Randi Hutter Epstein M.D. M.P.H.

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What Hungry Dogs May Teach Us About Ourselves

New Insights Into Dog Hunger Hormones May Lead to Strategies for Humans

The other day I was walking my dog when I ran into Dr. Jeffrey Friedman. In 1994, his Rockefeller University team discovered leptin, the hormone that controls appetite. People with low leptin are voraciously hungry—and obese.

Friedman offered a treat to Ellie, my 11-pound Havanese dog, but she turned up her snout. I mentioned that Charlie, my late Golden Retriever was so food-obsessed we had to hold him back from scrambling under parked cars to nab chucked leftovers. Could it be hormones? I thought my question was rather facetious because I was talking to a dog-owning hunger-hormone expert.

Turns out, he said, some dogs are prone to the same hormone defect as humans. He referred me to a University of Cambridge study. I got home, fed my dog (she only likes one kind of dog food), found the dog-hormone scientific article and emailed the leading investigator, Dr. Eleanor Raffan.  A few days later, we SKYPEd.

Raffan told me the leptin defect was more common among Labradors and flat-coated retrievers compared to other breeds—no surprise to Lab owners. Here’s what may come as surprise: Among the Labradors, the mutation was much higher among guide dogs compared to the rest of them — 50 percent versus 25 percent. Raffan has a hunch that food-obsessed puppies might be easier to train, giving them a leg-up into the guide-dog program.

Oddly enough her studies did not find the mutation in golden retrievers. I have to believe that Charlie, my late golden, must have some other yet-discovered hormone defect; that his biological drive for food is somewhere on that spectrum between the picky-eating Havanese and the food-focused Labradors. To be sure, Raffan’s research provides insights into why some dogs may be hungrier than others, but in larger sense it’s providing more clues to the physiology of hunger—and may lead to new ways to staunch the obesity epidemic in dogs and humans. (Apparently dogs are getting fatter, too) Already there are a few experimental drugs that seem to be helping the rare people with leptin problems.

However, if you do not have the defect, the leptin shots and any touted leptin diets won’t do anything. That’s because for most of us, eating too much is not just about one mutation, but probably lots of hormones that control hunger, satiety, stress—not to mention all kinds of emotions that go into appetite. Sometimes we eat when we’re not hungry. Still, Studies like this one (that highlight the power of our hormones ) will likely lead to new ways to help those with the rare hormone defect, and certainly shed light on the basic biology of appetite. As Dr. Friedman told me,  “I don’t think on the whole that humans have come to grips entirely with how powerful our basic drives are, how difficult it is to use conscious means to control them.”

And yet.. and yet. When my kids were as young as my son was is in this photo, we spent a lot of time baking cupcakes and brownies. The stirring had a soothing effect on the kids. I gained weight. Friends (perhaps unaware of our daily cooking habit) kindly said it was just my hormones. (of pregnancy? of motherhood?) Nope, it was Duncan Hines Ready-to-Spread Icing. To be sure, understanding hormones will glean insight into our human urges, but sometimes the solution is not rewiring our brains, but rewriting the grocery list.

 

For further readings, this New York Times piece delves into the dog hunger hormone.

Check out this commentary by Harvard scientists that puts  leptin findings in perspective.

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Fake News, Silicon Valley and Our Health

In today’s New York Times, Emily Parker writes about something that we all sort of know but don’t want to face: When it comes to fake news going viral, Facebook, Twitter, and Google aren’t the entire problem. We are. As she writes, we are the ones spreading the information; we are the ones who find it much easier to digest news that’s fed to us in bite-sized, easy-to-digest portions. She calls complex debate the vegetables (good for you/not appealing) while fake stuff is candy (junk/super-tempting).

Funny that she went for the health side of it, because the whole time I was reading about fake news and politics, I was thinking that the same could be said for health news. We want a quick fix rather than a nuanced discussion of the pros and cons.

