Inflammation is activation of the immune system in response to threat or injury to the body. Acute inflammation mobilizes the immune system to repair an injury or fight an infection. Once healing takes place the immune system goes back to baseline. Chronic inflammation, however, involves long term activation of the immune system caused by some ongoing stress to the body. More and more, researchers are beginning to show that chronic inflammation is the common pathway to many diseases. There are multiple causes of chronic inflammation. In this post I will write about the causes of chronic inflammation. I will also do a series of posts about the many diseases that chronic inflammation causes. These posts will be based on the structure of an excellent book: Inflamed – Deep Medicine and the Anatomy of Injustice. It is not easy to read because it is disturbing but I highly recommend it. I will also write about a test to measure chronic inflammation. I will write about things you can do to decrease chronic inflammation if you have it and how to prevent it if you don’t. There are many causes of chronic inflammation that have to do with the structure of our society. These are things an individual cannot control. These societal causes will take ongoing efforts by all of us to change some of the toxic structures of society.
The Process of Inflammation
The inflammatory process starts with damage or threat of damage to the body. That can be an infection, a wound, or perceived threat of such. The immune system mobilizes white blood cells called macrophages to the injured area or site of infection. The cells of the immune system also release a cascade of messenger molecules called cytokines that amplify inflammation. These include interleukin 1ß, interleukin- 6 and tumor necrosis factor -α. The liver also releases a protein called c-reactive protein. When the threat is neutralized the immune system helps the body start to heal by releasing anti-inflammatory cytokines including interleukin (IL)-1 receptor antagonist, IL-4, IL-10, IL-11, and IL-13.
In chronic inflammation the pro-inflammatory cytokines continue to predominate and the c-reactive protein continues to be elevated.
Causes of Chronic Inflammation
Causes an individual can do something about
Low levels of physical activity.
Having a BMI at or above 30 , especially when excess weight is deep within your belly (visceral fat). The best way to measure belly fat is to use a tape measure to measure your waist at the widest point. Increased belly fat is greater than 35 inches for women or greater than 40 inches for men
An imbalance of healthy and unhealthy bacteria in your intestine (dysbiosis). Dysbiosis can be caused by antibiotics and by eating foods low in soluble fiber.
Regularly eating foods that cause inflammation, especially highly processed foods, or foods high in sugar or salt
Inadequate sleep
Using tobacco products.
Regularly drinking too much alcohol
Periodontal disease (gum infection) and tooth decay
Perceived stress
Societal Causes
Experience of racism (structural or personal)
Poverty
Homelessness
Worry about debt
Work stress
Exposure to air pollution
Exposure to chemicals (pesticides and herbicides for farm workers, glyphosphate (RoundUp) for everyone, microplastics in our bloodstreams for everyone. Every day, we are surrounded by thousands of synthetic chemicals. They are in our food, clothes, tools, furniture, toys, cosmetics and medicines. We know the health effects of only a few of these).
All of the inflammatory cytokines can be measured but those are expensive tests. A simple inexpensive test that measures inflammation, both acute and chronic is high sensitivity CRP. It will also be high with an acute infection or injury, but will return to normal after the infection or injury have resolved. If it remains elevated when you are not sick or injured it is a sign of chronic inflammation. It may be worth asking your doctor to order this test if you have any of the individual or societal risk factors for chronic inflammation. A normal hs-CRP is less than 0.55 mg/dl in men and less than 1.0 mg/dl in women. If your hs-CRP is high in the absence of acute infection or injury, that can serve as motivation to make lifestyle changes to decrease your chronic inflammation and put you in a population that has less risk of developing any of the diseases associated with chronic inflammation.
Anti-inflammatory lifestyle
Exercise regularly. The CDC recommends 30 minutes of moderate exercise (walking briskly) for 30 minutes at least 5 days a week.
Eat mostly unprocessed or minimally processed foods and avoid sugary drinks or foods with added sugar or high fructose corn syrup. Also include foods with high soluble fiber such as beans, carrots, sweet potatoes, nuts, berries and most fruits (not fruit juice). Organic foods, while more expensive, have no residual pesticides or herbicides. If you eat meat buy grass fed beef, and pasture raised chicken and pork. Eat more plant-based foods than meat.
Avoid taking antibiotics as much as possible
Sleep. Average at least 8 hours a night
Floss your teeth daily, brush twice a day and see your dentist every 6 months
If you don’t smoke, don’t start and if you do smoke quit.
It is better not to drink alcohol at all, but if you do limit it to 1 drink a day or less.
Learn meditation or self hypnosis to manage stress. There are good books and videos, but an in person course is best if it is available.
Drink only filtered water and not bottled water in plastic bottles
Gas stoves cause significant indoor air pollution. If possible switch to an electric stove. Induction type burners actually heat more quickly than gas. If you have to use a gas stove, be sure to turn the ventilator fan on and open a window if possible.
Bottom Line
Chronic inflammation is the common pathway for many chronic diseases. There are many individual strategies that reduce or prevent chronic inflammation. Many of these strategies are not possible for people with socioeconomic problems. The stress black people experience from structural and individual racism, homelessness or inadequate housing, anxiety over debt, exposure to environmental synthetic chemicals, and exposure to air pollution are societal problems that we all have a responsibility to address.
My next post will deal with chronic inflammation and cardiovascular disease.
There are some new developments in the diagnosis of Alzheimer’s disease. These developments mean more people may be eligible for the new treatments for Alzheimer’ disease. In this post I will write about the new blood tests for Alzheimer’s disease and also revisit the available treatments. This will be an update of my previous post New Treatment for Early Alzheimer’s Disease – What You Need to Know.
Blood tests for Alzheimer’s disease
The monoclonal antibody treatments for Alzheimer’s disease only work if patients have evidence of amyloid proteins in their brains. Prior to the new blood tests, the only way to tell if patients had the amyloid protein was either to measure it in spinal fluid (which means a spinal tap) or to see it on a PET scan (which is a very expensive type of scan). The FDA has approved a new blood test that has been shown to work as well as a spinal tap or PET scan. It measures a protein called ptau217. The test is called the ALZpath ultra-sensitive pTau217 test. Because it requires just a blood sample, that means a lot more people will get the test and if positive will be eligible for treatment with the new monoclonal antibody treatments. This is a somewhat mixed blessing as I will outline below.
Theories of the cause of Alzheimer’s disease
On November 3, 1906, a clinical psychiatrist and neuroanatomist, Alois Alzheimer, reported “A peculiar severe disease process of the cerebral cortex” to the 37th Meeting of South-West German Psychiatrists in Tubingen, Germany. He described a 50-year-old woman whom he had followed from her admission for paranoia, progressive sleep and memory disturbance, aggression, and confusion, until her death 5 years later. His report noted distinctive plaques and neurofibrillary tangles in the brain at autopsy. In 1909 he presented two more patients with a similar history and pathology in the brain after death. These were all relatively young patients, so the name Alzheimer’s disease originally was applied to patients who developed dementia in their 50’s and 60’s (it was also called “pre-senile dementia.”
In later years it was discovered that many people who developed dementia at any age, including advanced age had the same plaques and neurofibrillary tangles when their brains were examined after they died. It turned out that 90 % of people who had dementia had these plaques and neurofibrillary tangles in their brains found at autopsy..
The Toxic Protein Hypothesis
The composition of the plaques turned out to be a protein called amyloid protein and the neurofibrillary tangles were composed of another protein called tau. The theory was that accumulation of these proteins was toxic to brain cells and that this toxic effect caused dementia. Because dementia is associated with age, it was hypothesized that in predisposed individuals gradual accumulation of these proteins in brain cells over many years eventually results in dementia.
There is one problem with this hypothesis. Several studies have followed aging people over time and measured the presence or absence of dementia. People in all these studies have agreed to have their brains studied after they died. In all of these studies anywhere from 12% to 30% of people who never had dementia during their long lifetimes (many were in their 80’s or older when they died) had plaques and neurofibrillary tangles that met the criteria for Alzheimer’s disease. It appears that the accumulation of amyloid and tau proteins is associated with Alzheimer’s dementia, but not necessarily the main cause of it.
Treatments based on the toxic protein hypthesis
There are three monoclonal antibodies now approved by the FDA for the treatment of Alzheimer’s disease. They newest ones are lecanemab and donanemab. They both target the amyloid beta protein that accumulates in people with Alzheimer’s disease. They are both used in people with mild cognitive impairment and they do reduce the beta amyloid protein as shown by follow up spinal fluid testing and/or PET scanning. Unfortunately, they only have a modest effect on slowing progression from mild cognitive impairment to Alzheimer’s disease. The cognitive test used in the studies of both drugs is called the Clinical Dementia Rating–Sum of Boxes. The range of this test is 0-18. Only people with mild cognitive impairment were included in the trials. The treatment group in the lecanemab trial got lecanemab, which has to be given by iv infusion every two weeks for 18 months. The placebo group got a saline infusion every two weeks. In both the placebo group and the treatment group, the scores on the dementia test got worse by 18 months, but the dementia scores for the treatment group did not increase as much as the placebo group. The absolute difference in the scores was about 14%. This was a statistically significant difference in slowing the progression of mild cognitive impairment to Alzheimer’s disease, but it’s not a very big difference.
Side effects of monoclonal antibody treatment
Both approved monoclonal antibody treatments attack the amyloid beta protein and produce an inflammatory response in the brain. This resulted in brain edema and/or micro hemorrhages in 17% of the treatment group vs 9% of the placebo group. Also nearly a quarter of the treatment group had reactions to the infusion. Most of the people with brain hemorrhages or edema did not have symptoms but some had headache, visual disturbance and confusion.
Expense of monoclonal antibody treatment
Lecanemab, which goes by the trade name Leqimbi is priced by the manufacturer at $26,500 per year. The other approved monoclonal antibody, aducanumab is priced at $28,200 per year. The UK has not approved either of these drugs because they don’t feel the modest benefit justifies the cost. The UK also points out that we have no idea what the long term effects of either one of these drugs might be.
