Which two diseases kill the most people worldwide?
Heart attack and stroke.
Hands down, these are the two biggest culprits according to the CDC. But they are not inevitable. They don’t have to happen to you. To a great degree, these diseases can be prevented, or at the very least, their progress slowed.
Keep in mind that the best treatment for disease is prevention.
To prevent disease, however, we must be able to identify risk factors for disease. And yes, there are non-modifiable genetic factors at hand—when it comes to genetic risk factors, some people are dealt a bad hand. What’s shocking is that globally we can’t even control two of the biggest—and preventable—risk factors for vascular disease in general: insulin resistance (pre-diabetes) and hypertension (high blood pressure). Why? One reason is that these two often fly under the radar for long periods of time prior to their being discovered. Hypertension and insulin resistance are silent killers, remember. They can do their damage quietly and insidiously, long before someone experiences any symptoms. It is not uncommon for a patient to show up in the ER with previously undiagnosed hypertension and a large hemorrhage in the brain. Or from a heart attack, or in a coma from previously undiagnosed diabetes.
Another related reason is that in general, surveillance is poor.
We simply are not aggressive enough. Have you asked yourself the question, “What risk factors for disease do I have?” No? Not good. Don’t for one second think that your doctor is going to be able to discover all your risk factors and save you in the nick of time. More often than not, that doesn’t happen. The bottom line: you have to assume responsibility for your own health.
Given the prevalence of both high blood pressure and insulin resistance, I recommend that everyone self-monitor themselves for the early signs of these potentially deadly problems. It’s easy, and you can do it right in the comfort of your home. And no, you can’t leave all of this up to your doctor. Those of you who think that you can wait for your annual check-up are making a terrible mistake. A lot can go wrong in the year or two between visits to the doctor. Procrastination will kill you. Also remember, you are never too young or too old for good health (my residency chairman used to say that).
Why Too Much Insulin Is Very Bad
Big Risk Factor #1: Insulin, excess insulin to be specific. Insulin isn’t just a risk factor for diabetes. Unhealthy levels of this hormone are a player in both heart attack and stroke, along with a whole host of other diseases. It is crucial for you to acquire an understanding of insulin, the stimuli for its secretion and its bodily effects, some good, others bad.
Insulin is secreted by the pancreas in response to the sugars we eat. It increases the concentration of glucose (sugar) receptors on cell membranes. The receptors subsequently bind the glucose molecules (in the blood) and transport them into the cell. The cell’s machinery utilizes glucose to produce ATP (adenosine triphosphate) or cellular energy. In the absence of insulin, one cannot utilize glucose as a fuel source. Remember, for the most part, we are burning either sugar or fat for energy! Juvenile (type I) diabetics secrete little if any insulin, and therefore have to inject the hormone in order to drive sugar into their cells to control blood sugar. Failure to do so WILL result in accelerated aging, early disease onset and potentially death from what is termed ketoacidosis.
Type II diabetes (aka adult onset diabetes) is characterized by insulin resistance in which is a surplus of circulating insulin. So why are they “diabetic”? It seems counterintuitive. Shouldn’t that excess insulin drive sugar into their cells and cause hypoglycemia or low blood sugar? It should yes, if one has normal insulin sensitivity. But type II diabetics don’t. Their cells are resistant to insulin, resulting in more insulin being required to drive circulating glucose into cells (where it is ultimately oxidized or burned). There is resultant elevation in both circulating insulin and blood sugar, both of which are pro-inflammatory. More inflammation equates to accelerated aging and early disease onset, right? You see, insulin is toxic to the blood vessel lining, and excess sugar induces the formation of what are referred to as advanced glycation end- products, or AGE’s, glucose-protein complexes that accumulate within blood vessel walls. Cumulatively, these two factors narrow blood vessel diameter, ultimately resulting in atherosclerosis. This accelerated atherosclerotic process is the root cause of premature stroke, heart attack and organ (kidney, eye) damage observed in diabetics.
The associated inflammatory state further exacerbates the vascular damage associated with the disease. Diabetes is a vascular disease, period. Patients succumb to the vascular complications of the disease (stroke and heart attack for example), NOT to the elevated blood sugar as a discrete entity (except in cases of ketoacidosis).
Again, diabetes is a disease that affects the blood vessels. And while it occurs mostly in overweight adults, diabetes can and does occur in individuals with normal body fat levels. So do not assume that your fasting blood sugar and your insulin sensitivity are normal just because you’re thin. CHECK THEM! How? With a glucometer. These small micro-processor based devices can be purchased inexpensively at virtually every pharmacy. I cannot overstate their value. With one, you can easily gain a handle on your insulin sensitivity and make efforts to optimize it.
