Obesity and sugar-mediated pathologies in the Talmud

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April 11 2016

Obesity and adult onset diabetes (also termed, diabetes mellitus or type 2 diabetes), when coupled with a sedentary lifestyle, are intimately connected as a health risk. In 2011-2012, the Centers for Disease Control and Prevention (CDCP) estimated that 34.5% of all American youth aged 12 to 19 years were either overweight or obese. For adult Americans classified either as overweight or obese, the estimates were 60.3% for 20-39 year olds, 75.3% for 40-59 year olds, and 71.6% for 60 year ols and above (Ogden et al., 2014). In 2011-2012, the CDCP estimated that 29.1 million adults had diabetes (or, 9.3% of the population), with 5-10% displaying type 1 diabetes, which develops early in life as an autoimmune disease. Of American seniors age 65 and older, the prevalence of type 2 diabetes was estimated at 25.9% (Smith, 2016). The connection between obesity and type 2 diabetes is a reflection of high caloric intake of foods rich in fat and sugar, coupled with a sedentary lifestyle.

The connection between obesity and diabetes is best demonstrated in the Yemenite Jewish community 40 years after their immigration to Israel. In 1949 about 100,000 Yemenite Jews immigrated to Israel. While in Yemen this community had a very low incidence of type 2 diabetes, estimated at 0.25% in men and 024% in women. By 1988-1989, the prevalence of type 2 diabetes in Yemenites who settled in Israel rose to 6.2% in men and 3.1% in women. Accompanying these increases in type 2 diabetes were an increased incidence in obesity, especially in women, both of which apparently were due to their change to a western diet (Cohen et al., 1963, 1993; Weingarten et al., 2000). 

Obesity and, perhaps, the sugar-related pathologies, diabetes mellitus and reactive (postprandial) hypoglycemia, are mentioned in the Talmud. In Bava Mezia (83b-84a) note is made of Rabbi Yishmael ben Yose and Rabbi Elazar ben Shimon being so overweight that a pair of oxen could pass under their juxtaposed stomachs without touching them. Although probably an exaggeration, the point was made that both sages were obese. In fact, their wives were described as even larger than them. Today, abdominal lipectomy is performed by plastic surgeons to provide symptomatic, functional, and cosmetic relief for patients with excess abdominal tissue (Semer et al., 2008). Apparently, this is not a novel surgical procedure, as Rabbi Elazar underwent this operation. He was given a sleep-inducing potion (i.e., an anesthetic), brought to a marble house (i.e., a room with walls faced with marble, perhaps to ensure cleanliness), and his abdomen was opened and a number of baskets of fat were excised (Bava Mezia 83b) (Kottek, 1996). Interestingly, this operation was performed prior to the knowledge of sterile technique and the availability of antibiotics.

In Bava Kamma (85a) an incident is described that triggers the Torah principle, “And if men quarrel, and one strikes the other with a stone or with a fist and he does not die but is confined to bed. If he gets up and walks outside on his support, the assailant shall be cleared; he shall give only payment for the loss of his time and he shall provide for his cure” (Shemos 21:18, 19). If person A strikes person B, person A must compensate person B for his loss of wages and for the medical expenses incurred to treat his wound. Our focus is on the word, “only,” which is an exclusionary word. The Tanna Kama questioned about secondary sores which developed subsequent to the main wound, which already healed. Should person A compensate person B for such secondary sores? The gemora clarified the case, in that person B disobeyed his physician’s advice and ate “honey or all types of sweets,” which are harmful to a wound. The wounded area worsened to a condition termed gargusni. So the Tanna Kama’s question whether person A should be obligated to compensate person B, who did not follow his doctor’s advice, causing the wounded region to progress to gargusni. The word “only” teaches that person A only needed to compensate person B for the initial wound and not for the subsequent secondary sores, termed gargusni, which developed because person B did not follow the medical advice presented by his physician. The gemora inquired for the identification of gargusni. Abaye (as explained by Rashi) defined it as “dead tissue.” The gemora inquired of the cure for gargusni and answered that the curative agents were aloe, wax, and resin found in wine barrels, which were smeared on the affected area. Tratner (1982) and Jacobi (1998-1999) suggested that gargusni refers to gangrene and person B was an uncontrolled diabetic. Ardire (1997) noted a case study in which aloe gel was used to treat a gangrenous lesion. 

