Heart of the Matter

My doctor said my HDL is 100, he said I will live forever and can eat whatever I want!

Is all cholesterol alike? Is the conventional wisdom that High HDL cholesterol is good always true? If you have very high HDL are you really protected from heart disease? If your HDL is very high is it a license to eat cheeseburgers?

Plenty of data accrued over decades and over 100,000 patients show that having levels of HDL cholesterol (the good stuff, as opposed to LDL the bad stuff) over 45 for men and 50 for women helps protect you from the development of heart disease. This has led to confusion on several fronts: a ratio of HDL to LDL or, more commonly a ratio of total cholesterol/HDL of >4 has been said to be protective and higher HDL levels have been felt to be helpful. Perhaps you recall this ratio on your lipid report.

All of this is true, especially at the low end of HDL. Very low HDL levels, below 35 clearly increase risk of heart disease, presumably because HDL in the blood stream scavenges up loose cholesterol particles and returns them to the liver for processing. However, a recent reevaluation of the lipid profiles in over 25,000 people in Europe by William van der Steeg (the EPIC-NORFOLK study) uncovered the previously unappreciated relationship that some patients with very high HDL levels (>70) actually have INCREASED risk of heart disease. This relationship only showed up because of the large number of people in the study. Since these very high levels of HDL are fairly uncommon, they weren't studied carefully before. There is no clear explanation for this observation. One theory is that in people with very high HDL levels the HDL particles are more cholesterol laden and can actually help deliver cholesterol to the tissues.

The bottom line? All HDL is not alike. Having very high HDL is clearly not better than having moderately high HDL and may be worse. Not commonly performed (but done routinely in our Wellness Clinic) determination of HDL by a blood processing technique called Nuclear Magnetic Resonance can differentiate ‘good' HDL from the not so good and help tell if your high HDL is protective or not.

Finally, cheeseburgers are bad for almost everyone if you eat enough of them even if your HDL is very high.

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Fat or fit? What is important..

Much has been made about our overweight society (65%   of adults are now overweight or obese in America).

Clearly weight has been contributing to our health care woes both in money (16% of GNP for healthcare, more than ANY other nation by at least 50%) and health (we are 32^nd in the world in overall health score and falling fast). Overweight people are famously discriminated against and satirized. We have fat camps for kids and the diet food industry is one of our largest.

Much less has been written about fitness or lack thereof, although all of us would agree that, despite the 10,000 in the Falmouth Road Race, few of us are exercising. In fact, a recent study showed only 18% of Americans get even modest regular exercise. How important is that to our health?  The answer is 'very'.

A recent article in the Archives of Internal Medicine (August 11/25, 2008) reported on reduced disability and mortality in self reported runners over a 21 year period. There was an astonishing 50% reduction in death rate and a 12 year delay in the onset of disability from chronic disease in these folks even though many had given up running in the interim, mostly due to aches and pains.  It seems that exercising over a period of years helps not only during that time but for years afterward.

Another more complex article in the same issue looked at the risk of diabetes and heart disease in obese and normal weight people. It turns out that about 20% of the overweight people had low risk and 20% of the normal weight folks had high risk. The difference? Overwight people who were exercising regularly had better risk profiles that the normal weight people who were sedentary.  Again, exercise was the key ingredient.

Maybe we should stop crucifying the overweight for their seemingly lack of self control and start mocking the unfit.  I'm only kidding of course, but it is pathetic how unfit we are, how we accept it so readily, even joke about driving to the end of the driveway to get the mail, and how much it is affecting our lives. Fit and fat is definitely healthier than thin and sedentary. Perhaps we should stop obsessing about weight and go for a walk.

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Attention Road Race Runners : Need to Beat That Heat!

Heat injury. What do you do with a temperature of 109?

Yikes! Can your temperature actually get to 109? Amazingly about the highest temperature you can get from an infection is about 105 in kids and about 103 in adults. If you have been unfortunate to have such an illness you can probably remember how awful you felt. However running in hot, humid weather can get your temperature up over 109! We see it all the time in the Falmouth Road Race with somewhere between 10 and 60 runners affected each year depending on the weather.

