Insulin and triglyceride levels after different breakfast meal challenges – measurement in dried blood spots (DBS)

I wish to share with my readers an interesting study that the ZRT research team presented recently at the 7th Annual World Congress on Insulin Resistance in San Francisco and won a Bronze Award among appox. two hundred abstracts submitted for competition.

Postprandial insulin and triglyceride (Tg) levels have been suggested as potential clinical tools to help identify individuals at high risk of atherosclerosis and coronary heart disease. Published studies have used a variety of meal types. We investigated the effects of 5 different breakfast meals on postprandial insulin and triglyceride levels, to see if meal type elicited different responses and to help identify a suitable protocol for routine risk assessment.

Blood spots were obtained by finger stick from 19 healthy volunteers after a overnight fast and then 2 hours after eating each of 5 breakfast meals. At least 1 week elapsed between each test meal. After collecting blood spots on a filter paper, they were allowed to dry and stored at room temperature until analysis. 6-mm disks were punched from the dried blood spots into 96-well plates; insulin was assayed using modified serum ELISA assay kits after extraction with extraction buffer, and Tg were assayed using an enzymatic assay following extraction with methanol . The DBS assay correlates highly with simultaneous serum testing, demonstrated in a previously published study. The serum/DBS correlation coefficients for insulin and Tg in that study were r=.93 and r=.91 respectively.

For statistical analysis, insulin and Tg levels were categorized as either normal or abnormal; within the “normal” classification, they were further categorized into “optimal” or “non-optimal”. For insulin, values >15 µIU/mL were “abnormal” and >8 µIU/mL were “non-optimal”, while for Tg, >150 ng/mL was “abnormal” and >100 ng/mL “non-optimal”. Using a Wilcoxon paired sign test, outcomes for each meal were compared to all other meals.

Insulin levels at 2 hours showed a difference in response depending on meal composition. Postprandial insulin appears to correspond to overall carbohydrate content; more abnormal/non-optimal results were seen after meal 4 (highest carbohydrate content) and the fewest abnormal/non-optimal results were seen after meal 2 (lowest carbohydrate content), despite the fact that meal 2 had the highest fat content and the most overall calories. Sustained, higher than optimal insulin levels 2 hours after eating could represent an additional cardiometabolic risk factor, even in individuals whose fasting levels are normal. Dietary choices may therefore increase a person’s chances of postprandial dysmetabolism. In non-diabetics, high postprandial insulin levels are an independent risk factor for coronary artery disease.

Tg levels at 2 hours did not differ significantly between meals, although only about half the values seen were in the normal range. We know from the literature that Tg levels tend to peak around 4 hours postprandially, and in our subjects Tg was still rising after the 2 hour measurement. A 4-hour sample may have elicited a between-meal difference, but compliance issues with collecting a sample 4 hours after eating might preclude postprandial Tg as a routine clinical test.

Convenient, in-home collection of DBS offers a simple tool to research the phenomenon of postprandial dysmetabolism. Assessment of DBS insulin levels 2 hours after a meal may help identify risk in individuals whose fasting levels are normal, and can indicate whether routine dietary choices are exposing them to greater risk than necessary.

Following is the abstract of the study that was presented at the conference.

Insulin and triglyceride levels after different breakfast meal challenges – measurement in dried blood spots (DBS)

Sonia Kapur, Margaret Groves, David Zava, Sanjay Kapur
ZRT Laboratory, Beaverton, Oregon, USA.

The metabolic conditions that predispose individuals to atherosclerosis are thought to be a postprandial phenomenon, termed “postprandial dysmetabolism”. In non-diabetics, high postprandial insulin and triglycerides are independent risk factors for coronary artery disease and cardiovascular events.

Pre- and postprandial serum testing for insulin and triglycerides is inconvenient for patients and practitioners, limiting routine application of these tests and their use in large scale clinical studies.

We developed finger stick DBS tests for insulin and triglycerides that correlate highly with venous serum values (r=.93 and r=.91 respectively), and evaluated these analytes in DBS from 19 healthy volunteers after an overnight fast, before and 2 hours after eating 5 different breakfast meals.

Meals consisted of: 1) glazed donuts, fruit smoothie; 2) boiled eggs, sausages, 2% milk; 3) bagel, cream cheese, boiled egg, 2% milk; 4) pancakes, syrup, tea with cream/sugar; 5) oatmeal, almonds, apple, skim milk.

Postprandial insulin levels >8 µIU/mL were classified as “non-optimal” while >15 µIU/mL were “abnormal”; triglyceride levels >100 ng/mL were “non-optimal” and >150 ng/mL “abnormal”.

For insulin, meal 2 (lowest carbohydrate, highest protein) produced the best (fewer abnormal/non-optimal) postprandial results and meal 4 (highest carbohydrate, lowest protein) the worst (more abnormal/non-optimal) postprandial results. For triglycerides, no meal differed significantly from the others in the number of abnormal or non-optimal classifications.

The convenience of in-home collection and analyte stability offer much wider scale use of the DBS tests for routine clinical assessment and large scale epidemiological studies of postprandial dysmetabolism.

Stress and Hypertension

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Testosterone and Men's Health

New Definition of Metabolic Syndrome

Did you know the new definition of Metabolic Syndrome? Did you know that waist circumference is now one of five criteria that physicians can use to diagnose metabolic syndrome?

The ATP III guidelines earlier did not consider the waist circumference as an important criteria, to diagnose metabolic syndrome, but a recent statement published online on October 5, 2009 in Circulation actually is a step forward to streamline the use of abdominal obesity in determination of risk of developing metabolic syndrome. The new statement on metabolic syndrome is a combined effort by International Diabetes Federation (IDF), the National Heart, Lung, and Blood Institute (NHLBI), the World Heart Federation, the International Atheroschlerosis Society, and the American Heart Association (AHA).