Other treatments for Alzheimer’s disease
The other major class of drugs that has been used for Alzheimer’s disease are the cholinesterase inhibitors. The theory behind using these drugs is that nerve cells that produce a neurotransmitter called acetyl choline are diminished in Alzheimer’s disease. The cholinesterase inhibitors have the effect of increasing levels of acetyl choline in the brain because they inhibit the enzymes that break it down. These drugs are donazepil (Aricept), rivastigmine (Excelon), memantine in combination with donazepil (Namzeric), galantamine (Razadyne) and tacrine (Cognex).
These medicines don’t work very well Fourteen out of 100 patients with mild to moderate Alzheimer’s disease have some improvement in thinking skills. Side effects, especially nausea and vomiting are common. None of these medicines has been shown to work any better than the others in the class.
Genetics
There is no specific Alzheimer gene. Almost 80 genetic sequences have been identified that either decrease or increase the risk of Alzheimer’s disease. If you have a first degree relative who has had or has Alzheimer’s disease, then your risk is increased somewhat. Each of these sequences has only a minimal effect by itself, so you would have to have a lot of them to substantially increase the risk of Alzheimer’s disease. It is estimated that genetics accounts for less than 5% of Alzheimer’s disease.
Integrated theory of cause of Alzheimer’s disease
In doing research for this post, I discovered a very interesting paper by Richard Armstrong that reviews current theories of the cause of Alzheimer’s disease and proposes a new integrated theory that accounts for everything we know about Alzheimer’s disease so far. Here is a link to that paper if you would like to read the whole thing: Review article: What causes alzheimer’s disease?. It is from a Polish neurological journal, but the article is in english.
On the basis of current evidence Dr Armstrong believes that the primary factor in Alzheimer’s disease is an age-dependent breakdown of anatomical systems and pathways within the brain and the consequent loss of synapses. The degree of this aging effect depends on the amount of lifetime stress (also called allostatic load). The brain is the ultimate recipient of stress through hormonal changes resulting from high blood pressure, diabetes, cardiovascular disease, and immunological problems. The result of all this is gradual disconnection of synapses, degeneration of nerve cells, and the expression of genes determining various reactive and breakdown products such as Aβ and tau. The brain has a protective mechanism that removes breakdown products, and this protective mechanism continues to function and prevents the accumulation of Aβ and tau. As a person enters old age and the effects of excessive body stress accumulate, then senile plaques and neurofibrillary tangles begin to form as the brain’s protective systems get overwhelmed. In this theory, accumulation of Aβ and tau are the result of loss of synapses and connections in the brain rather than the cause. By the time these proteins can be detected in the spinal fluid or blood, the process of brain degeneration is already well underway. It is no wonder that targeting these proteins with monoclonal antibodies only modestly slows but does not reverse the progression of mild cognitive deficit to full blown Alzheimer’s disease.
If Doctor Armstrong’s theory is correct, then we should see a markedly increased risk of developing Alzheimer’s Disease with aging in people with certain chronic conditions. Here are some numbers:
Metabolic Syndrome
Metabolic syndrome is defined by having at least three of the following five conditions:
Excess abdominal fat (Waist circumference greater than 40 inches for men or 35 inches for women)
High blood pressure (Systolic greater than 140 or diastolic greater than 90)
High blood sugar (fasting blood sugar greater than 100 mg/dl)
high blood triglycerides (fasting triglycerides greater than 150 mg/dl)
Low HDL cholesterol (less than 40 mg/dl)
People with metabolic syndrome have 11.5 times the risk of developing Alzheimer’s disease as they age as people without metabolic syndrome. About one in every three adults in the US has metabolic syndrome.
Type 2 diabetes
A recent review of the literature found that type 2 diabetes increases the risk of eventually developing Alzheimer’s disease by 56%.
Coronary artery disease
People with coronary artery disease, especially at a relatively young age have a 26% increased risk of eventually developing Alzheimer’s disease.
Sedentary Lifestyle
In a study from the UK the more hours a person spent sedentary, the higher the risk of all cause dementia. Since Alzheimer’s disease accounts for the vast majority of dementia, we can assume that the more hours per day you spend on the couch, the greater the risk of eventually developing Alzheimer’s disease.
Social Networks
Many longitudinal studies show that maintenance of supportive social networks (family, friends) decreases the risk of development of Alzheimer’s disease. Conversely loneliness increases the risk of developing Alzheimer’s disease
Heavy alcohol consumption
Light to moderate alcohol consumption (2 drinks a day for men and 1 drink a day for women actually decreases the risk of developing Alzheimer’s disease. Heavy alcohol consumption (4 drinks a day or greater for men and 3 drinks a day or greater for women) increases the risk of developing Alzheimer’s disease by 300%!
Bottom Line
The new blood tests help diagnose people with mild cognitive impairment who are at high risk of progressing to Alzheimer’s disease. This is only helpful if there are good treatments to prevent progression to Alzheimer’s disease. Unfortunately, the best current treatments modestly slow the progression from mild cognitive impairment to Alzheimer’s disease but do not reverse or prevent the progression. These monoclonal antibody treatments have significant side effects that include microhemorrhages and brain edema. At present there is no medical treatment to reverse or prevent Alzheimer’s disease.
Dr. Armstrong has proposed a theory that the non-hereditary form of Alzheimer’s disease results from loss of synaptic connections in the brain from chronic lifetime body stress and that the amyloid protein accumulations are the result rather than the cause of loss of synaptic connections in the brain. This theory is supported by the fact that people with lifestyle related chronic diseases (metabolic syndrome, diabetes, heart disease, sedentary lifestyle, lack of meaningful mental activity, loneliness, heavy alcohol intake) have a markedly increased risk of developing Alzheimer’s disease as they age.
The best treatment for Alzheimer’s disease is prevention. Risk of developing Alzheimer’s disease with age is decreased by maintaining normal body weight, eating mostly unprocessed foods, exercising regularly, staying mentally active, maintaining supportive social networks, and avoiding heavy alcohol intake.
We are inundated from social media and other sources about diets and how well they work. In this post I’m going to describe the current most popular diets and how safe and effective they are at producing weight loss. I’m also going to write about the physiology of appetite, what controls appetite, and the mechanisms involved in weight regain after dieting. I will also discuss the ways people have discovered to maintain their weight loss. I am not going to discuss medicines for weight loss or bariatric surgery in this post. Those are subjects for another day. I did do a previous post on GLP1 agonists for weight loss. If you are interested you can link to that post here.
Energy Balance
Neither humans nor any other animal can survive without food. Our bodies convert food into the energy we need to keep our bodies intact and to be able to move about. The measure of the available energy in food is calories. A calorie is the amount of heat energy required to raise 1 gram of water by 1 degree centigrade. This is a very small amount of energy, so the unit we usually use is 1000 calories or kilocalories. When you see the number of calories on a food label, it is always means kilocalories even though it says “calories” on the label.
If on average we eat more calories than we use, our bodies store the extra energy as fat and we gain weight. If on average we use more energy than we get from our food, our bodies use the stored energy from fat and we lose weight. If on average we eat as many calories as we use, our weight is stable. We are in energy balance. We can also gain weight by increasing our muscle mass, but in this post I’m going to write about weight gain and loss as changes in body fat. This is an immutable law. Diet claims that calories don’t matter for weight loss are simply wrong. Calories in versus calories out sounds simple, but energy balance in our bodies is not simple at all.
Our intake of calories is controlled by our appetite and the control of appetite involves multiple hormones and neurotransmitters at multiple places in the brain and in the body. Control of appetite is very complex. I will write more about this later in this post.
Energy we use is of two types. A certain amount of energy is needed just to keep our bodies functioning. This is called the basal metabolic rate. It is also called resting energy expenditure (REE). It varies with weight. The average REE is 1 kilocalorie per hour per Kg (2.2 pounds) of body weight. That means that for a person who weighs 70 Kg (154 pounds) the REE would be 1680 kilocalories per 24 hours, just sitting on the couch. To calculate your own REE, divide your body weight in pounds by 2.2 and multiply that by 24. That will give you the number of calories you use in 24 hours just sitting on the couch during the day and sleeping at night. In general it is going to be in the neighborhood of 1500 to 2000 kilocalories per day.
The other type of energy we use is the energy required to move our bodies. These are called active calories. Active calories also based on body weight. For a 154 pound person, walking briskly burns 280 calories per hour. More vigorous activity burns more calories. Here is an extensive table from the Department of Health Services of Wisconsin that shows kilocalories burned for various activities at different body weights: CALORIES BURNED PER HOUR.
So what would it take for you to be in energy balance if you weigh 70 Kg (154 pounds) and do brisk walking for 30 minutes 5 days a week? Brisk walking uses 280 kilocalories per hour, so 140 kilocalories for each exercise session. That would be 700 kilocalories per week or an average of 100 kilocalories per day. Regular household activities burn about the same amount per hour as walking, so if you do household chores for 4 hours per day including weekends, that would be another 1,120 kilocalories per day. Your REE is 1680 kilocalories per day. You would be burning on average 100 active kilocalories per day for your walking and another 1,120 kilocalories a day for household chores for a total of 2900 kilocalories per day. That number will be a little higher if you weigh more that 154 pounds and a little less if you weigh less than 154 pounds. To be in energy balance you would need to eat no more than 2900 kilocalories per day. If you exercise more, you can eat more and stay in energy balance, but you would need to add a lot more exercise.
Fortunately, you don’t have to do all these calculations. In a normal weight person your body stays in energy balance automatically. Obviously, people who are overweight or obese either are not now, or at some point have not been in energy balance. It doesn’t take being out of energy balance much per day to cause significant weight gain. Lets suppose you take in 100 more calories per day than you use. It takes about 3500 extra kilocalories to gain a pound of fat. That would equal weight gain of fat at a rate of a pound every 35 days, or 10 pounds per year.
Being overweight or obese has serious health consequences that escalate with the degree of obesity. In order for overweight or obese people to avoid these consequences, they need to make a conscious effort to lose weight. That is where diets come in. Exercise is important too, but more for maintaining weight loss than losing weight. Of course exercise is good for you whether you lose weight or not.
