Sex Hormones Are Not Just for Baby-Making

The preceding discussion notwithstanding, the ovary is more than just a storehouse for eggs. The bioidentical hormones that it produces ensure that our bodies will function properly throughout our lives, not just during our reproductive years.
I mentioned earlier that bioidentical hormones travel in the bloodstream to cells and tissues throughout the body, powerfully affecting our health. But once hormones reach their intended destinations, you may wonder, how do they actually exert their effects? Cells that depend on hormones to function properly have protein molecules called hormone receptors that act like tiny ignition starters. And the hormones, logically enough, act like tiny keys. When a hormone—say estrogen— encounters a cell that has a receptor for estrogen, it’s like when you put your key into your car’s ignition and turn it on to start the engine. When estrogen binds to and turns on the estrogen receptor, it stimulates the cell to produce a cascade of proteins that influence its behavior.
Estrogen receptors are found not only in the cells of reproductive organs, such as the uterus and breast, but also in the cells of the liver, digestive system, urinary tract, heart, blood vessels, bone, skin, and the brain.
The exact effect of estrogen depends on the type of cell that it encounters. For example, in the uterus and breast, estrogen’s main effect is to cause the cells that line the uterus and the milk ducts to grow and divide in preparation for pregnancy. In the liver, estrogen acts to control the production of cholesterol in ways that influence the buildup of harmful fatty deposits in the arteries. In the skeleton, estrogen preserves bone strength by helping to maintain the proper balance between bone buildup and bone breakdown. And in other parts of the body, estrogen appears to play a role in the regulation of body temperature, the ability to recall information from memory, and the elasticity of arteries and skin. This is only a partial list of estrogen’s effects.
When estrogen levels drop, the rate of bone loss accelerates rapidly. Indeed, the average woman loses 2 to 3 percent of bone mass a year for the first three years after menopause. As a result, osteoporosis is much more common in the decades after menopause. A woman’s risk of heart disease also increases sharply after menopause, but estrogen’s role in this process is still under study.
Two types of estrogen receptors—alpha and beta—have been identified. Scientists have known about the alpha receptor since the 1950s, but the beta receptor was identified only in 1996. In general, there are more alpha receptors in the reproductive organs (e.g., uterus and breast) and the liver, while beta receptors are more abundant in other tissues, such as bone and blood vessels. Estradiol appears to bind equally well to both types of receptors, while estrone binds preferentially to the alpha receptor and estriol to the beta receptor. We do not fully understand the role of the two types of estrogen receptors, their exact functions, or how they relate to the benefits and risks of our natural estrogen or the estrogen in traditional hormone therapies for menopause.
Nevertheless, recognition of differences in receptors has allowed pharmaceutical companies to manufacture a new class of medicines called selective estrogen receptor modulators (SERMs)—or, to use the more glamorous name, “designer hormones”—that act on one or the other of these receptors to selectively block or stimulate estrogen-like action in various tissues.
One of the first SERMs to be developed was tamoxifen. Known by its trade name Nolvadex and also available as a generic, tamoxifen is prescribed to treat breast cancer and prevent its recurrence in women with a history of the disease and to prevent its development in women at high risk. In the breast, tamoxifen acts as an antiestrogen by binding to the alpha receptor, thus preventing estrogen from accessing it. In other parts of the body, however, tamoxifen acts like estrogen. Another SERM, raloxifene, known by its trade name Evista, is approved for prevention of bone thinning in women after menopause and is being studied as a way to prevent breast cancer. In a recent “head-to-head” trial, raloxifene and tamoxifen provided similar protection against breast cancer but raloxifene had fewer risks. Both of theseSERMs increase hot flashes and the risk of blood clots, however. In the future, watch for additional developments with SERMs, which could eventually be designed to ease symptoms of menopause and protect bone and heart health without adding to the risk of breast cancer.
As with estrogen, receptors for progesterone also come in at least two forms. However, even less is known about their precise roles and functions, or how this information could be used to develop safer or more effective forms of hormone replacement therapy.
In addition to estrogen and progesterone, generally known as the female sex hormones, the ovaries, along with the adrenal glands, produce small amounts of male sex hormones known as androgens, including testosterone. Testosterone levels in women are only one-tenth as high as in men. Androgens are thought to work in concert with estrogen to maintain a woman’s sex drive, bone and muscle health, energy level, and psychological well-being. Indeed, androgen receptors are found in many of the same cells that have estrogen receptors.
Interestingly, a large proportion of the androgens produced by the ovary and adrenal gland are converted to estrogen by an enzyme called aromatase found in fat and muscle. (Other organs that contain aromatase include the brain, hair, skin, and bone marrow.) After menopause, this conversion actually represents the main source of estrogen in women. Because aromatase is found in fat cells, women who are overweight or obese tend to have higher levels of estrogen than thinner women.
At the same time, because muscle cells are also rich in aromatase, women with more muscle mass are more likely to have higher estrogen levels than their scrawnier counterparts. This is thought to be why heavier women, and women who keep their muscles active with physical activity, may be less likely to suffer from certain symptoms of menopause.
In recent years, medicines called aromatase inhibitors—anastrozole (Arimidex) and letrozole (Femara)—have been approved to treat women with early-stage breast cancer. These medicines work by blocking the aromatase enzyme, thus preventing the conversion of androgens to estrogen in fat, muscle, and other tissues. Together with tamoxifen, aromatase inhibitors form a powerful new arsenal to fight breast cancer. (Not all breast cancer cells have estrogen receptors, though. These medicines stifle the growth of breast cancer cells that have estrogen receptors but do not affect the growth of breast cancers that lack estrogen receptors.)

Several drugs and hormones have an effect on body weight.

