Type 2 Diabetes Mellitus -- A Primer

Insulin is a hormone produced by the pancreas; specifically, the beta cells of the pancreas, which are located in an area of the pancreas called the Islets of Langerhans. Insulin allows for the entry of sugar from the blood stream into cells of various organs such as the liver, skeletal muscles and fat tissues to be used as energy. Diabetes Mellitus simply means there is too much circulating sugar in the blood stream either because the pancreas does not produce enough insulin or because the cells stop responding to the insulin and thus glucose cannot enter the cells. Diabetes Mellitus is usually diagnosed by two fasting blood sugars of 126 or greater. It can also be diagnosed by a hemoglobin a1c (a blood test that measures the blood sugar over a 3 month time period) of 6.5 or greater or a glucose tolerance test greater than 200. A normal fasting blood sugar is less than 100. Pre-diabetes is diagnosed with a fasting blood sugar of 101-125. Diabetes Mellitus is the leading cause of blindness, kidney failure, and lower extremity amputations in America. There are two main types of Diabetes, Type 1 and Type 2.

Type 1 Diabetes Mellitus occurs when the islet cells of the pancreas that produce insulin are destroyed (usually by antibodies to attack a virus but which incidentally destroy the islet cells). If the islet cells are destroyed, then the individual cannot create insulin. Without insulin the individual will die, and therefore Type 1 diabetics require treatment with insulin in order to live.

Before Dr. Banting (and Best, and Collip and maybe Macleod) created an injectable form of insulin in 1921, Type 1 Diabetes was a virtual death sentence. Parents would often just watch their children wither away and die. Here for instance is a picture of a 3-year-old child before he was given insulin and 3 months after being on insulin.




From Lilly Archives

  It’s the SAME child, and the pictures are only 3 months apart. If you were this child’s parent, wouldn’t you feel that insulin was miraculous?

However, Type 1 diabetes (or the destruction of the pancreatic islet cells that create insulin) only accounts for approximately 5%-10% of diabetics in America. Most Americans with diabetes have Type 2 Diabetes.

Like obesity, Type 2 diabetes has increased dramatically in our country. Here is a nice graphical map from the Centers for Disease Control showing the increase in diabetes diagnoses and how it correlates with obesity.

The initiating insult in Type 2 Diabetes is usually insulin resistance. That means the cells that receive insulin are resistant to the insulin that the pancreas produces.

Some of the most insulin resistant cells of the human body are seen in the visceral fat. Visceral fat is the fat that surrounds the internal organs such as the heart, the liver, the pancreas and the kidneys. This visceral fat creates the central adiposity that can affect so many of us as we gain weight (“the beer belly”).

To counteract this insulin resistance, the pancreas initially produces more insulin in response. Thus early in the disease process (the pre-diabetic phase) the pancreas actually is producing too much insulin. This can occur 20-30 years before an individual is diagnosed with diabetes. The resistance of this visceral fat is often too great, and the pancreas eventually burns out, losing the ability to produce insulin. It’s like a car running out of gas. In fact, by the time most people are diagnosed with Type 2 Diabetes, the pancreas has already lost 50% of its ability to produce insulin.

One of the most effective ways to treat diabetes is likely to prevent it from occurring, particularly during this pre-diabetic phase.A large trial called the Diabetes Prevention Program, enrolled 3,234 individuals who were overweight and had pre-diabetes. The trial duration was nearly 3 years. Some participants received intensive dietary and lifestyle advice with a desire to exercise 150 minutes a week and lose 7% of their body weight, others received a diabetic drug called Metformin (850 mg twice a day) and a third group was the control group, receiving placebo pills and some basic literature on a healthy diet. Participants in the intensive lifestyle program reduced their risk of developing diabetes by 58% (and by 71% in those over 60 years of age). Approximately 5% of individuals in the intensive lifestyle group developed diabetes compared to 11% of the control group. Participants who used Metformin reduced their risk by 31% with 7.8% of individuals developing diabetes compared to 11% of the control group. Keep in mind that over 3 years the people in the Intensive Lifestyle group, only lost approximately 11 lbs.

Type 2 Diabetes Mellitus does not strike all people or groups equally. Individuals of certain races and nationalities often have increased incidence of diabetes. One of the groups with the greatest incidence of Type 2 diabetes is Native Americans that live in southern and central Arizona known as the Pima Indians. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)  has studied this group for over 30 years. They have a dedicated section on the Pima Indians here.