According to the new definition, people with any three of the following five criteria are considered to have the metabolic syndrome:
1. Increased waist circumference (population and country specific cut points)
2. High triglycerides (≥150 mg/dL)
3. Reduced HDL cholesterol (<40 mg/dL for males and <50 mg/dL for females)
4. Elevated blood pressure (Systolic ≥130 mm Hg and/or diastolic ≥ 85 mm Hg
5. Increased fasting glucose ≥ 100 mg/dL

Cardiometabolic Health Congress 2009: Some Important Lessons Learned

I just returned from Boston after attending the Cardiometabolic Health Congress 2009 and thought I would quickly share with my readers some of the important take home messages from the meeting. I will keep adding information to this post as and when I remember additional information that I learned at the conference. So, keep coming back for more and also I would really appreciate any comments or questions.

• Obesity and Central adiposity are the leading drivers of Cardiometabolic risk. Intra-abdominal obesity is now emerging as a new therapeutic target in cardiometabolic risk management.

• What is causing the epidemic of obesity and why is it so difficult to treat obesity? The reason is that the weight is controlled by a feedback system and so the plateau is caused by compensation ia parts of the system we can’t control.

• Important biomarkers to measure- CRP, triglycerides, LDL, HDL, HbA1c, blood pressure, waist circumference.

• High waist circumference is associated with several cardiovascular risk factors. High waist circumference is an easy measure of intra-abdominal obesity, which is characterized by accumulation of fat around and inside abdominal organs.

• Fat cells (adipocytes), especially in the abdomen are metabolically active endocrine organs, and not just an inert fat storage. Excess adipose tissue leads to increased expression of some hormones, suppression of others, thereby causing inflammation and disease.

• Excess adipose tissue in the abdomen attracts and activates macrophages, which leads to chronic inflammation and adipocyte insulin resistance.

• Adipose tissue products cause insulin resistance and inflammation. Adiponectin, which has been characterized to have anti-inflammatory properties, its levels are reduced in obesity; PAI-1 levels are increased in diabetes; CRP levels are increased in diabetics.

• Peptide hormones are known to have a physiological role in regulating energy balance. For example, Ghrelin in stomach; GIP, GLP-1, Somatostatin in intestine; Insulin, Glucagon, Amylin and Pancreatic Polypeptide in Pancreas; Leptin and Adiponectin in Adipose tissue.

• Standard small molecule oral therapies of type 2 diabetes are always associated with significant side effects and weight gain. Some newer peptide hormone analogues and combinations were shown to offer better future therapies for type 2 diabetes.

• Hypertension is a major component of cardiometabolic risk and Beta-Adrenergic –blocking drugs might have some important role in management of patients with hypertension. At the meeting some data was presented showing that beta-blockers with vasodilating properties have advantages over traditional beta-blockers in terms of less side effects.

• Diabetes prevention: We can do better by…Maintaining awareness of diabetes risk and also by developing strategies to more efficiently and effectively applying therapeutic lifestyle interventions.

• Answer to obesity related problems is Prevention and Lifestyle modification. It is important to understand the importance of physical activity, and how much and what type of exercise provides benefit. Location and measure of fat may have implication for impact of exercise training.

• Which is a better measure of risk- Waist circumference or Waist/ Hip ratio? Waist circumference is better predictor of overall risk and a better marker to monitor weight loss, especially in women because when they lose weight, they lose it both in waist and hip, so for this reason Waist/Hip ratio does not work as a sensitive predictor.

• What should be the Physician’s role in obesity management, especially in children? Physicians should track BMI in children and talk to their parents; recommend prevention plan that includes diet with more fruits and vegetables, diet rich in calcium and fiber, less consumption of energy dense foods, daily breakfast, reduced TV and other screen times; actively engage parents in the prevention and management program; recommend maintaining weekly goal cards to monitor progress.

• Few additional recommendations:
o Limit eating out in restaurants and no fast food.
o Encourage family meals meaning parents and children eat together.
o Use fast food trade off information sheets to find healthy alternatives.
o Limit portion sizes.
o Limit sweetened drinks.
o Promote physical activity at least 60 minutes per day.
o Use pedometers to monitor daily walking (should be close to 10, 000 steps every day).

Transdermal Delivery of Estrogen and Progesterone Improves Blood Pressure in Menopausal Women with High Stress

A new study from Dr. Kenna Stephenson’s laboratory at the University of Texas Health Science Center, Tyler, Texas in collaboration with ZRT laboratory in Beaverton, Oregon on the role of estrogen and progesterone in hypertension in menopausal women, will be presented at the 63rd High Blood Pressure Research Conference 2009 (Sept. 23- 26, 2009) in Chicago. I will be at the conference along with Dr. Kenna Stephenson to present this data. The study shows that luteal phase levels of progesterone and estrogen via transdermal delivery improve blood pressure in perimenopausal and menopausal women with prehypertension and job/ home strain.

Perimenopausal transition and menopause have been associated with hypertension but the underlying reasons for increased risk for high blood pressure in these women is not very clear. Several different factors like weight gain, loss of energy, depression, alcohol consumption, job/ home stress have been linked with increased risk for high blood pressure in menopausal and postmenopausal women. Women with high job/home strain are more vulnerable to hypertension, and the clustering effect of metabolic changes, inflammation, dysphoria, and high perceived stress are emerging as gender specific attributes of cardiovascular disease in women.

It is believed that during menopause, the circulating estrogen levels fall and the interplay of progesterone and estrogen levels increases the overall risk of hypertension in women. This new study from Dr. Stephenson’s laboratory involving experimental females demonstrate the profound impact of luteal phase progesterone and estrogen levels on endothelial function, vascular smooth muscle tone, and optimal homeostatic regulation. The effects of mimicking luteal phase progesterone/estrogen ratios on blood pressure and gender specific biomarkers in peri/postmenopausal were investigated.

