Ask The Doc: Dr. Tommy Wood on Familial Hypercholesterolemia in Athletes, Restless Leg Syndrome, His ‘Elite Performance Analysis’ Test and Much More

November 1, 2017

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Dr. Tommy Wood is back on the show for another edition of Ask the Doctor, Tommy’s sixth time as our resident doc. You can find Tommy over at NourishBalanceThrive, and be sure to check out their Elite Performance Analysis quiz. On this show, we catch up with Tommy and he tackles the following listener questions:

Tommy’s published Letter to the Editor in the Strength & Conditioning Journal, written in response to a point-counterpoint article:

• A Case for and Against a Ketogenic Diets in Athletes
• Point: Matthew Kavalek and Ryan Gannon
• Counterpoint: Mike T. Nelson

• Both sides made great points, but Tommy had some extra thoughts!
• Point:
  • “the beneficial effects of a KD on aerobic performance are fairly well established”
    • Wish that were true, but isn’t yet
    • Probably due to the nature of the studies
      • Louise Burke
        • Race walkers
        • Ketone ester in cyclists
    • Recent Caryn Zinn study
      • 5 cyclists on keto for 10 weeks
      • All of them lost weight
      • Peak power decreased
      • All of them saw worse time to exhaustion
      • But one had an increase in VO2Max
• Counterpoint:
  • Metabolic flexibility is important
  • Risk of “losing metabolic machinery”
    • This is only really true if you look at PDH
    • The rest of glycolysis is working just fine (FASTER study)
      • Extra pyruvate either via PC to OA
      • Or converted to lactate (Cori cycle)
    • If wanting to boost PDH and maintain metabolic flexibility on keto, do HIIT
• Remember:
  • For performance, some carbs are likely to always be important
    • Keto for the sake of keto doesn’t make much sense from a performance standpoint
    • Keto athletes still eat carbs!

 

Questions:

Ironman athlete, 50-year-old female, with familial hypercholesterolemia (FH) – LDL’s been high since 20s, on medications (Lipitor, Crestor), being advised a low-fat diet, training for Kona, having adverse effects from meds – what to do!??

• Everything MUST be discussed with a doctor/cardiologist
• FH is a result of mutations that reduce the expression or function of LDL-R
  • Reduces uptake of LDL into the liver
    • Increased LDL levels

• • When it comes to heart disease risk, LDL-P matters much more than LDL
    • High LDL-P isn’t enough
      • Need some damage to the artery for cholesterol to accumulate
  • Most people have heterozygous FH
    • Only one receptor mutation
    • Increase in death from heart disease
      • Highest risk is in the 20s-40s
        • Once you reach your 60s, risk is the same
    • Lower cancer risk
    • Overall mortality rate is normal
      • You have to die of something!
  • Family tree mortality study in Holland
    • • Mortality risk and cause of death varied widely
        • Lower in 19th Century
        • Higher in 1950s
      • Determined that environment was much more important than the mutation itself.
        • Smoking, diet, exercise etc
  • In those with hFH that have had a heart attack, their LDL is not higher than those who have not had a heart attack
    • • Have higher insulin and measures of insulin resistance.
  • HbA1c is one of the strongest predictors of atherosclerotic risk in FH

• Glucose control, insulin, and insulin resistance appear to be better predictors of CVD risk in FH
• Much like in people without FH
  • Angie has:
    • “High HDL”
      • Can be dysfunctional in the setting of high oxidative stress
    • Normal triglycerides
    • Likely has a Trig/HDL ratio <1, which means she has little evidence of IR
  • Statins
    • No clinical trials have shown efficacy of statins specifically in FH
    • Statins have a poor ability to reduce CVD risk as primary prevention in women
    • Some evidence that statins can impair adaptations to exercise
      • May have a greater negative effect in males than in females

• Most interesting:
  • Increase the risk of type 2 diabetes, especially in women
  • Most studies show about a 50% risk increase

