The Burden of Our Noblesse Oblige
Since we live in a food oasis, it should come as no surprise that since most people in the United States can eat like the old aristocracy that more and more members of our population are sporting bodies that resemble the ancient aristocracy. Yet, even in antiquity it was known that, while starvation should be avoided, obesity was not all good either. For some reason or another, the aristocrats of history were susceptible to certain diseases not seen in the poor. The classic example is gout.
Gout was formerly known as “the disease of kings” or “the rich man’s disease.” Gout is typified as a sudden attack of extreme pain, redness, and swelling of a joint with no known prior injury (though sometimes minor injuries, like stubbing a toe, can bring it on). Gout has always been associated with eating too much rich food. We now know, however, that gout is just one of a group of diseases that occur because of something called the “metabolic syndrome.” The metabolic syndrome is typically caused by consuming too much energy, leading to a series of physiological changes to prevent this energy from becoming toxic to the body. One of these changes is an increase in the production of a hormone called insulin and the formation of something called “insulin resistance”, whereby certain tissues in the body are not as receptive as they otherwise would be to insulin. Other changes include a general “pro-inflammatory” and “pro-growth” state that protects the body in the short term but, as one might imagine, is not great in the long term.
For those who do not deal with the consequences of the metabolic syndrome on a daily basis as I do in my office, take a moment and consider what might be some other long-term consequence of having too much of a growth hormone (insulin), too much resistance to that growth hormone (insulin resistance), a prolonged body-wide pro-inflammatory state from an increase in pro-inflammatory hormones, and toxic levels of blood glucose and other debris of an overwhelmed metabolism.
Any ideas? Here are a few. They will likely sound familiar:
Atherosclerosis is a hardening and occlusion of the arteries (the blood vessels that carry blood away from the heart). When extra energy is consumed, the body needs to put it somewhere. You eat food. It goes from your mouth, down you esophagus, to your stomach, and then to your intestines (first small, then large intestines). In your small intestines, food is broken down to its constituent molecules. These molecules then traverse through the walls of the intestines to the veins (the blood vessels that carry blood back to the heart) that are enmeshed within the intestinal walls. These food molecules then travel from these veins to the liver.
In order to store this extra energy, the liver attempts to help the body grow by creating its own cholesterol and triglycerides (fat) out of these building blocks and packaging them into protein/fat capsules that are not all that dense (because fat is not all that dense). These capsules are thus called very low density or just low density fat proteins. Fat proteins are also called “lipoproteins” as lipid is another name for fat. Thus, the most common name for these capsules are very low density lipoproteins and low density lipoproteins. The abbreviation for these are VLDL and LDL. Once their cargo is loaded, VLDL and LDL leave the liver and take their cargo throughout the body, so various growing tissues can use cholesterol and fat as building blocks. (Note, this is of course a simplification – one obvious oversimplification is that most particles start out as VLDL and become LDL later on as they transfer some of their low-density fat – but I digress).
As an aside, while cholesterol has a bad connotation, it is actually an essential molecule without which we would all be inanimate piles of goo. Cholesterol is what helps cells keep their outer membranes stable. This is especially the case with nerve cells (hence why cholesterol is essential for your brain). Cholesterol is also the chief substrate of many of our hormones, particularly vitamin D and the sex hormones, like testosterone and estrogen.
Anyway, with increased energy consumption, LDL tends to go up, for now hopefully obvious reasons. And since cholesterol is an important building block, it will naturally be deposited in areas of damage. We know that increased general inflammation is another part of the metabolic syndrome. This increased inflammation has a propensity to damage the inner lining of blood vessels, also called the “intima”. Fortunately, LDL travels in blood vessels and it is more than happy to attach to the damaged intima and deposit its cholesterol so that its worn out lining can be patched. However, just like what happens when you put too much putty on a leaky pipe, eventually the putty itself becomes a problem, clogging the pipe. A clogged artery because of too much LDL and cholesterol in the walls is atherosclerosis.