70 women (mean age 51.9 years) who met strict inclusion/exclusion criteria were treated with transdermal progesterone and estrogen titrated to physiological luteal phase reference ranges. Subjects were required to abstain from food or beverage for 10 hours prior to visits. After resting for 30 minutes in a quiet room, blood pressure was measured at the brachial artery using a validated semi-automated oscillometric sphygomonamometer.

It was observed that while the overall life strain in these women was high and remained high for 8 weeks, transdermal progesterone and estrogen treatment caused significant reduction in blood pressure; progesterone and PG/E ratios were also significantly elevated.

Recognizing the critical role of sex steroids in the vasculopathology of perimenopausal and menopausal women may provide a plausible gender specific approach to prehypertension. Whereas conventional hormone therapies have been shown to increase blood pressure and cardiovascular disease risk in women, findings from this study reveal that appropriate modulation of the hormonal milieu via transdermal physiological sex steroid therapy lowers blood pressure and may potentially buffer the adverse effects of high perceived stress and strain without inducing adverse effects on cardiovascular biomarkers.

Hemoglobin A1c to Become a Preferred Test for Diagnosing Diabetes

More than 8% of the US population, which means about 24 million people in this country are diabetic. The prevalence of diabetes is increasing and the number of diagnosed cases of diabetes is expected to reach 35 million by the year 2030.

The American Diabetes Association (ADA) along with the European Association for the Study of Diabetes and the International Diabetes Federation, is strongly considering recommendation of using the Hemoglobin A1c (HbA1c) test as a preferred test for diagnosing diabetes. Many physicians have already been using this test either as an alternative screening tool to diagnose diabetes or as an additional confirmation test for diagnosis. The conventional practice has, so far, used fasting plasma glucose and oral glucose tests to diagnose diabetes, but patients and their doctors do not find these tests very user friendly. Back in the year 2003, the International Expert Committee, including ADA did not recommend using the HbA1c as a screening tool to diagnose diabetes, because different clinical laboratories produced variable results and did not have standardized methods of measurement of HbA1c. However, initiatives by National Glycohemoglobin Standardization Program (NGSP) have improved consistency in the measurement of HbA1c by different laboratories. This move has made the experts to re-consider using the HbA1c test as a diabetes screening and diagnosing tool.

According to many experts, including Christopher Saudek, MD, professor of medicine at Johns Hopkins University School of Medicine in Baltimore, this is an easy to use test, which will be able to help diagnose more patients with diabetes, much earlier in the course of the disease. At this time, unfortunately, almost 40% of the cases remain undiagnosed, and one major reason for this is that the test in practice requires overnight fasting, and many patients either do not like fasting or they just forget to fast before the test. Testing of HbA1c does not require patients to fast, and thus, is perceived as easy and convenient.

The experts at the ADA have recommended that the HbA1c of 6.5%, confirmed by plasma glucose-specific test, should be used as a test to diagnose diabetes. The committee has also recommended further follow-up and more testing, when the HbA1c of a patient is tested at 6.0% or more. Some argument is provided by other experts like Davidson and colleagues (Buell C et al. Diabetes care. 2007; 30(9):2233-2235), about the acceptable HbA1c cutoff point for diagnosing diabetes. They believe that people with HbA1c of 6.0% or less should be considered normal, those with a value of 6.1% to 6.9%as pre-diabetics and a value of 7.0% or higher should indicate diabetes.

It is important for us to know that people with any of the following risk factors- obesity, high blood pressure/ hypertension or a family history of diabetes should get tested for their HbA1c, at least twice a year. Using HbA1c test as a screening tool, will help detect diabetes in more people, especially who are at risk and who would otherwise be left undiagnosed. This will help physicians and their patients intervene early and help them formulate optimal treatment strategies.

Testing of HbA1c is now even more easy and simple through dried bloodspot testing introduced by ZRT laboratory. The patients can perform this test at the convenience of their home, without going to a phlebotomist to get their blood drawn. For more details about dried bloodspot testing, visit ZRT website www.zrtlab.com or feel free to email me at skapur@zrtlab.com.

Healthy Looking but Still High Blood Pressure?

I recieved an email from a mom who shared with me few details about her 16 year old, healthy looking son's high blood pressure problems. She is very concerned about her son's future health risks associated with hypertension and is looking for some answers. I did respond to her email below, but I would appreciate comments from my readers and if any one has any suggestions in this case.

Mom: Dr. Kapur, My son, who is 16 years old, has been running a “borderline” blood pressure. He had an athletic physical last year and this year where the nurses repeated his pressures multiple times. He is 6’2” and 172 pounds. He plays basketball and soccer. He does not like, thus does not drink any type of soda pop...but he does drink gatorade type of drinks as well as lots of water. He is diet is good, but not great. We rarely eat fast food. I do grow my own garden and can/freeze food. BUT, being busy with an athletic schedule, he does occasionally eat food that is not healthy.
Family history includes a grandmother that died about 2 years ago at the age of 58 due to an apparent heart attack. She did have issues with hypertension. She was 5' 8" and 220 pounds. She was extremely active/busy. BUT she did have a lot of stress....mother of 12 children, drove school bus, and owned a restaraunt. She was asymptomatic expect for the hypertension that was being treated by 3 antihypertensive agents....Catapress Patch, Tenormin, and Hydrochlorothiazide. She had a similar diet to my son....probably better. Her activity did not include a regular exercise plan or a cardio plan....my son has a vigorous exercise plan as he continuously plays basketball and soccer. She was overweight....my son does not have any extra weight on his body.

What can be done to improve my son's blood pressure??? He is passing his physicals now, but I am concern that with time he will need medication to maintain a normal blood pressure. AND the diastolic number is more of the issue than the systolic. Nothing has been done at this point. If I do a cardioprofile, will you be able to guide me if his numbers are out of range???? Is it genetic? Or is there a mineral or nutrient lacking in his diet that is the factor. My mother and my son have always lived in the same town. We do live in a rural farming community. My parents farmed organically, but neighbors do not farm in the same way...thus I understand that the air, water, etc is contaminated.

