The Potbelly Syndrome: How Common Germs Cause Obesity, Diabetes, and Heart Disease

Introduction

In the late eighties my doctor predicted that I (Farris) would die from a heart attack within ten years. I took him seriously, so I joined the long lines of dieters trudging to and from salad bars. I went to the gym more often, went for walks during lunch breaks, and took the stairs instead of elevators—still I grew fatter. After roughly ten years of fretting about my blood pressure, weight, and cholesterol, I had the predicted heart attack. I survived, but it was pretty clear that rabbit food and exercise were not working for me.

I had spent most of my life solving problems for the U.S. Navy, so I tried to view heart disease as just another interesting problem to solve. I began by browsing through several websites maintained by the U.S. National Institutes of Health (NIH), taking notes, and printing the abstracts of journal articles. After a few weeks, I saw that several lines of research were converging on a new explanation for heart disease. The following are its main features:

• We all have mild, chronic infections caused by common germs.

• Some of these germs produce sores in our arteries, just as other germs produce sores on our skin. The sores in our arteries are sometimes called lesions, plaques, atheromas, or atherosclerosis.

• Most heart disease is caused by sores growing in the arteries that supply blood to the heart.

My heart attack was not caused by eating too much or exercising too little—it was caused by germs living in my arteries. No amount of exercise and rabbit food would have killed those germs; therefore, no amount of exercise and rabbit food would have prevented my heart attack.

I used this new information about germs to my benefit, as I will explain in Chapter 1, and then I began to study obesity. My doctor, like most skinny people, was sure that anyone with enough willpower could lose weight and keep it off. I was finding that harder and harder to believe. I had enough willpower to go to college at night, work forty years, and teach a martial art. I had tons of willpower, but I never seemed to have enough to lose weight. There had to be a better explanation for my obesity, and I found it after a few months of research:

• Infections stimulate the production of a stress hormone called cortisol.

• Cortisol steals glucose (blood sugar) from our muscles and liver to make more glucose available to the brain.

• The brain seldom uses all of the extra glucose, so some of it is converted to visceral (abdominal) fat. When this happens frequently, we develop potbellies.

Cortisol robs our muscles and livers of glucose by a mechanism called insulin resistance (Chapter 8). Most doctors believe that obesity causes insulin resistance, but there is a lot of evidence that insulin resistance causes obesity. People with insulin resistance must eat extra food to compensate for the glucose stolen from their muscles and liver. Part of this extra food is converted to fat and deposited around our waist. Some people with insulin resistance are not overweight yet, but most overweight people are insulin resistant.

Advanced insulin resistance is often called Syndrome X or dysmetabolic syndrome X, but potbelly syndrome (PBS) is a more descriptive term. Type 2 diabetes is a very severe, long-term form of insulin resistance, and it is the last and worst stage of PBS. People with PBS usually have heart disease as well, but PBS and heart disease are separate conditions.

The Potbelly Syndrome dispels several myths about blood pressure, cholesterol, and dieting. For example, it is a myth that we can force our weight down and keep it down by limiting the amount of food we eat. Research shows that only one person in twenty, and perhaps only one person in a hundred, ever loses weight and keeps it off while dieting. In the long run, diets make us fat. Worse yet, even thinking about diets may make us fat (Chapter 12).

This book was written to help you avoid heart disease and PBS. If it’s already too late to avoid these problems, this book can help you recover. The first few chapters explain how common germs cause heart disease and raise cortisol levels. Beginning with Chapter 6, the emphasis shifts toward cortisol-related illnesses: high blood pressure, obesity, and type 2 diabetes. Chronic subtle hypercortisolism is the technical term for potbelly syndrome, and Dr. Mårin explains how to diagnose this disorder in Chapter 16. The remaining chapters offer suggestions for dealing with PBS and heart disease. Most chapters offer lists of suggested readings, and references are listed at the end of every chapter. There is a glossary near the end of the book in case you are unfamiliar with some of the medical terms used here.

To recover from heart disease and PBS, you will need the help of doctors who understand both germs and cortisol. There aren’t many of these doctors yet, so you will have to help them a little for the next few years. At the end of each chapter is a reference list. We suggest that you give your doctors copies of any pertinent abstracts or articles mentioned in the reference lists. Most of the abstracts and many of the articles can be found on the Internet, but some are only available from medical libraries. Chapter 17 explains how to find scientific documents on the Internet.

Dr. Mårin and I hope that you will find this book both interesting and useful.

