I am an infectious diseases specialist and public health physician.  My career has been a series of opportunities to assist in the care of patients and collaborate with my colleagues.  I trained during the SARS outbreak and the anthrax scare, prepared for a possible ebola outbreak in the United States, and witnessed the innovation of scientists in discovering effective treatments for HIV and cures for Hepatitis C.

With the Coronavirus outbreak, it was almost other-worldly to see how significant the surge had impacted China.  I held onto a hope that cases would be appropriately protected from coming into the United States, and that the outbreak in other parts of the country would “fizzle out”.  The SARS-2-CoV was no SARS.  Although it is less severe, it is more easily transmitted.  We try to fit the virus into the categories of other zoonotic viruses, such as influenza virus, in which we were more experienced – and I did the same.  After all, who can be a novel coronavirus expert?

As I watch this pandemic unfolding in the United States, I realize that this is truly an unprecedented time.  Through the past few months, I have had the opportunity to be a resource for local KGW news, various newspapers such as Salem Reporter and the Sandy Post, and other sites such as the DO and Adventist Health website.  My general goal was to answer the questions with “facts not fear”.  Now that we are in the brink of a widespread epidemic in the United States, I have hope that we will persevere. But we can be sure that it isn’t just going to pass through without making an impact.

A virus is a force similar to a natural event. When a storm forms in the ocean, it ultimately will weaken after some time.  Though we can at least visualize a storm as it forms and moves. With a virus, a person who is ill becomes an appendage of the virus, its vessel that can deliver it to others unknowingly.  As our bodies are defined by natural forces, so too is a virus. Its presence is only as invisible as the capabilities of our technology to track its movement or the people that are spreading it.

When an infection emerges as an outbreak, there are no blueprints for how to address a mysterious disease as it spreads, while healthcare workers evaluate the initial patients in the clinics and hospitals – and inadvertently become infected and spread it; as epidemiologists and lab scientists collect data to analyze it and determine its cause; as other scientists discover an accurate test to use to diagnose it and get it approved; as industries manufacture it and distribute; while investigators work on vaccine and treatment options – all in live action.

Many people will succumb to this virus. Though many more will recover completely. Even as I realize that the impact of death from this virus will likely be less than the amount of deaths attributed YEARLY to influenza, I am not consoled completely.  Systems will be tested.  The societal support system will buckle.  The economy will be hit hard, as we have watched the stock market dive.  We will also continue to see decreases in growth, production, jobs, as we have watched events get canceled, flights and cruises get canceled or unfilled.    Those in the margins, such as the homeless, unemployed and chronically ill, will suffer a greater loss. People will die.

Society is like a living entity.  Its efforts have turned toward self-preservation and buffering the impact of this growing pandemic.  We shift toward producing masks and ensuring the our healthcare workers are protected.  We try to disrupt the chain reaction of this natural event through social distancing to “flatten the curve” as if removing the kindling away from a forest fire, lest one of us ignites and spreads the fire further.  At this time the collective consciousness is centered on one thing COVID-19.  It fuels our thoughts and fears, it fuels our actions, and it fuels our plans.

What will the future bring?  We are now living in an experience which is encapsulated by the course of this pandemic.  Moment by moment, we measure our actions, we speculate on the time left for it to pass, and we attempt to understand this epidemic any way we can.  The news outlets flood the public with exceptional cases – a women who is otherwise healthy in her 30’s developed respiratory distress because of COVID-19.  ER physicians on the frontline now in critical condition from the viral infection. These are true, unfortunate, and very sad to hear.  People will die.  Though most people will recover.

We all brace ourselves in the meantime. When will the caseload crest?  We await the next few weeks but realize that it will take longer than that.  The case load is steadily increasing throughout the world, with the United States now in the cross-hairs.  At the time of writing this, almost half of the 68,000 cases and counting in the US are from New York State (33,000).  The streets of the financial capital of the United States are barren.  We hear about the taxing effects it is having on the healthcare system there, but we also hear of the valiant efforts to organize assistance at this time of need.  Meanwhile the caseload in every state is gradually increasing, some of it outside of our vision – that which we have through testing.

We are now living in an experience which is encapsulated by the course of this pandemic.

Social Distancing

We speak of this concept of social distancing, which inherently makes sense to us.  In a viral infection, where hundreds of thousands to millions of particles are being expelled with each forceful cough, it becomes practically impossible to avoid getting infected without these measures.  Add to that the fact that the average person touches their face 25 times an hour.  Essentially, if you stay away from an infected person, then you don’t get the infection.

The concept of social distancing refers to the fact that a respiratory virus is incapable of surviving outside a host for more than a few days.  The history of social distancing goes back thousands of years, when people with physically stigmatizing illnesses like Hansen’s disease (leprosy) were isolated from the rest of societies in leper colonies.  More recently, in diseases such as tuberculosis and pandemic influenza (1918 influenza pandemic), it became increasingly understood that separating, essentially quarantining, those with infection could reduce the spread of illnesses.

The concept of social distancing is extended further out to social gatherings and is closer to a containment strategy.  Droplet-borne communicable illnesses like respiratory viruses spread mainly by coughing and sneezing.  These droplets usually have a radius of spread of about 6 feet.  If an infection were left to spread without any measure taken, up to three people can be infected on average by everyone infected person.  Those three people go on to infect nine people; those nine people go on to infect twenty-seven people and so forth.  This is known as basic reproductive number, or R naught (R subscript 0).

