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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.

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.

The Health Benefits of White Chocolate (yes, they exist)

I have a strange chocolate-related pet peeve. When someone tells me “You like white chocolate? But that’s not even real chocolate!”…it makes me want to hurl a block of white chocolate right at their smug face.

White chocolate gets absolutely no respect, while dark chocolate can apparently cure cancer and bring the dead back to life. And the darker the better. If you like 70% dark, your foodie friend will undoubtedly poo-poo that in favor of 85% or darker. Well it’s finally time to stand up, white chocolate lovers! All three of you. Because white chocolate is healthy, and here’s why.

The advantages of white chocolate

First off, dark chocolate is healthy, and is a PHD-recommended “supplemental food”. But just like how Arnold Schwarzenegger overshadows Danny DeVito in the movie “Twins”, so goes the relationship between dark and white chocolate. They share the same mother (the cacao tree) and the more popular sibling has desirable traits absent in the less popular sibling (flavonoids and psychoactive compounds). But just like Danny DeVito, white chocolate actually has a heart of gold (or rather, a heart of stable fatty acids).

White chocolate is simply cocoa butter plus some added milk, while dark chocolate is cocoa butter with (dark) cocoa particles added instead of milk. Each can have varying levels of sugar. White chocolate undergoes remarkably little oxidation during storage or cooking, unlike vegetable oils that autooxidize and may become carcinogenic. A quick look at the fatty acid profile of cocoa butter explains its stability. It’s made up of 60% saturated fat split between stearic and palmitic acids, about 30% monounsaturated, and only 3% polyunsaturated fat. The high stearic acid content means that cocoa butter has a smaller effect on cholesterol than do other fats with similar saturated percentages.

chloe-chocolate

Cats can’t read nutrition labels…or can they?

Plus cocoa butter has been shown to improve resistance to oxidation in rats when compared to vegetable oil. Cocoa butter may even help protect against fatty-liver related endotoxemia, via upregulation of an enzyme called ASS1 (argininosuccinate synthase 1, hee hee).

Dark chocolate sometimes contains mycotoxins and aflatoxins (which can be carcinogenic, depending on dose), whereas white chocolate doesn’t. While cocoa butter doesn’t have nearly as many health benefits as dark chocolate, it’s been shown to benefit platelet function and potentially atherogenesis more than dark chocolate (in men, but not in women…why must you be so confusing science?).

Finally, white chocolate isn’t toxic to dogs and cats due to low theobromine levels, whereas a high-percentage dark chocolate bar could kill a small dog. White chocolate also has negligible amounts of caffeine and other bioactive compounds, due these being water soluble and hence removed during processing. For those sensitive to dark chocolate, who exhibit symptoms such as as intestinal distress or headaches after consumption, white chocolate may be a good alternative.

Why is white chocolate a black sheep?

So why is cocoa butter rarely eaten (outside of chocolate bars), when other low-PUFA fats such as coconut oil and ghee are prized? Three reasons stick out: price, availability, and stigma. High-quality dark chocolate costs around a buck an ounce or less. It’s hard to even find high-quality white chocolate outside of some internet stores, and the price of edible pure cocoa butter is typically 50% or more above that of dark chocolate. Plus pure cocoa butter doesn’t really come in the form of standard-sized chocolate bars.

If you want bars, you have to jump down from 100% cocoa butter to around 30% or much lower, and these bars typically have almost 50% sugar content. Note that in 2002, the FDA set a minimum cocoa butter percentage of 20% in order for a product to be labeled “white chocolate”. But this definition also included minimum levels of milk solids and milk fat, so those staying away from milk may prefer pure cocoa butter. In my Willy Wonka white chocolate utopia, there would be 70%, 85%, and 92% white chocolate bars available at every grocery store, but as it stands you have to buy sugary white chocolate or make your own lower sugar version using cocoa butter.

“Cocoa Cooking”: say it three times fast

Stigma is a real problem for white chocolate producers. For some reason, the white chocolate lobby simply doesn’t have the power of Big Pharma or Tobacco, so you’ll never see ads encouraging you to try healthy cocoa fat in recipes. But you definitely can. The popularity of mole sauce suggests that even strong chocolate flavors can be handled in savory dishes. One chef says:

“It’s important that people break out of the mindset of chocolate as candy. Chocolate is chocolate. If you let it stand on its own, it becomes an ingredient like cumin or butter. If you let go of what your preconception of chocolate is–which for 99.9 percent of the people is a candy bar–it becomes another culinary weapon in your larder.”