Diets
I will write about the most extreme diets first, and then discuss the more moderate ones.
Keto (ketogenic) Diet
The brain is the second most active organ in the body after the liver. The brain normally uses glucose for energy but when glucose is not available and all the glycogen in the liver (which can be converted to glucose) is used up, the body starts to break down fat into something called ketones. The brain can use ketones for energy although it cannot use fat directly. The purpose of the ketogenic diet is to switch the whole body to the use of ketones for energy instead of glucose. This is accomplished by a high fat, very low carbohydrate and low protein diet. Protein has to be low because it can be broken down in the liver to form glucose. Carbohydrate is reduced to less than 50 grams per day which is less than the amount in a medium bagel. Protein is restricted to less than 1 gram per pound of body weight per day.
The ketogenic diet works because it decreases appetite, so despite eating calorie dense fat, total calories consumed are markedly decreased. It does lead to significant and fairly rapid weight loss. It is, however a markedly nutrient deficient diet. People who are on this diet must take supplemental multivitamins and minerals. Doing so keeps people from getting gross vitamin deficiency, but there is also a loss of micronutrients found in complex carbohydrates and it is unclear what the effects of this deficiency are. The ketogenic diet is very low in fiber, which alters the gut microbiome adversely. It decreases triglycerides and increases HDL, which are good, but it also increases LDL, which is bad. On the other hand, it decreases hypertension and has an anti-inflammatory effect. It is not clear whether the positive effects are outweighed by the LDL increase effects. So far, there is no evidence that ketogenic diets increase the risk of heart disease.
The main drawback of the ketogenic diet besides the nutritional deficiencies is that it is virtually impossible to stick to for more than a few weeks or months. Ketogenic diets do reduce insulin secretion since there is much less glucose for insulin to carry into the cells. The ketogenic diet may be useful in type 2 diabetics to reduce insulin resistance and decrease weight, particularly for diabetics in poor control. It is not a diet that can be maintained long term.
Very Low Calorie Diets
These diets restrict calories to 800 calories per day or less using proprietary liquid formulas that contain electrolytes and high protein to prevent muscle loss. VLCD diets lead to rapid and significant weight loss and are used primarily for people with severe obesity or medical complications of obesity. Such a diet should not be used without supervision of a physician. Again, like the ketogenic diet, VLCD diets should not be maintained long term.
Intermittent Fasting
Intermittent fasting is going without food for some period. Non-caloric drinks such as water or coffee are encouraged during fasting times. The simplest is restricted time eating. This involves skipping one or two meals per day and only eating during a restricted time. Whole day fasts can be once or twice a week or even every other day. One might think that a person would eat twice as many calories on a non-fasting day and so would not experience weight loss. This rarely happens. Intermittent fasting does reduce average calorie intake, and so people on any of the intermittent fasting regimens lose weight. People who start an intermittent fasting diet get very hungry at first on fasting days, but this hunger tends to decrease over time. It takes discipline to maintain intermittent fasting over a long period, but people who have the discipline to stick to the intermittent fasting regimen can stay on it long term. If the food they eat on non-fasting days is healthy (more on this later) then this can be a successful long term eating plan to maintain energy balance at a lower weight.
Paleo Diet
This is supposedly the type of diet that humans ate in the paleolithic period prior to agriculture when all humans were hunter gatherers. Of course people on the paleo diet do not become hunter gatherers. According to the Mayo Clinic a modern paleo diet includes fruits, vegetables, lean meats -especially game meats, fish, eggs, nuts and seeds. These are foods that in the past people could get by hunting and gathering. It doesn’t include foods that became more common when small-scale farming began about 10,000 years ago. These foods include grains, legumes and dairy products.
People on a version of the paleo diet do lose weight for exactly the same reason as weight loss on other diets. The average calorie intake on the paleo diet is substantially less than the standard American diet. It is not clear that excluding grains, legumes and dairy products is a good thing. Whole grains, legumes and dairy products supply high quality nutrients that may be missing in the paleo diet. The paleo diet is also more expensive and may be out of reach for lower income people. There are no long term studies of the health effects of the paleo diet.
Whole30 Diet
This is similar to the paleo diet but is recommended for 30 days. Foods to avoid are alcohol, sugar, dairy products and legumes and grains. There is a list of foods you can eat and all of these are unprocessed foods. The idea is that you reset your metabolism, and then you gradually add back the avoided foods and see how they make you feel. There is no evidence about the claimed long term good health effects of the Whole30 Diet. Like other diets that lead to fewer calories consumed, people do lose weight on this diet.
Plant based Diet
A plant based diet is exactly what it says. It is derived entirely from plants and eliminates all animal products including dairy products and eggs. The sources of protein are legumes, nuts, seeds, soy and lentils. Sources of fat are nuts, avocados, olive oil and vegetable oils. Plant based diets tend to focus on unprocessed foods. Unlike the other diets mentioned in this post, there is a lot of evidence that plant-based diets decrease the risk of developing diabetes (and also treat type 2 diabetes), decrease the risk of high blood pressure, heart disease and autoimmune diseases. Plant based diets have an anti-inflammatory effect, which probably is responsible for many of the benefits of plant based diets.
Unprocessed plant based food is more expensive than ultra processed foods and requires substantially more preparation time. People who live in poor neighborhoods often live in a “food desert” and unprocessed plant foods may not be available or be too expensive to buy. People who have low end jobs often have neither the time nor the equipment for food preparation. Although plant based diets have multiple health benefits, they are out of reach for a substantial part of the US population.
GOLO Diet
The GOLO diet is a proprietary diet plan you have to pay for. It is essentially a Mediterranean type diet that includes a supplement. The supplement has a lot of minerals and vitamins and there is no evidence that any supplement helps with weight loss. It is currently heavily advertised on television and social media. The research cited in all of these ads is research funded by the GOLO company. I will write about the benefits of the Mediterranean type diet next, but GOLO uses a standard dietary plan and a worthless supplement to make money. Don’t waste your money on this diet.
Mediterranean Diet
The original Mediterranean diet was the traditional diet of Crete, Greece and southern Italy in the 1960’s. Italians and Greeks no longer necessarily eat like this, but their original diet had lots of whole grains, vegetables and fish and used lots of olive oil. This type of diet has been studied more than any other and has very similar benefits to the plant-based diet. It reduces the risk of high blood pressure, diabetes, heart disease and autoimmune disorders. Here is the Mediterranean diet food pyramid from Wikipedia. It was developed by Oldways Trust, Harvard and the World Health Organization.
The things at the base of the pyramid are the things you eat the most and the things at the top of the pyramid you eat the least. Notice that red meat and butter are at the top of the pyramid. You don’t eliminate any class of food entirely in this diet, you just don’t eat the things at the top very often. Once again the diet includes mostly unprocessed foods and requires considerable food preparation.
The Standard American Diet (Also called the Western pattern diet)
It is no wonder that we have an epidemic of obesity! The standard American diet is almost the exact opposite of the Mediterranean diet and plant-based diets. It is very high calorie and high in ultra-processed foods. That is why all of the diets I described above cause weight loss. Almost anything is better than the standard American diet!
Weight Regain After Weight Loss
With any diet (other than the very low calorie diets) weight loss stabilizes after a while and then there is very frequently some weight regain. Why does this happen? During the evolution of the human species, obesity was very rare. Hunter gatherers, even the few modern ones that remain in remote parts of the world are not fat. In evolutionary terms, weight loss meant that there was not enough to eat, so metabolic strategies to conserve calories during times of starvation had high survival value. The result is that when we lose a significant amount of weight, the body thinks we are starving. Several things happen to conserve energy. The first thing is that the basal metabolic rate or resting energy expenditure (REE) decreases an average of 50 kilocalories per day, but people who are obese to start with and lose a significant amount of weight can have decreases of REE as much as 700 kilocalories per day. Another body adaptation to weight loss is that the muscles become more efficient and use less fuel. This means that the calories you burn per hour with exercise decreases as you lose weight.
Appetite
As I mentioned before, the control of appetite is complex. Almost all control of appetite is unconscious. Appetite can be consciously controlled only for a short time, just as we can consciously control our breathing for a short time, but most breathing is (fortunately) unconscious. The part of the brain that controls our appetite and food intake is the hypothalamus. The hypothalamus secretes some hormones on its own and controls other hormones and/or peptides that both increase and decrease appetite. One hormone that increases appetite is Ghrelin. It is secreted by the stomach, small intestine, pancreas and brain and has multiple effects. It increases appetite and food intake and promotes fat storage. Hormones that makes you feel full or satiated are Leptin and GLP1. Control of appetite is actually a lot more complicated than this. Below is a table taken from a review article about hormonal control of appetite. Here is a link to the full article. It is not for the faint hearted. Hormonal Regulators of Appetite
The table summarizes what we know about the hormones and peptides that increase appetite and stimulate feeding and those that make us feel full and inhibit feeding. As you can see, control of hunger and satiety is very complicated. All of this takes place outside of our conscious awareness.
Hunger
Hormone
Primary location of production
Receptors
Action
Hypothalamus
NPY
Medial arcuate nucleus (also widespread in CNS
Y1, Y5
Stimulating feeding and atagonizing satiety
AgRP
Medial arcuate nucleus
MC3R and MC4R antagonist
Stimulating feeding
Peripheral Peptides
Ghrelin
Stomach
GHS-R1a
Stimulating feeding by increasing NPY/AgRP and antagonizing Leptin effects
Satiety
Hypothalamus
POMC/a–MSH
Arcuate nucleus
NC3R and MC4R
Inhibiting feeding, stimulating basal metabolic rate and altering nutrient partitioning
CART
Arcuate nucleus
Inhibiting feeding
Peripheral peptides
Cholecystokinin
Duodenum, jejunum
CCK-A
Inhibiting feeding and stimulating gall bladder contraction, intestinal motility, and inhibition of gastric motility
PYY
Ileum, colon, rectum
Y2
Inhibiting feeding by inhibition of NPY and stimulation of POMC
Glucose-dependent insulin secretion, induction of beta cell proliferation, promotion of energy storage, enhancement of bone formation
Insulin
Pancreas
Insulin receptor
Inhibiting feeding
Leptin
Fat cells
Leptin receptor, Ob-Rb
Inhibiting NPY and AgRP and stimulating POMC and CART
Adiponectin
Fat cells
Adipo R1, R2
Inhibiting feeding
With significant weight loss (10% or more) the hormones that control appetite shift toward the hormones that make us hungry. Those includes Ghrelin, NPY and AGrP. The hormones that make us feel full, including leptin and others decrease.
