Dr. Jeffry Gerber - 'Primary Causes of Heart Disease - Framingham and the Muddy Waters'

so my name is dr. Jeff Gerber I'm a family doctor from Denver Colorado and as we like to say real food is medicine now I tell you it's fun traveling halfway around the world to give a couple of talks that's not really why we came this is why we came so that's my daughter Courtney and myself three days ago up on the reef having a blast and that's Courtney bonding with the sea turtle so I'd like to talk to you about diabetes heart disease and navigating through the muddy waters when it comes to cardiovascular risk assessment like to introduce you to a few people so that's me in the center and into the right is my engineering problem-solving colleague Ivor Cummins and he convinced us last year to visit the gentleman on the left of the screen and that's dr. Joseph craft who is now 96 and he is a retired pathologist and he spent a career studying insulin metabolism and he noted that there was a strong connection between diabetes and heart disease so much so that he said that those with cardiovascular disease not identified with diabetes are simply undiagnosed and I'd like to explain to you why I think he said this so dr. Kraft was the chief of pathology and nuclear medicine at st. Joseph's Hospital in Chicago for over 35 years and during that career he devised the test that we now call the 5-hour insulin assay and he did two tests in over 16,000 people he also personally done 3,000 autopsies and he had collaborated with other professionals looking for the root causes of chronic disease now dr. Kraft was well published in the literature but it wasn't until he retired that he wrote a book called diabetes epidemic and you and I wish that every healthcare professional would read this and this book really details his career it talks about the insulin assay and how it relates to cardiovascular disease and we'll talk a little bit about that so what dr. Kraft had set out to do was to demonstrate that the standard methods to to diagnose diabetes and pre-diabetes were inferior and by those standard methods were talking about blood glucose measurements now that could be a fasting blood glucose or after a two-hour glucose challenge or after an HB a1c test and the what he demonstrated is that hyperglycemia is a late finding now I'm just curious how many type ones do we have in the room here just a few so we just heard that talked about the type ones and this is slightly a different topic because we're talking about using fasting blood sugar as a screening tool whereas in type ones it's an absolutely great way to monitor type control so just so you understand the distinction hyperglycemia is a late finding and not a good tool for screening so the Kraft insulin assay was based on the radio immunoassay that was being developed in the 1950s the late 1950s and this was a method to measure low concentrations of substances in the blood in this case we're measuring insulin and at the time they knew that type 2 diabetes what they call back then an adult onset diabetes was a disease of insulin excess but nobody had quantitated it that's what dr. Kraft set out to do and to also create this gold standard so the test he had performed in the book he reported 14,000 subjects and is similar to a glucose challenge where you give 75 grams or 100 grams of glucose but what was different is not only did you measure glucose you measured insulin over a five-hour period of time and at intervals and in between and when dr. Kraft looked at the data he saw that it clustered into five distinct patterns there was pattern one that he called normal and then there was pattern five that he called love and then there were these three patterns in-between that he referred to as hyperinsulinemia or diabetes in tsechow and indeed what dr. Kraft had created was a new method to diagnose pre-diabetes and diabetes but also to diagnose diabetes at its very earliest stage and so let's look at the patterns briefly so here's pattern one and you can see that insulin is low let's say less than five micro units and it never Peaks above sixty micro units and now what we're going to do is superimpose the three patterns of hyperinsulinemia and you can see the pattern two and three in the yellow and the orange are similar in that they have a low or normal in insulin pattern four is different than those because the fasting insulin actually goes high and then the two-hour shoots up to almost two hundred micro units and so what he demonstrated was indeed diabetes or diabetes in situ were diseases of insulin excess now from a clinical standpoint I'm not necessarily interested in the specific patterns of hyperinsulinemia I just want to know that we have a problem of insulin and so what Kathryn Crofts from Auckland New Zealand did was her PhD research and her thesis based on the Kraft data and she simplified this for clinical use now I just met with Katherine for the first time last week when I visited Auckland that was an awesome experience and she's brilliant and so what she basically said is that you can measure a two-hour insulin and if it's under 30 you're diabetic and if it's over 40 you have diabetes or