Chromium
When talking about chromium we’re not talking about that stuff that gets applied to metals to make them shiny.
For more than 20 years I’ve been interested and intrigued by its role in metabolism. This month’s issue of Harvard Men’s Health Watch highlights some of the research indicating possible links between chromium deficiency and diabetes, high cholesterol, heart disease and weight management.
The journal is only available for subscribers, but let me summarize some of the data for you.
Chromium exists in many forms and not all are either absorbed or biologically active. Antacids, phytates found in grains and tannins found in tea may all lower the absorption of chromium.
A point that always comes up when we discuss supplements is that some people will feel that recommended daily allowances are too low and that using larger – sometimes vast – amounts will achieve additional biological effects. There is some evidence that very large amounts of chromium may damage cells in tissue culture but very little evidence for chromium toxicity in humans. People probably vary greatly in their tolerance to chromium.
- Diabetes: Chromium has attracted most interest because of its action on the binding of insulin to at least one of the insulin receptors. Insulin is more effective if chromium is present. Chromium also has a positive influence on one of the glucose transporters in cultured fat cells. The effects of chromium on glucose and insulin seems to vary in different species. So it is difficult to extrapolate from an animal study to humans. In people with both the major types of diabetes, the consensus seems to be that chromium supplements containing 200-1,000 mcg chromium as chromium picolinate a day have been found to improve blood glucose control. Chromium picolinate is the most efficacious form of chromium supplementation. There is a small pilot study that found that in women with polycystic ovarian syndrome, a low dosage of chromium picolinate improved glucose tolerance, but did not help with the hormonal or ovulatory disturbances. This has just been confirmed in a study using a higher dosage (1,000 mcg/day). Based on a detailed review of the literature, the United States Food and Drug Administration (FDA) has determined that chromium – at least chromium picolinate – does not reduce the risk that you might develop insulin resistance or diabetes and the American Diabetes Association agrees that the benefit of chromium supplements has not been conclusively demonstrated.
- Cholesterol: Chromium deficient rats develop high cholesterol levels. But the evidence that chromium supplementation helps cholesterol levels in humans is thin. Chromium may also help people with diabetes to lower their cholesterol levels. The published evidence indicates that any beneficial effects of chromium on cholesterol is much smaller than the effects of diet and exercise.
- Coronary artery disease: There is a study suggesting a correlation between chromium levels and the risk of having a heart attack, with lower levels being associated with higher heart attack risk. That does not, of course, necessarily mean that taking chromium supplements will reduce the risk of a heart attack.
- Weight management: Despite all the advertisements, chromium supplements have not been shown to be effective in producing sustained weight loss.
There remains a possibility that some other form of chromium may be more effective on some of these parameters. There has recently been some interest in a product called Diachrome, that contains chromium and biotin. There have been several very interesting presentations about it at international meetings, but we need to see if the results pass peer review and replication.
A diet containing plenty of whole grains, nuts, broccoli, and green beans, should provide you with enough chromium. Chances are that taking a supplement will not cause harm and may perhaps help if you are at high risk of diabetes. But the evidence is still controversial.
I know of several other studies that are underway, and I shall report them to you as they appear.
But for now, when it comes to buying supplements, this is another one of those times that I say, “Caveat emptor!“
Psychiatry Below the Neck
There is more and more evidence that schizophrenia and bipolar disorder and perhaps also major depressive disorder, are illnesses affecting the whole body and not just the brain and mind.
It has been known for over a century that some physical problems, including type 2 diabetes mellitus, obesity, cardiovascular diseases and some forms of cancer appear to be more common in people with major mental illnesses. All of this was known long before the current concerns about obesity, diabetes and some antipsychotic medicines. It is also clear that the physical problems cannot just be explained away by social deprivation and poor lifestyle choices.
The new understanding of mental illness as a systemic problem, opens up some extraordinary opportunities for treatment and perhaps even for prevention. In some new research due to be published next month, investigators have identified some abnormal proteins in the liver and on red blood cells that are similar to some abnormal proteins already identified in the brain.
