How important is Apo B?

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Most of us realize how important it is to control your cholesterol level, especially if you have additional risks for the development of heart disease. Of course, it’s not necessarily the total cholesterol that has to be controlled. Rather, it is cholesterol’s most important components, the “bad cholesterol” (HDL), and “good cholesterol” (LDL). Depending upon gender and age, HDL level should be at least 40-55 mg/dl. Depending on the risk of developing a future heart attack, LDL should be kept less than 70-100 mg/dl.

HDL levels are determined primarily by genetics (blame you parents for this one). LDL levels are determined by a combination of genetics and lifestyles (eating and exercise habits). Abnormal LDL levels are much easier to control than abnormal HDL levels.

Drug therapy is aimed primarily (but not exclusively) at lowering LDL to the recommended level of 70-100 mg/dl. But is this good enough?

After many years of research, it turns out that apolipoprotein B, Apo B for short, is a much more reliable predictor than LDL of the risk of developing heart attacks, and it also provides a much better assessment of cholesterol therapy.

In abbreviated form, the reason is as follows: The risk of LDL is not expressed by the usual measurement of how much LDL is in your blood stream. Rather, it’s the number of LDL particles in a given volume of blood that determines the risk, and this depends on how large the particles are. Small particles are much more dangerous than large particles. The Apo B measurement is a fair estimate of the LDL particle number and thus a better estimate of cholesterol risk and of progress of therapy.

The use of Apo B has already been adopted in Canada, but to my knowledge has not yet been adopted by our own National Cholesterol Education Program Adult Treatment Panel III (NCEP ATPIII) or by other “guidelines makers” in the US.

We appear to be years behind in the treatment of a condition that is the number one killer in the US! As a country that boasts of having the best medical system in the world, why have we not taken this simple step?

Many doctors, including yours truly, are already using Apo B as a guide. But in recent weeks I have gotten numerous complaints from patients who have received bills from their labs because insurance companies (mainly HMO’s and alike) stopped paying for the Apo B lab test. This is absurd.

Both patients and physicians must fight this non-payment trend. The physicians must fight it because this trend impedes their duty and ability to treat effectively, and the public must fight it because this trend will yield suboptimal medical outcomes.

Let your political representatives know that you care and want to change.

Sleep apnea, do you have it?

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More than 18 million Americans have sleep apnea, and almost everyone knows someone who has it. Many cases go undiagnosed for years. But what is sleep apnea, how do you make the diagnosis, and how is it treated?

There are three basic types of sleep apnea: Obstructive Sleep Apnea (OSA), which accounts for most cases, Central Sleep Apnea (CSA), and a mixture of the two. Here, only OSA will be addressed.

Sleep apnea was first described in medical literature in 1965, as a breathing disorder characterized by numerous brief interruptions of breathing during sleep. But don’t be misled; it’s been described quite accurately by Charles Dickens in his Pickwick Papers in 1837-1938, when he portrayed Joe as the fat, red faced boy who was repeatedly falling asleep during the day.

Sleep apnea is defined as the presence of more than 30 episodes of apnea (cessation of breathing), each lasting more than 10 seconds. In severe cases, apnea periods may last longer than 60 seconds, and may recur hundreds of times a night. Obstructive Sleep Apnea occurs mostly in the obese person, typically with a short neck. It may occur in persons who have abnormalities in the nose and throat, such as enlarged tonsils, polyps or excess adenoid tissue, which obstruct the flow of air while asleep. Most OSA patients are heavy snorers. During an apnea episode snoring stops, then breathing resumes with a typical “snort.” While sleeping, the tongue and throat muscles relax causing airway blockage. When the apnea period ends, these muscles tighten up temporarily, allowing breathing again until the next episode.

Full blown OSA leads to irritability and lack of concentration; learning and memory difficulties; sexual dysfunction, and the development of high blood pressure, headaches, irregular heart beats, premature heart attacks and sudden death. In sleep apnea there is a major disturbance of the sleep cycle. Sleep quality is poor, and in reality you are sleep deprived. As a result, you may fall asleep irresistibly during the day, even while driving. You may not realize that you fell asleep during the day while in a meeting or at lunch; but your friends notice it, and will hopefully tell you about it.