These folks not only feel awful but are at risk for permanent injury or even death. Each year nearly 500 people in America die from heat stroke. Most of these are elderly folks with chronic illnesses living in Arizona in the summer but some are fit, young and healthy individuals who die in the Grand Canyon while hiking or in road races in hot weather.  A larger group won't die but wind up in hospital for days or weeks and have permanent kidney or brain injury. Not something to trifle with.

Because it is run in August and because the temperature and humidity can both be high, the Falmouth Road Race has seen a large number of affected people. The medical teams at the race are well versed in care of individuals with heat injury and can quickly diagnose the problem, its severity and treat people on the spot. Prompt diagnosis and treatment are essential to prevent complications. It is our experience that high humidity is the biggest contributor so when the humidity is above 70% we expect trouble. Over the 35 years of the Falmouth Road Race we have learned how to diagnose and treat heat injured people quickly and efficiently. Happy to say that despite treating nearly 1000 runners we have not had a serious complication or death. Knock on wood!

So of the 10,000 runners who are the 50 who will become ill? The short  answer is that it is unpredictable. We have had runners who won the race and collapsed (Alberto Salizar in 1978) a Russian woman who was leading at the 6 1/2 mile mark and back of the packers. One key element is that people are pushing hard whether to win the race or break an hour and the weather is hot and humid. A disproportionate number of people are young, less than 25, male, relatively out of shape, went out drinking the night before and are trying to beat their friend's time. The combination of the poor judgement of youth, a sense of invincibility and dehydration from too much alcohol is a bad combination.

Typically, the medical teams stationed over the last 2  miles of the course will get a call on the radio from spotters that someone has collapsed. A key sign of heat stroke is delerium (confusion) and weak legs. The team quickly gets the person on a stretcher and rushes them to one of the three medical tents. There vital signs are taken including a rectal temperature. If they are confused, passed out and have a temperature over 106 they are unceremoniously dumped in a bathtub sized pool filled with ice. To anyone with normal body temperature this would be uncomfortable to say the least but to someone with heat stroke they usually lie back oblivious to the intense cold. We monitor blood pressure, pulse and temperature continuously and when the temperature reaches 102 we take them out. Usually by that time the entire tub of ice has melted! If people regain their bearings and feel OK we can get them on their way within an hour. If not they may need a few hours or overnight monitoring in the hospital.  The key to this approach is to get people in the ice within 10 minutes of collapse and to get them out before they get too cold. (For a more thorough discussion of this topic see the excellent article by Douglas Cassa, et. Al. In July 2007 in Exercise and Sport Sciences Reviews) I am happy to say that the experience at the Falmouth Road Race over the years has helped to define this illness and its treatment.

So unless you want an ice bath and a rectal temperature, drink a lot of water, cool off during the race and slow down or stop at the first sign of dizziness or weakness. Mostly, just run within your limits and enjoy the scenery.

 ________________________________________________________________

The wellness program will be well represented at the Falmouth Road Race number pick up and expo on Saturday August 9 from 10am to 3pm. We will have Dr Sbarra there to answer questions and will be continuously raffling off free Carotid Intima Media Thickness determinations. We will also perform CIMTs for all those who want to understand their risk of heart disease. There will be a special expo price of $175. Gift certificates for future tests will also be available. On your way  to buy a tee shirt, stop by to visit our booth.

If you are running on Sunday, GOOD LUCK and don't forget to stay cool and hydrated. If you start feeling dizzy and weak, don't just keep going, pour water on your head, walk a bit and cool off. We don't want to see you in the medical tent. I will give a report of the race in my blog(at Capecodtoday.com) next week. You don't want to find your case of heat stroke described there

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Let Me Call You SWEET Heart...

Can sweeteners stimulate your appetite and are they a health hazard?

Sugar is expensive, at least when you buy it by the ton. So if you are a soft drink maker or a donut maker you might consider looking for alternatives. Wa la!  Born the artificial sweetner and corn syrup  industry.

