So stoked for Jenny, she deserves every ounce of success…
Blood Work 2.0
So the number one killer of firefighters in the US is still Cardiovascular Disease (CVD)… CVD has been the leading cause of death by a huge margin for quite while and recently the 2010 NIOSH report on Line of Duty Deaths (LODD), a document that thoroughly reviews a few specific LODDs, has two CVD related cases in it; both firefighters died from massive heart attacks one on the treadmill during an annual physical and another in working fire. In the “preventative measures” section of each article it lists “screening for CVD” and “annual physical fitness evaluations” as primary steps for the department to take in an effort to reduce LODD from CVD related causes. So what does CVD screening mean? A good place to start is blood work; not just any panel of tests will do though, for any of the information to be relevant a few parameters must be on place.
Here is what to ask your Doc for and why:
Nuclear Magnetic Resonance (NMR) Lipoprofile
-Total Cholesterol
-LDL Particle Number (LDL P)
-LDL Size
-HDL
-VLDL
-Triglycerides
-Lipoprotein Insulin Resistance (LP-IR)
Lipoprotein (a) Lp(a)
Glucose
C-reactive protein
Total cholesterol: At this point I’m sure everyone has heard of cholesterol; a measure of the total compilation of blood lipids and proteins that escort fats and cholesterol around the body via the blood. Total cholesterol includes high-density lipoprotein (HDL), Low-density lipoprotein (LDL), and Very low-density lipoprotein (VLDL). Because of the broad range of particles in this measurement “total cholesterol”, as a marker of health, only tells part of the story; as humans, the norm is 120-140mg/dl.
HDL: This is the “good” cholesterol, if you want to assign labels, and it is responsible for “scrubbing” the arteries and transporting unused fats back to the liver for processing. HDL is affected by several factors including genetics and exercise but like all things it is wildly influenced by diet. For HDL you should shoot for a number over 50mg/dl.
LDL: If you ask anyone on the street they will tell you that these are “bad” cholesterol and they cause plaque build up and heart disease, naturally it is more complicated than that. LDL do the opposite of HDL in that they transport fats from the liver out into the body via the blood stream; where it gets sticky is that there are several types of LDL. There are the normal large-puffy LDL (type or pattern A), small-dense LDL (type or pattern B), and the aptly name “intermediate” particles for everything in between. Generally type A LDL is considered innocuous, it is large and puffy and bounces around the arteries with very little chance of becoming stuck. Type B on the other hand is considered atherogenic because it tends to lodge in the arterial walls and is responsible in part for plaque build up. Historically blood levels of LDL have been between 40-70mg/dl however the real emphasis should probably be on particle size not the total number. People who have predominately type A LDL are at much lower risk of CVD than those with predominantly type B LDL. To recap; total should be 40-70mg/dl but the type, A or B, is much more important. To further clarify, cholesterol is carried inside lipoprotein particles; it is helpful to think of cholesterol as a passenger and the lipoprotein particles as a vehicle. It’s not the number of passengers that causes a traffic jam… it’s the number of vehicles! Similarly, it’s not the amount of cholesterol that causes heart disease – it’s the number of lipoprotein particles! Only the NMR test actually counts the number of lipoprotein particles.
The higher the number of lipoprotein particles in your blood, the greater the risk you have for developing Coronary Heart Disease.
Triglycerides: These are a measure of circulating blood fat; contrary to popular belief they are not elevated by a high-fat diet, in fact quite the opposite is true. Elevated triglyceride levels are a clear indication of the bodies intolerance to or inability to effectively metabolize dietary carbohydrate, which when deemed excess by the liver is globbed together in groups of three and released into the blood. B Shift Breakdown: insulin resistance or high carb in take = high triglycerides… Our ancestors had triglycerides in the 50-80mg/dl range and generally anything under 100 is considered safe from a CVD perspective. That being said strength athletes (highly insulin sensitive) and those following a paleoish diet can routinely be in the 30-40 range which is awesome. If you are a drinker this is something to watch out for as alcohol can really jack with your triglyceride levels.
Robb Wolf’s Rule for Boozing: Drink enough to optimize your sex life, not so much that it impacts your blood lipids.
