A Good Friday Prayer

The Pange Lingua, from the album Illumination: Peaceful Gregorian Chants (CD, MP3 download):

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Vitamin C: Should you take it before and after surgery? Part 2

In Part 1, we found that taking vitamin C after orthopedic surgery is a good idea, and that vitamin C could help in other surgical situations as well. But that’s only half the story. Here’s the other half.

Vitamin C as a prooxidant?

The world of vitamin C was tipped upside down in 1998, with the publication of a controversial paper in the prestigous journal Nature entitled “Vitamin C exhibits pro-oxidant properties”. News media was all over it, predictably warning readers to be afraid…very afraid of taking vitamin C supplements. But the paper had a lot of holes, to put it mildly.

The study showed that some DNA was oxidized by vitamin C, but some DNA was also protected from oxidation by vitamin C (with the protection being around ten times greater in magnitude! A fact that was conveniently left out of the paper.). Plus the experimental technique may have oxidized some DNA by itself. So what happens when throngs of angry vitamin C supporters wrote in to the journal? The primary author backtracked, and his reply concluded “our study shows an overall profound protective effect of this vitamin.” Case closed. Or is it?

IRONing out the details…

Vitamin C is neither always an anti-oxidant or always a pro-oxidant, and not all studies are applicable to what goes on in your body. Take lab mice for example. Unlike humans, mice can synthesize vitamin C, and supplementation can paradoxically reduce their vitamin C levels. In humans, study results are mixed, with most showing either an anti-oxidant effect or no effect, and some showing both anti and pro-oxidant effects. Timing could also be an issue. In a study where vitamin C was added before LDL was experimentally oxidized, it displayed antioxidant properties. But vitamin C actually showed prooxidant properties when added AFTER the LDL was mildly oxidized. So what does this mean for surgery?

First things first: if you have iron overload (for example, due to hereditary haemochromatosis), be careful with high doses of vitamin C, especially during times of surgery. Unbound iron can interact with vitamin C to produce oxidative stress. Iron is typically bound to transfer proteins and largely safe from vitamin C, but a portion of iron stores may be released when tissue is injured and blood vessels are compromised. And when is a large mass of tissue injured? Surgery!

For people without iron overload, the implications of iron and vitamin C interactions are not so clear. There doesn’t seem to be much data about the interaction of vitamin C and iron during the surgical and post-surgical period. In vitro and trial evidence conflicts on whether vitamin C protects or chemically reduces (i.e. harms) iron in humans, and evidence is also mixed on whether vitamin C protects or occasionally causes protein glycation. Vitamin C can have differing effects on oxidation of depending on the target (lipids, proteins, or DNA) as well.

So the takeaway here may simply be: avoid taking supplements that contain iron and too many iron-enriched foods around surgery time (unless you are advised to by your doctor), and don’t go much beyond the PHD-recommended vitamin C intake. If you have a crappy diet and think vitamin C will save you, be careful. Overloading on vitamin C after tissue components are already oxidized could theoretically lead to further oxidation.

Crohn’s and Ulcerative Colitis

Crohn’s and ulcerative colitis patients often take vitamin C in combination with iron for anemia. That might be a bad idea, as high doses of iron worsen symptoms in Crohn’s patients. Even a single high dose of iron can cause intestinal lining oxidative damage in healthy individuals, and supplementing with quite small amounts of vitamin C and iron together leads to oxidative damage. Iron-enriched diets increase colon cancer in mice and injected vitamin C combined with iron causes ulcers in rats.

The combination of vitamin C, certain metals, and hydrogen peroxide makes up a free-radical generating process called the “Udenfriend system”. Diseased tissue, such as the intestinal tissue in bowel disorders, may contain higher levels of these components. While some in vitro studies show that the Udenfriend system is NOT your friend, others show that it doesn’t cause lipid or protein oxidation in vivo. Without a conclusive answer, it might be prudent to avoid going overboard with vitamin C and iron if you have Crohn’s or UC, especially around surgery.

