Part 2.2 Fats - Triglycerides and Essential Fatty Acids

From the previous blog post, you're familiar with saturated and unsaturated fatty acids. Now we’ll look at how we obtain and use fats (synonyms: fatty acids, triglycerides. lipids), how much we need/don’t need, and why.

Triglycerides (TG): You’ve seen this term on every blood panel your doctor has ever ordered, but what does it mean and why should we care? Fasting blood-borne TG levels higher than 150 mg/dL correlate with increased risk for heart disease, fatty liver disorder, early onset type II diabetes, kidney disorders and pancreatitis (Article). Usually the effects are asymptomatic until something alarming happens and we find a doctor. TG blood screens are recommended yearly to identify high levels before they cause problems.

Triglyceride with 1) Palmitic acid, 2) Oleic acid and 3) Linoleic acids hitched on. Notice different saturation.

We get fats from two different sources: 1) our diet, 2) our liver synthesizes them from other molecules in our bodies including glucose. Yes, when you eat excess sugar, your liver uses it to make fat. (Bummer). In plants and animals, fatty acids tend to travel in threes hitched to a glycerol molecule. The glycerol carrier molecule isn’t choosy about who hooks into those three sites, so one glycerol ‘car’ can have three different fatty acid ‘riders’ varying in length or saturation-style (see image). If only one FA is hooked up, it’s a mono-glyceride, if two, a di-glyceride, and three, a tri-glyceride. This latter form is how fats mostly occur in our bodies. TGs are very large energy-dense molecules, and a lean adult has enough TG stored in them (about 15 kg or 33 pounds) to survive for more than 2 months.

For us to access the energy in dietary fats, our digestive process performs a multi-step process to break TGs down into molecules small enough to cross the intestinal lining.

Feasting: When we eat, 1) we break large fat particles into smaller ones by chewing and stomach churn. 2) most TG disassembly happens in the small intestine where enzymes rip two fatty acids off the glycerol triple-carrier to liberate free fatty acids and mono-glycerides. 3) These smaller molecules are emulsified further by the addition of bile, and are finally able to cross the microvilli membrane into the intestinal cells. 4) Once inside the intestinal cells, the TGs are reassembled into their prior triplet form, and packaged with other goodies like cholesterol and fat-soluble vitamins (A,D,E), into shipping containers called chylomicrons. 5) The chylomicron containers are shipped into the intestinal lymph system and thence into the bloodstream to deliver TGs, vitamins and cholesterol to the tissues. If cells don’t need the energy, excess TGs are instead delivered to our storage units - adipose tissue for later use. Chylomicrons decrease in size as they deliver their load to the periphery and then the empty containers return for recycling in the liver.

Fasting: When we are not eating, 1) “Need Fuel!” signals are released by cells when their energy supplies run low. These signals hit two targets. 2) Our storage units (adipose tissue) react by breaking stored TGs into free fatty acids (mono-glycerides). The mono-glycerides diffuse into the blood, and head off to the cells that need energy, for example, your leg muscle cells if you are going for a walk. 3) The liver responds by constructing new TG’s from the free fatty acids floating in the blood stream plus glucose (we use sugar to make fat!! Bummer again.) 4) The liver packages the TG and some cholesterol and protein into VLDL (very low density lipoprotein) shipping containers and sends them out in the blood. The name very low density means they contain more TG than the accompanying heavier protein and cholesterol. As the traveling VLDL shipping containers drop their TG cargo into energy-requiring cells, they become LDLs, (low density lipoproteins - relatively more protein and cholesterol-laden, see previous post on cholesterol), then IDLs (intermediate density lipoproteins), and then finally HDLs (high density lipoproteins) mostly empty protein vehicles which scavenge cholesterol and return to the liver for recycling and disposal.

TLDR-version: After a meal: blood TG levels spike because chylomicrons are clearing fat from the intestine. Fasting blood TG levels respond to energy requirements via free fatty acids from adipose tissue, and VLDLs from liver.

If the system is working well, TGs disappear into their destinations efficiently, and blood TG levels lower to normal. If the system is consistently overloaded with dietary fats, or confused by lots of sugar-induced insulin, TG blood levels respond by remained elevated and cause trouble in heart and blood vessels, liver, pancreas, kidney and more. How to decrease Triglycerides in your body to optimum levels (less than 150 mg/dL)? There are lots of ways, but the simplest and cheapest are lifestyle choices.

