Establishing Accurate Cardiovascular Risk

Thanks to everyone that made it to my Cardiovascular health seminar on June 19th. This was part of our wellness workshops that we do every other tuesday at our clinic. As promised I've posted the information from the talk here. It was a bit bio-chemistry heavy, so even if you were at the class, it isn't a bad idea to go through the information again in case it didn't all stick the first time.

None of this information came directly from me, and rather is sourced from a lot of people that I really respect, including Chris Masterjohn, Chris Kresser, and the authors of dozens of published medical studies.

Basically our talk covered the real causes of cardiovascular disease. We have, as a culture, hanged our blame for cardiovascular disease on Cholesterol since a number of studies were incorrectly interpreted, or outright misrepresented to show that higher cholesterol levels cause heart attack and artherosclerosis.

Initial studies into artherosclerosis used rabbit models and found that injected cholesterol did not cause any artherosclerosis, but feeding rabbits cholesterol did cause artherosclerosis. What this means is that it is the introduction into the blood stream from the digestive system that becomes the crucial factor to creating the artherosclerotic plaques. This factor is something called a lipoprotein. These are the vehicles that carry cholesterol through the blood. The last L in HDL and LDL refers to this lipoprotein.

It works like this: cholesterol is fat soluble, which means it cannot be dissolved in blood (which is water based). In order to move through the blood it needs to be carried in a lipoprotein. A lipoprotein is the vessel that delivers cholesterol to the cells, brain and areas of the body that need it. Coincidentally it's also how fat soluble vitamins are carried through the blood.

We have this idea that cholesterol is bad in any quantities and the lower we can get our number the better. But in fact cholesterol is a vital part of proper body function, and does multiple important things including: sex hormone synthesis, stress hormone synthesis, cell membrane integrity, proper brain function, proper eye function, nerve conduction, development, bile creation, fat soluble vitamin absorption, and several studies are finding that adequate cholesterol levels have a protective effect against mental and emotional disorders.

If the cholesterol isn't the problem, what is? The lipoproteins that carry the cholesterol through the body are capable of oxidizing (or becoming denatured, or molecularly malformed). This oxidation creates a molecule that can penetrate through the inner most layer of the arteries, and once embedded in the arterial walls, can attract immune cells to cause inflammation, the result being the formation of an artherosclerotic plaque. If the LDL is not oxidized, studies indicate that even if they do penetrate into the vessel wall they will not attract the immune cells that ultimately result in an artherosclerotic plaque.

The body tries to protect against the oxidation of these Lipoproteins by packaging them with antioxidants when they are created. When the liver packages cholesterol and sends it out into the blood stream it includes Vitamin E and Coenzyme Q10, both of which are powerful antioxidants and protect the lipoproteins from oxidation. One reason that LDL is associated more highly with artherosclerosis than HDL is that the LDL cholesterol is packaged with less vitamin E than HDL. This extra Vitamin E is able to protect the HDL from oxidation more so that the HDL cholesterol isn't likely to penetrate into the vessel lining and cause the aggregation of immune cells.

The real fallacy of the current cholesterol testing is the thought that it is the total amount of cholesterol in the blood that causes the problem. What we're finding out is that it isn't the amount of cholesterol as much as it is the number of lipoproteins. The more LDL lipoproteins in the blood the more capacity for oxidative damage. It's like carpooling. If there are 400 people on the highway with you and they're all in their own individual cars, there are a lot of cars, and probably some snarled traffic. If on the other hand that same number of people are all carpooling and rather than 400 cars there are 9 buses, 15 vans and 10 cars, then there are only 34 vehicles rather than 400. Much less traffic, much less road rage. The same thing goes for cholesterol. If your LDL cholesterol is 100 and your particle size is very small, then you have a lot of vehicles on the road and more chances for oxidation. On the other hand if you have a lot of large fluffy particles (everybody's carpooling) then your chances of these LDLs oxidizing is much less. Another way to think of it is imagine you are in a room with balloons (LDL particles) all over the floor. You put on spiked shoes, are blindfolded and have to walk across the room trying not to step on and pop any balloons (you are now oxidative damage). The same amount of air has to be used to fill the balloons in the room, but you can use as many or as few balloons as you like. You would choose to fill only a few balloons really full, then you will have less chances of stepping on a balloon. If you fill a lot of balloons only partially full then you are more likely to step on a balloon with every step, you'll have more popping. So the ideal with LDL is to have fewer particles, that are large, rather than lots that are small. In fact this particle size is much more important than the total amount of LDL cholesterol these lipoproteins carry.

