro.

Recently (c. 2007) studies started to appear showing that opioids and opoid antagonists have TLR-4 activity. TLR-4 is a PAMP (pathogen associated molecular pattern) receptor. TLRs tell  immune cells what type of pathogens they may (or may not) need to get agitated about. In the case of TLR-4 this is gram-negative bacteria, and the ligand is lipopolysaccharide (LPS).

Except that pathogens aren't the only organisms to produce TLR-4 ligands; probiotics, saprophytes and other benign or beneficial bacteria can also have TLR-4 activity, and this exposure is associated with lower rates of auto-immune disease, allergies, depression, cancer and great deal else besides through the "Hygiene hypothesis" or "Old Friends hypothesis" (there are some good articles on this at Emily Deans' Evolutionary Psychiatry blog linked in my blogroll on the right hand side of the page).

The effects we would expect to see from TLR-4 activation by what I might term FAMPs (friend associated molecular patterns) if the Old Friends hypothesis is correct are the same ones attributed to LDN (which increases TLR-4 expression). The illnesses LDN is claimed to treat are all diseases that have come into prominence in the wake of microbiotal extinctions. In many cases they barely seem to have existed prior to the widespread use of antibiotics, disinfectants, and antithelmetics.

Brain Behav Immun. 2012 Mar;26(3):480-8. doi: 10.1016/j.bbi.2011.12.010. Epub 2012 Jan 5.

Mu opioid receptor activation modulates Toll like receptor 4 in murine macrophages.

Franchi S, Moretti S, Castelli M, Lattuada D, Scavullo C, Panerai AE, Sacerdote P.

Source

Dipartimento di Farmacologia Chemioterapia e Tossicologia medica, Università degli Studi di Milano, Via Vanvitelli 32, 20129 Milano, Italy.

Abstract

Opioids have been shown to affect both innate and adaptive immunity. We previously showed that morphine affects the macrophage production of pro-inflammatory cytokines after LPS in a NFkB dependent manner.
Toll like receptors (TLRs) play a crucial role in the signaling pathways which lead to NFkB activation. TLR4 is considered the Lipopolysaccaride (LPS) receptor.
The data here presented show that, in murine macrophages, morphine impacts on the immune function acting on the early step of pathogen recognition. Morphine, when added to RAW 264.7 cells and when injected into mice (s.c. 20mg/kg) is in fact able to decrease TLR4 both at mRNA and protein level in RAW cells and peritoneal macrophages. In the same cells, the mu opioid receptor (MOR) antagonist Naltrexone increases TLR4 levels, thus suggesting a role of the endogenous opioid system in TLR4 regulation. The effect of the two drugs is moreover lost in case of co-administration.
Experiments with MOR KO mice and with DAMGO (MOR specific agonist) confirm that the effect of morphine on TLR4 mRNA in peritoneal macrophages is due to the MOR activation. Moreover the effect on TLR4 is blocked by PTX thus indicating the involvement of a G(i) protein after MOR binding. This work unveils a clear link between MOR activation and TLR4, suggesting a new possible mechanism at the basis of the peripheral immunosuppressive effect of opioids.

Make no mistake, this is edge-of-your seat scientific stuff that for my money is predictive of rapid medical progress in unexpected directions. For example: Recent evidence implicates toll-like receptor 4 (TLR4) in opioid analgesia, tolerance, conditioned place preference, and self-administration. In other words, some of the anti-addictive effect of naltrexone blockade is due to its TLR-4 agonism, not its mu-endorphin antagonism (though the two are probably indirectly connected). One obvious implication of this research is that the dose range for both LDN and addiction treatment should probably be much wider. Some people will need larger doses or more frequent dosing for LDN to work, or even smaller doses; VLDN, (0.125-0,250mg) treatment has been used to suport methadone withdrawal; while AOD patients who do not tolerate 50mg naltrexone may well benefit from lower doses. The dose thresholds for endorphin and TLR-4 effects are likely to be different and to vary between indviduals.
Exciting - nay, exhilarating. Sometimes you just gotta love science. It's one of those gifts that just keeps on giving.
 
(more music - Steely Dan "My Old School")

More Junk Epidemiology - Cataracts and Vitamin C

This study on supplement use hasn't come up on the paleo radar, but it's a good example of how to expose junk epidemiology. It's from the Orthomolecular Medicine News Service - you can subscribe here and it's well worth doing, they don't mail often and are in the process of becoming  accepting of low-carb science (such as ketogenic diets for cancer) while trying to cling to the saturated fat is bad, only vegetables and supplements are healthy message. Because these are not stupid people, and they already have methods that work, it's an interesting struggle to follow. Their archives link is here.
It's another junk study from Sweden - what is it about those Swedes? Is it a case of scientific suevism?
I love that he refers to Bayesian analysis as the way to proceed in these cases. I'm no mathematician, but it makes sense to me.