Exponential growth leads to a significant surge of cases.  Even if only a small amount of people have severe disease, there could still be enough influx of those severely ill from the infection to exhaust our health systems.  This very thing happened in Wuhan, China, with the original outbreak surge and then again in northern Italy.  Social distancing attempts to lower this reproductive number, thereby reducing, even if only a delay, of the growth, allowing for a slower development of cases.  Social distancing also protects those at highest risk for acquiring the illness (healthcare workers) and those at highest risk for severe disease (the elderly, those with chronic conditions and immunocompromised), by removing yet another person with mild disease who can go on to infect others, eventually getting to those higher risk populations.  What happened in Kirkland Lifecare Center was a disaster with 81 elderly infected and 34 deaths from COVID-19.

Social distancing requires sweeping recommendations that include the following:

• No gatherings of up to 10 people or greater
• No sit-down meals in restaurants
• Cancellation of events, music, speaking and religious services
• Increased vigilance if someone were to have cold symptoms (during the flu and respiratory virus season)
• That they would avoid close contact with others, sneeze or cough into their arm sleeve not their hands and
• Wash hands regularly
• All should remember to wash hands, sneeze or cough in the arm sleeve or a tissue and wash hands after
• Wash hands before preparing a meal or before coming into the house.
• Cancel all international travel has also been suggested

There is no restriction on going outside, such as taking a walk in the park or going to the supermarket for provisions.  In fact, this might be helpful to provide a buffer from stress, anxiety or depression, as otherwise our lives have essentially been put on hold.  This is advised.

Outdoors, there would be little risk of acquiring any illness while in the park and social distancing of 6 feet can easily be addressed on a hike.  At a time of greater vigilance, it is with hopes that someone who is infected will also be mindful not to sneeze or cough without covering it.  Interesting greetings have come in the name of social distancing including the COVID-19 elbow bump and ankle hit.

Though, asking people to stop interacting with other and distance themselves is a difficult expectation. This means that those that already made plans like a spring break trip would have to cancel.  Unfortunately, social distancing didn’t hold many college students back from traveling and reveling in groups.

Though, what if social distancing didn’t need to be applied? What if testing capabilities would be accurate, available, and rapid enough to test people as they gather. Would a country need to jeopardize its economy and shut down its business sector? There are a few examples from this outbreaks where the countries didn’t have to enforce mass containment strategies. If you think about it, we are shutting down our entire society for something, instead of targeted quarantine to those that are infected.

The Benefits of Scaling Up Testing

Stopping a virus requires testing.  If a virus is able to be seen, it can be controlled.  We can start with the fact that the number of confirmed cases is likely a small fraction of the actual cases.  Yes, this means that the virus is not as fatal as we feared initially. A country like South Korea is the closest example of the importance of testing in identifying those who are infected with COVID-19, akin to “viral night vision goggles.”  South Korea, coming from the experience of a MERS outbreak in 2015, organized a massive campaign of testing of over 270,000 tests, most of it in drive-through fashion.  All of this was done without locking down the country.

However, a real time PCR test is not going to be positive in all patients with disease, so clinical suspicion should still guide recommendations.  The PCR has a variable sensitivity, depending on the source of the sample.  From an article recently published on Wuhan data of 1070 samples from 205 patients with COVID-19, 19% of whom had severe illness, a sample from the lower respiratory tract had the highest positive rate (14/15, 93% sensitivity).  Next in sensitivity was sputum (72 of 104; 72%), nasal swabs (5 of 8; 63%), fibrobronchoscope brush biopsy (6 of 13; 46%), pharyngeal swabs (126 of 398; 32%), feces (44 of 153; 29%), and blood (3 of 307; 1%).

If a patient is presenting with symptoms, a COVID-19 PCR can be ordered to confirm someone who may be infected.  If it is positive or the clinical suspicion is high, that person can be told to quarantine themselves for 14 days.  This could be used as targeted containment.  They do not spread the disease to other people, and, consequently, those at highest risk for death are protected by breaking this link.  Now that home tests are becoming available, a person who believes that they are infected can get an order from a physician through a telemedicine consult and use this test to determine their status and respond accordingly.  The virus is a catalyst to a chain reaction that requires humans to spread.  Testing removes a way to continue the reaction, arresting the process.

A second way to test someone is with serologic testing.  For some diseases, this can be used to make a diagnosis, but has largely been supplanted by more sensitive and specific (and more costly) methods like PCR.  Though there are some important differences.  For instance, take someone who had a recent viral syndrome that was mild and s/he didn’t get tested. The PCR tests for the presence of viral, bacterial or fungal or parasitic nucleic acid fragments.  In the case of someone with a resolved infection, they will have a negative PCR.  A serologic test measures the presence of antibodies that are made by our bodies after they come into contact with a pathogen.  If someone had COVID-19 and resolved, their PCR may be negative, but their serologies (immunoglobulin e.g.  IgM, IgG antibodies) will remain positive. Therefore, it can be a way to detect immunity. A positive antibody could be used to remove any restrictions on someone who either had confirmed disease or who was relatively asymptomatic with minor disease.