Some hormones cause weight gain and others cause weight loss. Hormones that cause weight gain are of particular interest, because if researchers can study and understand how they work, they may be able to develop drugs that can interact with these hormones in a way that makes it easier for people to lose weight. Insulin is a hormone that helps turn glucose (the sugar found in food) into energy the body can use. High levels of insulin lead to weight gain, although the reason why is not fully understood. Drugs used to treat diabetes, such as insulin and medications that make the body produce more insulin, cause weight gain. Obese people often have higher levels of naturally occurring insulin than their leaner counterparts.
Female hormones, like progesterone and estrogen, are associated with weight gain. Obese women most commonly begin to gain weight after puberty, when their bodies begin to produce these hormones. Birth control pills contain estrogen and progesterone, and are associated with weight gain. Today, birth control pills cause less weight gain than in previous years because they contain lower levels of estrogen. Some women may gain more weight than usual during pregnancy, up to 110 pounds (50 kg), which may be related to differences in their hormone levels during pregnancy, as compared to other pregnant women. Women who gain excessive weight during pregnancy may never fully lose this weight. Changes in hormone levels also occur during menopause. These hormone changes lead to a change in fat distribution, including increased central obesity (fat around the midsection or waist). This fat distribution is associated with increased health risks, especially heart disease.
Thyroid hormones increase metabolism and cause weight loss. People with the disease hypothyroidism (underactivity of the thyroid gland) have a smaller amount of thyroid hormone. People with hypothyroidism are predisposed to weight gain.When these individuals are treated with a drug that contains thyroid hormones, they lose weight. Thyroid hormones are dangerous in very high levels and must be monitored closely when taken. An excess of thyroid hormones in the blood can lead to several health problems, including high blood pressure, nervousness, insomnia (trouble sleeping), menstrual cycle changes, heart palpitations (the feeling that the heart is pounding), and fever. Several hormones that may play a role in weight gain have recently been discovered. One of these is leptin, a newly discovered hormone produced in fatty tissue. Increased leptin decreases food intake and increases metabolism in rats and, according to some early studies, in humans as well. Other hormones released by the stomach—including neuropeptide Y, cholecystokinin (CCK), enterostatin, and polypeptide Y 3-36— tell the body it has consumed enough food and should stop eating. Another hormone, ghrelin, is produced by the
stomach. Ghrelin signals hunger and increases appetite.
Ghrelin concentrations increase in response to weight loss. This may make ghrelin partly responsible for people gaining weight back after a successful diet. Table 2.2 lists some of the hormones that influence body weight. Clearly, many hormones affect body weight. Some of these hormones are known, and some have not yet been discovered. By studying these hormones researchers can better understand what causes people to gain and lose weight. Eventually, researchers may be able to develop drugs that can change levels of these hormones in the body, thus giving people who are overweight or obese another weapon in the weight loss battle. Intensive study is required to identify the possible negative effects of increasing or decreasing the level of hormones in the body.

OTHER HORMONAL DISORDERS

Finally, we turn to the common endocrine glands that occasionally produce a disease. Many people are concerned about the function of the thyroid gland. This endocrine organ, located at the base of the neck just below the “Adam’s apple” (larynx) is an important regulator of the metabolism of the body. Its overactivity results in characteristic symptoms, such as a rapid pulse, bulging of the eyes, nervousness, tremor, and diarrhea.
Tumors of the thyroid gland, as well as the overproduction of the brain hormone stimulating the gland to produce excessive amounts of thyroid hormone may cause these problems. Blood tests are available to determine the level of thyroxine, the major hormone, as well as others circulating in the system.
Although stress may be a precipitating factor in the development of hyperthyroidism, a failure to respond to the recommended change in lifestyle with increased rest and physical exercise, should lead a person to seek medical counsel, as surgery is occasionally indicated.
Many more people are concerned about underactivity of the thyroid gland. This is often blamed for obesity but in reality is seldom the cause. A tendency to fluid retention, sluggishness, drying of the skin, constipation, and fluid retention should lead one to seek the appropriate blood tests and accurate diagnosis. The typical patient with advanced hypothyroidism, called myxedema, becomes very complacent, with subdued emotional responses and dull mental processes. This so-called “bovine placidity” is much less distressing to its possessor than to the patient’s associates.
Neurologic syndromes are occasionally mimicked by hypothyroidism. They normally clear rapidly with replacement therapy. Many different forms of thyroid medications are available, but should not be used unless a definite deficiency is diagnosed. In such case full hormone replacement becomes necessary, usually for life.

TRACE MINERALS

Many trace minerals are known to be essential to physiologic processes. It is not known in all cases that supplementation of these can cure specific diseases, but a few of the common sources are listed below. Zinc is widely distributed in foods, particularly breads, cereals, lentils, beans, and rice. This nutrient is essential to growth, as well as in repair and healing processes. Copper is abundant in raisins, whole grain cereals, dried legumes, and nuts. It also plays a role in blood production, tissue metabolism, bone development, and nerve function.
Cobalt is a component of vitamin B12 and comes from a variety of sources. Called hydroxycobalamin, vitamin B12 is a vital ingredient in blood cell formation as well as healthy nerve function. Deficiency of B12 produces the disorder pernicious anemia. Vitamin B12 is found in many animal products, such as milk, eggs, and cheese. It is absorbed in the small intestine (ileum), and requires a protein intrinsic factor for complete absorption. Intrinsic factor is found in the stomach. It is often deficient in people who have chronic gastritis or those who have had the major part of the stomach removed by surgery. Total vegetarians should be sure that their diet includes some vitamin B 12. Many breakfast cereals, soy milks, and meat substitutes are fortified with 12. It is available in tablet form. One microgram is sufficient for daily protection.
On the other hand, many vegans have gone for years without evidence of vitamin B12 deficiency. There is a urine test that can determine any presence of B12 deficiency. It is called urinary homocysteine and methylmalonic acid.
Both of these substances are metabolites of vitamin B12. Together with serum B12 measurements, these analyses are effective in screening vegetarians for any trace of B12 deficiency before problems appear. The anemia of vitamin B12 deficiency is macrocytic, meaning that the red blood cells are unusually large. More serious are the nerve and spinal cord disorders that develop. Neurologic signs include loss of position and vibration sensation, combined with sensations of numbness and tingling. Later, serious impairment of gait and bladder (sphincter) control are seen. Some of these symptoms may persist long after vitamin 12 is again replenished. Moreover, this neurologic damage may occur before any evidence of anemia, making diagnosis very difficult in early stages. Prevention is the watchword for vitamin B12 disorders.
Selenium, like vitamin E, protects against cellular damage and lowers the risk of cancer. Cereal grains are good sources of this mineral also. Manganese and magnesium affect a host of enzyme systems. They likewise come from whole grain cereals, as well as many vegetables. Nickel, silicon, fluorine, and many other minerals are also important to the body. Whole grain cereals are a major source of Chromium. It is also found in Brewer’s yeast. This mineral helps to improve glucose tolerance and is an important preventive against the development of diabetes.