diabetes Institute so this is what we call the pesky pattern 5 so this is the low insulin response and you'll see why I call it pesky but there's two situations that are fairly obvious that you would have a low insulin response number one if you're a type 1 diabetic that you never produce the insulin in the first place and the second scenario is when you're what we call a burnt-out type 2 diabetic where your pancreas stops producing insulin but there's two other situations where we see this slow pattern and the first is when you are fasting and the second is when you're in a low carb diet now what dr. Kraft showed back in 1975 if you actually took somebody on a low-carb diet and you gave them carbohydrates you carbohydrate loaded them for a few days before this test this pattern 5 would revert back to a normal pattern 1 or something else now this doesn't happen to everybody but we now refer to this as something known as physiologic insulins ish I'm sorry physiologic insulin resistance now some people have argued well this pattern 5 that low-carb people are experiencing is representing something bad as if it's some type of glucose deficiency in the diet or some type of insulin deficiency but really what dr. Kraft demonstrated is this is just a normal physiologic adaptation to being on a low-carb diet and this is just interesting for us to do in office because we've done glucose tolerance tests over 2,000 over the last 16 years with and without insulin so this one gets a little bit technical but I really wanted to understand how insulin is a better measurement so you have to compare the two and so I looked at craft data and re compiled it and created something called a confusion matrix so your eyes my Cleo's glazed over but this is the confusion matrix and what it does is compares one method in this case hyperinsulinemia to hyperglycemia and so on the right of the screen we can see the positive and negative predictive value and that tells the individual their likelihood of having a given disease in this case hyperinsulinemia based on paper glycaemia and on the bottom of the screen we see sensitivity and specificity and that tells the research or the clinician how accurate or valid the tests method is in this case hyperglycemia so you run the test and the result comes back hyperglycemia you have a high sugar response well the positive predictive value is 97% and the specificity is 92% both high numbers so that tells us if your result returns hyperglycemia you can be fairly certain that you have hyperinsulinemia in fact you don't even have to do the craft in solana say we're all good the problem is when the test result returns you glycaemia or a normal glucose response and you can see the problem is that the negative predictive value is 28% and the sensitivity is 52% now I'd like to simplify that by showing in two pie charts so this is looking at negative predictive value and in this situation all the individuals were you glycemic they had normal blood sugar based on a fasting blood sugar and our to our glucose tolerance test but yet 72% of them failed to craft insulin assay that's not very reassuring and so here we're looking at sensitivity so we're comparing hyperglycemia to you glycaemia now it turns out that hyperglycemia can actually pick up 2% of the abnormals it's not the best but it's not bad but it misses 48% of the individuals that were you glycemic and yet failed the Kraft insulin assay so this is actually an argument to do more standard glucose tolerance tests in the office and we do that and unfortunately the mainstream doctors just have given up with that and they just do fasting blood work and at the end we'll talk about how you can approve upon the standard glucose tolerance test both with and without insulin but the important point here is that again hyperglycemia is a late finding and if you don't test insulin you're not going to know there's a problem so the next question could the Kraft insulin assay and predict population risk risk well let's take a look at that so there was a study last year that suggested that up to 52% of the population in the US are now pre-diabetic and diabetic that's a huge number that's a scary number okay and the action that number is about right based on standard testing and they actually did glucose tolerance test fasting blood glucose hba1c they did standard testing properly but of course they didn't measure insulin imagine if they measured insulin we would predict that at least 2/3 of the population would have failed to craft insulin assay the point is again if you don't test you're not going to know there's a problem so I would like to shift gears and talk about cardiovascular risk and ask the question is there a diabetes paradox so some actually say that despite seeing more diabetes and obesity that there's actually less heart disease so we have to think about that and I think since 1995 it's true that we've done a much better job treating the complications of heart disease thanks to the emergency medical system the intense care unit and modern-day procedures in the office okay but that's addressing what we call morbidity and mortality what we're really looking at is the incidence