My Response: Thank you for sharing this information about your son. His BMI (Body Mass Index) is 22.08. This BMI puts him under the body classification of “Average” type. So, for him losing weight should not be the focus for controlling the blood pressure, however he still should keep healthy lifestyle to stay fit. This is good that he does not drink any type of soda pop; at the same time drinking Gatorade type of drinks may not be recommended for people with borderline or high blood pressure because of their high sodium content. Sodium in Gatorade is about 450 mg per liter. According to FDA the sodium content should not exceed 360 mg per serving for individual foods and about 480 mg per full serving for full meal. For individuals at risk, these limits are even lower, so it is good to consume less of any such drink types with high sodium content.

The American Heart Association recommends that people with high blood pressure should eat foods with low-sodium, low-fat, and low-cholesterol. So read food labels and check for any names with “sodium” like sodium hydroxide, sodium benzoate, monosodium glutamate or disodium phosphate etc. You mentioned that you grow your own garden. This is excellent because consumption of processed foods should be minimal as those are usually high in sodium. Any type of canned or pre-packaged frozen food should be avoided. Herbs and spices like garlic and onion, basil, parsley, thyme, black pepper, turmeric, etc are should be used for cooking.

Few researchers have been able to identify some abnormalities in a gene that have been linked with hypertension and therefore, there may be some increased likelihood of problems related to high blood pressure in individuals with variations in this gene. It is difficult at this time to clearly identify the genetic cause of high blood pressure because it is the interaction of inherited mutations/ genes with other genes and the environment that we all live in. A test is available to detect such type of inherited genetic variations that encode for a protein called G-protein coupled receptor kinase type 4 (GRK4). An individual carrying this variation is more prone to conditions like hypertension. This type of genetic variation is linked with inability to eliminate sodium from the body. So, even without going for this type of genetic testing, limiting sodium consumption should help control blood pressure in healthy looking individuals like your son. Other than that, foods rich in potassium are good. Foods like soya, wheat bran, tomato, raisins, unsalted nuts, potatoes, spinach, zucchini, bananas, melons, oranges, and figs etc. have high potassium content. Potassium and sodium work together to control blood pressure. Honey and fish oils have also shown to regulate blood pressure in normotensive individuals.

Your son is 16 and very young and so I am sure alcohol consumption is not an issue in his case. Drinking alcohol also raises blood pressure in otherwise healthy looking people. Hypertensive patients should always stay away from alcohol.

Please look at the link below for few important ADA guidelines on regulating blood pressure.
http://www.guideline.gov/summary/summary.aspx?doc_id=12817&nbr=6619&ss=6&xl=999

First Michael Jackson and Now Billy Mays- Is There Something In Common?

First Michael Jackson and now Billy Mays, both died at a young age of 50 and both of them likely due to heart disease. Is this just coincidence or is there something common. Should we worry about the number 50?

Does the word “Stress and hypertension” ring the bell when you think of celebrities?

Billy Mays was in an airline accident a day before. Someone said ,”He survived the accident but probably this stressed the hell out of his heart which just never caught up…”. This is not just one time stress though; this is not because of a single event that one gets a heart attack. Heart disease develops overtime and several factors could contribute to this problem. “Mays suffered from hypertensive heart disease, and the wall of the left ventricle of May’s heart and the wall of one of his arteries were enlarged” said Vernard Adams, Hillsborough County Medical Examiner. So, is this hypertension that killed Billy Mays? Well, it is likely that he died of heart attack in his sleep, but it might take few more weeks to perform several tests to determine the exact cause of his death.

Although, a direct relationship between stress and hypertension is still unclear but stress can indirectly cause hypertension through repeated blood pressure increases and also by affecting the nervous system to produce hormones that raise blood pressure. Could an airline accident have caused sudden elevations in Mays’ blood pressure damaging his heart?

Hypertension is one of the most significant contributor to heart disease and stroke. Unfortunately one third of those who suffer from hypertension are unaware of their condition as it is asymptomatic. As a result, almost two thirds of those remain untreated or undertreated.
High blood pressure does not cause any symptoms, at least in its early stages and so it becomes very important to monitor your blood pressure regularly, once every year, if you think you are normal and have no risk conditions or disease. High blood pressure causes weakening of the arteries, which makes them more susceptible to damage and plaque build-up around their walls. This results in a condition called atherosclerosis.

What is considered to be normal blood pressure? Less than 120/80 mmHg is normal. What is Pre-hypertension? When the blood pressure is between 120/80 and 140/90, it is known as moderately high and the individual is pre-hypertensive. Finally, what is hypertensive? Blood pressure of 140/90 or higher (130/80 for diabetics) is called hypertension. So, the goals of therapy should be to lower the blood pressure to less than 140/90 for those without diabetes and to less than 130/90 for those with diabetes.

Regular blood pressure checks is the first step to lowering the blood pressure in order to avoid heart problems. Antihypertensive medications are helpful but even among those using such medicines, only about 53% have their blood pressure under control. American Diabetes Association has recommended that just a 12- to 13-point reduction in blood pressure by positive lifestyle changes can reduce risk of myocardial infarction by 21%, stroke by 37% and all death from cardiovascular disease by 25%.

Positive lifestyle modifications remain the cornerstone of controlling and managing blood pressure/ hypertension, which include 1) weight loss, 2) regular aerobic activity with at least one 40-minute moderate intensity exercise every week, 3) diet rich in fruits, vegetables, potassium and calcium, 4) reduced salt intake, and 5) moderate alcohol consumption. These changes are extremely helpful in controlling the blood pressure and also blood glucose and lipid levels, thereby helping in prevention of cardiovascular disease.

