#271 - AMA #51： Understanding and improving your metabolic health
Episode Stats
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Summary
In this episode, Dr. Nick Stenson and I discuss metabolic disease and how it feeds into the other 4 major diseases of aging, such as cardiovascular disease, cancer, neurodegenerative disease, and metabolic disease which is really a continuum of conditions.
Transcript
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hey everyone welcome to a sneak peek ask me anything or ama episode of the drive podcast
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i'm your host peter atia at the end of this short episode i'll explain how you can access
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or you can learn more now by going to peter atia md.com forward slash subscribe so without further
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delay here's today's sneak peek of the ask me anything episode welcome to ask me anything
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episode number 51 i'm once again joined by nick stenson today's ama focuses on questions we've
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gathered around metabolic disease if you've listened to this podcast or read my book you're
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probably familiar with what i call the four horsemen which are the major disease processes
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of aging these include cardiovascular disease cancer neurodegenerative disease and metabolic
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disease which is really a continuum of conditions in today's episode we really dive into that fourth
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horseman these conditions around metabolic disease these topics that we explore include questions
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about how metabolic disease feeds the other three horsemen and why we should be aware of our metabolic
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health we talk about the various metrics that i use with my patients to understand their metabolic
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health now this will include some common ones as well as some less common ones and of course we get
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into the various factors that you can manipulate in which to improve your metabolic health and they
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include some of the obvious ones but also some less obvious ones so if you're a subscriber and you want
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to watch the full video of this podcast you can find it on the show notes page if you're not a subscriber
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you can watch a sneak peek of the video on our youtube page so without further delay i hope you enjoy
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peter welcome to another ama how you doing good thanks for having me so today's ama we're really
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going to focus on metabolic health i think a lot of people are familiar with this term you call the four
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horsemen which are the four major diseases of aging that includes cardiovascular disease cancer
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neurogenetic disease and then metabolic disease which is really a range of conditions kind of from
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obesity all the way to type 2 diabetes and we haven't covered it on recent amas that closely and so
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what we wanted to do was gather all the questions that have come in on that and then put them into
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today's ama so we're going to hopefully get to as many as we can but this will include what is
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metabolic disease and how do you define it how it feeds the other three main horsemen and how it can
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cause problems for people and then really look at the metrics that you look at with your patients to
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understand on an individual level where they're at metabolic wise and so i think a lot of people will
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look at metabolic health from simple blood metrics such as hba1c or things that they can get with a
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typical annual physical but i know with you and your patients you look at a lot of other things
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and we're going to get into those details today which is you know what are those things what do you
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like to see and ultimately what can they tell people about their metabolic health and then we'll end
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the ama looking at kind of what are the lifestyle interventions that people can use to help improve
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their metabolic health and this will look at nutrition sleep and exercise so we have a lot to get to
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so with all that said anything you want to add before we get started no i mean i just think we're
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going to structure this discussion by probably spending a bit of time talking about the nuanced
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ways in which you could define or identify a person who's not metabolically healthy we'll come up with
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a very high bar for that on what you know real metabolic health looks like and then as you said
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we'll talk about okay what do you do about it if you're in this situation because most people
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listening to this myself included frankly will always have an area in which they could improve
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health let's start with a little bit a primer on metabolic disease and how it can feed into the
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other three horsemen which is cardiovascular disease cancer neurogenitor disease so to do this
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i think we need to kind of define metabolic disease or metabolic syndrome and look at how that feeds those
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other diseases i think a bit of historical context is helpful here there was a very famous remarkable
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endocrinologist by the name of jerry reevin definitely one of the regrets i have is not having
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interviewed jerry for the podcast before he passed away because i did know him and i'd met him several
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times jerry was at stanford for most of his career in the 1980s made an observation which was that
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where the following five signs went so too did cardiovascular disease cancer neurodegenerative disease
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he identified these five signs which we'll review in a second and he referred to it as syndrome x
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so he said look when people have truncal obesity elevated triglycerides depressed hdl cholesterol
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elevated blood pressure and elevated glucose levels this thing we're going to call syndrome x
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it seems to be a remarkable predictor of all of these chronic diseases of aging for the sake of time i'm not
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going to go through the entire history of this but what changed was that that terminology became