We complain that doctors keep changing their minds. Fifty years ago, hormone therapy for menopausal women was great, a few decades later it was dangerous, and now it’s good for some women, not others. Fifty years ago, natural growth hormone (from the brains of cadavers) was better than synthetic, then we were told the laboratory-made stuff was better.

Does that mean scientists were wrong? That we have to worry they are spreading fake news? No, it means we have to recognize that medicine is an uncertain art.

  • Don’t read every scientific study as the final word.
  • Be wary of people that tout quick fixes.
  • Appreciate that gleaning health information is often complex and takes more than a quick nod to understand. If you care about your health, care enough to read the whole story.
  • Understand that our knowledge of the human body is evolving.

“There is wisdom in the acceptance of uncertainty,” wrote Dr. Sherwin Nuland, my former medical school professor in an essay in the New York Times, six years before his death. Wisdom that isn’t easy to digest but it is good for you. That’s for sure.

For further reading on accepting uncertainty in medicine, I recommend this piece in the New England Journal of Medicine by Dr. David J. Hunter, professor emeritus of cancer prevention at Harvard T. H. Chan School of Public Health.

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Payoffs of Snooping

The Birth of Forceps Offers Insight to Birth Today

There’s an upside to being a snooping guest—you could find a long-lost treasure as this nosey 19th century mother-in-law did.

In 1813, Dr. William Codd’s mother-in-law was poking around he and his wife’s home in Essex, England. She noticed a crack in the floorboard, pried it open, and hoisted a box of metal trinkets. She must have thought the stuff looked scientific because she ran the box over to her friend, a retired surgeon who lived nearby. He knew immediately that she found a medical treasure. One that had been missing for a hundred years.

Inside the box were the world’s first usable forceps. They were created in the 1500s by the Chamberlens, passed down from generation to generation until Peter Chamberlen retired and hid them in the floor of his estate.

The story of forceps is one of a huge medical advance. Before forceps, babies stuck in the birth canal died, and sometimes so did the expectant mother. But it’s so much more. It’s a story of fierce competition and bitter debates.

The Chamberlen men developed this lifesaving device and then refused to share the secret because they figured (rightly so) it would give them an edge in the childbirth business. They became the male-midwives to aristocrats and royalty. And to make sure no one stole their idea, they stored the forceps in box the size of a coffin (so there were no clues about its size or shape) and then blindfolded the laboring women so she couldn’t sneak a peak, either. (As if a woman about to deliver a baby is going to grab a pen and paper—or quill and parchment—and jot down notes).

Eventually in the mid 1700s, Peter Chamberlen, a great-great nephew of the inventor, realized he could make money selling the design. So he did so to Dutch and then British doctors. When he retired, he buried the original forceps in the floor of his house. And there they remained until the nosey mother-in-law of the next home’s owner happened upon them.

I was telling the tale of the eccentric Chamberlens this week when I was interviewed on KWMR radio by Christina Lucas, a nurse in Point Reyes, California about the history of childbirth. I thought I knew the story pretty well until she said, “Where are the forceps now?”

I was stumped during the show, but promised I’d do some searching afterwards. Like most things in life, the answer was one Google click away. The forceps are now on display at the museum of the Royal College of Obstetricians & Gynaecologists.

Since the Chamberlen days—or really starting with the Chamberlen’s, forceps have instigated some of the most contentious childbirth debates. Women worried about the safety of high-tech birth (forceps) versus natural birth (sans forceps). The concerns are reminiscent of the cesarean section versus no-cesarean section debates today.

Today forceps fit into the natural category and many obstetricians believe that the art of using them (it takes a bit of skill) needs to be re-introduced to minimize the high rates of c-sections. There are also initiatives to teach forceps skills to women in developing countries, where surgical births may not be an option.

