By Dov Michaeli MD, Ph.D

So you don’t exercise. And you like your six pack. And you have a bit of a pot belly. But you are not overweight. In fact, your BMI is in the normal range. Do you feel pretty smug? Read on, and I think you’ll get shaken up a bit, as you should.

Central Obesity

The correlation between obesity and diabetes and heart disease is well known. In fact, we now know that people should be concerned not only about body fat, but importantly: where this fat is located. Waistline fat is a major risk factor of diabetes and heart disease, deceptively cute names like “love handles” not withstanding. But did you know that being a Michelin Man may end up in dementia?

The Kaiser study

I certainly did not suspect it. And I dare say,I don’t know anybody in the medical community who has.

Now comes a wonderful study, led by Rachel A. Whitmer of the famed Research Division of Kaiser Permanente in Oakland , CA , and tells us a very disturbing tale.

The investigators took advantage of the extensive medical records kept by Kaiser about their members. They conducted a longitudinal study of 6,583 members of Kaiser Permanente of Northern California who had their sagittal abdominal diameter (SAD) measured in 1964 to 1973. Diagnoses of dementia were from medical records an average of 36 years later (!), January 1, 1994 , to June 16, 2006 . Where else, with the possible exception of the Scandinavian countries, could you get such a long follow-up? And who else would pay for sagittal sections of the abdomen to carry out such a study? Only Kaiser Permanente, which is a non-profit HMO, with “non-profit” being the operative word. Before I go on, sagittal sections divide the body into left and right portions. Rather than waste a thousand words, check out this picture.

Bottom line: sagittal sections allow the determination of a pot belly size with great accuracy.

And the surprising resuls

A total of 1,049 participants (15.9%) were diagnosed with dementia. Compared with those in the lowest quintile of SAD, those in the highest had nearly a threefold increased risk of dementia (hazard ratio, 2.72). Now, you’d think that obesity in general could explain this astonishing finding. But when the BMI (body mass index) was taken into account the hazard ratio, or risk of dementia, was 1.92, or about twofold.Those with high SAD (>25 cm, or 10 inch) and normal BMI had an increased risk (hazard ratio, 1.89) vs those with low SAD (<25 cm) and normal BMI (18.5–24.9 kg/m²), whereas those both obese (BMI >30 kg/m²) and with high SAD had the highest risk of dementia (HR, 3.60). In other words, if you are not obese, but have those cute love handles, your risk is double that of “normal”, and if you are obese and blessed with central obesity, than your risk of developing dementia increases 4 fold! Food for thought, while you still can. Even more alarming: these subjects had central obesity since middle age. And you can’t find refuge in your good numbers; the association held after correcting for high cholesterol, high blood pressure, diabetes, heart disease, stroke, and other variables. And if you think that your sex will shield you, it won’t: the results were the same for men and women.

As far as I know, this is the first time that anybody studied the correlation between central obesity and dementia. Nobody has a clue how this works on the physiological or molecular level, but rest assured: researchers will rush in to investigate this surprising finding.

But for now, all I can say is: thank you Kaiser Permanente for this great study.

by Pat Salber

Perhaps the folks over at Hardee's fast food haven't heard the country is in the midst of an obesity epidemic.  They have just unveiled a new breakfast offering, the Country Breakfast burrito.  It consists of a two egg omelet filled with bacon, sausage, diced ham, cheddar cheese, hash browns and sausage gravy.  Surrounding this protein load is a flour tortilla.  The burrito weighs in at 920 calories.  That's right, 920 calories, about half of what you should ingest in a day.  This little baby also has 60 grams of fat.  All those calories and all that fat will only set you back $2.69.

According to a story by the Associated Press, Brad Haley, Hardees' marketing chief, says that the burrito offers the sort of big breakfast item normally found in sit-down restaurants with an added advantage.  "It makes this big country breakfast portable," he said.

Other Hardee offerings include the Monster Thickburger, a 1,420-calorie sandwich that contains two 1/3-pound slabs of beef, four strips of bacon, three slices of cheese and mayonnaise!  Want a healthy alternative?  Try the Hardees' chicken salad --it is only 1,100 calories and 83 grams of fat.  Supposedly, the chain does offer some low-calorie options, including roast beef and chicken sandwiches.

AP reports that the Center for Science in the Public Interest, a Washington-based advocate for nutrition and health, has called the Hardee's line of Thickburgers "food porn." I love it, food porn!

