What You Need to Know about Stress, Hormones & Weight Management

There’s a famous quote that strikes me as particularly appropriate for a conversation about stress. It’s widely attributed to the Dalai Lama as his reaction to what surprises him most about humanity:
“Man. Because he sacrifices his health in order to make money. Then he sacrifices money to recuperate his health. And then he is so anxious about the future that he does not enjoy the present; the result being that he does not live in the present or the future; he lives as if he is never going to die, and then dies having never really lived.”

Whether he actually said this, I find the point being made to be poignant – especially when we think about the rapidly increasing obesity rates in today’s world.

 

Today’s Biggest Health Problem?

Most medical experts cite obesity as our most urgent health problem. More than 65% of Americans are overweight to obese, and the numbers are still on the rise. This is in spite of the fact that we have spent billions of dollars on clinical research aimed at solving problems like diabetes, heart disease, high blood pressure, cancer, sleep apnea, and many others – all of which are associated with obesity.

Obesity increases free fatty acids, which leads to dyslipidemia, hypertension, and insulin resistance. This condition, collectively called metabolic syndrome, can progress to type 2 diabetes and/or cardiovascular disease. Obesity also causes mechanical stress to the body, resulting in sleep apnea, osteoarthritis, low back pain, and shortness of breath. Finally, all the hormones in the body become imbalanced as a result of excessive weight, and that can lead to multiple disruptions in hormone-dependent physiological processes, which in themselves contribute to further weight gain.

In the following paragraphs, I would like to focus my discussion on the hormone imbalances caused by obesity, and describe and discuss the hormones that have been implicated in weight gain and obesity, and the physiological reasons why fat accumulation affects hormone levels. At the same time, it is important to discuss the contribution of stress to obesity as cortisol (stress hormone) levels rise, promoting appetite dysregulation, increased blood glucose, and increased visceral fat storage.

The Bad News is Getting Worse

In 1970, 45% of Americans were obese. If you think that sounds bad, read on.

Current projections are that 74% of Americans will be in this category by the year 2020. What happened? Where did we go wrong? Is it that our lifestyles have changed so drastically? Are we eating differently? Is it the sugar consumption and/ or processed foods? Are we not as physically active as we used to be before? Are there any changes in our work habits that we need to look at carefully? Do we have increased lifestyle stress? The answer probably lies in a combination of all these factors, as people pay less and less attention to how their habits and lifestyles contribute to their health.

What can be done to rein in the escalation? How can we lose weight? Weight loss should be very simple according to the rule of calories consumed and calories burned; if we burned more calories than consumed, we should be able to lose weight very easily. Weight loss may not be too difficult for a motivated person who is willing to change their eating and exercise habits and reach a goal, but long-term weight management may be a challenge.

 

How Stress Impacts Weight Management

For proper weight management, it is extremely important to understand the role of the Hypothalamic-Pituitary-Adrenal (HPA) axis. Any type of stress can lead to HPA dysfunction and related disorders like Cushing’s syndrome, chronic stress, panic disorders, hypothyroidism, adrenal insufficiency, chronic fatigue syndrome, fibromyalgia, etc. Dysregulation of the HPA axis is a leading cause of metabolic problems that can contribute to body fat accumulation. Let us now look at the biochemical processes that are set in motion when the HPA axis is disordered and the end result is increased fat deposition.

The goal of the stress response, a key function of the HPA axis, is to maintain effective blood supply to brain, heart, and skeletal muscle, and to increase production of energy by stimulating gluconeogenesis (endogenous glucose synthesis) and ATP production, needed for the short term response to any chemical or mechanical stress to the body. The main components of the stress response system are the HPA axis and the sympathetic nervous system.

During a stress response, both CRH (Corticotropin-releasing hormone) and AVP (Arginine vasopressin) are secreted. AVP activates the noradrenergic neurons of the Locus Caeruleus/norepinephrine (LC/NE) system and CRH activates adrenocorticotrophic hormone (ACTH) release by the pituitary. The LC/NE system is responsible for the immediate “fight or flight” response, whereas ACTH drives the production of cortisol from the adrenal cortex. When high levels of cortisol are present, a negative feedback loop stops this pathway.