The result of all this is that even if we are sure we are staying on the same foods, we are unconsciously eating more of them. The result is weight regain. The bad news is that 80% of people who lose weight on diets regain a substantial portion if not all of the weight they lost within 1-5 years. The good news is that 20% of people maintain most of the weight loss they achieved even after 5 years. How do those 20% of people who lost 10% or more of their body weight keep from regaining weight? We actually know a lot about how they do it.
National Weight Control Registry
Here is the introductory paragraph from the National Weight Control Registry website:
The National Weight Control Registry (NWCR), established in 1994 by Rena Wing, Ph.D. from Brown Medical School, and James O. Hill, Ph.D.from the University of Colorado, is the largest prospective investigation of long-term successful weight loss maintenance. Given the prevailing belief that few individuals succeed at long-term weight loss, the NWCR was developed to identify and investigate the characteristics of individuals who have succeeded at long-term weight loss. The NWCR is tracking over10,000 individuals who have lost significant amounts of weight and kept it off for long periods of time. Detailed questionnaires and annual follow-up surveys are used to examine the behavioral and psychological characteristics of weight maintainers, as well as the strategies they use to maintaining their weight losses.
The extensive research on the 10,000 people in the registry who have maintained weight loss show the following things that they do. This list is again from the registry website.
98% of Registry participants report that they modified their food intake in some way to lose weight.
94% increased their physical activity, with the most frequently reported form of activity being walking.
There is variety in how NWCR members keep the weight off. Most report continuing to maintain a low calorie, low fat diet and doing high levels of activity.
What all this research means is that it is possible to maintain weight loss despite the cascade of hormonal mechanisms that kick in to conserve calories when weight loss happens that work to get us back to the weight that we were. It is possible, but not easy. It takes continual effort, although people in the registry do report that it gets somewhat easier over time.
Bottom Line
All diets when adhered to result in weight loss
Some eating plans are sustainable and are not nutrient deficient. These include intermittent fasting, plant-based diets and the Mediterranean diet.
More extreme diets such as the Keto diet, VLCD diets and Paleo diet are not sustainable and have various nutrient deficiencies.
Substantial weight loss triggers hormonal changes in the body that conserve calories. These changes are responsible for the fact that weight loss plateaus on almost any diet and significant weight regain even often back to the original weight occurs in 80% of people who lose a substantial amount of weight.
It is possible to maintain weight loss over many years, but it is not easy. Findings from the National Weight Control Registry suggest the following strategies to maintain weight loss
According to the World Health Organization as of 2019, 528 million people world wide were living with osteoarthritis, a more than one hundred percent increase since 1990. Osteoarthritis is the most common type of arthritis, affecting primarily the knees, hips, hands and spine. In this post I will write about the risk factors for developing osteoarthritis, both the ones you can’t do anything about and the things you can do to reduce your risk of developing osteoarthritis. Since osteoarthritis is so common, I will also write about the best way to manage osteoarthritis if you already have it.
Risk factors you can’t modify
Age
73% of people with osteoarthritis are over 55. The risk of osteoarthritis increases with increasing age. According to data from the CDC, osteoarthritis occurs in 3.6% in adults ages 18–34 to 53.9% in those age 75 and older.
Gender
The CDC estimates that about 1 in 4 women have been diagnosed with osteoarthritis, compared to about 1 in 5 men. The percentage of women with osteoarthritis increases after menopause. For example, among people aged 40–49, about 10% of women and 7% of men have knee osteoarthritis, but between the ages of 60–69, that prevalence rises to 35% in women and 19% in men.
Genetics
There is no gene for osteoarthritis. The genetic risk of osteoarthritis is the result of many genes, each contributing only a small amount of risk. The total genetic contribution to osteoarthritis is about 30%. In other words a little less than a third of cases of osteoarthritis are due to genetic factors.
History of joint trauma or injury
Any injury to a joint or a fracture involving a joint increases the risk of post traumatic osteoarthritis. For example the incidence of arthritis of the knee after ACL tears is as high as 60%.
Risk factors you can modify
Obesity
Maintaining the lowest weight that is practical for you reduces your risk of developing osteoarthritis of the hip and knee. Obesity markedly increased the risk of developing osteoarthritis and also serves as a multiplier for other risk factors.
Sedentary Lifestyle
Aerobic exercise and strength training decrease the risk of developing osteoarthritis. The best practice is to follow CDC recommendations: 150 minutes per week of moderate exercise such as brisk walking or 75 minutes of vigorous exercise such as running or cycling. Strength training twice a week.
Smoking
Smoking causes inflammation and double the risk of getting osteoarthritis. It is best to never start smoking. If you smoke, stopping smoking decreases your risk, although not as much as if you never smoked
Avoiding Certain Occupations and Sports
Occupations that involve long standing, bending and heavy lifting increase the risk of osteoarthritis, especially of the knees. They include workers in construction, firefighting, agriculture, fisheries, forestry, and mining. In a case-control study, men who worked for 11–30 years in building and construction work had a 3.7 fold greater risk of developing knee osteoarthritis.
Certain sports such as American football, soccer, competitive wrestling and competitive weight lifting are also associated with increased risk of osteoarthritis of the knee and ankle. There is conflicting evidence about long distance running. Some studies show increased risk, but one study showed that marathon runners have decreased risk of developing osteoarthritis.
How to manage osteoarthritis of the knee
Weight loss
If you are significantly overweight or obese then weight loss will decrease stress on the knee thereby reducing pain and slowing the progression of the arthritis.
Exercise
Aerobic exercise helps pain from knee arthritis. The best exercise is walking or swimming or water aerobics. Strengthening exercises for the quadriceps muscle are also helpful. Here is a link to a good description of quad strengthening exercises: Knee Arthritis Exercises. Physical Therapy can also be helpful and can provide equipment like braces or heel wedges that can also reduce pain. There is also some evidence that tai chi reduces knee pain from knee arthritis. If you smoke, stopping smoking can reduce inflammation and therefore pain.
Medicines
The first medicines to try with the least potential for side effects are topical medicines that you rub on the knee. The most effective ones are diclofenac and capsaicin. Both of these are available over the counter. Topical lidocaine patches can help temporarily, but don’t last as long as the other two.
Oral medicines that are the most effective are NSAIDs like naproxen or ibuprofen in combination with acetominophen (Tylenol). Long term use of oral NSAIDS can occasionally cause bleeding ulcers or kidney damage. If you are taking NSAIDs long term, these need to be monitored by your doctor.
Alternative treatments like glucosamine, ginger and S-adenosylmethionine (SAM-e) seem to help some people and are safe long term. Chondroitin has not been shown to reduce pain.
Joint Injections
Steroid injections in the knee can give temporary relief. This can last for months. These are generally safe every 3 months for up to a year. These injections are easy to administer and can be done by most family physicians without need for referral. Over time, as arthritis worsens they tend to not work as well. Multiple steroid injections have been shown to worsen arthritis, so fewer injections are better.
Cartilage injections have shown no difference from placebo in controlled trials. Some people get some benefit, but this may well be a placebo effect.
Surgery
The only surgery shown to be effective is total or partial knee replacement. Arthroscopic knee surgery to “clean out the joint” has been shown to have no more than placebo effect.
How to manage osteoarthritis of the hip
Exercise
All of the aerobic exercise options for knee osteoarthritis also work for osteoarthritis of the hip, but water exercise or cycling is better than walking. Avoiding certain activities that stress the hip such as stair climbing, or active sports like tennis can reduce pain. Tai chi can also be helpful for hip osteoarthritis. Canes or walkers can be helpful, but need to be prescribed by a physical therapist who can decide on the best appliance and show how to use it properly.
Medicines
Topical medicines do not work as well for osteoarthritis of the hip as well as they do for the knee. Oral medicines are the same as medicines for osteoarthritis of the knee.
Joint Injections
Steroid injections of the hip can be helpful but have to be done using ultrasound or x-ray to make sure the needle is in the hip joint. They are much more difficult than steroid injections of the knee.
Surgery
Hip replacement is the only surgical option. It tends to be less painful post operatively than knee replacement and requires less rehabilitation by physical therapy.
How to manage osteoarthritis of the hands
Home management
Home management includes periodic resting of the hands when doing repetitive activities such as typing. Heat also helps. A warm compress or paraffin wax hand bath can soothe affected joints.
Some adaptations of daily activities may be helpful. Here are some suggestions from Arthritis Health by Veritas:
Wear coats and shirts with zippers instead of buttons
Use long zipper pulls which are also larger than regular zipper pulls and therefore easier to grasp. Specialized zipper pulls are made with looper cloth or nylon and allow the user to stick a finger through and pull down.
Choose lightweight cooking and gardening tools that are easier to lift and hold
Buy slip on shoes to avoid having to tie shoelaces
Occupational therapy can provide hand exercises as well as splints and other home aids.
Medicines
Topical medicines also work well for hand and wrist osteoarthritis. The other medicines for knee osteoarthritis also can be helpful.
Joint Injections
Steroid injections can be very helpful, but are somewhat more difficult to do than knee injections. Hand or wrist steroid injections are usually done by an orthopedist or rheumatologist.
Surgery
Surgery for hand osteoarthritis is not done very often and when done usually involves fusion of a joint to relieve severe pain.
