Monthly Archives: June 2012

Rheumatoid Arthritis and Obesity

Rheumatoid Arthritis and Obesity

Reference:  Crowson et at Arthritis Care

In the last 30 years rheumatoid arthritis has increased by 9 people per 100,000,  an increase from 21/100,000/year  to 30 cases/100,000/year now.   Three quarters of its victims are women, though men get it too.  To date, our treatments have not always been very effective at reversing it, just holding it off.  That increase wouldn’t be so remarkable if it wasn’t for the fact that obesity is now being attributed for 52% of that increase.

That’s what Crowson and her colleagues found at the Mayo Clinic when they followed some 830 folks with RA and compared them to an age matched demographic group.  It was reported Monday, June 25th on NPR and I had a question about it on my email before I even got to work.

The net effect of obesity on risk for RA seems to be that it raises your risk for RA about 25%.  That’s something on the same order of your risk of getting lung cancer is you smoke.  We make a fit about smoking because that link is pretty tight.  What about being overweight for our risk of RA, which is one of the nastier illnesses around?

And just how does this association work?  The author points out that clearly there are many background causes for RA.  Because women get it more than men, the thought was that estrogen had something to do with it.  But lots of women get better when they are pregnant, and HRT has not shown to make it worse.  But overweight men make more estrogen. Could that explain the male component?

Or is the underlying pathology really the damage caused by inflammation?  And where does the inflammation come from?  That’s the key I take away from this study.  Fat cells, (one more time) nor NOT little, passive, quiet, calorie storage devices.  They perversely turn into active endocrine glands.  They spew out inflammatory markers that set off inflammation all over your body.  You just have to biopsy fat tissue and look at it under the microscope.  (JCI from 2003)

Hence, it should make sense that as we American’s have packed on the pounds, we have gotten fatter and then developed more RA.  Crowson even offered up a patient who talked about how much better she felt when she lost 65 pounds and how her rheumatoid arthritis got better.

What else might be one of those multifactorial causes for RA?  Earlier this year I did a series on wheat and since that series, I’ve had three different clients of mine who had RA tell me they got better when they stopped eating wheat.  I measured the wheat antibodies in one of them and found it to be equivocal.  None of those three clients has overt celiac disease.  But I referred all of them to read the Scientific America article in 2009, August by Fasano.  That article suggests that the process by which wheat gets our gut upset and inflamed may have a lot of overlap with how we get autoimmune disease in general.  I have more than a handful of clients whose Hashimoto’s disease of their thyroid got better when they stopped eating wheat. What do we get fat from?  Eating wheat.  Is it the wheat, or the reaction in our gut?  Something is awry with our food supply.

WWW:  What will work for me?  Each week I’m eating a little less wheat.  Summer makes it easy.  The farmer’s market is magnificent.  Grill those veges, eat that salad, enjoy your summer.  Drop the wheat and the arthritis.

Am I Overweight? What does My Leptin Say?

Am I Overweight?  What does My Leptin Say?

Reference:  PLOS, April 2 Nirav Shah and Eric Braverman

The BMI, or body mass index, is the common method of telling us if we are overweight or normal weight.  Unfortunately, it ends up causing a lot of confusion because we haven’t been able to sort out the variables of muscle mass, fitness, body habitus and all that.  Lot’s of men, who are quite fit and have lots of muscle get registered as being obese.  Lots of women, who are not fit but look small, have lots of fat internally and very little muscle.  They register normal but are obese.  There is a better test.  The DEXA (dual xray absorptiometry) scan is a CT scan that measures your content of total body fat precisely.  Problem is: expense and radiation.

What’s the problem with fat?  We have always thought that fat was just a place to store all the extra calories we ate.  We assumed it was a quiet little neighborhood of huge, oversized water balloon shaped cells storing those calories.  Turns out that’s wrong.  When you have a normal body habitus, in other words, normal healthy fat content, you fat tissue is very interesting under the microscope.  The cells are smaller and you have some 10% of the tissue is composed of other cells.   Calories flow easily in and out in response to insulin, activity and blood glucose levels.  As we get bigger, our fat cells change in size, behavior and morph into very active endocrine glands.  They secrete lots of inflammatory hormones.  Those hormones beacon inflammatory cells to come hang out.   If you biopsy someone who is obese their fat tissue looks quite different than slender folks.   As many as 50% of the cells are now inflammatory cells instead of 10%.  That means fat tissue is basically a sack of pus.  (Oooooo!  Yuck!)