Other surgeries

There are many different surgeries for many different conditions, and vitamin C hasn’t been studied for most specific examples. One type of surgery that there is evidence for is vascular surgery. In a randomized trial of vascular surgery patients, 2 grams of prophylactic vitamin C was tested for the purpose of decreasing inflammation and tissue damage. It ended up actually increasing oxidative lipid damage, which can lead to further vascular damage. Cardiac surgery can cause tissue injury when blood supply returns after a period of low oxygen. And guess what else happens when blood returns? Extra iron is released from storage, and this iron can theoretically be reduced (damaged) by vitamin C.

Conversely, vitamin C has shown promise for other surgeries. In a study of GI surgery, post-surgical oxidative stress was reduced by taking 500 mg/d of IV vitamin C. Note that IV vitamin C can lead to more than six times higher blood levels than oral intake. Since vitamin C is consumed at high rates during some surgeries, this effect seems logical, and certain patients may be very low in vitamin C before surgery and hence really need a vitamin C boost. Most often, studies combine a few antioxidants rather than testing just one, which makes singling out the effect of vitamin C difficult.

Physical therapy

In some surgeries (e.g. orthopedic surgery), surgery is only the beginning of the treatment. The rest of the treatment comes in the form of grueling, sometimes scream-inducing physical therapy that can last for weeks or months. Since muscles atrophy if a body part isn’t used much before surgery, the post-surgical period is important for muscle growth.

While vitamin C is important for joint healing, there is a small amount of evidence that vitamin C supplementation can interfere with muscle growth. And physical therapy is a combination of growing muscle, healing joints, and re-training the nervous system.

Reactive oxygen species (ROS) are not universally bad, and one of their important functions is to signal the body to increase protein synthesis as part of the mTOR pathway. Vitamin C in extremely large doses inhibits muscle growth (in rats) by quenching not just bad ROS, but helpful ROS as well. In humans the effect is uncertain, as the impact of supplemental vitamin C varies widely by study. Given the importance of vitamin C in wound healing and collagen formation, it’s likely unwise to avoid vitamin C in the post-surgical period. The takeaway may be to avoid massively overloading on antioxidants in general — large amounts of antioxidants other than vitamin C may impair muscle adaptation to exercise. And taking vitamin C to bowel tolerance directly after physical therapy may be both uncomfortable and unwise.

Conclusion

A healthy diet should support the entire endogenous oxidative system, as antioxidants often work together. So as usual, focus on getting a balance of nutrients from your diet, especially before and after surgery when nutrition is critical for healing tissue.

Vitamin C intake should be at least 500 mg/d after surgery in order to avoid the terrible pain condition RSD/CRPS. Moderate doses of vitamin C typically show benefit for oxidation, and are likely helpful before and after surgery. Only very high doses over extended periods or extremely high IV doses have been linked to adverse events like renal failure, and vitamin C studies typically only show prooxidative effects when combined with iron supplementation or in higher doses.

Thoughts on Palm Sunday

Today is Palm Sunday, the day of Jesus’s entrance to Jerusalem, when crowds who thought he might lead a new Jewish kingdom strew palm fronds on his way, an honor fit for a king. It was the only day of Jesus’s life when he was honored and cheered.

None of those cheering followers were to be found a few days later, when the crowd demanded his death.

For Jesus it must have been a bittersweet moment. He must have known that the cheers of Palm Sunday were mere flattery.

The Palm Sunday liturgy does not emphasize the day itself; rather it looks ahead to the painful events of Thursday and Friday, to his betrayal with a kiss; his abandonment and denial by his followers including the “rock” of the church, St Peter; his humiliation and death.

After the false pleasure of Palm Sunday, beyond the pain and desolation of Good Friday, comes the day of true joy: Easter, resurrection and new life. Joy, ultimately, is certain to triumph over pain. But, we mustn’t hasten too quickly to Easter. For there is a time for joy and a time for grief; and first we must grieve.