Management of Osteoarthritis of the spine
Osteoarthritis can happen in any part of the spine, but osteoarthritis in the lumbar spine is the most common. The symptoms are back pain, and if a nerve root is compressed, then the pain can radiate down one leg (or one arm if the arthritis is in the cervical spine). Treatment depends somewhat on the symptoms, but like other forms of osteoarthritis non-medication treatment includes exercise, weight loss, tai chi, and physical therapy. Acupuncture helps some people. TENS units sometimes help as well. If you smoke, stopping smoking decreases inflammation and therefore pain.
Medicines
The same topical and oral medicines for knee arthritis also help for spinal osteoarthritis.
Injections
Epidural (just outside the spinal cord sack) injections can be helpful and when they work can last for months or even years. They have to be given by a pain management specialist under x-ray guidance.
Surgery
There are several kinds of spinal surgery. If the spinal osteoarthritis is severe enough to cause pressure on the spinal cord, then part of the vertebrae compressing the spinal cord are removed and the vertebrae are fused. If just the opening between the vertebrae is pressing on a nerve, then that opening is enlarged to take pressure off the nerve root. Surgery can also involve fusion of vertebrae at one or several levels to decrease pain. This kind of fusion surgery is not always successful long term and should be avoided if possible.
Bottom Line
Osteoarthritis is the most common form of arthritis and prevalence increases with age. Over half of people over 75 have osteoarthritis. Women are more commonly affected than men, especially after menopause. Thirty per cent of osteoarthritis is genetic and the rest due to other risk factors including previous joint trauma, obesity, smoking, sedentary lifestyle, certain occupations and certain sports. Avoiding obesity altogether or losing weight if you are overweight, regular aerobic exercise as well as strength training twice a week and stopping smoking if you smoke all decrease your risk of developing osteoarthritis. For those who have osteoarthritis Non-medication treatments should be tried first. Surgery is a last resort when other methods have failed.
Longevity is the newest health buzzword. There are an increasing number of so-called longevity experts. They say, just read my book and follow my instructions and you can live past 100 years. Some of these “experts” focus on health span. They say follow my instructions and you will stay healthy and die suddenly at an advanced age. As of 4/21/2024 there are 34 books on longevity listed on Amazon.
In this post I will do my best to distinguish the hype from the science with regard to living a long and healthy life.
Hype
Calorie restricted diets – Some people have extrapolated mouse and rat experiments that show that animals fed restricted calorie diets live a lot longer than animals fed a normal diet. There is not one shred of evidence that this works with humans, and is more likely to lead to diseases of malnourishment.
Nutrtional supplements – Recommendations range from vitamins, to protein powder, to collagen powder, to herbal preparations, to encapsulated fruits and vegetables. There is absolutely no evidence that any of these things or any other supplements including multivitamins work to extend your life. Anecdotal reports of feeling better on these supplements are almost certainly a placebo effect
Anti-aging medicines – reservetrol, metformin, rapamycin have all been shown to prolong life in some experimental animals. In humans Metformin and reservetrol decrease the ability to exercise and rapamycin suppresses the immune system. There is no evidence whatever that these compounds increase life or health span in humans.
Extensive lab tests – Other than lipid (cholesterol) tests, there is no evidence that otherwise healthy non-obese people benefit from any blood tests. More about screening tests later.
Imaging tests – One of the most popular longevity “experts” ,Dr. Peter Attia, recommends full body MRI scans for his patients. Imaging tests in people who have no symptoms are much more likely to lead to over diagnosis and unnecessary treatment than to find things that really need to be treated,
Very intense exercise regimens – The only thing very intense exercise regimens accomplish that moderate exercise regimens do not is that the intense regimens are more likely to cause injury.
Science
Genetics
Up until into the 80’s, lifestyle is the major contributor to healthy aging. There are some people, however who remain healthy well into their 90’s and a few to past 100. Genetics is the main contributor to these “super centenarians.” There is not a single or even a few aging genes. Super aging is caused by hundreds of genetic variants called SNP’s (single nucleotide polymorphisms). We cannot alter our genes (yet), so there are no lifestyle changes you can make in order to live to 100 if you don’t have the rare combination of all these genetic variants.
That is not to say that lifestyle is not important to healthy aging. In the US, the average person’s last birthday in good health is age 65! Lifestyle changes will almost certainly help you do better than that.
Exercise
Regular exercise decreases your risk of chronic disease and therefore increases your chance of living healthier longer. To accomplish the maximum health benefit the CDC recommends 150 minutes of moderate exercise per week. Brisk walking or cycling at a moderate pace on level ground would qualify. If you choose high intensity exercise like jogging or running or high intensity cycling, you only need to do 75 minutes a week according to the CDC. The CDC also recommends activity to strengthen your muscles two days a week. For a population of adults doing this exercise regimen the risk of death is decreased by 17%. This regimen decreases the risk of heart disease, diabetes, certain cancers and decreases the risk of hospitalization or death from infectious diseases like COVID, flu and pneumonia. This regimen also increases bone and muscle strength and thus decreases the risk of falls and fractures. This exercise regimen also helps maintain a healthy weight.
Any amount of walking or activity decreases risk somewhat. The CDC recommended regimen decreases risk the most.
Nutrition
Eat mostly unprocessed foods and avoid ultra-processed foods. The best way to identify ultra-processed foods is to look at the ingredients label. If there are more than four ingredients, and/or if there are some you don’t recognize, then put that food back on the shelf. It is best to keep nutrition advice simple. The most concise recommendation I know comes from author Michael Pollan. “Eat food (food is anything your grandmother would have recognized as food), not too much, mostly plants.” I can’t do much better than that. Most of the evidence about the beneficial effects of good nutrition come from studies of the Mediterranean style diet. The Mediterranean diet adheres to Michal Pollan’s advice. It has lots of fruits, vegetables, fish, olive oil and very little meat. Adherence to this type of diet showed a 46% increase in living healthfully until 70 or greater.
Social Connectedness
The CDC defines social connectedness as the degree to which people have and perceive a desired number, quality, and diversity of relationships that create a sense of belonging, and being cared for, valued, and supported. An analysis of multiple studies showed that high social connectedness as defined above decreases the risk of premature death by 50%! High social connectedness also decreases the risk of heart disease, stroke and dementia.
Social Determinants of Health
The main reason that the US average health span is 65 years is the tremendous inequity of resources in the US. People who live in substandard housing (or no housing at all) do not have the opportunity or resources to do all of the things above that tend to extend life. That is why life expectancy at birth is related to zip code more than any other factor. My feeling is that we should expend our resources working on improving health equity, which will increase both life and health span for everyone rather than focusing on helping wealthy people live to 100.
Screening Tests
There are a few screening tests recommended by the US Preventive Care Task Force for healthy people. These tests are meant to find disease, especially cancer early so it can be more successfully treated and thus prolong healthy life. The absolute risk reduction of death for these tests is small, most around 1%, but that ends up saving a lot of people when you apply it to the whole US population. The recommended screening tests are listed below.
Mammograms for women beginning at age 50. Recommended every two years. Absolute risk reduction about 1%.
Pap Smears beginning at age 21 every 3 years through age 29 and then every 5 years from age 30 to 65. The absolute death risk reduction is .0009%, which means your would need to do pap smears on 11140 women to prevent one death from cervical cancer.
Colorectal cancer screening. There are three different tests: colonoscopy, the most invasive (recommended every 10 years), Cologuard (a stool sent to a lab in a box recommended every 3 years) and fecal immunochemical test (done on a stool sample and either tested at home or sent to lab recommended every year). All three tests reduce deaths from colon cancer with an absolute risk reduction of around 0.6%. Only colonoscopy can prevent some cancers by removing precancerous polyps.
Vaccines
There is no question that vaccines save lives by preventing some serious life threatening diseases, or making them less severe. Vaccines are especially important for infants and children, who are most at risk from the infectious diseases prevented by vaccines. Childhood vaccines prevent diptheria, whooping cough, tetanus, measles, mumps, rubella, polio, rotavirus (which causes severe diarrhea and dehydration in infants), hemophilus influenza (which caused joint infections and meningitis), hepatitis b, RSV (which causes severe respiratory illness), pneumonia caused by strep (the most common kind of bacterial pnuemonia), COVID (also for adults), meningitis, chicken pox, and HPV (the virus that causes cervical cancer in women).
Adults can get any of these vaccines, but also a vaccine to prevent shingles.
Bottom Line
Living in good health to past 100 depends on genetics, not lifestyle. Many things recommended by so called longevity experts do nothing to prolong life and may increase risk. There are a number of lifestyle changes including exercise, good nutrition, social connectedness, certain screening tests and vaccines that increase you chances of remaining healthy well into your eighties. The main cause of early death in the US is poverty, homelessness and systemic racism. Addressing these inequities is a lot more important than helping wealthy people try to live to 100.
Cholesterol is one of two fats in the bloodstream called lipids. Your liver makes almost all the cholesterol in your blood. Eating high cholesterol low saturated fat foods (such as eggs and shellfish) does not increase your blood cholesterol. The other fat is triglyceride. Almost all triglyceride comes from what we eat or is made in the liver from foods that have a lot of sugar or starchy carbohydrates. Fat does not dissolve in the blood, so these fats are carried in tiny droplets within a protein shell. These proteins are called lipoproteins. Any of these lipoproteins can be elevated without the others, so although many people may say, ”I have high cholesterol,” it is important to know what kind of ”high cholesterol” they have. In this post I will talk about the different kinds of hyperlipidemia (the medical term for high cholesterol), what kind of damage they can do, and how they can be treated both with medicines and diet.
Types of lipoproteins
There are four major classes of lipoproteins: chylomicrons, very low density lipoproteins (VLDL), low density lipoproteins (LDL) and high density lipoproteins (HDL).
Chylomicrons
Chylomicrons are the largest particles. They carry fat that you eat from the intestine to be used as fuel for the body or stored in fat cells. They are made mostly of triglycerides (90%), which is in the center of the particle with several different kinds of lipoproteins on the outside.