A study by Schulz et. al compared adult Pima Indians who live in Arizona to the adult Pima Indians who live in Mexico.  These individuals have the same genetic heritage but a different lifestyle and different environment with a remarkably different effect on their health. 

Of the Pima Indians in America



(NIDDK)


63.8% of males are obese (average BMI of 33.3)
74.8% of females are obese (average BMI of 35.5)
34.2% of males have diabetes
40.8% of females have diabetes





Of the Pima Indians in Mexico

(NIDDK)

6.5% of males are obese (average BMI of 23.8)
19.8% of females are obese (average BMI of 26.3)
5.6% of males have diabetes
8.5% of females have diabetes







The striking difference in diabetes and obesity appears to be related to the different diet and energy activity among the different groups.  One could simply state that the Pima Indians in America eat poorly, don't exercise and get diabetes. Yet, there appears to be more.  Many different populations and groups may have similar body mass indexes to the Pima Indians in Arizona yet they don't have near the rate of diabetes.  In 1962, the geneticist James Neel proposed the "Thrifty Gene" theory.  That is, that certain populations are more apt to store energy.  When they are working and living in a hard and difficult climate, they need the ability to store energy.  This energy can be used during times of difficulty or famine.  However, if you place such individuals in an environment where there is little activity and great amounts of nutrient-poor calories, their body will respond by rapidly absorbing calories from the environment.

Personally, I find James Neel's theory appropriately elegant. This ability to store energy may have led to an advantage for the individual who is living in a difficult environment. It allows the individual to survive harsh environments and gives them the ability to store energy for times of famine. Thus, in some respects, the ability to develop diabetes may be a sign of the strong organism -- an organism that can very effectively store energy. This is not "a problem", or "a disease" of the individual. Rather, it almost becomes a measure of a disease of a culture that doesn't respect the individual organism's ability to effectively store energy.

Look at the desert environment in which the Pima Indians have lived for thousands of years. Over generations they have had to develop the ability to survive the harsh climate. To survive, they may have developed this "thrifty gene" to endure months of famine and hardship. However, if you place such an individual in an environment where there are plenty of low quality food choices, then the organism will adapt by rapidly storing this energy as visceral fat.

Perhaps the problem isn't with the individual who has diabetes, per se, but rather the culture or environment that the individual finds him/herself in. It is like taking a Lamborghini and instead of putting in 93-94 octane you put 87 octane mixed with sugar in the gas tank. The Lamborghini, which requires high octane fuel to keep the car at peak performance, may suffer even more from such a concoction than a Ford Pinto that runs on leaded gas. That doesn't mean the Lamborghini is a more "defective" car, it just means that it uses energy very effectively and requires higher quality fuel to run. If one respects the beauty and power of the Lamborghini, then one might try to optimize the fuel that is placed in it.

Other groups can develop Type 2 diabetes very easily. Individuals from South Asia can have very high rates of Type 2 diabetes, up to 4 times the rates of other ethnic groups. As stated in the last post, there is even a South Asian BMI calculator which defines "overweight" as a BMI of 23.1 to 25 and obese a BMI greater than 25. Again, it seems to be related to their ability to store and develop visceral fat that is resistant to insulin.

The risk for all Americans for developing diabetes in their lifetime is approximately 11% by the age 70. However, there are certain genetic traits that rapidly increase that risk. If an individual has a parent that has diabetes, lifetime risk is approximately 33%. If an individual has 2 parents with diabetes, the risk is close to 50%. Again, certain ethnicities have significantly greater rates of diabetes than other groups. But again, it doesn't seem to be simply genetic. There is a strong environmental element as well. The lack of physical activity coupled with often large portion sizes and calories of poor nutritional value can foster a dramatic increase in diabetes, particularly among certain groups. This has led some researchers to conclude that we live in a "diabetogenic culture," particularly for certain groups.

So where does that leave you, dear reader? Do you have diabetes? If not, what is your risk of developing diabetes? Perhaps if your risk is high or if you have pre-diabetes or diabetes, hopefully some of this information can be empowering. If one does have diabetes or is at a high risk, I think it might be best to view oneself as possibly inheriting a body that can store energy very effectively. To maximize its energy storage ability, it will likely be very beneficial to eat a highly nutritious diet and maintain or create an active lifestyle. This is not to say that this is necessarily an easy process. To effectively tap into the power of a body that effectively absorbs energy means that the individual will have to respect its power and often fight the easy temptation to eat a diet high in processed foods and empty calories.