In the scenario described in Talmud Bava Kamma (85a), the only information provided is that person B ate sweets and was prone to ulcers, nothing is known of whether he was obese or whether he followed a sedentary life style. However, a study by Basu et al. (2013) noted that the occurrence of type 2 diabetes correlated primarily with sugar intake, and was independent of obesity and lack of exercise. If person B was a type 2 diabetic, the advice of the physician to curtail the intake of honey (a concentrated source of sugar) and other sweets was the correct prescription, as their consumption would lead to diabetic ulcers. As noted in Mishlei (25:27), “Eating honey to excess is not good.”

Type 2 diabetics may exhibit recurrent infections (e.g., boils and carbuncles; skin infections) and dysfunctional, prolonged wound healing. Optimal nutrition is needed for wound healing. Leukocytes (i.e., the white blood cells involved in destroying invading microorganisms) require sufficient glucose to produce the ATP needed for chemotaxis and phagocytosis to fight microbial infection. Thus, the wounds of those diabetics lacking sufficient insulin, heal poorly because they are prone to microbial infection. In addition, diabetics are at risk for ischemic wounds, because they are likely to have both small-vessel diseases that impair microcirculation and to have altered hemoglobin with an increased affinity for oxygen and not readily releasing oxygen to the tissues (Huether and McCance, 1996). In the case noted in Bava Kamma (85a), if person B had uncontrolled diabetes, dysfunctional wound healing would be an expected symptom. If left untreated, diabetic ulcers would result and progress to tissue necrosis (Rashi), possibly leading to gangrene.

Rambam may have seen patients with diabetes. Dr. F. Rosner (1984) suggested Rambam was describing diabetes mellitus when he stated, “Individuals in. whom sweet white [humor] occurs are very somnolent [hyperglycemia?]. To those who have an excess of sour white [humor], hunger occurs, then they become extremely thirsty. When this white liquid is neutralized, the thirst will disappear.” In Aphorism no. 69, chapter 8 of The Medical Aphorisms of Moses Maimonides, Rambam described his encounter with diabetics as follows: “Moses says: I, too, have not seen it (diabetes) in the West (either Spain, where Rambam was born or Morocco, where he fled Almohade persecution), nor did any of my teachers under whom I studied mention that they had seen it. However, here in Egypt, in the course of approximately ten years, I have seen more than twenty people who suffered from this illness. This leads to the conclusion that this illness occurs mostly in warm countries. Perhaps the waters of the Nile, because of their suaveness (sweetness?), may play a role in this.”

Possibly, another sugar-mediated disease is noted in tractate Gittin (67b), with chapter 7 commencing with the following case: “If one was seized with kurdiakos and said, “Write a bill of divorce for my wife, he did not say anything,” and he is to be disregarded. Rashi explained that kurdiakos was a type of delirium caused by a demon who possessed someone who drank large quantities of new wine. Rambam, in his commentary to Mishnah described kurdiakos as a type of epileptic seizure that rendered the person incoherent. Hankoff (1972) postulated kurdiakos to be delirium tremens, a severe form of alcohol withdrawal that caused severe mental or nervous system changes.

Yerushalmi Gittin (7:1) described a person with kurdiakos as an individual exhibiting insane behavior, such as sleeping overnight in a cemetery, tearing his clothes, and destroying what is given to him. The mental confusion of this individual is explained using an example of a weaver. While working with black thread the weaver was given a red thread and, apparently being unaware of the change in thread color, continued weaving. In tractate Gittin (67b) the remedy for kurdiakos is for the person to consume lean meat broiled on coals and to drink fresh watered-down wine. 

Dr. Leo Levi (1989) provided a novel diagnosis of kurdiakos, analyzing the features noted in the Talmud as following: (1) symptoms: transient mental confusion (cannot distinguish between black and red thread); (2) etiology: excessive intake of glucose (probably as grape juice, since “new wine” when mentioned in the Talmud was, as yet, unfermented, lacked a significant alcohol content, and had a high sugar content); and (3) treatment: a diet high in protein (lean meat) and low in carbohydrates (highly diluted fresh wine). From his analysis, Levi concluded that this person exhibited the condition termed reactive (postpranial) hypoglycemia. This pathology occurs after consuming a large carbohydrate-based meal, causing the pancreas to over-secrete insulin. The secretion of insulin leads to the removal of glucose from the blood stream and its storage in the liver. Insulin secretion continues much after the digestion of the meal, causing the level of blood glucose to decrease to below normal (i.e., hypoglycemia). Symptoms of hypoglycemia include, amongst others, unclear thinking, confusion, irrational behavior, and disorientation. The accepted treatment for reactive hypoglycemia is a high-protein, low-carbohydrate diet, as noted in the Talmud.

People are people. Obesity and sugar-related health issues are not unique to this generation. As noted in Koheles (1:9), “There is nothing new under the sun.”



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References: Bava Kamma: 85a  

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