VLDL (very low density lipoproteins)
This is the next smallest class of particles. They contain about 50% triglycerides, 25% cholesterol and the rest a type of fat called phospholipids. They are made in the liver and carry triglycerides and cholesterol to the cells.
LDL (low density lipoproteins)
LDL particles carry more cholesterol than the others. They also deliver cholesterol to the cells. High levels of LDL particles are associated with an increased risk of heart disease. More about this later.
HDL (high density lipoproteins)
HDL particles have the most protein and the least amount of fat contained within them. That makes them more dense, hence the name, high density lipoproteins. The function of HDL particles is to carry cholesterol and triglycerides back from the cells to the liver. This decreases LDL in the cell walls of the arteries and helps prevent heart disease. Low levels of HDL are associated with increased risk of heart disease and high levels with decreased risk of heart disease. Paradoxically, very high levels of HDL actually increase the risk of heart disease.
Cholesterol
Cholesterol is essential to your body. Cell walls are made up of mostly cholesterol. Cholesterol is used to make many essential hormones in the body including estrogen, progesterone, androgen, cortisol and many others. Cholesterol moves in and out of cells to do it’s job. If LDL (and therefore cholesterol) is too high, it can accumulate in the walls of arteries at spots where there is inflammation. More about inflammation later. The immune system sends special cells called macrophages to ”eat” the offending LDL particles, but that causes more inflammation and more accumulation of cholesterol. This cholesterol buildup is called a ”plaque” and these can cause narrowing of the artery and can also cause blood clots to form which can completely block the artery. The result is a heart attack or stroke.
Triglycerides
Triglyceride levels are affected by what we eat. We absorb triglycerides directly from eating saturated fats but the liver also converts any unneeded calories to triglycerides that are then stored in fat cells. Very high triglyceride levels can cause pancreatitis (inflammation of the pancreas). It is likely that high triglycerides also increase the risk of heart disease and stroke, possibly by being deposited in the arterial walls like cholesterol. We are not sure at this point the exact mechanism that connects high triglyceride with cardiovascular disease
Inflammation
Inflammation in the artery walls starts the whole process of cholesterol buildup and plaque formation. In fact, one of the main reasons that statin drugs like atorvastatin (Lipitor) work is that they reduce inflammation in the walls of the arteries as well as lowering LDL (and thus cholesterol). It may well be that inflammation of the artery walls can cause plaque formation to begin even in people with normal LDL levels. We can get some idea how much chronic inflammation is going on in our bodies by having a blood test called high sensitivity C-reactive protein (CRP).
So what causes inflammation of the artery walls and is there anything we can do about it?
Inflammation is increased by our old friends: highly processed foods, sugar, high fructose corn syrup and a diet high in starchy carbohydrates. There is pretty good evidence to suggest that eating large amounts of saturated fats (essentially animal fats) also produces inflammation. Increased belly fat secretes a substance that causes chronic inflammation (See my previous post Why is the United States so fat and what to do about it for instructions about how to measure your belly fat). Finally, inflammation of the gums from plaque on your teeth leads to inflammation in arteries. Of course smoking cigarettes also increases inflammation in your arteries.
You can reduce inflammation in your arteries by stopping smoking if you are a smoker, eating unprocessed foods, especially fresh vegetables, fruits and berries, nuts and fatty fish. Taking good care of your teeth also helps. That means flossing daily and seeing the dentist for cleaning once every 6 months. Regular exercise such as walking at least five times a week also reduces inflammation. If your abdominal circumference is above normal, then losing weight will reduce inflammation. All of these things also tend to reduce LDL and triglycerides too, so you get double duty from these life style behaviors.
When you need to take medicine for hyperlipidemia
A significant portion of high LDL and/or triglycerides is genetic. You can make all the lifestyle changes I talk about above and still have high lipids. If that is the case, then you need to talk to your doctor about starting cholesterol medicine. That will likely be one of the class of drugs called statins. There are quite a few of these and they vary in potency, side effects and drug interactions. Almost everyone will be able to tolerate one of the statins without any significant side effects. There are a few people that have adverse reactions to all of the statins. There are some new non-statin medicines that look promising for decreasing LDL in those few patients who can’t tolerate statins. Your doctor will help you find the right medicine for you to help lower your LDL and/or triglycerides.
Bottom Line
All fats in the blood are carried by special proteins called lipoproteins. Cholesterol is carried mainly by LDL. In the presence of inflammation in the arteries, high levels of LDL lead to plaque formation in the arteries that can eventually lead to heart attack or stroke. High levels of triglycerides also increase the risk of heart disease. Lifestyle changes can reduce both inflammation and number of LDL particles and triglycerides, thus reducing population risk of cardiovascular disease. Sometimes lifestyle changes are not enough and cholesterol lowering medicines are needed.
We are inundated with information about what increases or decreases our risk of heart disease. In this post I will talk about what risk really means, how we calculate risk, and some things you can do to reduce risk of heart disease. OK, here we go.
Risk: What does it mean?
Although we often talk about individual risk (or luck, which is the same thing) risk really only applies to populations. We know, for example, that in the population of people buying lottery tickets, one person will win the lottery. We know that for certain, but we have absolutely no way of predicting who that person will be. The millions of other people who buy lottery tickets will not win the lottery. The population chance of winning the lottery ranges from one in 42 million to one in 176 million depending on the lottery. Any individual’s chance of winning the lottery though is either 0% or 100%. You either win it or you don’t. The very low population chance just means that there will be millions and millions more people who don’t win.
The same thing is true for risk of heart disease or any other disease. We can define a population that has a certain risk of heart disease, let’s say 15% over ten years. We can be very sure that 15% of that population will develop heart disease. but 85% of those people will not develop heart disease. For any individual, we have absolutely no way of knowing or predicting whether they will or will not develop heart disease. Individual risk is either 0% (you won’t get heart disease) or 100% (you will get heart disease). Even though a population risk of 15% is considered high risk of heart disease, the vast majority of those people will not get heart disease. Their risk is 0%. If you are one of the 15% who gets heart disease then your risk is 100%.
Doctors and other health professionals talk about individual risk, even though there is really no such thing. They do this to try to get people to change their behavior or to convince them to take a medicine. If you successfully change your behavior in a healthier direction or you take a medicine that you were not taking before, you then belong to a different population that has a lower risk of disease. Even though you belong to a lower risk population, your individual risk is still either 0% or 100%.
Relative Risk Reduction vs Absolute Risk Reduction
When research is done on some medicine or other intervention to see if it works, the medicine or intervention is given to one population and a placebo (inactive medicine) to another very similar population and the results are compared. A common way to report how much the intervention reduces the risk of a particular disease compared to the risk in the control group is to report it as relative risk reduction.
Here is a real world example. Eating a handful of nuts per day reduces your risk of heart disease by 20%. That sounds like a lot for a very simple intervention. The problem is that number does not tell you anything about the baseline risk of the population. What we want to know is 20% of what?
Suppose we have determined by a risk calculator that you belong to a population that has a 15% risk of heart disease over ten years. 20% x 15% = 3%. The absolute risk reduction is 3%. That doesn’t sound quite as impressive, does it? What is really important for you to know about a treatment is how much it reduces the risk compared to the baseline risk of the control population; that is, you want to know the absolute risk reduction for the population of people treated compared to the people who are not treated. Often results are not reported that way and you have to calculate it yourself. More about this later on.
How do we calculate the population risk of heart disease?
There are several heart disease calculators that let you know what heart disease risk population you belong to. Although each of them talk about calculating your individual risk of heart disease over the next ten years, what they really mean is that you belong to a population that has that risk. Remember that there is really no way to calculate risk for an individual. Here is a link to a page from Harvard Health Publishing that lets you try out each of three different risk calculators: Heart Attack Risk Calculators.
How to put yourself in a lower risk population for heart disease
In order to calculate absolute risk reduction of any medicine or change in behavior, you first have to calculate the risk of the population you are currently in. Multiplying the relative risk reduction of any change times your current population risk gives you the absolute risk reduction of that change. The higher your current population risk, the greater the absolute risk reduction of any change. That means that the first thing you have to do is to use one the risk calculators in the link above to calculate your current population risk of getting heart disease in the next ten years.
In the examples below I’m going to assume a moderate ten year population risk of heart disease of 9%. Remember that if you are in a population whose risk is higher than that, the absolute risk reduction of each change will be larger.
Things that don’t involve taking medicine
In this post I’m going to focus on things you can do to reduce your population risk of heart disease that don’t involve taking medicines prescribed by your doctor. Medicines that treat high blood pressure or high cholesterol can also lower your population risk of heart disease. That is a discussion better left to you and your doctor, however.
Exercise
Regular exercise, depending on the amount, decreases 10 year risk of heart disease by 31 to 45%. For a moderate population risk of 9%, that translates to an absolute risk reduction of 2.8% (.09 x .31) to 4% (.09 x .45). To get the higher level of absolute risk reduction you have to exercise moderately for 150 minutes a week and do activities that enhance muscle strength twice a week. Simply being active most of the time as opposed to sitting most of the time puts you in a population that has a significant absolute risk reduction, on the order of 2-3%. Exercise level is included in many of the risk calculators. If your population risk includes exercise then you should not count that separately.
Saturated vs unsaturated fat
Despite what we have all been told over the years, the evidence is pretty weak that eating saturated fat increases your population risk of heart disease. On the other hand, eating more unsaturated fats does decrease your absolute risk of heart disease. Most studies show that people who ate the most polyunsaturated fats (vegetable oils) had about a 25% relative risk reduction for heart disease. Using our 9% population example the absolute risk reduction is about 2% (.09 x .25).
Eating fish
Eating fish twice a week reduces your relative population risk by 16%. Using our 9% population risk example, that translates to an absolute risk reduction of a little over 1% (.09 x .16).
Eating nuts
As I mentioned at the beginning of this post, eating a handful of tree nuts (cashews, pecans, almonds) reduces the relative population risk by about 20%. In our 9% population risk example, the absolute risk reduction is about 2% (.09 x .20).