Jayne Hurley, senior nutritionist at the Center, said the burrito is "another lousy invention by a fast-food company."  The "country breakfast bomb," as she called it, represents half a day's calories and a full day's worth of saturated fat and salt, to say nothing of cholesterol.  "That's all before 10 o'clock in the morning," she said.

Hardees' Haley makes no apologies:  "We don't try to hide what these are," he said. "When consumers go to other fast-food places they feel like they've got to buy two of their breakfast sandwiches or burritos to fill up. This is really designed to fill you up."

Way to go, Hardees.  Keep on fillin' us up.

Brian Klepper 

How do you live a long life? Take a two-mile walk every morning before breakfast.

Harry Truman
33rd US President, who lived to 88

DAWN, n. The time when men of reason go to bed. Certain old men prefer to rise at about that time, taking a cold bath and a long walk with an empty stomach, and otherwise mortifying the flesh. They then point with pride to these practices as the cause of their sturdy health and ripe years, the truth being that they are hearty and old, not because of their habits, but in spite of them. The reason we find only robust persons doing this thing is that it has killed all the others who have tried it.

Ambrose Bierce, The Devil's Dictionary 

I started taking long walks with my close friend Bob thirty-five years ago when we were students in Holland. We would walk and discuss the things that young people ponder, passing time in the brisk beautiful outdoor landscape of Northern Europe. We always maintained a quick pace, but never minded the effort, because the activity was filled with ideas and always-inviting scenery.

When I returned home, walking was a habit that stuck with me. When Bob and I lived in the same town, we'd get together regularly to walk the dogs. On my own, I found that I could go out for a stroll and think, chewing on whatever I was working on and, getting a little distance from it, find perspective. Elaine and I still walk, constantly, and that's where we get some of our best talking in. Walking has been respite from the rush, a place to hash out conflicts or work out plans, a way to meditate and regain balance.

When I left my post at the University of Florida about 20 years ago and returned home, I traded a landlocked town for the coast. As quickly as I could, I resettled within a few blocks of the beach in a small community on an island off Jacksonville, in Northeast Florida. Then, as now, I was literally within a five minute walk of a 300 foot wide, hard-packed, sugary white sand beach on the Atlantic, stretching for miles both north and south. In addition to the spectacular, always changing beauty of a vibrant seascape - birds, dolphins, turtle nests, fish and other sealife; the boats and ships just offshore; the surf rolling in and lapping the beach - it was perfect terrain for a habitual walker.

Even so, as easily accessible as it is, and though I know lots of people long for just this sort of environment, there have been periods when I lost my discipline, when I took the opportunity for granted and somehow just didn't get around to it.

Then came the moment 5 years ago when I unexpectedly had open heart surgery, a 5 vessel CABG, the result of lousy genes and the gradual relentless buildup of plaque choking off my blood vessels. During the procedure they collapsed and then re-inflated my lungs, and I knew it would take work to ameliorate my shortness of breath. I started walking again immediately, through the halls, on the second day in the hospital following my surgery, and by the time I left 3 days later I was up to walking more than a mile a day.

I continued when I returned home and worked through recovery, and though increasing my distance went slowly, I kept at it. During a follow-up with my surgeon, he commented, "The best thing you can become is a walking fool. It's low impact, steady and its good for you in all kinds of ways, especially with what you're up against."

And then, again, time passed and I got comfortable and distracted. I skipped my walks and then they trickled away, until I was just walking weekends again. I told myself that I was really in OK shape, but the truth was that I put on weight and that I had slipped into a malaise.

Recently, I had a discussion with a good friend, a preventive cardiologist, who gave it to me straight. I had shared the numbers from my last blood panel. "Look," he said, "you're not taking this seriously. Unless you get your LDLs (the bad cholesterol) down below 60,  you're going to continue laying down plaque, and the risk increases. If you're interested in doing what you can do, you need to get religion on this. Get lean. Eat carefully and ramp up your exercise."

And so I have.

This isn't just theory. Below is a picture from the REVERSAL Trial, led by Steven Nissen MD, chief of Cardiology at Cleveland Clinic. It clearly shows the before and after effects of managing LDL to below 60. After 18 months of the reduced LDLs, there's been a significant opening of the vessel. This is what I'm shooting for.