The Weight of the Matter

The statistics are sobering. Over 1/3rd of us are obese. In 2012, The London School of Hygiene and Tropical Medicine calculated the average Body Mass Index for 177 countries, and America was in the top 5 with an average Body Mass Index of 27.82 (behind Tonga, Micronesia, Croatia and Greece).

From the Centers for Disease Control:
69.2% of adults over 20 years old are either overweight or obese
35.9% of adults over 20 years old are obese
41.8% of 60- to 74-year-old males are obese
36.9% of 60- to 74-year-old women are obese

According to the National Health and Nutrition Examination Survey (NHANES), the average male weighed 166.3 lbs in 1960, and by 2002 he weighed 191 lbs, an increase of nearly 25 lbs. The average female weighed 140 lbs in 1960, and by 2002 she weighed 164.3 lbs. Thus, we live in a country with heavy citizens and one in which, over the past half century, its citizens have become heavier. As they age, they become heavier still.

According to the CDC, obesity is associated with coronary heart disease, type 2 diabetes, hypertension, cancers of the endometrium, breast and colon, dyslipidemia, stroke, sleep apnea, liver and gallbladder disease and gynecological problems such as abnormal menses and infertility. It is associated with medical costs of $150 billion dollars, or 10% of the medical budget. The center has a good video segment on it here

Many Americans don’t realize they are overweight or obese. Harris Interactive performed a poll, and 30% of overweight individuals thought they were normal weight, and 70% of obese individuals felt they were simply overweight. As stated in an earlier blog post, from a medical perspective, obesity is defined by the body mass index (BMI). A BMI of 30 is obese, while a body mass index greater than 25 is overweight. The body mass index was created by Adolphe Quetelet in the 1800s, was advanced by the epidemiologist Ancel Keys in the 1970s, and has been used for population studies for decades.
A visual representation of the Body Mass Index is seen in this chart below:

To use this chart, find your height on the left and your weight on the top and then determine your body mass index. Determine your BMI with minimal clothes and no shoes. A healthy body mass index is considered from 18.5 to 24.9, overweight from 25 to 29.9 and obesity from 30 onwards. A BMI calculator is also located online from the National Heart Lung and Blood institute.

As a simple epidemiological tool, it can give a good deal of information about groups, as higher BMIs are associated with increasing risk of certain disease states, particularly diabetes.  The Harvard School Department of Public Health sent out screening questionnaires to over 51,529 U.S. male health care providers over a 5 year period of time. They also analyzed the data from over 114,000 female nurses.  As can be seen by the graph below, BMI strongly correlated with the risk of developing diabetes, particularly for women.  Even women in the "healthy BMI range" still had a substantially increased risk of developing diabetes if their body mass index was 24 instead of 21.

 Adapted from Colditz GA, Willett WC, Rotnitzky A, Manson JE. Weight gain as a risk factor for clinical diabetes mellitus in women. Ann Intern Med 1995;122:481-486; and Chan JM, Rimm EB, Colditz GA, et al. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care 1994;17:961-969.

Other weight scales have been used in the past. For instance, in 1942 Louis Dublin, a statistician working with Metlife, examined the mortality and weight of 4 million Metlife subscribers and developed a Desirable Body Weight for men and women. He divided people up into Small, Medium and Large frame based on their skeletal structure. He determined the skeletal size based on the size of the elbow, but you could also estimate skeletal size by wrapping your right thumb and middle finger around your left wrist.  If your thumb overlaps your middle finger, you are small frame, if they just touch then you have a medium frame, and if they don't touch, you are large frame.  His scale was determined with his subjects wearing shoes and 3 lbs of clothes. For the most part, his desirable body weights seem thinner, around a BMI of 21-23. The major criticism of the Desirable Body Weight Scale came from a gentleman named Andres, who stated that it may be a good scale for individuals, but as people aged, more weight may actually be protective from a health standpoint.

