The term “Metabolic Health” is popularly used these days referring to the absence of any feature of metabolic syndrome. Features of disordered metabolic health are apparent in those who have normal body weight, although more common in those who are obese. Metabolic syndrome is defined as 3 of 5 of the following criteria: blood pressure greater than 120/80; fasting glucose greater than 100 mg/dl and/or HbA1C greater than 5.7%; triglycerides over 150 mg/dl; HDL less than 50 mg/dl in women or less than 40 mg/dl in men and a waist circumference greater than 102 cm in men and greater than 88 cm in women.
So, what percentage of the population would you estimate is “metabolically” healthy? The answer is astounding. The University of North Carolina, Chapel Hill performed a study analyzing data from NHANES (National Health and Nutrition Examination Survey) ranging from 2009 to 2016. The data compiled documented the presence or absence of the above criteria defining metabolic syndrome. Patients were considered healthy if they lacked all five of the criteria in the absence of any medication used to treat those features. Astoundingly, only 12% of the group (comprising over 8000 patients) met those criteria. Alternatively, 88% of this population carried at least one of the 5 risk factors for progression to diabetes and/or cardiovascular disease.
The above data represents population statistics from several years ago; I am confident that things have gotten worse over time as our population’s waistbands expand. Based on my experience, the data is scary, but not at all surprising.
Early Detection, Action is Essential
As an endocrinologist, I ran a busy diabetes/endocrinology practice for 24 years in Nashville, Tennessee. Most of the patients seen already had overt diabetes and advanced disease. In other words, the horse had already escaped the barn. But a significant number of patients came to me for other reasons such as thyroid, adrenal, pituitary and parathyroid disease, just to name a few. Many times, I would evaluate the problem at hand and come up with a solution that required long term monitoring while noting that this abnormality did not represent an immediate threat to the individual’s overall health. However, after assessing the patient both physically and “on paper”, I noted that many of these patients had metabolic syndrome which was unrelated to the presenting problem. It was very difficult for me to ignore these life-threatening issues.
Studies have shown that patients with Type 2 diabetes, have had insulin resistance for many years prior to the diagnosis of diabetes. Insulin resistance means that the body does not use glucose normally and the pancreas is required to produce large amounts of insulin in order to keep blood sugars normal. After many years of insulin over-secretion, the beta cells of the pancreas (that make insulin) eventually fail. It is when the pancreas can no longer keep up with the increased insulin demand that diabetes finally occurs.
What if we identified these patients at risk early in the process so that we could delay, or better yet, prevent the onset of diabetes and cardiovascular disease as well? It is much better to prevent disease with lifestyle changes and medication (and less costly) rather than waiting until the disease has already resulted. As the old saying goes, “An ounce of prevention is worth a pound of cure.” What can we do to stop the progression of disease in its tracks? Does prevention really work? What are the practical aspects of this proposal?
The answers to the above questions are complex. I will provide some solutions that are essential in treating this national health crisis.
Be your own health advocate.
The patient should be already convinced that he/she wants to improve their individual situations and are willing to work in that direction. Physicians are very busy these days treating patients that mostly already have overt disease. The time and reimbursement deficits present in our current health care system make it impossible for most primary care physicians to focus largely on disease prevention. The patient needs to understand what his/her health implications truly are and the dire consequences of ignoring them.
Identification of the problem is straightforward. Two of the five criteria for metabolic syndrome (triglycerides and high-density lipoprotein) are documented in a standard lipid panel. A1C and fasting glucose are also easily identified from a morning blood draw. Blood pressure can be measured both at a physician’s office and at home. I recommend home blood pressure monitoring for many patients so that we can see what the results are at various times of day under typical life circumstances. The waist circumference can be obtained by taking a tape measure and measuring at the top level of the hip bone.
Wear a Continuous Glucose Monitor.
A more precise level of glucose dysregulation can be documented by wearing a continuous glucose monitor (CGM). A CGM measures interstitial blood glucose approximately every 5 minutes. Sensors can typically be used 10 to 14 days before expiration. This data gives a real-time view of blood sugar levels throughout days and nights continuously. Many patients with early glucose intolerance will have post-meal glucose excursions. While the fasting blood glucose and A1C may remain normal, the pancreas can’t handle the glucose load of the meal properly causing blood sugars to rise inappropriately, albeit not yet into the diabetic range. This phenomenon, if documented, identifies patients at risk for diabetes who do not yet have abnormalities of fasting glucose or A1C.
Modify your lifestyle. Explore pharmaceutical treatments.
Once these criteria have been identified what’s next? How do we use this knowledge for prevention of disease? The treatment consists of lifestyle modification and the use of pharmaceutical treatment. Weight management is essential. Everyone knows that appropriate diet, physical activity, stress management and avoidance of tobacco products are key components of a lifestyle most appropriate for longevity. But how about those patients who are doing their best with the above but still can’t lose a pound? Or those who have lost some weight but battle every day to keep the weight off? What do we do next?
There are a variety of safe, proven and effective pharmaceuticals for diabetes prevention, lipid management, blood pressure control and achievable, sustainable weight loss. With the aid of a well-trained medical professionals, these tools can be prescribed to individuals who are interested in doing the most they can to prevent morbidity and mortality. My goal is to provide just that. As a concierge physician, I have the time and interest to devote to patients who clearly want to take charge of their health. Freedom from the burden and restrictions of insurance reimbursement, I can totally focus on the individual patient and use my years of personal and professional experience to provide cutting edge care. For those interested, please contact me.
