Thursday, July 31, 2014

Paleo and Endurance Exercise: The Pendulum hath swung back

One of the more "interesting" things I find with most hardcore advocates of the Paleo or Primal diets is that they love to use the evolutionary template when it suits them and discard parts of it that don't jibe with their preconceived notions of what they believe to be optimal.  I have been guilty of this at times myself.  A couple of great examples are the use of starches in the diet and the predominantly meat-heavy diet they believe our ancestors ate.  There are a couple of great examples of hunter gatherer tribes that eat tons of starches with no ill effects, the Hadza being the most well known.  As far as meat being a huge part of the diet, this is debateable.  What is not debateable is that large fatty cuts of meat were not the norm.  Just because a hunter gatherer didn't discard the fat from a lean animal doesn't mean they ate fat ad libitum in the same vein as bulletproof coffee.  What is also not debateable is that even if they ate a more animal-based diet, they were doing so while also consuming 100-150g of plant-based fiber, something you are unlikely to get with today's vegetables without high doses of supplemental fiber.  This would be highly protective of the microbiome that our ancestors had and makes your bacon and nut butter-based diet not applicable to theirs.

Another great example of ignoring the data comes in the form of eschewing exercise in the aerobic energy pathway.  There are numerous traits that humans have evolved that set us apart from our primate ancestors and make us incredibly adept at endurance running.  You can see this anatomically in the way that we are built as well as physiologically in the way our energy systems operate.  These adaptations include adaptations to the tendons and ligaments that allow for greater forces, enhanced thermoregulation through sweating, glutes that can generate large forces and help stabilize the leg, a pelvis and spine that can absorb and stabilize against greater forces, larger joints surfaces in the lower body to improve shock absorption, and a foot well adapted to generating large forces(1).

A body that can absorb large forces like this, from a walking perspective, is unnecessary.  It's also unlikely that animals that were once our prey were being sprinted down by a much slower animal.  Since some of these adaptations predate modern humans, and weapons used at the time were not sharp enough to pierce the flesh of animals when thrown from a distance, it seems likely that endurance running may have been something that drove the evolution of modern humans.  (For a more thorough rundown of this, I recommend the book The Story of the Human Body by Dr. Dan Lieberman).  In addition, many of the adaptations to endurance exercise that we see in modern research imply that endurance running is indeed important to human health.

There are other benefits of endurance exercise that show great promise in human health, and many of these are separate and sometimes diametrically opposed to resistance/sprint training.  Quite a few of these adaptations are complementary to the adaptations of resistance exercise and affect the brain as well as the cardiovascular and immune systems.  Over the course of the next 2 blogs, I will take a look at the adaptations to both strength training and endurance exercise and how you can practically apply this information to enhance your health.

In the first blog, we will go over what the research shows us to be the beneficial adaptations from strength training and endurance exercise.  Do you eat MCTs or coconut oil for the ketones?  Are you looking to improve your ability to burn fat efficiently?  Is brain performance important to you?  Will a robust immune system improve your quality of life?  We'll take a look at how resistance and endurance training each affect these systems and why ignoring endurance exercise is a mistake.

In the second blog we will go over how we can apply this information to your exercise program.  How much?  How often?  How intense?  What kind?  All of these questions are important and we will cover them all.

Hopefully this series gives you a new appreciation for an exercise modality you have likely been ignoring while following a Paleo or Primal lifestyle.  While strength training and sprinting are both excellent forms of exercise, they do not provide you with all of the benefits you could be getting from a program that includes both of these modalities with endurance training.

Monday, July 21, 2014

Factors out of your control: Why it's time to stop counting calories

For years people relied on the energy balance equation to help themselves lose weight.  Since a pound of fat contains 3500 calories, all you need to do to lose a pound of fat is burn 3500 more calories than you eat.  Sounds simple enough, the problem is that this isn't how it works.  While the calorie surplus or deficit that you create likely has some relationship to how much weight you lose, we don't know how strong that relationship is or how strongly other factors impact this number.  In this blog I will go over the primary reasons why this approach should be abandoned.

1)To lose a pound of fat you need to burn far more than 3500 calories.