You Can Do These Tests At Home.
Here are two tests that you can do by yourself at home: a Fasting Blood Sugar (glucose) and a Glucose Tolerance Test.
[Note: The fasting blood sugar incidentally is included in the BASIC METABOLIC PANEL obtained prior to your initial clinic visit.]
No, you don’t need your own at-home laboratory. All you need is a glucometer, a small, portable device about the size of a smartphone that measures the concentration of glucose in the blood. Most of the available glucometers are accurate and highly reliable. All include detailed instructions. Truth be told, they are very simple to use.
- FASTING BLOOD SUGAR:
Your morning finger-stick glucose (after an 8 hour fast). This test is a rough indicator of insulin sensitivity. Optimal values are 70-85 mg/dL. We’ve all been told that “less than 100 is good.” That’s incorrect. 99 mg/dL is one click away from pre-diabetes.
Even people with modest elevations in fasting glucose (above 85 mg/dL) are at increased risk of a heart attack. This was demonstrated in a study of nearly 2,000 men where fasting blood glucose levels were measured over a 22-year period. Men with fasting glucose over 85 mg/dL had a 40 percent increased risk of death from cardiovascular disease.
You are considered pre-diabetic (insulin resistant) if your fasting serum glucose is > 99 and diabetic if it is > 125 on two serial fasting glucose tests. Either of these conditions places you at elevated risk for vascular disease, and accordingly heart attack, stroke and cancer. And it sneaks up on you! Typically, pre-diabetes (insulin resistance) is asymptomatic. This is precisely why EVERYONE should own a glucometer! It’s too late when you’ve been transported to a local ER having lapsed into a hyperglycemic coma! A glucometer allows for early identification of this potentially lethal disease. Don’t hesitate! Buy one today and perform this second test to gain an even better assessment of your insulin sensitivity.
- GLUCOSE TOLERANCE TEST (GTT):
There are numerous studies that demonstrate the harmful effects of elevated postprandial (after-meal) glucose. In fact, poor glucose tolerance (a measure of insulin sensitivity) may result in severe cardiovascular system morbidity seen in diabetics. Part and parcel, there is a direct association between 2-hour postprandial glucose and carotid artery intimal medial thickness (wall thickness), a feature of atherosclerosis. Let me put it in more basic terms: if your 2 hour post-meal blood sugar is elevated, the more likely you are to be damaging your arteries. Similarly, “food comas” are indicative of elevated postprandial blood sugar and elevated insulin levels, both of which are toxins to the endothelium (blood vessel lining
How efficiently your body clears glucose from your bloodstream (returning blood sugar levels to that of a fasted state) is a direct function of your insulin sensitivity. Insulin is secreted by the pancreas in response to a sugar load (75g in the case of the oral glucose tolerance test for adults). Glucose receptors (cell membrane proteins with an affinity for the glucose molecule) migrate to the cell surface (from inside the cell) and attach to passerby glucose molecules in the bloodstream. The glucose molecules are then internalized and utilized to generate cellular energy (ATP).
There is dysregulation of this process in the diabetic state. Specifically, glucose transport into the cell is impaired. Such insulin “resistance” causes a reactive hyperinsulinemia (i.e., more insulin is secreted by the pancreas in order to drive glucose into the cell). Again, insulin is toxic to the lining of the blood vessels and it stimulates adipogenesis (synthesis and storage of fat), so it is crucial that we maintain low levels of circulating insulin chronically. How? By maintaining a high degree of insulin sensitivity. Therefore, for a given sugar load, one would ideally secrete the least possible quantities of insulin to return serum glucose to normal fasting levels.
A glucometer allows for early identification of the potentially LETHAL DISEASE, diabetes mellitus.
How does one maximize insulin sensitivity?
Resistance training, stress reduction and proper nutrition, of course. Minimize post-prandial glucose spikes with low glycemic index complex carbohydrates. This will reduce the incidence of “hyperinsulinemic” states, as will adding muscle to your body. And why is muscularity so important? Because muscle, in addition to its role in locomotion and postural maintenance, serves as a depot for both protein and glycogen (a polymerized form of glucose). Glucose is taken up by muscle cells (via the aforementioned receptor-mediated process) in response to its utilization during exercise, specifically intense resistance training. By virtue of this, muscle serves to lower serum glucose and improve one’s insulin sensitivity. If you hadn’t figured it out by now, muscle serves many beneficial metabolic roles.