• • Strategies
    • Maximise expression of LDL-R
      • Ensure proper thyroid function
        • Adequate calories
          • Says she’s hungry all the time
        • Adequate insulin (carb cycling?)
    • Manipulate PCSK9
      • Insulin sensitivity and *some* insulin
      • Minimise inflammation
  • Chris Masterjohn would suggest a Kitavan-style diet
    • 20% fat, 10% protein, 60-65% carbs
    • High-quality carbs (whole foods)
      • Refined carbs can increase LDL-P number
    • Probably need more protein for an athlete
  • Others would say eat a low carb diet
    • Minimises glucose influx and insulin levels
  • I’m agnostic
    • Eat whatever maximises performance while:
      • Minimising inflammation
      • Keeping HbA1c and markers of insulin/IR low
• In summary
  • • What causes heart disease in FH is what causes heart disease in everybody else
    • LDL levels don’t matter on their own
      • In the HUNT-2 study, overall mortality decreased with increasing total cholesterol in women
• Take this stuff to doctor to review and make decision!
  • Ask for evidence that statins will reduce her risk of CVD as primary prevention in FH
  • Discuss the linked papers
  • Track advanced particles (LDL-P, Lp(a) etc)
    • Carnitine can reduce Lp(a)
    • Can also increase endurance performance
  • Take Q10 if continuing on the statin
    • Doses up to 600-1,000mg until muscle pain stops
    • Also fat soluble vitamins
  • Alternatives
    • Ezetimibe and low-dose statin
    • PCSK9 inhibitor?
  • Identify and minimise sources of inflammation
    • Ensure proper training and recovery

 

Husband needs advice for wife: References and guidance on how a natural eating lifestyle can help cure low serotonin and depression, and pros and cons of SSRIs like Prozac.

• • Let’s initially say that the assumption that depression is due to a deficiency in serotonin is correct.
    • • SSRIs as the main treatment
    • Revisit previous Ask the Doc (talked about serotonin and PMS)
      • Paper by Rhonda Patrick and Bruce Ames
        • Tryptophan shunted away from serotonin production in the setting of stress and inflammation
          • Minimise those
        • Exercise and insulin (carbs) both increase the uptake of large neutral amino acids (like the BCAAs) into the muscles, which reduces competition for tryptophan to enter the brain
        • Vitamin D is required for the production of the TPH2 enzyme, which converts tryptophan to 5-HTP
          • SUNLIGHT!
        • Omega-3 fatty acids are needed at synapses in the brain to make sure serotonin signalling work properly

• Serotonin is important for mood
  • However, the suggestion that depression is due to a serotonin deficiency is not that well proven
• In general, the benefit from SSRIs in depression is minimal
  • Old studies comparing antidepressants to active placebos (usually atropine) showed very similar effects from both
  • When compared to inert placebos
    • ~40% reduction in symptoms from anti-depressants
    • ~30% reduction in symptoms from placebo
  • Though they haven’t been compared directly, the effect size of SSRIs smaller than or at best equal to that seen from:
    • Meditation
    • Exercise (aerobic, yoga etc)
    • Diet
      • SMILES trial
        • 12-week trial in moderate and severe depression
        • Whole food-based Mediterranean-style diet
          • Remove sugar, fried foods, and processed grains
  • Depression probably isn’t directly due to a serotonin deficiency
    • BUT is tightly correlated to inflammation
      • Genetic susceptibility
    • Optimise vitamin D and some Omega-3s
    • Reduce stress and inflammation
    • High-quality diet has an effect size at least as large as taking SSRIs
  • To get off SSRIs
    • Strategies from Dr. Josh Turknett
    • CHECK with psychiatrist
    • CAN go cold-turkey (with permission)
    • Need to believe that the other strategies are at least as good (if not better) than the pill
    • A good trick is to try paired conditioning
      • Taper down the drug (i.e. 50%)
      • Take it with something else
        • An action – meditation or exercise
        • Vitamins (Vitamin D)
        • Sugar pill (real placebo)
• Imagine getting that same mood boosting effect as you would from the full SSRI dose
  • • Taper again (25% or 0%)
  • Placebo still works even if you know it is a placebo!
    • Cure – Jo Marchant

 

Athletes in 50s experiencing twitchy legs in bed (restless leg syndrome). Struggling to relax muscles and can twitch violently every couple of minutes for what seems like forever. What’s the research say on drinking pickle juice before bed? The Swiss brand, Sponsor, is now selling shots of vinegar, pickle juice, magnesium & quinine to relax muscles – is there any science behind this tonic?

