Prevent and Reverse Metabolic Syndrome & Heart Disease. Vikram Raya MD FACC August 2015 Cardiology - ACP Costa Rica

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1 Prevent and Reverse Metabolic Syndrome & Heart Disease Vikram Raya MD FACC August 2015 Cardiology - ACP Costa Rica

2 Acknowledgements Institute for Functional Medicine ACP Costa Rica

3 To dispose a soul to action we must upset its equilibrium - Eric Hoffer

4 Discussion Points CVD COSTA RICA METABOLIC SYNDROME ENDOTHELIAL DYSFUNCTION ATHEROSCLEROSIS/INFLAMAT ION LAB TESTING MEDITERRANEAN DIET CV REVERSAL/RISK REDUCTION STRATEGIES

5 Obesity Adult Prevalence Rate - United States 18th (33%) - Canada is 48th (26.20%) - Costa Rica is 73rd with (23.70%) 2008 World CIA Factbook

6 STROK E LIVER DISEASE DIABETES Colon Breast Prosta te CANCE R HEART DISEASE ARTHRI TIS

7 Heart Disease is an Issue in Costa Rica

10 METABOLIC SYNDROME

11 ENDOTHELIAL DYSFUNCTION

13 Endothelial Injury and Inflammatory Response in Atherogenesis Endothelial Thinning/Injury Exposure of Foam Cells to Blood Macrophage Foam Cell/Plt Interact Fibroproliferative lesion Mature Atherosclerosis Plaque Rupture of Fibrous Cap Coronary Thrombosis

14 3 stages of Atherosclerosis Decades of long immunoinflammatory signaling and damage Fatty Streak Fibrous Plaque (fibroatheroma) Complex Thrombosis- Prone Plaque.

15 Atherosclerosis Initially a disease of the vessel wall NOT A DISEASE OF THE VASCULAR LUMEN Not until late stages does obstructive CAD occur

17 Fatty streaks present in 50% of children age on Autopsy

18 Location of Atherosclerosis Primary atherosclerotic site is usually at arterial bifurcations, branch points. Laminar flow is interrupted and immuno-inflammatory process that starts at these lesion-prone areas with a dysfunctional endothelium

20 Testing/Diagnostics

22 HIDDEN RISK

23 Established and Emerging Biomarkers Measurements: WC, WHR, %Body Fat Analysis Glucose and Insulin: A1cPre-DM , DM > 6.5 OGTT FBG (Pre-DM) > 125 (DM) Fasting Insulin < 17microunits/L Metabolic: Adiponectin/Leptin/AST/ALT Other Labs: CBC, Ferritin, Homocysteine, FIbrinogen, 25 OH Vitamin D3 Lipid Profile/Lipoprotein Profile TG/HDL Ratio (< 3.0 Normal, >3.0 Insulin Resistance) Apo B, HDL, Apo A1 LDL Particle Size Vascular Inflammation LpPLA2(PLAC) HS-CRP IL-6, IL-17, TNF alpha)

25 TRIGS + WC - MI RISK BIOMARKER Logitudinal crosssectional studies suggest that high TG along with WC was associated with angiographic CAD. Elevated TG levels > 150 also associated with MI and CVA NHANES III. Miller. M et al. Circulation April 2011

26 Etiologies for hs-crp Correct underlying Cause DIET (sugars, trans/sat Fats, insufficient fruits/vegetables) OSA Stress Lack of Exercise Toxins & Heavy Metals Infections (Dental) Obesity/Metabolic Syndrome/Vascular Inflammation

27 LDL and HDL Driving LDL down, decreases risk of inflammation, oxidation HDL decreases inflammation and number of cells in plaque reducing risk of rupture Human infants, primates, Hunter-Gatherer ancestors, Aboriginals have a LDL-C of 60 mg/dl Statins and novel anti-lipid agents we can achieve reductions to 60 mg/dl > 60 LDL shows progressive loss of NO and endothelial dysfunction in clinical animal and human trials Mayo Clinic Proc. 2011: 86;162 Lancet 2005: 366; 1267

Detecting At Risk Individuals Offers Oppo Many of the victims of coronary heart disease who are apparently healthy die suddenly without prior

32 Detecting At Risk Individuals Offers Oppo Many of the victims of coronary heart disease who are apparently healthy die suddenly without prior symptoms. 1 Identification of vulnerable patients, subjects with a high likelihood of develo Naghavi M, et al. Circulation. 2003; 108:

33 Hippocrates 400 BC

36 Fiber Intake and CVD Hispanic Americans 18.8 g Whites 16.3 g Blacks 13.1 g Increased Fiber results in reduced LDL-C Recommended intake is g/day