The glucocorticoid hormone cortisol is a major player in the stress response because of its role in temporarily shutting down all long-term metabolic processes to facilitate immediate survival and maintain homeostasis. Cortisol’s main job is to increase gluconeogenesis, decrease insulin sensitivity, reduce growth hormone production, lower thyroid hormones, and inhibit the immune response, while increasing fat and protein mobilization for energy needs.

Acute cortisol secretion by the adrenals during stress mobilizes peripheral amino acids from muscle as well as fatty acids and glycerol from peripheral fat stores to provide substrates for glucose synthesis by the liver. But when cortisol levels are elevated chronically, the functions that are intended for short-term responses to a stress stimulus are prolonged and this leads to changes in body fat distribution and especially increased visceral adiposity (belly fat), which creates several metabolic abnormalities leading to the conditions known as metabolic syndrome.

When cortisol levels increase under stress conditions, DHEA production also begins to decrease through “the pregnenolone steal.” In simple terms, this means that under chronic stress conditions, there is increased production of cortisol while other hormones with a common precursor to cortisol, like DHEA, progesterone, aldosterone, testosterone, and estrogens are depleted. If the stressor does not go away and the stress condition becomes chronic, then a phase of stress adaptation begins, characterized by decreased cortisol production, sometimes known as “adrenal fatigue.” The cortisol production further decreases until the stage when there is complete adrenal failure.

 

The Bottom Line on Stress & Weight

To summarize, acute stress causes a short term increase in glucocorticoid release, which induces fatty acid mobilization and decreased food intake; whereas chronic stress is associated with sustained cortisol secretion, which leads to redistribution of subcutaneous fat stores to visceral adipose tissue, resulting in central obesity and several metabolic and endocrine abnormalities.

Food consumption also increases during this time as a result of interactions between neuropeptide Y (NPY) and melanocortins as well as leptin and insulin, all of which are consequences of disordered metabolism that goes along with obesity.

Leptin is secreted by adipocytes in proportion to body fat stores and its primary effect is to signal to the brain that there is enough fat in the body, so that food intake can be stopped. Normally, leptin inhibits NPY expression and secretion, thereby controlling the food intake. During chronic stress, excess cortisol enhances the NPY content and induces leptin secretion as well as leptin resistance, thereby inhibiting leptin-¬induced reduction of food intake. Therefore, increased production of cortisol actually induces overeating, worsening obesity despite elevated leptin levels.

Leptin interacts with thyroid hormones, in addition to many other factors, and thyroid hormones may modulate adipokine levels by regulating adipose tissue metabolism – a topic I’ll address in a follow-up blog post. We need to have a better understanding of thyroid hormone abnormalities and their effects on metabolic rate and body fat storage.

In additional blog posts in this series, I will discuss the role of other hormones like estrogens and testosterone in obesity and weight management. It is known that estrogens can influence energy intake and energy expenditure via hypothalamic signaling and play an important role in body weight, fat distribution, energy expenditure and metabolism. Also, obesity is frequently associated with low testosterone levels. Obesity-related hypogonadism is complex and involves many different factors, which lead to changes in body fat mass and further changes in adipokine release and inflammatory pathways.

In conclusion, we must be aware that the adipose tissue is involved in the metabolism of cortisol, and that chronic stress contributes to obesity and leads to a complete imbalance of several other hormones that are impacted by changes in cortisol production. Therefore, hormonal imbalance is a key feature of obesity, and understanding the mechanisms behind this can help people struggling with weight management issues.

Advantages and Disadvantages of Testing in Serum, Saliva, Urine or Capillary Dried Blood

Diagnostic testing using body fluids is a cornerstone of modern medicine.  While urine analysis has been used by doctors since the middle ages, blood plasma and serum testing was developed during the last 100 years.  More recently, routine saliva testing for hormones was introduced, followed by commercial testing in capillary dried blood spots.  Dried urine testing has now eliminated some of the disadvantages of liquid urine collections, making this methodology more accessible.