The United States has significantly ramped up testing from the beginning of March (less than 10,000 tests) to 103,945 tests up to March 19th, 2020.  South Korea did 10,000 tests a day and still leads the pack.  As we gain a greater understanding of this epidemic and look back like Monday Morning quarterbacks, one of our conclusions will be that testing can shape the epidemic and the mortality rate.  As we look at Germany’s COVID-19 outbreak and see the significantly lower case fatality rate compared to other countries (CFR 0.29), it is no coincidence that they are second on the list for total tests performed.  Testing visualizes the virus and bolsters social distancing strategies.

In this last week of March, we are beginning to see the impact of this virus.  The caseloads of virus, the amount of hospitalizations and the amount of deaths are expanding.  We have gained much insight while we prepare ourselves for what will unfold.  Some of it is still in our control, such as the testing and social distancing practices.  Some of it has already been shaped by the preceding weeks, and we just don’t know about it yet.

One of the most underwhelming things of controlling an outbreak is that it will act like a “dud,” when measures work. We can’t rely on positive feedback after reducing the impact of an outbreak. The natural force dissipates with less cases and less deaths.  Invariably it gets looked at as unnecessarily sounding an alarm or as overly drastic measures.

We hope that the measures that have been imposed will effectively flatten the curve cases. We hope that scaling up our tests to anyone symptomatic – in the near future – will improve our ability to stop or mitigate the harm caused by this automaton – this natural event.  By what is occurring in New York City already, we fear that we may have already been too late. Most people will recover completely, but there will be deaths.

Future directions

Imagine that we develop a global epidemic surveillance and tracking system that can be immediately activated to mount a response to any outbreak. Scientists can determine the viral genome within a day of sounding an alarm of an outbreak. All countries can respond with assistance in various fields. A streamline way for making tests can ensure a test is developed and mass produced in the matter of days. These tests can be immediately employed to determine cases, which can then be effectively quarantined or treated. The outbreak dissipates as we gain the upper hand in controlling this force.

In many ways, we have the technology already. Sometimes, people can get in the way of best intentions. There are structures already in place which inhibit rapid upscaling. There is money and time needed to shift attention toward one effort. There are egos and communication gaps. Maybe after this outbreak, we can begin to realize that more effort and global collaboration up front would protect the entire world’s societal fabric, its economy and more importantly its people. When an outbreak occurs in one part of the world, it is as if a local infection occurs on our body. We have to believe that any outbreak could expand. We must act proactively to prevent that from occurring, even if the only assurance is knowing that it could have been worse – and has been before.

Thank your for reading this article.   Please share it if you found it helpful. Stay tuned for articles to come on viral and host interactions that cause disease, ways in which we can bolster our immune system to protect us from severe disease, and ways to keep balanced in this time of social distancing.

Below are some of the recent coronavirus-related media appearances that Dr. Cirino has had on television news, online news, and podcasts for infectious diseases issues:

Title with Link:  Can you get Coronavirus from packages sent in the mail

Source:  Finder

Author:  Cheryl Wagemann

Type of Assistance:  Written Format for HARO

Date:  March 23, 2020

Title with Link:  COVID-19 updates: The U.S. socially isolates as pandemic spreads

Source:  The DO

Author:  Andy Brown

Type of Assistance:  Telephone interview for internet article

Date: March 18, 2020

Title with Link:  Salem-area health officials say local coronavirus cases likely a matter of when, not if

Source:  Salem Reporter

Author:  Rachel Alexander and Saphara Harrell

Type of Assistance:  In-person Interview for news article

Date:  March 3, 2020

Title with Link:  Gresham medical, school, senior center officials address COVID-19 concerns

Author: Christopher Keizur and Teresa Carson

Source:  Sandy Post

Type of Assistance:  Interview

Date:  March 2, 2020

Title with Link:  What should I do if I’m sick? Are children more at risk? Doctor answers your coronavirus questions

Reporter:  Brenda Braxton

Source: KGW News

Type of Assistance:  Question and Answer Session

Date: March 2, 2020

Title with Link:  What are coronavirus symptoms? How are they different from the flu? Your questions answered

Reporter:  Morgan Romero

Source:  KGW News

Type of Assistance:  Interview excerpts

Date: February 26, 2020

Title with Link:  Adventist Doctor explains dangers of coronavirus

Reporter: Ashley Khorslien

Source:  KGW News

Type of Assistance:  In studio Interview

Date:  February 18, 2020

Title with Link:  Coronavirus:  News vs. Reality

Source:  Adventist Health Website

Type of Assistance:  Contributed Writing, excerpts

Date:  February 2, 2020

What is “healthy” and would you know it if you saw it?

From nature, we gather our understanding of life and how our environment affects us.  We develop insights or “laws” – of gravity, entropy and heavenly bodies, through the observations we make in the world around us. 

At its essence, a law is a concept that is simplified, universal and expected.  If I dropped my cellphone as I was trying to put it into my pocket, I would expect that it would fall down not up.  The same goes with any sized object and from any height.  In health, for a law to exist, we would expect that it would be, at its core, an explanation that could be applied to any living organism with consistent results.  Even as we gain a greater understanding of molecular structure and other chemical signals that interface with health and disease, a law would be further enhanced through these discoveries, not broken.      