These proteins are primarily involved in energy metabolism in cells and in protection against oxidative stress. The implication from this is that schizophrenia and many of the associated health problems may be a consequence of impaired energy metabolism together with damage by free radicals.
You will see why this is so exciting: it looks as if we have an entirely new way of approaching, treating and perhaps preventing the most serious of mental illnesses.
Another Nail in the Coffin of BMI
In August I outlined some of our reasons for believing that the most common measure of overweight and obesity – the body mass index (BMI) – can be very misleading and should probably be abandoned, or at least consigned to the back burner.
A team at the Hammersmith Hospital in London led by Professor Jimmy Bell has been using a novel type of MRI scan to locate the distribution of fat in the body. The problem is that 40% of the population has “bad” fat around some of their internal organs including the heart, liver or pancreas, even though many appear thin. So even though they may look slim, they may still be at risk of conditions like insulin resistance, diabetes and hypertension because of this hidden fat.
As we have said before, from a health perspective, it is the distribution of fat that is all important, rather than just the amount of it. This study confirms what metabolic physicians have been saying for years: BMI gives you the wrong idea about how much fat you have.
Once you know about the distribution of your fat, we can design precise lifestyle changes to work on it. As an example, the strategies that we use for overall weight management are not the same as the strategies that we use for reducing intra-abdominal fat. There are very good physiological reasons why diet does little to reduce the fat around organs. It is there to provide fuel during exercise, so specific exercises are the way to rid yourself of this internal fat.
At the moment there are very few centers that can do this kind of scanning, but with the growing evidence of its importance, that is likely to change. In the meantime, be aware that aerobic exercise and strength training, particularly if it involves the large muscles of the back trunk and lower limbs is the quickest way to rid yourself of these dangerous fat deposits.
Fat in itself is essential for normal health, but fat in the wrong places can be a killer. And BMI tells you nothing about the fat lurking in the hidden parts of your anatomy.
Carpal Tunnel Syndrome and Diabetes
Carpal tunnel syndrome is a relatively common neurological problem in which the median nerve is compressed in the wrist.
The classical symptoms are:
- Tingling, numbness or burning in the fingers or hand, especially thumb, index, middle or ring fingers, but not your little finger. It is most typically present on waking, but can occur after using the hands. Some people “shake out” their hands to relieve their symptoms.
- Pain radiating or extending from the wrist up the arm to the shoulder or down into you’re the palm or fingers, especially after forceful or repetitive use.
- A sense of weakness in the hands and sometimes a tendency to drop things
- Numbness, especially in the tips of the thumb, index, middle and ring fingers.
- Eventually the small muscles that control the thumb, index and middle fingers can weaken and atrophy.
In many people there is not obvious cause, although it is more common in women approaching menopause, and these days it can be one of the problems associated with using a computer mouse of keyboard for long periods. Every student of health care learns that there is a great long list of causes including:
- Pregnancy
- Rheumatoid arthritis
- Trauma
- Hypothyroidism
- Diabetes
- Amyloidosis
- Acromegaly
- Myeloma
- Tumors
Although I was taught about carpal tunnel syndrome not just as a cause but also as a predictor of diabetes more than 30 years ago, it has been forgotten by some non-specialists.
There is some new research from King’s College in London that has suggested that carpal tunnel syndrome may be a harbinger of diabetes.
As many as 20% of people with diabetes have a compression neuropathy such as carpal tunnel syndrome, and in people with limited joint mobility – a complication of diabetes – the incidence may be as high as 75%. The new research indicates that carpal tunnel syndrome may precede the diagnosis of diabetes by up to 10 years. The work was based on an analysis of 2,655 people who were diagnosed with type 2 diabetes in 2003-2004. The researchers excluded people with other known risk factors for carpal tunnel syndrome. The relative risk for subsequently developing diabetes was 1.63.
This research shows once again that diabetes can sometimes make its presence felt years before it has been formally diagnosed. A study published in 2003 found that 56% of people with peripheral neuropathy of unknown cause actually had abnormal glucose tolerance tests.