Another factor to consider is what makes up the lipoproteins. If the problems start when these LDL particles oxidize, then the question becomes: can we make them more stable and keep them from oxidizing? The answer fortunately is, yes. Lipoproteins are made from polyunsaturated fatty acids. These are inherently unstable fats, so we want to make sure we get them from good sources and don't over consume them. The industrial seed oils typically used in America for cooking are actually already oxidized because of the heat needed to extract them. Using only cold pressed, or extra virgin oils reduces the pre-oxidation of these fats so that when they are used to construct the Lipoprotein membranes they are already much more stable.

The last factor to consider is the antioxidant capacity of both our lipoproteins and our blood. Our antioxidant capacity is a relative thing. We begin with our background level of inflammation. This is a result of the amount of stress, injury, toxins, our metabolic rate and unhealthy nutritional ingredients. Then that background inflammation is measured against our antioxidant level (a function of the antioxidants we take in and the antioxidants that our bodies manufacture (like glutathione, superoxide dismutase and coenzyme Q10). We may be more than covering our inflammation with our antioxidant level if we are eating a healthy and nutrient rich diet, or we may be coming in way under par if we are frequenting fast food and consuming junk food. The more our antioxidant deficit the more these Lipoproteins will oxidize and lead to artherosclerosis and heart disease. 

We also need to protect our endothelium. Remember the oxidized LDL need to actually penetrate into our endothelium in order to initiate the formation of arthersclerotic plaques. We can prevent this by improving the integrity of our endothelium. How do we do this? Something called shear stress. Shear stress is a term in physics referring to stress occurring parallel to a surface, or in terms of fluid dynamics in a laminar flow to the walls. In blood vessels we see that the areas with the greatest shear stress have the least incidence of artherosclerosis and the areas with the least have the greatest incidence of artherosclerosis. Shear stress causes the endothelial cells to get busy protecting the vessel walls by improving collagen synthesis, organizing cells in a more protective formation, causing dilation of the vessel and increasing the blood flow through the region. We can increase our shear stress in our vessels simply enough, by getting some exercise. (And we can help this proces along by making sure we are getting adequate vitamin C in our diets as Vitamin C is an important cofactor in the formation of collagen)


So, are there tests that can give us a true evaluation of our true cardiovascular risk? Yes, here are the tests that I recommended and in fact we can order these tests directly through our office. 


LDL particle size
This can be measured by various labs, the testing methods include the VAP (vertical auto profile), the NMR (nuclear magnetic resonance) and a few types of electrophoresis testing. These tests are inexpensive and are often covered by insurance.

Apo B/A1
This tests the actual number of particles. Apo B refers to apolipoprotein B which is a protein found on the surface of LDL particles. There is only one of these proteins per particle so looking at the count of Apo B will tell you how many LDL you have in the blood, or how many cars on the road. The Apo A1 tells you how many HDL you have, as there is one and only one Apo A1per HDL particle. Recent studies seem to indicate that it is the ratio of the two that indicates most reliably the cardiovascular risk.

HsCRP
The High Sensitivity C-Reactive Protein is an indicator of the amount of inflammation in the blood. This is a useful marker as it will indicate the tendency for the LDL particles to oxidize, and as we know it is the oxidized particles that really pose the most risk in terms of cardiovascular risk.

Just to recap:
1. Get accurate testing...see above.

2. Reduce the chances of oxidation: ensure adequate antioxidant capacity by reducing your oxidative risk (stress, food and environmental toxins, general physical damage, metabolic activity-ie excessive calories, industrial seed oils, unhealthy omega 3:6 ratio) and increasing your antioxidant activity (eats your fresh greens and fruits, grass fed meats, organ meats, and eliminate nutrient poor and calorie dense foods)

3. Improve endothelial integrity: get moving!

Thanks for reading, and thanks all those who made it to this seminar!
Kieran

PS: here's a letter you can bring to your doctor requesting more accurate testing:

Establishing Accurate Cardiovascular Risk 

The typical measures used to evaluate a person’s risk of experiencing a heart attack or stroke, or other disease risk associated with Atherosclerosis are the LDL (low density lipoprotein), HDL (high density lipoprotein), VLDL (very low density lipoprotein), particle size (the smaller, denser the LDL the worse), the total cholesterol (the added together LDL and HDL), blood pressure, and triglycerides. 

While these measures are valuable, newer research is showing that there are other measures that more accurately indicate cardiovascular risk. 