If life’s nature is bittersweet, it is inevitable that our own lives will recapitulate those ups and downs. Let me share some of my own recent up and down moments, bitter and sweet.

Shou-Ching is in Australia at the moment, spending a few weeks with her godparents, who are in failing health. As their health declined, they found it difficult to cook, and their diet for some time now has consisted largely of packaged foods and pre-prepared dumplings. It is difficult to know how to help them; they have pain, disability, and cognitive decline; and Shou-Ching’s godmother, in particular, may have little time left. “Old age shouldn’t be this hard,” Shou-Ching wrote me. Yet, it is a blessing for Shou-Ching to be able to share time with them, and do them a bit of good.

Kirk MacLeod, a PHDer whom many of you learned about in this blog post, passed away last week from metastatic colon cancer at the age of 42. He was a kind, strong-spirited, courageous man. His cancer was already advanced four years ago when it caused his colon to rupture; yet he was able to make an 11 mile swim for charity last August, from New Brunswick to Prince Edward Island across the Northumberland Strait. The swim benefited Brigadoon Children’s Camp, a charity for children that meant a lot to Kirk. His family has set up a memorial page and suggests donations to Camp Brigadoon as the best way to honor Kirk.

Ironically, Shou-Ching is in the midst of developing an anti-cancer drug that probably would have saved Kirk. Unfortunately, under the laws of the land it can at present be used only to rescue laboratory rodents. Perhaps in ten years, it will pass the regulatory hurdles for use in humans.

Last week brought mingled pleasure and pain to me as a sports fan. I grew up near the University of Connecticut and have rooted for its sports teams since childhood. On Monday the men’s basketball team won the national championship, and on Tuesday the women’s team followed suit. The men’s team has now won 4 of the last 16 championships and the women’s team 9 of the last 20 (and 8 of the last 15).

This year’s men’s team was an unexpected champion. They were not the most talented team in the field, but they were the gutsiest. Their defense became spectacularly good in the tournament; no matter who was on the court, all five defenders synchronized their movements and seemed to be always in perfect position. They held powerful opponents to 54 points or less in the last three games.

Their excellence was no accident, but the fruit of two years of dedicated, gritty effort. Suffering came before the joy, and made the joy possible. I like this highlight video because it shows the fruits of virtue rewarded. Watch the post-championship dancing:

A subplot of the tourney was the story of Lacey Holsworth – ‘Princess Lacey’ – an 8 year old who died of cancer last week. Here’s an ABC News segment about her connection to the Michigan State Spartans:

And here is MSU coach Tom Izzo talking about Lacey at a vigil on the Michigan State campus:

These cancer deaths are painful. Yet why do we mourn them so? A dinner party is a good thing, Santayana noted, though it comes to an end; so too is life something to celebrate, be it ever so short. Death can never diminish life’s worth, nor triumph over joy.

One positive to sickness: it helps us appreciate good health. We regularly receive reader success stories, and they are always a source of joy. From last week:

  • In two weeks on our diet, Primal Psychologist reported improvements to Raynaud’s and hypothyroidism, and hints of relief from amenorrhea.
  • Andy Grove writes in an Amazon review: “I have been following this diet as closely as possible for 4-5 months and have lost close to 25 lbs in weight and improved my health considerably. I have been relying on daily medication for asthma since childhood (I am now in my 40s). My asthma did not improve immediately on this diet – it took several months, but I have not had any asthma at all in just over 3 weeks now. This is an incredible change for me.”
  • Healthy Amelia, who will be at the May Perfect Health Retreat, writes: “My appetite is WAY down and my sugar cravings have diminished a lot. I feel almost incapable of overeating. When I’ve had enough, I have to stop right in my tracks with a feeling of not being able to take even one more bite. I can’t eat even half what I used to for dinner. Very interesting.”
  • Paula, who had been on Primal for three and a half years, reports: “Tomorrow will mark the end of my second month on the PHD. I have lost about 10 lbs and hit a new low weight…. Benefits so far: Weightloss in spite of binges. Stable mood. Stronger in the gym. Better sleep. Better response to carbs. Decreased PMS. Better sex life.”