While a pound of fat does contain 3500 calories, you never burn 100% of your fuel from fat.  In fact, under ideal conditions, you only burn 60% of your calories from fat.  The kicker here is that ideal conditions involve walking, not running.  So when you up the intensity from walking to running, you actually start burning more sugar as a percentage of total calories.  Since you are burning more calories by running, this means that you are likely burning more total fat calories while running but it is at a lower percentage.  So when you walk, you need to burn 5833 calories to lose a pound of fat and when you run this number increases.   For a person who weighs 160lbs, this means they would need to walk 58.3 miles to burn 1 pound of fat, more than 2 marathons.  If you held the same fat burning efficiency for running, you would need to run 1.84 marathons to burn a pound of fat.

2)The body adapts to energy expenditure/intake

It is a well known phenomenon that a person's resting metabolic rate, the amount of calories they burn during rest, drops when a person restricts calories.  In a study conducted in 2007, researchers found this phenomenon to hold true and also found that physical activity also decreased in people undergoing calorie restriction(1).  Another well known phenomenon is that a person who has never run a mile before will burn more calories running that mile the first time than they will once they've been running a mile for a couple of months.  Calories burned is not a static number and is completely different from person to person and even within the same person after they've been exercising or dieting for a period of time.

3)Nutrient/Energy extraction from bacteria

Another problem that mucks with the inputs of the energy balance equation is that bacteria found within your digestive tract alter the amount of nutrients and energy you absorb from your food.  It's obvious that absorbing more energy from your food will throw your calculations off, but not absorbing the proper nutrients from food that power fat burning pathways can prevent fat loss and lead to nutrient deficiencies over time.

4)Hormones matter and a calorie isn't a calories, strictly speaking

Systems within the body communicate with one another via hormones.  In order to burn fat efficiently it's important to have proper hormonal signaling within the body since fat can only enter fat burning pathways.  If all calories were created equal, they would all be able to enter any energy pathway to provide fuel just fine, this isn't the case.  To burn fat, fat burning pathways have to be signaled by hormones to ramp up, and 2 hormones that have a significant impact on fat loss are leptin and insulin.  Leptin is a hormone that is secreted by fat cells and is important to appetite regulation, regulation of energy expenditure, and regulation of fat stores.  Having chronically high levels of leptin leads to leptin resistance, meaning the body doesn't receive the signal properly and appetite and fat storage aren't regulated properly.  Insulin regulates the storage of fat and helps select which fuel you use.  When insulin levels are high, the body stops burning fat because insulin signals the body to store it.  In insulin resistance, this signal is not received so the pancreas pumps out more insulin, preventing the use of fat for energy.  It is believed that leptin resistance precedes insulin resistance which can eventually lead to Type 2 diabetes, a reversible metabolic state that can be ameliorated through diet and lifestyle modification. Just attending to calories in and calories out doesn't take errors in hormone signaling in to consideration.

5)Diet induced inflammation

Many people are familiar with inflammation as it pertains to cuts, bruises, and injuries.  Inflammation is initiated by the innate immune system and is used to help clear pathogens from the body and begin the healing process.  Dietary inflammation can occur due to overeating or from eating foods that inflame the digestive tract.  High levels of leptin are known to activate the immune system(2) and this is likely the mechanisms by which overeating increases inflammation.  For foods that inflame the digestive tract, gluten is a known cause of inflammation for all people and other foods can be a cause of GI tract inflammation in some people but not others.  In general, a small amount of acute inflammation is not seen as something an otherwise healthy person should worry about, it's when the inflammation becomes chronic that troubles arrive.  High levels of certain inflammatory markers induce insulin resistance in muscle and fat tissue, sparing glucose so that the immune system can use the glucose to ramp up defenses.  This causes blood glucose levels to rise and insulin levels to rise as well.  A breakdown of this can be found in this blog.


The calories in vs calories out approach to weight loss has taken an inordinate amount of time to die.  The approach doesn't work, the inputs to the equation are dynamic and, thus, constantly changing, and the human machine is far more complex than a car that burns gas.  If fat loss is an important goal of yours you should drop the calorie counters, ignore the calorie burn on your treadmill, and improve the way your "machine" works by paying attention to what it needs.  This includes good quality sleep, stress management, daily physical activity, a nutrient dense diet with at least 6-9 cups of vegetables per day, and weekly vigorous activity.

Thursday, July 17, 2014

Looking for the reason why you can't I lose weight or why you keep gaining it?

I am a member of quite a few facebook groups and work with people trying to lose weight and this question comes up very often.  To me, it really isn't rocket science and I can typically find at least a couple of things that people do that hold them back from attaining whatever health or weight loss goals they are trying to attain.  More often than not it's because they take an overly myopic attitude towards weight loss.

