American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, February 3, 2017

The 'them' in 'us'

It is a season of our particular discontent, political and otherwise. Wherever we reside on any given spectrum of party, preference, or ideology, the rifts between us are on painful display. We are a house, a nation, and even a world much divided.

Struggling, then, to make my customary case for solidarity among the crowds of us, I turn this year to the solidarity among the crowd within each of us for some help. I mean our microbiome, and the particular goad to make that the focus of this homily is a recent commentary in JAMA, reflecting on the potential importance of those bacteria, and their genes, to the risk for, and management of, rampant obesity and diabetes.

The microbiome, as you likely know, refers to the vast village within, necessary indeed not only to raise a human child, but to sustain a human adult. Trillions of bacteria inhabit every one of us, and it is doubtful we could live at all were it not so. The exact numbers are a topic of some controversy, as is the margin by which our bacteria outnumber our cells; but that they do outnumber our cells is established. The human component of every human is something of a rounding error relative to the bacterial.

That is all the more so when genes are considered. As the JAMA article indicates, bacterial genes may outnumber our own by two to three orders of magnitude. That's a big deal, because those genes manufacture compounds that become part of our inner worlds, just as the products of our own genes do. We are massively influenced, in every aspect of our physiology and metabolism, by the citizens of a diverse internal community.

How diverse? That's the most interesting part of all this. Biological diversity is best measured at the level of DNA, certainly not appearance. Where it counts, almost all biological diversity is expressed by bacteria. Stated differently, the deep, meaningful biological diversity among bacterial species is far greater than the diversity among all other living things, including both plants and animals. Down near the bedrock of biology, penguins and pine trees are not only more alike, but almost indistinguishably similar, compared to the diversity just among bacteria. That invites us to ponder the comparative similarities between any two of us: Palestinian and Israeli, perhaps, Hindu and Muslim, male and female, black and white.

In the case of the microbiome, that astonishingly diverse community, itself only a sliver of the diversity among all bacteria, functions in stunning solidarity with both itself and us, the host. Our bodies provide the real estate those bacteria call home, and deliver to them their essential sustenance. They, in turn, mix their gene products with our own, altering everything from the integrity of our cells and tissues, to the balance of our many hormones.

It is indeed now clear this influence pertains powerfully to the risk of such conditions as obesity and diabetes. When, for instance, the bacterial flora from mice “designed” to be obese are transferred into lean, healthy mice, they can make those mice obese as well. The same works in reverse. Much the same is true of diabetes and other conditions, and similar patterns seemingly pertain to humans, although that evidence is rather less emphatic to date for the predictable reasons.

But important as the microbiomial influence surely is, I think we tend to get a bit carried away. Yes, a salutary balance of bacterial flora tends to favor a lean and healthy host; but so, too, do eating genuinely well and exercising routinely. Eating well and being active may not make everybody lean, but when they are truly done, they truly work far more often than not.

There was very little obesity or type 2 diabetes 100 years ago, and virtually none in children. Was that because our predecessors had deep and ancient knowledge we've lost of the care and feeding of the microbiome? Of course not; they knew nothing of it. Knowledge of the microbiome and its importance is very modern.

What's clear is that what's good for the real estate is good for the residents, as much as vice versa. So, yes, our healthier ancestors almost certainly did have healthier microbiota. But tempting as it is to think we need to know what to feed our microbiota to make ourselves well, history and epidemiology indicate the opposite is true. When humans take good care of themselves, they tend to thrive. Presumably, so too do our symbionts, if only by happenstance.

I pay close attention to the fascinating and fast evolving literature on the microbiome, and certainly agree we cannot be well if there isn't balance and relative harmony there. In rare circumstances, effective treatment of human ills may require direct attention to microbiomial imbalance.

But most of the time, that isn't the case. Certainly, appreciation for the microbiome is not an invitation to ignore what we already know about promoting, protecting, or restoring our own health. Diet and exercise and healthy living work reliably to promote health and prevent disease, whether or not influence on the microbiome is part of the pathway. People can be healthy with no knowledge of taking care of their bacterial residents. Rather, they take care of those bacteria accidentally by taking care of themselves. As our knowledge of, and respect for, the microbiome evolve, we are well advised to bear this in mind- lest the whole endeavor become an exercise in procrastination.

Speaking of evolution, these reflections attest to both the power of it in biology, and our need for it in modern culture. The dizzying biological diversity of bacteria is testimony to evolutionary forces, as is our symbiotic relationship with trillions of those organisms.

To combat obesity and diabetes, and the other great scourges of modern epidemiology, will require that our perspective evolve past a choice between pursuing the details we don't have, and applying the reliable knowledge we do. The next, great opportunity to add years to lives, and life to years, resides in the domain where those two are reconciled.

But advances in health offer little to cheer if we cannot find our way to reconciliations among ourselves. To combat the arguably greater scourges of division, distrust, and hate, we must evolve a perspective that takes us past us and them, to common cause. Perhaps the “them” within each of us can help, for they remind us that in the vast sweep of biological diversity, all of humanity is a very close-knit family.

Families, of course, can differ- but love generally prevails. May it be so.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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