From the week before that:

  • In the midst of a longer philosophical treatise, Euthyphro wrote: “After adopting, four years ago, the Perfect Health Diet, I have not once gotten the common cold or anything else. The anatomical structures of my body have become increasingly robust, especially after the inclusion of pogo jumping.”
  • Angela Jane Hampton wrote: “From someone who had vitamin deficiencies, severe neutropenia, next to no weight to lose, multiple food intolerances and chronic fatigue and no idea how to get out of my hole. I thank u. For writing this book, it’s (sorry about being cliche) changed my life. 7 years since I could say I feel well, great even! Thank u!”
  • Mark Barnes-Williams wrote: “I’ve lost 14 lbs in 4weeks and my energy levels have improved, the recipes are tasty and would recommend this way of eating for life.”
  • Another reader emailed: “I have followed the Perfect Health Diet with great success and am an avid cyclist …  When I switched over to the PHD I never really missed a beat on the bike and my IBS symptoms went away.  In fact both my peak performance and endurance have increased.”

As always, we’re grateful for every reader who reports results, especially in Amazon reviews.

I have one last pleasure to report. A few days ago my friend Jennifer Fulwiler sent a copy of her new book, Something Other Than God:

Jennifer is at once hilarious and thoughtful. This is her conversion story. I’ve read about a quarter of it so far, and though it is not as funny as her Christmas letters – but what is? – it is deeper and equally entertaining. Highly recommended.

In conclusion: A blessed Holy Week to you, dear reader. Our lives mingle pleasure and pain, suffering and sorrow. Life is brief, and we all witness the loss of loved ones. As Henry James said, it is worse than that: Evil is insolent and strong; beauty enchanting but rare; goodness apt to be weak, folly stubborn; wickedness to carry the day; the corrupt to be in great places, the good in small. Yet for all that, life gives plentiful ground for joy. May you find it and treasure it.

Vitamin C: Should you take it before and after surgery? Part 1

In 2010, I read that some guy named Paul Jaminet claimed to have contracted scurvy a few years prior. My first reaction: the man is clearly on drugs. No wonder he’s causing a stir in the paleo community. Or maybe he’s watching too many episodes of House? Either way, poor Shou-Ching :(

Well, it turns out that Paul’s scurvy experience is not so uncommon in low-to-zero carb dieters who might otherwise appear to have adequate vitamin C intake. Vitamin C deficiency is a big deal — aside from some well-known roles (e.g. immune system, growth), it’s one of a variety of micronutrients that can be helpful when recovering from injury.

Orthopedic surgery and pain

One of the biggest injuries of them all is an intentional injury known as “surgery”. Studying chronic pain as part of a PhD thesis, I had run across instances of vitamin C being used to prevent a terrible pain condition sometimes caused by surgeries called RSD (Reflex Sympathetic Dystrophy, alternately called Complex Regional Pain Syndrome or CRPS). Being in the middle of a series of orthopedic surgeries at the time, I wanted to avoid RSD like the plague.

So what is RSD? It’s an experience that’s tough to capture with words. Like how do you explain being in love to someone who hasn’t experienced it? RSD often brings burning, constant pain, coupled with swelling and immobility. In some cases, a light gust of wind across your skin can feel like a hot poker; laying a blanket on a patient can feel like barbed wire to them. Pain levels of different conditions are compared using the McGill Pain Index, on a scale of 0 to 50. A bone fracture is 18, childbirth is in the 30s, RSD (formerly known as causalgia) is at 42 — making it one of the, if not the most, painful of chronic conditions.

What if I told you that taking 500 mg/day of vitamin C starting immediately after surgery can nearly eliminate the occurrence of RSD? The same timing and dose may apply in cases of injury (bad ankle sprain, suspected ACL tear, etc).

