Metabolic Syn-drone

Metabolic syndrome is a play with a cast of millions. It's full of characters we all see daily. We see them in shopping malls, restaurants, bars, city streets, on the job, and nearly everywhere (in Western society). B.R., one of my recent encounters, so typifies this syndrome I had to present his case en-blog, to show the somewhat typical and blissfully ignorant face of this illness/modern distillation.

B.R. is a 46 year old male (not his initials and not exactly his age, but close) with non-insulin dependent diabetes (a blood sugar today of 176), obesity, hypertension, hyperlipidemia, sleep apnea (untreated), gastric reflux and a heaping of denial and ignorance that might now be considered epidemic. In a human play involving this constellation of signs and symptoms (he also doesn’t sleep well and feels exhausted all the time) the drama from my perspective involves a backdrop which shows a sheer lack of insight and offers a rich look into what appears to be going wrong with a large segment of society. He is retired/disabled due to a back injury. We open with the interview:

I ask B.R. an open ended question, “You have high blood pressure?”
He chuckles and replies, “Yeah, that’s what they tell me.” His wife, who is also obese, chuckles in response to his reply.
I continue, “Your blood pressure is 155/95 today. It’s not well controlled”
“Yep . . . I don’t always take my medication,” he admits.
I move on, “You have diabetes as well?”
He chuckles again, “I control it with diet.”
His wife corrects him, “No doctor X gave you medication, don’t you remember?” She looks at me, “He takes it once in the morning and once at night.”
He turns to her, “Do I?”
“Don’t you remember?”
His weight is 284 lbs and he’s 5’10” tall. (BMI of 40.2)
He has shortness of breath with minimal exercise, has what may be developing angina, all of which leads to a fairly sedentary life.

The frustration is: Where do you start with someone like B.R.? Is he a lost cause and do we move on to the next generation or do we all simply plod along with him and wait for the wake-up call; the heart attack the stroke the severe angina the coronary artery stent, the peripheral neuropathy the diabetic foot ulcers and the amputations? Usually by then it’s too late and the connection between the gallon of ice-cream and the below the knee amputation isn’t ever made. As B.R.’s metabolic syndrome worsens due to his increasing central obesity, insulin resistance, hyperlipidemia, and more, the treatment is simply to eat less and exercise more. The treatment isn't a medication or a high-tech procedure, but a simple dietary and lifestyle change. But in B.R.'s case the disease processes are setting in solidly and the diet and lifestyle changes, while desperately needed, will without question require medications and expensive procedures to maintian his life over the next 10 years. And what about the cost?

A to Z weight Loss Study

One of the more startling results of the A to Z Weight Loss Study is the interpretation of the results. Again, the study found that after 12 months, those participants on the Atkins diet lost more weight and ended with a metabolic (cardiovascular disease) profile no worse than those on the comparison diets thought to be “healthy” diets. Those participants in the Atkins diet arm of the study on average consumed significantly more saturated fat, more protein and less dietary fiber than the other diets (Table 2 of the study in question[1]). They in essence ate large amounts of foods that might be considered unhealthy by most current nutritional standards. And after a year (granted that’s a fraction of the time needed to prove it a safe and healthy diet) the participants lost the most weight and didn’t suffer with metabolic indices indicative of unhealthy eating.

One critical aspect of this study to keep in mind is the brief glimpse it gives. Dietary lifestyles take many times ten to twenty years of exposure to impact for example the cardiovascular system. While indices of cardiovascular risk are within the range of other “healthy” diets, the indices measured may not tell the entire story. As a case in point, the genesis of atherosclerosis is thought to be due to trapped Low Density Lipoproteins (LDL) stuck in the arterial walls, consumed by tissue macrophages which expire in the arterial wall leaving thick goo. The goo expands into the arterial lumen and the nidus of a plaque is created. With that genesis in mind, might the Atkin's diets impact the oxidizability of LDL, leaving the absolute amount of LDL unchanged?