We are at a crossroads in our understanding of health, which I believe will take us to a time where more people will be able to realize better health and enjoy a long and productive life.  Can our understanding of “healthy” form a basis of how to construct health promotion and disease prevention efforts?  For example, wouldn’t it be better to determine a patient at risk for a stroke, than for s/he to have one and offer therapy afterwards.  Although many doctors already see patient with behavior challenges in their clinics – those who continue to smoke or do harm to themselves that do not want to change.  We already know that our current health system is “problem-focused” and limited in scope, since addressing disease is a palliative effort compared to preventing it and assisting in behavior change.  Still pharmaceutical companies spend millions of dollars on research and earn millions more on medications for depression, diabetes, heart failure and erectile dysfunction.

What is “healthy” and would you know it if you saw it?

The motif of nature and the four seasons and how it resonates in understanding our lives has been the subject of much writing and poetry.  We are born, as a seed germinates, then develop and ripen to our sweetest and most active forms before we begin to diminish, wither and die.  Nature is also a biologic mirror as well to the story and structures of our bodies…which takes me to a contemplative walk in the park to think of these questions.

Does nature provide lessons to us about our health?

When I am out in the park, I take a look at the oak trees and think about their components from most peripheral to most internal:  the leaves, the branches the trunk, the bark, and the roots.

In the spring, I look around and see the trees and their outstretched branches with blossoms in full bloom and small leaf buds starting to develop and grow into what will become full leaves in summer.  Each leaf shows veins that make patterns not unlike the branches of a tree itself.  The leaf identifies the tree and vice versa.  Using a magnifying glass, I see how complex the patterns are.  I realize that each leaf is fulfilling a role for the entire tree.    Is optimal growth and functioning a clue to what it is to be healthy as humans?

Our respiratory system reminds me of the trees and branches that I see outside on my hikes.  I read that if you were to take the segments of our lung airways and place them end-to-end, it would measure 1500 miles!  That is a lot of detail inside our chest.  The characteristic of branching patterns that display self-similarity is the definition of a fractal.  This complexity seems inherent in what it means to be healthy.

It also interesting and not coincidental that our lungs represent the pathway of oxygen into the bloodstream, while the leaves are the surface, in which carbon enters the tree and oxygen exits.

How does outside interact with inside?  With a tree, there are two routes:  from the immediate outside – that which the leaves and branches comes directly across and from within the network of roots that connect the outside soil to the trunk, branches and leaves.

The trunks of some trees that I see have either small knobby areas or oval-like structures which are known as a callus.  It occurs when something happened to the tree that disrupted the bark.  The tree heals like what would happen if we had an injury to our skin – our skin heals with a scar.  Does that tell me about what happens to our health?

My mother was diagnosed with diabetes when I was in medical school.  I learned that blood in her circulatory system became thicker and overburdened by too much sugar, as insulin secretion was diminished or was made less effective by adipose tissue.  Even the process of the decay in insulin production is tied to a similar disease process.  In this setting, the sugar could get through the entire system and cause changes from within the circulatory beds that can affect one’s vision, kidney function and sensation – their ability to feel what they are touching and more.  This could lead to skin ulcers on their feet and legs.  What initially starts in the circulatory system leads to damage to the other systems and affects the body as a whole.

So, health seems to relate to the natural design of our body and how it adjusts to the outside environment.  Like the root system in a tree, maybe our gastrointestinal system serves that purpose in our bodies, by breaking down the food we eat and absorbing the nutrients, proteins, sugars and fats in food.  Our liver is a filter system with a series of tubes that allow detoxification of the blood to be secreted as bile in the intestines.

How can we see the health of the trees and our body from the outside in?

When I look at nature and analyze the trees, I notice that some of the trees don’t look completely upright or as healthy as others.  What happened in the lives of those trees?  When I see how leaves change color in the fall, the color changes occur along the areas of the venations or are initially small areas where chlorophyll pigmentation has altered  

I notice people who are overweight and wonder what is happening in their bodies to cause them to gain weight. Is it just a question about what types of food one is eating that leads to this weight gain. Maybe it is like a plant that deals with a specific type of soil nutrient – it continues to work, even if the soil may not be right, until it can later improve. Only we are putting in the wrong food source.

Does the body work better when it is a specific weight?

A tree is capable of making its own food source through photosynthesis using the light of the sun, chlorophyll and water. As the food is created by the tree, it is directly used in growth. Any unused sugar is transported from the leaf through the phloem to be stored in the trunk or roots as a starch. It can then be converted back to sugar for growth during the next spring.

This process is not unlike what is planned in our bodies with the excess sugar. We take in food – sometimes in disequilibrium, which is utilized for maintenance and functioning of the body. Any excess sugar will be stored in the adipose tissue as triacylglycerols to be used for growth or in a state of starvation (such as in between meals).

The process of storage in adipose tissue continues providing there is a trigger – and it comes in the form of excess carbohydrates in the diet. In one way glucose is a energy source for the body; in another way, it is toxic to the blood in high levels. Insulin’s role then is to transport sugars out of the bloodstream to be used as energy – including energy storage. This leads to deposits in adipose tissues and weight gain. It is only with a shift in diet toward lower carbohydrates, that these stores can be utilized and weight loss can occur.