1) Exercise: This burns up extra TG’s floating around and decreases excess levels stored in your adipose tissue.

2) Cooking and eating: Many flavor molecules are fat-soluble which are lost in “fat-free” foods. To makeup for the lack of flavor, processed fat-free foods have sugar added to them to make them more palatable. It’s best to avoid these processed hidden-sugar-laden foods, because type 2 diabetes is risky. Instead, get more creative in the kitchen. Select recipes that are more veggie-forward, discover more pungent and umami-rich ingredients like fermented foods, spices, herbs, mushrooms etc. Instead of frying foods, roast, bake or slow-cook. It’s definitely a life-style change, but one that will benefit your health-span.

3) Drinking and smoking; Decrease alcohol intake and eliminate smoking - both are correlated with increased TGs, metabolic syndrome and morbidity from many causes.

4) Medication or supplementation: Fibrates, Niacin (prescriptions needed) and Essential Fatty Acids somewhat decrease levels of blood TGs.

Essential Fatty Acids (EFA’s) Also called Omega-3s and 6s, these are fats that we get from our diet, most notably fish oils from fish that need insulation in cold water, salmon, sardines, mackerel, steel head trout, cod, (yes, there was a reason for cod liver oil...) as well as flax, walnuts, and leafy green vegetables. The omega nomenclature (biblical reference here, science is not without a sense of humor) tells you how far from the end of the molecule the unsaturated kink is (see the final fatty acid ‘rider’ in the image above). We cannot make these EFA’s in our body and we’ll die without them, hence: essential. They are an important part of cardiac health, vision, inflammation regulation and other important functions. This is why nutritionists are always all over you to eat fatty fish like salmon. If you take the skin off your salmon before you eat it, you are losing much of the oil, so eat the skin! (Salmon skin hint: Grilling makes it even more delicious.) Include these foods in your weekly intake; walnuts, flax, chia seeds, salmon, herring, sardines, oysters, dark leafy greens, pine nuts, Brazil nuts, sunflower seeds/oil, pecans.

Overall takeaway: Balance your fat (triglyeride) intake with lots of healthy food choices, move around to burn off excess energy, eat fish and other delicious foods with EFA’s, and you’ll have solved the fat conundrum, plus you’ll enjoy the wonderful benefits of a healthy heart, liver, pancreas, kidneys and long healthspan.

Cholesterol levels; Statins and Exercise

Is one better than the other? Are they interchangeable? How do they interact? Is a multiple approach the answer? As with anything to do with biology, the answer is “it’s complex”.

Statins have been one of the most prescribed drugs to lower high cholesterol in the US since their introduction in the early 1990s. Let’s start with understanding cholesterol , why should it be lower in many people, and ways to approach it.

Our livers make a daily genetically-determined amount of cholesterol. It is necessary as a cell membrane stabilizer, a precursor of sex hormones, vitamin D and bile, and as part of the fatty-acid transport system in our blood. Animal foods add a dietary source of cholesterol, but whether dietary cholesterol is actually worrisome has been debated for years (current thoughts -> less problematic, but stay tuned...) We manage cholesterol levels internally with a recycling mechanism that recaptures some, and we also lose some through our gut. The liver uses cholesterol to create bile acids which are secreted into the intestine to facilitate absorption of dietary fats. Some of these bile acids are lost in the feces.

Handy food tips: eating high fiber foods causes more bile to be swept out of the intestine, indirectly lowering your cholesterol. Certain plant foods, (avocado, flax, peanuts) contain phytosterols, which compete with cholesterol for reabsorption sites in the intestine, thus increasing cholesterol elimination. Take home tip: eat higher fiber foods like apples, oats, beans, lentils, leafy greens and consider including avocado, flax and peanuts.

It gets a bit more complicated because you’ll hear about more than one type of cholesterol (total cholesterol reflects the sum of LDL and HDL in lipid profile blood work). Vastly simplified, LDL is a blood-borne vehicle which carries lipids and cholesterol (sloppily) out to the perifery for use in cellular metabolism and repair. The HDL vehicle returns to the liver picking up scraps of cholesterol stuck to the insides of blood vessel walls on the way. Higher HDL levels are good, because it correlates with decreased heart disease risk (you’ll want it high, remember H for high HDL). If one’s levels of LDL creeps up, this is concerning because more cholesterol and fatty acids could get dropped in the blood vessels. Narrowing and hardening of arteries due to plaques, drive up blood pressure and risk of atherosclerotic events such as heart attack and stroke. (So you want it low: remember L for low LDL). Make sure that you know your ratio of HDL to LDL (different for men vs women, but around 3.5 is good). Total cholesterol is a less precise number.