1

Germs and Potbellies

[The idea that germs cause chronic diseases] is so simple and so significant that one would think it would have been recognized by many and would be the starting point for any discussion of the causes ofdisease. Not yet.

—PAUL W. EWALD, PLAGUE TIME

When I (Farris) was twenty-two I worked at Cape Canaveral, and my work took me to South America and the Caribbean. On a trip to Brazil I became extremely ill, and while I was recovering I developed a large potbelly and several small, annoying health problems. I kept telling my doctors that I was infected with some rare tropical parasite, but they ignored me. After thirty-seven years of chronic illness, topped off by a heart attack, my health problems included:

• A huge potbelly that was still growing.

• Extremely high blood pressure.

• Migraine headaches, insomnia, fatigue, and depression.

• Feeling cold most of the time.

• Chronic sore throat, stuffy nose, and lung infections.

• Atrial fibrillations (rapid, erratic heartbeats).

• Irritable bowel syndrome.

• Chronic eye infections and deteriorating eyesight.

• Thin, dry skin with fungal infections, white scales, and dark blotches.

In February of 1999, I learned that I was infected with a bacterium that is now called Chlamydophila pneumoniae (CPN). CPN is not a rare tropical parasite; it is one of the most common germs on the planet. It affects some people more than others, and the older we get, the more likely we are to become infected with it.

I was given an antibiotic called clarithromycin, and within two months all of the illnesses listed above vanished. My potbelly was melting away. My heart was as steady as a metronome and my blood pressure dropped forty points. I found myself taking deep breaths just for the pleasure of feeling the air move freely in and out of my lungs. My legs seemed to have motors in them, and I walked for miles as easily as the wind blows. I felt like I was twenty years old again.

If I had stayed well, there wouldn’t be any need for the rest of this book. You could jot clarithromycin on a scrap of paper and you would know everything you need to know about CPN and the diseases it causes. Unfortunately, I was back in the hospital with most of my old symptoms by July. CPN, it turned out, was not going to be so easy to get rid of.

Even though I was sick again, my outlook on life had improved one hundred percent between January and July. Feeling really good for the first time in decades, even if only for a few months, had shown me that a steady loss of health followed by an early death was not inevitable. One other thing became clear in those months—I could not depend on my HMO doctors to keep me well. If I was going to get well and stay that way, I would have to learn a lot more about my own health problems.

I had been haphazardly collecting materials for a book about CPN, but I didn’t get serious until I saw that the beneficial effects of clarithromycin were wearing off. After that, I spent hundreds of hours reading abstracts from the United States government’s PubMed database (www.ncbi.nih.gov/entrez/query.fcgi). If an abstract was particularly interesting, I would copy the entire article from the medical library on the San Diego campus of the University of California.

One day I stumbled onto an article about a chemical that made CPN grow faster in laboratory dishes. The chemical was hydrocortisone succinate, and it is a synthetic version of the stress hormone cortisol. Within a few hours of learning about hydrocortisone succinate and cortisol, I discovered that many of my health problems were identical to those of people with a cortisol related disease called Cushing’s syndrome.

CUSHING’S SYNDROME

In 1912, Harvey Cushing described one of his potbellied patients as follows:

She has become stout, her weight increasing from 112 pounds two years ago to 137 pounds at present. Other noteworthy symptoms have been insomnia, tinnitus, extreme dryness of the skin, frequent sore throat, shortness of breath, palpitation, purpuric outbreaks, marked constipation, sudden attacks of dizziness with falling, a definite growth of hair and mustache during the last few years with marked falling out of the hair of the scalp. She feels chilly and cold all of the time and suffers from insomnia rather than from drowsiness. Muscular weakness is extreme and there is much complaint of backache and epigastric pains.¹

This patient, Miss M.G., was only twenty-three years old. In addition to the disorders described above, she suffered from high blood pressure, headaches with nausea and vomiting, spontaneous nosebleeds, stunted growth, malformed bones, bleeding hemorrhoids, easy bruising, swelling of her feet, absence of menses, double vision, and bulging, painful eyes. Altogether, Miss M.G. had more than thirty separate disorders.

Miss. M.G.’s potbelly and all of her other ailments were caused by an excess of cortisol, a condition known as Cushing’s syndrome or hypercortisolism. Miss. M.G.’s case was extreme, but millions of people have milder forms of hypercortisolism.