or the prevalence or occurrence of new disease and that's a tougher one to get it now it is true that during this period of time we see that people have cut back on smoking we've cut back consuming trans fats but at the same time we see diabetes and obesity on the rise so you have to consider all that now one way we can address this question is by looking at something called subclinical cardiovascular disease and you can do that with imaging of the blood vessel and we're going to talk at the end about a test called the calcium scan it's it's a test that actually sees the disease it's an amazing test but when you start to look at studies such as this you could see that with more diabetes and obesity there is more heart disease and that's the whole point of this presentation so we don't see that there's any diabetes paradox at all so what did dr. Kraft have to say about heart disease well he said that atherosclerosis is a metabolic disease and so you're therefore want to focus on diabetes and pre-diabetes and if you don't you're going to miss cardiovascular disease and then in 1988 a gentleman by the name of Jerry reven comes along and makes headlines for something called the metabolic syndrome and what we more properly called today the insulin resistance syndrome and he too noted that atherosclerosis was a metabolic disease and he broke it down into different components namely glucose intolerance hyperinsulinemia just like dr. Kraft and most importantly atherogenic dyslipidemia where we're now looking at the quality of the cholesterol not necessarily the quantity and we measure the quality by looking at ratios of triglyceride to HDL looking at the particle size and that was what was important in fact they don't talk about total cholesterol and LDL concentration when we discuss metabolic syndrome also elevated blood pressure and abdominal obesity was involved now it also turns out that the insulin resistance syndrome was associated with many of the other chronic diseases that we see today and this was fascinating to me when I had first learned about the metabolic syndrome because it now described a root cause for all of these chronic diseases that we see in modern-day society but it was also frustrating to me although doctors knew about the metabolic syndrome they didn't know what to do about it why because as we see it it's it's it's a nutritional syndrome that you treat with nutrition specifically a low-carb diet and you know that low-carb diets haven't been popular doctors are looking for medication now metformin may address this but it doesn't really get at the root cause and even dr. Kraft and Jerry Raven wouldn't touch that giant elephant in the room the nutritional aspect because they didn't want to upset their colleagues they just focused on their methodology so as I see it they missed the golden opportunity but you know what it's our turn yes so it's well established in the medical literature that this strong link between diabetes and heart disease but when it comes to clinical medicine not so fast and unfortunately I see this all the time on the one side we have diabetics that don't know that they have heart disease and the other side we have heart patients that don't know that they're diabetic and even worse their doctors are clueless and the question is why is there such a disconnect well welcome to the framingham distraction yes that's Framingham Massachusetts we're back in the 1940s they tracked the population over decades to see which ones had heart attacks in which ones didn't and then they followed other things that seem to be negatively associated and they called them risk factors and we know them today is bad cholesterol smoking high blood pressure diabetes and since the original work they've come up with different guidelines tools and risk calculators all with a central theme to lower that bad cholesterol and we're all familiar with this and this is where the problem is you go to the doctor's office and he checks your cholesterol and it gives you advice to lower the bad cholesterol either with a low-fat low-calorie diet and or medication but what this approach doesn't address is metabolic disease hormonal dysregulation and it doesn't properly measure diabetes this approach misses the mark so here's your Framingham risk score you ask a couple of these questions and you take a guess whether you're going to live or die it's a statistical guess based on epidemiology and it's very hard for any of this to apply to the individual again as I said it's really heavily cholesterol weighted some people argue well we were met at measuring metabolic disease because you know diabetes is is listed there yeah but again in the emphasized cholesterol they D emphasize diabetes they don't measure blood sugar properly they don't measure insulin properly these are the muddy waters of Framingham so what's so important about lowering cholesterol anyway medical doctrine tells us that high cholesterol is bad and requires remedy as if to imply that cholesterol is innately toxic well what are the mechanisms to support this well they talked about decades that there's a problem between concentration gradients of cholesterol in the blood