VITAMIN DEFICIENCIES 2

Vitamin B6 deficiency is seen occasionally in individuals who eat very few plant foods. Seizures occur in babies fed formulas deficient in B6. This has especially been a problem when a relatively high kidney excretion develops during pregnancy, while a mother was given high dose supplements. A number of drugs interfere with vitamin B6 utilization, such as isoniazid, used in the treatment of tuberculosis. Eating a natural varied diet, it is not difficult to get plenty of pyridoxine. It is the vegetable source of vitamin B6. Scurvy is another vitamin deficiency with worldwide prevalence as well as a colorful history. This condition is caused by a deficiency of ascorbic acid, also called vitamin C. It was a common cause of mortality in sailors during the fifteenth and sixteenth centuries. James Lind, a British naval surgeon, developed a simple cure in 1747 by giving the sailors two oranges and one lemon every day. Their swollen gums, weakness, and bleeding tendencies responded dramatically, giving rise to the nickname, “Limeys.” In more recent times scurvy appears more commonly in alcoholics, food faddists, and the impoverished elderly living on a grossly unbalanced diet.
The principal manifestations of scurvy are hemorrhages in the skin, swollen and bleeding gums, aching muscles, fatigue, and emotional changes. These symptoms appear after two months of depletion. Appearing occasionally in children, scurvy produces tenderness and swelling in the legs. Extreme pain may be present. Finally, after the teeth erupt, swollen gums and bleeding develops. Skeletal changes show signs of growth retardation. In some cases of a vitamin-D deficiency syndrome, rickets, may co-exist.
A carefully taken feeding history is helpful for the diagnosis of infantile scurvy. After 46 months of age any infant fed solely with the bottle, using only boiled cow’s milk or a milk substitute, may develop this disease. Fresh orange juice or another dietary source of vitamin C is rapidly curative. Extremely high supplements of ascorbic acid are seldom necessary. They may produce an abnormal dependency, based on the development of increased excretion originating in the kidneys to compensate for this superabundance.
Large doses of vitamin C can also inactivate vitamin B12. That, at times, unfavorably affects reproduction. Vitamin A is primarily manufactured by the conversion of dietary betacarotene into the active form, retinol. One of the first symptoms of vitamin A deficiency is inability to see in reduced light (night blindness). A later change in the eye is the presence of dryness, xerophthalmia. The conjunctiva becomes opaque, the secretion of tears decreases, then a sticky secretion appears over the cornea, called the Bitot spot. This mark has the appearance of a flake of meringue. Further destruction of the cornea may occur, leading eventually to blindness.
In treating the acute disease, a supplement of vitamin A is recommended. The prevention of deficiency using a balanced diet containing green and yellow vegetables, fresh fruit, and vitamin-supplemented milk is entirely adequate. Green and yellow foods such as carrots, cantaloupe, squash, and dark green leafy vegetables are considered excellent sources for this vitamin.
A high intake of carotene appears in adults using carrot juice or a similar food concentrate excessively. Carotenemia may color the skin, but should not be confused with jaundice. It is considered harmless and will subside when the carotene intake is reduced. Hypervitaminosis A, on the other hand, can produce an acute toxicity. In infants, it presents as drowsiness, vomiting,
and other signs of increased intracranial pressure. Adults commonly develop a headache within hours after any injection of a toxic dose. Blurred vision, nausea, vomiting, or drowsiness may also develop. The skin peels and hair loss occurs. With chronic ingestion of high doses, liver changes resembling cirrhosis are seen. Psychiatric side effects manifest themselves, but prognosis is good when vitamin A ingestion ceases.
Vitamin E is the common name of a group of related fat-soluble vitamin, called tocopherols. They vary in their potency, with the alpha form being thought most active. A number of animals develop a Vitamin E deficiency syndrome, with deterioration in the muscle fibers, impaired reproduction, or anemia. Clinically, these insufficiencies are rare in adults. When the diet contains enough polyunsaturated fatty acids, plenty of dietary vitamin B is usually available. Unfortunately, optimistic expectations of many researchers have been disappointed in spite of the literature proclaiming the miracleworking powers of this vitamin. We do not know for certain whether vitamin B supplementation can favorably affect physical endurance, cardiac status, sexual potency, or longevity in individuals with normal blood levels of Vitamin B (tocopherols).
A number of vitamins affect the production of blood or its proper coagulation. Vitamin K is present in most edible vegetables, particularly the green leafy ones. A similar vitamin is also produced by intestinal bacteria. The gradual accumulation of vitamin K levels in a newborn baby explains easily why ancient recommendation for an eight-day circumcision was made to the Jews. Hemorrhagic disease of the newborn as well as in adults is prevented by proper blood levels of this vitamin. Vitamin B12, folic acid, and iron are also closely related to blood production and have been discussed in Chapter 4, dealing with the circulatory system.