With the innovations in testing methods comes a need to understand which body fluids serve the doctor and patient best in a variety of testing situations.  This is particularly important when testing hormones in patients using supplemental hormones by a variety of administration routes.  The following helps to outline the advantages and disadvantages of each of the commonly-used methods. 

Serum/Plasma - Advantages 

 

·        Accepted as gold standard testing method by the conventional medical community

·        Wide range of hormone tests available: Ideal for testing peptide hormones

·        Automated with FDA-approved methodology

·        Costs covered by most insurance carriers

·        Familiarity with established levels and ranges

Serum/Plasma - Disadvantages

·        Invasive -sharp needle in arm

·        Stressful -inconvenient to patient-requires driving to blood draw station

·        Phlebotomist required

·        Processing of specimen-centrifugation

·        Shipment-Biohazard labeling and requires cold packs

·        Normal ranges (+/- 2 SD) are too wide-more geared for disease than failing health

·        Difficult to measure multiple times during day due to collection logistics

·        Usually measures TOTAL and not BIOAVAILABLE fraction of hormone in bloodstream

·        Limitations with testing of sex hormones: No distinction between bound and free hormone

·        Cannot be used to measure hormone metabolites

·        Not a valid method for measuring hormones delivered topically -gross underestimation of hormone distribution to tissues

Urine  - Advantages 

·        Non-invasive

·        Simple collection procedure

·        Measures total daily output of steroids

·        Measures steroid metabolites

·        More likely covered by insurance carriers

Urine - Disadvantages

·        Problem with 24 hr urine collections: Inaccuracy in collecting all urine-missed collections

·        Inaccuracy in determining volume of urine collected during 24 hours

·        Up to 40% of 24-hour urine collections are done improperly

·        Results altered by liver or kidney disease

·        Diurnal hormone patterns (cortisol). Inconvenient for assessment of monthly variations (estrogen and progesterone)

·        Expensive and advanced testing technology required for better accuracy

Saliva - Advantages

·        Simple

·        Stress-free

·        Noninvasive (no needles)

·        More convenient than blood testing for health care provider and patient

·        Measures the “unbound” biologically active or free hormone levels

·        Ideal for measuring and accurately monitoring transdermal application of hormones

·        Optimized for multiple collections any time of day/month, any place

·        No special processing (eg, centrifugation, ice-packs) prior to shipment

·        Hormones stable in saliva for weeks

·        Ideal for evaluating cortisol secretion patterns, and balance and flow of estrogens and progesterone.

·        Salivary estriol can be tested to identify women at risk for preterm labor: It spikes approximately two weeks prior to the onset of labor

·        Convenient shipment by regular US mail

Saliva - Disadvantages

·        Restricted to steroid hormones-no thyroid or peptide (e.g. FSH, LH) hormones

·        Technically more challenging: need 10-20x sensitivity-more problematic for hormones at very low concentration (i.e., estrogens)

·        Interfering substances - food, beverages

·        Sublingual use of hormones leads to spurious high test results (direct contamination of the oral mucosa)

·        Problematic for those with poor saliva production

·        Restrictions regarding eating, drinking, make-up and brushing teeth

·        Hormone metabolites cannot be measured in saliva

Capillary Dried Blood Spot - Advantages

·        Convenient-Simple collection procedure

·        Can be collected at remote sites - samples are stable when dried

·        More latitude in collection timing than serum-i.e. night time sampling for cortisol & insulin

·        Dried serum analytes very stable for at least a month at ambient temperature-shipping simplified-allows for international shipment without need for Biohazard Label

·        Wider range of analytes can be tested than in saliva - similar to serum/plasma

·        Results & ranges equivalent to serum/plasma for endogenously produced hormones

·        More accurately reflects tissue uptake of exogenously used hormones than serum/plasma (gross underestimation)

Capillary Dried Blood Spot - Disadvantages

·        Finger-prick with a needle inconvenient for some

·        Not all analytes can be tested in dried blood

·        Sometimes sample contamination problems in patients using their hands to apply topical hormones.