Apo B/A1

Apo B-Apolipoprotein B is a measure of the artherogenic particles (particles that cause artherosclerosis found in LDL and VLDL cholesterol). The best measure of this test uses it as a ratio measured against apolipoprotein A-1 (a protein found in HDL cholesterol), an ideal ratio yields a lower number. In the medical journal “Nutrition, Metabolism, and Cardiovascular Disease” Schianca et al established 0.9 as the upper safe ratio for males, and 0.8 for females. A clear cut off is difficult to establish and many would argue that the idea of a clear number at which absolute health risk is established is a result of flawed logic and rather the relative risk of CV event increases with an increased Apob/ApoA-1 ratio and needs to be weighed with other signs of risk such as those below.

HsCRP

High Sensitivity C reactive protein is a marker of inflammation. 2 concurrent readings 2 weeks apart should be done for best accuracy. A HsCRP less than 2 mg/L demonstrates the lowest risk factor. 

LDL particle size

Established through Vertical Auto Profile, Electrophoresis, or Nuclear Magnetic Resonance, this identifies patients as either pattern A or B in regards to their LDL particle size. Our understanding of lipid metabolism would indicate that the smaller, denser particles have spent more time in circulation and would therefore have accumulated more oxidative damage, resulting in more artherogenic capacity. 

Conclusion

The problem with current cholesterol testing is that it fails to measure the ability of that cholesterol to cause damage. Cholesterol is an essential part of a healthy functioning body. The amount of cholesterol in the body isn’t the issue as much as the ability of that cholesterol to oxidize. The likelihood of the cholesterol to oxidize is a function of the anti-oxidative capacity of the body, and the overall level of inflammation in the body. Drugs to reduce total cholesterol fail to fully address this issue. This end is better served by ensuring the body has adequate anti-oxidative capacity through healthy diet, relaxation, and in some people supplementation. CoQ10 and Alpha Lipoic Acid are 2 potent antioxidants that assist in the fat soluble tissue. Amino acid supplementation can also help by promoting the production of glutathione, the body’s antioxidant powerhouse. N-acetyl Cysteine is a great start for this. Lastly, milk thistle increases the generation of glutathione by optimizing liver function. 

Kieran Jones L.Ac. Advanced Wellness and Rehabilitation

From the Pages of Poultry Science

You know what herb I love? Astragalus. Huang friggin Qi. It is such a powerhouse of actions. Recent articles and old articles never seem to tire of singing its praises. When I returned to grad school after a pretty physically demanding surgical bout my very traditional, very knowledgable teacher, Lucy Hu, recommended just this one herb, 40 qian of it in a big pot of water every day for a week to regain my strength.

It's an amazing herb. It's even graced the pages of "Poulty Science". That's right in 2009 Poultry Science published an article (full text) describing the synergistic actions of astragalus polysaccharides and probiotics. There were 4 (chicken) treatment groups: chicks given probiotics, chicks given just Astragalus polysacchardes, chicks given both, and those given neither. The chicks were vaccinated against Newcastle Disease prior to the Astragalus and Probiotic regime, the aim of the study being to gain improvement in vaccination through herbal medicine. It was found that all measures of immune function was improved in the probiotic group and in the Astragalus group, but was improved more in the combined group. The immune function was measured by evaluating antibody titers to Newcastle Disease, T-cell counts, and weighing the immune organs (thymus, spleen, and bursa of fabricius (an avian organ involved in maturation of B cells)). They found as you'd expect that both astragalus and probiotics improved all measurements of immune function, but both together demonstrated a synergistic effect on the immune function of these chicks. I should note that while the measurement of serum antibody titers against Newcastle Disease was also improved most in the combined group, this improvement lacked statistical significance. The researchers also removed the cecum and illeum from the chicks and assayed the concentration of bacteria present there. This measure also demonstrated synergistic gains in the combined treatment group over those in the probiotic group and the Astragalus group (although astragalus alone did show ability to improve intestinal bacteria counts). The combined group not only had increased lactobacillus and bifidobacteria, but also had decreased e. coli numbers, indicating not only an increased bacteria presence but also a healthy modulation of relative bacteria levels. Huang Qi modulates intestinal bacteria! I thought that was pretty exciting, but I am kinda a dork.