and cholesterol in blood vessel wall in recent years they said no no it it's it's inflammation that's what the but overall we we find that these mechanisms remain elusive so what about the studies to support this so the diet heart pipe ah thesis tells us to reduce saturated fat in the diet but as we know that has been mostly unproven what about medication well you can tell patients who are free of heart disease to take a statin but the benefit is actually very very quite very small indeed and so we don't recommend that anymore to our patients it is important to recognize that there is a small mortality benefit to giving a statin in patients that have pre-existing heart disease what we call secondary prevention so you have to keep that in mind but overall we are not impressed so we can further debunk the lipid hypothesis by looking at some other studies and there's several I just have two listed and they're associational studies but they can challenge a null hypothesis or the default hypothesis in this case the lipid hypothesis so in 2009 they looked at a hundred and almost one hundred and forty thousand patients that were hospitalized with acute cardiac events and then they looked at their cholesterol and what they found was that three-quarters of them were actually at the Framingham cholesterol goal so the question is if they were a goal what were they doing the hospital having heart attacks makes you wonder we have another study in 2015 that looked at large populations of elderly people and they looked at their cholesterol and what they found is that the ones who had higher cholesterol actually live longer go figure so let's compare all that to the mechanisms for metabolic disease and hormonal dysregulation and I refer to this as the root cause diagram it's very similar to the metabolic syndrome and you can see that the livers involved the fat cells are involved the blood is involved and we see this atherogenic dis lipedema so we put this all together and we call this metabolic mayhem and downstream it leads to things such as inflammation oxidative stress and advanced glycation which is ultimately damaging to the blood vessel wall and as a result we see after escora --ss it is important to understand that atherosclerosis is the body's attempt trying to repair the damage and this reminds me of the plumber so your pipes are leaking what do you do you call the plumber he comes to your house you wrapped some tape around the problem and most importantly you give him some money I'm not referring to the cardiologist now am i but what didn't he do he didn't check the water pressure he didn't check the minerals in the water he didn't address the root causes and so you see it's the same with atherosclerosis now what's the role of that bad cholesterol well maybe it's not the cholesterol is innately toxic but rather it's there as a consequence of all this other stuff makes sense so do we have studies to support these mechanisms can we compare diabetes and heart disease risk can we look at glucose and insulin can we compare insulin to cholesterol we have a couple studies to show you so this is the Helsinki policemen's trial it's from the 1970s and they tracked the individuals over the years and then they looked at their insulin what's neat is that they measured to our insulin so they measured insulin properly and so we have low insulin high on group and so this is the low insulin group at five years the risk of having a cardiac event was 1% and then we can look at the high insulin group at five years their risk went up to nine percent to the untrained eye that doesn't seem very impressive but actually that's huge that's a nine-time nine full difference all almost an order of magnitude what we call a ten ten times different it's actually a huge difference and so now let's compare this to what generally happens to cholesterol over this time period so we have low cholesterol high cholesterol group so the low cholesterol group at five years the risk was three percent and then we have the high cholesterol group what do you think happens to their risk when the cholesterol is high does it go up does it go down does it stay the same well the risk went up but just by one percent that's not even one and a half time so if you're comparing nine times to one and a half time that's a huge difference it's like the elephant versus the mouse and the elephant the elephant represents insulin and the mouse represents bad cholesterol and the elephant elephant will predict risk much better every single time so here's some other studies that more properly look at insulin and glucose and virtually all of them insulin glucose significantly car-door correlate with cardiovascular risk whereas the bad cholesterol doesn't seem to correlate these are case control studies by the way and the the statin injuries tree actually hate them because it doesn't support their medications but you know there are situations where we do prescribe it but if you actually look at there's three studies there in the red that showed that there's an inverse relationship between cholesterol and heart disease meaning that when the cholesterol went down the heart disease risk one and the