Indeed, for most of its history, chocolate was exclusively used with savory/spicy ingredients. Cooking cocoa butter with meats or veggies may give them a heartier flavor, or you could try something more daring like salmon with white chocolate sauce. Snacks made with cocoa butter may be more practical than snacks high in coconut oil, as cocoa butter doesn’t melt around room temperature like coconut oil does.

Compared to dark chocolate, white chocolate needs much less sugar to mask bitterness (especially for us supertasters). It also complements delicate flavors whereas bitter dark chocolate overwhelms them, so my hunch is that white chocolate (or just cocoa butter) could provide a versatile base for things other than just sauces and desserts.

If you cook for someone, and the dish has cocoa butter or white chocolate in it, be prepared to defend your daring choice. Concerning the claim that white chocolate isn’t actually chocolate, I find that a bit ludicrous. When cocoa beans are pressed, they ooze out cocoa butter. It’s very similar to the relationship between olives and olive oil, or coconut flesh and coconut oil. When’s the last time you heard “Olive oil? But that isn’t even real olive!” I’ll chalk the misunderstanding up to the prevalence of fake white chocolates (below 20% cocoa butter or often none at all) combined with the rarity of dishes made with cocoa butter. You can’t like white chocolate if you haven’t had it, or if all you’ve had is an overly-sugared white chocolate bar.

Conclusion

Theobroma, the genus containing the cacao tree, translates to “food of the gods”. Chocolate was used as currency by ancient Mayans, and kept in safes with gold and precious stones. While dark chocolate is currently exalted as a king among medicinal foods, white chocolate has become the court jester. This is a shame, as white chocolate holds promise as a healthy and underutilized cooking ingredient.

White chocolate and cocoa butter keep extremely well at room temperature, so don’t be afraid to buy some and do your best Iron Chef impression. If the dish works out, feel free to comment here with the recipe. And if you find a high-quality white chocolate bar low in sugar, let me know. Kamal/Chocomal/Caramal excels in taste-testing.

Is Mineral Water an Underrated Supplement?

Many of us try to eat an ancestrally-influenced diet, which brings up a question: should we also drink similar types of water as our ancestors? There are a few practical reasons why mineral water makes for an interesting source of nutrients. Unlike food, water is calorie-free. And unlike supplements, you don’t have to remember to take water each day. Plus some people really enjoy the taste of mineral water.

So let’s take a peek into the world of mineral waters and health. The reason we’re focusing on mineral water is that it’s a type of water that contains measurable nutrients, and is thus somewhat less susceptible to pseudoscientific claims (yes, I’m looking at you “alkaline water”).

What does mineral water have that you want?

Minerals, duh! Which ones though? The Cadillac of mineral waters, Gerolsteiner, tested as having 112 mg of magnesium per liter of water and 368 mg of calcium, along with 134 mg of sodium.

20140315_170453

The Ford Focus of mineral waters, Poland Spring, has just one milligram of magnesium and calcium per liter, and four times that much sodium! (meaning four milligrams…just showing the power of ratios to deceive) So what do these numbers mean in terms of health benefits or detriments?

Let’s start with magnesium. Magnesium is a PHD-recommended daily supplement, unless you get enough from food. Rather than choking down two horse pills, some people prefer powder, epsom salt baths, or spray. Magnesium has oodles of therapeutic functions outside of its commonly known roles in heart and bone health, extending to bowel disease, migraines, anti-aging effects, and reducing chronic inflammation. Unfortunately magnesium levels have taken a hit from routine municipal water softening as well as lower concentrations in crops.

Most tap water contains negligible amounts of magnesium. So unless you live in Lubbock, Texas (where the tap water has 60 mg/L of magnesium, almost twice as much as any other major US city), bottled waters are the best option for liquid magnesium replenishment. My local Trader Joe’s sells Gerolsteiner and San Pellegrino, and other grocery stores sell Perrier and Evian. The latter two contain very little magnesium, while San Pellegrino has half as much as Gerolsteiner.

Sodium and calcium…eh

High-sodium mineral waters sometimes get a bad rap, even though low salt intake is associated with higher mortality rates. Plus the sodium in mineral water is usually in the form of sodium bicarbonate, which has been shown to actually decrease blood pressure in hypertensive patients.

