“In the last few years, new insights have made it possible to visualize the manner in which upper-body obesity connects to glucose intolerance, hypertriglyceridemia and hypertension, with hyperinsulinemia being the key intermediary. … This article examines these insights and propose (sic) an overall hypothesis for their interrelationships, with the hope that greater awareness of the critical role of upper-body obesity will increase attention to the need to prevent it or, failing that, to correct it.” (1)
In this paradigm-shifting 1989 paper, Dr. Norman Kaplan argues that the frequent coexistence of obesity, hypertension, glucose intolerance (predecessor to diabetes) and hypertriglyceridemia (predecessor to heart disease) suggests a shared pathogenesis, specifically “insulin resistance with hyperinsulinemia, long recognized as a metabolic derangement of obesity.”
From “The Deadly Quartet: Upper-Body Obesity, Glucose Intolerance, Hypertriglyceridemia, and Hypertension” by Norman Kaplan.
Kaplan notes that upper-body obesity (abdominal obesity) is more closely related to metabolic disorders than general obesity. He further illustrates how abdominal fat leads to hyperinsulinemia as the pancreas secretes greater amounts of insulin to regulate glucose levels as insulin resistance develops. The resulting hyperinsulinemia subsequently induces hypertension through its effects on the kidneys, nervous system and vasculature. Finally, larger abdominal fat stores release free fatty acids that lead to hypertriglyceridemia while further worsening hyperinsulinemia through effects on the liver.
Kaplan thus presents this “Deadly Quartet” as a single metabolic pathway that begins with increased upper-body obesity and peripheral insulin resistance and leads to heart disease, diabetes and hypertension. He notes, in conclusion, that interventions which improve insulin sensitivity—including weight loss via certain diets (high-carbohydrate diets are specifically argued against) and exercise—might be the most effective tools to manage and prevent each and all of these conditions.
References
1. Kaplan NM. The deadly quartet: Upper-body obesity, glucose intolerance, hypertriglyceridemia, and hypertension. Archives of Internal Medicine 149(7): 1,514-1,520, 1989.
Comments on Dr. Kaplan and the Deadly Quartet
14 Comments
I love that stuff, and of course I agree mostly. Also, I’m no expert. But in those articles, I often miss the role of muscles. Both muscle mass (glycose storage) and training (use of glycose as fuel). Are there any bodybuilders or endurance athletes with diabetes? Because most of them life of high carb low fat diets. So, carb intake should not be demonized but rather set in relation to activity. Your body needs proteins, your body needs (some) fats, your body needs calories no matter if it comes from carbs or fats, but you only “need” carbs for when you’re active. Right or wrong?
Like most things, the devils in the details. Carbs are not bad - depending on quantity, quality, and timing. Eating a protein heavy breakfast and a carb heavy lunch (watch HS students eat) would not be a good choice - you’re getting all/most of your protein in one setting and likewise for carbs at lunch. So even though the daily macro count would look balanced, this person would be receiving a huge dosing of sugar and insulin at one time, and having to release glucose via the liver and glucagon at another time.