Lipoprotein Insulin Resistance (LP-IR) Score: The LP-IR score is an assessment of insulin resistance, on a scale ranging from 0 (most insulin sensitive) to 100 (most insulin resistant), that combines the results of 6 lipoprotein particle numbers and sizes based on their differential strengths of association with insulin resistance. Using this method it is possible to predict Impaired Glucose Tolerance (IGT) and Diabetes early enough that, in most cases, it can be treated with lifestyle, nutrition, and exercise changes. As I wrote about in Blood Sugar, this is huge for reducing the risk of heart disease.
Lipoprotein (a): High Lp(a) predicts risk of early atherosclerosis independently of other cardiac risk factors, including LDL. In patients with advanced cardiovascular disease, Lp(a)indicates a coagulant risk of plaque thrombosis and accumulates in the vessel wall which increases clotting. Because of its unique ability to predict heart disease in people who would otherwise test “clean” I think it is important to include this test on your first run of lab work.
Glucose: This test is indicating what your fasting blood glucose levels are and is only relevant in context. Meaning that it is very dependent on what you ate for dinner, how much sleep you got, what your stress levels are, etc. etc. Read Blood Sugar
C-reactive protein (CRP): Long story short, this is a marker of systemic inflammation. CRP is a by-product of immune cell activity and indicates a response that could be totally normal or an indicator of health problems. CRP can and should be elevated any time the immune system is battling an infection of any kind. But what happens if your CRP is elevated and you don’t have any obvious infection? It could mean that your body is fighting a hidden battle in places like your gums and gut lining, CVD is linked very closely with gingivitis. Healthy levels of CRP are below 1.0mg/l.
There are several ways to get your blood work done, one of course is to ask for it during a check up with your Doc another is to send away for a kit online. Whichever you choose be sure that you get it done and if your numbers are not what they should be please look to your diet before you start taking any medication.
Reno Fire is Saving Lives @robbwolf
The United States will spend roughly $2.5 trillion this year on health care. Almost three-quarters of that is spent treating chronic diseases like diabetes and heart disease. But now, just across state line in Reno, there is a new approach: the city is putting its money on prevention.
There is an especially good reason for Reno’s new approach; Under Nevada law, the so-called “Heart-Lung Bill,” if a police officer or firefighter has a cardiovascular event after they have been employed for five years, it’s considered to be work related. A single workers comp claim for such an event can easily cost the city $1.5 million.
Salt Part V
Healthy Salt Recommendations
How much, and what kind of salt to include in the diet
According to research, there exists a range of sodium intake that likely confers the best health outcomes for most people. As I explained in part 3, findings from a 2011 study demonstrate the lowest risk of death for sodium excretion between 4000 and 5990 milligrams per day. (1) Sodium excretion greater than 7000 milligrams or less than 3000 milligrams per day was associated with a higher risk of stroke, heart attack and death. This lowest risk range equates to approximately two to three teaspoons of salt per day.
Salt Part IV
When Salt Reduction May Be Warranted
As we have discussed in the last three articles in my series on salt, the evidence for universal salt reduction is weak and often conflicted. Across different cultures, dietary salt intake is at best weakly correlated with blood pressure or cardiovascular risks, and associated with poorer health outcomes at either extreme of salt intake, both low and high. As a general recommendation, it seems that salt restriction for most people may be both unnecessary and possibly harmful in the long run.
While most people have no reason to restrict salt to the levels recommended by various health organizations, there are a few health conditions in which lower salt consumption may be necessary, based on clinical and population data. Generally, these are people with serious health problems, particularly suboptimal kidney function, and the data supporting salt restriction in these individuals is somewhat controversial.
Paleo Protein Powder
An excerpt from Amy Kubal’s post on whey…
Supplement ‘Facts’
Let’s look at the label – sure it says it has 20 grams of protein, all the essential amino acids, is 100% ‘pure’ – blah, blah, blah… Unfortunately, what you think you’re getting and what you’re actually getting can be two very different things. Protein powders fall under the realm of ‘supplements’ in the eyes of the government and therefore are not regulated nor checked for purity or content. A Consumer Reports investigation uncovered concerning amounts of arsenic, lead, mercury and cadmium in several well known and darn right popular protein powders – we’re talking ‘exceeding maximum’ pharmacologically deemed ‘safe’ numbers here. And do you really know what else could be in there? There have been several cases and reports of seemingly innocent ‘protein powders’ being contaminated with anabolic steroids or like substances which have resulted in positive ‘doping’ test results.