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syndrome x it referred it became now metabolic syndrome and now we have some numbers that go
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with those things so many people are probably familiar with these but you know we're now
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defining truncal obesity as a waist circumference of more than 40 inches in men more than 35 inches
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in women we're defining elevated triglycerides as over 150 milligrams per deciliter we're defining low
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hdl cholesterol is below 40 milligrams per deciliter in men below 50 in women we define elevated
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blood pressure as above 130 over 85 or taking medication for high blood pressure over 120 over
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80 and fasting glucose is greater than 100 milligrams per deciliter and the syndrome is defined as having
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three or more of these so i won't suggest that this is the best way to evaluate metabolic health i think
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there are many more nuances that we're going to go into but at a minimum i think everybody should know
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where they stand on those things and by the way even though metabolic syndrome is defined as having
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three or more of those having one of those is still worse than having none having two is worse than
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having one etc so in an ideal world you wouldn't want to have any of these things no and i think that's
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good to kind of set that baseline there and so the next question is then how does metabolic syndrome
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kind of feed the other horsemen and those other diseases we could spend the entirety of this ama going
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through the literature on this it's so voluminous and so one-sided that i don't think it's particularly
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interesting i'll probably just touch on a couple of high points and we'll leave all the details in the
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show notes but if you look at all the meta-analyses of all-cause mortality cardiovascular mortality cancer
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mortality cancer incidents dementia incidents all of these things all point in the same direction
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once you have metabolic syndrome you're at an increased risk of everything your risk of
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cardiovascular disease goes up by 135 your cardiovascular mortality goes up by 140 your all-cause mortality is up
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by 58 your mi risk 99 it's basically a doubling your stroke 127 when you look at cancer it's a 56 percent
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increase in age-adjusted risk of cancer mortality if you have met sin in particular there are a handful
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of cancers that seem especially impacted by this so endometrial cancer seven times as likely esophageal
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cancer almost five times as likely gastric cancer twice as likely liver kidney twice as likely so there
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are a handful of cancers that even appear to be especially exacerbated by metabolic syndrome or by obesity
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and overweight and so i think most people understand that smoking is an enormous driver of risk for
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cancer it is it remains the number one environmental trigger of cancer but obesity is number two and if
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you look more closely at the data it's really metabolic syndrome which obviously overlaps a lot with
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obesity if we turn our attention then to neurodegenerative diseases and we'll start with parkinson's disease
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the largest meta-analysis on this study suggests about a 24 percent higher risk of parkinson's disease
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in those with metabolic syndrome compared to those without it also appears to be graded again just as we
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see in atherosclerosis we see that having three of the risk factors for metabolic syndrome is a 31 percent
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higher risk of parkinson's disease while having all five 66 percent increase in risk when it comes to
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alzheimer's disease it's about a 10 percent increase in alzheimer's disease for those with
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met-syn and what's interesting at least in the meta-analysis we looked at was i thought that was actually a
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surprisingly low number i thought that having metabolic syndrome only increasing alzheimer's disease by 10 percent
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struck me as low but if you look more closely at the data you'll realize that there actually appears to be a
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protective role in the abdominal obesity risk factor so when you do the analysis by looking at each of the
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metrics of medicine individually there's about a 16 percent reduction in quote-unquote protective
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benefits of abdominal obesity now this is likely due to reverse causality meaning having alzheimer's
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disease is more likely to lead to abdominal obesity but nevertheless i think that's why those numbers
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don't look as big when you look at all forms of dementia because remember alzheimer's disease is the
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most prevalent form of dementia but there are many forms of dementia that are not alzheimer's there's
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vascular dementia lewy body dementia frontotemporal dementia so all comers vascular dementia is about
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a 37 percent increase in risk yeah so i think that's a really good and kind of quick overview of how
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metabolic syndrome can feed into the other diseases and like you said we'll have a lot more detail in
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the show notes because the reality is we just don't want to spend the entire ama on that because i think at
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this point people kind of understand okay this is an important thing to care about and i should
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understand this for myself and so the next section then starts to get to how do you identify
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beyond just the metabolic syndrome what are some other metrics that someone can look at
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to know their kind of specific metabolic health and one question that we get a lot which is just
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starting at the basics is how helpful is body weight and bmi to actually understand someone's
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metabolic health it's such a crude tool it's understandable why body weight and bmi are
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used as health indicators at the population level you know you're stuck with things that are very simple