While much more is also going on in regards to atherosclerosis, this is the gist of it, at least in the beginning (for instance, I haven’t mentioned a thing about the role of LDL oxidation, LDL size, foam cells and macrophages, the potential role of lipopolysaccharide, LDL receptor abnormalities, nor of the process of atheromatous plaque rupture). Yet, all of these more complicated processes are nonetheless still part and parcel of the metabolic syndrome.
Hypertension is the (typically) pathological increase in blood pressure. Hypertension can occur because of a variety of factors related to the metabolic syndrome. One is from a general hardening of the arteries from atherosclerosis, as above. Harder, narrower pipes make the pressure of the fluid flowing through them go up, such as with all such things according to Bernoulli’s Principle. Another is specifically from hardening and narrowing of the arteries going to the kidneys (keeping enough blood from going to the kidneys and tricking them into thinking the body is short on blood, making them retain fluid and thus increase blood pressure).
Yet another, more subtle reason is that insulin and glucose together can directly lead to hypertension. Remember that increased energy intake typically causes increased insulin production in the pancreas. Insulin with glucose tells your kidneys to hold onto sodium. Water tends to go where the sodium goes (osmosis), so more insulin means more water and salt in the blood and hence more blood pressure.
The effect of insulin on sodium retention is really, really important for more than medical reasons. Like we will see later, nutrition, obesity, and the metabolic syndrome are rife with politics. Part of this politicking has to do with salt (sodium chloride or NaCl) intake. While the appropriate amount of salt intake varies from healthy individual to healthy individual, and some people for one reason or another cannot tolerate too much sodium, if your kidneys are working and you are also eating sufficient potassium (bananas, $0.59/pound), you should be able to eat salt to taste without ill effect.
Yet, there is a misconception among some scientists and physicians about how salt and the kidneys work.
Perhaps the misconception comes from how salt makes blood pressure go up in people with low blood pressure who are dehydrated. Salt intake helps water get absorbed from the intestines and can help somebody who is dehydrated with low blood pressure get hydrated with good blood pressure. Since salt helps people with low blood pressure get normal blood pressure, it was presumed that even more salt must cause good blood pressure to go to high of blood pressure.
But, this isn’t the case when your kidneys work. If your kidneys are not getting instructions otherwise, if you eat more salt you just pee out more salt.
This changes with too much insulin and blood glucose, however. Insulin, combined with having too much sugar in the blood, directly acts on the kidneys to cause them to hold onto sodium and increase the blood pressure. Thus, ultimately, salt is only the proximate problem. The ultimate problem is insulin resistance and elevated blood glucose. These are both caused by the metabolic syndrome.
This discrepancy between conventional wisdom, the reality of salt, and the politics behind it were nicely explained by Gary Taub’s article, “The (Political) Science of Salt” in 1998.
Besides salt regulation, another reason that the metabolic syndrome leads to hypertension is that it causes your body to always be in a “fight or flight” response (also known as increased “sympathetic tone”). One of the things typical of this sympathetic tone is that it causes many of the body’s blood vessels to constrict, increasing blood pressure. Just like putting your finger partway over the outlet of a hose (back to Bernoulli’s Principle). You might now be asking yourself: why does the body go to “fight or flight” in response to having too much energy and the metabolic syndrome? Well, the metabolic syndrome increases inflammation. And if you’re perpetually inflamed, your body’s going to naturally think it’s under attack. Just as you would experience a fight or flight response from your body’s automatic (in medical jargon, autonomic) nervous system if you found yourself attacked by a bear or judo champion (or worse, both simultaneously), so this molecular destruction elicits a similar phenomenon.
Technically, this is a misnomer, as what happens is an increase in the number of lipoprotein particles containing fat and cholesterol. Remember LDL from above?
The relationship between the metabolic syndrome, systemic inflammation, and obesity is a little trickier than at first blush. One thing to know is that too much energy floating around the blood (such as in the form of blood sugar or glucose) is toxic both in blood vessels and inside cells. The body needs to turn sugar into something else like fat or a type of starch called glycogen in order to mitigate this toxicity. The body can only hold a little bit of glycogen, thus most glucose gets turned into fat and stored. Dietary fat and protein can of course also get stored as fat. This fat gets built up both under the skin (aka subcutaneous fat) and around the organs (aka visceral fat).