Earlier this year, researchers form the Netherlands did a retrospective review of 516 people with carpal tunnel syndrome, and found only two people with diabetes. They therefore recommended that routine screening for diabetes was not worthwhile in otherwise typical carpal tunnel syndrome.
I disagree with them.
I think that it would be wise to screen people with carpal tunnel syndrome for any disturbances of glucose metabolism, including insulin resistance, and if they are at a particularly high risk of developing diabetes, it would be worth going ahead and doing a glucose tolerance test. We don’t often do them these days, but this would be one of those times.
Consequences
We have a new little kitten and this morning, despite trying to keep her in the house, she scooted outside and then ran into the local feline bully. The poor little creature came in with a nasty scratch on her ear, and perhaps the understanding that the world can sometimes be a scary place. We had tried to advise and guide her, put sadly she had to learn for herself that there can be unpleasant consequences from running outside.
Similary we all want the best for our children and the people around us, but sometimes we can do them harm if we don’t help them understand the consequences of their actions.
We teach children how to cross the road, and later on, how safely to drive a car and deal with dangerous or exploitative people. We can’t live their lives for them, but we can try to help them understand the consequences of their actions.
Sometimes this important gift fails to materialize when a child or other loved one is struggling with a chronic illness.
Let me explain.
During my clinical career I dealt with two groups of clinical problems in which the biggest difficulty was not diagnosis, but helping people to stay on the treatment that they needed. The two problems were diabetes and psychiatric illnesses. By treatment, I certainly don’t just mean taking medicines: I mean being able and willing to follow a course of action.
There are dozens of reasons why people decide against taking the treatment that they need, whether it’s surgery, medication, psychotherapy or homeopathic remedies.
- Some people don’t see the point of treatment: they are happy as they are even if the illness is causing unseen damage
- Others just forget their treatment
- Others don’t like the side effects, or they are frightened that they may get side effects
- People worry about stigma and about being seen as somehow different
- There are even a few who like being ill: not just the experience of, say, having lots of extra energy, but being cared for and looked after. I have known people who have spent 40+ years in bed, sometimes with quite minor problems.
- Some just deny that they are ill: The extent of the denial can be amazing.
I saw an article on the BBC this morning about a young woman who believes that she went blind from the complications of diabetes because she “rebelled” as a teenager and was probably in denial.
It reminded me of a young woman whom I was once treating. Her metabolic control was becoming worse and worse. She was getting blurred vision and she was rapidly gaining weight. Her mother became extremely indignant when I asked – very, very gently – if the young woman might be pregnant. The patient and her mother vehemently denied the possibility. Less than a month later – on Christmas Eve – I had to arrange for the teenager to have emergency laser therapy on her eyes for severe diabetic retinopathy. Four weeks later she gave birth to a healthy, but very large baby girl. Both mother and daughter were in denial until the very end, and mother did not want to help the daughter face the consequences of failing to treat her diabetes or the pregnancy.
I’d like to give you two other examples of failing to face consequences.
In the first, a family saw me on television and asked me to see their son. He had a major neurological illness, did not want to take medicine, and It turned out that he had already seen some of my colleagues in my department. The parents wanted me to force him into taking medicine.
The second involved someone with attention deficit disorder (ADD) who could not remember to take her treatment or to follow through with any of the therapies that we recommended. Her parents wanted us to treat her. After a while it became impossible, because she had no interest in being treated.
But here is the point. The young man with the neurological illness had something progressive. He could not yet be declared legally incompetent, but he could not see that without treatment he would become very sick. The young woman with ADD also had a potentially progressive illness and was on a slippery slope. Not that the ADD was becoming worse, but because the behavioral consequences of the illness were leading her into more and more risky behaviors.
In each case the parents wanted doctors and other therapists to “Do something.” Yet in each case the parents were probably the only people who could help their kids.
