METABOLIC DYSFUNCTION II

This week, as promised, I will dive deeper into Dr. Attia’s advice on metabolic disorder because I believe that it is very important that we understand that this is the root cause and begin to use the knowledge provided by Dr. Attia to begin to heal ourselves.

As I advised last week, I have lost too many family members and friends to at least one of these Horsemen.  This week, I am again distressed, as another colleague and friend, died after battling cancer for some time.

METABOLIC SYNDROME

As I indicated, Dr. Attia believes that what we eat and how the body processes it may be very important to how long we live and how well we live.  So, he advises that you can’t fight the Horsemen without taking on metabolic dysfunction first.

You will recall Dr. Attia’s advice from last week’s article that the problem is excess or visceral fat.  The surplus fat that spills over into other areas of your body; into your blood, as excess triglycerides; into your liver, contributing to non-alcoholic fatty liver disease (NAFLD); into your muscle tissue, contributing directly to insulin resistance in the muscle; around your heart and your pancreas, infiltrating your abdomen and accumulating between your organs thereby increasing your risk of cancer and cardiovascular disease.

As he notes:

“According to the Centers for Disease Control (CDC), more than 40% of the US population is obese (defined as having a body mass index (BMI) greater than 30), while roughly another third is overweight (BMI of 25 to 30).  Statistically, being obese means, someone is at greater risk of chronic disease, so a lot of attention is focused on the “obesity problem,” but I take a broader view: obesity is merely one symptom of metabolic dysfunction.  Not everyone who is obese is metabolically unhealthy, and not everyone who is metabolically unhealthy is obese.”

Dr. Attia calls this cluster of problems “metabolic syndrome” (or MetSyn), and it is defined in terms of the following five criteria:

1. High blood pressure (greater than 130/85)
2. High triglycerides (greater than 150 mg/dL)
3. Low HDL cholesterol (less than 40 mg/dL in men or less than 50 mg/dL in women)
4. Central adiposity (waist circumference more than 40 inches in men or more than 35 in women)
5. Elevated fasting glucose (more than 110 mg/dL)

If you meet three or more of these criteria, then you have metabolic syndrome.  Notice that obesity is merely one of the criteria; it is not required for metabolic syndrome to be diagnosed.  The problem runs deeper than simply unwanted weight gain.  Therefore, obesity itself is not the issue but is merely a symptom of other problems.

OBESITY AND METABOLIC DYSFUNCTION

Note that obesity and metabolic dysfunction are NOT the same thing.  Dr. Attia notes:

“Studies have found that approximately one-third of those folks who are obese by BMI are metabolically healthy.  At the same time, some studies have found that between 20 and 40% of nonobese adults may be metabolically unhealthy.  A high percentage of obese people are also metabolically sick, of course—but many normal-weight folks are in the same boat, which should be a wake-up call to all.  This is not about how much you weigh.  Even if you happen to be thin, you still need to educate yourself about your metabolic health.”

It’s not only obesity that drives bad health outcomes; it’s metabolic dysfunction

Some 42% of the US population is obese (BMI>30).  Out of a conservatively estimated 100 million Americans who are metabolically unhealthy, almost exactly one-third are not obese.  Many of these folks are overweight by BMI (25-29.9), but nearly 10 million Americans are normal weight (BMI 19-24.9) but metabolically unhealthy.

Some research suggests that these people might be in the most serious danger, having more than triple the risk of all-cause mortality and/or cardiovascular events than metabolically healthy normal-weight individuals. 

NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD)

As noted above, surplus fat that spills over into your liver, contributing to non-alcoholic fatty liver disease (NAFLD), one of the first signs of impaired liver function, is highly correlated with both obesity and excessive cholesterol.  NAFLD is the precursor to non-alcoholic steatohepatitis, or NASH, identified by doctors at the Mayo Clinic in 1980, which has since blossomed into a global plague.

As Dr. Attia notes: 

“More than one in four people on this planet have some degree of NASH or its precursor, NAFLD, which is highly correlated with both obesity and excessive cholesterol, yet it often flies under the radar, especially in its early stages.  Most patients are unaware that they have it—and so are their doctors, because NAFLD and NASH have no obvious symptoms.  The first signs would generally show up only on a blood test for the liver enzyme alanine aminotransferase (ALT for short).

Rising levels of ALT are often the first clue that something is wrong with the liver, although they could also be a symptom of something else, such as a recent viral infection or a reaction to a medication.  And the American College of Gastroenterology recently revised its guidelines to recommend clinical evaluation for liver disease in men with ALT above 33 and women with ALT above 25—significantly below the current “normal” ranges.

NAFLD and NASH are basically two stages of the same disease.  NAFLD is the first stage, caused by more fat entering the liver or being produced there than exiting it.  The next step down the metabolic gangplank is NASH, which is basically NAFLD plus inflammation, like hepatitis but without a viral infection.  This inflammation causes scarring in the liver, but again, there are no obvious symptoms.  This may sound scary, but all is not yet lost.  Both NAFLD and NASH are still reversible.  If you can somehow remove the fat from the liver (most commonly via weight loss), the inflammation will resolve, and liver function returns to normal.

In other words, your liver can recover from fairly extensive damage, up to and including partial removal.  But if NASH is not kept in check or reversed, the damage and the scarring may progress into cirrhosis.”

You should care about NAFLD and NASH because they represent the tip of the iceberg of a global epidemic of metabolic disorders, ranging from insulin resistance to type 2 diabetes.  Type 2 diabetes is technically a distinct disease, defined very clearly by glucose metrics, but Dr. Attia believes that it is simply the last stop on a railway line passing through several other stations, including hyperinsulinemia, pre-diabetes, and NAFLD/NASH.

He advises that if you find yourself anywhere on this train line, even in the early stages of NAFLD, you are likely also enroute to one or more of the other three Horsemen diseases (cardiovascular disease, cancer, and Alzheimer’s disease).  So, you can’t fight the Horsemen without taking on metabolic dysfunction first.

So the problem begins when your subcutaneous fat tissue reaches capacity and the surplus begins spilling over into other areas of your body as visceral fat.  And it doesn’t take much visceral fat to cause problems.

As Dr. Attia notes:

If you are a forty-year-old man who weighs two hundred pounds. If you have 20% body fat, making you more or less average (50th percentile) for your age and sex, that means you are carrying 40 pounds of fat throughout your body. Even if just 4.5 pounds of that is visceral fat, you would be considered at exceptionally high risk for cardiovascular disease and type 2 diabetes, in the top 5% of risk for your age and sex.

It may have taken you a long time to get there, but now you are in trouble—even if you, and your doctor, may not yet realize it. You have fat accumulating in many places where it should not be, such as in your liver, between your abdominal organs, even around your heart—regardless of your actual weight.  But one of the first places where this overflowing fat will cause problems is in your muscle, as it worms its way in between your muscle fibers, like marbling on a steak.  As this continues, microscopic fat droplets even appear inside your muscle cells, which is where insulin resistance likely begin”

Next week I will look at Dr. Attia’s advice on the first of the four horsemen, Type 2 Diabetes.   Again, I strongly urge you to read Outlive and I hope that these excerpts will help convince you to do so.

Have a disciplined week as you work to build your financial freedom and improve your longevity.  If you find this advice helpful, please share with your friends and colleagues.  As usual, I look forward to your questions and comments.  Be safe.  Take good care, and if you can, help someone in need.

Cheers, Nigel

 Nigel Romano, Partner, Moore Trinidad & Tobago, Chartered Accountants