Over the course of the last couple of weeks I have come up with a checklist that I will be using with my clients to help them troubleshoot their weight loss issues.  The impetus for this is two-fold.  First, I may see someone in a Paleo group say they are sticking to the diet to the T but not losing weight or someone in a Fitbit group say they are getting their steps in but nothing is happening.  More often than not, when I question what they are doing for the other variables they should be paying attention to, they aren't doing anything.  I see the same thing with clients.  They may be getting their steps in every day, eating a proper diet, or getting in 3 weekly workouts but they aren;t doing all of these things consistently.  The second reason for the checklist is that it will gamify the process and provide a measure of accountability for my clients that they didn't have before.  Gained some weight this past week?  Look at the list.  Think you were good on your diet this week but not sure?  Look at the list.

While I am only using the checklist with my clients right now, I think a lot of these, "Why am I not losing weight?" questions can be answered simply by paying attention to the primary lifestyle factors that a person trying to lose weight should be paying attention to and creating a checklist to make sure yo are doing them.  I have my own specific way of dealing with each factor that I won't get in to, but most people will have an answer to that question simply by knowing what is important for weight loss and general guidelines for each.


If you're not winding down at the end of the day and getting to bed at a reasonable hour, you basically trash your ability to lose weight by messing with hormone signaling, especially insulin.  You should put yourself in bed with the lights off and no distractions at least 8 hours before you need to get up.  This is a bare minimum.


Stress should be managed for the same reason.  One thing that sticks out like a sore thumb to me is that people who manage stress poorly also tend to have a difficult time losing weight.  I don't think there is a single reason why this is the case, there are many.  However, one glaring issue for me is that people who are not "planners" don't typically manage stress well and are the first ones to regress on weight loss when an opportunity presents itself.  I used to be guilty of this myself on numerous occasions.  If I put myself in to a situation where people are eating junk food and I haven't planned for this by having a healthy option for myself, I'll eat junk food.  If I know I am going to have a heavy client load one week and don't attend to it until the last minute, I won't work out that week.  If I am taking a 7 hour car trip and I don't make a point to get some low level physical activity in before and/or after it I won't get any in.  A quote attributed to Benjamin Franklin sums this up nicely, "If you fail to plan you plan to fail."

3)Intense physical activity

Whether it be working out with weights or playing a sport competitively or in a social setting, people really need to get intense physical activity in regularly.  I used to believe that 2 times a week was sufficient, but now believe that 3-4 times a week is significantly more effective.  In order for something to qualify for this factor, it should include the entire body and generate a significant sweat.  Good examples are weight training, flag football, rowing, or rock climbing. More often than not, this activity should also be 45 minutes to an hour long.

4)Daily physical activity

Many people feel that blowing themselves out at the gym 3-4 times a week is enough physical activity to lose weight, but multiple studies show that it can't make up for sitting around all day long.  At a bare minimum, people who wish to lose weight should be taking 10,000 steps a day which equates to 5 miles of walking throughout the day.  If I were to say that any one of these factors is the most underutilized, it's this one.


People who are trying to lose weight should be eating a highly diverse diet that is mostly of plant origin by volume and contains little to no processed food.  If most people did this they would have no problem losing weight and would score quite a few weekly points on my checklist.  Where it gets tricky for most is that this requires a lot of preparation and a lot of people shop for convenience.  However, if I had a dollar for everyone who told me that they'd give anything to get to their goal weight I'd be a rich man.  In the grand scheme of things, utilizing 5-10% of your day preparing the proper food is a fairly small price to pay for someone willing to do "anything".

6)The "It" factor

What is the "It" factor and who has "It"?  Some may call it mental toughness, some may call it willpower, but I believe it to be more than that.  The "It" factor is knowing what you need to do to achieve a goal and the willingness to do that to achieve it.  Michael Jordan had the "It" factor.  Michael Phelps has the "It" factor, and many captains of industry and people who have become elite at what they do have "It".  From a weight loss perspective, "It" is preparing lunches for the week on Sundays if that's what you need to do to eat properly at work.  "It" is waking up 20 minutes earlier so that you can take a 20 minute walk after breakfast before your 30 minute commute.  "It" is resisting the inertia holding you down on the couch to watch TV after you eat dinner and going for a walk or work out.  "It" is realizing that the end of the fiscal year is a busy time of year for you at work so you plan your workouts accordingly.  Neglecting these things may seem small, but it adds up over the course of a year.  People with the "It" factor just do "It", and as a result they typically get "It".  The whole reason to develop a checklist for yourself is to determine if you are getting "It" done.  In fact, "It" is exactly what your checklist should measure.