Excess adipose tissue hinders movement and body mechanics, alters pressures and challenges metabolism, thereby affecting normal processes. The adipose tissue makes it harder for the heart to beat and the lungs to aerate properly.

To some extent, the body adapts – but only up to a point. Complex organisms are able to adapt, the term homeostasis. When my father was diagnosed with high blood pressure, he was told that it might get better with weight loss. He fueled himself with a mostly plant-based diet and at one point lost weight. Even with as little as five to ten pounds, blood pressures improve. These changes seen in weight normalization are far greater than the activity of any pill.

How does our food intake affect our health?

I observe how leaves and other vegetables are so complex and whether that is the way our food should be – more complex in structure.

Look at the foods above: the top is Romanescu broccoli and the bottom is sliced bread. Compare the inherent complexity of spinach leaves, cauliflower and cabbage with that of processed foods, originally harvested from nature. The very act of processing food releases some of the most important constituents of food – the fiber – to create a food more akin to Euclidean geometry – the square piece of bread, the round cookie or biscuit. These foods are composed of simple and complex sugars.

It seems that these simple foods that we eat may be the wrong types of food for our complex bodies. The foods are held by loose bonds that break upon entering our mouth. There is no further digestive component needed, and the sugar is absorbed into the portal bloodstream through the jejunum. The liver meets it head on and attempts to detoxify the glucose. Insulin shifts the sugars to be stored as glycogen and fat in the liver, and once a critical threshold is met, complexed sugar spills out into the bloodstream as triglycerides. They trigger inflammation in the blood vessels contributing to atherosclerosis or otherwise get stored in adipose tissue. What was taken from the outside is processed in the body and enters into the bloodstream to affect our our entire body. The spikes in insulin and products of bacterial fermentation of sugar in the gut lead to important biological changes including creating pleasure and craving with foods higher in sugars, to the further detriment of the organism. It is only further compounded by liquid sugar found in sodas and juices.

How about getting older?

As we grow older, our structure changes – we shorten in stature because our bones demineralize and desiccate (dry up); our skin wrinkles and fingers and toes get colder; we can’t see or hear as well as our eyes and ears change.  My patients remind me that even our ability to taste decreases – and might lead some to choose sweeter foods.  Do these changes represent the tip of an iceberg about what is happening in our entire bodies?

When we look at the season of autumn – when the leaves start to dry up and change color.  A close look at a leaf with a magnifying glass reveals that these changes in color and appearance of the leave occur in small fragments congregating around the venations of the leaf prior to the confluent color change.  Similarly, the changes of the skin – a decrease in collagen production – that produces wrinkles occurs over time, as we move toward a phase of wilting.

Depending on how warm the climate is, the leaves on some trees stay viable toward the month of December, while the trees in colder climates are bare of leaves by then.  Are there ways to reduce the process of aging in our bodies?

It also reminded me of our experiment with Protozoa, single-celled organisms.  As a child, I remember a class experiment with Paramecia, where we put a dropper full of concentrated saline (salt) solution into the fluid where the Paramecia were swimming around.  Immediately, they swam away in the opposite direction from where the solution was coming.  Does our body have a way to protect itself from these changes?

The acid-base buffering system of our body is an example of how dynamic our bodies are.  If there were an ingestion of acid (like a poisoning of aspirin, causing metabolic acidosis), our body would be able to balance that effect without killing us – up until a point.  It wouldn’t be the same with the Paramecia – they would die with a little perturbation.  Our bodies are able to adapt to the environment and that dynamic ability is a picture of health.

Think about how our heart beats – is it like clockwork?  It actually isn’t.  The system adapts to changes in position, respiration and other stimuli to allow for the dynamic sinus arrhythmia.  Studies have found that when pulsations are less dynamic, there is an increased risk for mortality. 

Is the “climate” in our bodies something we can control – and can this extend the time of our healthy years?  It reminded me of my grandfather who a lot of people thought was younger than his age.  You and I have seen people in the gym, thriving, working out and keeping up with others decades younger – and the looks of disbelief when they reveal their age.  

Think about the natural cycle of nature – starting with the blossoms and leaf buds of the spring, proceeding to the fully developed leaves of the summer, then with the changes and eventual death of the leaves during the autumn and the slow state of the tree during the winter time.

Do we also become less complex as we go through this process of dying?

What is health and how can I tell it when I see it?

That brings us back to the first question.  I am observing what is happening in front of me, though it proceeds as it has for decades and centuries.  Trees stay alive even during the winter – the main structures that die are the leaves, only to grow back next spring. Even this process is happening in our bodies, as we shed hair, skin and cells in our gut – up until a point – some of which is programmed and some of which is modifiable.  We are interested in the modifiable. 

As I see it, health is a state that is far from static – it is the ability of an organism to withstand the environment, to harness it and to grow and maintain itself – to thrive.  We have organs in us similar to filter system or a root system which allow us to take in nutrients needed for growth and metabolic operations and use what is in the environment.  Just like the when you cut a tree you don’t see the soil inside it, so too does our blood work with what is absorbed after the liver detoxifies it – up until a point. 

