Like Joe, most people have never heard of Syndrome X, but they certainly need to. Dr. Gerald Reavens, a physician and professor at Stanford University, chose the term to describe a constellation of problems that have a common cause:
insulin resistance. Through medical research, Dr. Reavens estimates that more than 80 million adult Americans have Syndrome X.
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Let’s take a moment to look at the common cause of Syndrome X, the body’s developed resistance against insulin.
What Is Insulin Resistance?
Americans are infatuated with a high-carbohydrate, low-fat diet, although in truth, most Americans eat a high- carbohydrate and high-fat diet. Over the years our diet has taken its toll, and many of us have become less and less sensitive to our own insulin as a result. Insulin is basically a storage hormone that drives sugar into the cell to be utilized or stored as fat. The body desires to control our blood sugars. Therefore, when the body becomes less sensitive to its own insulin, it compensates by making more insulin. In other words our bodies respond to increasing blood sugar levels by forcing the beta cells of the pancreas to produce more insulin in order to control our blood sugars.
Individuals with insulin resistance need more and more insulin as the years go by to keep their blood sugars normal.
Although these elevated insulin levels (hyperinsulinemia) are effective in controlling our blood sugars, they also may lead to some serious health problems. Below is a list of harmful effects elevated insulin levels cause. These are the problems that constitute what Dr. Gerald Reavens has labeled Syndrome X:
• significant inflammation of the arteries, which can cause heart attack and stroke
• elevated blood pressure (hypertension)
• elevated triglycerides—the other fat in the blood beside cholesterol
• lowered HDL (good) cholesterol • increased LDL (bad) cholesterol
• increased tendency to form blood clots
• development of significant “uncontrolled” weight gain—usually around the middle (called central obesity) When all of the Syndrome X factors are combined, our risk of developing heart disease actually jumps twentyfold.
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Considering the fact the heart disease is the number-one killer in the industrialized world today, we cannot afford to disregard a growing risk of developing it!
After patients have had Syndrome X for several years (maybe even ten to twenty), the beta cells of the pancreas simply wear out and can no longer produce such high levels of insulin. At this point insulin levels begin to drop and blood sugars begin to rise.
At first only mild elevations of blood sugar may develop, which is known as glucose intolerance (or preclinical diabetes).
More than 24 million people in the United States are at this stage of glucose intolerance.
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Then, usually within a year or two, if no change in lifestyle occurs, full-blown diabetes mellitus will develop. The aging of the arteries then accelerates even faster as blood sugars begin to steadily rise.
What Is the Cause of Insulin Resistance?
Several theories suggest reasons why we become less and less sensitive to our insulin over the years. But I truly believe insulin resistance is the result of the Western diet. Though we focus heavily on cutting back on fats, our love affair with carbohydrates continues. What many Americans don’t fully realize is that carbohydrates are simply long chains of sugar that the body absorbs at various rates. Did you know white bread, white flour, pasta, rice, and potatoes release their sugars into the bloodstream even faster than table sugar? It’s true. This is why such foods are called high-glycemic.
On the other hand foods such as green beans, brussels sprouts, tomatoes, apples, and oranges release their sugars into the bloodstream much more slowly and are therefore considered low-glycemic foods.
Our nation tends to eat far too many high-glycemic foods, which in turn causes blood sugars to rise very rapidly and stimulates the release of insulin. When our blood sugar drops, we feel hungry. So we grab a snack or eat a big meal, and the whole process starts all over again. After a period of time, the release of insulin has been overstimulated so often that our bodies simply become less and less sensitive to it. In order for the body to control the blood sugar levels, the pancreas needs to put out higher levels of insulin. It is these elevated levels of insulin that cause the destructive metabolic changes associated with Syndrome X.
How Do You Know If You Have Syndrome X?
