It is estimated that only 12% of the US adult population is metabolically healthy (source). Over the last year I have been working to improve the metabolic health of my patients as part of the chronic pain treatment. The success has been variable, but I have seen dramatic results in some patients.
Recently I started to read the book “Metabolical” by Robert Lustig. This book contains some errors and his style might not be for everyone, but overall it is an excellent resource for understanding metabolic health. He proposes eight molecular pathways that can be altered in metabolic diseases:
1. Glycation - determined by glucose level
2. Oxidative stress
3. Mitochondrial dysfunction
4. Insulin resistance
5. Membrane Integrity
6. Inflammation
7. Epigenetics
8. Autophagy
In our clinical practice we cannot easily assess the molecular pathways, but we can get some idea from the vital signs and lab work. I recommend everybody to be involved in their own care because that is the only way to understand the significance of metabolic health.
Labs:
- Lipid profile (LDL-C, HDL-C, Triglycerides). The one I look at first is the triglycerides. The goal should be below 150 mg/dl (even better if under 100). Most common causes of increased triglycerides are sugar/fructose and alcohol. LDL cholesterol (the so called bad cholesterol) is a complicated topic because there are different types of LDL and these are not assessed on the regular labs.
- Homocysteine level – high levels (over 15) might be due to folic acid deficiency
- Alanine aminotransferase and aspartate aminotransferase (ALT and AST). ALT needs to be below 25. If ALT is elevated then we need to measure GGT. If GGT is over 35 then likely there is a need for liver ultrasound to assess the liver fat. Fatty liver can lead to NASH (nonalcoholic steatohepatitis) which is the leading cause of liver transplant in US. Sadly, the children have fatty liver at alarming levels: one study estimated that about 1 in 4 obese children has fatty liver disease (source). Other studies put the prevalence of fatty liver at even higher levels in obese children.
- Uric acid – goal is below 5.5. This podcast episode is a really good discussion about uric acid.
- Fasting insulin – if above 15 microunits/ml then insulin resistance. Obesity is the most common cause of insulin resistance.
- Fasting glucose
- Hemoglobin A1c – aim for close to 5%. The medical system has decided that hemoglobin A1C of 7% is good enough, but this is far from optimal. The goal of 7% was chosen because it is really difficult to safely decrease hemoglobin A1C to normal levels with medications. The only way to normalize hemoglobin A1C is diet.