The Good Gut

Taking Control of Your Weight, Your Mood, and Your Long-Term Health

I have spent 30+ years in the practice of internal medicine attempting different strategies to change behavior when bad habits happen to good people.  Too often, lifestyle epiphanies occur after major shake-ups such as the diagnoses of diabetes or other serious conditions.  I particularly like the ‘bibliotherapy’ approach, and I’m always on the lookout for good self-help book recommendations to add to my short list of those that truly effect change.

I am pleased to report here that “The Good Gut” is just such a book, well-written in a way that makes it one of those notable non-fiction works that you’ll read cover to cover, not losing interest or comprehension somewhere between a paragraph’s start and finish (no flipping ahead to see how much longer this chapter!).  The Drs. Sonnenburg do not tediously repeat and overstate the standard health caveats to avoid sugar, lose weight, and exercise, but rather expand on their primary point, namely the importance, care, and feeding of our fellow life bacterial travelers. 

As a regular reader of the latest medical literature, much of the content herein was not news to me.  The presentation, however, in everyday layperson language, was personally compelling in ways that the New England Journal of Medicine is not.  A recent search on the NEJM web-site for ‘gut microbiota’ returned 28 articles, not one of which with a title so compelling as to change my diet for life.  Oh right, I’ve already done that, changing out breakfast foods long before the Sonnenburgs’ book and the rest of menu as a result of this read.

I will be recommending this book to my patients, and I also commend it to you.  This book will be released 4/21/15.

Kefir and breast cancer

(thanks to Dr. Jacob Schor once again for bringing yet another health topic to my attention; check out his web-site at denvernaturopathic.com to subscribe to his newsletter)

Human beings have a self-preservation mechanism in the gag reflex; when something unexpectedly unpleasant in taste or texture hits the mouth, the entire upper digestive system reacts quickly and violently to eject to the offender. The first time I learned about this survival mechanism, I had just taken a large mouthful of buttermilk with my childhood friend Jean's encouragement. She raved about how tasty it was when, in fact, it was vile. I laughed hard and gagged simultaneously, sending the buttermilk through my nose.

Decades later, I accepted a small jar of homemade kefir from my patient V who took a bottle of the worthy stuff to work every day along with a container of home-cooked stew. As she is absolutely one of the healthiest people I know and care for, I was eager to start a kefir habit of my own. But oh heavens, it's surprisingly tart and foul, worse than buttermilk, and I spit the stuff out. New research suggests, however, that it may be the latest and greatest chemopreventive agent against breast cancer. Maybe chocolate syrup can enhance the taste. Check this out:

Canadian nutritionists cultured human breast cells--both cancerous and not-- in the lab, then fed the little colonies extracts of kefir, yogurt, and plain old pasteurized milk in various concentrations and checked out who thrived and who died(1). Kefir depressed tumor cell growth in a dose dependent fashion--the more kefir present, the fewer the cells. A .63% kefir extract dose (now perhaps even I could handle that) decreased tumor cell numbers by 29% and the 2.5% formula felled those cancerous bad girls to 56% their pre-kefir numbers. The yogurt also suppressed tumor growth, but less vigorously than the kefir. And the milk stimulated both lines of breast cells--normal and malignant--at concentrations as low as .31%!

Do I want to wait for more info, more studies? I think not. I'm calling V tomorrow for her kefir recipe. After all, if I fully expect it to taste sour and slightly carbonated, I can overcome the urge to cough it out through my nose.
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(1) Chen, C et al. Kefir extracts suppress in vitro proliferation of estrogen-dependent human breast cancer cells but not normal mammary epithelial cells. J Med Food. 2007 Sep;10(3):416-22.

Waist circumference

It's the new vital sign. Waisted fat (i.e. fat socked beneath the abdominal musculature and carried front and center like an unfolding pregnancy) is known to be a potent marker and cause of both cardiovascular and diabetic risk. While the ideal dimensions of a healthy waistline are in dispute, thus far 40 inches/102 cm. for men and 35 inches/88 cm. for women are cited as goal.

How to measure a waistline is a hot topic. In fact, the International Chair on Cardiometabolic Risk, an organization headquartered in Quebec City, established a sub-committee to review the existing medical literature on the subject and establish a waist circumference protocol. Let it never be said that we doctors don't take our tasks very seriously.

The expert panel reached two conclusions: 1) "It didn't matter" where you measured distended abdomens with respect to predicting mortality from diabetes, cardiovascular disease, or all other causes. If the silhouette looked apple-ish (think Tweedles Dee and Dum), that defined the problem, and the bigger the gut, the worse the risk. 2) They decided to establish a protocol nevertheless to put an end to the "mass confusion" that existed on the subject so that both providers and patients could measure midriffs and follow weight loss progress.