Most physicians do not routinely request blood insulin levels for their patients. But there is a simple (although indirect) way to see if you may be developing Syndrome X or insulin resistance. When your blood is tested you will routinely get a lipid profile, which includes the levels of total cholesterol, HDL (good) cholesterol, the LDL (bad) cholesterol, and triglycerides (the other fat in the blood). Most everyone is familiar with the ratio you obtain by dividing the total cholesterol by the HDL cholesterol. But if you divide the triglyceride level by the HDL cholesterol, the ratio you get is an indication of whether you are developing the syndrome. If this ratio is greater than two, you may be starting to develop Syndrome X. Also, if you notice that your blood pressure or that your waistline is increasing, it is even more likely that you are developing a serious case of Syndrome X.
Here’s an example of how to do this simple test. Let’s say your triglyceride level is 210 and your HDL cholesterol level is 30. Dividing 210 by 30 equals a ratio of 7. Since this is definitely greater than a ratio of 2, you would conclude you have early signs of insulin resistance or Syndrome X.
As soon as a person begins developing insulin resistance, his physician should recommend and support lifestyle changes, because, as I pointed out earlier, this is when cardiovascular damage really begins. Therefore, physicians need to be readily aware of the early signs of developing insulin resistance via the triglycerides/HDL cholesterol ratio. Insulin resistance is totally reversible at this point. We must never be content to wait until a person becomes fully diabetic before treating him.
When a patient treats his insulin resistance with simple but effective lifestyle changes, not only does he prevent accelerated damage to the arteries, but he also avoids diabetes itself. This is true preventive medicine. A healthier lifestyle, not the drugs we prescribe, will make the difference.
Without question, I believe that doctors have overdepended on medication to treat diabetes. Most physicians would agree that diet and exercise can help patients with diabetes, but we simply do not invest enough time in helping them understand that changing those very habits is the best offense against the devastating complications of the disease.
I realize it is much easier to write a prescription than to educate and motivate patients to make key changes in exercise and nutrition. But diabetes would be so much better controlled if we did not depend so heavily on meds. Even the representatives of the drug companies who visit my office agree that a high-fiber diet that includes low-glycemic foods is very effective. But they always maintain that patients usually will not make such changes in their diet and therefore must have medication.
This is not what I see. In my practice the majority of patients would rather make lifestyle changes than take more medication, though much depends on the doctor’s attitude and approach. Consistently, when I take the time to explain
all of this to patients and then ask them what they would like to do, more than 90 percent respond that they would rather try lifestyle adaptations first.
Joe can show us how this works.
How Joe Whipped Syndrome X
Joe was very concerned about his lab results and so he felt motivated to immediately change his lifestyle. We placed him on a modest exercise program, a low-glycemic diet, and a regimen of antioxidant and mineral supplementation. I repeated Joe’s blood work twelve weeks later and documented amazing improvement: his cholesterol level dropped from 250 to 150, his HDL cholesterol increased 10 points to 41, and his triglyceride level plummeted from 1,208 to 102. His triglyceride/HDL ratio had decreased from 40 to 2.5. Joe accomplished all of this without any medication and within just twelve weeks. Both he and I were thrilled.
If you are in a health predicament like Joe’s, you can achieve a similar outcome with the same commitment to lifestyle and eating adjustments. Syndrome X and its deadly ramifications can be beat.
Now let’s turn our attention to the progressed development of diabetes and how to reverse its devastating effect on our bodies.
Diagnosis and Monitoring of Diabetes Mellitus
The most common screening technique for diabetes is a fasting blood sugar test like the one I gave Joe. Physicians also use a sugar-challenge test, in which an individual is given a sugar load (a pop-like drink that is loaded with sugar), and then takes a blood sugar level test two hours later.
Most physicians believe that a two-hour blood sugar above 190 (definitely above 200) is the level needed to diagnose diabetes. A normal two-hour blood sugar level should be less than 110 and definitely less than 130. (Patients who have a slightly elevated fasting blood sugar and a two-hour blood sugar between 130 and 190 are classified as having glucose intolerance—preclinical diabetes—and not actual diabetes.)
Since a blood sugar measurement indicates only how a patient is doing at a particular moment, another helpful test is a hemoglobin A1C, which reveals the amount of sugar found in a red blood cell. (I like to have a patient with diabetes or diabetic tendencies have this test done every four to six months.) Since our red blood cells remain in the body for approximately 140 days, this test is a great indicator of how well a patient is truly controlling his or her diabetes. The normal range for a hemoglobin A1C in most labs is 3.5 to 5.7.