Hormones and Skin Wellness

(Authors: Dr. Sanjay Kapur and Margaret Groves)

Skin health is a major concern, especially in ageing women, which is very good news for the cosmetic and anti-ageing industry. It is no coincidence that the decline in hormone levels as people age parallels the decline in skin properties frequently associated with ageing. A major culprit for the skin thinning, wrinkling, and dryness associated with ageing is the decline in hormones such as estrogen and progesterone in women, and testosterone in men. Hormones are intrinsically involved with processes affecting the maintenance of skin health, such as collagen content, skin lipid levels, elasticity, wound healing, glycoaminoglycan content, and facial hair patterns.
The skin is one of the main targets of estrogen action, and facial skin expresses much higher concentrations of estrogen receptors than the skin of the breast or the thigh. This means that the effects of declining estrogen levels as women progress through menopause are more obvious on the skin of the face than on the skin covering other parts of the body. Reduced availability of estrogen affects skin health in a number of ways: these include wrinkling, dryness, thinning, reduced collagen content, slower wound healing, and loss of elasticity.
Obese men and women often don’t show this deterioration in skin health to the same extent as normal weight people; this is because they maintain higher estrogen levels as a result of increased aromatase activity in fat and skin tissue. Aromatase is an enzyme that converts testosterone into estradiol and androstenedione into estrone, and it is present in large quantities in fat tissue. Estrone and estradiol are therefore found in larger amounts in obese individuals than in normal weight people of the same age. Estradiol is the most potent estrogen, and its main source is the ovaries in reproductive women. Estrone, with weaker estrogenic effects, becomes the more prominent estrogen produced in postmenopausal women as their ovaries stop estradiol production.
Studies of estrogen replacement therapy have shown some improvement in those skin properties affected by low estrogen levels, e.g. increased collagen content, skin thickness, and skin elasticity. Hormone replacement has also been found to increase skin surface lipids, which enhances the barrier function and may prevent dryness. Estrogen also plays a role in maintaining skin glycoaminoglycan content, which retains moisture.
Low testosterone in men is associated with thinning skin. This is thought to be because there is less testosterone available for local conversion to estrogen through the action of aromatase present in the skin. Testosterone replacement has been found to increase skin thickness.
Progesterone has been used in cosmetic skin creams as well as in hormone replacement therapy, and has been found to improve skin thickness and elasticity. Studies have indicated no adverse effects when progesterone is used for this purpose, although some women find that progesterone cream can result in skin breakouts, possibly as a result of other ingredients in the formulation.
Low progesterone levels are thought to increase the impact of androgens on sebaceous glands and body and head hair. This is because progesterone reduces 5-alpha reductase activity, which converts testosterone to its active metabolite dihydrotestosterone (DHT). DHT is the culprit for androgenic side effects in women such as unwanted facial hair growth, which tends to appear with ageing or in androgen excess conditions such as PCOS. In both men and women, excess DHT in the skin contributes to acne, and in the skin of the scalp it is responsible for “male pattern baldness”.
High levels of hormones can contribute to skin discoloration, e.g. the brown patches (“chloasma”) associated with pregnancy or with hormone replacement therapy.
Hormones are important for skin wellness, but caution should be exercised by women and men seeking to reverse skin deterioration by using hormone replacement. Hormonal deficiencies can be identified with minimally invasive laboratory testing and treated with hormone replacement to improve overall health and wellness as well as to mitigate the effects of ageing. However, hormone replacement should be done with appropriate monitoring to ensure that no higher than physiological hormone levels are achieved. It is important to understand that hormones have powerful effects throughout the body. While hormone replacement is not usually recommended solely for cosmetic purposes, proper monitoring of hormone levels in an ageing population can help identify deficiencies that can be resolved with judicious hormone use, which may have the added benefit of improving skin wellness and thereby saving substantial costs in cosmetic treatments.