Have you ever went to the meat counter and asked the butcher to cut you off a big slab of whey or cracked open an egg to be greeted with a white powder? I’m guessing it’s a great big negatory on that one. Believe it or not protein powders are a processed food. Yes, you heard that correctly – these powders are far from a ‘natural phenomenon’. You cannot milk a cow and get a powder, city kids you’re just going to have to trust me on this one. So, where does the powder come from? In the case of whey, it’s often a waste product of cheese making and unless you’re getting the super pricey, meat is a better deal, protein powder from grassfed animals you’re likely getting ‘grain-fed waste’. Let’s also consider the process that makes the whey into a powder (it’s liquid in real life…) – this process be it whey or egg white often utilizes extremely high heat (like higher than cooking). This ‘hot air’ denatures the protein to an extent that may increase its carcinogenic load. And hold on, there’s more!! Some of these powders even come with some bonus MSG!! Remember that rule about food that comes in a package, needs a label and can live on a shelf for an extended period of time? Apply that here.
Blood Sugar
We all know that heart disease kills more Fire Fighters than all other causes of line of duty deaths put together. It is a significant problem for us, and not only does it cost the lives of our brethren, it costs our employers and ultimately the taxpayers a metric shit ton of money annually. So what gives? It’s no big secret, all you have to do is watch ten minutes of TV and you will see adds for fifteen different drugs and “heart healthy” food choices all promising to ward off the dreaded myocardial infarct. So how does something as obvious as heart disease keep sneaking up on us? If we are so savvy about prescribing drugs and recommending diets to would-be victims how can it still be the leading cause of line of duty death? Would it surprise you to know that almost 50% of first time hearth attack sufferers had “normal” cholesterol and blood glucose lab values? Would it surprise you to know that blood glucose is a predictor of hearth disease? It surprised me…
I have already written about cholesterol and problems with using it’s most basic metrics as a measure of heart disease risk so I will leave it alone in this post. The focus here, as the title indicates, is blood sugar.
When we think blood sugar we think diabetes and Wilford Brimley, but it turns out that nearly 70% of all diabetics die from heart disease. It stands to reason then that being diabetic greatly increases your chances of developing heart disease, 2-4 times in fact. So what exactly is diabetes? Simply put, it’s a disease process that ends with your body not being able to regulate its blood sugar. Whether it is type 1 or type 2, essentially your body lacks the ability to produce sufficient amounts of insulin to clear sugar from your blood. This could be because the beta cells in the pancreas that secrete insulin are damaged from genetic and environmental factors or the body has been subjected to so many blood sugar spikes that the cells have become insulin resistant. Either way, eventually, this lack of effective insulin leads to chronically high blood sugar, which wreaks havoc system wide. Elevated blood sugar is associated with thickening of arterial walls, elevated triglycerides, elevated small dense LDL, low HDL, and systemic inflammation, all of which are associated with increased risk of heart disease. Studies published in the last 4-5 years have shown such direct correlation between heart disease, insulin resistance/diabetes, and the subsequent elevated blood sugar, that some forward thinking health screeners are predicting cardiovascular disease up to 20 years out using measures of average blood sugar. All of this is pointing to an obvious conclusion that maintaining “normal” blood sugar is a great way to reduce risk of heart disease. So how do we do that?
I will give you a hint of what not to do: What do you give a diabetic patient with low blood sugar if they don’t quite need D50? That’s right, orange juice, or milk. Add some “heart healthy” Honey Nut Cheerios and you have an American Diabetic Association (ADA) recommended breakfast.
The next question has to be what is normal blood sugar? But first we need to cover the three common ways it is tested and to do that I will quote Chris Kressor.
Fasting blood glucose
This is still the most common marker used in clinical settings, and is often the only one that gets tested. The fasting blood glucose (FBG) test measures the concentration of glucose in the blood after an 8-12 hour fast. It only tells us how blood sugar behaves in a fasting state. It tells us very little about how your blood sugar responds to the food you eat.
Up until 1998, the ADA defined FBG levels above 140 mg/dL as diabetic. In 1998, in a temporary moment of near-sanity, they lowered it to 126 mg/dL. (Forgive me for being skeptical about their motivations; normally when these targets are lowered, it’s to sell more drugs – not make people healthier.) They also set the upward limit of normal blood sugar at 99 mg/dL. Anything above that – but below 126 mg/dL – is considered “pre-diabetic”, or “impaired glucose tolerance” (IGT).