Hypertension is not just a problem of adults, but children should also be monitored for high blood pressure. Children also develop hypertension due to same reasons as adults- unhealthy diet, not being active and accumulating some extra pounds. When diagnosed with high blood pressure, children should be treated with making healthy lifestyle changes aimed at weight control and increased physical activity. In some cases, pharmacologic intervention may be required.
Although age does increase your risk of getting a heart disease and you cannot do much about this, but you can definitely control other risk factors that multiply the overall risk.

Of course, heart disease has nothing to do with the number 50 and all those in their 50’s or turning 50 should not be alarmed. Celebrate your 50th year and celebrate the lives and legacies of Michael Jackson and Billy Mays, and remember it is never too late to make healthy and positive lifestyle changes.

If It can Happen to Michael Jackson, It Can Happen to Anyone…

The world is in shock and mourning Michael Jackson’s sudden death reportedly due to cardiac arrest. As people are posting tributes to him everywhere, he is being remembered as “The King of Pop”, “Icon”, “Legend”, but there is one thing that we all need to remember is that he was human just like all of us.

Michael’s unexpected passing away at just 50 leaves behind a good lesson for us. We need to stop and think seriously. Yes, this is a catastrophic tragedy, and all of us are perplexed thinking how could someone like Michael, who was not obese, had a thin stature, physically active as a dancer, very athletic die of cardiac arrest. It is not very uncommon for healthy looking people to have heart disease; and cardiac arrest is the first sign of heart disease.

Someone asked me a question this morning “Dr. Kapur, given that the initial explanation of the sudden death of Michael Jackson was cardiac arrest - can you explain the relevance or relationship of that event to Cardiometabolic Syndrome?”

Cardiac arrest occurs when there is disruption of electrical signals in heart muscles, which therefore prevents the heart from pumping blood effectively, causing a heart attack. There are more chances of getting a cardiac arrest when there has been previous heart damage due to a heart attack (blockage of arteries). This does not mean that someone who has not had any previous event cannot have a cardiac arrest. It has been reported by several studies that people with high cholesterol, high blood pressure and/or with family history of heart disease or diabetes are at risk of dying of heart disease even when they appear thin and healthy. Stress, smoking and drug abuse have been shown to have an added risk. So, even when we are athletic, thin looking with no family history of heart disease, we need to be aware of our cholesterol and triglycerides at all times.

“What steps should those who might be reflecting upon their own ‘heart health’ take to insure that they are being smart about preventative steps?”

Healthy eating, active lifestyle and monitor your health regularly without waiting for your doctor to tell you what to do is the key. Check cholesterol levels and In addition to cholesterol levels, it is important to check glucose and inflammatory markers like C-reactive protein, which is emerging as an independent risk factor for heart disease. It is recommended that people care for their own health and wellness by monitoring their cardiometabolic markers like cholesterols, triglycerides, hemoglobin A1c and C-reactive protein and not wait for their doctor to suggest these tests. This is because even doctors will not suggest these tests until they see any symptoms; so why wait until any symptoms appear. Heart disease and diabetes are like an iceberg that is hundred times larger than what is seen on top. These diseases start way before the actual symptoms appear. It is smart to be proactive and take steps to prevent such diseases.

As we all say “Adieu” to Michael, let us learn a lesson that he leaves behind for us…

What is Cardiometabolic Risk?

Soft Drinks, Fruit Drinks, Energy Drinks and Cardiometabolic Risk

It really depends upon how much we like soft drinks, fruit drinks, energy drinks or any other type of sweetened caloric beverages before we can make a choice between our cravings and our cardiometabolic risk. Scientific research has shown a number of times in the past how much we have to be watchful of our caloric consumption, not just from the food we consume but also from the beverages we enjoy. Nurses’ Health Study has shown about 49% increase in the risk of coronary heart disease in women due to regular soft drink consumption. Nurses’ Health Study II has also shown a direct link between sweetened drinks and increased risk of diabetes, irrespective of total body weight. Framingham study has suggested a strong association between metabolic syndrome and soft drink intake. Another recent research study reported about 44% increased chances of getting diagnosed with metabolic syndrome if someone consumed one soft drink every day as compared to those who did not drink such sweetened caloric beverages frequently.

Unfortunately, there is a rising trend in the consumption of flavored and sweetened energy drinks, fruit drinks, vitamin water especially in United States and the intake of these beverages has tripled in last few years, which is now emerging as a major cause of obesity in children and also conditions like weight gain, insulin resistance and other cardiovascular risk factors in adults.

We have definitely seen some direct or indirect effects of the sweetened caloric drinks on our overall health and wellness. Several articles have been published in this direction, both scientific and in lay press; many research studies have identified statistically significant associations between soft drink consumption and increased body weight, diabetes and heart disease. There is no doubt about adverse and unhealthy effects of most of the sugar and fizzy drinks and I think there is no need for us to wait for further evidence to prove it again. It is time to do something about correcting the mistakes we have made so far.

All along we have been saying “We are what we eat”, but now it is all about “We are what we eat…and drink”. It is not very difficult to watch what we choose to drink when we think of healthy weight loss or just when we are thirsty. I remember my grandma sharing with me benefits of drinking water, green tea, pomegranate juice for several health reasons she could outline (all appearing non-scientific at the time) as she never went to school, but now when I think of those, I feel she knew much more science than most of us scientific pundits of today.

What are we waiting for? What more proofs do we need before we do something about this problem? Why are we debating on this subject for so long? We are becoming aware of what we eat, but should we also not be concerned about what we are drinking or what we are making our children drink? Let us create a better “Healthy Tomorrow” for our generations to follow.

Let us stop and make some intelligent choices about “drinking healthy” and let us appeal to manufacturers to make healthy drinks free of any harmful effects. At the same time, let us practice and educate ourselves about picking up the right drinks in order to prevent and manage any chronic diseases like metabolic syndrome, diabetes, heart disease and other related conditions. Let us all work together.