Another study looked at Bai Zhu in a similar application. (sorry no full text). This study looked at Bai Zhu as an adjuvant with Foot and Mouth Disease vaccination in mice. They found increased antibody titers in the group that received Bai Zhu prior to vaccination. The ramped up immune function ala Bai Zhu meant that the immune system could mount a more robust defense against Foot and Mouth Disease antigens leading to greater protective effects. Bai Zhu boosted immune system equals better functioning vaccines. (of course the argument being begged is: start raising them naturally and you won't need vaccines at all. I'm with you, but let's get what info we can out of their efforts.) The authors noted that administration of Bai Zhu stimulated immunoglobulins associated with both the Th1 and Th2 divisions of the immune function. Th1 immune function is aimed at protection against intracellular pathogens such as viruses and certain bacteria. Th2 immune function protects against extra cellular pathogens including most bacteria and parasites. The authors concluded, "when the purpose of a vaccination is to activate both Th1 and Th2 immune response, the oral administration of RAM (Rhizoma Atractylodis Macrocephalae) before immunization is indicated." (bold are my words)

We think of Bai Zhu mainly in terms of its ability to tonify the spleen qi. But Bai Zhu also treats spontaneous sweating, demonstrating its effect on the wei qi. From Bensky, "Most materia medica texts agree that the spontaneous sweating referred to here is the result of dampness obstructing the flesh and preventing the harmonious interaction of the nutritive and protective qi; the interstices and pores then become disordered, and sweating occurs randomly." Is this earth dampness that's interfering with ying/wei function a result of dampness accumulating in the intestines (dysbiosis?) and therefore reduced through Bai Zhu's actions on supporting intestinal health-spleen qi? To much western science in your TCM? I'm with you, hard not to try to connect the dots though.

I'm not a huge fan of a lot of vaccines. I think they are wildly overused and often not the best treatment option. I basically abhor the flu shots peddled out of walgreens and rite aid. I think that their use is more financially motivated, than motivated by good science. Having said that, I think the eradication of Polio should go down as one of the major achievements of man. Vaccines have their time and place. Knowing about these studies gives us a way to make best use of them and incorporate them into a holistic healing approach for our patients. 

There are three take aways for me: 

1. Utilize those herbs in all of my patients, that we know to boost wei qi, through mechanisms that adhere to an attentive pattern differentiation.

2. Provide supportive care for those resorting to vaccines so that they may work more effectively with fewer side effects. Preliminary wei qi support, followed by astragalus and other qi tonics, and prebiotics.

3. Incorporate astragalus into the treatment approach for dysbiosis. I would love to see astragalus polysaccharides compared to inulin and other prebiotics in this regard. I suspect that astragalus is superior  at least in regard to the immune activities, but it would probably depend on the patient's Zheng.

Thanks for reading...

Leaky Gut, Intestinal Bacteria, and a pile of Studies

Just attended a seminar by Dr. Daniel Weber of Panaxea International and came away with a pile of new studies to read. There was way to much info to fit into my blog, but I'll pick a few gems and write about those in the next few days.

I'll be throwing a study on astragalus and the modulation of intestinal bacteria, and look at a few formula that have been found to treat leaky gut, also...

Here's the link to panaxea.

Here's a great blog article for all you raw milk haters.

And, here's the world's best shoe. I'm having a hard time not breaking into sprints in parking lots...

I'll get those studies out soon...

Systems Biology and TCM

I was reading The End of Illness the other day by Dr. Agus (I know I'm a sucker for anything featured on the Daily Show). He gets into explaining the role that proteomics can have and will have in the future of medical diagnosis. Proteomics is a systems biology approach to lab analysis that takes a snapshot of the various peptides present in a tissue sample and thereby quantifies and qualifies the relative strength of inflammatory, homeostatic, and other processes in the body to arrive at a richer and more nuanced view of health. Sounds an awful lot like some good old bian zheng (or pattern differentiation) to me. Nobody tell them they can do it without all that expensive machinery, our economy needs those purchases.

Well, I dove a bit deeper and found that a lot of research has been done, looking at systems biology approaches such as proteomics, transcriptomics and metabolomics and how well it correlates across patients with the same TCM diagnosis, and the answer is, wait for it....pretty darn well. There is some really interesting stuff out there on this subject. We know that multiple Western Medical diagnosis can have the same TCM diagnosis. If they also have the same proteomic profile, then Western Medicine may finally have a tool that puts them at least in the same ballpark as TCM in terms of overall diagnostic ability. Granted their diagnostic accuracy with this technique is pretty crude still and it'll take a pretty long time before this sort of diagnostic approach really reaps gains for them. But, the value to me is in having anther peg to hang a hat on when I think of what exactly is happening in the body when I think of kidney yang deficiency, or spleen qi deficiency, or liver qi stagnation. Before I outrage my chinese medicine brethren, I am in no way suggesting that this sort of understanding is any more "real" or "true" than our own understanding of them or that any blood test can replace our unique diagnostic skills and approach. Truly complete understanding of the patient's health I think is like the Tao in that understanding it in abstractions is possible but when grasping for a concrete and objective finality inspection will always yield a deeper level of murkiness. So...so to the fun part! The studies!