VITAMIN DEFICIENCIES 1

Although definite diseases can be associated with the excess intake of certain vitamins, these are seldom seen on a large scale. Much more common are the deficiencies described below. Pellagra is a disease caused by the deficiency of niacin, one of the B vitamins. The name is derived from the rough skin characteristically seen crusting around the hands and neck. Painful burning of the mouth, shaking of the body, and less commonly, mental disturbances can result. Pellagra was common in the United States in the early 1900’s. A healthful diet was discovered to be curative. One of the essential amino acids, tryptophan, is converted into nicotinic acid, a counterpart of niacin. Deficiency of other nutrients sometimes complicates the disease. Individuals subsisting on a diet primarily of corn are predisposed to pellagra, since corn protein is low in tryptophan and most of the milling removes the vitamin.
Classically pellagra is characterized by the “three D’s” — diarrhea, dermatitis, and dementia. Certain earlier symptoms may develop, however, including loss of appetite, indigestion, weakness, burning in the mouth, and insomnia. Pellagra most commonly appears in the spring or early summer, when the dietary deficiencies of winter combines with renewed exposure to the sun seems to precipitate the outbreak. The skin problems begin to look much like a sunburn. Burning may be intense. Sun-exposed areas, such as the neck, arms, and hands are affected most commonly. Later the skin becomes brownish in color, then rough and scaly. Soreness of the mouth is typical, with inflammation of the tongue. Diarrhea may or may not be present. Mental disturbances usually begin with episodes of nervousness and tremor. Later there occurs confusion, depression, or even delirium.
Early replacement of the B-complex vitamin with high doses of niacinamide is recommended. This related substance does not cause unpleasant vascular flushing like nicotinic acid does. Most people can take them orally. As symptoms subside, all vitamins should all be obtained from a wellbalanced, varied diet of natural foods.
Thiamine Deficiency, called Beriberi, has been known to western medical science since the seventeenth century. Recognized first in the Orient, beriberi has been associated with a deficiency of thiamine. It commonly appears when the diet exclusively consists of polished rice. Cases are occasionally encountered in the United States, particularly in infants and in alcoholics. Three main types of this disease are identified. A chronic form called “dry beriberi” causes tenderness in the calf muscles and weakness in the legs. The acute form, “wet beriberi”, is characterized by cardiovascular changes, with edema, congestion of the lungs, and heart failure. In alcoholics, the brain damage may be irreversible. Beriberi in infants continues to be a health problem in the Far East, where a child may lose his voice, develop heart failure, or gastrointestinal changes with vomiting and constipation.
Adequate nutrition for the breast-feeding mother is particularly important for its prevention. The therapeutic response to Thiamine in infants and adults with beriberi involving the heart is dramatic. A rapid transition, however, should be made from vitamin supplementation to a diet containing adequate wheat germ, rice polishings, or whole grain cereals. This disease is entirely preventable, and reflects one of many conditions following the wake of the industrial revolution.
Riboflavin deficiency is still common in many developing countries. In the Unites States there appears to be a correlation between low income and riboflavin intake. Milk and certain vegetables are good sources of riboflavin. However, when the milk is exposed to direct sunlight a considerable amount of this vitamin is destroyed. Riboflavin is reduced when the food is treated
with alkali, such as we find in certain preservatives and the use of soda. Lack of riboflavin usually results in sores, developing at the corners of the mouth, inflammation of the tongue, and sore throat. Late findings affect the nerves, as well as the blood, with the development of anemia. Replacement of the vitamin rapidly reduces these changes.

MALNUTRITION

Although over-nutrition so characteristic of obesity could be considered a type of malnutrition, such diagnosis is usually reserved for the deficiency syndromes. In all parts of the world various deficiencies of vitamins, minerals, protein, or calories can be seen. Deficiencies are naturally more prevalent in countries where food supply is limited and poverty abounds. Careful analysis
of food intake and any form of intemperance—such as manifested in alcohol consumption, bizarre food practices, food faddism, or the abuse of drugs— are productive to evaluate these conditions. Repeated closely spaced pregnancies and psychological disturbances manifested by a change in food intake should be assessed. Chronic infection, anorexia, or diarrhea likewise may profoundly affect the nutrient balance.
Measurement of height and weight should never be omitted. These are the most commonly used measurements of growth in children and adolescents. Other body measurements include skin fold thickness, head circumference, and biochemical tests measuring blood levels of various nutrients, such as proteins, vitamins and minerals. At times, therapeutic trials of replacement nutrients play a role in the diagnosis of deficiencies. In general, however, nutrient stores must be depleted before low blood levels of any nutrients are found. Changes in the body chemistry and functional neurologic defects occur late in the course of a deficiency. Take a careful history for invaluable help in the initial phase of treatment. Then combine this with a high index of suspicion for various nutrient-related disorders. In spite of modern technology and transportation, there are still large areas in our world where famine is epidemic. In fact, the risk of mass starvation in many countries is all too real, and often associated with other diseases. Body changes during the starvation reflect physiologic attempts to adapt to undernutrition. Fat stores are utilized first in order to spare structural protein. Thus, body fat diminishes more rapidly than does muscle. Extensive losses occur later in other organs, especially the liver and intestines. Fortunately, the central nervous system and circulation maintain themselves, whatever the cost to less essential parts of the organism. The person during starvation also conserves calories by reducing his output of energy. Voluntary physical activity decreases, as does the metabolic rate. A semi-starved patient complains of feeling tired, irritable, and depressed. He may also show lack of ambition, and narrowing of interests, then develops muscle soreness and cramps. The hair begins to fall out, andcuts and wounds heal slowly. Cold temperatures are poorly tolerated.
Ultimately, the individual looks haggard, pale, and emaciated. At times swelling (edema), particularly of the eyelids and cheeks appear, masking the degree of weight loss. The pulse weakens and the eyes become dull, looking like unglazed porcelain. Without relief and too often alone, the hapless victim of starvation then dies on the street of some large city.
The rehabilitation diet for patients recovering from starvation must begin with small quantities of the simplest food, taken at frequent intervals. A natural diet is preferable to the use of “predigested” end products. Vitamin and protein supplementation are ordinarily unnecessary. General dietary allowances should be approximately 100% of those recommended on the basis of the patient’s “desirable” weight. Recovery from starvation, however, advances at a very slow pace. Weakness, fatigability and muscle aches, as well as depression, may persist for weeks to months. Recovery of strength and working capacity is slow. Eventually, recovery is sure, and a life has been saved.
Protein Calorie Malnutrition is another type of disorder seen in early childhood. One such syndrome, called kwashiorkor, appears most commonly between the ages of one and three years. This tragic disorder occurs frequently in Africa in children displaced from their mother’s breast by subsequent pregnancies. Conditioning factors, such as diarrhea, parasites, and skin rash may be seen. Edema is the principal sign. It is associated with low serum proteins. The child’s face may appear round and moon-like. The hair changes with lightening of color, straightening of curly hair, and stripes of lightened color that attest to oscillating levels of good and poor nutrition in the past.
The other major type of malnutrition is called nutritional marasmus. This compares with severe semi-starvation in adults. It most commonly affects infants during the first year of life. The most conspicuous features in marasmus are wasting of muscle and fat, with growth retardation. Affected infants appear prematurely old, and often suffer from vitamin deficiency. Both types of malnutrition respond to a careful feeding regimen of simple foods, given first at frequent intervals, containing both adequate protein and calories.