In any event, if you’re as curious about childbirth history as I am—and if you happen to be in London—it’s worth a stop at the Royal College of Obstetricians and Gynaecologist’s museum. You have to make an appointment. The College is near Regent’s Park, a lovely part of town.

And if you’re really curious, you can hop on a train from Liverpool street to Hatfield Peverel in Essex and see the Chamberlen’s former home. It’s called Woodham Mortimer Hall. There’s a blue plaque on the door that rehashes the history in a few sentences. The Hall is now private, but you can see if from the outside and visit the cemetery nearby. (It’s also a lovely area of the English countryside…where I got my first puppy, a Golden Retriever.)

I’m glad that Christina pushed me to get to the end of the mystery. But the one thing we’ll never know is what Dr. Codd said when he got home that afternoon and found his mother-in-law dismantling his flooring.

 

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What We Don’t Know about Egg Donation

Should potential egg donors worry about potential dangers?

For anyone undergoing any kind of medical treatment, it’s always weighing the benefits of treatment (will this save my life? Cure my illness?) versus potential side effects (can I endure, say, the headaches or whatever comes with the drug?).

For women undergoing fertility treatments, there’s been a push in recent years to minimize the amount of hormones and the amount of cycles—that will lower any potential risks of drugs and also plummet the cost. (The drugs can costs hundreds of dollars).

The whole risk-benefit ratio is different when it comes to young women who are egg donors. The upshot isn’t making a family but making money. The downside is unknown. The sperm and egg industry have long been unregulated fields.

In today’s New York Times, Jane Brody writes about Jessica Grace Wing, a Stanford undergraduate who served as an egg donor three times. Then she got colon cancer and died at the age of 31. There is no proof that the hormones she took to make her spew lots of eggs in one cycle caused her colon cancer. But there aren’t studies proving the safety.

And that’s the issue. Wing was the perfect egg-donor-candidate. She went to a top college, was pretty, athletic, thin, and musical. The hope is that all of those positive things were tucked into the genes in her egg destined to be passed along to the offspring. The fee for her eggs helped pay for college. Where I teach, I hear my college students laughing about the alluring advertisements in the school newspaper. To them it all seems so silly that their genes (not their hard work,not their home environment) got them into college and into egg-donorable standing. It’s just always seemed crazy to me that this business has fallen more in line with the way we deal with any other commodity we want to sell rather than a medical procedure that needs to be tracked for safety.

Her mother, a physician, along with other doctors have been pushing for data bases that can keep track of the donors and their health. This is an idea that has been debated since the egg donor industry started. When I was working on my last book, Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank, I talked to sperm donors and egg donors and the folks who run the businesses. For the most part, the folks “donating” the eggs and sperm (they really sell them), do not want the hassle of the oversight or the bureaucracy of keeping some kind of national data base. The sperm concern isn’t about dangers of donating. Men don’t take hormones. They masturbate in a room. But there are concerns that some men who may be harboring genetic diseases are passing along those illnesses from one bank to another—perhaps unbeknownst to them. The issue for egg donors is their own health. We need to be able to tell these young women—offered thousands of dollars to take heavy doses of hormones that make their bodies release multiple eggs in one month—what the health risks are.

This fear isn’t new. It makes headlines each time there’s a death of a young woman. Today is was a New York Times piece. Two years ago, it was a New York Post piece that showed the photograph of a beautiful young egg-donor who got terminal cancer and had a starring role in a documentary, Eggsploitation. In this day and age, when data is easy to collect and analyze, it’s a shame that we are collecting all kinds of data on what brands of toilet paper people like and who is likely to buy this hat versus that coat, but we can’t collect and monitor data from women who may be risking their lives to help other women make babies.

References

Zarek SM1, Muasher, “Mild/minimal stimulation for in vitro fertilization: an old idea that needs to be revisited,”  SJ.Fertil Steril. 2011 Jun 30;95(8):2449-55. doi: 10.1016/j.fertnstert.2011.04.041. Epub 2011 May 7.