I will be Speaking at the A4M Meeting in San Jose on September 9-12, 2009

I will be talking about "Simple Cardiometabolic Risk Screening using Bloodspot Technology" at the 17th Annual World Congress on Anti-Aging Medicine & Regenerative Biomedical Technologies on September 9-12, 2009 at the San Jose Convention Center in San Jose, CA.

The growing numbers of people with cardiovascular disease and diabetes in the United States is a consequence of metabolic disorders largely associated with obesity. As people age, the decline in hormone levels and the decrease in activity levels can combine to increase an individual’s tendency to visceral obesity, which sets up the metabolic conditions that lead to cardiovascular disease and diabetes and are referred to as cardiometabolic risk. Blood spot testing for cardiometabolic risk markers can reach a large number of people and help them control their risk by making lifestyle changes. This can significantly improve wellness in the aging population. A simple blood spot test can conveniently and accurately assess cardiometabolic risk, giving people the opportunity and motivation to control their risk with appropriate lifestyle changes. Broader screening in the aging population may be the key to reversing the growing incidence of cardiovascular disease.

How is Testosterone related with Cardiometabolic Risks?

Certain risk factors have been shown to cluster with clinical conditions like obesity, type 2 diabetes and cardiovascular problems. Such clustering of risk factors have led investigators to propose a new condition called cardiometabolic risk syndrome. Cardiometabolic risk has gained much attention recently and has been linked directly with visceral adiposity. Few investigations have implicated a direct link between centrally obese men and low levels of testosterone. Association of Testosterone with insulin resistance, obesity, diabetes and atheroschlerosis has been presented earlier but has not received much attention. Higher incidence of metabolic syndrome has also been hypothesized to be associated with decline in testosterone levels. There is evidence that testosterone replacement therapy results in reduced insulin resistance and central obesity in type 2 diabetic men. In this study, we have investigated relationship between testosterone and markers of cardiometabolic risk.

A cohort of male patient samples from ZRT database was selected for the study and categorized in tertiles based on testosterone levels with low (<300),>800). The relationship between testosterone levels and cardiometabolic risk was evaluated using bloodspot testing of insulin, hemoglobin A1c, triglycerides and high sensitivity c-reactive protein. All bloodspot assays were developed in house and showed good correlations with serum/plasma levels of risk markers tested.

A total of 124 male patient samples (41 with testosterone levels <>800 ng/dL) were tested for cardiometabolic risk markers. Mean age (+/- SD) was 50.8 (+/- 12.8). Insulin (4.7 µIU/mL) and high sensitivity c-reactive protein (1.83 mg/L) were found to be significantly lower in the highest tertile with testosterone levels greater than 800 ng/dL when compared with insulin (6.3 µIU/mL) and hs-CRP (3.46 mg/L) concentrations in the lowest tertile with testosterone levels less than 300 ng/dL. There was no significant difference observed in HbA1c and triglyceride levels in different groups.

Our data suggest that a higher testosterone level in men is associated with lower CRP and insulin concentrations. These patients may have a lower risk of developing metabolic syndrome and/or atheroschlerotic cardiovascular events.

How does stress level affect overall risk of getting heart disease?

Stress and depression, both have been linked with diabetes and heart disease. Understanding these two factors can actually help our doctor formulate a suitable treatment plan. So, it is important that we share this with our health care provider even if they forget to ask. Any kind of stress or depression can lead to more complications, if left untreated.

Stress causes release of some hormones which can further lead to elevated blood glucose levels. When the blood glucose levels increase and if there is not enough insulin being produced by the body or if the insulin is not working properly, then this results in excessive glucose in the blood, which can ultimately lead to development of diabetes.

Stress can come from many sources, including stress from one’s occupation, job strain especially in this economy as we are going through recession; many of us are losing jobs, homes, which is very sad and unfortunate. So, this stress can cause increased production of a stress hormone called cortisol, which then makes the liver produce more glucose, which means more glucose in blood and less usage of glucose by the tissues, less insulin production by our pancreas, thereby causing a condition called insulin resistance. This insulin resistance can finally lead to diabetes and/ or heart disease.

It is extremely important to maintain blood glucose levels, especially in diabetics and this can be done through stress management training. Sharing the cause of stress with the primary care doctor, family or friends is always helpful. Sometimes, social support can reduce the stress and this way it can reduce the risk of heart disease.

Similarly, depression causes several changes in our hormones thereby leading to a hormone imbalance, can decrease body’s immunity; can affect changes in bone metabolism; and can cause cardiovascular dysfunction. This can result in decreased quality of life. People living under any kind of depression are at higher risk of getting type 2 diabetes or heart disease.

What should be done to avoid becoming a victim of conditions like stress and depression?

Hormone balance, in addition to healthy diet and exercise, is the answer. Hormones affect everyday health and wellness by interacting with every single cell inside our bodies, and if these do not do their job well, a negative ripple effect is created thereby disrupting overall homeostasis resulting in damaged and disturbed physiology. Therefore, it has been suggested by various published scientific studies that keeping the hormone levels of the body in proper balance within the normal ranges helps in reducing risk of getting diagnosed with conditions like heart disease and diabetes.

Does our Heart Age?

Unfortunately, the answer is YES; the heart grows older as well as we age. Although several people like me always say “Oh I’m never getting old....I’m young at heart and will stay young forever”...which is good and this is how we should live with a positive attitude. With this type of attitude, we can sure increase our life by minimum of 5 years and may be more too.

Again, it depends upon our mental outlook and how we live, and not just the age. Science agrees with this, but at the same time, we have now come to know so many different facts about our heart health and we should realize that with increasing age, even with a positive attitude and sound mental acuity, our heart undergoes some changes, and it continues to undergo those changes even when there is no disease, even when the person is healthy and has no known risk condition or a disease.