They concluded for purposes of simplicity that the top of the iliac crest (aka pelvic or hip bone located on the side of the body at roughly, well, the waistline!) was a good anatomic marker easily found by physicians and the public alike. And in a bit of good news, spokesman and sub-panel chair Dr. Robert Ross assures us that the bathroom scale may not be the first reporter of success in weight loss programs, but rather that waist circumference may fall in a reassuring and healthful sort of way before the pounds start to drop off.

Lipotoxicity

It starts with ectopic lipid deposition. Don't you just hate that--looking for fat in all the wrong places...and finding it? But we're not talking thighs, waists, and back ends here, but rather heart, muscles, liver, and pancreas.

Researchers theorize that our overconsumption of lipid-rich foods results in oversecretion of insulin. As a result, our livers produce too much sterol response element binding protein 1c (you might know it as SREBP-1c) which results in that organ gearing up to take those extra calories and turn them into fat molecules called triglycerides. Great gobs of these calorie-dense triglycerides then float through the bloodstream on their way to some storage depot where they will sit waiting for the coming famine that never comes. It's merely annoying to wear the extra fat in rolls about your waist, but it's downright toxic to stow them in your heart, muscles, liver, and pancreas.

Ectopic fat, i.e. triglycerides stored in all the wrong places, results in a world of metabolic trouble with a capital T that rhymes with D that stands for diabetes. Once in muscle cells, the fatty acids cause the muscle tissue (our biggest bodily consumer of sugar) to resist the actions of insulin, thus preventing the uptake of sugar out of the bloodstream and into these cells.

Fat stowed in pancreatic cells further amplifies this metabolic mess by killing off the very cells that make insulin. When the human body goes one Big Mac over the line, therefore, we not only eat fat but our liver makes more fat, our muscles become insulin resistant, and our pancreas are rendered less able to make more insulin.

Too much fat in, too much fat made, too much fat stowed in the wrong places. The lipotoxic effects of overeating, the lipocentric theory of diabetes. Two lessons: 1) Don't ignore the high triglyceride levels on lab panels--they're a huge red flag that you're on the way to diabetes, and 2) Don't discount the enormous value of any weight loss, even a little, with respect to preventing and treating diabetes.

Lovaza

"And I'll need a script for Lovaza..."

Dang, one of those humbling moments. What on earth is Lovaza? Should I just ask or should I excuse myself for a moment on the pretext that I need a new prescription pad, then look it up quickly in the PDR? Well, by hook or by book, I found out what it was.

Lovaza is Omacor. Omacor, by any name, is a high potency omega-3 fatty acid supplement, but that particular name was entirely too similar to Amicar, a drug used to prevent or treat serious bleeding in hemophiliacs. Not that anyone would have trouble reading my writing, but if they should, that's a heckuva mistake to make.

I always ask my patients about the supplements they take during their annual exams. As a result, I know that most everyone is on to the fish oil fad instead of the previously top popular vites C & E. Research suggests that use of these oils can prevent sudden cardiac death(1), decrease risk of Alzheimer's disease(2), improve the mood(3), and lower triglycerides.

So why pay for fancy prescription strength Lovaza when you could do a 3 for 1 deal at Puritan.com(current sale price)? The two products have similar EPA and DHA content--one capsule of either the OTC or rx variety has roughly 1,000 mg of these worthy fatty acids which is the recommended dose for persons already diagnosed with coronary artery disease. Patients with elevated triglycerides (blood fats) should consider a daily dose of 4,000 mg.
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(1)Is it death or tuna casserole deficiency?
(2)Be the right sort of fat head
(3)Fishing for a good mood

What's a triglyceride?

Blood sugar is circulating glucose, and triglycerides are circulating fats. Both of these nutrients are on their way somewhere other than the bloodstream --sugar to the cells for ready energy, and triglycerides to storage sites on your hips and back end for the theoretical famine that never comes.

Elevated triglycerides indicate that you eat too much, you weigh too much, or you are becoming resistant to the effects of insulin. An elevated triglyceride level may indicate a future risk of diabetes. Not only are triglycerides a marker for trouble, they ARE trouble when present in the blood in elevated quantities. They are toxic to the beta-cells of the pancreas, so as one becomes resistant to insulin and triglyceride levels rise, these circulating fats kill off the insulin-producing cells of your pancreas in a vicious, diabetic circle. They are also toxic to heart muscle cells, and, when stored in the liver, can contribute to the development of liver disease especially when combined with alcohol.

