4 Horsemen Series: Inflammation
The first topic in the 4 Horsemen Series will be on Inflammation. My mentor Dr. Kalish coined the term the 4 horsemen, which is a unique way of describing the major instigators of physiologic damage that happens to our bodies as we go through life.
"Inflammation is generally defined as a response to stimulation by invading pathogens or endogenous signals such as damaged cells that results in tissue repair or sometimes pathology, when the response goes unchecked."
- Nature Immunology 19 July 2017
Inflammation by definition should be good. It is the way your body defends itself against harmful viruses, bacteria, fungi. It is the way your body heals itself after injury. In the acute setting, under the right circumstances, inflammation is absolutely life saving and health promoting. When you fracture a bone, it generally takes 6-8 weeks for it to heal normally. During this time the inflammatory process ramps up and promotes the repair process. After that time, the mechanisms of inflammation cool down and turn off. That is how it is supposed to happen.
When we think of inflammation as a pathologic process or a process that causes harm or detriment to our bodies, we are referring to chronic, unchecked, continually ramped up inflammation that is not promoting healing and health. In fact, it leads to the opposite, chronic diseases in many forms. In medicine, when there is a chronic inflammatory component to an illness, we add the word "itis." Gastritis, colitis, enteritis, chondritis, arthritis, myositis, pleuritis, pneumonitis, and the list goes on and on.
Inflammation is clinically seen with classic signs described in latin as rubor, calor, dolor, and tumor, or in english redness, warmth, pain, and swelling. When you sprain your ankle, it swells up, becomes painful to touch and with movement. When you contract cellulitis or an inflammation of the skin generally caused by Staphylococcus or Streptococcus bacteria, you will note pain, redness, swelling, and warmth. This is acute inflammation in action.
However, contrast this with chronically painful and achy joints, depression, low energy levels, unexplained GI symptoms and weight gain more often seen in chronic inflammation. Sometimes there are no symptoms at all, and you just wake up one day with heart disease or cancer or an autoimmune condition.
In conventional medicine we are fairly good at diagnosing problems, and really good at naming them. We generally end up treating the symptoms of pain with NSAIDs such as ibuprofen, meloxicam, diclofenac. If there is an autoimmune component we may shut down totally or part of your immune system. If its cancer we may radiate the problem, cut it out, or try to eradicate it with chemotherapy. That being said, what do we offer in terms of finding the root cause of your Hashimoto's Thyroiditis, or Lupus, or cancer for that matter?
Not a whole lot.
When you were diagnosed with hypothyroidism, how many of you were told you likely had an autoimmune condition called Hashimoto's thyroiditis? How many of you were told about the concept of molecular mimicry? How many people had their diet's changed, their gut repaired? How many of you were put on levothyroxine or Synthroid and shown the door? And lets not forget about those who have a normal TSH and T4 levels yet still have the symptoms of hypothyroidism and are basically told sorry, live with it?
In functional medicine we attempt to get to the bottom of the root cause of your disease. One of the ways we do that, is looking at your inflammatory markers. These are chemicals or cytokines such as IL-6, TNF-alpha, IL-1 beta, C-reactive protein, etc. These are chemicals your body makes when inflammation is ramped up. Again if you have a cold or the flu or pneumonia, we want these things ramped up. But if you are in your normal state of health just living your life, we want these chemicals as low as possible.
Do you suffer from depression? It could be in part caused by or made worse by inflammation. Just take a look at this. Investigators injected subjects with endotoxin, a potent pro-inflammatory substance, and within hours, people were significantly more depressed, fatigued and less socially interested.
Do you have heart disease, coronary artery disease, peripheral vascular or cerebrovascular disease? AKA have you had a heart attack? Heart blockages? Pain from walking associated with blockages in the arteries in your legs? Have you had a stroke? As you can see below, having higher inflammation levels, your risk for vascular disease goes up.
Are you worried about developing cancer or do you have cancer? According to this paper from 2011, in the Journal of Epidemiology, "Serum hs-CRP was positively associated with the risk of cancer, although causality cannot be inferred in this cross-sectional study. The results support the hypothesis that chronic inflammation plays a role in cancer."
Just a few years later in 2015, the research regarding inflammation and cancer evolved to the point where, the International Journal of Breast Cancer states, "Chronic inflammation is a key contributor for breast cancer, right from its causation, initiation, promotion, progression, metastasis, and clinical features. Serum CRP assay is a simple, cheap, and sensitive test available widely. The potential utility of CRP as a risk predictor for breast cancer is questionable in clinical practice. But CRP will have the promising role as an additional prognostic predictor of survival."
This is why inflammation investigation and mitigation is so important to the Functional medicine practitioner. Not because its "in vogue" or a fad word right now, but because it is at the core of most disease processes.
So where does all of this chronic, un-necessary, harmful inflammation come from? Generally speaking almost always from the gut or toxins. However the causes are many and we as functional medicine doctors, are trained to investigate the root causes. For example, take a look at the table below. As you can seen in the physiological damage column, the 4 horsemen, which are the major instigators of chronic disease are located. However, you see in the underlying cause column, which is a fairly comprehensive list of things that cause the 4 horsemen to ramp up. On the far right of the table, are what you are possibly currently experiencing and where mainstream medicine focuses.
Diet pills, energy drinks, antidepressants, anxiolytics, proton pump inhibitors, hormone replacement, pain killers, allergy medicines, skin creams, and immune suppressing drugs. As you can see, again, mainstream medicine focuses on the far right side of the table.
In functional medicine we don't want you miserable so we will not exclusively focus on the left side or the table. We will help you with your pain and depression symptomatically, but we are continually going back to the left side of the table, and trying to figure out why you are having the problems you are having, and how to cut them off at the most fundamental level.
As the father of modern medicine once said...
Stay tuned for the next topic in the 4 Horsemen Series!
Casey B Peavler, M.D.