1986 Met Life Desirable Body Weight for Women

 

1986 Met Life Desirable Body Weight for Men

Overall, the BMI may be a useful tool to estimate an individual's or country's risk for certain disease states. However, there are potential limitations of the BMI. The BMI does not take into account several factors, such as one's gender, nationality, body composition (such as waist circumference or lean body mass). Not all fat appears to be equal. The visceral fat, the fat in the abdominal cavity around the inner organs (such as the liver, the pancreas, the kidneys) appears to harbor much greater risk in terms of insulin resistance and future cardiac morbidity. Here is an MRI of abdomens of the same waist circumference, yet some individuals have more muscle mass, and some have a great deal more intra-abdominal adipose (fat) tissue -- the white stuff instead of the dense grey muscles. 

(From Wikipedia)

In regards to identify individuals at greatest risk, efforts to determine body fat composition have been undertaken. 

The waist-hip circumference ratio is a bio-metric study to help determine this visceral adiposity. Here is a nice diagram from the International Chair on Cardiometabolic risk to measure one’s waist.

(They also have a good website at www.myhealthywaist.org) The size of the hips is usually determined with both feet together and using a measuring tape around the largest part of the hips. For men, the Waist to Hip ratio should be less than 0.9, and for women, less than 0.85. An absolute waist circumference of 40 inches for men and 35 inches for women also puts individuals at risk for cardiovascular events.

Writing in the American Journal of Epidemiology, researchers determined that waist circumference was more predictive of coronary heart disease among middle aged and older US Men than the BMI alone.

Another concern regarding the BMI is differences across nationalities. In Japan, for instance, a BMI of 25 is considered obese by the Japanese Society of Obesity, secondary to the increased risk of diabetes in Japanese over a BMI of 25. In 2008, Japan instituted a law for workplaces and governmental facilities to measure the waistlines of all adults aged 40 to 74. The cutoff was 33.5 inches for men and 35.4 inches for women. Honestly, how many white or black American males have waistlines less than 33.5 inches? In Silicon Valley, where many people are from South Asia, there is a South Asian Body Mass Calculator created by Sutter Health, which defines healthy weight as a BMI of 18.5 to 23, overweight as a BMI of 23.1 to 25, and obesity as a BMI of > 25. They recommend any South Asian with a BMI over 23.1 to get screened for diabetes, hypertension and hypercholesterolemia. One of the major concerns for the increased rate of disease states at lower BMIs among certain ethnic groups is that they may be more prone to create this visceral fat and thus place them at higher risk of disease. In such cases, a waist to hip ratio may be more accurate in defining risk.
For its own definition of obesity, the American Council of Exercise focuses on total body fat percentage. This is often determined with various measurements such as calipers or bioelectric impedance analysis, which sends a small current through the body to estimate total body fat. By their guidelines:

Description     Women        Men
Essential Fat   10-13%       2-5%
Athletes           14-20%       6-13%
Fitness            21-24%      14-17%
Acceptable      25-31%       18-24%
Obesity          >32%          >25%


So where does that leave us, dear reader? I truly think it depends on knowledge of your own risks. If you are from South Asia or India, a "normal" BMI may place you at significant risk for heart disease compared to a white American. If you are Denver Broncos Corner Back Tony Carter, you may have a BMI of 25.8, but your lean body mass is likely very high, so are you really overweight? While the average American male has gained nearly 25 lbs since 1960, he was much more likely to smoke in 1960, which makes it unlikely that the 1960s male was "healthier" than his counterpart in 2014. The weight we carry, in my opinion, requires awareness of our ethnicity, our waist-to-hip ratio, our waist circumference to help assess our own visceral adiposity and an honest assessment of our risks based on our blood sugar, cholesterol and blood pressure. And, honestly, most of us could stand to lose 5 to 10 lbs, and even such a small amount of weight loss can lead to reduced risks of many disease states.

If you like, you can even evaluate yourself on the London School of Hygiene and Tropical Medicine's Global Fat Scale.

Sources for blog that don't have links (since I can not figure out footnotes...)

http://www.cdc.gov/nchs/fastats/overwt.htm

http://www.cdc.gov/nchs/data/databriefs/db56.pdf

http://usgovinfo.about.com/od/healthcare/a/tallbutfat.htm

http://care.diabetesjournals.org/content/17/9/961.full.pdf+html  (good article...)

http://annals.org/article.aspx?articleid=708530

http://aje.oxfordjournals.org/content/141/12/1117.short

Anatomy of a Cigarette

My earlier posts introduced continuous quality improvement concepts, which can hopefully be used to effect behavioral change for healthier living. The next few posts will delve into various disease states and various agents that can promote disease states. This post deals with smoking.