There are a number of tactics to decrease risk of atherosclerosis and improve one’s health span. The simplest one is to go on statins, also known by the following terms: atorvastatin (Lipitor), fluvastatin (Lescol XL), lovastatin (Altoprev), pitavastatin (Livalo), pravastatin, rosuvastatin (Crestor) and simvastatin (Zocor). Statins are a class of pharmaceuticals that block the creation of cholesterol in the liver, thus decreasing their overall level in the blood. They have been researched to be effective in their short-term goal of cholesterol reduction, but they are a life-long commitment of medication. Many question their side effects (myalgia, or muscle pain for some, low tolerance in others) contraindication in pregnancy, and a possible blinding effect to more overarching issues like poor nutrition or a sedentary lifestyle.

If the simplicity of taking a drug can distract us from making decisions that lead to longer term health, what happens when we choose not to use it any more? What habits are we grooming? Perhaps different lifestyle choices can be used collaboratively with statin drugs, to reduce dependence on Big Pharma and turn our attention back to creating our own healthy lifestyle. Enter: Exercise. Free, no negative side effects and many additional benefits.

Exercise and effects on Cholesterol:

We have a love-hate relationship with exercise (OMG why?!) More on this in another post, but for now let’s look at how exercise affects cholesterol levels. I’ll define exercise here as “movement to increase heart rate and respiration to meet increased activity-induced metabolic demands”.

Mechanisms are a bit murky, but it seems that exercise changes the size of LDL to make them less likely to stick on vessel walls, and increases transportation of LDL to the liver, expediting elimination. A metastudy suggests protective results of exercise are seen when folks exercise for at least 150 min/week, 5 X a week. This is a bare minimum. I suggest at least double that. Sitting is the new smoking - actually, don’t do either, they are both associated with increased risk of atherosclerosis.. (I recognize the irony of sitting to type this, I am looking forward to getting off my butt and going cross country skiing). Also, more intense exercise is more health-protective than moderate intensity, and both aerobic and resistance training are effective modalities in changing cholesterol levels.

“But I don’t have time to exercise…”

Actually, No - you don’t have time to be sick.

Though it’s much easier to take a pill than change your lifestyle and priorities, statins have a long list of inconvenient side effects (common ones are headache, muscle ache, flushing, drowsiness, dizziness, GI upset, rashes, and less common ones include hair loss, inflammation and sexual dysfunction). Plus there’s cost, medical appointments and insurance involved. Increased activity is free, available to everyone, and have very convenient side effects such as improved sleep, muscle tone, mood, bone mass, resilience, immunity, lower weight, blood pressure and stress levels, among many others. Reprioritizing to include more vigorous activity in your life is a choice that will have many long-lasting positive effects on your health.

From where I stand, if you are dealing with a diagnosis of dangerous cholesterol levels, statins are an effective and safe-enough-for-most quick fix. But it’s not the best long-term choice. Updating priorities and habits to add vigorous enjoyable movement to your life will have effects above and beyond cholesterol levels. And this is only one side of the coin - healthy food choices (a few quick tips above) are also very important.

Brainstorm about how to add more enjoyable vigorous playtime to your life to create your own joyful healthy lifestyle, minimize dependance on pharmaceuticals, and enjoy energetic spill-over of all the healthspan benefits statins cannot offer.

A heart-felt commitment: Exercise

Well ‘tis the week of Valentine’s Day, and all it’s hearty associations. Here are some ways to show love to the most important heart in your life - your own.

How does exercise improve our heart health? In so many ways. Here are three biggies.

Cardio means heart, and vascular means vessel. Therefore, the cardiovascular system includes both the heart muscle itself, and all the vessels (arteries, veins and capillaries) through which the blood flows. Exercise affects many things that improve the function of this system of pumps and tubes, and the hormonal milieu in which it works.