So we've cut out most breads and sweets. Cookies are out. Our diet is mostly fruits, veggies and fish. Once you get your head around it, it makes sense and you gradually lose the longing for the comfort foods: a milk shake, macaroni and cheese, or a fried fish sandwich.

And then there's the walking. It's a flat 3 miles, 50 minutes door-to-door, down to the lifeguard station on the beach and back, walking fast. Right now, in the NE Florida swelter, I'm soaked through when I return. I do this twice a day. On my suburban beach, around 6AM, there are 200 people out there walking before work. After work, you see  a lot of them again.

 An embarrassing quantity of pounds has melted off. I'm becoming leaner and stronger than I've been in years. The next blood panel will tell. When I'm tempted by some forbidden food, I think of 60 and my will to shrink the plaque that's strangling my vessels.

And I walk.

Bill Bestermann

Whenever a commercial runs on television and the topic is a statin drug, there is a long rendition of potential side effects.  There are warnings that you should report muscle pain or weakness and that you should have tests to check your liver.  Certainly, reasonable caution is prudent with any medication but one of the main reasons you see a doctor is to have a knowledgeable, wise person help you consider the risks and benefits of a potential treatment.  When it comes to risks and benefits, there is no happier story in all of medicine than the statin drugs in lowering cholesterol.

These medications are very powerful.  In South Carolina, where I practiced for 30 years, roughly half of the population dies of vascular events.  In the early part of my career I admitted a very large number of patients to the hospital with heart attacks and strokes.  Far too many of them died.  We just did not have very much that worked very well.  When I entered medical school, I was performing calculations with a slide rule.  It is hard to realize just how much the world has changed and the medical world has changed technically as rapidly as any professional field.  The statin drugs are one of the most amazing technical developments.   

The statin drugs do have very real side effects.  Here is the big picture.  I have admitted hundreds of patients to the hospital with problems caused by arterial disease.  Many of them died.  I have admitted one patient to the hospital with a cholesterol therapy complication-and he walked out of the hospital.  The television commercials on statin therapy warn of liver problems.  If you compare a million patient-years of statin use with a million patient-years of no statin use-there is no difference in the number of serious liver problems.  I have never admitted anyone with a statin-related liver problem.  There is an issue of muscle pain or weakness.  The incidence of muscle pain or cramps may be from 1%-5%.  But the problem is that so many patients who are at risk have aches and pains anyway.   The pain that goes with statin muscle injury is like the flu—it is all over the body—it is diffuse.  If you think you are weak but you can get out of a chair without using your arms to push up—you probably do not have a significant statin myopathy.   Significant muscle injury can be detected by measuring a CPK lab test.  Muscle injury occurs more frequently when statin drugs are used in combination with other medications that cause the level of the statin drug to increase.  Many times we can get around the muscular complaints by changing the drug or the dose.  Only one in 10,000 patients treated with a statin develops the serious muscle injury called rhabdomyolysis.

These medications have a very powerful effect in preventing cardiovascular events.  Statin therapy alone reduces coronary mortality by 42% and combination therapy (statin plus niacin) aimed at abnormal lipids may lower vascular events by as much as 90%.  These effects are almost immediate, extremely potent, and very impressive.  If a single dose of a statin drug is given to a laboratory animal prior to the creation of an experimental infarction, the
size of that infarction is reduced by half.  That is important news because it is the size of the infarction that determines the likelihood of most of the adverse outcomes of the heart attack including congestive heart failure-the number one cause of hospitalization for Medicare patients.

Bench science with rats sometimes does not extend to humans, but data from the National Registry of Myocardial Infarction suggests that we can extend this concept to patients.  There were 300,823 patients in the registry reporting to the emergency room with an acute heart attack.  Myocardial infarction victims with new or continued statin treatment during the first 24 hours experienced a mortality of 5% and those with no statin treatment experienced  a mortality of 15%.  Statin-treated patients had lower risk of cardiogenic shock, arrhythmias, cardiac arrest and rupture—all typically related to the amount of heart muscle killed by the artery blockage.