OBESITY 2

The dietary treatment of obesity constitutes our mainstay for successful therapy. It is crucial to maintain good nutritional balance with any diet chosen, especially limiting the calories sufficiently to lose weight. Crash diets should be discouraged, as a weight loss of 2-3 pounds weekly is quite
sufficient for most obese patients to regain their healthful profile without looking like a “dried prune.” I always emphasize the use of natural foods, such as fresh fruits, whole grain cereals, and vegetables. Modest limitations of salt intake helps prevent fluid retention. Avoid as much as possible all rich foods, such as gravies, sauces, salad dressings, and desserts containing much
sugar. Be sure to reduce fried foods, as fat contains 9 calories per gram compared with 4cal./gm, for most carbohydrates and proteins.
For individuals finding it difficult to maintain a low calorie diet continuously, a fast one day a week using limited amounts of clear liquids is encouraging. Some find it more satisfactory to restrict their food intake to two meals a day, usually with a hearty breakfast and lunch and little or no supper. I teach my patients that being hungry one-third of the time is better than being hungry all of the time. Thus, these people can accept a two-meala- day plan and profit thereby. It is not necessary, however, in most sensible reducing diets to be hungry in a physiologic sense at all. The use of natural foods in abundance will satisfy the appetite, particularly if a few olives or nuts are included for “satiety value.” Snacking should be eliminated. Some commonly used snacks may require a great amount of exercise to burn up the calories taken in this way. Exercise has also been endorsed as a method to increase caloric loss.
Although the stimulus to the circulation, as well as the balancing effect on the emotions are profound, a very minimal caloric effect is obtained with exercise, compared to the reduction in food intake. The metabolic rate, however, increases with exercise, sometimes lasting for hours. Obese subjects are prone to more sedentary patterns of behavior and often walk and work more slowly than their leaner counterparts. Motivational factors, goals, and an overall emphasis on physical fitness is important to achieve the very real benefits that exercise can make toward a weight reduction regimen. The use of appetite suppressants, amphetamines, hormones from the
thyroid gland and diuretics, are mentioned only to discourage their use. Their indulgence always upsets the balance of body chemistry and places a false emphasis upon “miracle drugs” rather than diet in treating the obese. More radical surgical procedures include the jejuno-ileal bypass (creating an unnatural shunt between two parts of the small intestines) and gastric stapling (where the stomach size is drastically reduced with a row of staples). Such measures should not even be considered unless a grave medical emergency exists. In such cases there are usually safer approaches, such as fasting or dental wiring. All of these do not reach the underlying cause,
namely dietary reeducation, emotional stabilization, and the promotion of overall physical fitness that are so essential to long-term success in weight control.
This more rational handling of obesity can be a challenging and rewarding discipline to both patients and health counselors. A person’s victory over appetite often proves the key to unlock many dimensions of fulfillment in emotional, as well as spiritual lines.

OBESITY 1

The single most prevalent metabolic disorder in countries where food supplies are abundant is obesity. A person is considered over weight if his weight exceeds the upper range of ideal weight for his body frame. He is considered obese if his weight exceeds by 15-20% his ideal weight. Obesity occurs when the caloric intake exceeds the energy requirement of the body for physical activity and growth, with resultant accumulation of fat. This excessive adipose tissue may be distributed generally over the body or may be localized. Hormones from the pituitary, thyroid, adrenal, and sex glands all play important roles in fat distribution.
For the most part, obesity is preventable. Unfortunately, however, the follow-through of treatment for prolonged periods is usually difficult. Relapse becomes extremely common.
The amount of body fat can be estimated from the measurement of skin fold thickness with calipers. Most commonly employed, however, are bathroom scales, and the commonly available tables for estimation of desirable weight with relative guidelines for determining obesity. Some
physiologists claim that certain persons are more efficient than others in their ability to digest, absorb, and utilize food. Although this theory is not completely substantiated it has been observed many times that some obese patients lose weight much easier than others, on a given caloric intake.
Direct study of fat cell size by biopsy and the subsequent measurement of the isolated calls permits calculation of the total number of fat cells in the body. The average non-obese adult has approximately 40 trillion fat cells. Individuals who develop obesity in the middle years of life develop larger fat cells. Those who develop obesity during their growing years increase fat cell numbers, as well as size. This potential of forming new fat cells, with excessive food intake during growth, enhances our emphasis on prevention in childhood. Most studies demonstrate weight loss in both types of obesity to be associated with reduction in cell size, but seldom are there actual loss of fat cells.
Psychological and cultural factors influence our tendency toward obesity. Certain persons may have abnormal appetites, using food as a substitute for satisfaction that ordinarily would be supplied in other ways. In this respect, these persons resemble somewhat the alcoholic, hence are often termed ‘foodaholics.”
Increased food intake may also result from depression or anxiety. The resulting obesity may increase a persons tendency toward isolation. Merely reducing food intake without understanding the underlying emotional problems is usually unsuccessful. Some cultural groups place great emphasis on food, developing habits of overeating at an early age. In fact, in some societies obesity is associated with success and even health. Education of individuals, families, and all ethnic groups in society is important to achieve proper understanding of fantastic health benefits obtained in weight reduction, also enabling the provision of emotional support during the transition.