What do I mean by that? Some parents enable their children to avoid the consequences of refusing treatment. I asked the young man’s family what they did if he refused his medications? The answer was that they yelled at him. Yelling helps nobody. But they were aghast when I suggested that his treatment should be linked to having “privileges” at home.
If he truly genuinely needs help, and he can’t see it, sometimes the best way forward is for the person to have to face some consequences.
Whether or not he took his treatment, he might get yelled at, but after that he could go to his wing of the house, watch TV, play on his computer and order food. No
consequences. I suggested linking TV watching to participation in
treatment. The family would not countenance it. They wanted to displace
all the responsibility onto other people who should tell him what to
do. Yet they had unwittingly sabotaged every attempt at treatment in several
countries.
Treatment is a matter of discussion and agreement. And yes, of course, mentally competent people have a right to turn down treatment. But if they cannot see the consequences of their folly, then family and friends may be the only people with the leverage to help them.
Every one of us has wants and needs. If someone is stuck, then those wants and needs can help us to help them. This isn’t a matter of being coercive: it is sheer practicality.
The young man with the neurological problem saw no need for treatment because his every wish was being fulfilled: he even had servants waiting upon him. The young woman with ADD was probably not safe to be driving around in a car, yet her parents gave her one and paid for the gas and insurance anyway. They did not link treatment with providing all those things. So she saw no need to be treated.
Nobody wants to mean to a person suffering from an illness, but sometimes we need to mobilize all the resources that we have to help a person. It is entirely a matter of being pragmatic. The person saying, “Force my son to take his medicine,” is obviously speaking out of frustration. No clinician can or should do such a thing. Confrontation will scuttle any chance of setting up a therapeutic alliance with someone.
We do have some techniques for helping people. One very promising approach that we have been using is called motivational interviewing, and there are others. But even those will have little value unless people can see the advantages of treatment and the consequences of not being treated.
The best way of staying motivated to do something like stop smoking or manage your weight is to combine the advantages of taking action with the disadvantages of staying where you are.
If you know someone who has a real problem and is refusing help, ask if there is anything that you can do help motivate them to face the consequences of what they are doing. It can sometimes be the kindest and most loving thing that you can do for someone.
Diabetes in Indigenous Peoples
The BBC is today carrying a story BBC NEWS | Health | Diabetes ‘threat’ to indigenous. about a report presented at a diabetes conference in Melbourne, Australia.
Those of us in the metabolic field have been acutely aware of the burgeoning problem of abdominal obesity and Type 2 (non-insulin dependent) diabetes in many of the indigenous peoples of Asia, the Pacific, Australia and the Americas, in part a consequence of Western diets and sedentary lifestyles: Diabetes was unknown in the Pacific before World War II.
The combination of genes for insulin resistance, that were valuable
during evolution, with extraordinary environmental changes is the
culprit.
There are up to eight million new cases of diabetes across the world each year and it is predicted that around 250 million people will be affected by 2050.
The main reason for being so worried about the diabetes is not the disturbance in glucose itself, but the complications of Type 2 diabetes that include an increased risk of heart disease, stroke, eye and kidney disease.
Some experts are predicting that the scourge of diabetes could wipe out some indigenous groups. On the other hand, urgent action now could quickly reverse the trend.
Medicine and the Transformation of Illness
Something important has been happening in the medical field over the last century. And like most important concepts, once I mention it, everyone says, “Oh, that’s obvious.” Yet I have seen little discussion of it except in an occasional book or speculative paper.
The concept is this: modern medicine has been transforming the nature of illness in far-reaching ways. There are many illnesses that once were fatal, and which have now been transformed into chronic problems. Yet most conventional health care providers are still wedded to the short-term resolution of symptoms.