Looking at these 6 factors, it may seem like weight loss is a lot more than burning more calories than you eat, and it is.  However, knowing about these factors and paying attention to them is just part of being successful when it comes to weight loss.  More than any other factor, success in any field is dictated by persistence, or the "It" factor.  Pick a sport and anyone who is highly successful at it can be found practicing while their friends and lesser talented competition are on a beach or hanging with friends.  Look at any successful business person or parent, and you will find that their priorities align with what it is they truly want to be great at.

None of these things just come to people, they have to be worked on and perfected over years of practice, failure, and refinement.  Weight loss is no different.  People who want to be successful at it work at it and prioritize it in their life.  They don't run in to situations every week where they have nothing to eat but food that goes against their goals.  They don't skip workouts because something else comes up or because work or family life is getting busy.  Day in and day out they make sure they get done what needs to get done.  If something pops up and they can't work out at their designated time, they are working out late that night or first thing the next morning.  They get their steps no matter how busy they are.  There are 24 hours in a day, there is plenty of time to work, enjoy your family, AND work on your goals if you truly want to attain them.  The trick is to know yourself and learn the techniques necessary to prioritize your weight loss goal.

Monday, July 14, 2014

Fine with gluten before starting Paleo but not anymore? This may be why...

Many people who undertake the Paleo Diet often experience problems when introducing gluten back in to their diet despite not having noticed any issues prior to beginning the diet.  There could be a host of reasons for this phenomenon.  First, they may have had an issue before and never noticed.  Many people see relief from multiple issues when beginning a Paleo Diet, perhaps gluten was the issue.  Secondly, there could be a change to the microbiome that occurs with the diet.  In this blog we will explore a few studies that could be evidence for this second reason.

While humans are unable to fully digest gluten because they lack the enzymes to do so, there are many strains of bacteria that colonize the GI tract that can.  A recent study that looked at the microbiome of 22 human subjects found that 144 strains of bacteria found in the feces may participate in gluten metabolism(1).  Some of the strains were able to metabolize gluten themselves while others made enzymes that could degrade gluten extracellularly, perhaps to break up the peptides for other symbionts.

The interesting part of this study is that a few of the strains were able to break down one of the more problematic peptides for people with celiac disease, the 33-mer.  Obviously the more gluten you consume the more abundant these species would become holding everything else constant, so losing a few of these guys could be an issue.  Going from a diet high in gluten to one very low in gluten and then testing the waters with a weekend gluten bomb may overwhelm your bugs' ability to breakdown gluten and, voila, problems.

Another study in 2010 found that microbes found within dental plaque and saliva produced enzymes that are capable of degrading gluten in vitro(2).  These enzymes were capable of degrading 2 of the more problematic proteins found in gluten, the 33- and 26-mer.  Interestingly, these bacteria can do so over a wide pH range meaning they could, in theory, work in regions of the digestive tract outside of the mouth.  Even more interesting is that people who undertake a Paleo Diet tend to see an improvement in oral health which includes improvement in plaque deposits in the mouth.  Could this lead to a decreased ability to metabolize gluten due to a drop in abundance of these gluten degrading microbes?

A follow up study by the same authors zeroed in on a couple of specific strains of microbes with powerful gluten degrading capabilities.  These microbes had a powerful ability to break down both the 33- and 26-mer peptides with the remaining proteins not being able to initiate an immune response(3).  One of these microbes was found to colonize both the oral cavity as well as the duodenum, meaning it may participate in gluten degradation in both the mouth and small intestine.  While healthy subjects did have a higher percentage of this bacteria in the duodenum than people with celiac disease, the difference was not significant(6.5% vs 5.9%).