In one study, in the American Journal of Chinese Medicine, they looked at "heat" type asthma in a group of patients and sought a systems biology style correlate of this TCM term. They found that those diagnosed with a "heat" pattern demonstrated an increase in eosinophil cationic protein, which according to wikipedia is released during degranulation of eosinophils...ie inflammatory process and in our medicine, a very simplistic, and potentially unreliable indicator of heat patterns. I know I would trust my 4 examinations long before the ECP count in my patients serum as an indicator of their pattern, but you gotta give it to them for trying.

Another article, in the Journal of Pharmaceutical and Biomedical Analysis (sorry no free full text). Looked at multiple studies on this subject and the authors wrote about various zheng and their relevant systems biology style biomarkers:

Investigations into the characters of the ‘Kidney-Yang Deficiency syndrome’ induced by high dose of hydrocortisone and the therapeutic effects of Rhizoma Drynariae, classic TCM in treating the syndrome, have been performed by robust metabolomics method based on UPLC/MS [44]. It was found that significant difference in metabolic profiling was observed from hydrocortisone-induced group compared with the pre-dose group by using PCA. The time-dependent regression tendency in Rhizoma Drynariae treatment group was obtained, and the major metabolic alterations responsible for group separation were linked to some significantly changed metabolites like phenylalanine, N(2)-succinyl-L-ornithine, phenylacetylglycine, creatinine, hippurate, L-proline, and citrate. Biochemical changes were related to the disturbance of amino acid metabolism, energy metabolism and gut microflora, which are helpful to further understand the ‘Kidney-Yang Deficiency syndrome’ and the therapeutic mechanism of Rhizoma Drynariae. Therefore, metabolomics not only opens out mechanism of classical TCM theory on syndrome but also enriches current research on complex diseases [45].

So in plain english that means they induced kidney yang deficiency in these rats by giving them hydrocortisone then compared the metabolites present in their blood with those in other rats with their kidney yang intact. They found changes consistent across the study group in terms of the amino acid building blocks present. They attributed the changes in the biochemical profiles of these rats to not only this difference in the metabolites, but also the energy metabolism that resulted from it as well as changes in gut flora. I really appreciate their recognition of the gut flora (other systems biology folks also ascribe huge importance to these bacteria). I think the gut flora should be considered its own discrete organ from the western sense and I consider it to occupy a pretty large part of what we recognize as the spleen zang in Chinese Medicine.

I try not to jump up and down too much when a new testing method comes out. I don't, for instance, see this new approach as a reliable diagnostic for autism. (check out this great blog post on this subject by Paul Whiteley.) What I do think, is that this is an exciting new way to look at the body. A way that allows for gray areas and very subtly nuanced differences. This type of investigational approach serves due respect to the organism whose true nature often defies clear distinction.

Wound Healing and Chinese Herbs

I get cuts, scraps bumps, bruises and so do my patients. Some of them heal quickly, while others seem to remain at a standstill for months, oozing red tissue angrily and present weeks after the offending impact. Proper healing of wounds is dependent upon numerous factors and as such is a reflection of overall health. 

But first here's a great resource, does everybody know about this nutritional information database?

Luckily, we have lots of options in Chinese Medicine to speed healing. First, from a Chinese Medicine perspective...

Just a quick heads up for those out there who aren't versed in Chinese Medical theory, the references to organs in this paragraph relate to their function within Chinese Medicine, which is distinct from their physiological function recognized by western medicine. We know that the spleen is the organ most closely associated with flesh, and also that the lungs regulate the skin. Sufficient function is required in both in order to have appropriate healing. The kidneys also play a role as the foundational yang substrate for the transformation and transportation of the spleen. The lungs also rely on healthy kidney function as the ability to properly effuse lung qi and moisture throughout the body, moistening the cou li requires unrestricted ventilation of the lungs, which pivots on sufficient grasping of the lung qi by the kidneys. The kidneys lastly play a pivotal role in healing by maintaining appropriate yin and yang balance in the body as a whole. For instance the decreased healing we see in Cushing's syndrome or menopause seems to have a basis in what our medicine would call kidney qi and yin deficiency respectively. Western medical recognizes the intricate work that the white blood cells do and makes clear the reliance on a healthy wei qi. The spleen in a western sense stores monocytes and deploys them when a wound requires more immune cells, a healthy healing process relies on sufficient stores of monocytes in the spleen whether you can relate this to the chinese medicine spleen or not seems murky. 