While everyone is obsessed about the subcutaneous fat, since that’s what you see the easiest in the mirror, it’s this visceral fat, or visceral adipose tissue (VAT), that is the real problem. We now know that this VAT does not just sit there doing nothing but storing energy. Rather, it acts as a potent hormone-producing endocrine organ. And the hormones that it elucidates are very pro-inflammatory, such as the infamous interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha). These pro-inflammatory hormones, particularly TNF-alpha, are targeted in certain medications like infliximab and entanercept when dealing with autoimmune diseases such as rheumatoid arthritis and lupus.
The reason it is important to realize that it is the VAT that is frequently the biggest trouble maker is that someone can have plenty of VAT and not appear overweight (at least not in the Rubens sense). The slang term for this is “skinny-fat”. For those who are skinny-fat, your body has tricked you into thinking you are doing better than you are. Of course, if someone has increased subcutaneous fat or is Rubenesque, they are much more likely to have VAT too. But being skinny-fat is a major problem for those who eat like kings, are superficially lean, and think they are getting away with something.
Diabetes mellitus literally means “sweet urine.” Back before urine dip sticks, doctors tasted the urine of their patients. If someone had a problem putting the sugar they ate into their cells, their blood sugar would go up to the point that the kidneys couldn’t keep it all in the body. It would thus leak through the kidneys and make urine sweet. Because physicians, especially those prior to the twenty-first century, had a really hard time naming anything in English, instead of calling this disease simply “sweet urine disease”, they had to call it “diabetes mellitus”.
This brings up a theory I’ve long since had: I’ve always wondered if tasting too much urine gives one a penchant for ancient Latin and Greek. Whichever the case, I’m glad for dipsticks and that most medical nomenclature is moving towards the vulgate (see what I did there?).
Anyway, before the obesity epidemic, the most common type of diabetes was found in children. This was called “insulin dependent diabetes mellitus” or IDDM or diabetes mellitus type 1 (DMt1) because their bodies stopped making insulin. This usually occurred when a virus or some other cause destroyed the parts of the pancreas that make the hormone insulin.
Recall from above that insulin tells cells to take sugar out of the blood and use it for energy or storage. More recently, as food has become ever more available (especially the high sugar, high rendered fat, high refined flour food of kings and queens), the “problem” is not coming from the pancreas, but from the tissues that insulin has to work on.
As stated earlier, free glucose is toxic. It is toxic both in blood vessels as well as in cells. Yet with too much blood sugar or blood glucose there is a dilemma. While insulin is trying to get glucose into cells so as to protect blood vessels, the cells don’t want it. The cells are trying to protect themselves. Thus these cells (particularly muscle, fat, and liver cells) become “insulin resistant.” However, the pancreas doesn’t care about what’s going on in these cells. All it knows is that blood glucose is getting too high. So, it pumps out ever more insulin. What eventually happens is that no matter how much insulin the pancreas pumps out, it’s not enough to override the cells’ resistance. At this point, you have a ton of both insulin and glucose floating around in your blood and eventually glucose starts spilling out of your kidneys. When this happens, you have insulin resistant diabetes mellitus (IDDM) or diabetes mellitus type 2 (DMt2). If this happens for too long, eventually the parts of the pancreas responsible for insulin production burn out. When this occurs, the individual has both insulin resistant and insulin dependent diabetes mellitus.
Osteoarthritis is classically known as the “wear and tear” type of arthritis. This is to distinguish it from “rheumatoid arthritis”, or the type of arthritis that is from the body’s immune system attacking joint capsules. And certainly, wear and tear has a lot to do with many cases of osteoarthritis. Consider the almost invariable fate of the shoulder of a professional baseball pitcher or of the neck bones of a football offensive lineman or fighter pilot. In these individuals, they will likely get this wear and tear even if they don’t have a trace of the metabolic syndrome.