Dr. Sanjay Kapur is putting the spotlight on Dried Blood Spot testing

Click here for my recent interview that was featured on CaribPress


Dr. Sanjay Kapur is a scientist with extensive experience in biomedical research. He has strong interest in health and wellness with an emphasis on heart disease, diabetes and obesity. As Scientific Director of ZRT Laboratory, Dr. Kapur has been instrumental in developing a technology called dried blood spot testing that is being utilized for early detection of major indicators associated with heart health.

CaribPress chatted with the scientist about dried blood spot testing, cardiometabolic syndrome and his journey from India to Canada and to the United States.

CPress: Why biomedical research and when did you decide to venture into the research field?
Dr. Kapur: I have spent almost twenty-five years in the research field, but research in the area of biomedicine was something that I wanted to do at an early age. My grandparents died of heart failure and diabetes. Genetically I am very likely to develop these conditions and pass them on to my next generation. I do not have symptoms of such diseases right now.

CaribPress: What is dried blood spot testing and does this testing have the FDA (Food and Drug Administration) approval?
Dr. Kapur: Blood spot testing is a minimally-invasive form of hormone and wellness testing. With a simple finger prick, samples of blood are dropped onto a card which is dried and mailed back to the laboratory. Dried blood spot testing has been used for several decades. Sometimes the FDA approves the sample collection method, sometimes they approve the methods which are used for testing different biochemical markers. Our methods for testing the biochemical markers are FDA approved and the lab supplies that we use as part of our procedures to test these biochemical markers are also FDA approved.

CaribPress: Define and discuss cardiometabolic risk.
Dr. Kapur: This is my favorite subject. Cardiometabolic is a fairly new term. It involves all the factors that define the overall risks of developing cardiovascular disease. Like age, race, gender, genetics, diet, physical inactivity, obesity, smoking, all these things are responsible for increasing the risk for cardiovascular disease that play a part as much as 10-15 years before you start to see the symptoms. All these things together are what we call Cardiometabolic Risk.

CaribPress: Can you talk about the estimated cost to a patient for dried blood spot testing?
Dr. Kapur: ZRT Laboratory offers many tests. All of the tests have different prices and depends on the test that is being done. The prices vary depending if someone has insurance or not. For someone who does not have insurance, it is much cheaper to have the tests done in dried blood than the more conventional serum testing. It is more cost effective to test using dried blood spot testing because you don’t have the added cost of going to a phlebotomist or a doctor’s office for a blood draw.

CaribPress: Is dried blood spot testing suited for middle-income or third-world countries?
Dr. Kapur: Absolutely, actually it is more convenient and suited for those countries. Especially for those people living in remote areas and those people who have absolutely no access to labs with the latest technologies. Because of this dried blood spot testing, they can collect their own samples by a simple finger prick and mail them back to the lab in the regular mail. This method of testing is ideal for people who do not have access to a lab but need to monitor risk factors such as cardiometabolic risk markers.

CaribPress: Can you share something memorable in your journey from India, Canada and to the US?
Dr. Sanjay Kapur: I received a post-doctoral fellowship and went to French speaking Quebec, where they did not speak English and I did not speak French. I was in India at the time, so the interview was conducted over the phone and I was hired. The fellowship was with Laval University, Chul Research Center and I was there for three years.
When I think back, this journey has been, I would say, tough — a lot of struggles. At the same time, I would say, it was a great learning experience for me. Traveling from India to French speaking Canada (Quebec City), without knowing anyone there; adapting to this new culture, including the weather; working at the hospital, doing research, then moving to California for a very exciting research project that involved designing anti-cancer drugs.

CaribPress: Can dried blood spot testing be used for Sickle Cell and HIV testing?
Dr. Kapur: ZRT Laboratory does not do HIV or Sickle Cell testing. ZRT testing primarily involves steroid hormone tests, other tests relating to hormone balance, and cardiometabolic risk testing. Other labs are using dried blood spot testing for HIV. For sickle cell, I saw a study that came out in 2006 that screened for sickle cell and the blood spot method they have developed works for that type of screening process.