Finally, treatment with statin drugs can lead to achieving that most elusive goal in the treatment of vascular disease.  You can reverse cholesterol buildup in your arteries.  Dr Steven Nissen of the Cleveland Clinic has proved this in the Asteroid trial.  Using an intravascular ultrasound catheter (IVUS), Dr Nissen was able to show that lowering LDL cholesterol to 62 with high-dose Lipitor (atorvastatin) significantly reduced the size of the cholesterol deposit obstructing a heart artery.  When you examine the IVUS catheter trials that have looked at how the amount of plaque changes depending on the LDL level, it looks like the break point is in the mid-70s.  When your LDL is over 75 you are putting cholesterol down in the artery.  When it is less than 75, you are pulling cholesterol out and not just in that artery, but in all of the arteries in the body.

The statin medications to lower LDL cholesterol are a great addition to the tools that are available to reduce the toll of arterial vascular disease.  It is important to approach them with a positive attitude and if you think you have a side effect you need to discuss it with your doctor.  Is it really related to the statin?  Is it severe enough to warrant stopping the drug.  Can it be reduced or eliminated by changing the drug, reducing the dose, or changing other medications in the medication program.?  It is important to find a way to continue these medications if this goal can be accomplished safely—and usually it can be!

William Bestermann is Medical Director of the Vascular Medicine Center of the Holston Medical Group in Kingsport, TN. He is also President of the Cardiovascular Center of Excellence program under the auspices of the Consortium for Southeast Hypertension Control.  Click here to read his other articles on TDWI . You can reach Dr. Bestermann at whb@hmgkpt.com.

Dr. Diana Fite, fully recovered after a stroke. From the NY Times 052807There is a pretty amazing story in the NY Times about an emergency physician, Dr. Diana Fite of Houston, who had a stroke while driving her car. She was able to call 911 on her cell phone and tell the ambulance drivers exactly where to take her so that she could get state of the art stroke treatment…Memorial Hermann Hospital. Because she was knowledgeable about hospitals in the Houston area, she wasn’t taken to the closest hospital, rather she was taken to the best hospital.

She was given a blood thinner, tPA, and the clot in the artery feeding her brain dissolved. She had a complete reversal of her stroke symptoms – a total paralysis of her right side.

This story is all the more remarkable to me because I have known Dr. Fite for years because of our work with the American College of Emergency Physicians (ACEP). Dr. Fite is only 53 years old. Had she not had a good recovery from her stroke, her career in Emergency Medicine would probably have been over.

My mother had a big stroke in her 70s. It was devastating. In a few moments, she went from being independent to a life of dependence. She could no longer walk and she could no longer perform many ordinary activities of daily living without help. It was depressing and she was depressed.  Her life was never the same again.

The most important point of the NY Times article is not Dr. Fite’s dramatic recovery from a serious stroke. Rather, it is her forthright discussion of her failure to take simple preventive steps to avoid getting the stroke in the first place. She had a five year history of high blood pressure that she ignored. She also had high cholesterol. No one likes to have to take medications every day for the rest of their lives, but the alternative, living forever with the consequences of stroke, are even more inconvenient.

So, I suggest you check out Gina Kolata’s stroke story in the times, including the video that outlines crucial facts about stroke. Other good resources on stroke and stroke prevention are listed below:

• Brain Basics: Preventing Stroke
• Brain Attack Foundation
• American Stroke Association

Pat Salber, MD

Living with diabetes can be tough. There is so much stuff to learn and so many things to do. It can be hard to keep track of everything. And, it can seem overwhelming, particularly around the time you are first diagnosed.

That’s why I am recommending if you have diabetes or if you know someone who has diabetes, get your hands on a great little book, "Know your Numbers, Outlive your Diabetes.” It is written by Richard Jackson, MD, a doc at the world famous Joslin Diabetes Center and Amy Tenderich, a professional journalist who also happens to have diabetes (check out her website: www.DiabetesMine.com).

Five Numbers to Know

This book points out that there are five essential tests everyone with diabetes should have:

• Hemoglobin A1c (often just called A1c). This is a measure of the average blood glucose levels over the previous two to three months
• Blood pressure
• A full lipid profile – not just a total cholesterol, but a full panel that determines LDL, HDL (often called good cholesterol), and triglycerides (blood fats that go up after we eat)
• Microalbumin: a test of whether diabetes has cause kidney damage
• A Retinal Eye Exam to asses whether there is any evidence of eye damage

The authors explain what these tests mean and how often you should get them. What I particularly like is that they stress that you need to be the owner of these numbers:

“These numbers belong to you, and knowing them is your right, as well as critical to your health – just like the numbers in your bank account.”