According to the Centers for Disease Control, smoking cigarettes is responsible for nearly 90% of all lung cancer deaths in men and 80% of all lung cancer deaths in women. According to the Department of Health and Human Services, over 20% of all coronary heart disease deaths are attributable to cigarette smoking. According to the National Cancer Institute, among current smokers, over 50% of all deaths (both men and women) are attributable to smoking cigarettes. Most smokers know many of the health consequences of smoking, but they continue to smoke. Why? I hope this post may elucidate some of the possible reasons.

“The cigarette is ... among the most awe-inspiring examples of the ingenuity of man....The cigarette should be conceived not as a product but as a package. The product is nicotine....Smoke is beyond question the most optimized vehicle of nicotine and the cigarette the most optimized dispenser of smoke.”

To me, those few simple sentences speak volumes. They were written in 1972 by a Philip Morris senior researcher named William Dunn. Those words express why cigarettes fascinate me. I am an internal medicine physician with a strong interest in smoking cessation, but I find myself continually amazed by a simple cigarette.

I view cigarettes as exquisite nicotine delivery systems.

The middle of a lit cigarette can reach over 1,000 degrees Fahrenheit. This heat generates a smoke that allows almost instantaneous absorption of nicotine as it passes through the mucous membranes of the mouth. Further, the nicotinic effect of smoking can be auto-regulated at the will of the smoker -- that is, he can take short, frequent puffs or long, "satisfying" draws. He can extinguish it when he desires. What other drug can be so instantly regulated by the user?

Then there are the cigarette additives: ammonia, for example. Ammonia is a "base" substance. That is, it makes its environment less acidic and more basic. As smoke is inhaled, ammonium compounds neutralize the natural acidity of the mouth from a pH of around 6.8 to a pH of between 7 and 8. This increase in the mouth pH allows for more nicotine, which is also a basic substance, to be absorbed through the mucous membranes. Thus, by adding ammonium compounds, it is possible to "free the base" of nicotine, giving the smoker a much stronger "hit" of nicotine. With ammonium compounds, nicotine can be “free-based,” much the way cocaine is free-based with baking soda.

And ammonia is only one of hundreds of chemicals in a cigarette. There's menthol, which anesthetizes the back of the throat, allowing greater ease of smoking; cocoa, which opens up the lung airways and allows for deeper inspirations; and various sugars and sweeteners, which can soften and improve the taste of a cigarette.

Further, nicotine is incredibly addictive. In fact, according to the National Institutes of Drug Abuse, nicotine is more addictive than heroin or cocaine. This can make "breaking the habit" much harder than it seems.

I think an understanding of some basic pharmacology can help the smoker who decides to quit. Nicotine lasts in the body for six weeks. That is why nicotine patches use step-down approaches over a six-week period of time. And that is one reason why six weeks is considered a critical time-period to be smoke free, because by that time all the nicotine is effectively out of one’s system.

And that’s just the power of nicotine.

But, although the physical addiction to cigarettes can be very strong, the psychological addiction can be even stronger. Most people don’t just "smoke" cigarettes. Rather, they are smokers. Smoking changes their identity. And, I feel, this is why many people who desire to quit can break the incredible physiological addiction and be smoke-free for six to 12 weeks, but find it much more difficult to be smoke-free for a year or a lifetime. Ultimately, the smoker has to see herself a non-smoker. This is really a change in self-identity.

The ex-smoker not only has to resist the urge of a cigarette for the rest of her life, she also has to resist the thought of seeing herself as ever smoking a cigarette again, not after a satisfying meal, not after a stressful experience, and not even after a loved one passes away. Stopping smoking is a life-changing event.

And that’s why I ask smokers not only to set a quit date, but also to set a freedom date. Freedom from the cigarettes that don’t really offer stress relief or pleasure or satisfaction, but really only offer heart attacks, lung cancer, throat cancer and emphysema. In my opinion, one does not quit smoking; rather one sets himself free from it.

The CDC has a five-step plan to become smoke-free:

1. Get ready.
2. Get support.
3. Learn new skills and behaviors.
4. Get medication and use it correctly.
5. Be prepared for relapse or difficult situations.