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and reliable but if you hold up the figure from i don't remember which chapter in outlive it's from
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but it's from you know an analysis that i did to basically try to disentangle obesity and metabolic
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syndrome so if you take a look at that figure and by the way these are data that came from you know
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the nih and these turn out to be kind of conservative numbers but conservatively speaking you have at the
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time of this analysis 2021 108 million obese people in the united states these are adults and 150 million
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non-obese so obese being defined as a bmi over 30 now if you look at the people who are obese and have
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metabolic syndrome it's 62 percent of the obese have metabolic syndrome so that's 67 million people
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are obese with metabolic syndrome conversely if you look at the 150 million people who are not obese
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22 percent of those people have metabolic syndrome for a 33 million and so what you can see is that
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you've got a hundred million people and again i think that's a very conservative estimate others have
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come up with numbers as high as 125 million but call it a hundred million people with metabolic syndrome
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in the u.s but what i think is most interesting is a third of them are not obese and so if you think
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about all the things that we look at in our patients and all of the metrics we have on them i can just tell
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you i don't know the bmi of one of my patients and i don't care because i'm not trying to practice
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medicine on a population basis so i don't even know my bmi i know i'm overweight by bmi but it's not
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something that we're going to manage ultimately bmi it's not that helpful it doesn't account for
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body composition it doesn't account for insulin sensitivity in any way shape or form we just don't
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rely on it at all we'll do dexa scans we'll get into those details but we don't care about bmi
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that kind of leads us it's a good intro to this next section which is what are those metrics that
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you use with your patients to understand their metabolic health at an individual level and so i think
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what might be helpful for people is if you just kind of run through what those are and then what
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we'll do after is we'll double click on each of them some of them going into more detail than others
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depending on past content but i think it'd just be kind of helpful for people just to hear that full
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list quick yeah i mean we kind of organize them as functional tests imaging tests you know typical
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or regular biomarkers maybe some special tests and we'll even talk about things that are only done
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in research that we don't do but you might see these things show up in papers that you're reading so
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on the kind of regular slash traditional blood-based biomarkers we look at uric acid homocysteine
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triglycerides hdl cholesterol fasting glucose insulin hemoglobin a1c and liver function tests now i'd say
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one of the less common things that we do look at is resting and fasting lactate levels and obviously
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lactate performance in response to exercise so that's also kind of a functional test when it
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comes to the functional stuff though we're looking at zone two output we look at cpet testing so
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effectively the oxygen utilization co2 production under stress oral glucose tolerance tests again i
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don't put that down as a traditional blood-based biomarker because i think of that as really a
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functional test although of course it relies on these biomarkers continuous glucose monitoring and
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then whole body respiratory suites we personally don't do that in our practice we do all the others
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but we don't do the whole body respiratory stuff but you can do that to obviously get a sense of
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respiratory quotient imaging studies can be really valuable here so dexa scans which are measuring
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visceral adipose tissue and also measuring muscle mass body fat which is certainly more relevant
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than body weight or bmi we certainly would never rely on ct scans for looking at visceral fat although
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one could do it and you do get it with mri if you have the right software liver ultrasound along with
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algorithms that combine liver ultrasound with blood test to look at fibrosis scores become very
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important as you want to understand the prevalence of fatty liver disease and though we don't do this
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you might see this kind of stuff in research studies and it's very interesting stuff so you could look
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at c16 saturated fatty acids this gives you a sense of fat metabolism and of course intramuscular biopsies
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will give you a great sense of how much fat is being stored in a muscle and that can be obviously
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relevant for insulin resistance and it's obviously mechanistically important as well as we discussed in
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the jerry shulman podcast again those aren't things that we're doing in clinical practice i think it's
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really helpful for people just to kind of hear that whole list and now we'll jump into kind of each of
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those into a little more detail some more than others and we'll kind of look at what trends you're
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looking for what are the ranges you like to see and then ultimately it will lead to the second section
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of this which is how do you improve those various metrics so why don't we start with some of the more
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regular or traditional biomarker tests that most people will probably get at any type of physical
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screening annual exam they go to can you kind of walk through what those are and what metrics you're
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hoping to see within your patients thank you for listening to today's sneak peek ama episode of
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