WATER RETENTION

Adults who suddenly increase their body weight may have an increase in fatty (adipose) tissue, accumulation of fluid (edema) or both disorders. Weight gain in excess of two pounds per day usually implies excess fluid retention. It is easy to confirm this by comparing the body weight in the morning and then again in the evening. Weight gains of less than two pounds during one day usually will subside by the following morning. Fluid retention may disclose increased salt and water intake or decreased sodium and water secretion.
Checking weight changes from morning to evening often provides early evidence of disease. Dietary indiscretion, the use of diuretics, excessive intake of licorice root, or a cortisol-type drug preparation may also be responsible. A special type of fluid retention called cyclic edema occurs predominantly in women. This is characterized by periodic episodes of fluid retention, frequently accompanied by distention of the abdomen, Patients may weigh several pounds more in the evening than in the morning. Although there is some relation to the menstrual cycle, evidence suggests also that psychological and hormonal factors may be related. The treatment of cyclic edema includes restriction in salt intake, rest in the feet elevated (supine) position for several hours during the day, and the use of elastic stockings.

Careful medical work-up is sometimes indicated to evaluate underlying causes.

HYPOGLYCEMIA

Low blood sugar, usually called hypoglycemia, has many causes. The most common one relates to our fast-paced lifestyle. Excessive sugar intake, frequent snacking, and caffeine or cola beverages contribute to this frequent malady. When the blood glucose level falls rapidly, emergency “fight-orflight” stress responses take over. The individual feels weak, very hungry, and frequently becomes irrational. Emotional reactions to hypoglycemic episodes vary from agitated to angry, depressed to suicidal. Personalities change rapidly, but return to normal function with some form of food.
Rather than frequent feedings such as the “six meal a day” diet, I recommend the following regimen: First, begin the day with a wholesome, hearty breakfast. Some whole grain cereal, bread, nut butter, or fruit makes a great way to start the day. Avoid coffee and frequent snacks. They both aggravate any tendency to low blood sugar. Mealtimes should be at regular intervals, usually five or six hours apart. Stress factors can affect hypoglycemia. Exercise is a great way to reduce or relieve stress. Try for an hour or two of extra sleep at night. Or find a weekend for a refreshing minivacation.
Careful testing of your blood, including the five-hour Glucose Tolerance Test (GTT), may help your medical advisor to “fine-tune” your dietary and lifestyle regimen. Most individuals can overcome this metabolic imbalance, particularly the so-called reactive hypoglycemia. This type comes several hours after a meal or sugar-rich snack. It responds very well to the remedies mentioned above. Rarely, tumors of the pancreas may produce abnormal secretions of insulin. In such case the symptoms of hypoglycemia occur during a fast, often early in the morning. Removal of the tumor is necessary to cure this uncommon condition. Finally, diabetes mellitus may be associated with hypoglycemia. It occurs in the context of early diabetes, erroneously termed borderline. Overdoses of insulin will produce hypoglycemia. They occur during vigorous exercise or at night. Adjusting the insulin dosage along with dietary modification will level the blood glucose fluctuations in all but the most “brittle” diabetics.

DIABETES MELLITUS 2

This is associated first of all by the achieving and maintaining of an ideal body weight. Our third goal is the prevention or delay of the specific complications associated with diseases of the eye, kidney, and nerves. Finally, we try to stem the accelerating atherosclerosis to which the diabetic is particularly liable. Success in these therapies depends on how well the patient has been instructed and his conscientiousness in following directions. The avoidance of cigarette smoking, with regular daily exercise, the monitoring of the urine and blood sugar, cholesterol and triglycerides, blood pressure and body weight are all imperative. Basically, however, the treatment of diabetes revolves around an appropriate diet.
The dietary treatment must meet the basic nutritional requirements. These are usually the same as those of a nondiabetic patient and, of course, to be acceptable, taste, variety, economy, and other nutritional factors should be considered. The prevention of high blood sugar occurring after a meal is important to avoid aggravating the symptoms. On the other hand, if a person is taking insulin it is important to provide enough calories of the right type to prevent hypoglycemic reactions. Ideal body weight should be achieved as soon as possible. In order to delay the atherosclerotic complications, the diet should be low enough in fat and animal products to normalize the serum cholesterol and triglyceride levels.
The basic caloric requirement is dictated by age, ideal weight, physical activity, climate, and the patient’ s occupation. An approximate calculation can be obtained by multiplying the ideal weight in pounds by ten. Individuals who are less active or past middle age should reduce their calories somewhat. Meals should be regular, usually spaced 5-6 hours apart. They are ideally limited to two or three meals a day, the latter especially for those taking insulin. I recommend taking the greater number of calories at breakfast, in order to provide energy during the active part of the day. Suppers should be light, eaten several hours before going to bed.
Careful regulation of the insulin level can usually avoid the necessity of a bedtime snack. The fat content of the diet should definitely be reduced from the 40% eaten by the average American. Protein should also be reduced slightly. The remaining calories should be obtained from complex
carbohydrates. This can lower the insulin requirement dramatically, and in many maturity onset diabetics, make a need for the needle entirely unnecessary. Some dietary suggestions for diabetics, as used in my institution, are presented in the accompanying tables. Insulin therapy is usually necessary for diabetes of juvenile onset. Several types are available, having fast, intermediate, and long duration of action.
Most of the insulin used in the United States today contains 100 units per milliliter. This has helped considerably to standardize the syringes and simplify the self-administration of this hormone. Regular or crystalline insulin is the shortest acting and is usually used for emergencies. Its duration of action is 6 to 8 hours. Intermediate acting insulins, such as NPH or Lente have a peak effect in 8-12 hours and usually last for 24. The longer-acting insulins are seldom used. At times, a second small dose of intermediate insulin before bedtime is preferable to increasing the daily dose.
It is preferable to have a small amount of sugar spill in the urine during the day than achieve such rigid glucose control as to render the patient hungry all the time or prone to hypoglycemic reactions. Be sure to rotate the sites of injections and use sterile techniques in the administration of all insulin hormones. Although many diabetic patients develop antibodies to the insulin used, only a few, about 0.1% will develop insulin resistance. A regular exercise program helps, in combination with the low fat diet, to lower daily insulin requirement. Using the more convenient but less physiologic oral diabetic pills should be discouraged, because of numerous side effects, particularly an increased acceleration of vascular complications. Hope is definitely on the way for patients with diabetes, who will eat properly, exercise regularly, and keep their weight under control.