1. Get Ready
Set a Quit Date and KEEP IT. Make yourself a diploma. Plan for your quit date by getting rid of all cigarettes and ashtrays, and don’t let people smoke in your home. Then, once you quit, don’t smoke –- NOT EVEN A PUFF!

2. Get Support and Encouragement
Tell your friends and family members that you have quit. This creates a positive peer pressure force to remain smoke free. Further, contact local agencies such as the local Health Department. Find a “stop smoking buddy.”

3. Learn New Skills and Behaviors
Develop action strategies to stop smoking. You may need to distract yourself. Talk, walk, exercise, drink water, but DON’T OVEREAT! If you associate smoking with certain activities, then change your routine –- take a different route to work, eat breakfast in a different place, eat a mint instead of using cigarettes. If you smoke for stress relief, find different activities to supplant this role (a hot bath, exercise, reading, etc.) CELEBRATE your daily successes with at least one enjoyable activity every day.

4. Get Medication and Use It Correctly
Nicotine replacement products, Buproprion SR (Zyban®) or Chantix can double your chances of success. Ask a physician if one of these products is right for you.

5. Be Prepared for Relapse or Difficult Situations
Most people relapse before they quit. Most relapses occur within the first three months after quitting, so be especially vigilant during this time. Avoid alcohol and other smokers. Accept a few extra pounds (most gain less than 10). Finally, accept stressful situations as challenges to see if you can find other means of stress relief besides getting a cigarette.

I have posted an 8 minute youtube video on smoking which you may find informative.

Lastly, for a little personal plug -- I do have a trademarked anti-smoking cartoon character named Jack Jackass. Check the Smoking Mule Fool out at www.JackJackass.com

Your Own Root Cause Analysis

A Root Cause Analysis is a problem-solving method to determine a primary cause of a causal chain which can lead to operating events.

For our purpose, we will define your Root Cause as current aspects of your behavior which impact your health. The more brutally honest you are with yourself, the greater opportunity you will have to induce meaningful change in your own life. The next questions are an overview to help you determine your own root cause of disease processes. These questions are simply an overview and may not be as in-depth as required for your own individual situation.

#1) How healthy are your parents and your siblings?
Your family tree is part of your genetic heritage. As you the share the DNA of your family, if you partake in the same environment and share similar behavioral activities, there is a fair likelihood that you will share similar health care-related events. Looking at organisms to which you are most similar can give you a clue as to a potential causal chain of events which may impact your own future health.

#2) Do you smoke?
This does not have a follow-up question, such as “If so, how much?” Smoking, according to the Centers for Disease Control, is the leading cause of preventable death in America. Smoking is so noxious to individual and public health that the only true treatment for this addiction is cessation.

#3) Are you obese? Are you overweight?
Obesity is defined by the Body Mass Index (BMI), a determination created by Belgian statistician Adolphe Quetelet in the 1800s. It came to fame from the work of the epidemiologist Ancel Keys in 1972 and has become used to determine obesity rates for different societies and countries by the World Health Organization. You can also use an online calculator from the National Heart Lung and Blood Institute. Some fault the BMI because it does not take into account several factors such as visceral adiposity (the belly fat around the organs) or total body fat percentage, but it has been studied and used for so many years, it is helpful to identify one’s own BMI. It is often surprising to realize how little weight is required to be obese or overweight. For instance, a 5 foot 8 inch individual is considered obese with a weight of 197 lbs, and overweight at a weight of 165 lbs.

#4) Do you have hypertension, and/or elevated cholesterol?
The Joint National Committee on the Prevention, Detection and Treatment of High Blood Pressure is a committee which determines blood pressure guidelines. Their latest (JNC 8) was just released in December, 2013 but primarily focused on treatment guidelines for specific blood pressure readings. The prior report, the JNC 7 which was released 10 years earlier in 2003, had the following guidelines.