Looking at these studies, we can come to some conclusions.  First off, while humans cannot digest gluten, there are microbes in the upper part of the human digestive tract that can.  Second, there is the potential that initiating a gluten free diet for an extended period and then reintroducing large amounts of gluten all at once could become a problem if these microbes decrease in abundance and impact the host's ability to break down gluten.  From these conclusions, it's safe to say that weekend gluten bombs are not a good idea for most people who go gluten free.  If you intend to continue to eat gluten, you may want to keep a little in your diet from time to time to maintain a significant presence of the microbes that break it down since we are unable to.  Finally, if you decide you are going to have gluten and haven't had it for a while, slowly introducing it may be a better approach than slamming down a 6 pack of brewskis and eating half of a pizza in a 3 hour period for the same reason.

Author's note:  I personally limit my gluten exposure due to the potential effects on the microbiome.  I'm not telling you whether or not you should eat gluten, I'm just giving advice on the appropriate ways to deal with reintroducing it if you have given it up for an extended period of time.    Obviously this advice doesn't apply to people with celiac disease who, at this time, should never consume gluten.

Thursday, July 10, 2014

Having problems losing the baby weight? Check yo gut!

As many of you current moms may know, losing the extra weight you put on during pregnancy is no easy task.  For the most part, the assumption has always been that this is due to hormonal changes that follow after pregnancy.  While that is likely a big piece of the puzzle, there is another variable lurking that could play as big of a role, if not a bigger, in your fat loss troubles: Your gut bacteria.

In a study published in Cell back in 2012, researchers took a good luck at how the microbiome changed for expectant human mothers throughout pregnancy.  The authors found that a woman's microbiome changes significantly from the first trimester to the third and that, in the third, gut bacteria changes similar to those seen in obesity change the metabolism of the pregnant mother(1).  These changes lead to increased inflammation, insulin resistance, and hyperglycemia.  When the babies had their microbiome tested, it more closely resembled the mother's during the first trimester and became more similar to the mothers as the children aged.  Finally the microbiome of women in their first or third trimester was given to germ free mice.  The mice given the third trimester microbiome gained significantly more weight than germ free mice given the microbiome from the women in their first trimester, and the the mice given the third trimester microbiome had the same metabolic changes associated with obesity. 

One of the more interesting aspects of this study is that the changes in the microbiome didn't really correlate with the mother's diet.  This supports the notion that there is an evolutionary advantage for this change and that the mother's physiology is likely impacting this change in one way or another, not her diet.  Another interesting aspect of this study is that it sort of implicates that this microbial change, which is highly advantageous in pregnancy to conserve energy for the baby, may be a significant contributor to the obesity epidemic in all humans.  Since a child's microbiome most closely resembles their mother's at the first trimester and becomes more similar as they age, it is unlikely that a child gets any significant microbial transfer from their father outside of the environment they share, which is also the same as the mother's.

Despite their being many similarities between the third trimester and obese microbiomes, including decreased diversity, some of the microbial changes seen in the third trimester of pregnancy diverge from the obese microbiome.  The obese microbiome sees a decrease in Bacteroidetes and an increase is Firmicutes which leads to increased sugar absorption while the third trimester microbiome sees no such change.  This change is primarily driven by prolonged excess calorie intake.  Could excess calorie intake from the third trimester through the first year or so of a child's life help promote or reinforce this this change in the mother?  It's likely, but that wouldn't necessarily mean that this change is required.  Insulin resistance blocks fat burning so any metabolic change that induces insulin resistance will reduce a person's ability to burn fat.

So now that we have an understanding about what the study shows, how does this help us?  Hormonal changes should not be your only concern and there is the potential that this weight doesn't need to be so difficult to lose.  Since there is likely significant crosstalk between the hormonal and microbial systems, eating a diet that promotes a healthy and diverse microbiome should put you in the best position to lose the weight when these two systems will allow it.  This includes ample amounts of fiber from fruits and vegetables to help control the inflammation associated with the third trimester microbiome as well as a diverse diet to promote microbial diversity.  This is likely the diet that new human mothers ate for hundreds of thousands of years, and it is likely the diet that will provide the quickest, smoothest transmission back to a more healthy microbiome.

Depending on your level of insulin resistance, it may be a good idea to reduce carbohydrate intake for a little while until you restore proper blood glucose control.  Finally, if there is ever a good time to make sure you're not stocking up on excess calories and scarfing down Ho Hos, the period right after you give birth is that time.  Even if you're breastfeeding, there really isn't a need to increase your calorie intake.  Once delivered, the nutritional demands of the baby are met through the milk, but since the baby is no longer inside of you there is no need to increase caloric intake beyond what you did for your third trimester.

