Download Sugar, Carpal Tunnel Syndrome and the Global

Sugar, Carpal Tunnel Syndrome and the Global Compression Theory
Misty Carriveau, OTR, CHT
In the book, Sugar Crush: How to Reduce Inflammation, Reverse Nerve Damage, and
Reclaim Good Health, co-author Dr. Richard Jacoby, one of the country's leading
peripheral nerve surgeons, reveals his theory about the relationship between sugar
consumption and many disease processes we don't typically associate with high
carbohydrate diets including carpal tunnel syndrome (CTS). In the 1970's it was widely
believed that CTS was a mechanical problem caused by repetitive motion, keyboarding
and the introduction of the personal computer. Dr. Jacoby proposes that the rise in carpal
tunnel syndrome between the 1950's and 1980's was not because of computer use, but
rather the introduction of high fructose corn syrup in 1957 and the subsequent dramatic
rise in sugar intake. Through his Global Compression Theory, Dr. Jacoby also links high
carbohydrate diets to conditions like plantar fasciitis, Alzheimer's disease, MS, ALS and
Autism.
The History of Sugar Consumption in the US
In the late 1700's the price of sugar dropped dramatically after the discovery that sugar
could be extracted from the sugar beet and crystallized and an increase in sugarcane
production in the tropics. By the 1800's sugar became a bigger part of the standard
American diet and people ate on average 25 pounds of sugar per year. By the 1970's
sugar prices had risen sharply due to international trade tariffs and sugar quotas. This is
when high fructose corn syrup (HFCS) entered the scene, allowing the food industry to
continue making sugary, crunchy junk food at an affordable price for consumers because
it was not only cheaper than sugar (because corn was a subsidized crop) but also sweeter.
As a liquid sweetener, it was easy to put in soda, juice, hamburger buns, pizza dough,
sauces, salad dressings, yogurt, cereal, crackers, chips, etc. Today, the average American
consumes 160 pounds of sugar per year, or to better visualize this, 27 teaspoons per day.
Sugar's Evil Twin
The problem with the introduction of HFCS, besides the fact that the food industry puts it
in practically everything, is that it's worse for you than sugar. Table sugar, or sucrose, is
made up of 50% glucose and 50% fructose. Glucose can be metabolized by any cell in
the body so as it enters the bloodstream from the intestines, it has a better chance of being
burned up before it enters the liver. Fructose however can only be metabolized in the
liver where it is quickly converted and stored as fat. HFCS, comprised of 45% glucose
and 55% fructose, with it's high fructose content overtaxes the liver and often leads to
what is known as a “fatty” liver. Excessive alcohol intake also leads to a fatty liver
because ethanol, like fructose, goes straight to the liver to be converted and stored as fat.
So How Does Sugar Compress Nerves?
A. Lee Dellon, M.D. PhD, professor of plastic surgery and neurosurgery at Johns
Hopkins University School of Medicine, most known for perfecting nerve decompression
surgeries in the 1990's and developer of the two-point discrimination test, stated, “When
injury is deep inside the body, such as inside the nerves servicing any end organ, hidden
inflammation can trigger pain, trauma, and chronic disease. Experts are only beginning
to understand how sugar fans these flames.” Hand therapists are all too familiar with the
inflammation that leads to scarring that traps and compresses blood vessels, nerves and
tendons. This inflammation is at the heart of the Dr. Jacoby's global compression theory.
The inflammation that leads to scarring and compression occurs over three main
pathways: The Maillard reaction, the polyol pathway, and the nitric oxide pathway.
The Maillard reaction, or glycation, is the chemical reaction between glucose
and amino acids within blood vessels. When a protein reacts with sugar it
damages the protein causing it to become stiff and malformed. These damaged
proteins are appropriately named AGE's or advanced glycation end products.
Since AGE's are recognized by the body as a toxic form of scar tissue, immune
cells secrete large amounts of inflammatory chemicals in an attempt to break these
end products apart and flush them out of the body. Glycation essentially causes
the endothelium in blood vessels to swell and get gummed up and sticky.
Wherever AGE's occur, inflammation occurs. So glycation and AGE's that are
produced in and around nerves, cause them to swell and become compressed.
The Polyol Pathway. This is the pathway the body uses to metabolize excess
glucose. The pathway begins when glucose is broken down by an enzyme called
aldose reductase into sorbitol. Sorbitol cannot pass through cell membranes so it
gets stuck wherever it's made. When sorbitol starts to build up within the cell, it
attracts water into the cell causing it to swell. When sorbitol enters and builds up
in nerve cells through the polyol pathway, the nerve swells and becomes
compressed against the surrounding bone and tissue. In places where the nerve
passes through tight tunnels, like the carpal tunnel, the nerve becomes even more
compressed and the swelling also reduces blood flow to the nerve depriving it of
nutrients and oxygen.