Normal: <120 systolic (top number) AND < 80 diastolic (bottom number) Prehypertension: 120-139 systolic OR 80-89 diastolic
Stage 1 Hypertension: 140-159 systolic OR 90-99 diastolic
Stage 2 Hypertension: >160 systolic OR > 100 diastolic

Regarding cholesterol results, there are various recommendations on cholesterol lowering medications, yet studies have consistently shown that often the lower the total cholesterol and bad cholesterol (LDL), the lower the risk of cardiovascular disease. As a corollary, an elevated good cholesterol (HDL) can reduce the risk of heart disease. However, merely taking medications to raise the good cholesterol has not shown cardiac protection. Rather, it appears to be much more cardio protective if one can raise the good cholesterol with exercise and activity. A low cholesterol diet to also decrease the total cholesterol and LDL cholesterol also seems to be a good choice for cardio protection.

#5) Do you have heart disease?
Have you had a heart attack, angina (chest pain related to heart disease), a heart rhythm problem or an enlarged heart? The greatest risk factor for a future heart disease is a personal history of a prior cardiac event. In short, if you have had a heart attack, you have a much higher risk of developing future heart disease. For instance, Bill Clinton had coronary artery bypass surgery at age 57 (2004) but then had cardiac stent placements at age 63 (2010).

#6) Do you have diabetes?
Diabetes is most commonly diagnosed by two fasting blood sugars of 126 or greater. However, a normal fasting blood sugar is less than 100. Diabetes is considered a “cardiovascular event equivalent”, meaning that the risk of having a heart attack is similar to the risk of a person that already had a heart attack. If one knows one’s cholesterol, blood pressure, and blood sugar numbers, a very informative calculator has been created by the American Heart Association to allow individuals to obtain their 10 year risk of heart disease. I advise you to play around with the numbers on this calculator. Notice if a 45-year-old man has a healthy body mass index of 23 and has good cholesterol numbers and a good blood pressure, the risk of heart disease may only be 1-2%, but if that individual has diabetes, the risk jumps to > 20%.

#7) Do you have cancer? Or are you at increased risk of cancer?
For nearly all cancers, life expectancy is increased if one catches it an earlier stage. However, I view cancer as a process and the best treatment, if possible, is to avoid its creation in our bodies if at all possible. Knowing the risk factors for various cancers, as well as informed knowledge about appropriate screening tests, can be beneficial. MD Andersen has some nice online calculators to determine survivability of breast, colorectal, esophageal and pancreatic cancers.

#8) Are you sedentary?
The Sedentary Behavior Research Network (did you even know there was such an organization?) defines sedentary behavior as “any waking activity characterized by an energy expenditure ≤ 1.5 metabolic equivalents and a sitting or reclining posture” Without a commitment to activity, it is possible for many of us to exist as sedentary individuals throughout our work and home life. With normal activity, an individual usually walks around 4000-6000 steps a day. It requires a commitment to obtain 10,000 steps a day, which is the amount recommended by many public health agencies. However, more studies are also coming to light stating that the intensity of exercise may also play a role as well. For instance, running may equal 250 to 300 steps a minute.

#9) Are you depressed or stressed?
Depression is commonly based on questions associated with sadness, lack of initiative, excessive feelings of guilt, decreased energy, decreased concentration, change of appetite, and feelings of suicidality. If symptoms are overwhelming, one should seek professional help immediately, but often many of us can harbor simmering feelings of depression. Further, it is not only depression or stress, but the way we react to these feelings (such as overeating, smoking or excessive rumination and sedentary behavior) which can lead to future disease states.

Now, write a short descriptive statement of yourself. Such as, “I am a 44-year-old male non-smoker with a BMI in the obese range. I am sedentary. I do not know if I have high blood pressure and I am not aware of my cholesterol. My mother, who smoked, had a heart attack at 61 and is still living and my father is 75 in fair health on no major medications (but he does not see a physician regularly). Maybe I’m a little depressed.”

Or

“I am a 50-year-old female smoker with a BMI in the normal range. My cholesterol is slightly elevated by my last physical exam and my blood pressure would place me in the prehypertensive range. My father died at the age of 76 (he smoked and had emphysema) and my mother is alive at the age of 80 and is in good health (she stopped smoking at the age of 60). I don’t consider myself depressed. Based on a Framingham Risk Factor calculation, my risk for cardiovascular disease in the next 10 years is 6%.”

A basic root cause of medical illness in both examples is different. While obesity is probably the greatest concern for the 44-year-old male in the former example, in the latter example her smoking is the most likely cause of her ill health.