CaribPress: Talk about the accuracy of dried blood spot testing vs. conventional testing.
Dr. Kapur: Dried blood spot testing is as accurate as the conventional serum testing. The instruments such as auto analyzers that we use, and the methods that are used to test serum are all the same. The only difference is that the dried blood spot samples are absorbed onto a filter card, so those blood samples have to be first rehydrated and extracted for analysis. So, once they are reconstituted back into liquid form in the lab, we can test them the same way as a conventional test.

CaribPress: Discuss universal testing using saliva and dried blood spot testing.
Dr. Kapur: At ZRT Laboratory, we have tested more than one million patients using saliva and dried blood spot testing. It is getting very popular. This is coming up as the future of blood testing. There is always going to be a role for conventional serum tests, especially in hospitals where the lab is on hand and where some tests require immediate results, but many risk markers, hormones, and other substances can be tested in dried blood spot or saliva that can be collected at home. People are looking for convenience and lower costs when it comes to taking care of their long-term health.

CPress: What was the impetus for you to be a part of ZRT Laboratory?
Dr. Kapur: I have been a research scientist with ZRT Laboratory since July 2005. I was back in California and read about Dr. David Zava, the President and founder of ZRT. Dr. Zava had done a lot of research on breast cancer and hormone imbalance. He published articles and books, so I got very interested in hormone imbalance. At the time I was not very much aware of how hormone imbalance can lead to all these diseases and health conditions. So with my background in science I thought it would be a great opportunity for me to join this research team.
Most of the research that I was involved with before coming to ZRT was biochemical research. I thought it would be a great opportunity to join hands and I wanted to help ZRT to conduct research. I wanted people to benefit directly from this research. Most of the research that I had been involved with was mainly biomedical and more academic and it was not research that would directly go to benefit the public. So, after spending so many years in research, I wanted to do something that would directly go on to help people improve their health.
ZRT started this lab by developing a simple and almost non-invasive saliva testing. Later on we developed the dried blood spot technology. We developed this technology to make it easier for testing and convenience to allow everyone to take control of their own health and knowledge — and in particular to be proactive in terms of prevention.

Testosterone and Diabetes

A recent interview on Beyond 50 Radio featuring Dr. Sanjay Kapur

Click on this link above and listen to my interview with Daniel Davis on Beyond 50 Radio show where we discussed how Testosterone plays an important role in our lives and possibly has some link with Diabetes.

Low Testosterone has been shown to cause conditions like insulin resistance, metabolic syndrome, central obesity, which further lead to problems like type 2 diabetes and cardiovascular disease. Research studies have shown a link between low levels of testosterone and abnormal lipid levels, increased inflammation, high blood pressure etc. However, it is still not quite clear what comes first- is it that low testosterone levels cause type 2 diabetes or is it that type 2 diabetes result in testosterone level drop. Some research groups have seen improvements in insulin sensitivity, reduction of mid-section obesity, decreased cholesterol levels etc., by testosterone replacement therapy. Some other studies have shown that high doses of testosterone do not have the same benefits as shown by normal physiological levels. Therefore, it is important to monitor testosterone levels using proper testing methods, especially if one is supplementing testosterone to ensure that any supplementation is kept within physiological levels.

Stress and Heart Disease

How Does Aging Affect your Heart?

Fruit Drinks, Energy Drinks and Heart Disease

Vitamin D Deficiency, Obesity and Cardiometabolic Risk: Is there any Relationship?