Yet osteoarthritis is skyrocketing in people who hardly ever or never played sports or participate in activities that lead to bad joint mechanics and overuse. Why is this? Well, it should come as no surprise that a body-wide state of inflammation will affect your bones and joints in addition to everything else. In fact, besides smoking, obesity is the strongest predictor of spine arthritis and pain. And wear and tear arthritis in general is now considered another manifestation of the metabolic syndrome. More about this can be found here.
Like everything, there is a strong genetic factor to things like Parkinson’s and Alzheimer’s Disease. However, it now appears that for many if not most people, the pro-inflammatory and pro-growth (without the necessary cleanup) attributes of the metabolic syndrome also can cause or contribute to these disorders. In fact, many now consider Alzheimer’s to be “diabetes type 3.”
Caveats and Summary
As with osteoarthritis, it is imperative to note that while the metabolic syndrome makes it more likely that someone will get one of these diseases, there are other reasons to get these diseases besides the metabolic syndrome. Huntington’s Disease is also neurodegenerative and is strongly based on genetics. Hypertension may be present in individuals who are very lean with little VAT. And there are many other diseases whose incidence goes way up with the metabolic syndrome but can be present without it as well. Take cancer. Cancer is a disease that is strongly associated with the metabolic syndrome (and inflammation in general – consider smoking and lung cancer). Yet, there are many instances of cancer that likely have little to do with the metabolic syndrome. All eukaryotic organisms get cancer. Tapeworms get cancer. Trees get cancer (though not metastatic, since they have no real vasculature (phloem and xylem don’t count). I have (almost) always been lean and I know from my own scans that I have very little VAT, yet I’ve had cancer.
That said, the incidence and prevalence of diseases caused by the metabolic syndrome are skyrocketing. In the United States, this is costing us at least $350,000,000,000 (350 billion dollars) a year, while a true assessment of its cost is almost impossible to assess. To give you a sense of scale, the entire 2015 Medicare budget was 606 billion dollars.
But this is not new. The actions of the aristocracy have always cost society. In the past (and present), this cost was the forceful collection of taxes and enforcement of labor from the lower classes so as to maintain a certain lifestyle. Unfortunately, while the ability to eat like an aristocrat has been democratized and enhanced, this has also enhanced the costs. And these costs are both to the health of the individual as well as the society as a whole.
A concept that has been present throughout time has been that the nobility has not just power but responsibility. In France this was termed the “noblesse oblige”, or the obligations of the nobility. Unfortunately, when it comes to food, while we have democratized and enhanced the powers of the ancien regime, we have yet to appropriate or expand upon the responsibilities that come with them.
Thus it is imperative that we establish new obligations. And the chief obligation of our newfound powers is to not exercise these powers fully.
The great stoic philosopher Lucius Annaeus Seneca, writing in the time of Nero in the first century, said in a letter,
“…the bounds of nature, which set a limit to man’s wants by relieving them only where there is necessity for such relief, have been lost sight of; to want simply what is enough nowadays suggests to people primitiveness and squalor.”
For all of time humanity has fought against the ravages of famine and insufficiency. Now we fight to resist an overabundance of food and consumable energy. Yet to resist abundance is not in our nature. We possess a psychological and physiological desire for food. Particularly for food with combinations of fat, salt, and sugar. As we will discuss in Part Two, it is this physiological and psychological attraction, combined with advances in our ability to easily create food that exploits this attraction, that is the root cause of obesity and the metabolic syndrome.
In the meantime, while we have covered some of the basics regarding food abundance and how eating like nobility leads to the physiological burdens of nobility, it is important to delve into politics. For, while the economic and physiological details of the causes of obesity and the metabolic syndrome are intricate, they are nonetheless relatively straight forward. However, there is a trend for bad science, faulty methodologies, and political dogma to create a paradigm that obfuscates, confuses, and inverts this problem.
It is time to revert this inversion.