Oral glucose tolerance test (OGTT)
The OGTT measures first and second stage insulin response to glucose. Here’s how it works. You fast and then you’re given 75 grams of glucose dissolved in water. Then they test your blood sugar one and two hours after. If your blood sugar is >140 mg/dL two hours later, you have pre-diabetes. If it’s >199 mg/dL two hours later, you’ve got full-blown diabetes.
Hemoglobin A1c
Hemoglobin A1c, or A1c for short, has become more popular amongst practitioners in the past decade. It’s used to measure blood glucose in large population-based studies because it’s significantly cheaper than the OGTT test.
A1c measures how much glucose becomes permanently bonded (glycated) to hemoglobin in red blood cells. In layperson’s terms, this test is a rough measure of average blood sugar over the previous three months. The higher your blood sugar has been over the past three months, the more likely it is that glucose (sugar) is permanently bonded to hemoglobin.
The “normal” range for A1c for most labs is between 4% and 6%. (A1c is expressed in percentage terms because it’s measuring the percentage of hemoglobin that is bonded to sugar.) Most often I see 5.7% as the cutoff used.
Each of these metrics has its own problems and inaccuracies but the underlying issue is that lab values are set by people and are innately arbitrary. For instance, in the OGTT if your 2 hour test number comes back at 139mg/dl you are good to go, no diabetes here. Why? Because you tested one point under the cutoff. This might be ok if the arbitrary cutoffs were set at a very conservative number where there was little chance of the patent having diabetic symptoms. Unfortunately this is not the case. The original numbers were set by a committee in 1978 who was tasked with determining a black and white line in the sand when in came to diagnosing diabetes. The reason being that, at the time, it was very difficult for people to get health and life insurance if they had been diagnosed with diabetes because the current pharmacological therapies weren’t effective. This led the group to set the cutoff so high that anyone who hit it was sure to be very much diabetic with little hope recovery. The ADA reviewed the literature again in 1998 and made a few slight adjustments to FBG values setting the new normal at <126mg/dl. Unfortunately they left out the part that shows a near doubling of heart disease risk between FBG levels of <100mg/dl and 110mg/dl.
So if you get blood work done that includes a standard lipid and metabolic panel and the values all read “normal” except for a slightly elevated FBG, circa 101mg/dl, odds are you are at significant risk for heart disease and no one will catch it.
What to do what to do?
It is pretty clear in the literature that keeping you blood sugar under 140mg/dl at all times is imperative. Even short duration exposure to that amount of circulating sugar can cause permanent damage to the body. So how do you know if you hit 140? Should you just eat very low carb all the time and hope for the best? That’s one way but what we in the fire service might find is that even with a low carb diet our blood sugar regulation gets knocked out of whack all the time by sleep deprivation, chronic and acute stress, significant exposure to toxins, and so on. I think it is important to take charge of our own future and in this case we have a cheap and easy tool to help us keep tabs on our blood sugar. Enter the glucometer. Whether you have one on the engine or you go buy one from Walmart get your hands on one of these and follow the protocol laid out below.
Step one: test your blood sugar
- 1. Test your blood sugar first thing in the morning after fasting for at least 12 hours. Drink a little bit of water just after rising, but don’t eat anything or exercise before the test. This is your fasting blood sugar level.
- 2. Test your blood sugar again just before lunch.
- 3. Eat your typical lunch. Do not eat anything for the next three hours.
- 4. Test your blood sugar one hour after lunch.
- 5. Test your blood sugar two hours after lunch.
- 6. Test your blood sugar three hours after lunch.
Record the results, along with what you ate for lunch. Do this for two days. This will tell you how the foods you normally eat affect your blood sugar levels.
On the third day, you’re going to do it a little differently. On step 3, instead of eating your typical lunch, you’re going to eat 60 – 70 grams of fast acting carbohydrate. A large (8 oz) boiled potato or a cup of cooked white rice will do. For the purposes of this test only, avoid eating any fat with your rice or potato because it will slow down the absorption of glucose.
Then follow steps 4-6 as described above, and record your results.
Step two: interpret your results
If you recall from the last article, healthy targets for blood sugar according to the scientific literature are as follows:
| Marker | Ideal* |
| Fasting blood glucose (mg/dL) | <86 |
| OGGT / post-meal (mg/dL after 1 hour) | <140 |
| OGGT / post-meal (mg/dL after 2 hours) | <120 |
| OGGT / post-meal (mg/dL after 3 hours) | Back to baseline |
| Hemoglobin A1c (%) | <5.3 |
Hemoglobin A1c doesn’t apply here because you can’t test it using a glucometer. We’re concerned with the fasting blood sugar reading, and more importantly, the 1- and 2-hour post-meal readings.