DIABETES MELLITUS 1

We now turn to the common problems of metabolism that can often be treated, controlled, or prevented in a home setting. Knowledge of sugar diabetes is important, because of its high prevalence. This disease has been recognized from antiquity. Both Greek and Chinese writings have mentioned it; and in the sixteenth century Paracelsus initiated the study of the chemistry of diabetic urine. The word mellitus, introduced by Thomas Willis one hundred years later, describes the sweetness of the diabetic urine, “as if imbued with honey.” This rapidly led to a dietary approach to this disease, until finally Langerhans, a medical student, in 1869 described the islets in the pancreas where the basic production of insulin occurs. Two Canadians, Banting and Best, finally prepared the extract from dog pancreas that was capable of reducing the elevated blood glucose level. A fascinating long history of discoveries marks the approaches to understanding and treating this common disorder.
It is estimated that there are about 200 million diabetics in the world and approximately 4.2 million in the United States. This disease is more frequent in older people. Hence, as the population grows and becomes older, diabetes will continue to increase. With treatment, the life expectancy of the diabetic is increasing, and since inheritance is an important factor, the more diabetics that have children, the greater will be the prevalence of this disease, Obesity is also on the rise and appears to precipitate diabetes among those predisposed to it.
Next to obesity and thyroid disorders, diabetes is the third most common problem in metabolism. Interrelated are the metabolic or hormone, and vascular or long-termed components of this disease. The latter consist of an accelerated arteriosclerosis that leads to premature aging and particularly affects the eyes and the kidneys. Gangrene of the foot, arteriosclerotic heart disease, blindness, and kidney failure (uremia) are the most frequent manifestations of the vascular syndrome. Statistically, the diabetic is faced, not only with a decreased life expectancy, but also with the eventual possibility of disabling complications.
The early detection of diabetes first involves a high index of suspicion. This disease is two and half times more frequent in relatives of known diabetics. Furthermore, 85% of diabetic patients were or are overweight. Four out of five diabetics are over 45 years of age. Mothers who deliver large babies have a high potential for the development of diabetes.The simplest screening test for this disorder is a urinalysis for sugar.
Measurement of the blood sugar (glucose) level in the fasting patient should also be encouraged as a screening tool. The five-hour Glucose Tolerance Test is less commonly performed for diabetes, but is usually used to diagnose and evaluate hypoglycemia. Pathologic changes occur with the passage of time in diabetes, and seem accelerated by failure to control this disease. The
islets of Langerhans in the pancreas typically deteriorate, resulting in the lack of insulin production. Atherosclerosis occurs earlier in a diabetic patient, often leading to coronary artery disease and stroke as the most frequent cause of death. These also occur from the lack of insulin production. The eyes show changes after 10 to 1 5 years of diabetes. Small retinal hemorrhages, dilated sacs in the weakened blood vessel (aneurysms), and waxy patches (exudates) develop.
Later a dangerous type of new blood vessel forms, then further hemorrhages and gradual or sudden loss of vision. Although marvelous advances in the diagnosis and treatment of these visual complications have been made, diabetic eye disease remains the second most frequent cause of blindness in the United States. Increased tendencies toward cataract formation also occur. In the kidney, characteristic damage to the filtering unit (glomerulus) progresses to destroy renal function. Infections of the kidney and urinary tract are common, and many patients go on to develop high blood pressure, serious loss of protein, and later kidney failure.
The symptoms of diabetes, as mentioned above, are multiple. Increased fatigability and weakness is common. The diagnosis is frequently suggested by history of increased thirst (polydipsia), increased urination (polyuria), and excessive hunger (polyphagia) in association with weight loss. Long standing disease is reflected in the pathologic changes mentioned above.
Two typical types of diabetes mellitus are seen. The juvenile onset type is characterized by a rapid onset, with instable diabetes, associated with loss of weight and strength, irritability, and the three “polys” mentioned above.
Insulin therapy is mandatory in this type of patient and long-term medical counseling is needed. The second type of diabetes is termed maturity onset. Frequently symptoms are minimal or absent at first. Weight loss or weight gain may be present. These may be increased tendency to urinary infections or Vaginitis. Blurred or decreased vision, anemia, loss of sensation, or other neurologic problems may send the patient to the physician. Since many patients are obese, the reduction of weight associated with a careful diet can bring a return of health to most people who will cooperate with simple health principles.
The treatment of diabetes involves several basic principles. Doctors aim to correct the underlying metabolic abnormalities and thereby reduce diabetic symptoms.