The heart muscles start to weaken and when the heart beats, these heart muscles cannot relax completely between those beats, and when this happens they become stiff; as a result they start to function less efficiently and they don’t do their job of pumping blood very well and finally give up. The loss of good function of these heart muscles gets worse when there is any heart disease. Another thing is that as the heart grows older, it does not respond effectively to adrenaline and this is the reason that older heart cannot contract or cannot pump blood faster or vigorously when there is a need, especially when we exercise or do any physical activity. So, we should not be surprised if we see our capacity to walk briskly or to work out and exercise has decreased as compared to when we were young. We all know and have experienced that all that was so easy to do when we were 16 or 18 or 20, is extremely difficult as we get older. Our heart just doesn’t function that well any more. This is also the reason for changes in our blood pressure, normally high when the heart muscles are too stiff.

The decrease in the capacity of heart to work efficiently differs from person to person. It all depends on how we live our life, what other conditions have we developed? Do we have any other disease? How and what kind of decisions we made in life when it came to eating right or how much we exercised?

We have to realize the importance of healthy life-style changes as early as possible in our lives. It is never too late. All the risk factors basically affect overall quality of life and of course how long we live. Let us not wait till the last minute when our doctor has to tell us that it is too late. Let us take charge of our own health and wellness and do something about it.

Do you agree with me?

Heart Disease- Diabetes- Obesity: What Have we Achieved so Far?

We know that the heart disease and diabetes pose significant threats to our health, especially as we grow older and of course major challenges to the medical community. Although there have been major advancements in the medical field as far as detection and treatment of these conditions is concerned, but unfortunately these problems continue to result in serious health complications, disability and premature death. The sad part is that the overall incidence of these diseases is still going to increase as more and more people continue to age and also with rise in obesity rates, especially in US.
Did you know that few scientific studies came out in 2005 which showed that the life expectancy has declined for the first time in this country!!! How did this happen? We thought that we were working hard to create better world with so much of advancement in all field including medical science. Yes, no doubt we HAVE made a lot of progress in terms of finding cure and treatment for so many different conditions....BUT why still almost a MILLION Americans die of cardiovascular disease every year, which means 1 death every 34 seconds, and out of all those about 50% are above the age of 50 and this is just due to heart disease. What about Diabetes? Did you know that as of today almost 20 million Americans have diabetes and this number has increase by more than 60% since last 10 years, and again more than 50% people who have diabetes are above the age of 50. It is unfortunate that now we have started to see more and more cases of children with diabetes, which we could never imagine earlier, because at one point diabetes was considered as a condition in only the adults.

Can you IMAGINE how much it costs us every year in terms of dollar figure to fight against both heart disease and diabetes? Collectively, these conditions cause more than 1 million deaths every year and result in more than $620 billion in direct and indirect costs.

So, what happened? Where did we go wrong? Should we stop and rethink what did we do differently OR what did we NOT do that we have to see such increase in the prevalence of these conditions?

I think the problem is that we have a luxury of choosing a bad lifestyle and as we age we start to realize that the choices we made earlier in life were probably not the smartest ones.

What do you think?

What makes C-Reactive Protein so Important?

C-reactive protein (CRP) is known to increase when there is inflammation in the body. Inflammation has been linked with atherosclerosis by various different clinical research studies. Therefore, it has been suggested that testing for CRP levels in the blood can help detect an individual’s risk of getting a heart disease. However, there are two types of tests that can detect CRP levels in blood- (1) one that detects high levels of CRP and (2) the other is a highly sensitive assay that detects very low levels of CRP (hs-CRP). Higher levels of CRP could be seen in case of systemic inflammation, whereas very low increase in CRP level is observed in case of vascular inflammation, which has been linked with atherosclerosis, which means formation of fatty deposits or plaques in the inner lining of arterial walls. High levels of hs-CRP may also be helpful in determining the overall risk of stroke or peripheral artery disease. Several different studies have shown that higher levels of hs-CRP mean higher risk of heart attack. Some of the major factors that can contribute to vascular inflammation include- smoking, hypertension, hyperglycemia and/or dyslipidemia. People who do not exercise and have sedentary lifestyles may also have higher CRP levels. Patients with any of these conditions and/or who are centrally obese should be tested for hs-CRP levels; and if the levels are higher than 3.0 mg/dL, then they should be retested to confirm high levels. The CRP levels higher than 10.0 mg/dL could indicate non-cardiovascular causes of inflammation and those could include infectious diseases, some autoimmune disorders or even cancer.

What is CardioMetabolic Risk? Is it different from Metabolic Syndrome?

Cardiometabolic Risk is clustering of various risk factors, which put an individual at high risk of developing type 2 diabetes and cardiovascular disease. It also includes the abdominal obesity (the visceral obesity) and several other markers that have not been considered traditionally while defining overall risk of cardiovascular disease.

Cardiometabolic risk is not something different from Metabolic Syndrome; neither it has been coined to replace Metabolic Syndrome. We have known that metabolic syndrome involves insulin resistance, obesity in terms of large waist, high triglycerides, high blood pressure, low HDL cholesterol. Cardiometabolic Risk includes, in addition to all these risk factors, high LDL cholesterol, Inflammation (high C-reactive protein), smoking, physical inactivity, unhealthy eating, some psychosocial issues like stress and depression and high blood glucose, in addition to race, gender, age and family history.

All of these together and also each one of these independently increase the risk of disease and other related complications. So, cardiometabolic risk is a global risk condition involving all these markers that increase an individual’s overall risk of developing type 2 diabetes and cardiovascular disease.