Western Medicine wise...Healing of wounds passes through 4 main stages beginning with homeostatic (where the immediate danger of bleeding is addressed), then inflammatory (where numerous immune cells and inflammatory mediators cooperate to guide the initial patch work), then proliferative (where progressively more permanent materials are laid down) and finally the remodeling phase, where the wound is prettied up; fibrin that was laid down haphazardly is made to point the right direction. 

A lot of the information about wound healing comes from the full text of this article, and good ol' wikipedia: here. 


The inflammatory phase is the phase where most of our patients are going to be able to benefit from our help. It's the most complex in terms of the interaction of various cell types. It's arguably where our herbal interventions can have the most influence. 


The inflammatory phase involves the immediate constriction of local vasculature mediated by prostaglandins and thromboxanes, which is followed shortly by vasodialation, mediated largely by histamine, which enhances the aggregation of immune cells both by increasing local perfusion and creating porous vessel walls. 


Neutrophils are the initial responders, arriving on the scene within the first 24 hours. They are responsible for cleaning up foreign and damaged tissue at the sight of injury. Their function is important and it was found through rat experimentation that the lack of sufficient neutrophil presence resulted in poor debridement of the site and decreased fibrinoplasia. 


The macrophages move in next and are key. They proliferate in the second to third day (48-96 hours) and carry out multiple functions: detecting the low levels of oxygen in the local tissue they are triggered to induce angiogenesis (the laying down of new blood vessels, and lymph vessels.) The presence of new vessels is key to the continued healing of the wound. They also coordinate the recruitment and aggregation of other cells at appropriate times through the secretion of cytokines and growth factors, thereby conducting the transition from step to step along the healing process. They "express inducible nitric oxide synthase, and are a source of nitric oxide production in the early phase of wound healing." Nitric oxide, besides having antimicrobial actions, also facilitates reepitheliazation, collagen deposition, and speeds the rate of wound closure. So numerous steps in the healing process are carried out by the macrophages, and numerous steps in the healing process are carried out by other cells, which are orchestrated by the macrophages. Wow, those macrophages are busy little blobs.


T-lymphocytes, moving in next, have actions in would healing that are not yet fully clear. Experiments done on rats showed that eradication of certain types of T cells (CD8) increase the strength of a healed wound, whereas eradication of all types of T cells results in a decreased strength of a healed wound. Lau and friends concluded that they "...may bracket control of the proliferation phase of wound healing." In other words they tell when to start and stop laying down fibrin and collagen. Too much fibrin and collagen and there is a big lumpy scar, too little and there is a weak closure that may open again. The T cells maintain moderation in this process. 


What can't be overstated is just how crucial the immune cells are in this process. They are doing much more than just attacking invaders, but supervising and directing every stage of the healing process. We can see right away why conditions like diabetes that decrease immune function also affect wound healing. Also, knowledge about the cells active in each phase of wound healing can give us useful clues in how to best help our clients heal. We can look at the place where the healing process is going awry and stimulate specific components of the immune system. Such as the macrophages if the issue is presenting during the inflammatory phase, and specific immunity if it's the proliferation phase that is buggered up.

When it comes to stimulating wound healing there are a number of herbs that I remember from school stimulating healing: huang qi, hua shi, mo yao, ru xiang, and others. When we look at the classifications at the end of the Chen book "Chinese Medical Herblogy and Pharmacology" we find just 5 herbs listed as stimulating the generation of flesh: di yu, gu sui bu, lu hui, lu lu tong, and shan yao. And a trip through the medical literature reveals still a different list that includes: san qi, dan shen, shu di huang, sha ji, and huang qi.

This is a great study from Poland, looking at the proangiogenic actions of a handful of herbs and their application in wound healing. By proangiogenic they mean "making new blood vessels" this is what the macrophages do during the inflammatory phase to speed healing and bring more tissue to the site. It is crucial in the healing process. Anyway, this article is great, it is chalk full of little nuggets of scientific minutiae that bring a bit more clarity to our understanding of these herbs. First, they looked at ginseng (including ren shen, xi yang shen, and san qi.) Then, as western medicine loves to, they got all microscopic and looked at the chemical nature. What they found is that there are multiple ginsenosides (over 40) present in various types of ginseng and the types present and the quantities of each dictate the actions. In the author's words:

The ginseng root contains 2–3 % ginsenosides

of which Rb1 and Rg1 are the most abundant (Sengupta

et al., 2004). The mass-spectroscopic compositional analysis

performed by Sengupta et al. has revealed that Rg1

and Rb1 are present in all investigated extracts, however,

each extract displays distinct ginsenoside composition,

especially in the ratio between the two.