At the foot of the page I've included an abstract from a review of vitamin C for prevention of Complex Regional Pain Syndrome. This is an impressive result; 0.22 relative risk of this debilitating after-effect of fracture surgery from supplementing 500mg or more ascorbic acid daily for 45-50 days. An unusually effective clinical use for any supplement.
While the authors of the various trials cite the antioxidant effect of ascorbic acid and the toxicity of ROS as a mechanism, I suspect that improved integrity of the collagen matrix in the early stages of bone regrowth might also account for these benefits. After all, that's why ascorbic acid is a vitamin.

Music; Intermezzo from Cavalleria Rusticana by Pietro Mascagni.

Cataracts and Vitamins: The Real Story

by Damien Downing, MBBS, MSB, and Robert G. Smith, PhD

(OMNS Mar 5, 2013) "Hidden danger of everyday supplements is revealed" blared the headline in the UK Daily Mail [1] - a newspaper that is well known for declaring that, for example, "coffee causes cancer" and "coffee reduces cancer risk" on different pages of the same issue. This time it is reporting on a study out of Sweden that appears to show that taking vitamin C or vitamin E supplements increases your risk of developing a cataract - by about 20% for C and 60% for E. [2] It makes a good headline, but does it make sense?

Is this research?

No. They didn't give anybody anything, or do anything to them, This was just a computer exercise in which they re-analyzed postal questionnaires sent to the entire male population aged between 45 and 79 in an area of Sweden, and matched the responses to another database of cataract operations. Although the title says that it is "a population-based prospective cohort study," prospective would really mean that they followed the group of subjects, the cohort, closely over a period of time, without losing many of them. In fact they simply had their computer go through some old electronic records. Nobody was interviewed, and no checks or validation exercises were carried out. No researcher met any of the men in the study, ever.

Is it reliable?

No. The first really serious shortcoming of this paper, the gorilla in the room, is that half the men never replied in the first place, and then the authors deliberately excluded a lot more for reasons such as diabetes - one of the other main "outcomes" of the study and a big risk factor for cataracts. Finally, they omitted to account for another few thousand people, so that in the end they were only studying 27 percent of the original population. If they had randomly selected this sample of the population that would be fine, but in fact the subjects selected themselves by bothering to fill in and return the questionnaire, or not. What were their reasons? We know not. That means that already several types of selection bias have been introduced, and all the results are now meaningless.

There could even be what's known as indication bias - when cause and effect get mixed up. So, for instance, cataracts can take decades rather than years to develop, and people with early symptoms might be more likely to take supplements to ease their eyestrain. If the study goes on entirely in a computer, there's no way of telling.

Is it scientifically plausible?

No. The study contradicts many other studies that have shown either no effect or actual benefits of vitamin C and E for preventing cataracts and other eye diseases. Cataracts are common among older people, and it is well known that antioxidants can reduce the risk of developing them if taken long-term. Smoking, obesity, and diabetes are well-known risk factors for cataracts, and antioxidants are known to prevent the damage caused by these factors. [References below]. In one study, vitamin C supplements taken over 10 years or more reduced the risk of cataracts by about 80%.This is a huge dose-related effect, strongly suggesting the benefit of antioxidants in preventing cataracts. The effect was not apparent for short-term use, suggesting that any shorter-term study may not identify the benefit. (Jacques et al, 1997).

Studies should not be viewed in isolation, because that leads to the "coffee causes cancer" and "coffee reduces cancer risk" absurdity. The effect of a discrepant study such as this is to marginally adjust the current information about risk. Let's say that based on previous studies, as listed below, we thought there was an 80 percent probability that taking vitamins would help to prevent cataracts; after this one we might revise that to 75 percent. This is known as Bayesian probability [after an English minister 300 years ago] and makes a whole lot more sense than the supposedly black-and-white, 95% confidence-interval type of statistics used here. If a gambler isn't a Bayesian he's an idiot; every hand, every throw, alters the odds. So does every study.

The conclusions here are also dodgy because there is no real data on the amounts of the vitamins taken - only a guesstimate from an earlier study of 248 men - and even occasional use was tabulated as use of supplements. For this to make a substantial difference to the health outcome isn't really plausible.

So, in real life?

To prevent age-related diseases of the eye including cataracts, the best current advice is to lower oxidative stress by stopping smoking, reduce excess weight (diabetes again), eat an excellent diet along with a multivitamin supplement and additional supplements of vitamin C (3,000 - 6,000 mg/day in divided doses), vitamin E (400-1,200 IU of natural mixed tocoperols and tocotrienols). This will greatly help prevent oxidation of the tissues of the eye. Artificial forms of vitamin E (dl-alpha-tocopherol) are only 50% as biologically active as the natural form (d-alpha-tocopherol). Taking alpha-tocopherol alone is thought to lower the effective uptake of the other beneficial forms of vitamin E, so it's important to take the natural form of mixed (alpha-, beta-, gamma-, delta-) tocopherols.

(Dr. Damien Downing is a practicing physician specializing in orthomolecular medicine in London, UK, and Dr. Robert G. Smith is a neurophysiologist specializing in eye research at the University of Pennsylvania.)

(I don't have a picture of a Swedish epidemiologist, so here's a Swedish battleship. Technically a Sverige class coastal defense ship, a small battleship of limited speed and range built for defending Sweden's shoreline and harbours.)