They even give you advice on how to get your hands on these numbers:

“It is your right to request them, so don’t feel intimidated about speaking up….A call to the office should suffice…” but they recommend, “make the call at a time when you have some other paperwork to do, and use a speakerphone so that you don’t get too frustrated trying to get through or waiting on the line.”  It seems like they may have had some first hand experience calling doctors' offices.

Don’t feel like you have to do everything at once

There is a chart in the book that the authors titled “Your Diabetes Health Account.” Using it, you can compare your numbers to the certain targets in order to determine how well you are doing. For example, if all of your numbers are at optimal targets, you can see that you have five “bags of money” in your diabetes account. These are your health assets. If your tests are past due or way out of whack, then you have health debts which should be paid off as soon as you can. By taking a close look at your diabetes health account, you can pinpoint your focus of what you need to do to get your health account back in balance.

They counsel, “Rather than depressing you, knowing your priorities should boost your confidence; you have learned exactly which health factors are most important for you right now and which may not need attention on an everyday basis."

Take Action

Once you learned your numbers and assessed your diabetes health account, it is time to take action. The book provides strategies for how to improve every one of the five essential factors. The tips provided are practical, but detailed enough to help even a novice diabetes-self-manager get started.

The first part of the book lays out the strategies for improvement and the second part dives deeper into the diabetes toolkit they are helping your prepare. Advice on diet and exercise are clear and easy to follow. For example, one strategy for portion control, an important element of a weight loss diet, is to share a meal. Pretty simple, huh? Or you can divide your food before you start to eat and have it put into a “doggie bag” before it automatically goes into your mouth to end up around your middle. Avoid buffets. We all know we eat too much at buffets…it is simply too easy to pile it on the plate.

Other good information

There are chapters on diabetes drugs and diabetes devices as well as information about low and high blood sugar. The chapters are well laid out with important information placed in boxes.

Sprinkled through the book are stories of real people living with diabetes, like Loretta, a kindly grandmother with type 2 diabetes who lost weight and brought her hemoglobin A1c into control or Marci, a “high-powered New York City account executive" who enlisted her husband to help her deal with “diabetes frustration.”

Empowerment

Yeah, I know, some of you hate the “empowerment” word. But that is what this book sets out to do. It arms you with information. It helps you understand your particular needs and challenges. And it provides guidance on how to go, one step at a time, from where you are now to where you want to be in terms of diabetes health.

So, there you go. If you have diabetes, if someone you care about has diabetes, or if you are a health professional working with people with diabetes, then buy (and read) this book. You will be glad you did.

Pat Salber, MD

An article in the NY Times declares that one in eight adults in NY City has diabetes. That is 12.5% of the population or 700,000 people. Lest you feel relieved that you don’t live there, let me remind you that the rest of the country is not all that far behind. Overall, about 10.3% of Americans have diabetes and about a quarter of them don’t know it (yet). 

An additional 24% of adults in NY (and in the rest of the country) have abnormally high blood sugars that have not yet reached diabetic levels.  This condition is known as pre-diabetes.

Not too many years ago, the diabetes rate was 6%--half of the current NY rate. But our self-indulgent ways have caught up with us. Too little exercise, too many calories plus too much stress adds up to an epidemic of obesity, particularly abdominal obesity.  Abdominal obesity, especially visceral obesity, is linked to the development of Type 2 diabetes in genetically predisposed individuals.

It’s just a “touch of sugar.” Why all the concern? Because diabetes and it precursor, pre-diabetes, are the most familiar manifestations of a constellation of metabolic changes, known as cardiometabolic syndrome. Other manifestations of this syndrome are high blood pressure, dyslipidemia ((high triglycerides and low HDL (“good”) cholesterol)), clotting abnormalities, and problems with inflammation. People with cardiometabolic syndrome, even if they haven’t yet developed full-blown diabetes, have an increased risk of heart attacks and strokes.

Cardiovascular disease, strokes, and peripheral vascular disease are all very expensive conditions to treat in our technologically sophisticated health care system. These conditions already occupy some of the top slots when it comes to where our health care dollar are spent. So imagine what is going to happen now that the rates of diabetes have doubled (with no end in sight).

So, this epidemic of diabetes and pre-diabetes is not just a health care issue that burdens individuals and their families living with the disease. It is a looming societal problem that threatens to bankrupt our already fragile health care system. It could cause health care insurance premiums to escalate even further, impacting not only employers who provide coverage, but also public payors, like Medicaid and Medicare.