Monday, July 7, 2014

Understanding inflammation: Why you can't fix a diet problem with exercise

Most people are under the impression that they can eat whatever they want and just rely on exercise to undo the damage by creating a calorie deficit.  The problem is that weight gain is a fairly complex problem with many underlying issues, a caloric excess being only one of them.  Two of these issues that have garnered a lot of attention over the last few years are chronic inflammation and insulin resistance.    While 10 years ago one could argue that these two are only associated with one another and one doesn't necessarily cause the other, there is a significant amount of data that shows that they are associated with one another, that one does cause the other, and, ironically enough, they both reinforce one another(1).  In this blog we will look at how modulating inflammation through diet can help improve fat loss.

Before we start off, I feel it's important to point out the purpose of this article.  First off, if you begin to deal with inflammation but you still eat more calories than you burn, you will gain weight.  Calories do matter, period.  However, managing inflammation tends to decrease calories by improving hormonal signaling in the body.  The end result typically leads to a decrease in appetite and better fat burning through better hormonal signaling.

Second, inflammation isn't bad.  Inflammation is a good thing and is necessary to fight infection as well as improve athletic performance by allowing you to adapt to training.  However, high levels of inflammation or inflammation at the wrong time is very detrimental to performance and overall health.  An additional factor to take in to consideration is the current physiological state of the person, which can determine how much of a negative impact their food choices can have.  The purpose of this article is to give a clearer understanding of what paying attention to inflammation can do for you as well as providing context to when it is something that should become a concern.

For years epidemiological research showed an association between inflammation and insulin resistance but up until recently we had no idea how, or in which direction, it worked.  Does inflammation cause insulin resistance or is it the other way around.  Recent research has shown that increased levels of chronic inflammation signal insulin resistance in fat and muscle tissue, potentially to preserve glucose for the immune system.  I covered this very topic in a blog found here.  In addition, as chronic insulin resistance persists and the pancreas begins to create less insulin due to damage, more inflammation is created as the anti-inflammatory effect of insulin on the inflammatory FOXO1 gene decreases(1).  So not only does inflammation cause insulin resistance, over time insulin resistance will reinforce inflammation by creating more inflammation.  Leptin, a hormone that tends to be high in people with insulin resistance, is highly inflammatory.  So how does this relate to diet?

Certain foods can increase inflammation, particularly foods containing gluten, a storage protein found in wheat and other grains(2).  This in and of itself is not a bad thing.  In fact, an otherwise healthy individual with a healthy diet can probably have foods that contain gluten with little to no problem.  Maintaining a healthy gut microbiota promotes an anti-inflammatory effect that potentially counteracts the inflammatory effect from gluten.  A diet that promotes healthy gut flora and this anti-inflammatory effect tends to be highly diverse and contains a large amount of fiber from vegetables and fruit.  However, I don't believe many people pay attention to this and a high vegetable/low grain diet is certainly not the norm, particularly in people who think they are going to eat whatever they want and exercise it away.  Unfortunately, excessive exercise can make the problem worse by contributing to the inflammation and increasing hunger, or at the very least not allowing the immune system to repair the damage caused by the low quality diet.

So what should you take from this?  First, pay attention to the quality of your diet and shift away from focusing on calories in and calories out.  Second, make sure your diet is diverse and you consume a large volume of vegetables.  Third, if you choose to eat foods that are more inflammatory, your need for vegetables likely increases to counteract the inflammation.  Finally, understand that you cannot fix a diet problem with exercise and shift your approach accordingly.

Thursday, July 3, 2014

MIssing Microbes: A book review

I recently purchased the book Missing Microbes: How the Overuse of Antibiotics is Fueling our Modern Plagues and finally got the time to read it. This book hits me on so many levels.  First, it's on a topic I find very interesting, the bacteria in our guts and the functions they perform for us that we're unable to perform on our own.  Second, the author takes a very balanced approach in looking at how antibiotics, as well as C-sections, have contributed to significant changes in our microbiome that may be a causative factor in many of the diseases we see today.  Finally, it provides insight in to how and why we may want to change the way we look at things when it comes to our healthcare system.