•
•
The Nitric Oxide Pathway. In the endothelium of blood vessels, the protein Larginine goes through a complex process in which it binds to the enzyme nitric
oxide synthase (NOS) to be converted to nitric oxide (NO). When the
endothelium releases NO, blood vessels dilate and blood flows freely. The nitric
oxide pathway can be blocked in two ways.
The glucose-ascorbate antagonism theory, developed by Dr. John Ely, explains
how vitamin C and glucose compete for the insulin they need to migrate into
cells. Since glucose trumps vitamin C, too much glucose can block vitamin C
from entering the cell. Vitamin C is essential to the chemical process needed to
convert L-arginine to nitric oxide. Increased glucose levels in the vessels blocks
vitamin C from entering the cell and thus blocks nitric oxide production
contributing to constricted blood vessels.
Another way in which the nitric oxide pathway is blocked is through high levels
of a protein called asymmetrical dimethylarginine (ADMA). John Cooke, M.D.,
PhD. published an article in 2004 “Asymmetrical Dimethylarginine: The Uber
Marker?” in which he noted that people with high risk factors for endovascular
diseases like diabetes, smoking, high blood pressure and high cholesterol, also
had higher levels of ADMA in their blood. ADMA acts much like L-Arginine and
also binds to the enzyme NOS, except when ADMA attaches to NOS it converts
to peroxynitrite (OONO) instead of the ever important NO. Therefore increased
levels of ADMA block the production of NO and causes blood vessels to constrict
and dramatically reduces blood flow. In fact, blood flow can be cut in half by a
mere 19% reduction in the radius of a vessel.
The Bigger Picture and Global Compression Theory
The explanation of these pathways is probably oversimplified but it's easy to see the big
picture: excess sugar causes systemic inflammation. This unrelenting inflammation and
the body's attempt to repair it leads to ongoing scarring that causes compression in any
area where blood vessels and nerves pass through a tunnel or small space. These tight
spots don't just apply to peripheral nerves. Enter the global compression theory. Here are
examples of this theory at work:
•
The ninth cranial nerve, the glossopharyngeal nerve, is affected in ALS, or Lou
Gehrig's Disease. Researchers with the US Centers for Disease Control and
Prevention and the National Institute for Occupational Safety and Health reported
that the incidence of ALS was four times higher in National Football League
players than in the general population. Professional athletes consume large
amounts of carbohydrates on top of experiencing repetitive micro-trauma to
cranial nerves. The global compression theory proposes that ALS could be
caused by compression of the 9th cranial nerve made worse by repetitive
•
•
mechanical trauma to the nerve.
An early marker of Alzheimer's disease is loss of smell. The first cranial nerve,
the olfactory nerve, reaches the nose through a very tight tunnel between the nasal
cavity and the brain. The hippocampus, the brain's memory center, is also part of
the olfactory nerve nucleus. The global compression theory proposes that
compression of the olfactory nerve is the root cause of the development of
memory loss.
Dr. Jacoby points out that most of his patients with plantar fasciitis (who are not
serious athletes or long distance runners) also often have high blood sugar and are
often in the early phases of peripheral neuropathy. His theory is that plantar
fasciitis stems from compression of the lateral plantar nerve in the tarsal tunnel
and the pain associated with it is due to the fascia pressing on swollen nerves.
Studies on relationships such as these are only beginning.
Nutrition Education: An Important Tool for Hand Therapists
The fact that sugar is an inflammatory substance is old news. The new part for us is the
possible link to compression neuropathies as well as other disease processes. It's
important to recognize the warning signs and as part of a comprehensive treatment
strategy, educate patients about their diet.
Type 2 diabetes is a disease that unfolds slowly and even though the warning signs are
there, the patient and doctor often do not recognize them until it's too late. The authors
point out a shocking statistic that 40-50% of American adults will be diagnosed with type
2 diabetes. We see patients everyday who are likely on the road to type 2 diabetes. Think
about the patient we are seeing for a wrist fracture after her third fall this year from the
beginning stages of peripheral neuropathy in her feet or the patient with multiple trigger
fingers along with carpal tunnel AND cubital tunnel syndrome! Metabolic abnormalities
cause problems long before there is a diagnosis. Signs that the patient may fall into this
metabolically abnormal category include:
•
obesity
•
family history of type 2 diabetes
•
high triglycerides
•
high blood pressure
•
low HDL (less than 50 mg/dL for women, less than 40 mg/dL for men)
•
high fasting blood sugar (normal is less than 100 mg/dL but preferable is 75-80
mg/dL)
rd
The Occupational Therapy Practice Framework, 3 edition, published in 2014,
describes the occupation “Health Management and Maintenance - developing, managing,
and maintaining routines for health and wellness promotion, such as physical fitness,
nutrition, decreased health risk behaviors and medication routines”. Nutritional
education is well within our scope of practice and a treatment strategy that can go a long
way toward the end goal of promoting healing, pain resolution, return to function,
preventing re-injury and improving overall quality of life.