Another important consideration: The study was conducted in women. Is the result generalizable to both women and men? Or is another study with the same methodology needed for men? And what if the results were different, what could we conclude? The answer from my perspective is: it depends on the winds of nutritional change. Trans fats were never found to be unhealthy (lead to adverse cardiovascular indices) in men yet the unsavory results of the Nurses Health Study were generalized to men (never mind the results of the Physicians Health Study, which found no adverse metabolic effects of trans fats in men). But that’s another soap box.

What do the authors of the study conclude? I’ll quote one the study authors ending remarks:

“Physicians whose patients initiate a low-carbohydrate diet can be reassured that weight loss is likely to be at least as large as for any other dietary pattern and that the lipid effects are unlikely to be of immediate concern.”

So there you have it. The whole nutrition cycle begins to churn again. Fat is good for you, carbohydrates are evil and the Atkins diet we all shunned for so many years because of the perceived adverse effects of eating bacon, pork and fatty foods, is shown to be as healthy as all the other dietary approaches. As Daniel Boornstein was quoted as saying,

“The greatest obstacle to discovery is not ignorance—it is the illusion of knowledge.”


[1] Christopher D. Gardner et al. Comparison of the Atkins, Zone, Ornish, and LEARN Diets for Change in Weight and Related Risk Factors Among Overweight Premenopausal Women: The A TO Z Weight Loss Study: A Randomized Trial JAMA. 2007;297:969-977.

Contribution or Consternation: The A to Z Weight Loss Study

The diet and weight loss chronicles received a retro boost recently with the publication of a study in the Journal of the American Medical Association. The A to Z weight loss Study randomized willing participants to one of four diets: Atkins, Zone, Ornish or LEARN.

Studies such as this, examining the most effective method of losing weight, have been plagued with methodological and patient related issues. High dropout rates, poor compliance with diet protocols and short duration of study have left the conclusions drawn from these studies nebulous at best. Layer that with popular diet authors espousing the virtues of low carbs, zone eating, eliminating refined sugar, or in the case of the American Heart Association, eating by the dictates of the No Fad Diet, and the public becomes confused.

So to further the confusion and nebulousness, we have the A to Z weight loss Study. The A to Z Weight loss Study published in JAMA compared the Atkins, Zone, Ornish and LEARN diets in premenopausal women. Naturally media-reported ultra-short sound-bite analysis declared the Atkins diet the winner. The Atkins Diet, you ask in dismay? Didn’t they go away after bankruptcy and weren’t the virtues of this diet debunked? Apparently not.

Let’s look at the study. The endpoints of the study examined weight loss, changes in lipid profiles (total, LDL, HDL cholesterol and triglycerides) as well as changes in waist to hip ratio, % body fat and a few other variables. The participants were generally obese women in the age range 25 to 50 years with a BMI range of 27 to 40 (average in the 31 to 32 range) followed for 12 months with frequent follow-up visits. The interesting point of this study is that it addressed some of the prior problems plaguing similar weight loss studies. Lets look at them individually:

Drop out rate: The study randomized 311 participants to one of four diet groups listed above. Atkins had 77, Zone 79, LEARN 79 and Ornish 76. Of the four diet groups the number of dropouts respectively were 9, 18, 18, 17 which isn’t a terribly bad drop out rate.

Regression to a regular diet: This is where the low carbohydrate dieters start eating higher percentages of carbs and likewise the low fat dieters eat more fat. In short, the dieters regress to a normal diet and give up the basic principles of the diet. Again, in this study, regression to a normal diet resulted, but wasn't terribly bad.

The result: Much to the chagrin of the scientific world, (and the authors of the losing diet plans)the Atkins protocol won the horse race. Those on the Atkins diet lost a significantly greater percent of BMI, had lower % body fat, and had significantly lower triglycerides with no change in LDL cholesterol. The authors of the study concluded there were no adverse metabolic effects for those women following the Atkins diet regimen.