POTBELLY FACTS AND HYPOTHESES

At this point, from my experience with clarithromycin and my study of Cushing’s syndrome, I knew three important facts about potbellies:

1. Potbellies are usually accompanied by some of the disorders Miss M.G. had.

2. Potbellies and potbelly-related disorders are often symptoms of hypercortisolism.

3. My potbelly shrank and my potbelly-related illnesses disappeared aftertaking a drug that killed bacteria.

From these facts, I developed three hypotheses:

1. Since I had many of the same disorders that Miss M.G. had, I might have hypercortisolism.

2. Since my cortisol-related problems disappeared after taking clarithromycin, it seemed likely that clarithromycin had somehow lowered my cortisol levels.

3. Since clarithromycin is best known for killing bacteria, maybe bacteria are able to raise cortisol levels.

My cortisol levels had not been measured yet, so there was no way to test my first and second hypotheses. My third hypothesis was confirmed by browsing through PubMed, where I learned that infections raise cortisol levels by initiating acute phase responses (Chapter 2). Acute phase responses (APRs) produce inflammatory substances to kill germs. Then they produce anti-inflammatory substances to protect us from the inflammatory ones. Cortisol is the most important anti-inflammatory substance.

Inflammatory substances and cortisol oppose each other, as shown in Figure 1.1, but together they manage to kill most germs and eliminate most inflammations. Some germs survive, however, producing mild inflammation and a small excess of cortisol for as long as we live. These are the germs that cause heart disease and potbelly syndrome.

Figure 1.1. Inflammatory Processes and Cortisol Oppose Each Other

All adults have multiple chronic infections. If our particular combination of infections shifts the pointer toward the left side of the scale, we will lose weight and have more of the illnesses associated with inflammation.

If our infections are such that the pointer moves over toward the right side of the scale, we will gain weight and have more of the illnesses associated with cortisol. Most of us have a mix of both inflammatory and cortisol-related disorders.

POTBELLY SYNDROME

When we are young and have only a few chronic infections, cortisol does an excellent job of canceling the effects of inflammation. We look and feel good. Unfortunately, we accumulate more infections and inflammation as we get older. Our cortisol rises, but it does a poorer and poorer job of canceling the effects of inflammation. At the same time, the side effects of cortisol become stronger. We start to feel our age.

The competing effects of inflammation and cortisol produce different results in everyone, but there are patterns of illness that recur in millions of people. One of these patterns is formed by the close association of abdominal obesity, high blood pressure, and high blood sugar. This pattern has had many names in recent years, including:

• Syndrome X

• Metabolic syndrome X

• Dysmetabolic syndrome X

All of the X syndromes are defined a little differently, and most researchers believe they are caused by poor diet or lack of exercise. Other researchers, who noticed that the X syndromes all resemble mild cases of Cushing’s syndrome, suspect that they are caused by cortisol. Eventually, the arguments of this latter group convinced me that the X syndromes are in fact caused by cortisol. Since none of the existing X syndromes included cortisol in their definitions, I defined a new one, dropped the X, and called it chronic subtle hypercortisolism. That’s an accurate term, but it is pretty awkward, so I call it potbelly syndrome or PBS for short. The main features of PBS are abdominal obesity, high blood pressure, and a small, long-term excess of cortisol. Type 2 diabetes is an extreme form of PBS. Dr. Mårin, who has studied cortisol and the X syndromes for many years, developed a more formal definition of chronic subtle hypercortisolism/PBS (Chapter 16).

Some of the same germs that cause PBS also cause heart disease. As shown in Figure 1.2, germs trigger acute phase responses that produce inflammation and cortisol. The inflammation causes heart disease, and the cortisol causes PBS. As you will see in later chapters, this theory fits the facts pretty well, and it explains why diet and exercise cannot prevent either obesity or heart disease.

Figure 1.2. overview of the potebelly syndrome

Most germs make us losed weight,but a few long-lasting germs unbalance our endocrine systems,lower our metabolic rate,and make us gain weigt.those are the germs of intterest in this book.

PBS AND HEART DISEASE ARE BOTH TREATABLE

My experience with clarithromycin was a little like finding the fountain of youth, then watching it go dry. Clarithromycin worked great, once, but the effects didn’t last long, and it had less effect each time I used it. The same thing happened with other antibiotics, and my health deteriorated to the point where I knew which doctors worked each shift in my HMO’s emergency room.

Many Kinds of Fat

Fat is stored in fat cells, and fat cells are grouped together in fat depots scattered around the body. Subcutaneous fat depots are located under the skin, where they provide insulation to protect us from cold. Subcutaneous fat is often called diffused fat.

Visceral fat depots are located around our viscera (internal organs). The viscera and the visceral fat are located in a sort of bag made from the abdominal muscles.