Furthermore, exercise physiologists have found that triglycerides stored in muscle cells make it very hard to lose weight. Intense aerobic exercise is needed to use up these muscle fat stores before overall weight starts to fall. Elevated triglycerides also cause HDL-cholesterol levels to fall, a combination called atherogenic dyslipidemia which means an abnormal pattern of blood fats well-known to leave cholesterol plaque in your arteries.

Now calcium?

Gotta stay light on the feet these days when it comes to advice. Hormones? Depends. Zetia? Fuhgeddaboutit. Calcium? Maybe not... especially for the elderly.

New Zealand investigators asked 1,471 old ladies (average age 74) to take calcium citrate, 1000 mg/day, or not, and then checked out who suddenly pitched over dead (as in cardiac arrest), had a heart attack (MI), or suffered a stroke in the five years following. Their primary intention, actually, was to prove once again that calcium supplementation improves bone density, but they also theorized that it might improve cardiovascular health as well.

Wrong. In the final analysis, the old gals on calcium had double the risk of MI, 1.4 times the risk of stroke, but no increased risk of sudden death. When all these endpoints were combined, the cardiovascular risk from the recommended dose of calcium each day was increased 1 and 1/2 times over the unsupplemented group. Looked at another way, doctors would need to treat 50 old ladies with calcium to prevent one symptomatic fracture over 5 years, 44 to cause one MI, 56 to cause one stroke, and 29 to cause one cardiovascular event.

What are they saying about this one?

Dr Erin D Michos, Johns Hopkins University: This is a thought-provoking study, although not definitive, but further work should be done.

Judy O'Sullivan, British Heart Foundation: Anyone who has been advised by their doctor to take calcium supplements to protect their bones should not stop doing so in light of this study alone without medical advice.

Dr. Ian Reid, senior author on paper: What we think is happening is that the higher calcium intake—and particularly the bolus of calcium that supplementation provides—is somehow accelerating the laying down of calcium in the artery walls of the heart...The way I interpret this is that if you have preexisting heart disease—which probably most of our participants did, although they probably weren't aware of it—then the extra calcium appears to be bad. But if, on the other hand, you are 54 and you have nice clean arteries to your heart, then probably calcium is not going to cause you any major problems. That's my take on it. But I don't know if it can be proven.

What am I going to do? Just like most of my patients, I find calcium tablets big and gross. Sometimes I take them, sometimes I don't. I plan to keep up that strategy and advise my patients of the above information. If I was even older than I am, I think I'd leave my calcium tablets on the shelf and face up to yogurt, vitamin D, and exercise.

Got Cake?

Mauigirl commented on a previous post about weight loss in dementia about the possible correlation between lost pounds and diminished taste perception. Here's an item of interest:

Turkish researchers have discovered the reason why aging women might cut themselves a big piece for breakfast. Their study, published several years ago in the British Dental Journal, found that postmenopausal women had a significantly diminished ability to sense sweets rolling over their palates.

While the women demonstrated no altered sensitivity to salt, sour, or bitter tastes compared to an age-matched group of old guys, they were not near so moved by a gob of Turkish taffy crammed in their mouths as the gents were. Nearly half the female test subjects noted that they had changed their eating habits in favor of sweeter food.

If you are enjoying your a.m. pastry and coffee with nary a care for the consequences, the researchers warn, "The crucial issue to be aware of is that the possible changes due to menopause can lead to more serious health problems, although these changes may not be uncomfortable to the patient."

Weight loss and dementia

Women who develop dementia are much more likely than men to be involved in making meals, and, therefore, it is likely a loss of interest in food preparation and eating during the prodromal phase of the disease has an impact on their weight.
---David Knopman, MD Mayo Clinic

Calorie deprivation prolongs life. Skinny yeast cells, fruit flies, threadworms, monkeys, and women are more likely to become skinny old yeast cells, fruit flies, etc. The problem, however, with skinny old ladies is that they are more likely to be demented when old than their fleshier colleagues.

Mayo Clinic investigators reported in Neurology* that women who lost cognitive functioning lost significantly more weight in the decade prior to the dementia diagnosis than a control group of aging women who maintained brain function through the years. Interestingly, there was no such correlation for old guys getting goofy, suggesting that the problem was not so much eating well when presented with food as buying and preparing the food period.

Dr. Knopman notes that this obseravation is not useful for diagnosis as "the weight loss was so subtle and so small and nonspecific." So skinniness does not beget dementia, but rather the first glimmering of dementia (a loss of interest in usual activities such as food preparation) leads to weight loss.

Shoot, I lost interest in food preparation after number one child left home. I am completely enthusiastic, however, about food prepared by others.
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Knopman, D et al. Neurology. 2007;69:739-746.