While you may strongly suspect sleep apnea, the definitive diagnosis is made in a sleep laboratory, where the severity of the disorder can be quantified, and treatment suggested.

Treatment is individualized, usually consisting of a pressurized face mask at night to allow better airflow and to minimize the number and severity of apnea episodes. Surgery to remove excess tissue in the throat is occasionally recommended. Alcohol and caffeinated beverages have to be kept to a minimum, and sleeping medications must be avoided.

Most importantly, the long term therapy of Obstructive Sleep Apnea must include weight management. Reducing weight to normal or near normal range frequently eliminates the sleep apnea altogether, allowing you to return to normal life.

If you suspect that you have sleep apnea, have it formally diagnosed and, above all, take care of your health, no one will do it for you...

Exercise and Aging

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You’re asking yourself: I’m a Senior Citizen; do I really need to exercise?

“Rest is precisely what aging people do not need” stated William Evans, Ph.D., of the U.S.D.A Human Nutrition Research Center on Aging at Tufts University about ten years ago. And it hasn’t changed since.

Starting in middle age, people gain fat, and lose muscle, strength, bone, and aerobic capacity. Their risk of heart disease, diabetes, high blood pressure and osteoporosis rises. While a healthy diet can help reduce these risks, exercise is at least as important. The single most important step to slow down the aging process is strength training. Many of us believe that we lose our ability to respond to exercise as we age, but nothing is further from the truth. You can strengthen your muscles as you age, and the improvement may even be more noticeable than at a younger age.

Women are at a special risk because they have less muscle mass to begin with, and they start to lose muscle strength more rapidly after 60. The Framingham Heart Study showed that half of women aged 65 or over can’t lift ten pounds. Muscles weaken rapidly after age 70. At age 20, 90% of the volume of the thigh is muscle. At age 90, it’s only 30% muscle, the rest is fat and bone. With weight lifting, muscle mass can be increased by 10%, but the increase in strength can be 200%. When women lose weight by dieting alone, they may also lose muscle and bone. With exercise and weight lifting, muscle and bone are preserved.

Dr. Steve Blair of the Cooper Aerobics Institute in Dallas has shown that inactivity is as risky as having a high blood cholesterol level.

Strength training: Lift a weight heavy enough so that your muscles will feel fatigued after eight or nine lifts. For a healthy 65 year old, that's about 20 pounds (60-80% of maximum lifting capacity). If you lift weights properly, it will not dangerously increase your heart rate or blood pressure. Weights should be lifted without holding one’s breath. Move slowly, take time to warm up and cool down, so that muscle stiffness is minimized. With exercise you can become more limber and increase your range of motion. Weight lifting promotes weight loss; the number of calories you burn increases with your muscle mass. So, the more muscle mass you build, the more calories you burn.

Aerobic exercise: While strength training is important, don't abandon aerobic exercise, which increases cardiovascular fitness, reduces blood pressure, increases HDL cholesterol (the "good cholesterol”), and reduces the risk of dying of heart disease, diabetes, and even colon cancer.

A reasonable recommendation today is that aerobic exercise be done at least three days a week for 30 to 45 minutes each time, and strength training 2 or 3 days a week.

What’s the reward? It’s very simple: Not only will you feel better about yourself, you’ll live longer. So what are you waiting for?

How does your health carrier treat you?

A few days ago, while getting rid of some "old stuff" in my office, I found an interesting denial letter sent to a patient of mine in 1986 (yes, 23 years ago) from a major health insurance carrier in Connecticut. The letter states that:

"Your contract defines a medical emergency as the sudden and unexpected onset of a condition requiring medical care which the patient obtains immediately after the onset. Heart attacks, cardiovascular accidents, loss of consciousness and convulsions are examples of medical emergencies.