authors have to be careful when they present data like that that kind of contradicts everything else so future research we want to further compare insulin to bad cholesterol we'd like to see interventional food trials looking at low carb vs. low fat and heart disease we want to track subclinical disease with scans such as the calcium scan and we'll talk about that and measure cardiovascular outcomes but the bottom line it's the insulin stupid and I'm talking about the good doctor there my doctor colleague to recognize that atherosclerosis is a symptom of diabetes and you therefore focus on metabolic disease hormonal dysregulation and insulin and to realize that many are at risk again it is a nutritional syndrome we're not treating it with medication we're treating it with diet and it's somewhat frustrating because you know in the u.s. how are you going to convince doctors that they're going to make money telling people how to eat better ahead but true so what is the diet and lifestyle advice that we're going to recommend to prevent those arteries from being clogged so the advice should be based on metabolic disease and what drives it what drives hormonal dysregulation and insulin so carbohydrates is the fourth first culprit then protein and in this context natural fat saturated fats are metabolically neutral and this advice should probably be for the majority of the population because we're saying that at least two-thirds of the population have this problem right and so this is the advice that we give our patients that low-carb is best we cut sugar grains starch fibers okay we eliminate processed food especially the highly allergenic Industrial vegetable oils canola corn and soy and we replace it with monounsaturated fats and saturated fats if this is working right people are going to eat less and I think it's important that the low carb diet includes a message of eating less but it happens as a consequence movement and active activity are important smoking cessation sunlight the list goes on there's lots of tweaks but we don't have time to discuss clinical assessment I wish that everybody in the healthcare field would read doctor crafts work would read Katherine Crofts PhD thesis that talks all about the importance of measuring insulin to understand that again standard methods of measuring blood sugar are late finding and you can't rely on them again I think that more people should do the glucose tolerance test we have improved the sensitivity by including a one-hour glucose we can do insulin we can measure a fasting insulin perhaps under 5 micro units is a good good number and we do the Catherine Cross method of insulin assay we measure the 2-hour level less than 30 you're okay above 4 do you have a problem and this testing is probably for the standard population so if you're on a low-carb diet you don't necessarily have to do this Kraft insulin assay have to consider whether you want a carbohydrate load or not but again in the general population the insulin acetate can be really beneficial and you can measure inflammatory markers we still measure lipids but we're looking at quality not quantity and we can do standard body fat waist to height measurements so lastly we're going to talk about cardiovascular imaging and there's many tools and many methods but we're looking one for ones that are non-invasive and relative we inexpensive and the one at the bottom is the coronary artery calcium score that we prefer and you have to understand that this gives us some historical information because it takes a lifetime to develop plaque so we have to thank some of the founding fathers of this technology that dates back some thirty years so there's one physicist and the rest of them are all cardiologists and you might recognize arthur a gaston on the bottom left who was famous also for the south beach diet so this guy was way ahead of his time and so these are two images of two different people of the calcium scan or the CT scan of the heart where we're actually now seeing the disease we're visualizing the disease so how this technology works it's a high speed cat scan and it's available everywhere in Australia as far as I understand yeah cool and so it takes a high-speed image of the heart and in different slices and it can see the calcium in the blood vessel it adds it up and then you get a score now as atherosclerosis develops first it's soft plaque and as as its Harding the calcium builds up and you can see the calcium and then measure it so the individual on the right has a very high calcium score you can see that area bright rate bright white represents the left anterior descending artery what we call the Widowmaker artery and David Bobbitt has produced a wonderful documentary called the Widowmaker movie and it talks all about the calcium scan and I recommend that you watch it but we might say that this individual has a high in the thousand range okay we don't have much history on that person but on the left of the screen we do have some history on that individual so that one has been on a low-carb high-fat diet for over 15 years is from the United States and initially lost 40 pounds so you can convert that and has remained on