The oral glucose tolerance test does not need to be performed in a doctor’s office as you may have been told. And yes, for wondering mothers out there, it is exactly the same test you had while you were pregnant, at the doctor’s office. You can easily perform the test at home however, and obtain a baseline to which future studies will be compared.
- After an 8-12 hour fast (during which all medications and supplements are withheld), obtain a baseline glucose level using your glucometer. This is your fasting glucose.
- Obtain a 75-gram (2/3 cup) glucose drink (readily available online or in select health food stores). Drink the entire solution within a 5-minute period (or less) else the test results will be inaccurate. You are now at “time 0.”
- Test and record your blood glucose at time “1 hour.”
- Test and record your blood glucose at time “2 hours.”
- Test and record your blood glucose at time “3 hours.”
NOTE: DO NOT EXERCISE DURING THIS 3-HOUR PERIOD AS THIS WILL AFFECT THE TEST RESULTS.
Remember, the above results are “ideal” or optimal. Do not panic if your numbers do not fall into the “ideal” category, but do something about it! Why? Because you can! Type II diabetes is a preventable disease. Let me mention again, you are considered pre-diabetic (insulin resistant) if your fasting serum glucose is > 99, and diabetic if it is > 125.
It is likely that your glucose tolerance test will be abnormal if your fasting glucose is elevated, as the former is a sign of insulin resistance (barring other confounding factors such as stress and overtraining). Should this be the case, you must seek medical attention. And you must make every effort to improve your insulin sensitivity through proper nutrition (and the associated weight loss), resistance training and stress reduction techniques to name a few.
Remember, diabetes is the underpinning of a variety of lethal diseases, such as coronary artery disease and cancer. Yes, cancer! In this context, does it surprise you that the diabetes drug metformin significantly reduces breast cancer incidence in post-menopausal women? The oral glucose tolerance test may be repeated to monitor your progress. Graph your results (glucose versus time). Shoot for the “ideal” numbers at all hourly points in time.
Why Track Your Blood Pressure?
Big Risk Factor # 2: High blood pressure, the “silent killer,” affects 1/3 of the adult US population. As noted earlier, it is a major risk factor for heart attack and stroke. That’s why everyone should own a blood pressure cuff and take their BP at home. It’s a cheap piece of home medical equipment that can save your life. Without it, you won’t be able to catch high blood pressure in its earliest phase, when simple life style interventions can do the trick.
You don’t go from normal BP to high BP overnight. It simply doesn’t just ‘pop up on you.’ The vast majority of cases take years to develop; it slowly creeps up on you. And this to some degree confers protection. How? Because it can be identified early, and it increases in a predictable pattern. Year after year, blood pressure slowly trends upward as arteries stiffen. We know this. This can be tracked and you can intervene early! Prior to your first heart attack.
Hypertension, or high blood pressure, occurs when the resistance to blood-flow away from the heart increases. This occurs for a variety of reasons, some of which are genetic, but most are environmental and therefore modifiable. Remember too, that there are very complex interactions between one’s genome and the environment; therefore risk factors are not mutually exclusive. Eating a high salt diet does not necessarily mean that you will develop hypertension, contrary to what you have been told—only about 1/3 of the population is salt sensitive. How many people do you know that eat poorly, are obese, yet have normal blood pressure? I know plenty of them. This is clearly due to factors other than the environment (i.e. dietary salt intake).
That being said, we as individuals still have a significant amount of say in where our blood pressure falls on any given day. Those that are “salt sensitive” for example, will respond dramatically to low salt, high potassium diets. Some will not however, requiring a different treatment approach. No matter, the bottom line is that blood pressure needs to be in check. As was discussed in the Supplement chapter, the Framingham Study data demonstrated an increasing relation between systolic blood pressure and all-cause, cardiovascular mortality. More simply stated, the higher your blood pressure, the more chances you have of succumbing to a heart attack, period. Seems logical, right?
Well it is!
What Is Normal?
Normally, blood pressure should be less than 120/80.
Refreshing your memory, the top number, or “systolic,” is the pressure in the arteries when the heart beats (when the heart muscle contracts), while the bottom number, or “diastolic,” is the pressure in the arteries between heartbeats (when the heart muscle is relaxing between beats and refilling with blood).