Abdominal fat is any fat between the chest and hips, and an excess of abdominal fat produces a potbelly. Visceral fat presses against the abdominal muscles and produces potbellies that are hard to the touch. Subcutaneous fat produces soft potbellies.

Researchers studying potbellies usually do not distinguish between visceral and subcutaneous obesity, so we will use the term abdominal obesity unless we are specifically referring to visceral or subcutaneous obesity.

Visceral fat accumulates in response to the hormone cortisol. The effect of cortisol on subcutaneous fat is not clearly established.

Between hospital visits, I worked on this book, and at some point I realized that I ought to focus on treatments more than causes if I wanted to be around to see the book in print. This insight prompted me to study ways to fight infections and reduce cortisol levels. What I learned has kept me pretty spry for several years, and some of it may help you. The best of the books I read are listed in the chapters where they will be of most interest, and the last four chapters are devoted to avoiding, or at least surviving, heart disease and potbellies.

SUMMARY

It’s easy to see, now, why $170 worth of clarithromycin had such an amazing effect on my health. By killing at least some of my germs, clarithromycin lowered my cortisol levels. My potbelly and my potbelly-related illnesses faded away as my cortisol levels dropped. Clarithromycin could not kill enough germs to completely cure me, so I had a relapse a few months later. When the germs came back, my cortisol levels rose again and all of my cortisol-related illnesses returned.

Chronic infections, hypercortisolism, and PBS can be defeated, and learning about them is the first step toward victory. The next chapter explains how germs raise cortisol levels.

RECOMMENDED READING

At the end of most chapters, I have listed books and websites with additional information about infections or PBS-related topics. I don’t agree with everything these books and websites say, but I think they are useful.

Microbe Hunters, by Paul de Kruif (Harvest Books, 2002).

This book is one of the all-time classics in medical literature. It begins with the first microbe hunter, Antoni van Leeuwenhoek, and it ends with Paul Ehrlich’s attempts to cure syphilis in the 1920s. For some unknown reason there was a copy of Microbe Hunters in our barn when I was a kid, and it was one of the first books I read.

New Guinea Tapeworms and Jewish Grandmothers, by Robert S. Desowitz (American Museum of Natural History, 1981).

Germs that make us fat won’t seem half as strange after you read Dr. Desowitz’s funny and fascinating book. In fact, I recommend reading all of his books.

Parasite Rex, by Carl Zimmer (Free Press, 2001).

The host-parasite interactions described in Parasite Rex are creepier than the movie Alien. The pictures are astonishing.

Plague Time, by Paul W. Ewald (Free Press, 2000).

This book describes the unending battle between humans and germs. It is beautifully written and easy to understand. It does not discuss the germ-cortisol interaction, but it describes many of the other tricks germs use to attack us.

REFERENCES

Epigraph: Ewald, Paul W. Plague Time: How Stealth Infections Cause Cancer, Heart Disease, and Other Deadly Ailments. New York, NY: Free Press, 2000, p. 56.

1. Cushing, Harvey. The Pituitary Body and Its Disorders: Clinical States Produced by Disorders of the Hypophysis Cerebri. J.B. Lippincott Company, 1912, p. 217.

2

Stress, Infections, and Cortisol

Cortisol… belongs to a class of hormones called glucocorticoids, which affect almost every organ and tissue in the body. Scientists think that cortisol has possibly hundreds of effects in the body.

—EILEEN CORRIGAN, NATIONAL INSTITUTES HEALTH

Our adrenal glands produce three important stress hormones: epinephrine (adrenaline), norepinephrine (noradrenaline), and cortisol. Epinephrine and norepinephrine are the famous fight or flight hormones that prepare us for instant action. They are only produced in response to fairly large stressors, and they usually don’t have much effect on our general health. Cortisol, however, is always present in the bloodstream, so small changes in stress produce corresponding changes in cortisol levels.

Cortisol is so powerful that a slight excess can—over a period of years—have terrible effects on our health. We will discuss those effects in later chapters; here we will focus on the small stresses that cause most cases of potbelly syndrome.

STRESSES, STRESSORS, AND STRESS RESPONSES

Technically, stresses are changes caused by stressors. When you climb stairs, your foot pressing down on a step is a stressor; the slight downward bending of the step is a stress. This simple terminology is complicated by the fact that many stresses are also stressors. In the following chain of stressors and stresses, each item is a stressor to the items listed below it and a stress caused by the thing above it:

• A cold wind blows across