“Metabolic health” may sound like a snooze fest, but it is among our nation’s most serious challenges. The term describes what millions of Americans lack: trim waistlines, good blood pressure and optimal levels of blood sugar, triglycerides and cholesterol. The better-known results include epidemics of diabetes and heart disease, though some people also may develop liver and kidney diseases and even cancer due to poor metabolic health.
Anyone paying attention could be forgiven for thinking that there are two competing responses. The lifestyle response associated with the Trump administration’s “Make America Healthy Again” or “MAHA” movement says that nutrition and exercise are the keys. The medical intervention side prioritizes the use of drugs and surgeries to influence aspects of human metabolism. Both are right, but neither would produce game-changing results on its own.
So, let’s set aside the competition and cue the constructive consensus.
It starts with understanding the basic definition of metabolism, which is the breaking down of nutrients to create energy. It is logical that both the nutrients and the processes involved in breaking them down will determine metabolic health, and that problems can arise on either side of the equation (or both).
MAHA’s emphasis on reducing Americans’ consumption of ultra-processed foods is very positive. Those are the tempting foods that have had the nutritional life crushed out of them in favor of fat, salt and sugar. They challenge our willpower and our evolutionary programming, which tells us to eat as much as we can, when we can. In a world of cheap and plentiful food, the results are weight gain and the familiar litany of metabolic dysfunctions.
Ditto the praise for MAHA’s call to exercise. Getting and staying in motion burns at least some of our excess calories and promotes metabolic balance.
The lifestyle side is right in stressing that governments could do much more in terms of nutritional warnings, school lunch menus, the regulation of food additives and other levers. But America as a whole won’t achieve metabolic health without medical interventions; at least three groups of people would be left behind by lifestyle changes alone.
The first group simply needs help over the finish line. We all know someone — or are someone — who went through a diet and exercise conversion but still cannot achieve those ideal measures of metabolic health. Interventions such as bariatric surgery and the pharmaceutical industry’s cholesterol-controlling drugs and remarkable new weight-loss treatments can be essential legs up for these many people.
The second group includes those who have already suffered the consequences of metabolic dysfunction. Lifestyle changes can ward off diabetes, heart disease and liver problems in some people but cannot always control or reverse the damage already done. Medical interventions offer these people the best chances of holding their own.
Finally, there is a group of people whose metabolic processes just don’t work properly, despite avoiding lifestyle risks. Problems with the breakdown of nutrients via our bodies’ natural processes, including what we call “regulation” of energy metabolism, can have genetic and environmental causes entirely beyond the control of individuals. In some cases, the problems manifest in unexpected ways, including autoimmune disease or unchecked inflammation.
The company I work for, focuses increasingly on this group of people. Our study of one enzyme called ACLY in the energy-regulation cycle led us from helping the first group with a novel cholesterol treatment to detecting a possible link between the same enzyme and a liver disease called Primary Sclerosing Cholangitis, which has no apparent lifestyle causes.
This disease involves inflammation and fibrosis of the liver and bile ducts, eventually leading to liver failure. It is considered a “rare” disease in the sterile terminology of public health, but more than 40,000 American sufferers (and counting) have only 10-20 years between diagnosis and the need for a liver transplant, or death. Only a new treatment will change this prognosis.
You can see why I reject any disconnect between lifestyle and medical interventions. If not for our understanding of the interplay between nutrition, biological processes and targeted treatments, we would not have been led to a possible Primary Sclerosing Cholangitis treatment.
Underneath recent rhetoric, MAHA and the biomedical industry know that they belong together. We need to start saying as much. It is time to stop arguing and to put those energies back to work toward saving lives.
Stephen Pinkosky is the vice president of early and preclinical drug discovery at Esperion Therapeutics, Inc., in Ann Arbor, Mich.