It is time to get deadly serious about doing something about prevention. We need to rapidly move to institutionalize regular exercise programs in school and at work. And we need affordable, easily accessible healthy eating options. That means we must be willing to regulate, legislate, and maybe even implement taxes (oh, oh, the tax word!) that can get us to where we need to be. Failure to do something now will almost certainly result in huge adverse financial consequences that will ripple through society in the not too distant future.

Dr. Bill BestermanWelcome, Dr. Bill Besterman, Guest Blogger for TDWI.   Bill is the President of the Cardiovascular Center of Excellence program under the auspices of the Consortium of Southeast Hypertension Control. He is currently in the process of moving to Holston Medical Group in Kingsport Tennessee to establish a Cardiovascular and Diabetes Center in that practice.

The American people have the power to determine the way medical care is delivered. The people decided they wanted to choose their own consultants and would not put up with gatekeepers and dramatic restriction on specialty care -- and there are no longer gatekeepers. Evidence-based care in cardiovascular diseases has the potential to improve health and save money. It is time that the people demanded consistent application of evidence-based care from the people who pay the bills -- employers and the government. One need look no
A drug-eluting stentfurther than the recent controversy around drug -eluting stents to see the potential benefits of action.

The drug-coated stents are a great example of an idea that makes perfect sense but has not lived up to the promise. This is a pattern in the American system. We are always pressing for the new and improved.  And, we rush to wide adoption of new technology before the risks and true benefits are fully understood.

These new procedures quickly become the standard of care and it is very difficult to change once in place. The actual approved indications for drug-eluting stents are quite narrow.  They are only to be used in uncomplicated patients with a single blockage. Fully 60% of these stents have been used off-label in more complicated patients with multiple blockages or other serious conditions like diabetes. Now that we have more experience with these devices we have learned that they may trigger fatal blood clots years after they are implanted.

But that does not address the larger reality. The whole idea that heart attacks are caused by fixed, severe arterial blockages of 70% or more that require bypass surgery or stenting has been pretty thoroughly discredited. Actually, Erling Falk wrote an article over a decade ago that showed that over 2/3 of heart attacks occurred where the actual arterial obstruction was 50% or less. It makes sense that a severe blockage would cause a heart attack-they were frequently found in patients who developed that problem. It would make further sense that opening the blockage would prevent heart attack-it just has not worked out that way.

Myocardial infarction or heart attack occurs when a semi-liquid, inflamed cholesterol deposit bursts through the wall of the artery. When that cholesterol hits the blood in the artery it is a powerful stimulator of clot formation and it is the clot that blocks the artery very quickly and causes the heart attack. That is why taking aspirin as a blood thinner lowers the chance of heart attack by a third and that is why the heart attack process itself can be aborted by a clot buster. The idea of the unstable plaque is the new paradigm. When there is a severe blockage anywhere in the artery there is potentially dangerous plaque virtually everywhere in the artery.

This new understanding is supported by some of the best minds in cardiology:

• Steven Nissen, acting Chief of Cardiovascular Diseases at the Cleveland Clinic says, “the risk of death from myocardial infarction is not reduced in patients with stable coronary artery disease who undergo intervention” (bypass surgery or angioplasty/stenting).
• Peter Libby, Chief of Cardiovascular Diseases at The Women’s and Brighhams Hospital says, “Bypass surgery and angioplasty provide rational and often effective therapies for these fixed, high-grade stenoses. However, these treatments do not address the nonstenotic but vulnerable plaque. It is of interest in this regard that despite the well-accepted benefit of coronary bypass surgery on anginal symptoms, this treatment does not prevent myocardial infarction.”
• William Roberts, editor in chief of the American Journal of Cardiology observes “There is no evidence that either arterial angioplasty or bypass prolongs life.” Period.

Is this overstated? I don’t think so. A couple of years ago at the American Society of Hypertension meeting in New York, Dr. Libby was a featured speaker. Having read his work, I was eager to hear his presentation. In the question and answer period after the session, I asked Dr. Libby if he stood by his statement from 10 years ago, that medical treatment of arterial disease outperformed mechanical interventions to open blockages. With that question, he became very animated and made it clear in no uncertain terms that the evidence strongly supports that position.