Let me give you three examples:
- The first is diabetes mellitus. There are two main types, and at least ten subtypes. Type 1 diabetes is what used to be known as juvenile onset diabetes or insulin-dependent diabetes. It usually comes on in childhood or adolescence, is associated with severe damage to the beta cells in the pancreas that produce insulin. People with this problem usually become very sick very quickly and need insulin to keep them alive. Until 1922, when the first patient was treated with insulin derived from cows, the illness was usually fatal. Insulin transformed it into a chronic illness. People were kept alive, but now we saw the emergence of diabetic eye disease (cataracts and retinopathy), disease of the blood vessels supplying the limbs, heart and kidneys, kidney failure, infections and many other chronic problems. In 1935 Sir Harold Himsworth, the father of a friend of mine, identified a second type of diabetes. He published a classic paper on his discovery of insulin resistance in 1936. This is what is now known as Type 2 diabetes, and used to be called maturity onset diabetes. This is a more chronic illness, but carries many of the same complications. The point about these two types of diabetes is not just that they have disturbances of glucose and lipid metabolism. That on its own matters little. It is the long-term consequences of the elevated glucose and lipids that causes all the problems.
- The second is hypertension. Again, this often used to be a fatal illness. Until the invention of the sphygmomanometer most people did not know that they had high blood pressure, and most often would die of strokes. Hypertension is now also a chronic illness. The problem is not the blood pressure itself, but the long-term consequences of an elevated blood pressure. That is why most physicians are now trying to prevent the damage to the heart, eyes and kidneys, instead of just focusing on the blood pressure numbers themselves.
- The third is Lyme disease. This is a bacterial illness that is acquired by being bitten by a tick. It is said to be the fastest growing infectious disease in the United States, primarily because we are spending more time venturing into the wilderness, and the deer population – a major carrier of the tick – is increasing in most Eastern states. Lyme disease can make people very ill. We identify acute and chronic types. The acute can usually be treated if identified quickly and if the correct treatment is given. But sometimes identification can be very difficult, and inadequate or even inappropriate treatment may lead to the chronic form. We have even seen people who have been treated exactly as the experts say, but have still developed the chronic form of Lyme disease. The biggest problem with Lyme disease is that it is a great masquerader: it can look like so many other illnesses, from multiple sclerosis and rheumatoid arthritis to chronic fatigue syndrome and syphilis.
We could pick out other examples. I have mentioned some of the problems of thinking that attention deficit disorder is just a problem with getting good grades in school. When in reality the problem is that inadequately treated ADD is associated with a range of long-term problems that occur outside of school hours.
For many years now some practitioners have been warning about the long-term consequences of symptomatic treatment alone. One of the most eloquent critics of this way of treating people is the Greek homeopath and teacher George Vithoulkas. I like and respect George, but he takes a militant view, saying that conventional treatment simply suppresses illnesses, rather than treating them. His solution is to use homeopathy for everything. He is a genius and also a natural healer, so he can probably get away with that. Most of us cannot.
So the fundamental tenets of Integrated Medicine include medical treatment to deal with the acute problem, but a combination of approaches to prevent the problem from becoming chronic. Or if it has become chronic, then how to change its course over time.
As I’ve said before: Combinations are Key. Not randomly giving an antibiotic as well as a homepoathic remedy, but precisely tailoring the combination to the individual.
Shock Waves and Diabetes
A psychiatrist friend once called me to say that he knew that he had to change his job. He was in the second year of his Freudian training analysis, and as he was driving to work he experienced a severe pain in the back. He told me that it felt as if someone had put a knife in his back. This, he told me, was a psychosomatic reflection of the mean back stabbing environment in which he was working. “Tell me more about the pain,” I said. “Just like a knife,” he said, “it’s the most obvious example of my body telling me what’s going on here.” I suggested that he should come over for me to give him a physical check up, but he was having none of it.
The following day he passed a large kidney stone.
It’s important to listen to your body, and to try and understand its message. It’s also important to respect every aspect of your being: physical, psychological, social, subtle and spiritual. A physical pain may be telling you about something in your environment or it may just be telling you that there’s something wrong with your body. Sigmund Freud once famously remarked that “Sometimes a cigar is just a cigar.”
I was reminded of this story as I was reviewing a new report about an association between the use of sound waves – lithotripsy – to shatter kidney stones and the eventual development of diabetes. Approximately 10 percent of men and 5 percent of women under the age of 70 will experience a kidney stone.