Increasing dietary fiber
Fiber in the diet can be increased by eating lots of whole fruits, vegetables and whole grains. Observational studies show this causes a population relative risk reduction of 16%. In our 9% population risk example, the absolute risk reduction is a little over 1% (.09 x .16).
Not Smoking
Smoking cigarettes doubles the relative population risk of heart disease. Using our 9% example, the population absolute risk increase is 9% (1 x .09). Conversely, if you quit smoking your absolute population risk would be cut in half.
Putting it all together
If you make all the exercise and diet changes outlined above, they add up. Lets do the math.
9% ten year risk of heart disease -3% for exercise – 2% for eating more polyunsaturated fats – 1% for eating fish twice a week – 2% for eating a handful of nuts per day – 1% for increasing dietary fiber = 0! Obviously no one has zero risk of heart disease over ten years but this calculation makes the point that doing multiple things that reduce your absolute population risk of heart disease by small amounts add up to a large reduction in your population risk of heart disease. Doing all these things puts you in a population that has less than 1% ten year risk of heart disease. Does that mean you won’t get heart disease if you are a member of this population? No it doesn’t. Remember that it is impossible to calculate the risk for an individual. What being in this population does mean is that only a very few people will get heart disease over the next ten years.
Bottom Line
Risk refers to populations, not individuals. Relative risk reductions are reported in the medical literature most of the time because they are larger and look more impressive. Absolute risk reductions are important to know, because they take into account baseline population risks. If you calculate your baseline population risk by using one of the risk calculators, you can easily calculate absolute risk reduction by multiplying the baseline population risk times the relative risk reduction reported in a study or magazine article. Even though one behavior change produces only a small absolute risk reduction, multiple small absolute risk reductions add up to a big absolute risk reduction.
In my previous post, I described two population studies that showed that some people who had the structural brain changes of Alzheimer’s disease showed no evidence of dementia during their lives. How did their brains become so resilient? That is the subject of this post.
Sleep
There is a drainage system in the brain that removes beta amyloid proteins that can accumulate to cause Alzheimer’s disease. This drainage system only operates in stage 4 sleep. The problem is, of course, that elderly people who are at the highest risk of Alzheimer’s disease tend to have less deep stage 4 sleep. Nonetheless, getting adequate sleep significantly decreases the risk of Alzheimer’s disease. Sleep deprivation even in midlife is associated with an increased risk of developing Alzheimer’s disease later on in life. Adequate sleep for the vast majority of people means 7-9 hours of sleep a night. There are many other health benefits of adequate sleep (and conversely many health risks with chronic sleep deprivation). If you would like to learn more about sleep there is an excellent book by Matthew Walker called Why We Sleep. He also has a podcast if you prefer to listen rather than read. His podcast is called the Matt Walker Podcast.
Purpose in Life
A sense of purpose in your life substantially reduces your risk of developing Alzheimer’s disease. If your job gives you a sense of purpose, then continue to work as long as your health (or your employer) permits. If you are already retired, then find something to do that gives you a sense of purpose. It could be volunteer work or a part time job, or a hobby that you find meaningful. Anything you do that helps other people is more likely to give you a sense of purpose.
Good Nutrition
The subject of nutrition keeps coming up whenever we discuss any health topic. Eating a nutritious diet including high fiber, minimally processed foods decreases your risk of developing dementia. Here is a link to my previous post on good nutrition: Good Nutrition: A Review of the Evidence
Exercise
Regular exercise reduces the risk of developing Alzheimer’s disease. Although any regular exercise including walking reduces risk, the kind of exercise does matter somewhat. Walking out of doors especially on trails in parks stimulates your brain because you have to pay attention to where to put your feet. Even if you live in a city, you likely have access to parks with walking trails. Even walking several blocks in the city outside stimulates your brain more than walking on a treadmill at home or in a gym.
Drink less alcohol
Heavy alcohol use substantially increases the risk of developing dementia, but light to moderate alcohol use may actually be protective. 14 or less units of alcohol per week does not increase your risk of dementia and may somewhat reduce your risk. A unit of alcohol is 10 ml (about 1/3 of an oz) of pure alcohol. Here is a link to a calculator that calculates how many units are in multiple kinds of alcoholic beverages: Alcohol Change Unit Calculator.
Don’t Smoke
Smoking increases your risk of developing Alzheimer’s disease by 60%. If you do smoke, quit. If you don’t smoke, don’t start.
Learn New Skills
When you learn new things, your brain forms new connections and the more new connections are formed, the more resilient is your brain. This resilience helps protect your brain function and substantially decreases your risk of developing dementia. It is important to do a variety of things that stimulate your brain. Just doing crossword puzzles or other games that purport to stimulate your brain have not been shown to decrease the risk of dementia. Start keeping a journal, write a blog, learn a new skill that requires eye-hand coordination. Take art lessons, or woodworking lessons, or lessons in any other new skill that strikes your fancy. Engaging in creative activities helps form a variety of new brain connections, and those are what protect you from dementia.
Social Contacts
Frequent face to face contact with friends and family substantially reduces your risk of developing dementia. We are social animals and our brains were designed to interact with others. Loneliness may increase the risk of developing dementia by as much as 40%. Conversely, a good social support system can reduce the risk of developing dementia by as much as 60%. Contact with others mainly through electronic social media may reduce the risk of dementia somewhat, but interactive face to face contact with others seems to be necessary for reducing dementia risk substantially.
Bottom Line
There is nothing you can do that reduces your risk of developing dementia to zero. You can, however reduce your risk quite a bit. Get 7-9 hours of sleep a night. Avoid highly processed foods. Exercise regularly, especially outside if possible. Drink 14 units or less of alcohol per week. Don’t smoke. Maintain a sense of purpose in your life. Continually learn new skills. Maintain an active social network.
If you do all of these things, you stand a good chance of remaining alert and having a productive life well into your eighties and nineties.
This is the third post in a series on chronic diseases in the US.
Statistics
High blood pressure (hypertension) is the 5th leading cause of death in the US. In 2019 half a million people in the US died with hypertension as the cause or major contributing cause. Two thirds of all strokes and half of all heart attacks are caused by hypertension. The old definition of hypertension was a systolic blood pressure of 140 or greater and/or a diastolic blood pressure of 90 or greater. There is a new definition of hypertension that we will talk about later, but by the old definition, one out of every 4 people in the US have uncontrolled hypertension. By the new definition nearly half of people in the US have hypertension.
Definitions
The medical term for high blood pressure is hypertension. Blood pressure has two components. The systolic pressure is the pressure when the heart beats, forcing blood out of the left ventricle into the arteries of the body. The diastolic pressure is the pressure left in the arteries between beats. Both are equally important, and an increase in either one (or both) increases risk.
It has been known for a long time that there is a continuous increase in risk of cardiovascular disease and stroke as blood pressure rises. The lower your blood pressure the lower your risk. The spot on that blood pressure vs risk curve where we define the disease hypertension is arbitrary. The vast majority of deaths, strokes and heart attacks come from systolic blood pressures of 140 or higher and/or diastolic blood pressures of 90 or higher.
The new definition of hypertension
Blood pressure categories in the new guideline are:
Normal: Less than 120/80 mm Hg;
Elevated: Top number (systolic) between 120-129 and bottom number (diastolic) less than 80;
Stage 1: Systolic between 130-139 or diastolic between 80-89;
Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg
There are no new data on the continuous increase in risk as blood pressure rises. The American Heart Association and other associated groups have simply decided to change the spot on the risk curve where hypertension is defined. They point out that the risk of cardiovascular disease is 3.5 times higher in the Elevated category than in the normal category. That sounds like a lot, but three times a very small risk is still a very small risk.
Measurement of blood pressure
High blood pressure has no symptoms, so you don’t know if you have it unless you measure it. In order to figure out where you are on the blood pressure risk curve, you have to know what your average blood pressure is. Blood pressure should not be measured until you have been sitting quietly for 5 minutes. That clearly does not happen the vast majority of the time when the nurse or medical assistant takes your blood pressure in your doctor’s office. More likely you have rushed to get there, had trouble finding a parking place, walk into the office already agitated and anxious, and the nurse takes your blood pressure as soon as you sit down. That is a recipe for having a falsely elevated blood pressure!
Home blood pressure measurement
The best way to determine your average blood pressure is to measure it at home. There are lots of very reliable reasonably priced home digital blood pressure monitors. Choose one that has a cuff that goes on your upper arm, not your wrist. The wrist blood pressure monitors are not very accurate. Also check that the cuff is the right size for your upper arm. If your upper arm is very large, then you will need a monitor with an extra large cuff. It is a good idea to measure the diameter of your upper arm before you buy a blood pressure monitor. Here is a link to an article by Forbes Health that rates the top ten home digital blood pressure monitors: Best Blood Pressure Monitors of 2022. Note that the highest ranked one is not the most expensive one. Any of the OMRON monitors are good, so if that brand is what is available in your local pharmacy, that brand would be fine.
Measure your blood pressure twice a day for at least two or three weeks. You should sit quietly in a chair for five minutes before you measure your blood pressure. You should not measure your blood pressure right after you have had your morning coffee. Either measure it before coffee (or tea) or about two hours after your last cup. All of the good monitors keep a record of your blood pressures, and some of them will calculate the average for you.
What to do based on your average home blood pressure
Normal (less than 120 systolic and less than 80 diastolic): You don’t need to make any diet or lifestyle changes based on your blood pressure
Elevated (systolic 120-129 and less than 80 diastolic): Although your risk of cardiovascular complications is a little higher than if your systolic pressure was less than 120, it is not much higher. You might want to make some modest diet and lifestyle changes (which I will discuss later). You definitely do not need blood pressure medicine.
Stage 1 (systolic between 130-139 or diastolic between 80-89): This used to be considered normal by the old definition of hypertension. Blood pressure at this level bumps up your risk of stroke or cardiovascular disease by a bit more than the elevated category but it still would be considered moderate risk. You would definitely want to make some diet and lifestyle changes and if you did that you would likely still not need blood pressure medicine.