We’ll start with the main pumping station - the heart itself. Made of specialized muscle - cardiac muscle - composed of cardiomyocytes (cardio = heart, myo = muscle, cyte = cell), spontaneously generate their own electrical impulses. Heart cells in Petri dish will beat by themselves, and when they grow to touch each other, they beat in synchrony by sharing their electrical waves across their cell membranes. In our own hearts, we have an inner pacemaker poetically called “The Bundle of His” and the “Purkinje fibers”. Go and nerd out on these terms , but for now, I’ll simply say these structures coordinate our cardiomyocytes and keep our heart beating regularly day in, day out until we die (or need an artificial replacement pacemaker). Fibrillation is when our inner pacemaker loses control and all the cardiomyocytes start beating independently. The heart just quivers uselessly, and the owner suffers a heart attack. A defibrillator shocks and resets the inner pacemaker to reorganize synchronicity, keeping the owner alive until the paramedics get there. This is why first aid classes now involve training on an AED or an Automated External Defibrillator.

Strong muscles are more efficient and squeeze more powerfully. By performing aerobic (with air/oxygen) exercise that challenges us past our comfort zone, we forcibly require our cardiac muscle to pump more blood through the lungs and thence to outlying tissues meeting the increased oxygen and nutrient requirements. The heart, like any muscle, will rise to repeated challenges and hypertrophy (become larger). Unchallenged muscles atrophy (become smaller), and cardiac muscle is no different. Cardiac atrophy is not a good idea, so regular exercise is needed to maintain cardiac muscle mass and performance. A general indicator of good heart health is a low resting heart rate (50 - 60 beats per minute), indicative of powerful and efficient cardiac muscle. Take your resting heart rate when you have just woken up and are still lying in bed - here’s how, and here’s a comparison chart. There are exceptions due to medications like beta blockers and various medical conditions.

Take home message #1; perform daily aerobic exercise that challenges your heart muscle to maintain it’s size and efficiency.

The other part of the system are the blood vessels. Arteries move oxygenated and nutrient-filled blood outwards to the peripheral tissues. Capillaries in the tissues are so delicate that O2 and nutrients filter out toward the cells and cellular waste products and CO2 diffuse back in. Veins collect blood with CO2 and waste products and return to the core for purification via lungs, kidneys and liver. Then the whole process starts again. This is a massively simplified overview of course, but you get the idea of circulation.

As with any system of pipes, restriction of flow causes problems, so maintenance of smooth healthy vascular tubing is crucial. Your arteries are muscular (a variety called “smooth muscle”) and complex triple-layered tubes that contract, dilate and secrete slippery substances to keep their inner walls clean. Exercise increases the level of nitric oxide in the arteries, maintaining a flexible and open lumen, thus enhancing blood flow. Aerobic exercise causes the heart to push more blood through the tubes and flushes the system, cleaning the insides of the vessels and reducing risk of build-up. What might build up? Sticky substances like Low Density Lipoproteins (LDL), platelets (clotting factors) and trapped blood cells may collect inside the vessels if they are damaged due to inflammation. Consistent flushing helps keep things flowing. These principles apply especially to the little arteries that feed the heart muscle itself - the coronary arteries. Constriction of the coronary arteries is called Coronary Artery Disease, or CAD and can lead to heart attacks. Exercise decreases this risk.

Take home message #2: daily exercise boosts blood flow by flushing our blood vessels and increases the presence of nitric oxide which keeps vessels open and slippery.

A more general effect of exercise on our system involves stress reduction. Exercise is shown to reduce the amount of stress humans typically perceive. Whether is it’s due to a reorganization of our hormonal response (cortisol/adrenaline) or simply the feeling that we have “done something” (which is mentally relieving) is still up for debate. Our sleep improves when we physically tire our bodies from regular exercise, and sleep is when we repair ourselves to become stronger and more able to face our challenges; mental, physical and emotional. Stress hormones released during negatively stressful situations can depress the nitric oxide in our arteries and increase other inflammatory substances that may rub away at our inner vessel linings to increase the risk of cardiovascular injury and events.

Take home message # 3: daily exercise is a way of inhibiting stress-response chemicals, lowering the risk of damage to our cardiovascular structures.

Make a daily date for 30 - 60 minutes of heart-rate boosting exercise for a long, happy and heart-felt commitment to your cardiovascular system.

Every day is Valentines Day when it comes to your heart!

That's a stretch...

Ahhh, stretching. That thing that feels so good, but no one has time for.