SYMPTOMS RELATED TO THE ENDOCRINE SYSTEM

We now present a few common symptoms and the possible relationships to specific endocrine diseases. Clinical experience is certainly important in interpreting these relationships. Nevertheless, the suspicion that there is something wrong is often the first step toward an accurate diagnosis.
Weakness and increased fatigability are without doubt the most frequent symptom of adults seeking medical diagnosis. In the majority, these complaints derive primarily from emotional or psychological disturbances. When hormone abnormalities are suspected, one should inquire first whether the symptoms have been accompanied by weight loss. If so, insufficiency of the adrenal gland, overactivity of the thyroid, and diabetes mellitus should be considered.
Adrenal insufficiency is usually accompanied by increased pigmentation, low blood pressure, and perhaps salt craving. Hyperthyroidism is suggested by goiter (enlargement of the thyroid gland), bulging eye changes, tremor, and heat intolerance. Sugar diabetes is usually accompanied by excessive urination and increased thirst. Without weight loss, but with symptoms of weakness and fatigability one could consider underactive thyroid, underactive pituitary gland, overactive parathyroid gland with high calcium levels, and hypersecretions of aldosterone, another hormone from the adrenal gland regulating the salt balance. The first of these are associated with hypoactive reflexes, intolerance to cold, dry skin. Hypopituitarism is suggested by delayed or absent menstrual cycle, impotence, decreased tolerance to cold, hypoglycemia, and low blood pressure. Hyperparathyroidism is usually associated with bone pain, kidney stones, and increased urination. Elevated aldosterone levels are accompanied by high blood pressure, muscle weakness, and signs of potassium depletion.
Menstrual irregularities are associated with four major hormone disturbances. Primary failure of the ovaries prior to a natural menopause is characterized by hot flushes, weight gain, emotional instability. Secondary ovarian failure, associated with reduced stimulating hormones from the
pituitary gland is often related to diseases in the thyroid or adrenal.
Underactive thyroid gland is often associated with excessive menstruation, as well as decreased flow. The final, but much more rare syndrome is seen in conjunction with adrenal gland dysfunction. The menstrual irregularities in this case are usually associated with increased muscle development, increased body hair (hirsutism) and other signs of masculinization. The use of birth control pills should always be investigated as a cause of menstrual irregularity.
Breast changes are also commonly associated with hormone disorders. Enlargement of the breast in males (gynecomastia) occurs normally at puberty and may persist through adolescence. Rarely, hormone-secreting tumors of the adrenal gland or testes may also produce these problems.
Several varieties of drugs may cause breast changes as well. Abnormal lactation (galactorrhea) is sometimes observed in-patients with tumors of the pituitary gland. A number of drugs, including some antihypertensive and tranquilizing preparations may also produce this problem. Hypertension may also be associated with hormone disorders, although it is more commonly related to stress, salt intake, and obesity. Cushing’s syndrome or adrenal gland excess can definitely cause high blood pressure and should be considered if unusual obesity, associated with a tendency to bruising, is present. An episodic hypertension is caused by secretion from the adrenal medullary tumor called pheochromocytoma. The picture of rapid heart rate, nervousness, sweating, although classic, is infrequent. Increased secretion of the parathyroid hormone or the adrenal hormone aldosterone can also cause hypertension, and should be excluded in complete diagnosis of the problem.
Obesity suggests the possibility of a hormone disturbance, but it is usually caused by habitually increased food intake or deep-seated emotional problems. Diabetes should definitely be investigated and excluded in the presence of obesity, particularly in adults. Thyroid disorders are commonly related and can be evaluated with simple blood measurements. One must also
consider the possibility of problems induced by hormone administration, as we see the frequent prescribing of cortisone preparations, thyroid or sex hormone in nonspecific therapies for varying symptoms. These so-called iatrogenic (physician caused) problems can often be improved by the discontinuance of the offending drug.

Your Hormones Doing If You Are sleeping

When you were young, your mother may have told you that you need to get enough sleep to grow strong and tall. She may have been right! Deep sleep triggers more release of growth hormone, which fuels growth in children and boosts muscle mass and the repair of cells and tissues in children and adults. Sleep’s effect on the release of sex hormones also encourages puberty and fertility. Consequently, women who work at night and tend to lack sleep are, therefore, more likely to have trouble conceiving or to miscarry.
Your mother also probably was right if she told you that getting a good night’s sleep on a regular basis would help keep you from getting sick and help you get better if you do get sick. During sleep, your body creates more cytokines—cellular hormones that help the immune system fight various infections. Lack of sleep can reduce the ability to fight off common infections. Research also reveals that a lack of sleep can reduce the body’s response to the flu vaccine. For example, sleep-deprived volunteers given the flu vaccine produced less than half as many flu antibodies as those who were well rested and given the same vaccine.
Although lack of exercise and other factors are important contributors, the current epidemic of diabetes and obesity appears to be related, at least in part, to chronically getting inadequate sleep. Evidence is growing that sleep is a powerful regulator of appetite, energy use, and weight control. During sleep, the body’s production of the appetite suppressor leptin increases, and the appetite stimulant grehlin decreases. Studies find that the less people sleep, the more likely they are to be overweight or obese and prefer eating foods that are higher in calories and carbohydrates. People who report an average total sleep time of 5 hours a night, for example, are much more likely to become obese compared to people who sleep 7–8 hours a night.
A number of hormones released during sleep also control the body’s use of energy. A distinct rise and fall of blood sugar levels during sleep appears to be linked to sleep stage. Not getting enough sleep overall or enough of each stage of sleep disrupts this pattern. One study found that, when healthy young men slept only 4 hours a night for 6 nights in a row, their insulin and blood sugar levels mimicked those seen in people who were developing diabetes. Another study found that women who slept less than 7 hours a night were more likely to develop diabetes over time than those who slept between 7 and 8 hours a night.