Our bodies are a reflection of what is inside and how it relates to what is outside.  A diabetic may have numbness in their legs; a person with high blood pressure may have swelling in their legs; a person with a bad liver will develop jaundice.  As our bodies change, our structure changes and inherently our function changes.  We do have some control over this.  I am reminded of some of my patients, after they were diagnosed with diabetes, who started an exercise program and began to eat healthy food:  they were able to lose a significant amount of weight and reduce or stop insulin and other diabetic medications.

Ultimately what is in play is a shift from our more complex, functioning, dynamic lives to one where complexity diminishes, either slowly, from the blunting and structural changes in aging, or more rapidly, with the damage that occurs with disease.  The change in complexity to simplicity reaches a threshhold when we die – and even then our bodies further disintegrate into the various chemicals that were holding our lives in place.

Summary

1. Health requires the interplay of multiple complex structures that provide protection, buffering and dynamic adaptation to the host.

2. Disease can occur by way of external (injury or trauma) or internalized toxins (via the gastrointestinal system). Chronic metabolic disease occurs in the bloodstream and works its way through the entire body via the bloodstream.

3. Food should be complex, largely plant-based to balance short and longer term energy needs, while avoiding excess of simplified, processed foods that are easily broken down and enter the bloodstream.

4. Aging and disease represent forms where the complex structure begins to be blunted or simplified largely as a result of inflammation and scarring, such that a change in structure leads to a diminishment of function. These changes are in part modifiable.

5. The body external is a window to the body internal and We achieve dynamic stability as we approach being “healthy”.

Thanks for reading. If you enjoyed what you read, please share.

September is Alzheimer’s disease awareness month. Many of you may know friends or family members who are in their seventies or older and are developing signs of mental slowing, or mild cognitive dysfunction or already have Alzheimer’s disease. I have seen the same changes in my parents as well. As Your Health Forum is all about prevention and risk reduction, this post will take a summary of dementia a step further and offer measures – all without a prescription – that can assist one who has mild cognitive dysfunction and protect others from ever developing it.

Introduction

An estimated 14% of the population over 70 has signs of cognitive decline characterized by a progressive decrease in memory, processing, recall and executive function. The endpoint of this decline is dementia, or major neurocognitive disorder, as preferred by the Diagnostic and Statistical Manual of mental disorders (DSM). If you are among the fortunate ones who live to be a nonagenarian (90), an age group that now compromises about 5% of the US population and is expected to increase, there is a one in three chance that you will develop some degree of dementia – a not so fortunate prospect.

Worldwide, it is estimated that approximately 47 million people are living with dementia, mainly in developing countries. In the background of an obesity epidemic which has had the greatest toll in these countries, prevalence rates of dementia are projected to rise in the ensuing decades.

Although cognitive decline occurs with aging, it does not just suddenly begin when you hit a certain decade or birthday. Cognitive decline probably begins around middle age. In a cohort study of British civil servants, researchers detected deficits in cognitive testing even in a 45 to 49 age group when compared to their testing a decade earlier (-3.6%). The gap widened in the 65 to 75 age group, with a decline of almost 10% of their testing a decade earlier.

Your risk of dementia is not random or left to the fates. What if dementia were like a train heading toward an inevitable cliff and within our control are the accelerator and the brakes? There are several proactive measures that can reduce the velocity of decline and even stimulate new brain growth as we age.

The post will outline the mechanism of decline in the brain’s processing, along with ways in which we may preserve our brain’s health. The overarching theme is when the body is healthy, the brain is healthy.

Mechanism of Cognitive Decline and Dementia

When most people think of dementia, Alzheimer’s dementia comes to mind (no pun intended), which comprises 60-80% of cases of dementia; vascular dementia is the second most common type. The pathology of Alzheimer’s dementia involves the build-up of protein substances in the brain, beta-amyloid in senile plaques and dysfunctional tau in neurofibrillary tangles (see image below). These progressively damage the brain’s neurocircuitry and leads to brain shrinkage, or atrophy. Studies have supported that the physiology of degeneration of other forms of dementia, although each with distinguishing attributes and causes, is not that diverse from Alzheimer’s dementia and likely overlap.

What is less clear is why this occurs? Traumatic experiences, both physical (including traumatic brain injury (TBI)) and psychological, and chronic disease states have been associated with an increased risk of developing dementia. Focus will be on chronic diseases.

Beta-amyloid and other inflammatory markers are elevated substantially in insulin resistance and obesity states. Although there is a negative relation of dementia risk and higher BMI in the elderly (it may be due to higher BMI correlating with muscle mass), mid-life obesity was associated with a higher risk as BMI increases. Being overweight or obese increases the risk of developing dementia by 2.3 and 3.6-fold, respectively. Significant obesity unleashes a maelstrom of inflammatory substances including triglycerides, that increases β-amyloid production and leads to progressive changes. Obesity and all of its associated conditions, including diabetes, high blood pressure and sleep apnea, contribute to dementia.

Signs and Symptoms and Work-up of Dementia:

A person with mild cognitive impairment may develop more serious dementia over a period of several years, though more rapid decline can occur. A concept known as cognitive reserve has been shown in individuals with higher education and occupational skills, and relates to a resilience that protects one from a more rapid decline even in the face of greater pathologic changes. It is postulated that it may be related to greater neural links, i.e. greater neuroplasticity, that compensate a person.