• Start by talking about exercise-associated muscle cramps
  • This is what the Sponser supplement is designed to improve
• A large amount of the research has been done by Kevin Miller, Central Michigan University
• Initially thought that cramps were due to:
  • Dehydration
  • Electrolyte depletion
  • Some combination of the two
  • Mainly based on anecdotal studies and case reports
    • Controlled trials have shown these are likely not the cause
• Pickle juice does reduce cramping
  • Does so faster than it would take to replenish electrolytes or fluids
  • Many doses (1-2ml/kg) of pickle juice have been shown to have negligible effects on sodium and potassium levels during exercise.
    • Unlikely to be due to dehydration or electrolytes
• Another product – Hotshots
  • Roderick Mackinnon and Bruce Bean
    • Roderick won a Nobel prize for describing the structure of ion channels that contribute to nerve impulses
  • Contains acid, ginger, cinnamon, and capsaicin
• The Sponser and Hotshot product both aim to do the same thing – desensitise certain pain receptors (Transient Receptor Potential or TRP channels)
  • TRPV1 and TRPA1
• Now thought that cramps are due to hyper-excitability of α-motor neurons
  • • Brainstem and spinal cord
  • Basically get permanent contraction of the muscle
    • Or a reflex movement without a significant stimulus
• Exciting the TRP channels (skin, tongue, oesophagus, stomach) dampens down the overall excitability of other nerves
  • Use of capsaicin creams to reduce pain
• May be best to use a combination of TRPA1 and TRPV1 agonists?
• TRPV1 activators
  • Garlic
  • Capsaicin
  • Clove
  • Cinnamon
  • Acetic acid
  • Piperine (black pepper)
• TRPA1
  • Ginger
  • Mustard and wasabi
  • Acetic acid
  • Green tea catechins
• Long term quinine for muscle cramps may increase death risk.
  • Used for restless leg syndrome (I used to prescribe it!)
  • Reduces leg cramps by about 25%
    • BUT long term use (usually in the elderly) is associated with increased risk of death!
• For myoclonic jerks, as you get during early sleep, the evidence isn’t as good
  • But the hyperexcitability of spinal nerves (or decreased inhibition from the brain) is thought to be part of it
    • Similar mechanism of action to cramping
  • 5-HTP may also help
• My tip: Brew a chai (green) tea with some chili and add apple cider vinegar!
  • Or eat curries

 

A 37-year-old female runner with Ulcerative Colitis in need of advice. Took prednisone (steroid) for last flare, never lost the weight gained, a lot of bloating issues and cortisol belly, considering digestive enzymes, fermented foods. Not following a specific diet, still eating gluten and dairy.

• Will certainly have digestive issues and a different gut microbiota in UC
• Autoimmune
  • Some evidence for elimination diets
    • Specific Carbohydrate Diet
      • May be better for Crohn’s, but some evidence in UC too
    • Low FODMAP diet
    • AIP
    • I would trial one of these in that order, and re-introduce slowly over time. Dairy and gluten are two common culprits
• But good evidence for probiotics
  • VSL #3 and E. coli Nissle 1917 (Mutaflor)
  • Bio-Three (Streptococcus faecalis, Clostridium butyricum, and Bacillus mesentericus). This is a product that contains it.
    • Probiotic-3 from Advanced Orthomolecular Research
  • Mixed Bifidobacteria and Lactobacillus strains. (i.e. D-Lactate free Bifido and Lactobacillus probiotic from Custom Probiotics)
  • Bifidobacterium longum
• UC is associated with increased intestinal permeability and visceral fat
  • May contribute to her bloated feeling
  • Should improve as inflammation improves
    • Elimination diet
    • Probiotics
• Other anti-inflammatory approaches
  • Soothing gut tonics – popular in our athletes
    • • Curcumin, Boswellia, Quercetin, Marshmallow
    • GI-revive (DfH)
    • Enteromend (Thorne)
  • CBD
    • Great data in animal models of IBD
    • Some promising data in humans, including people we know and have worked with
      • Difficult to get high-quality CBD due to extraction issues
      • Elixinol is popular
        • 15mg 1-4 times per day
• If you think you have gut issues – try NBT’s automated “Elite Performance Analysis” at NBT.AI

More references (mentioned on show):

• https://enduranceplanet.com/ask-the-doc-how-fasting-affects-females-differently-causes-and-treatments-for-pms-why-hba1c-is-an-unreliable-marker-and-more/
• https://enduranceplanet.com/dr-richard-maurer-decode-your-blood-tests-for-optimal-results-managing-insulin-cholesterol-thyroid-weight-fitness-and-more/
• https://enduranceplanet.com/nikki-kimball-on-depression-a-fat-adapted-diet-and-ultrarunning/

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