Nutrition Advice for Lowering Sugar Intake
Dr. Jacoby is a proponent of a ketogenic diet which is at least 75% fat and limits carbs to
under 50 grams per day. There are major caveats to this diet and even some doctors
believe it to be “a very fringe treatment”. Contraindications include women who are
nursing or pregnant, women with fertility complications, people with kidney disease,
hypothyroidism, adrenal fatigue and athletes requiring high glycolitic output. The
ketogenic diet is NOT something therapists should be recommending to patients.
However, the authors consulted with a nutrition expert and offer a “plan B” blood sugar
regulation diet.
Blood Sugar Regulation Diet
The blood sugar regulation diet is basically a low-glycemic diet. The glycemic index (GI)
was developed by nutrition researchers in the 1990's to take the guesswork out of
choosing foods that are low in sugar. The GI value indicates how long it takes the food to
be absorbed into the bloodstream compared to the same amount of pure sugar but it's not
based on standard serving sizes. Therefore researchers came up with the glycemic load
(GL) which is the glycemic index based on a standard serving. So the GI of parsnips is
very high (97) while the GL due to it's high fiber content is 10. In general, it is
recommended to choose foods with a GI below 55 and GL of 10 or less. An excellent
searchable database to find out the GI and GL of foods is http://dietgrail.com/gid/.
1.
Reading Labels
The foods with the lowest GL are often vegetables, fats and proteins from natural
sources. It's difficult to find a low GL food that comes in a package. However reality is,
it would be tough to go without those convenience foods all the time. That's why it's
important to know how to read labels and a useful skill we can teach our patients.
1. Take into consideration the portion size.
2.
3.
4.
Fat: Check for trans fats and if it contains trans fat, don't eat it. All other fats are
good and since fat does not make you fat (sugar does), ignore this part of the
label.
Carbohydrates: If it has more than 10 grams of carbohydrate and 0g of fiber,
don't eat it. If it has fiber, subtract the amount of fiber from the total carbohydrate
grams to get the net carbs and if its still greater than 10g, don't eat it. Finally, if
there are any sugars, it means these sugars have been added beyond what already
naturally occurs in the food product and this food should also be avoided.
Ingredients: Anything that ends in -itol or -ose is sugar. Ingredients are listed
according to volume of each in the food. If sugar is the first ingredient, it means
the food is mostly sugar. Also, beware of added preservatives, food colorings,
artificial sweeteners and anything that doesn't sound familiar.
Other Inflammatory Foods to Avoid
1. Give up sugary drinks including fruit juices and energy drinks.
2. Avoid fruit that has been peeled, cooked and processed.
3. Use (organic, grass-fed) real cream, not milk. One cup of milk contains 12 grams
(3 teaspoons) of sugar. Fat-free milk is just sugar-water because once all the fat is
removed, the only thing left is sugar. Milk substitutes usually contain added sugar
as well so it's important to read the labels.
4. Avoid soy unless it's fermented.
5. Avoid fried foods.
6. Avoid artificial sweeteners and food additives like MSG, preservatives, colors,
etc.
7. Avoid cooking oils high in omega-6 including corn, soy and canola. Use olive oil
when lightly sauteing on low heat. Use the more stable coconut oil or grass-fed
organic butter for medium to high heat cooking.
8. Avoid alcohol.
9. Avoid processed meats like deli meats, sausages and bacon preserved with nitrites
and nitrates. Instead choose healthier brands that are preserved naturally.
As the food industry continues to deceive the public about what is healthy with crafty
food labels and marketing strategies and general practitioners and surgeons have little
time to devote to nutrition education, occupational and physical therapists have a
responsibility and a unique opportunity to educate patients on the role of nutrition in
health, disease prevention and the healing process.
Resources:
Jacoby, Richard P., Baldelomar, Raquel. Sugar Crush: How to Reduce Inflammation,
Reverse Nerve Damage, and Reclaim Good Health. HarperCollins Publishers, New
York, NY. 2015