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.