Therefore, it is very important to detect, treat and control for these factors well in time, before it is too late. Lifestyle modifications like weight reduction, regular exercise/ physical activity, healthy diet, quitting smoking, all have benefits in terms of reducing the risk. We must understand that improvement in any one of these health markers results in improvement in other markers because our body does not work in isolation. Similarly, when there is any one of these risk factors present in a person, there could be other related conditions also that have not been diagnosed. So, clinicians should screen patients during their regular visits for any or all of these risk factors for cardiovascular disease and diabetes.

How will the screening help?

This will help them:

1. Understand the comprehensive picture of their patient’s overall health and alert them about any possible future health condition.
2. Facilitate better communication with their patient to make better clinical decisions, one they have identified different markers.
3. Intervene at an early stage, as we know that conditions like insulin resistance and hyperglycemia occur long before the clinical diagnosis of diabetes.

Routine screening and early assessment may help both the physician and their patient work together to address important lifestyle changes like healthy eating, qutting smoking if they smoke, include 30 minutes or more of exercise or physical activity of any kind 5 days a week, to avoid risk of developing type 2 diabetes and cardiovascular disease.

Such assessments provide great tools to clinicians and their patients for a comprehensive and broader management of different health conditions, especially for cardiovascular disease and diabetes risk.

Dried Blood Spot Screening for Cardiometabolic Risk Markers shows Benefits of Exercise

The prevalence of diabetes and cardiovascular disease is increasing at an alarming rate. Several clinical and observational studies have demonstrated reduced risk of diabetes when physical activity increases. Simple screening tools are needed to monitor effects of treatment interventions in individuals at high risk.

At ZRT Laboratory in Beaverton, Oregon we assessed the application of dried blood spot technology to measure important cardiometabolic risk markers. Dried blood spot collection has advantages compared to conventional blood draws, such as minimal invasiveness, low sample volume, convenience of repeated measurements and ease of sample storage and transport.

Fifteen participants (28- 63 years of age) enrolled in a fitness study that included 30 minute exercise/ brisk walking five days a week for four months. Levels of insulin, hemoglobin A1c, C-reactive protein and triglycerides were measured in blood spot samples obtained by a simple and easy finger stick before and after the program. Dried blood spot samples were stored at -20C until used for analysis using modified methods developed in house from commercially available assays.

Insulin levels decreased significantly ; triglycerides dropped by 18% and C-reactive protein levels also showed significant improvement. The HbA1c levels remained unchanged during the program.

In conclusion, exercise/ brisk walking for 30 minutes five days a week for four months improved cardiometabolic risk factors independently as confirmed by dried bloodspot testing. This simple screening method has important implications for monitoring overall cardiometabolic health of high risk individuals.

Which is more important- C Reactive Protein or Cholesterol?

I wish to open this discussion to get feedback from all those clinicians and researchers out there struggling to find out which one is a better predictor of overall risk of cardiovascular events. Many of us and in fact most of us have been focussed on the cholesterol levels to determine the risk until a recently published study (JUPITER Study) in New England Journal of Medicine reported that C Reactive Protein (CRP) may be a better predictor and an independent marker of cardiovascular risk as opposed to just LDL cholesterol. The study showed that patients with high LDL cholesterol and high CRP levels were at higher risk than those with high LDL cholesterol but low CRP levels. It was also observed that patients with normal LDL cholesterol with high CRP levels are at higher risk than those with normal LDL cholesterol and low or normal CRP levels. In these patients, measuring only the LDL cholesterol may not be very helpful or in other words, these patients may not be identified as those at risk and may end up developing a coronary artery disease.

We know that CRP is released in response to any inflammation in the body. Several studies have shown a connection between inflammation and atherosclerosis, which is basically attested by the JUPITER study.

Does that mean that we should start measuring CRP levels regularly to screen or monitor patients at high risk? Is it still important to measure LDL cholesterol? Do we really need to know the triglyceride levels? Should we still look at other risk markers now that we have CRP as an emerging independent marker?

I personally feel that body does not work in isolation and relying upon just one or two risk factors may not be a smart decision. It is extremely important to consider the overall balance of major physiological functions within the body to get a comprehensive picture of overall risk.

Ten Simple Lifestyle Changes to Reduce your Risk of Heart Disease

With obesity rates continuing to rise to epidemic levels, the fattening of America goes hand in hand with a cluster of health problems generally referred to as “metabolic syndrome,” including high blood pressure and high levels of the blood fats, triglyceride and/or cholesterol. Insulin resistance, where the action of insulin in the body is impaired and fails to control blood sugar levels, also complicates the picture. When these things happen all at the same time, as is generally the case, their collective impact is to raise Type II diabetes and cardiovascular disease risks simultaneously. Increasingly referred to in medical circles as the “cardiometabolic syndrome,” people with even one of its components may be at increased risk for others. Knowing what to watch for can make the difference between having, or preventing, full-blown disease; so early detection of risk factors and proactive preventive measures can help individuals lead a active, healthy and happy life.

There are 10 simple lifestyle changes that I wish to outline below, which can lower the overall risk of getting a heart disease. This information is not very new to us and we talk about the importance of all these facts in our everyday lives, but the question is how many of us consider these seriously.

More than a century and billions of dollars in medical research, hundreds and thousands of clinical trials- all have come to realize how important it is to:

1. Lose weight (especially some extra pounds accumulated in our abdomen)
2. Increase physical activity to at least 30- 60 minutes a day
3. Eat a healthy diet that includes more of whole grains, fiber, fruits and vegetables, lean meats, eggs, fish, beans and nuts
4. Quit smoking
5. Reduce stress levels
6. Manage dyslipidemia; maintain normal levels of cholesterol (both LDL-C and HDL-C) and triglycerides
7. Control hypertension
8. Limit alcohol consumption
9. Check for inflammation
10. Keep your hormones in balance

We keep asking for new tools for our physicians to formulate a magic pill, but let us stop and rethink how we can help our physicians formulate optimal treatment strategies for effective management of any or all risk conditions by considering the ten simple changes listed above.