As Sir William Bragg (1862-1942) was quoted as saying, “The important thing in science is not so much to obtain new facts as to discover new ways of thinking about them.” What if, after digesting Sir Williams quote, the important thing about diet, health and weight loss wasn’t so much what you ate, but how much of it you ate (in terms of calories)? More commentary later.

Othorexia Nervosa

As Oscar Wilde said, “I am not young enough to know everything.” And likewise the concept of a person being too concerned about eating healthy food, might have traction. It might just make sense in the context of my own life: I might be too concerned about my health, my bank account, my children’s activities, my carbon footprint, my automobile emissions, my lack of knowledge of the arts, my lack of knowledge of auto mechanics and on ad infinitum. Volley along now, I too might be the creator of a new DSM IV category: Dysplernecess.

Dysplernecess: Eating until it hurts.
Anyone with Dysplernecess has the unavoidable compulsion to eat whatever comes to mind without pre-conception or planning. When in a bakery they point to each and every pastery and state, “I’ll have one of those, one of those, oh, and one of those,” until the glass case is quite empty. They make up diagnoses, accuse others of focusing too much on healthy eating, and publish a book to prove their point(s).

Take the 10 point test to see if you qualify:

Two points for each yes:
1. Did you publish a book recently titled “Health Food Junkies”?
2. Is your last name Bratman?
3. Is the point of eating to achieve a pleasurable state?
4. If eating a twinkie is fun, would you eat ten?
5. Do you frequent all-you-can-eat buffets without remorse?
6. Does your waistline keep expanding?
7. Do you eat anything you like and not think twice?
8. Do you spend more than three hours a day thinking about new DSM IV diagnostic criteria to describe healthy eaters?
9. Do you feel a sense of achievement when you eat the most pie at a pie eating contest?
10. Has the rate of heart disease and obesity gone up in those around you?

A score of 6 to 8 you may have Dysplernecess. If you scored more than 10, you probably need to be put on a statin, have a treadmill test and get frequent blood pressure checks. Also; purchase a bathroom scale.

All tongue-in-cheek of course, but moral absolutists that consider watching what you eat to be a sin, need desperately to consider the trends. Where did the obesity trend come from? Answer: Not paying attention to what foods are composed of and allowing too much of said undescribed and tasty foods to enter the oral orifice. Where did the trend in hypercholesterolemia come from? Answer: See last answer. I could go on.

Road Food

Traveling and dining out for each meal brings home some interesting observations on Western society. It doesn’t take a brilliant critic of our current food culture to very quickly notice patterns in food intake while on the road. First off, the food choices available to travelers in essence involves marketing a taste driven machine; and it’s not a process we want to intellectualize about very much. Nutrition information is not just lacking, it’s suppressed. By that I mean it might be a bit depressing for the causal nutrition clerk to tally the day-in day-out calories, saturated fat and lack of fiber when jumping from one national chain restaurant to the next. Avoid the national chains you offer as an armchair quarterback? Try as I might, and knowing what I know, the local grocery stores didn’t offer up what the weary traveler needs. Like the battered fighter on the ropes, at some point you give in to the chain restaurants and order up. Like a “tractor beam” from the old Star Trek series, we were drawn in by the smell, the anticipation and the ease of entry. But honestly, we tried to avoid them.

Theoretical arguments against eating at chain restaurants are workable from the safety of home. However, on the road, after numerous hours on dreary pock marked pavement with the nearly constant hum of the engine wearing senses thin, a city or town rises in the neon light like an all-you-can-eat Phoenix. Neon signs proclaim Burger King and Pizza Hut with enticing visions of reprieve from the constancy of the road. And taste experience is king in neon food chain land as each establishment announces savory meals offered up at the likes of Tony Roma’s and Applebee’s. Tony Roma’s advertises in bold letters a “Slab-Fest” going on. I paused at that trying to imagine what the patrons of the restaurant engaging in the slab gluttony might look like. Hardee’s advertises a gigantic monster burger with many too many pounds of ground beef on thick slices of cheese all covered in the usual suspect fixins and a secret sauce to boot.