Hypertension is defined as serial blood pressure readings of 140/90 or more, according to the American Heart Association. According to its website, blood pressure screenings should begin at age 20. Why? As discussed previously, high blood pressure does not develop overnight. Typically it is years in the making. That being said, pre-hypertension is defined as systolic pressure of 120-139 or a diastolic of 80-89. “Or” rather, one or the other. If you qualify as pre-hypertensive based upon serial blood pressure readings, do not take this lightly.
This is potentially a harbinger of things to come if left untreated. Deny denial! Blood pressure is an easily tracked and modifiable risk factor once a baseline is established. So, head down to your local pharmacy and purchase a properly fit home blood pressure monitor. I don’t care how old you are. Do it!
This next step is very important.
I want you to bring the cuff to your doctor’s office or to your health care practitioner. Have a member of the medical staff take your blood pressure, as per norm, using the manual cuff. Several minutes later, retake your blood pressure (in the same arm) with the purchased home monitor. Note the differences between both systolic and diastolic pressures, between the manual cuff and the home monitor. This is the offset or a rough measure of the inaccuracy of your monitor. A manual blood pressure as performed by a trained medical professional, is the most accurate non-invasive measurement, and therefore is considered the gold standard against which your home monitor may be calibrated or standardized.
In light of the inherent inaccuracies of the portable home units, I use them to track trends for the most part. Yes, I am always aware of the offset value and accordingly the blood pressure as an absolute number, but more concerning to me is where my blood pressure is relative to where it was. My personal goal is a 110/75. Yours should be similar regardless of age if you are currently normotensive. Some of you, women in particular, may have even lower pressures. Good for you! Stay right where you are! Use your monitor on a weekly basis and track your blood pressure over time. Chart it. This is not overkill. This is diligence and a requirement for health. Don’t assume that a one-time normal blood pressure reading exonerates you from routine surveillance. Remember, arteries stiffen or lose their compliance over time. So get a jump on it, and should your blood pressure start trending upward, consult with your doctor to talk strategy.
Those pre-hypertensive and hypertensive among you (33 percent of American adults have hypertension) have got some work to do. Track your blood pressure daily. Aim to normalize your pressure over time; you should know how by now. Those of you on anti-hypertensive medications, attempt to wean yourself off one med at a time (except for maybe an ACE inhibitor or β-blocker). If you are heavy, lose weight. I guarantee you will shed at least one medication as your bodyweight normalizes.
Case in point is the patient who undergoes bariatric surgery and loses a significant amount of weight. Blood pressure often normalizes obviating the need for medication. This was best exemplified in a study cohort of 1,025 patients who underwent gastric bypass surgery: 66 percent had normalized their blood pressure (and maintained it) at year 5 postoperatively. Interestingly, 86 percent of patients also experienced resolution of diabetes. Resolution! This data suggests that insulin resistance and hypertension may be indirectly related to each other through the effects of obesity. In fact, this cluster of risk factors is termed the Metabolic Syndrome, or Syndrome X. While there are various defining criteria for Metabolic Syndrome, all definitions include insulin resistance (impaired glucose tolerance), hypertension and obesity. And these are things that you can test for at home!
High Blood Pressure Can End Badly.
Hypertension, particularly chronic hypertension, is a major risk factor for stroke, heart attack, congestive heart failure, peripheral arterial disease and is also a cause of chronic kidney disease. Why? As stated previously, elevations in arterial pressure traumatize the blood vessel lining and promote the development of atherosclerosis. Remember, the inciting event in the atherogenic (plaque forming) process is blood vessel injury. By walking around with high blood pressure, you are damaging your arteries! Let me repeat that, you are damaging your arteries as you read this if your blood pressure is high. This is akin to the damage inflicted by a high glycemic load meal. In fact, hypertension and diabetes go hand and hand as both diseases afflict severe damage on the vascular system.
The vascular damage inflicted by hypertension is not what ultimately causes the problem, however. It’s the body’s response to the injury that kills us: atherogenesis or plaque formation.
This is a very intricate, multifactorial, inflammatory process. This shouldn’t surprise you. Damage invokes inflammation, right? It’s a normal response to injury. Consider for a second how the body heals a surgical incision. White blood cells are brought into the area in response to chemical messengers released from the injury site (incision). The area is cleaned of debris and growth factors stimulate cellular proliferation. Collagen, the material from which scars are made, is laid down. All this in response to an injury, acutely. So why should the inner lining of a blood vessel be any different? Well, there are some differences (for example, cholesterol is used as the reparative substance) but the processes are very similar. Unfortunately, the end result is narrowing of sometimes crucial blood vessels that supply arterial blood to the heart or brain (the brain, of course is more important to a neurosurgeon). If this narrowing exceeds a critical threshold... heart attack or stroke results respectively.