As a Fitness Professional, I’ve witnessed countless times when folks work their butts off in class, sweating and strengthening, and then disappear before the end (citing ‘lack of time’) avoiding the post-workout cool-down and stretch. The last part of the workout is sacrificed by a perception that it is less necessary. (I’d argue that it’s not ‘lack of time’, but ‘lack of time-management’ that’s truly the culprit, but hey…) Hence the second part of my career as Massage Therapist - stretching people back out, after they have contracted themselves into a state of pain and injury. We can get away with the perception that stretching is unnecessary for only so long (usually our 30’s), until our bodies become less elastic and start to give us musculo-skeletal clues that a lifetime of contraction without extension isn’t beneficial. Joint issues, imbalances, uneven tendon and ligament wear and tear, low back pain and more all stem from a lack of elasticity and length in the tissues. Although you’ll probably never be able to put your leg behind your head again like you did when you were 8, boosting your flexibility will make life activities more easy and fluid, enhance balance and increase active range of motion.

What is stretching? For the purpose of this post, I’ll define it as an activity or movement that returns a part of the body to a lengthened and extended resting position. For example after sitting for many hours at a computer our hip flexors (muscles that bring our leg toward our chest) have been held in a shortened position. Because they attach to our anterior lumbar vertebrae, if they are not lengthened back out, we increase the risk of low back pain.

How does it benefit us? More flexible tissues allows our life more lightness and ease. It’s wonderful to have the shoulder mobility to reach backwards for something, or lift our foot up to clamber over a boulder on a hike without worrying about it. Stretching creates more mobility around joint, reducing wear and tear and the risk of injury. Decreased pain and tightness during activities, and increased reach and ability ripples out into our life, reducing our stress levels and boosting our health span.

Why is stretching so uncomfortable? You may be overdoing it. The discomfort comes from pain receptors in the muscle when it is overstretched. Muscles are also attached to tendons and tendons should not stretch, so being aware of how to address stretching correctly and safely is important. Dehydration can also be a factor. (see my previous post).

How do I stretch pleasurably? Warm up a bit first. Think of your muscles like uncooked spaghetti. Cooked spaghetti is much more mobile. Even 5 minutes of movement will increase the metabolism in the muscle and move some blood through. Irrigated and warm tissues are pliable and more willing to accept length. Use the idea of green-, yellow-, and red-flag pain markers. Move yourself slowly into the yellow-flag stretchy-discomfort feeling, and then slow down your breath to access your calming parasympathetic nervous system. Don’t let yourself go into red-flag pain - your muscles will contract to protect themselves. Moving slowly bypasses the muscle spindle reflex - a reflexive contraction in your muscles that protects from damage due to a sudden unexpected lengthening. Hold the stretch for 30 seconds. Stretch after your work out, it’s not so important before.

Can UV light or sunlight deactivate Covid19?

Short’ish answer - It’s complicated and maybe expensive, but perhaps. Can we harness the power of UV to kill viruses and other pathogens without harming ourselves?

Unfiltered sunlight, contains a full spectrum of electromagnetic radiation frequencies, spanning dangerous high-powered rays, Ultraviolet or UV, the visible light spectrum, warming infrared and low-power radio waves. Luckily for us, the ozone in our atmosphere reflects or filters out the really harmful high-frequency radiation, or we’d all be crispy critters, but some UV, visible, and radio waves do come through.

The UV radiation is made up of UV-A (less powerful; gives us wrinkles) UV-B (more powerful; if we’re exposed for long time gives us sunburns and skin cancer) and UV-C (most powerful, sunburn in seconds, will fry you.) Luckily, UV-C is filtered out by the ozone layer, so we are not affected by it when we are outside in the sun. To better understand how to harness the power of UV, let’s examine how UV radiation causes damage.

UV radiation creates gluey fusions or crosslinks in genetic material (DNA or RNA). If you think of a DNA strand like a zipper, a UV-induced crosslink will cause the unzipping machinery to get stuck at the fused part, messing up replication. The more powerful the UV, the more crosslinks, and therefore more damage, potentially lethal to something with a small genome, like a virus. It does take longer to damage something bigger and more complicated like a human genome, but UV damage can build up over time.