Symptoms of dementia include short and long term memory loss, word forming issues, speech and comprehension decline, misplacing objects, confusion, agitation and change in behavior. The severity of the symptoms progress over time. What a person might initially dismiss as a part of their personality, “I can be forgetful”, transforms into a convincing deficit. The news can be devastating when a person realizes that they are going through these changes. There is also a significant stigma associated with cognitive decline and dementia.

Dementia can be assessed in the clinical setting with several screening tools. Usually a family member who suspects that their loved one is developing dementia will accompany them to the clinic visit or alert the provider. A clinician will perform a Mini-mental status exam (MMSE – below) or other screening test, take a history and a examine the patient to assess for any obvious risk factors or physical findings. The patient’s medication list will be reviewed in detail for any concerns (See Polypharmacy post). The examination will look for cardiovascular associations (carotid bruits (turbulent sounds) from increased atherosclerosis).

The clinician may order screening bloodwork (e.g. CBC with Diff, Homocysteine, methylmalonic acid, Thyroid (TSH) and RPR (screen for neurosyphilis). A blood test of amyloid precursor protein (APP) levels looks like it may be promising to be as an adjunct in the work-up for dementia with a high sensitivity. An MRI with diffusion weighted images or A PET scan of the brain may also be ordered. All of these studies can assist in making the diagnosis of dementia and rule out other causes.

Dementia-Prevention Duty! – 10 Ways to take charge:

Fortunately, there are some things that can be done to help delay, and in some cases, prevent cognitive decline that is normally associated with aging. Though it requires an important change that becomes more difficult as dementia advances – one of behavior. A healthy lifestyle may afford significant improvements in memory, mental clarity, and even emotional balance. Not included is mention of medication options or supplements. As with many things in health, prevention and addressing cognitive impairment at its earliest stages has the most effect. Get your health as optimal as possible with these simple steps and make some lasting changes to improve your brain health:

1.Keep the body moving

For such a small organ that is the brain, weighing only 3 lbs, it commands approximately 20% of the total blood supply and oxygen demand of the entire body. Improvements in aerobic capacity of the body maximize the functioning of the brain. One randomized control trial of 120 older adults showed that aerobic activity can increase the hippocampus, an area known for spatial demensions, by 2% and trigger higher levels of Brain Derived Neurotrophic Factor (BDNF), responsible for building new neural connections. Aerobic exercise increases cardiac output, not only conditioning the vessels of the body but also the brain. Increased oxygen delivery to the brain cells allows for neurogenesis and the retention of memory and critical thinking.

In addition, weight-bearing exercises, particularly with lower extremity strength building, have been shown to improve the production of neurons and create new synapses in the brain. These studies support the neuroplasticity of the brain to improve connections associated with physical movement. This can be particularly effective in those who suffer from neurodegenerative diseases such as Parkinson’s disease and Multiple Sclerosis. These patient are at increased risk of cognitive decline, directly associated with progressive mobility limitations.

2. Ensure that all senses are functioning at their best (use devices if needed)

Hearing impairment is significantly and independently linked to a greater risk of developing dementia. One study in 2011 conducted by Lin et al. showed mild, moderate and severe hearing impairment were directly associated with a 2-fold, 3-fold and 5-fold risk of dementia over a 10 year period – a “dose-dependent” association.

The mechanisms behind this are likely multiple. The auditory cortex is located at the temporal area of the brain, in the same area where the speech centers. The cochlear nerve (in the middle ear) which encodes the sound and carries the signal to the auditory cortex. The auditory cortex also linked to the thought processing, other sensory perceptions, emotion generation and speech. Imagine not being able to hear something clearly because of hearing impairment — the material cannot be retained in memory.

A progressive decline in hearing is part of aging – but can be accelerated by the impact of tympanic damage from loud noises. Unfortunately, the rates of hearing aide use have been reported to be less than 25% of those that could benefit from them.

Sure, the eyes can develop a skill such as lip-reading, which enhances auditory peripheral encoding. But — another change that occurs with aging and accelerates in dementia is visual decline. Optimizing the senses can promote maximal ability to socially interact, synthesize data and maintain learning – all of these activities preserve neural circuits and mitigates dementia.

3. Keep calm and carry on.
Unhealthy stress and trauma, be it from real or perceived psychological or physical abuse, is intimately tied to increased activation of the stress response (hypothalamic-pituatary-adrenal (HPA) axis, leading to production of cortisol by the adrenal glands. Higher levels of cortisol have been associated with memory impairment and even lower brain volumes in middle-aged adults.

The brain benefits of stress reduction techniques, such as meditation, are numerous. Most of us are aware that meditation helps to quiet the mind, clear our thinking, and reduce stress, but there is actually a change in brain chemistry that results from this. Physiological changes include:

• An increase in the production of glutathione, the “mother of all antioxidants” which has been shown to be decreased in mild cognitive impairment.
• Preservation of telomere lengths and decline at slower rate within your DNA. Stress perceived or real has been associated with telomere shortening, and hence greater cellular aging.
• A possible increase in the production of Brain Derived Neurotrophic Factor, which leads to new neural development and reduces the risk of dementia

Just a few minutes of quiet breathing per day is enough to get you started in the right track to improving and preserving cognitive ability, bolstering your cellular vitality, and improving overall health.