Seeking out the less common establishments like the backstreet Thai restaurants or corner bistros might offer up more international flavors with gourmet dishes (and higher price tags per meal), but the nutrition clerk in me was tallying up the saturated fat and calories next to the check, trying to figure out which is the larger. I usually based the tip on some fractional multiple of the total grams of saturated fat. Needless to say the wait staff made a fortune off of me.

In the final analysis, each time I travel it makes me wonder about all those road weary truckers, travelers and communters who frequent the aforementioned neon establisments regularly. Health implications and cost aside, the taste experience alone is akin to mainlined heroin, making it nearly impossible to return to fruit and granola as a snack and the simplicity of vegetable rich meals as a norm. And the number of obese patrons I saw reinforced my conviction: We are truly a society and culture addicted to food. Not food for sustenance and nourishment, but food strictly for the taste experience.

Vitamin B12 (Part Deux)

This complex and confusing mass of chemical scribble to the right is B12. Most publications regarding vitamin B12 will neglect to reflect on a few fascinating facts regarding the molecule. Complex as it looks, the molecule itself is speculated to have been around for 3 to 4 billion years. That’s billion years.

The next fascinating factoid regarding B12 is it’s made by some our bacterial arch enemies, including Klebsiella pneumoniae, Salmonella typhimurium and E-coli (if offered a precursor, cobinamide). Not arch enemies in a strict sense, as many of the colonic bacteria indeed reside happily in our colons coexisting in harmony with us and making loads of vitamin B12 (only to have us excrete it), but arch enemies in the sense that if given the opportunity, in a weakened host, will kill us.

Is this beginning to seem like a good bacteria/bad bacteria story? If they coexist in our colons, performing innocent fermentation functions, living happy healthy lives, but have the capacity to cause disease and death in their human hosts, all the while producing a molecule critical to our survival, what would you call that? That’s more than symbiosis, that’s co-dependence.

Absorption and Disposition of B12
When again considering the sources of B12 many would point to those sources as evidence of animal consumption for many millions of years. Although geophagy and coprophagy are possible sources of the vitamin, there’s minimal evidence of either from anthropological data. And while strict vegans might argue the point, that leaves meat eating as the only consistent source of B12 over the history of man.

The absorption of vitamin B12 from dietary sources requires a chorus of activities and proteins to effect the separation and transport through the intestinal wall and into vital tissues, organs and cells. After chewing a B12 containing food a molecule called Haptocorrin binds B12 to shuttle it through the upper stomach and small intestine to keep it safe from either acid damage or bacterial consumption. In the small intestine a protein call Intrinsic Factor (IF)—which is secreted by the stomach—binds B12 and shuttles it to a receptor in the ileum. From the receptor, the IF-B12 complex is absorbed by endocytosis and the B12 is transferred to another shuttle protein called transcobalamin-II. The transcobolomin-II B12 complex is taken to tissues and taken up by an as yet unknown mechanism into cells.

B12 body stores are adequate enough to last for 3-5 years without any intake before a deficiency state sets in. Those as greatest risk of a B12 deficiency are individuals with minimal animal food sources, such as vegans and strict vegetarians, and the elderly consuming a series of “tea and toast” style meals as well as those with missing IF or short guts due to surgery.

A deficiency of B12 leads to a host of problems the least of which is a severe anemia. The anemia can take two forms:

1. Pernicious Anemia: Lack of IF

2. Megaloblastic Anemia: Lack of dietary B12

Deficiency of B12 can lead to devastating and permanent central nervous system degeneration with ataxia, numbness and spinal cord degeneration.

Note: I'll be traveling for a week or so.