Ivor Cummins is a biochemical engineer with a background in problem solving. Following a disturbing set of clinical test results, Ivor used his skills to determine the root cause of his heart disease risk and turn the situation around. He now gives frequent public presentations to share his findings and talk about their implications for healthcare. Jeffry Gerber is a medical doctor from Denver, Colorado, who has long been interested in nutritional medicine. Known as Denver’s diet doctor, Dr Gerber has spent years treating patients with low carbohydrate diets to improve their metabolic health. This joint talk was given at the Public Health Collaboration conference 2017 in Manchester.

Talking from an engineering standpoint, Ivor goes through his test results that he received from the doctor. His gamma glutamyl transferase (GGT), ferritin and cholesterol levels were all way above the normal range, indicating a serious health risk. By researching the literature, Ivor came to the conclusion that the cholesterol profile was not a major concer, as LDL is not correlated with increased risk of heart disease when HDL is high. Increases in GGT levels, however, are associated with greatly increased risk of heart disease, coronary artery disease and type 2 diabetes. Likewise, increased ferritin levels were associated with increased risk of diseases such as atherosclerosis. Ivor then discovered metabolic syndrome (insulin resistance) which he identified as the root cause of his poor liver metrics. Indeed both GGT and ferritin are also strong markers of metabolic syndrome.

Ivor’s conclusions from his research led him to try a nutritional-only interventio, eliminating exercise, alcohol intake and other confounding variables. He began to eat a low carb diet, restricting starchy and sugary foods whilst keeping healthy fats and greens high. Ivor notes that he passively factored in some intermittent fasting, but only because his appetite was so well-controlled on his new diet. After 8 weeks of following this approach, his GGT and ferritin were back within normal range. In addition, his blood pressure, weight, waist circumference and lipid profile also improved.

Applying his new-found knowledge to a broader setting, Ivor shows how insulin resistance can be thought of as a spectrum, where high insulin resistance contributes to many chronic diseases. He highlights a few important factors, which he calls “levers”, in reducing insulin resistance and promoting metabolic health.

Dr Gerber takes over to give a clinician’s perspective on the topic, beginning by introducing Dr Joseph Kraft’s 5hr insulin assay. This test can be used to diagnose diabetic pathology and is much superior to common tests such as the oral glucose tolerance test (OGTT), which give many false negatives. Since insulin resistance is the underlying issue in metabolic syndrome and diabetes, an inappropriately high insulin response is the best diagnostic. Sadly, this kind of insulin-centric test is seldom used in diabetes diagnosis.

Currently, there seems to be a large disconnect between heart disease and diabetes diagnoses and, as Dr Gerber explains, this is due to neglecting the role metabolic and hormonal disorder. Instead, the focus remains on cholesterol, the victim of the lipid hypothesis, which has actually proven to be a poor biomarker for cardiovascular disease and mortality in general. Atherosclerosis is in fact the body’s attempt to repair damage to the vasculature by inflammation, oxidative stress and advanced glycation end products (AGEs). This implies that cholesterol is present as part of the body’s response to the damage, rather than playing a damaging role itself.

In reality, diabetes and heart disease go hand in hand, to a much greater degree than is currently appreciated. In a 2015 study, Euroaspire IV investigators found, using the OGTT on coronary heart disease sufferers, that two thirds of the supposedly non-diabetic group were in fact diabetic. In addition, if Kraft’s gold-standard 5hr insulin assay had been used, Dr Gerber predicts that the entire ‘non-diabetic’ group would fail it. In fact, Dr Kraft himself said “those with cardiovascular disease not identified with diabetes… are simply undiagnosed”.

It is important to address the underlying metabolic dysregulation underlying both diabetes and cardiovascular disease, when considering treatment. The best way to do this, Dr Gerber explains, is not with medication, but with a low carbohydrate diet and other lifestyle changes.

In addition to treatment, proper diagnosis must also be ensured. For diabetes and underlying metabolic dysregulatio, the OGTT works to a point, but the insulin assay is superior. The best way to measure coronary artery disease directly is the coronary artery calcium (CAC) test. This test scores the level of calcified plaque present in the coronary arteries, and is an excellent marker of heart attack risk, as it measures the disease itself.

Dr Gerber finishes by proposing the cost of healthcare could be massively decreased by appropriate diagnosis of diabetes and heart disease, and treatment of the metabolic dysregulation underlying both of these.

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