Artificial sweetners are expensive to make but up to 200 times sweeter tasting than sugar so a little goes a long way toward sweetening your diet soda. Corn syrup or high fructose corn syrup as the processed form is  known is just about as sweet as sugar but, due to US government subsidies to corn growers and high tariffs on imported sugar, is much cheaper. Since the mid-80's when HFCS was first used by Coke and Pepsi, its use has skyrocketed. An editorial in the Archives of Internal Medicine this week stated that currently 20% of carbohydrate intake and 10% of all calories consumed by Americans is from HFCS!

The questions are: do these sugar alternatives contribute to obesity or to other health issues?

This has been heavily debated in the lay, internet and medical literature. The sum on ‘other health issues' (i.e. cancer and heart disease)  is that in 25 years no convincing evidence has come forward that there are cancer or other health risks from artificial sweetners. Skeptics still say the definitive study has not been done and feel there is a coverup. Indeed the original FDA approval of aspartamine was provided by Ronald Regan for his buddy Donald Rumsfeld's company G.D.Searle without any independent studies on safety. Fortunately for the rest of us there have been no obvious health risks identified. They do contribute to your appetite for sweet things. High intake increases your insulin levels and may make you hungry sooner. Paradoxically, they may contribute to obesity.

How about HFCS, does it contribute to obesity?

In the same issue of AIM (July 28, 2008) researchers reported from Boston University that eating HFCS sweetened beverages increased weight and the incidence of diabetes in African American women. It didn't matter if they drank soda or fruit juices. This is no surprise since virtually all, ‘healthy alternative' and ‘all natural' fruit drinks like Frutopia, Nantucket Nectars,  Gatorade,  Snapple, Newman's Own Lemonade, etc.,etc.,etc. have HFCS as their second ingredient, after water and an insignificant amount of actual fruit juice.  They act nutritionally like expensive soda. The incidence of diabetes and increased obesity in these women of 25-31% was directly related to the amount of HFCS in their diet.  It appears that drinking sweetened drinks made them fatter and gave them diabetes.

The bottom line:

we are eating increasing and shocking amounts of corn syrup. It is definitely contributing to the obesity epidemic. It can give you diabetes. There is no good reason to drink these products. We would be better off making alcohol from the corn for our cars or feeding the world's hungry. As an alternative, try water! It is healthy, all natural (well, mostly) cheap and won't rot your teeth or make you fat or give you diabetes. As for sweetners, they contribute to an appetite for more sweet things and maybe for food in general. Like salt we should save this taste for special treats not make it the flavor of every meal.

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Only 3% of Americans are healthy!

defining the ‘magic formula' for achieving good health

A study published by a group at my alma mater, Michigan State University, by Matthew Reeves, M.D. defined a healthy lifestyle and measured its impact on health in an article published in the Archives of Internal Medicine.

They defined the ‘magic formula' for achieving good health which, if adhered to, reduces the incidence of heart disease, stroke and diabetes by 70% and the incidence of cancer by 30%!  What formula could be this powerful and this magical? How expensive this must be. How strange it must be that we don't know about it for if we did wouldn't we all subscribe to it?

This magic formula is as follows: not smoking, maintaining a normal or near normal weight, eating 5 servings of fruit or vegetable a day and exercising 30 minutes a day.

Amazing isn't it that this formula could be so powerful? Imagine what our health care budget would be like if 70% of the most common and most expensive diseases went away? The only thing I find more astonishing than the magic formula is that only 3% of Americans adhere to these 4 healthy habits! The other 97% are content to risk crippling illness and take ever bigger doses of medicine rather than doing some simple things that we all know well will not only make us feel better but we now know, reduce our disability and make us live longer to boot. It is truly a magic formula but one we can all adhere to at virtually no cost and with no side effects except perhaps more regular bowel movements.

There is a tendency to discount this kind of lifestyle advice, no matter how compelling perhaps because it seems to good to be true or that this kind of adherence is too difficult. With the benefits so dramatic, however, we all should consider this advice more seriously. Save your own life!

My thanks to Monte Ladner, M.D. for his recent lecture on this subject from which much of this information was obtained.  I urge you to visit his website (www.fitness rocks. com) for the complete lecture and for podcasts on a long list of interesting health topics.    

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