Now it gets tricky: can we find a UV wavelength that will kill viruses, but not humans? And if so, can we build emitters to continuously sterilize public places like airports and hospitals? Turns out UV-A (315-400 nm) is too feeble, UV-B (280-315 nm) too dangerous and UV-C (100-280 nm) even more so. BUT far-UV-C (207-222nm) might do the trick. (A nerdy aside, a nm = nanometer, or a billionth of a meter. 1 meter = 1,000,000,000 nanometers. Mindbogglingly small.)

An article in the June 2020 journal Nature studied far-UV-C sensitivity on previously identified coronaviruses and influenza viruses. Exposure to far-UV-C disables the D/RNA of very small things, like a virus, but does not penetrate the first few layers of dead skin cells on our body, or the layer of tears protecting our eyes. The information generated by the experiment has been extrapolated to the similarly-structured Covid19 (size of the virus, length of genetic material, spike proteins). According to the article, continuous low-dose far-UVC light emitters could result in over 99% of eradication of virus in 25 minutes.

This could be a game changer for use in high traffic and danger areas like airports and hospitals. More research on the subject asap please!! But where does that leaves us regular folks without far UV-C emitters? I guess we wait until product testing and subsequent manufacture allows such technology to be publicly and affordably available. Heading outside and hoping sunlight will work will not be enough.

Sunlight containing the regular UV spectrum will increase your vitamin D levels which are immune supportive, and being in the light will boost your mood. But until we verify the efficacy of far-UVC and then build enough units to make a difference, we are back to the advice of: wear a mask to contain your exhalations and protect you from other’s, wash your hands, don’t touch your face, maintain healthy spacing and cooperate with quarantine directives. We’ll get through this, but only if we all do it together.

Wash your hands! And other ways to avoid (corona)viruses

Half the world seems to have lost their minds about the 2019 Novel Coronavirus (2019-n-CoV). We can protect ourself from viruses with some basic calm common sense. A biggie is increasing the frequency of hand washing, especially after being in public places.

Coronaviruses, like Rhinoviruses and Adenoviruses, cause upper respiratory tract infections - also known as colds, and there are hundreds of varieties. There are very few confirmed 2019-nCoV detected in the Northeastern US at this time, so relax. If you have a cold, it’s just a plain ole’ bummer of a cold. SARS is a type of coronavirus, and caused a panic a few years ago. Deaths caused in China by this particular coronavirus seem to be from pneumonia, and the affected patients already had a compromised immune system or respiratory tract to begin with. Most coronaviruses will simply give you a cold and then you’ll be done with it. Influenza on the other hand, causes the flu and can be quite deadly (over 12K in the US annually, and in 1918, a pandemic caused 20 - 100M deaths globally) so really, it’s statistically much more important to get a flu shot than to freak about coronaviruses. Remember that viruses are not bacteria, so antibiotics will not do anything against a virus. Take care of yourself so you can fight it off and decrease the chance of an opportunistic lung or sinus bacterial infection happening afterwards, because then you will have to deal with antibiotics.

That said, it’s good to take public health warnings seriously and there are many things we can do to decrease our risk of coming down with a cold (or flu). The biggest is to WASH YOUR HANDS frequently. Though viruses don’t survive well on hard surfaces, they do transmit in wet coughs and sneezes if breathed in, and will transfer to your membranes via your hands if you come in contact with infected droplets. Masks might contain coughs or sneezes if worn by an infected person, but they are not really airtight enough to protect healthy folks. Washing hands was found to be more effective than hand sanitizers because the alcohol-based sanitizer must be in contact with a mucusy virus preparation for 4 minutes before the virus is killed - most people would not rub their hands with sanitizer for that long.

Best way to wash hands - wet hands, add regular soap, scrub for more than 20 seconds, then wash off hands and dry them. Microbes are less likely to be spread or picked up with dry hands. The soapy water will dissolve the grease and oil on your hands and items (viruses) stuck to it. Everything then goes down the drain when you rinse your hands. Use the paper towel (of a corner of your clothing) to then open a public bathroom door handle. Hopefully by washing your hands frequently, you reduce the viral exposure to a smaller dose your immune system will be able to squash quickly. Sleeping and eating well support a healthy immune system ready to fight for you.

If you do have a cold, contain your coughs and sneezes. Best bet - stay home and take care of yourself with rest and fluids instead of “toughing it out” and infecting everyone. Folks will thank you. And maybe reschedule that trip to China for another time.