At the same time, there is compelling evidence that proper treatment of high-risk patients can make all the difference. 80% of adult onset diabetics die of cardiovascular causes. Most of these patients have high sugar, blood pressure and cholesterol. Proper control of each of these risk factors to established goals reduces the risk of a vascular event by about half. So if all three risk factors are controlled to goal to risk can be reduced from 80% to 40% to 20% and then 10%. Maybe it is not 10% but it is a really important number and only 5 diabetic patients have to be treated for a few years to prevent a vascular event. The latest data shows that only 7% of type 2 diabetics have all three risk factors controlled to goal.

The Institute of Medicine of the National Academy of Sciences produced a report in 2001 called Crossing the Quality Chasm. That report said our system is set up to deal with acute conditions like chest pain. It said that our system is not designed to provide effective care for chronic diseases and that our health care routinely fails to deliver its potential benefits. There is no better example of this than our fixation on the old paradigm of the blocked artery. It is time to move our system from late interventions of modest benefit to early identification of high-risk patients and a comprehensive approach to risk factor management...but it is not going to happen until patients and the people who pay the bills insist on it.

There is a lot of concern in the medical community about the epidemic of obesity in children. Fat kids usually grow up to be fat adults. Also, fat kids are increasingly being diagnosed with Type 2 diabetes, a disease that used to occur almost exclusively in middle-aged overweight adults. The concern is not only that these children will have to take diabetes medications to control their blood sugars, but also that they will develop all of the complications of diabetes (such as heart disease, stroke, amputations, renal failure and blindness) while still quite young. Childhood obesity occurs in both boys and girls. It impacts well-to-do and middle class families as well as families living in poverty. Although certain ethnic groups are disproportionately affected, such as Hispanics, African Americans, and Native Americans, childhood obesity is being seen in all kinds of people. Our kids, like us adults, are suffering from too many calories consumed and not enough calories burned. We are already starting to see the medical complications of obesity in children.

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We’ve heard that trans fats are bad for us and something we should avoid. In fact, trans fats notoriety has earned them a place on the Nutrition Facts food label starting this year. We are also familiar with the fact that polyunsaturated fats are good fats. We are told that we should consume them preferentially over fully saturated fats. Although we use these words in conversation, do we really know what they mean? Do we understand why food manufacturers, restaurant cooks, and home cooks use one type of fat instead of another when producing a complex food, such as a cake or French fries? The answers to these questions are the meat and potatoes, so to speak, of food science, the science of modern day food processing and manufacturing. It is a fascinating field. We would all benefit from learning at least some of the basics of food science so that we can make informed and healthy choices when we shop. The difference between fat and oil Fat is solid at room temperature and oil is a liquid. Sources of fat in the diet Fats and oils come from animals, including marine animals, and vegetables. Examples of animal fats include lard from hogs and butterfat from milk. Fish oils include cod liver oil (does any one use this anymore?)

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Check out DiabetesPHD on the American Diabetes Association website. It is a risk assessment tool that uses Archimedes, a sophisticated computerized health modeling program to determine your risk of developing heart disease, stroke, and/or diabetes and its complications (kidney failure, eye problems, foot problems) over the next thirty years. The best thing about this program is it gives you a chance to see what happens to your risk if you lose weight, reduce your blood pressure or improve your cholesterol levels. You can also model the impact of taking certain medications or having better health habits (not smoking, taking an aspirin a day if you are over 40). It is pretty cool to watch the graphs of your risk improve in front of your eyes when you lop off 40 pounds or lower your cholesterol by 40 points.

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Most of us know that having a high total cholesterol level in our blood is not a good thing. We also may have learned that one type of cholesterol, LDL or low-density lipoprotein, is particularly bad and places us at risk for coronary artery disease and other forms of atherosclerosis, such as stroke. However, a significant number of individuals who have had heart attacks and other forms of atherosclerotic disease do not have high total cholesterol or high LDL levels. So screening for total cholesterol or LDL cholesterol alone will miss a some people who are at risk for bad things, like heart attacks and strokes. It is important to know and control your LDL cholesterol, but, for many people, it is not enough. HDL or high-density lipoprotein is often called the “good” cholesterol. High levels are thought to protect against atherosclerosis and low levels of HDL are considered a risk factor. Another type of fat, triglycerides, is elevated in some lipid disorders. High triglyceride levels are now believed to be a coronary artery disease risk factor in some individuals.

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