Stage 2 (systolic 140 or greater or diastolic 90 or greater): The risk of stroke or heart disease is substantially high and gets progressively higher as the blood pressure increases. You still should do diet and lifestyle changes, but you probably will also need blood pressure medicine. If you have stage 2 hypertension, you should definitely see your doctor.
Risk factors for hypertension
Surprise, surprise! The risk factors for hypertension are almost the same ones that increase your risk of type 2 diabetes, heart disease, cancer, and stroke. They are:
Heredity (not simple and involving multiple genes each contributing a tiny part)
Increased body fat, particularly increased waist circumference
Sedentary lifestyle
Eating high sugar, high carbohydrate processed foods
Eating too much salt
Diet and lifestyle changes to decrease blood pressure
Reduce sodium in your diet. That means no added salt and staying away from high sodium foods. Here is a link to an article from drugs.com describing a 2 gram sodium diet: 2 Gram Sodium Diet. If you are simply not willing to get rid of added salt completely, switch to Morton’s Lite Salt. It is half sodium chloride and half potassium chloride. It tastes exactly like salt but has half the sodium of regular table salt.
High blood pressure, even very high blood pressure has no symptoms. Because of that everyone should determine their average blood pressure at least once a year.
Home blood pressure measurement is the most accurate way to know your average blood pressure.
Measure your blood pressure twice a day for at least 2-3 weeks and calculate the average.
If your average blood pressure is in the elevated range or higher, then diet and lifestyle changes will help reduce it.
If you have stage 1 or 2 hypertension you should see your doctor.
This begins a series of posts on chronic diseases. Nearly half of Americans suffer from at least one chronic disease. Chronic diseases include diabetes mellitus, high blood pressure, cancer, stroke, heart disease, respiratory diseases, arthritis, obesity, and oral diseases. Chronic diseases are responsible for 7 out or every 10 deaths in the United States. Almost of these diseases can be prevented or managed successfully.
Type 2 Diabetes mellitus has reached epidemic proportions in the United States. One in every ten people in the United States has type 2 diabetes mellitus. It is the 7th leading cause of death in the U.S. In this post I will talk about the causes of type 2 diabetes mellitus, how it can be prevented, and how it can be treated by diet and exercise modification.
Terminology
The correct terminology for excesssive blood sugar is diabetes mellitus.The greek word from which the word diabetes comes means ”a large discharge of urine.” Mellitus comes from the greek word meaning “sweet.” There is another kind of diabetes (large discharge of urine) called diabetes insipidus, which is a completely different disease. Diabetes insipidus is caused by a deficiency of a hormone called vasopressin that is secreted at the base of the brain.
There are two types of diabetes mellitus and they both cause high blood glucose but they have completely different causes. Type 1 diabetes mellitus is an autoimmune disease that destroys the beta cells in the pancreas, which are the cells that produce insulin. It usually occurs in childhood, often following a viral infection. It is much less common than type 2. People with type 1 diabetes mellitus have high blood glucose because they produce no insulin at all and have to be treated with insulin. People with type 2 diabetes mellitus make plenty of insulin, at least in the beginning of the disease. Their bodies are resistant to insulin, and even though their insulin levels are high, the insulin can’t carry glucose into the body’s cells like it is supposed to and the blood glucose rises. In the rest or this post I’m going to talk exclusively about type 2 diabetes mellitus.
Causes of type 2 diabetes mellitus
Type 2 diabetes mellitus is caused by a complex interaction between genetics and environment.
Heredity
Type 2 diabetes mellitus tends to run in families. The lifetime risk of developing type 2 diabetes mellitus is 40% for individuals who have one parent with type 2 diabetes (I will leave off the mellitus from here on out for the sake of brevity) and 70% if both parents are affected. We know some of the genes that are associated with risk of developing type 2 diabetes but they only account for about 20% of the heredity, so there are a lot more genes to find. Genetic risk is not destiny, though. Environment plays a huge role in the development of type 2 diabetes.
Causes of Insulin Resistance
Insulin resistance is the hallmark of type 2 diabetes. Insulin resistance starts well before the onset of diabetes. At first your pancreatic beta cells make enough extra insulin to keep your blood sugar normal. Eventually, though, they can’t keep up and blood sugar starts to rise. A number of things can lead to insulin resistance, which I will outline below.
Abdominal body fat
Increased waist circumference (greater than 40 inches for men and 35 inches for women) is a marker for what is called visceral fat, which means fat around the internal organs. Visceral fat is one of the main causes of insulin resistance. Just being over fat in general is also a cause of insulin resistance.
Sedentary Lifestyle
Lack of regular exercise causes insulin resistance. I will talk more about exercise later on when I discuss preventing and treating type 2 diabetes.
Diet
A diet high in processed foods with starchy carbohydrates and sugar (or high fructose corn syrup) causes increased insulin release and can eventually lead to insulin resistance.
Microbiome
The microbiome refers to the 100 trillion bacteria that live in our intestinal tracts. The bacteria in the microbiome help digest our food, regulate our immune system, protect against other bacteria that cause disease, and produce vitamins including B vitamins B12, thiamine and riboflavin, and Vitamin K, which is needed for blood coagulation. It turns out that the microbiome may also promote or reduce insulin resistance depending on what kinds of bacteria live in our intestine. Research about this is just beginning, but here is what we know so far. People with type 2 diabetes have a lower diversity of bacterial species in their gut. They specifically lack bacterial species that produce something called butyric acid. Increased bacterial diversity in the microbiome and especially bacteria that produce butyrates are associated with lower insulin resistance. At this point we don’t know if changing the microbiome will help treat or prevent diabetes, but this is an exciting possibility.
Prediabetes
When genetic predisposition and environment interact, insulin resistance starts to develop. There is a condition called prediabetes. It develops up to ten years before people develop frank type 2 diabetes. There are two tests used to diagnose prediabetes (or actual type 2 diabetes). One is called fasting blood glucose. The blood glucose is tested after fasting overnight. Another test is called hemoglobin A1C. It turns out that glucose in the blood forms a molecular bond with the hemoglobin in red blood cells. This molecular bond lasts for the life of the red cell, which is about 90 days. The amount of hemoglobin that is bonded to glucose is proportional to the average blood glucose level over the 90 day life of the red cell. We can measure the amount of hemoglobin bonded to glucose and that gives us a pretty good measure of the average blood glucose over the last 3 months.
Prediabetes is defined as a fasting blood glucose of 100-125 and/or a hemoglobin A1C of 5.7%-6.4%. If either one of these values is higher, then that makes the diagnosis of type 2 diabetes.
The importance of finding prediabetes is that by making diet and lifestyle changes people can prevent the onset of type 2 diabetes. It is much easier to prevent type 2 diabetes than it is to treat it once you already have it.
How to prevent or reduce insulin resistance (whether you have prediabetes or have progressed to frank type 2 diabetes).
Increase your exercise. The CDC recommends 150 minutes a week of moderate exercise (brisk walking for 30 minutes, 5 days a week, for example) or 75 minutes per week of vigorous exercise (jogging or running for 25 minutes 3 days a week for example).
Avoid highly processed foods with added sugar, honey, maple syrup and especially high fructose corn syrup. Replace them with fresh fruit, fresh vegetables, fish and poultry.
Increase the soluble fiber in your diet. Soluble fiber promotes growth of diversity in your microbiome. Here is a link to an article from Healthline.com that identifies the top 20 foods with soluble fiber: Top 20 Foods High in Soluble Fiber
Eat fermented foods with live bacteria in them such as plain yogurt (sweeten with added fruit or berries, not sugar) sauerkraut, or kimchi. These add healthy bacteria to your microbiome. Here is another link to Healthline.com that lists a number of fermented foods that are good for you: 8 Fermented Foods and Drinks to Boost Digestion and Health.
Dietary Treatment of Type 2 Diabetes
If you already have type 2 diabetes you can do all of the things listed above to decrease insulin resistance, which means you may be able to get by on less or no medicines. If you are on any diabetic medicines other than metformin, you should let your doctor know of any changes you plan to make in your diet or exercise. He or she may want to reduce your medicines so you don’t get your blood sugar too low.
There are some additional dietary changes that may help your blood glucose be under better control and reduce or eliminate your diabetic medicines. These are things you definitely need to check with your doctor before you try them.
Ketogenic Diet
There is good evidence that a ketogenic diet is very good for people with type 2 diabetes.
What are ketones?
Normally your body uses glucose for energy for the brain and other body functions. Insulin carries the glucose into cells so they can use it for energy. If you don’t take in enough carbohydrates to produce glucose for energy, then your body starts to mobilize fat. Fat cannot be broken down to glucose, but it can be broken down to something called ketones. Your body and brain can switch over to using ketones for energy. Ketones require little or no insulin to get into cells.
What do you eat on a ketogenic diet?
A ketogenic diet is a very low carbohydrate high fat diet. That sounds unhealthy and it can be if you eat mostly saturated fats. A good ketogenic diet uses mostly healthy unsaturated fats. Here is a link to another Healthline.com article that discusses ketogenic diets for type 2 diabetes: How the Ketogenic Diet Works for Type 2 Diabetes. Do not start a ketogenic diet without checking with your doctor first!
Intermittent Fasting
Intermittent fasting means exactly that. Fasting means not taking in any calories for certain periods. There are all sorts of ways to do intermittent fasting. Most commonly, people fast for 24 hours every other day or they eat all their meals within a limited time period, between 7AM and 3PM for example. There is increasing evidence that intermittent fasting improves control of type 2 diabetes over and above the fat loss that results. Here is a link to a recent review article about the benefits of intermittent fasting for type 2 diabetes: Intermittent fasting: is there a role in the treatment of diabetes? A review of the literature and guide for primary care physicians.
It is important to drink plenty of water when doing intermittent fasting. If doing fasting for longer that 24 hours, one needs to drink liquids with electrolyes rather than plain water. People with type 2 diabetes should NOT start an intermittent fasting program without checking with their doctor.