Surgery for kidney stones used to be horribly traumatic. As a very young student and junior doctor I assisted in more than one operation to remove them. The invention of the lithotripter – a device that uses ultrasound to break up stones, so that they can be passed out of the body – was a big advance. Though the treatment itself is far from being painless, it is much better than major surgery, It is a shame to learn that the treatment is not as innocuous as we thought. This is important, because about 1 million people in the United States have had shock wave lithotripsy (SWL).
In a study published in the May issue of the Journal of Urology, researchers at the Mayo Clinic followed up on a group of 630 patients who had been treated with SWL in 1985. The Mayo was one of the first centers to use the technique, the hospital keeps wonderful records, and so it was one of the few places in the world where it was possible to follow people 19 years after treatment.
Almost 60 percent of the patients responded to a questionnaire and were matched to an equal number of patients whose kidney stones had been treated by some other method. Among the SWL group, 16.8 percent had developed diabetes, compared with 6.7 percent of the control group, and 36.4 percent had high blood pressure compared with 27.9 percent of the control group. According to the study, the development of hypertension was related to the treatment of stones in both kidneys, while the onset of diabetes bore a relationship to the number of shocks administered and the intensity of the treatment.
This makes sense: the kidneys are key controllers of blood pressure, and it has long been known that stones, inflammation, infection or vascular disease in the kidneys can cause elevated blood pressure. Perhaps the treatment scars the kidneys. And it is not surprising that sound waves powerful enough to shatter a stone might also cause damage to the tissues through which they are passing; which include the pancreas.
These findings will need to be replicated, particularly with newer model lithotripters. But even before that, I’m sure that the criteria for gets the treatment will be modified, and it will also be necessary to re-think how the treatment is done. As an example, instead of shooting one powerful burst of sound waves at the stone, it may be necessary to fire several low intensity burst from different directions that all crisscross in the vicinity of the stone.
For now, if you are one of the unlucky ones who gets a kidney stone, discuss this new research with your doctor before having lithotripsy. And if you have access to a good acupuncturist, naturopath or homeopath, ask them if they have had any success in treating kidney stones, and if “Yes,” whether they would be prepared to work with your physician to help you.
Laughter is The Best Medicine
“Time spent laughing is time spent with the gods.”
–Japanese Proverb
In the book and movie Anatomy of an Illness, Norman Cousins reported how he overcame a sever arthritic condition with a combination of huge doses of vitamin C, together with a positive mental attitude and hours of laughing at Marx Brothers movies. He wrote that, "I made the joyous discovery that ten minutes of genuine belly laughter had an anesthetic effect and would give me at least two hours of pain-free sleep. When the pain-killing effect of the laughter wore off, we would switch on the motion picture projector again and not infrequently, it would lead to another pain-free interval."
I’ve had a longstanding interest in the vascular endothelium, the single layer of cells that line blood vessels. Some very small blood vessels consist only of endothelial cells. These cells form the interface between the blood and the tissues, and they are involved in many disease processes. They are involved in diabetic vascular disease, arteriosclerosis, inflammation, many infections, and they play a role in the spread of tumors. There is some new evidence that laughter is good for you in more ways than one.
Investigators from University of Maryland School of Medicine found that watching a funny movie had a healthy effect on blood vessel function, allowing them to expand and contract more effectively in response to changes in blood flow. But watching a mentally stressful movie, like a war drama, may have the opposite effect, causing the vascular endothelial cells to narrow and restrict blood flow. On average, artery diameter increased by 22% during laughter and decreased by 35% during mental stress.
This work follows on from earlier research that showed an inverse association between sense of humor and coronary heart disease: people who laughed a lot seemed less likely to suffer form heart disease.
There is a very nice review article available online that confirms what is intuitively obvious humor and laughter may have a positive influence on health and on the outcome of many diseases.
There may be something to the old saying, "You don’t stop laughing because you grow old; You grow old because you stop laughing.”