It is the ratio between the two types that seems to have the real action on angiogenesis. A predominance of Rg1 lends to more angiogenesis actions while a predominance of Rb1 seems to limit angiogenesis. San Qi is predominantly Rg1, while ren shen and xi yang shen are both predominantly Rb1. This proangiogenic action of san qi might go a long way towards explaining it's apparently contradictory actions of stopping bleeding while invigorating blood. More blood vessels means holding that blood in the body, while also carrying it away from the site.

The study also looked at aloe vera. It wasn't clear whether they looked at Aloe Vera gel, or at what we know as Lu Hui, which are quite different. Lu Hui is the dark resinous material removed from the fiberous outer rind of the aloe plant, then dried, or charred. Aloe Vera gel on the other hand is the gelatinous material removed from the inner compartments of the stalks of the aloe plant. The chemical constituents are different, but one chemical that they both contain (and many wound healing herbs do) is sitosterol (in Lu Hui it's Beta sitosterol). This chemical has pretty strong actions on increasing angiogenesis and it's where this study put most of its money on why aloe works.

Sea buckthorn, or sha ji, has also demonstrated results in accelerating wound healing. It also contains large amounts of sitosterol (57-76 and 61-83% of the seed and peel respectively) as well as a high oil content, and a number of flavonoids. It has the special application in TCM of being used to treat hematomas, and Bensky also notes it can be applied topically to treat burns.

Sea Buckthorn, Aloe Vera, and Curcuma Longa (jiang huang) were tested together as a topical treatment for slow healing wounds by Gupta and friends. In Gupta's words: "treatment increased cellular proliferation and collagen synthesis at the wound site." He found benefit in both diabetic and normal rats. He used a water extraction of the first two ingredients and an alcohol extraction of the third, combined in a specific ratio (1:7:1) for best results. Sounds like a good thing to have on hand in the clinic.

Astragalus was investigated and found in some studies to contain the ingredients that should speed healing, but was found in another study that topical application did not speed healing of diabetic ulcers, until it was given combined with rehmanniae at a 2:1 ratio. Enter the synergistic actions of herb combining. This is an exciting new arena of research where they are attempting to examine how herbs interact. It's wicked complicated though, and the nice thing is we don't really need to know the why to continue prescribing our herbs in traditional combinations. For me this gives me more reason to respect the formulas created over the centuries. Besides being well balanced in their actions, the formulas that have persisted all these years likely have synergistic actions that go beyond their cumulative effects. It is also a  good reason to try to always use herbal mixtures that are extracted or decocted together unless the classics specified another method. So for all the granule people out there, that means just pouring the 4 ingredient powders together to make si wu tang is different than buying the formula decocted together and granulated. You may be losing actions, or introducing other actions that weren't part of the traditionally recognized actions. I'd love to do a post someday on what science knows so far about herb combining. Anyway, back to wound healing...

I found it interesting that Huang Qi contains phytoestrogens that are able to bind to and stimulate estrogen receptors. Here's a nice study showing that. (the others that they looked at that also had estrogen activity, so you don't have to go look up the botanical names were: ge gen, yin yang huo, suo yang, she gan, huang qin, jue ming zi, bu gu zhi, hu zhang, he shou wu, and da huang, they didn't look at shan yao sorry.) As we know estrogen has a proliferative and protective effect when it comes to flesh; mucosa thin and skin thins in menopause and this seems a likely mechanism by which astragalus operates (when taken internally). Astragalus also has actions on increasing wbc count (specifically in regards to macrophages) and macrophages have so much going on in the process of wound healing it seems a no brainer to get our poor healers on huang qi (and our diabetics for that matter.)

So in conclusion there are numerous ways to improve wound healing from directly stimulating new tissue growth via topical application of powdered herbs or extractions with angiogenic actions (san qi, lu hui, sha ji, dan shen, etc.) if you use huang qi topically to improve healing you need to include shu di huang in a 1:2 ratio (huang qi : shu di). Giving herbs internally that regulate and support healthy immune function and improve white blood cell production such as adaptogenic herbs (huang qi, ren shen, san qi, dong chong xia cao, bu zhong yi qi, si jum zi tang etc) will support wound healing by making sure that the cells that are active in wound healing are available to complete the tasks. I know most people in this healing trade always look to treat the root as well as the branch and this area is no exception. Dab a bit of that 2:1 huang qi shu di juice on that thing, or better yet follow Gupta's lead and make your very own 1:7:1 mixture of sha ji, aloe gel and jiang huang but after you've addressed it on the surface, get that patient on some qi tonics as well.