"The information received from the hospital does not indicate that a similarly acute condition existed when services were rendered for ... Therefore, we are unable to provide benefits."

In reality, the patient had acute appendicitis, was admitted to the hospital at 2 AM, and had surgery within an hour. The appendix was about to burst. I guess that's not an emergency. Can you imagine how much energy it took to reverse this denial?

Do you think that things got better in the 23 years since this episode? Unfortunately, things only got worse, and it's going to take a lot of sincere effort and energy to fix them.

Do you have any war stories?

The Better Sweeteners

There’s no question that refined sugars, widely used in the US and hidden in many foods, are a major health hazard and their use should be minimized. But if you like your food to be sweetened, what can you use safely?

Here are some of my favorites:

1. Agave syrup. Agave syrup (also known as agave nectar) is a natural plant product extracted from the agave plant in several states of Mexico. It’s a liquid resembling honey, but less viscous. It is a little less sweet than sugar, and is available in light and darker varieties, depending on the degree of filtering. The darker varieties have more of the plant product in them, and have the additional caramel-like flavor.

Agave syrup is not calorie free. It has the same number of calories as sugar, but it contains much more fructose than sugar, and therefore raises blood sugar levels to a much lower extent than does sugar (table sugar, or sucrose, is made of 50% glucose, 50% fructose; it’s the glucose that causes most of the damage). As a sweetener, agave syrup is considered much safer than sugar, but because it does contain the same amount of calories as sugar, it should be used in moderation.

Agave syrup can be used in cooking. It’s a good substitute for other liquid sweeteners. When used instead of solid sweeteners, the consistency of the baked product will change.

2. Erythritol. Erythritol is a natural sugar-alcohol (not to be confused with regular table sugar or with the ethanol present in alcoholic beverages). Erythitol is produced from glucose, usually derived from corn, by yeast fermentation. It’s available as a powder, is about 2/3 as sweet as table sugar, and can be used in cooking and baking. It is present in many commercial foods, and in chewing gum. Unlike table sugar, erythritol does not cause tooth decay.

Erythritol’s main advantage is that it’s almost calorie free, and does not significantly raise blood sugar or insulin levels. Erythritol is considered very safe, but using it in very large amounts may cause abdominal bloating and discomfort.

3. Xylitol. Xylitol is a natural sugar-alcohol, a powder with some similarities to erythritol. It is present in plants, fruits and vegetables, and also in the human body as part of glucose metabolism. Most xylitol used and sold commercially is extracted and processed for human consumption from birch and corn. Xylitol contains approximately half the calories of table sugar, and causes a significantly smaller increase in blood sugar and insulin levels than does table sugar. It is considered “tooth friendly,” not causing tooth decay. Xylitol is much more likely to cause abdominal bloating than erythritol, which may limit the amount one can use.

Are you a dog lover? Make sure your dog doesn’t get a hold of your xylitol. In dogs, xylitol can cause severe hypoglycemia which can be fatal.

4. Truvia. Truvia is a natural product made from rebiana, a sweetener derived from the sweet leaves of the Stevia plant. It is approximately 200 times sweeter than table sugar, and has essentially zero calories. Stevia is native to South and Central America; its leaves are harvested and dried, and are steeped in fresh water in a process similar to that of tea making. Unlike agave syrup, Truvia is available as a powder. It contains erythritol as its first item on the list, but most of its sweet taste comes from the rebiana. According to the Truvia website, you can cook and even do some baking with Truvia. But I’m not so sure about “traditional” cake baking.

When shopping, read those labels and pay special attention to sugar or sugar-like ingredients like corn syrup and high fructose corn syrup. Frequently, you’ll find more than one sweetener in the ingredient list. In my opinion, this is done mainly to confuse us by shifting these sweeteners to a lower position on the ingredient list, and to make us think we’re consuming less of the bad stuff.

My vote (as table sweetener)? Erythritol, agave, xylitol, Truvia, in that order of preference.