a low-carb high-fat diet a Whole Foods diet ever since and you can see that there's no calcium in the left anterior descending artery and that is the same throughout the entire sequence now that's important because that person happens to be me so I have a perfect calcium score of zero that's amazing right I think Rod Taylor has a perfect calcium score of zero how many people have had this scan just a few okay but what's really important is that because I have a perfect score of zero my risk of having a cardiovascular event Inlet in next 10 years is less than 2% one study gives me a 15-year warranty that I won't drop dead from a heart attack now I hope I'm not jinxing myself and that this stays true but am i genetically blessed while I do have diabetes and heart disease in my family I do have some favorable genetic markers but perhaps it's everything that I've been doing right that gives me a score of zero and I need to keep it that way so I can tell you that the studies show that this is reproducible and quantifiable and here's just a smattering of them and you can see that as your score goes from zero to a thousand your risk goes up by an order of magnitude this has been done in literally hundreds of thousands of people and although we call calcium a risk factor it really isn't a risk factor calcium is seeing the disease plaque has calcium calcium is plaque there one in the same and this summarizes a calcium score so you can have a low risk as zero your risk tenure prevent rate is less than 2% versus a high square of a thousand where your event rate goes up 37 times it's beyond an order of magnitude in terms of difference now as you can imagine the calcium score blows it blows away Framingham risk and we can illustrate so we can look at the middle risk individuals and Framingham would say their 10-year event rate risk is 10 percent well are they all at 10 percent well let's look at the calcium scan well no so we can see that we have ones who have a very low risk in fact they have a zero score we have true middle middle risk and then we have the true high risk whether the risk goes up 36 times and again this just illustrates how Framingham takes a guess and the calcium scan sees the disease itself so what if you get a calcium scan and the first one says hi are you doomed well it depends and this is where you want to try to stabilize your calcium and let me illustrate so we have individuals here who started out with a high score up to a thousand and we follow them over three and a half years this is real data and we define progression of calcium as greater than 15% a year so what happens to their risk well they have a 50/50 chance of having a major cardiovascular event uh-oh that's a problem but then let's look at these individuals they also started with a high score of a thousand but they stabilized their calcium and that's defined as progression less than 15% a year and when you go out six years guess what their risk was only 3% that's almost equivalent to having as your calcium score so the point is you want to stabilize your calcium and you can do the scan every two to three years maybe sooner if you're really concerned there is a little bit of radiation to consider and you need to take action you want to address this with diet and lifestyle and perhaps in the ones that have really really high calcium scores you might want to consider medication and that includes statins by the way so just a few more points about the calcium scan it's now in the 2013 guidelines but hardly any health care professionals know about it we use it as a wonderful tool to promote health and we think that other healthcare professionals GPS and the likes should be offering this test methods to patients to get them to take proper action when the test is used properly it's not going to lead to more unnecessary testing it's relatively inexpensive and non-invasive just a small amount of radiation it's true that it doesn't detect salt plaque but it doesn't really matter it is the mathematics that predict the risk it's been done and over you know hundreds of thousands of patients and lastly the calcium score is obligatory and all US presidents and astronauts so why isn't it available to all of us like our insurance companies don't pay for this test today you have to pay out-of-pocket although the price is dropping so I hope that the money waters are clearing when it comes to cardiovascular risk assessment we talked about the power of the calcium scan we talked about the root cause and how to properly take action and so when you are and your doctor or grabbing for the Framingham risk calculator it's best to think about diabetes metabolic disease and hormonal hormonal dysregulation because what's most important is to recognize the diabetes is a vascular disease thank you for your time

Channel: Low Carb Down Under

Views: 45,780

Rating: 4.8990827 out of 5

Keywords: Low Carb Down Under, LCDU, www.lowcarbdownunder.com.au, Dr. Jeff Gerber, Denver's Diet Doctor, Heart Disease, Diabetes, Cardiovascular Disease, Low-Carbohydrate Diet, Insulin, The Framingham Study, Dr. Joseph Kraft

Id: eii1zqQq8TM

Length: 35min 36sec (2136 seconds)

Published: Sat Oct 15 2016