If you’ve read the Perfect Health Diet book then you know the potential dangers of supplementing calcium. On the other hand, for those who lack leafy greens or dairy in their diets, mineral waters could be a good option. European mineral waters, that is. As might be expected of the land of higher life expectancy, finer wines, longer maternity leaves, and smellier cheeses, European mineral waters tend to have far more calcium (and magnesium) than their American counterparts. Popular European waters such as the aforementioned Gerolsteiner, San Pellegrino, Perrier, and Apollinaris all have between around 100-370 mg of calcium per liter. The higher end of this range would bring a calcium-deficient diet close to optimal levels when drinking 1-2 liters a day.

“Trace” Minerals sound so insignificant

…but they’re not! One of the most important trace minerals is lithium. While high-dose supplementation of lithium may impair immune and thyroid function (these doses are prescribed for psychiatric disorders), an optimal lower dose (but higher than what Americans typically take in through food) is linked to longer lifespans and lower rates of mental illness. Areas where tap water has the lowest lithium levels have higher suicide and homicide rates.

Rather than splitting lithium supplement pills to get small enough doses, one could get low doses of lithium through mineral water. “Lithia waters”, mineral waters high in lithium, were a craze in the late 1800s and early 1900s due to numerous testimonials on their miraculous health benefits. But most mineral waters actually have quite low lithium levels, so you have to look hard to find a water that provides enough to equal very low-dose supplements.

If you can find a brand that has somewhere between 0.1-0.3 mg per liter (or more) of lithium, it may produce some beneficial effects. Gerolsteiner, for example, contains 0.13 mg per liter. It might not take much to produce benefit — microdoses of lithium as small as 0.3 mg per day have been shown to improve cognitive impairment in Alzheimer’s patients. Note that diets low in plants and seafoods typically have lower lithium levels, and lithium concentrations in plants varies widely (Texas and western states have much higher lithium levels in soil and water than the rest of the country)

To sparkle or not to sparkle, that is the question

Some people love sparkling water. But in an informal survey (me surveying myself), sparkling water has been found to be difficult to drink in large quantities because it doesn’t go down as smoothly while gulping and makes you burp. That mitigates the ease of using water as a supplement. There’s an obvious way to get around this — just let the water go flat.

20140315_170532Alternately, you can choose a water that is not carbonated (aka “still water”). The problem is that still waters typically have much lower mineral levels than naturally carbonated waters. For example, Gerolsteiner offers a still water that has less than half as much magnesium as its popular sparkling water. Gerolsteiner’s website explains why this is:

“Gerolsteiner takes its mineral water from various sources in the depths of the Volcanic Eifel…It is the natural carbonic acid that allows the water to absorb the valuable minerals and trace elements from the rock.”

Note that a couple California-sourced still mineral waters such as Adobe Springs (also sold as “Noah’s Spring Water”) have magnesium levels comparable to fancy European sparkling waters, and also have that distinctive mineral water taste. But while some people love the taste of mineral water, others find hard water off-putting. To counter this, you can add lemon or let some cut berries infuse throughout it. Classy!

What does mineral water have that you don’t want?

One notable effect of drinking mineral water is a reduction in mean weight of your wallet. To reduce the cost and help with portability, you could try Concentrace, a concentrated little bottle of dried minerals from the Great Salt Lake that has the salt removed. I’m torn between the ease of using Concentrace and the possible dangers of using it. First the good part: you just put a few drops of Concentrace in your water, and it becomes highly mineralized with not just magnesium but a variety of trace minerals. Concentrace may improve joint pain, as shown in this trial of knee osteoarthritis (although this study doesn’t appear to be indexed by Pubmed…hmmm…).

However, be careful with the Concentrace. Tap water is not allowed to have more than 0.01 parts per million of arsenic. The Concentrace instructions say to use a total of 40-80 drops per day, so let’s say you use 20 drops in a glass of water. That comes out to right around 0.01 parts per million of arsenic. Uh-oh?

So is mineral water an underrated supplement?

There’s probably a reason why mineral water springs were highly prized by so many ancient cultures, with people traveling many miles to seek health benefits. In modern times, the World Health Organization has recognized magnesium levels in drinking water to be an important public health issue, due to the possible heart disease benefits of drinking hard water.

We didn’t even get into potential benefits from taking in higher amounts of other trace minerals. Nor did we discuss benefits from higher intake of bicarbonate, which is present in many minerals. Or how about skin hydration benefits, or the ability of hard water to avoid mineral leeching that happens when boiling foods in soft water?

The magnesium and calcium in mineral water is also typically highly bioavailable (even more so when consumed with a meal). All in all, mineral water may be a useful addition for those that can afford it, as it can provide a reliable daily boost to levels of important nutrients.