The book begins by taking a look at the rise of "Modern Plagues" that have only recently become prevalent in Western society but have yet to become epidemic in more traditional ones.  Obesity, Type 2 diabetes, allergies, and asthma are just a few things he tackles in this section.  Next he moves on to the microbes that were once our chief enemy and how they have always, and will continue to well past our extinction, rule the planet.  He then moves on to the microbes that have become our friends, our microbiome.  Our microbiome is the collection of bacterial cells that live within our body and outnumber our own.  In fact, he states that without us our microbes would do just fine; but without all of the microbes that cover our skin, colon and every crevice of our body, we would essentially be losing an organ critical to our survival.  In other words, we would likely be dead.

Probably one of the more telling things he mentions early in the book is how microbial diversity keeps our inner ecosystem in balance.  Just like a forest teeming with life, diversity promotes inner balance.  However, when a keystone species within that ecosystem is lost, the ecosystem, or a large part of it, collapses as other species that were dependent on that one also thin out or disappear. Furthermore, while we focus on microbial species that are abundant in humans, these may not necessarily be the lynchpins that hold everything in place.  A great example of this is how people assume calcium is the most important mineral for maintaining bone density because it is the most abundant while current research seems to point to magnesium as being more important.  Most abundant doesn't necessarily mean most important, it only means most plentiful  This is important because the differences between our microbial genes are far more important than our human genes.  Wiping out an entire species can have huge implications on our health.

He discusses the usual dance of functions associated with the microbes in your colon, immunity as well as nutrient generation and absorption, but adds a few functions that I was unaware of.  These include blood pressure regulation, estrogen regulation, and generation of chemicals required for optimal brain development.  This could perhaps be the link between gut bacteria and autism.  The scary part is that you don't need to wipe these microbes out forever to have bad consequences, removing them during a critical time in development can have pretty serious effects.

For most of the book Dr. Blaser focuses on the stomach microbe H. Pylori and how antibiotics wipe it out.  He states on many occasions throughout the book that we don't know that losing H. Pylori is the cause of the problem, but we do know that losing H. Pylori or another microbe associated with it is not good.  This is a refreshing take because most authors try to push their agenda as being the primary reason we are seeing XYZ, but Dr. Blaser doesn't take that approach, he is much more scientific and points to changes throughout the microbiome as being important, not just the loss of a single species.

Another balanced approach he takes is towards antibiotics.  Many times throughout the book he praises antibiotics and the many problematic pathogens they have eradicated.  What he sees as the two most problematic issues with antibiotics is over-prescription and the profit system around the pharmaceutical industry.  A decade ago antibiotics were prescribed for basically everything as there was no observable downside to using them, an attitude that has been overturned by current research in to the microbiome.  Antibiotics have their use and should be taken when appropriate, but only when appropriate.  The days of haphazardly taking an antibiotic for a virus, something they don't work against, need to be over.

The biggest hurdle Dr. Blaser sees going forward is the way the pharmaceutical industry is set up.  It makes no sense for a profit driven company to develop a targeted antibiotic because that limits the number of people they can sell it to.  Broad spectrum antibiotics are where the research goes because they have a wider application and, thus, a wider customer base.  The problem here is that in addition to wiping out the bad bugs, they wipe out the good bugs and could potentially wipe out a keystone species if it is sufficiently small in numbers or multiple rounds of broad spectrum antibiotics slowly decimate the population.

Finally, another problem that is taking center stage these days is the use of antibiotics in livestock.  While most people look at the use of antibiotics in these animals as a preventative measure due to the poor conditions they are kept in, they are actually given antibiotics because it makes them grow larger.  In fact, 70-80% of the antibiotics sold today are used specifically for this purpose.  There are multiple problems with doing this including promoting antibiotic resistant microbes, antibiotic residues creeping in to our food, and runoff from farms contaminating the water supply with antibiotics.  He goes over the many repercussions of antibiotic exposure, not just from taking them in therapeutic doses, but from constant low dose exposure that we likely get from these avenues every day.

Throughout the book Dr. Blaser sheds a lot of light on how our microbiome helps us, how it has been changed, and the consequences of these changes.  While there is a focus on H. Pylori as this is the microbe he has spent most of his life studying, he is extremely thorough in covering everything.  I highly recommend this book to anyone who is concerned for their health or their child's.  A relationship between IBD, GERD, heartburn, and several other non-lethal but potentially annoying health issues can be traced to changes in our microbes.  Dr. Blaser does a great job of describing how and why these things happen and provides a prudent approach for preventing them through changes in healthcare policy and our attitude towards the necessity for drugs and procedures that may not be necessary.

Missing Microbes by Martin Blaser, MD