Until now we have been talking about several different risk conditions like adiposity, cardiovascular disease, diabetes, osteoporosis, hormone imbalance, vitamin D deficiency and other related disorders. After spending billions of dollars in medical research, we have collected huge amount of data and a wealth of information. It is time to get serious and make use of this information. Let me put it this way, we have collected most of the pieces of a big puzzle and now it is time to put together these pieces and complete the puzzle. We all recognize that our bodies do not work in isolation and so we need to look at all the body systems together as one system, which controls how we live our lives. I believe we may already have answers to so many questions. We may not have to spend more money into research to collect more data, which might create more confusion for us and more challenge to analyze all that new data. We could keep debating over what we should or should not do, but for now, since I titled this piece with a focus on role of vitamin D in obesity and cardiometabolic risk, let me discuss how vitamin D is emerging as a strong candidate to consider when we accumulate few extra pounds in our bodies, especially around our abdomen.

Now that holidays are over and New Year has begun, many of us are busy exercising and trying to shed those extra pounds we gained enjoying cookies and treats. Most of us have been indoors by the fireplace, especially in the Northwest where I live and where sun is known to be a luxury. Of course I do not have any reason to envy those who are in Midwest, especially after reading the newspaper this morning to see how most of the country is under the grip of winter chills with temperatures as low as 52 below zero in the Midwest. My point is that we have not had a chance to get out and get some sunlight so we could make some vitamin D. We all know how important is, sun exposure for endogenous production of vitamin D in the skin. There is evidence now that vitamin D is implicated in the cardiovascular morbidity and mortality, in addition to its role in musculoskeletal health. There is also some evidence that vitamin D deficiency is associated with obesity. We could argue that this association is indirect because obese individuals are less active and thus they get less sunlight exposure. However, some studies have shown that since vitamin D is fat soluble and therefore stored in fat tissue, which makes it less bio-available when there is more fat tissue. Obesity has been shown to have connection with insulin resistance and metabolic syndrome. Does that mean there is a link between insulin resistance, metabolic syndrome and vitamin D deficiency? The answer is yes, because some computed tomography imaging studies combined with measurements like BMI and waist circumference have suggested that vitamin D may be related to variation in regional adiposity and thus could be implicated in insulin resistance and metabolic syndrome, thereby connected indirectly with all biochemical mechanisms including inflammatory pathways leading to conditions like diabetes, atherosclerosis and coronary heart disease.

A recent study by Susan et al. that appeared in the January 2010 issue of Diabetes journal has shown that vitamin D deficiency is related with increased BMI; there is an inverse relation of 25-hydroxyvitamin D [25(OH)D] with subcutaneous and abdominal fat even in individuals who are lean with low BMI; and finally there is strong correlation between 25(OH)D and markers of insulin resistance, especially connected with abdominal adiposity. One could argue that some other factors like limited physical activity or low vitamin D intake may have caused the observed correlations, but the good thing is that this study took into consideration those confounders too as their subjects were all young to middle aged, with little comorbidities and low medication use. The study showed independent association between subcutaneous fat or visceral fat with 25(OH)D. It is also discussed that only differences in sunlight exposure are not enough to account for vitamin D concentration differences between obese and non-obese individuals. I will not go into too many details here about biochemical mechanisms that have been discussed to explain possible association of vitamin D with adiposity. Several findings have suggested multiple mechanisms involved with good evidence that vitamin D deficiency is implicated in obese individuals and thus connected with insulin resistance and related disorders.

So, for now the message is, let us watch out for those extra calories that we throw into our bellies. I am not asking you to stop enjoying cookies and left over treats from holidays, but what I am saying is that it is time we pay more attention to what we eat, how much we eat and what we do to metabolize all the extra calories we consume. Let us take good care of our waistline and if we see someone with a big waist, let us help them by making them aware of how vitamin D deficiency could be something to look for. How do we know we are vitamin D deficient? Well- there are tests available that can help us determine the vitamin D levels in our body and how much supplement do we need to replenish healthy levels. To make our life easy, there is a dried blood spot test available, which involves convenient home collection of sample, which is simply mailed to the laboratory and analyzed. You do not have to get out of home, get an appointment with a lab or phlebotomist, drive across town or take off from work. Does that not sound good? Feel free to email me (skapur@zrtlab.com) if you wish to share some thoughts or need more information. Let us continue this discussion.

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.