Sorry there was so much mumbo jumbo from the science side in this post, I'll keep the next post a little more Chinese Mediciney.

All the best

Welcome to my first blog post!

Hello! Welcome to my blog! (if indeed anybody out there is actually reading it!) 


What's if for? This blog is intended as a resource for acupuncturists, herbalists and medical doctors to learn about new research in the application of science based herbs to patient care. It'll also be useful to those laypeople out there who want to have a more involved hand in your care (and by the way kudos to you!). I'll go through recent studies both from Chinese and English sources that offer useful clinical nuggets, and investigate them in light of the classical wisdom on those herbs and formulas. I recognize and value the empirical wisdom of the thousands of years of knowledge in Chinese Medicine, but also recognize that modern experiments are valuable in understanding the nuances of the application of these herbs. 


I guess a brief introduction is in order. I'm Kieran Jones. I'm an acupuncturist practicing in Washington State near Seattle. I attended Five Branches University in Santa Cruz, Ca, graduating in 2009. I'm currently applying to attend a Doctoral Program at Oregon College of Oriental Medicine. 


Anyway, enough about me, lets get to the studies. To kick it off lets look at a promising herb called dan shen and it's use in the treatment of something we didn't hear about using it for in Chinese Medicine School.


Hopefully most of us know about the spontaneous fractures that occur as a result of taking the Biophosphonate drug Fosomax, and many of us probably know patients still taking Fosomax. I just saw one a few weeks ago. It leaves us wondering, how we can best treat these patients for their risk of fractures, without (hard to say this with a straight face) increasing their risk of fractures. 


Well, enter the chinese herb Dan Shen. Categorized as a regulate blood herb in the Chinese Pharmacopeia, Dan Shen invigorates the blood, tonifies the blood and calms irritability due to blood heat. (source Materia Medica 3rd edition) Dan Shen has been long used to treat pain associated with what Chinese Medicine calls blood stagnation, and has a particular affinity (tropism we say in the herb nerdery) for the heart.


An exciting study came out back in 2004 looking at this amazing little herb's action in the treatment of Osteoporosis with pretty encouraging results. In this study by Liao et. al., rats were ovariectomized (ovaries removed) leaving them without the glands that make their estrogen. Without the protective effects of estrogen they began a made dash for osteoporosis, their bones thinning like pre weigh-in high school wrestlers. They were treated variously with estrogen, the dan shen extract (tanishonine) or a control injection of deionized water.


The results were that dan shen protected against bone loss almost as well as the estrogen did. Also the dan shen didn't have any significant effects on increasing the weight of the uterus as the estrogen did. (meaning the dan shen was not stimulating the estrogen receptors, but was working through another mechanism. This is important because as we know the use of Hormone Replacement Therapy can increase the risk of cancer, heart attack and stroke, so we want to avoid stimulating those receptors in this patient population.) 


Note that this was a fat soluble extraction of Dan Shen, which is traditionally extracted in a water based decoction. This is key. The active ingredients in various dan shen preparations varies widely so the safest bet is to get the raw herb for your patients and either extract it yourself or send them home to decoct it. It isn't immediately clear to me how many of the fat soluble components are retained in the water decoction. If anybody has seen a detailed analysis of the constituents in a water extraction of dan shen, I'd love to see it. 


The authors stated Dan Shen's ability to decrease the loss of bone mass as a result of its action on decreasing the actions of the osteoclasts, however, unlike estrogen it does this without decreasing the action of the osteoblasts. The constant back and forth action of the osteoblasts and osteoclasts ensure the bones remain both dense (enough material) and structurally strong (properly placed material). After all, anybody can carry a stack of two by fours into your living room, but unless they are placed strategically in the walls at the correct locations they won't increase the strength of your house. Here are the authors:

Unlike well-known antiresorptive agents estrogen, as shown in this study, which inhibit bone resorption accompanying with a subsequent decrease of bone formation through coupling mechanism^[16], tanshinone treatment only decreased mineral apposition rate but not mineralizing surface at the PTM of OVX rats. In addition, all bone formation indices such as mineralizing surface, mineral apposition rate, and bone formation rates were not altered by tanshinone treatment at the LV in OVX rats. Furthermore, tanshinone also thickened the trabecula whereas estrogen did not have such effect as shown in the current study. These results indicate that tanshinone does not inhibit osteoblast bone formation occurred on bone surface while inhibiting bone resorption thus causes a positive bone balance resulting in bone gain.

Add to that the benefits Dan Shen shows in preventing cardiac ischemia and it's a bit of a no brainer getting your elderly patients on this as a regular piece of their herbal supplementation!


Later till next time!