Now, after identifying the individual behavior, it is best to go a step further. Why is the 44-year-old male overweight? Does he eat at night? Is it stress eating? Does he exercise enough? Why doesn’t he know his cholesterol and blood pressure? Does he live in a state of fog of his overall health? If a root cause of the primary ill health can be identified, action can be taken at both the psychological and physical level to effect change. Asking the deeper questions about why we participate in an unhealthy activity may unlock a psychological answer to help implement the physical changes which are required.

Regardless, once the undesirable activity is targeted, it can help to take some time to research or develop a SYSTEM for behavioral change for yourself. The key point here is to invest in a SYSTEM for change -- using something consistently -- a video, a coach, a book, a youtube, whatever works and whatever makes you accountable to effect this change. I view both health and disease not as static events but as processes. We want to move from disease progression to health progression. Lastly, aspects which can help develop effective systems are often stronger if we have knowledge about the benefits of change. That is why the next few postings will go into detail regarding the earlier questions.

Prevention and Quality : Defining the Terms

I believe prevention is the weakest link in American healthcare. But what exactly is prevention? Mirriam Webster defines prevention as “The act of preventing. Effectual hindrance.” It defines prevent as “to be in readiness for…to go or arrive before…to keep from happening or existing...to hold or keep back.” The key to these definitions is that prevention is an active process. Ironically, it is almost an active process of creating hindrances.

In regards to healthcare, even the terminology of prevention has been difficult. The Institute of Medicine (IOM) in 2009 stated “The definition of ‘prevention’ is itself a problem. Since the release of the 1994 IOM report, the IOM has emphasized the need for clear definition to guide the field.” In fact, there was even a Preventions Definitions Project sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA) created in 2009.

The SAMHSA definition of prevention is as follows. “Prevention is a proactive process that empowers individuals and systems to meet the challenges of life events and transitions by creating and reinforcing conditions that promote healthy behaviors and lifestyles.”

Breaking down this definition of prevention into its component parts displays a systems oriented approach for the individual and communal structures to create healthy behavior. Firstly, prevention is a “proactive process” meaning that we as individuals and communities must actively engage in health oriented activities (or actively avoid unhealthy ones) to create a meaningful result. This system based approach seeks to create an effective response to the various events that can occur. A common saying among those that are systems oriented is “it’s the process not the person.” If the system is not producing the desired outcome, then change can be made to the system to produce a desired outcome. If one has a sharp and clear image of a desired end product, and the system is failing to produce that end result, then a reworking of the system must be performed. As the old computer saying goes “Garbage In, Garbage Out.”

Secondly, it “empowers individuals and systems” that is, it strengthens and gives resources to individuals and systems to promote a healthy outcome. This section alludes to the responsibility of the system and the individual to promote a healthy outcome. Responsibility in this respect does not refer to individual blame, or fault. Rather it refers to the individuals and systems “ability to respond.” Both the individual and the system must be able to respond to various threats which the individual may encounter.

Thirdly, “to meet the challenges and life events by creating and reinforcing conditions that promote healthy behavior and lifestyles.” . This in itself is a continual, ongoing process to always achieve the desired end result. Further, the system must be dynamic in its ability to respond to ongoing challenges.

In short, prevention is a systems based process that can empower the individual to ably respond to the contingencies of life and life events to promote a healthier outcome. This occurs by the individual using effective system based tools and the individual him/herself being part of a systems’ based process to promote effective change.
The next step is to create a personal quality prevention system.

The IOM defines healthcare quality “as the extent to which health services provided to individuals and patient populations improve desired health outcomes. The care should be based on the strongest clinical evidence and provided in a technically and culturally competent manner with good communication and shared decision making.
Total quality is best defined as an attitude, an orientation that permeates an entire organization, the way in which that organization performs its internal and external business. People who work in organizations dedicated to the concept of total quality constantly strive for excellence and continuous quality improvement in all that they do.“

Although the IOM report refers to healthcare systems, I believe that this definition can be extrapolated for the individual as well. Quality is based on the best clinical evidence. From an individual’s perspective it is based on education and knowledge of what treatment works, why it works, what its risks are and what are its benefits. From a quality standpoint each decision is made with these questions in mind. Once the decision is made, the next step required is often the hardest – implementation.

The next step of implementation requires ruthless honesty. Once we are aware of our situation, we must then take the sobering step of acknowledging it, and, if necessary, changing it. In a systems oriented approach this is often described as a Root Cause Analysis.