The goal is to make sure your blood sugar never rises higher than 140 mg/dL an hour after a meal, drops below 120 mg/dL two hours after a meal, and returns to baseline (i.e. what it was before you ate) by three hours after a meal.
There are a few caveats to this kind of testing. First, even reliable glucometers have about a 10% margin of error. You need to take that into account when you interpret your results. A reading of 100 mg/dL could be anything between 90 mg/dL and 110 mg/dL if you had it tested in a lab. This is okay, because what we’re doing here is trying to identify patterns – not nit-pick over specific readings.
Second, if you normally eat low-carb (less than 75g/d), your post-meal readings on the third day following the simple carbohydrate (rice or potato) challenge will be abnormally high. That’s why your doctor would tell you to eat at least 150g/d of carbs for three days before an OGTT if you were having that test done in a lab.
If you’ve been eating low-carb for at least a couple of months before doing the carbohydrate challenge on day three of the test, you can subtract 10 mg/dL from your 1- and 2-hour readings. This will give you a rough estimate of what your results would be like had you eaten more carbohydrates in the days and weeks leading up to the test. It’s not precise, but it is probably accurate enough for this kind of testing.
Step three: take action (if necessary)
So what if your numbers are higher than the guidelines above? Well, that means you have impaired glucose tolerance. The higher your numbers are, the further along you are on that spectrum. If you are going above 180 mg/dL after one hour, I’d recommend getting some help – especially if you’re already on a carb-restricted diet. It’s possible to bring numbers that high down with dietary changes alone, but other possible causes of such high blood sugar (beta cell destruction, autoimmunity, etc.) should be ruled out.
If your numbers are only moderately elevated, it’s time to make some dietary changes. In particular, eating fewer carbs and more fat. Most people get enough protein and don’t need to adjust that.
And the beauty of the glucometer testing is that you don’t need to rely on someone else’s idea of how much (or what type of) carbohydrate you can eat. The glucometer will tell you. If you eat a bowl of strawberries and it spikes your blood sugar to 160 mg/dL an hour later, sorry to say, no strawberries for you. (Though you should try eating them with full-fat cream before you give up!) Likewise, if you’ve been told you can’t eat sweet potatoes because they have too much carbohydrate, but you eat one with butter and your blood sugar stays below 140 mg/dL after an hour, they’re probably safe for you. Of course if you’re trying to lose weight, you may need to avoid them anyways.
You can continue to periodically test your blood sugar this way to see how you’re progressing. You’ll probably notice that many other factors – like stress, lack of sleep and certain medications – affect your blood sugar. In any case, the glucometer is one of your most powerful tools for preventing degenerative disease and promoting optimal function.
If you are fascinated by all this blood sugar talk check out the following links:
http://chriskresser.com/category/health-conditions/diabesity
Salt Part III
The 3rd installment of Chris Kresser’s salt myth…
In my last two articles, I discussed the history of salt in the human diet and the physiological need for salt. Many proponents of the Paleo diet suggest limiting salt based on evidence of low salt intake during the Paleolithic era. This limitation meshes with recommendations made by various health organizations, such as the USDA and the American Heart Association, who suggest limiting sodium to at least 2,300 mg per day and even as little as 1,500 mg per day. (1, 2) And if our Paleolithic ancestors ate a low salt diet, then it certainly must be healthy, right?
Robb Wolf on sleepy firefighters and diabetes
Check it…
This video is part of a series that talks about the nuts and bolts of heart disease in Firefighters and Cops. I could rewrite the entire scenario but instead I will post an excerpt and throw Robb a bone by linking the rest of the article and sending all 15 of my readers to his site.
“If a police officer, fire fighter or similar city worker has some kind of major medical event while on duty, the state of Nevada considers that a workman’s comp issue. Dealing with the initial medical expenses can run upwards of $1 million while the medical claims to retire that same individual average $1.2 million. That is a serious chunk-o-change out of the city coffers to say nothing of the trauma experienced by the person who suffered this event, their families, co-workers etc. These events were not unique to UNLV. Anyone in the police/fire scene was well aware of the health of our service personnel and knew something should be done to help these people. I want to get this story on video and include the key players to describe their part in this story, so I’m just going to supply a 30,000 ft over flight for now.”
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