What did the study find?  “BMI characterized 26% of the subjects as obese, while DXA indicated that 64% of them were obese. 39% of the subjects were classified as non-obese by BMI, but were found to be obese by DXA. BMI misclassified 25% men and 48% women.”   Now, the BMI has been around for about 200 years and is a simple mathematical formula.  Your BMI is calculated as your weight in pounds divided by your height in inches squared, times 703.   Over 25 is overweight and over 30 is obese.   By DEXA scan the American Bariatric Society defines obese for women as being over 30% fat and for men 25% fat.

Now, what makes this study significant is that it also measured leptin.  Leptin is your feedback hormone from fat tissue that tells you to stop eating.  As we get pudgy, we get leptin insensitive.   We lose the feedback message to stop ingesting calories.  And leptin correlate strongly percent body fat, with disease and morbidity, whereas just plain BMI does not.  This study suggests that we need to know our percentage fat, but more importantly, our leptin levels.   Levels over 30 ng/mL correlated strongly with higher percentage body fat.  It’s leptin that gets you in trouble.   Leptin makes us put out C-reactive protein, and CRP starts the inflammatory cascade.

This is a huge step forward.   It’s not the scales so much as the percent of fat in your body that matters.  This is why being fit and overweight can be safer than unfit and skinny.  And leptin, or your sensitivity to it, may be one of the keys that unlock the connection and the mystery.

WWW.  What will work for me.  I step on the scales every day.  And groan.  But I’m also exercising every day.  I have a lovely body fat measuring machine at work that is 99% as accurate as a DEXA scan, without the radiation called an “InBody”.  My BMI is 26, so I’m a bit over the top. My percent body fat, by my “InBody” is 18.7%.  Normal percent is <20% for men.  Whew, that’s not so bad.  Maybe I’ll step on that everyday instead.  And then, when I’m brave, measure my leptin levels.

Written by John E Whitcomb, MD   Brookfield Longevity and Healthy Living Clinic, 262-784-5300  or

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Calcium and Heart Disease Risk

Calcium and Heart Disease Risk

Reference:  Rohrmann, Heart, May 23, 2012

Finally, we are beginning to debunk the calcium myth!  We have been so simplistic, it’s just painful to watch.  Our bones are white, calcium carbonate is white, ergo: calcium must be good for you.  If you eat it, it will work.  That has been the level of our logic when it comes to bone and calcium.  We have recommended for years that you take calcium to make your bones stronger.  And indeed, there is a tiny shred of evidence that it helps for bone strength.  But, women in most of the world consume as little as 25% of the calcium we consume in America and have denser bones with as few as 1/80th the number of fractured hips.  Our frantic consumption of calcium just leads us down the road of constipation and more broken hips.

But this study was about heart disease and calcium.  What Dr. Rohrmann found was that calcium in food may lower heart disease risk, calcium in supplement form made it worse.  Following 24,000 people for eleven years with 354 heart attacks, 260 strokes and 267 deaths from cardiovascular disease, this study was part of the huge EPIC (European Prospective Investigation into Cancer and Nutrition) study.  Folks who ate a moderate amount of calcium in their diet from natural food sources did better.  Moderate meant about 860 mg a day.  But folks who took a supplement of calcium had an 86% increase risk of heart attack.

What’s the truth to parse out of this study?   Before I get 100 panicked emails from readers who want to know what to do?  Bone health is all about vegetables.  The truth is that bones need much more than calcium, but vegetables are a great source of calcium.  In fact, when you compare 500 calories of animal products such as beef, pork, chicken and milk versus 500 calories of spinach, limas, potatoes, tomatoes and peas you get 252 mg in the animal products but 545 mg of calcium in the plants.  But the plants also give you 548 mg of magnesium versus 51 and on and on with virtually every nutrient needed for bones.  Plants contain more!  Vegetables give you all 17 critical nutrients needed for bone except B12.

Finally, vegetables don’t make you acidic.  Animals net acid load requires buffering capacity and your buffer is calcium bicarbonate from your bones.  We have now measured the net acid load from eating meat, eggs, milk and cheese.  For every gram of animal you eat, you lose 1 mg of calcium from your bones.  You can’t eat enough calcium to make up for what you lose by eating all that acid.  If you have a bathtub that’s running empty, you don’t bring in a second hose to refill it, you first plug up the drain.  What’s still not explained is how the Inuit have healthy bones……

WWW:  What will work for me.  If you want healthy strong bones, you eat spinach, peas, potatoes, tomatoes and less cheese, meat, milk.  And this study says, you shouldn’t take calcium supplements.  I suspect the folks who took the supplements had the best intentions.  Let’s stop the misguiding.  Popeye and Olive Oil had it right. When you stop your calcium supplement, reach for the frozen spinach instead.