Aside from antioxidant mechanisms (stabilizing free radicals that would normally damage lipid membranes and microcirculation), vitamin C can help normalize pain-inhibiting pathways involving dopamine, NMDA, and other neurotransmitters, and has shown promise for a variety of pain conditions in animal models. A higher vitamin C dose of 2 grams was shown to reduce morphine use after surgery. Reducing opioid intake post-surgically should be approached with caution, and always listen to your doctor. That being said, some people can’t tolerate opioids, are at risk of addiction, or just want to avoid the constipation that often accompanies painkiller use. In the above trial, patients took it orally just before surgery, as vitamin C peaks four hours after administration which coincides with waking from surgery.

I’m no actuary, but the numbers seem to favor taking a dose of vitamin C insurance for orthopedic surgery and injury. But is this also true for other surgery-related cases? The answer is not so straight forward.

Hospital food isn’t optimally nutritious? Whaaa?

The reputation of hospital food is a tier below airline food — bland, unsatisfying, and noted for having gelatinous blobs. Aside from taste, the other thing about hospital food (along with tube feeds, and intravenous nutrition) is that it will likely deplete your micronutrient stores, including vitamin C. Not only is the food not incredibly nutritious, but hospital patients often don’t eat much. Is it because of the taste or because of being sick in the hospital? Who knows.

One of the most important times to optimize your nutrition is when in the hospital. In surgical patients, supplementing with 200 mg of vitamin C is not enough to attain adequate vitamin C levels or reduce oxidative stress.

If you can get enough vitamin C perioperatively (how much is “enough” will be explored in part 2), it may prove therapeutic to a variety of conditions. In GI surgery, 500 mg of vitamin C by IV reduced post-surgical oxidative stress. Several trials have shown that taking 1-2 grams of vitamin C before and after heart surgery prevents atrial fibrillation and reduces hospital stay.

The benefits of vitamin C extend to less critical conditions as well. After laser surgery for skin, topical vitamin C reduced skin injury and restored acidic skin pH. Acidic skin provides defense against microbes, and inflamed skin can have a higher than normal pH. Vitamin C also has anti-acne effects (possibly by lowering sebum secretion and preventing water loss from skin) and reduces pigmentation (e.g. for freckle reduction or to help remove skin marks).

Vitamin C for other serious conditions

High doses of vitamin C show promise for critical care patients such as those with major burns. Surgical patients with major infection or critical illness require tissue to be replaced at a high rate, and hence use up vitamin C quickly — 300 mg isn’t enough for repletion but 1000 mg is. If you have borderline vitamin C stores before a hospital stay, there’s a chance that vitamin C dipping further will lead to fragile capillaries, poor wound healing, and possible hemorrhage. Luckily, bleeding ceases in under 24 hours with vitamin C supplementation, and adverse skin changes are reversed in 2-3 weeks.

Even if you’re as healthy as an ox, there’s a good chance that you’re the (welcome or unwelcome) nutrition adviser among friends and family with health conditions. If grandma or grandpa is hospitalized with a respiratory infection, remember that vitamin C significantly improves respiratory function in these patients. Vitamin C combined with vitamin E also reduces oxidative damage caused by sleep apnea, which has been called an “oxidative stress disorder”.

Finally, if you fracture your wrist, that is one instance where taking vitamin C (500 mg/d for 50 days) is unequivocally and officially recommended by evidence-based guidelines.

Conclusion

In part 2, we’ll check out some reasons to be cautious when considering vitamin C intake before and after surgery.

Paleo Magazine Radio Interviews Russ Crandall, Whitney Ross Gray, and Me

Tony Federico and Paleo Magazine Radio have put together a great podcast.

In Episode 30, Tony interviews Russ Crandall, creator of The Domestic Man blog, about his new PHD-based cookbook, The Ancestral Table; and Whitney Ross Gray and me about the Perfect Health Retreat.

I was honored to be the first repeat guest on Paleo Magazine Radio, having previously appeared on Episode 3.

Check out Episode 30: The Domestic Man and His Ancestral Table and Paul Jaminet PhD and The Perfect Health Retreat.

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