4. Eat like it matters
Would you put the cheapest fuel in a race car and expect top performance? Similarly, we should think this way about our bodies. However, with a third of the US population now obese, eating habits are hard to break. Convenience and comfort foods like high-carbohydrates and processed foods are linked to obesity, diabetes and atherosclerosis, hardening of the blood vessels that carry blood throughout the body – the circulation of the brain included. An increased risk (RR 1.16, without diabetes, 1.4 with) was seen in one study in patients with higher glucose levels even without diabetes. Eating a diet rich in fresh produce, whole grains, and quality proteins is ideal for optimal brain and body health, as well as promoting optimal weight. Eat like it matters, because it does.

5. Maintain social connections and healthy relationships
If you run on the introverted side (like me), it may be better for the sake of your mind to sway toward the social butterfly side. It may be related to the stimulation of conversation and neurotransmitters that shape and protect the brain. In one study, loneliness was associated with a double the risk of dementia in a four year longitudinal cohort study of 823 older persons. Brain derived neurotrophic factor (BDNF), responsible for building new neurons and neuroplasticity, increased with social interaction, as shown in an animal study. Additionally, the Harvard study showed a multitude of benefits of longevity from social connection in middle age and beyond. Those individuals that maintained rich social connections and loving relationships with family were less likely to develop dementia and other related diseases. Neurotransmitters such as dopamine, oxytocin “the love hormone”, and serotonin are likely at play. If there were any reason to maintain old friendships and develop new ones, brain health would be it. Maybe that is why one is silver and the other gold.

6. Get some sleep!
Even one night of compromised sleep can adversely affect brain chemistry. Quality sleep allows the brain to clear out toxins that naturally accumulate during the day. Researchers at Duke University studied the effects of gamblers in various states of sleep deprivation and found that those who had gotten enough sleep tended to make conservative decisions when playing. Sleep deprived players, however, made riskier decisions that ultimately resulted in the loss of both money and time that otherwise wouldn’t be spent in that atmosphere. Never underestimate the power of a good night’s sleep; it is your body’s best reset and protection against illness, disease, and aging. For more information of the importance of sleep, refer to a past submission.

7. Spend time outdoors in nature
Taking nature walks is not just good for your body; they are good for your brain as well. Taking a nature walk is not only an exercise but also a multi-sensory experience. A growing research base suggests that experiences that stimulate multiple senses often lead to improved neural circuitry, likely protecting against dementia. A reduction of stress and blood pressure are also seen – both factors related to dementia. Other benefits include improved sleep, a stronger natural immunity (natural killer cells), fewer disturbing and troublesome thoughts, and an overall sense of happiness. Even after dementia has develoed, initiatives to provide those with dementia nature hikes have shown improvements in connection and motivation.

8. Stay at a healthy weight
As stated before, research has consistently shown that those who experience weight gain or obesity in mid life are significantly more at risk for developing dementia and experiencing cognitive impairment. Conditions that are prevalent in obese individuals such as hypertension, cardiovascular disease, and diabetes all have their adverse impacts on the brain; keeping fit and healthy through the middle of your life might not always be easy, but it is essential to reduce the risk of cognitive decline.

9. Pick up an instrument or just sing along.

Music therapy for dementia can have a number of positive effects on the brain, which comes when multiple areas of the brain are recruited simultaneously. Music consists of words and rhythm, encouraging word-finding and synchronization. It evokes memory of past events associated with the music and time it was first heard as well as reduces stress. It is a social experience as well. Various reward neurotransmitters may be involved, including dopamine and serotonin. In evoking multiple brain neurocircuitry units, “neurons that fire together wire together” (Hebbian Theory). Elizabeth Stegemoeller wrote an excellent, detailed summary on neuroplasticity and the benefits of music therapy in dementia. Shout-out to Anne Tillinghast and The Backstrokes in Portland, a post-stroke and stroke awareness group with whom I have had the honor to play in their song circle. It is never too late to learn an instrument.

10. Refrain from recreational drug use
There is a lengthy body of evidence that links substance use with an increased risk of dementia. Any drug, no matter how mild it might seem (tobacco and cannabis), has the ability to interfere with the way neurons send, receive, and process signals coming from other areas of the body and within the brain. Consequently decision-making, judgement and coordination are impaired in the short term. Multiple drugs have been tied to possibly severe long-term neurocognitive dysfunction, including alcohol, cigarettes, marijuana and elicit drugs like meth and heroin. The practice of abstinence from any substance is likely a healthier decision than casual intake, but the “dose is the poison”.

Protect that brain!

Like the master switch to all of our systems, the brain is the most important resource that we have. Think of the brain as a network of sensors and effectors (i.e. receiving and sending signals). Where there is more stimulation to the body, i.e. exercise, there is greater signaling to the brain – and the brain fortifies. It is no surprise that the changes of aging, with superimposed chronic diseases, impact the brain as much as the rest of the body – (think of the blood supply needed for the brain). An optimal state of health can preserve the brain’s function throughout life. Even a health commitment at a later age can still reap rewards by reducing the velocity of cognitive dysfunction and is worth a try.

“mens sana in corpore sano”

“A sound mind in a sound body”

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