HALE STUDY The Healthy Aging: a Longitudinal

aged 70-90 years, adherence to a Mediterranean

50% lower rate of all causes and cause-specific

43 HALE STUDY The Healthy Aging: a Longitudinal study in Europe 7 Country Study Among individual aged years, adherence to a Mediterranean diet and healthy lifestyle is associated with > 50% lower rate of all causes and cause-specific mortality. Knoops et al. JAMA. 2004;292(12):

44 PLANT BASED DIETS

45 Plant Based Diet: BP/LDL Fruit and Vegetable intake is associated with lower BP Evidence for increased Fruit/Vegetable consumption decreasing LDL levels Effect is due to soluble fiber and plant-based sterols

49 Regression of CAD: Role of Statins

50 EPIC TRIAL: CV Risk Reduction 300,000 + participants of which 44,561 patients vegetarians Lower BMI, non-hdl cholesterol, SBP 32% lower risk for ischemic HD. 3 portions vs 8 portions Vegetables/Fruits 22% CV risk reduction (4% lower risk per portion-80grams) Crowe et al, EPIC

51 Thought Leader in Reversing Heart Disease DEAN ORNISH MD

52 Ornish Program for Reversing Heart Disease Medicare approved program in several states in US 4 elements: nutrition, exercise, stress management, and group support in 2011, 4000 pts with CVD adherence of 88% Weight 16 lbs in 1yr SBP, DBP, TC, Trigs, LDL major reductions Exercise Capacity 8.7 METS to 10.8 METS (24% in 1yr) A1c 7.4 to 6.8 in 1yr 97% reduction in severity of angina

53 Exercise

55 Exercise Benefits Each additional healthy lifestyle factor decreased cardiometabolic risk by 31% Compared to those with 0-1 Healthy lifestyle factors, 5-6 factors conferred 70% lower cardiometabolic risk HEALTHY LIFESTYLE FACTORS Fruits/Vegetables > 5/d Meat Intake < 2/d Never smoked 2-6 drinks alcohol TV < 2 hrs/d moderate to vigorous physical activity > 4h/wk Shi L et al. BR J Nutr 2011:1-7

57 Exercise Recommendations ACSM - moderate intensity Health Benefits - 30 min x 5 days = 150 min/wk Reversing CHD - 50 min x 6 days =300 min /wk PHASE 1: Initially walking program 20 min 3 x week PHASE 2: Cardio (5 d/wk), Strength (2-3d/wk), Flexibility (2d/wk) PHASE 3: Cross Train with HIT and start gauging PVO2 - oxygen consumption American College of Sports Medicine 2011 Position Statement

58 Sleep & Circadian Rhythm Disorders of sleep and circadian rhythm: increased hunger, decreased glucose and lipid metabolism broad changes satiety hormones Maury E, et al. Circ Res 2010; 106 (3):

59 Sleep Hygiene Target: 7-9 hours per night 15 min bedtime relaxation ritual Sleep duration and efficiency: Magnesium 200 mg TID Sleep Initiation: 1-3 mg Melatonin Sleep Maintenance: Valerian root + lemon Balm

60 Sleep Apnea and Heart Disease HTN (50% increased risk with OSA) AFIB (4 times risk with OSA) CAD/MI (70% of Heart disease have OSA) CHF (triggered by OSA) WHY??? Apneic episodes > Hypoxia > LV strain > Cardiomegaly/CHF & microvascular angina

61 Stress Reduction Non Moving: Meditation/Prayer Deep Breathing Guided Imagery/Hypnosis Biofeedback Spa/Sauna Moving: Yoga Tai Chi/Qi Gong Exercise Dance

Role of Behavioral Coaching Medium and High intensity diet and physical activity behavioral counseling in overweight/obese persons with CVD risk factors is

62 Role of Behavioral Coaching Medium and High intensity diet and physical activity behavioral counseling in overweight/obese persons with CVD risk factors is critical Effective in making small but effective changes (diet and exercise) resulting in decreased lipids, BP, FBG, Diabetes incidence and weight after mo

63 Make time for health otherwise you will make time for disease...

64 Supplements Vitamin D: Check levels, goal >50, Supplement as appropriate IU daily CoQ10: mg/daily; metabolic syndrome, CHF, CAD, statin myopathy, DM, HTN EPA/DHA: 1 gm daily for CVD prevention

68 TAKE HOME POINTS Obesity and CVD are emerging issues in Costa Rican Healthcare Endothelial dysfunction is a precursor to CV Disease Physical exam and Constellation of diagnoses constitute Metabolic syndrome a dangerous driver of CVD Treat in a system based approach with advanced labs and diagnostics, Exercise, Sleep, Nutrition Choose a Medierranean Style Diet - such as the Cardiomeatobic Food plan to prevent & reverse CVD Coronary disease reversal is possible, plant based diet is recommended

70 Gracias

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