What is the underpinning of this process?
I snuck it in, in the above paragraph, in case you didn’t see it. Well, the atherogenic process is no different than any other pathophysiologic process. Think hard. Inflammation, chronic inflammation.
We’ve discussed how inflammation is a promoter in diseases such as cancer, diabetes and autoimmune processes (lupus and multiple sclerosis, for example). Vascular disease is no different. Arthritis, same thing. And the two are very much related. Think about it. With arthritic processes such as cervical spondylosis (arthritis of the cervical spine or neck), the spinal canal or tunnels through which the nerves exit the spine become narrowed.
Once this narrowing or stenosis reaches a critical threshold, patients develop symptoms such as pain, weakness or numbness in an extremity, sometimes necessitating surgery. Decompressive spinal surgery is a large part of my practice. Vascular disease, in a similar vein (no pun intended) is manifested as angina or myocardial infarction (heart attack) when it affects the coronary arteries or claudication (leg pain or numbness) when it involves the peripheral blood vessels. You’ve heard of PAD, right? On those commercials? This stands for Peripheral Arterial Disease. Basically your limbs are becoming ischemic or deprived of needed blood. Muscular demand for oxygen is not being met because of critically narrowed and stiffened blood vessels.
Why? Chronic inflammation from chronic vessel wall injury. Treating inflammation with supplements such as omega-3 fatty acids and pharmaceuticals such as aspirin, is integral to the management of both arthritis and vascular disease. And I use them aggressively in my practice. Surgery is a fix when all else fails, but one that is not treating the etiology of the disease. Unfortunately, some patients present to the office far along into the disease course and require surgery due to weakness or debilitating pain, for example. This parallels a patient presenting to the ER with crushing chest pain and a first time heart attack. That individual is destined for a heart catheterization and most likely an angioplasty.
The cat is long out of the bag at this point. And why is this? Why are so many afflicted? Heart disease is preventable for the most part. Yes, according to a study performed by the Harvard School of Public Health, “82 percent of heart attacks were attributable to failure to follow a healthy lifestyle that includes exercise, good eating habits, and abstinence from smoking.” The study cohort of 84,129 women was followed over a period of 14 years.
Whether they knew it or not, the nurses were modifying modifiable risk factors, hypertension (and the resultant inflammation) being one of them, through diet and lifestyle choices such as exercise. And you can too! In fact, you have technology at your fingertips that will allow for identification of a multitude of risk factors, many of which can be modified. These include glucometers, smart phone-based exercise and sleep trackers, as well as home blood pressure monitors. This is in addition to the myriad of laboratory tests (discussed in the next chapter) that will allow one to assess for biochemical markers of disease.
The Double Whammy: High BP, High Insulin
The combination of high blood pressure and insulin resistance can lead to Metabolic Syndrome, a condition which affects 44 percent of the U.S. population older than 50. It is bad news at any age.
Metabolic Syndrome is associated with a variety of diseases such as type II diabetes, coronary artery disease, PAD, and rheumatic diseases, psoriatic arthritis for example, and aging in general. Does this surprise you? Metabolic Syndrome is simply a cluster of risk factors that, in a synergistic manner, amplify your chances of developing a fatal disease. Its etiology has yet to be elucidated, but as you may have surmised, inflammation is suspected to be a major player. This is mediated by the effects of various cellular messengers or cytokines secreted by... fat cells, particularly those that surround your organs. Yet another shocker! Reduce fat, reduce bodily inflammation and reduce your propensity for disease. Are the aspirin and metformin making more sense now?
Whether it’s a single disease risk factor or Metabolic Syndrome, do everything in your power to eliminate it. Start with lifestyle modifications such as diet and exercise. Get Serious about your health! Do not wait until more risk factors accumulate. Use the home monitors as the barometers of your effort, as your personal guides to treatment. You will notice gradual changes in your fasting (AM) glucose for instance. Check this on a weekly basis. And chart it. Your fasting glucose (and the glucose tolerance test) is a measure of your insulin sensitivity, and to a great degree, your health. For most of you, as fat is shed, insulin sensitivity will improve, and so will your waist line. You will see the progress right on your glucometer!
Ultimately, technology will allow us to measure far more than blood sugar from the comfort of our home. Detailed biochemical testing will migrate from the doctor’s office to your doorstep. Tricorder anyone?