References:

1. http://www.dailymail.co.uk/health/article-2283178/How-vitamin-pills-raise-risk-cataracts-hidden-danger-everyday-supplements-revealed.html

2. Selin JZ, Rautiainen S, Lindblad BE, Morgenstern R, Wolk A High-Dose Supplements of Vitamins C and E, Low-Dose Multivitamins, and the Risk of Age-related Cataract: A Population-based Prospective Cohort Study of Men (2013) American Journal of Epidemiology, published online. DOI: 10.1093/aje/kws279

Vitamin C lowers cataract risk:

Head KA. Natural therapies for ocular disorders, part two: cataracts and glaucoma. Altern Med Rev. 2001 Apr;6(2):141-66. [vitamin C alone or with vitamin E reduces risk of cataracts]

Jacques PF, Taylor A, Hankinson SE, Willett WC, Mahnken B, Lee Y, Vaid K, Lahav M. Long-term vitamin C supplement use and prevalence of early age-related lens opacities. Am J Clin Nutr. 1997 Oct;66(4):911-6. [Huge effect, 77% - 83% decrease in lens opacities]

Vitamin E lowers cataract risk:

Rouhiainen P, Rouhiainen H, Salonen JT. Association between low plasma vitamin E concentration and progression of early cortical lens opacities. Am J Epidemiol. 1996 Sep 1;144(5):496-500.

Nourmohammadi I, Modarress M, Khanaki K, Shaabani M. Association of serum alpha-tocopherol, retinol and ascorbic acid with the risk of cataract development. Ann Nutr Metab. 2008;52(4):296-8. doi: 10.1159/000148189.

Seth RK, Kharb S. Protective function of alpha-tocopherol against the process of cataractogenesis in humans. Ann Nutr Metab. 1999;43(5):286-9.

Engin KN. Alpha-tocopherol: looking beyond an antioxidant. Mol Vis. 2009;15:855-60. [ vitamin E likely plays a role in preventing cataracts]

Smoking increases risk:

Mosad SM, Ghanem AA, El-Fallal HM, El-Kannishy AM, El Baiomy AA, Al-Diasty AM, Arafa LF. Lens cadmium, lead, and serum vitamins C, E, and beta carotene in cataractous smoking patients. Curr Eye Res. 2010 Jan;35(1):23-30. doi: 10.3109/02713680903362880.

Hiller R, Sperduto RD, Podgor MJ, Wilson PW, Ferris FL 3rd, Colton T, D'Agostino RB, Roseman MJ, Stockman ME, Milton RC. Cigarette smoking and the risk of development of lens opacities. The Framingham studies. Arch Ophthalmol. 1997 Sep;115(9):1113-8.

Healthy diet prevents cataracts:

Mares JA, Voland R, Adler R, Tinker L, Millen AE, Moeller SM, Blodi B, Gehrs KM, Wallace RB, Chappell RJ, Neuhouser ML, Sarto GE; CAREDS Group. Healthy diets and the subsequent prevalence of nuclear cataract in women. Arch Ophthalmol. 2010 Jun;128(6):738-49. doi: 10.1001/archophthalmol.2010.84.

Williams DL. Oxidation, antioxidants and cataract formation: a literature review. Vet Ophthalmol. 2006 Sep-Oct;9(5):292-8.

J Foot Ankle Surg. 2013 Jan-Feb;52(1):62-6. doi: 10.1053/j.jfas.2012.08.003. Epub 2012 Sep 15.

Efficacy and safety of high-dose vitamin C on complex regional pain syndrome in extremity trauma and surgery--systematic review and meta-analysis.

Shibuya N, Humphers JM, Agarwal MR, Jupiter DC.

Source

Texas A&M Health and Science Center, College of Medicine, Temple, TX, USA. shibuya@medicine.tamhsc.edu

Abstract

Complex regional pain syndrome (CRPS) is a devastating condition often seen after foot and ankle injury and surgery. Prevention of this pathology is attractive not only to patients but also to surgeons, because the treatment of this condition can be difficult. We evaluated the effectiveness of vitamin C in preventing occurrence of CRPS in extremity trauma and surgery by systematically reviewing relevant studies. The databases used for this review included: Ovid EMBASE, Ovid MEDLINE, CINAHL, and the Cochrane Database. We searched for comparative studies that evaluated the efficacy of more than 500 mg of daily vitamin C. After screening for inclusion and exclusion criteria, we identified 4 studies that were relevant to our study question. Only 1 of these 4 studies was on foot and ankle surgery; the rest concerned the upper extremities. All 4 studies were in favor of this intervention with minimal heterogeneity (Tau(2) = 0.00). Our quantitative synthesis showed a relative risk of 0.22 (95% confidence interval = 0.12, 0.39) when daily vitamin C of at least 500 mg was initiated immediately after the extremity surgery or injury and continued for 45 to 50 days. A routine, daily administration of vitamin C may be beneficial in foot and ankle surgery or injury to avoid CRPS. Further foot and ankle specific and dose-response studies are warranted.

http://www.ncbi.nlm.nih.gov/pubmed/22985495