The goal for a diabetic is to keep tight control so that the hemoglobin A1C remains below 6.5 percent. When patients are able to do this, their risk of developing a secondary complication is less than 3 percent. But if they maintain a hemoglobin A1C of greater than 9 percent, their risk of developing a secondary complication related to diabetes jumps to 60 percent.
This comes as a shock, especially in light of the fact that the average treated diabetic in the United States maintains a hemoglobin A1C of 9.2. Needless to say, this is not a great endorsement for our health-care system when it comes to diabetes.
Of greater concern is the fact that at the time of actual diagnosis of diabetes by a physician, a majority (more than 60 percent) of these patients already have major cardiovascular disease.
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This puts the patient at a disadvantage before he even starts treatment. You see, once insulin resistance begins, the process of atherosclerosis ( hardening of the arteries) accelerates dramatically. This is why it is critical for physicians to recognize Syndrome X in their patients as soon as possible and encourage lifestyle changes that can correct the problem.
A patient may have Syndrome X many years before he truly becomes diabetic. By this time treatment to reverse damage is simply too late.
Obesity
All of us have heard the media and physicians claim that the reason diabetes is becoming epidemic in the United States and the industrialized world is because so many people are developing obesity. This is really not the case. The media has put the cart before the horse, so to speak. Insulin resistance (Syndrome X) leads to central obesity, not the other way around. In fact obesity is a major aspect of this syndrome.
What do I mean by central obesity? This has to do with how your weight is distributed in your body. If it is evenly dispersed all over or you are heavy in the bottom (pear-shaped), you may need to drop some weight, but in relation to Syndrome X, you are fine. But if you have gained substantial weight around your waistline (are apple-shaped), you may be in trouble.
I have had many patients in their late twenties or early thirties come into my office complaining that they are gaining a significant amount of weight. What bothers them is the fact that their eating habits and activity level have not changed, but they’ve put on thirty to forty pounds in the past two or three years. Why are they gaining so much? Typically it is because the patient has developed a resistance to insulin. These patients have begun various diet programs but were not able to lose much weight. Such diets are essentially high-carbohydrate, low-fat; this makes the insulin resistance only worse. If these people do not correct the underlying problem for their weight gain—insulin resistance—they will not lose weight. How frustrating it must be to keep going back to their support group but never coming close to losing the kind of
weight the others are!
I encourage all of my patients to begin balancing their diet by eating low-glycemic carbohydrates with good protein and good fat (which I’ll explain later in this chapter). When this diet is combined with a modest exercise program and cellular nutrition (chapter 17), the underlying insulin resistance may be corrected. The weight will then start coming off as mysteriously as it came on. My patients are often amazed at how they are losing weight without really even trying. They feel good, and their energy level is remarkable.
Please know that when I say diet, I’m not referring to a fad diet. A fad diet is something that you start with the intention of someday quitting (the sooner, the better!). Instead, I’m talking about a healthy lifestyle that has the side effect of fat loss. I work aggressively with my patients for about twelve weeks so they know exactly how to apply these principles to the way they like to eat. Losing weight is not the answer. Correcting insulin resistance is the key.
Treating Diabetes
All physicians agree that we should first give our patients a chance to improve their diabetes by encouraging them to make effective lifestyle changes. But as I’ve noted, many physicians simply give lip service to such changes while relying heavily on medications to control the disease.
If we are going to make any significant headway in decreasing the number of diabetics, as well as help current diabetics improve control of their disease, two things have to happen. First, we need to pay more attention to insulin resistance, the underlying problem in the overwhelming majority of cases of type 2 diabetes mellitus, and not simply focus on treating blood sugar levels (see box). Second, we need to aggressively encourage lifestyle changes that will improve insulin sensitivity. I strongly believe that in type 2 diabetes mellitus, physicians should rely on medication as a last resort.
Doctors Are Treating the Wrong Thing
In a review article for the Mayo Clinic, Dr. James O’Keefe stated: “Therapeutic efforts in patients with diabetes have focused predominantly on normalizing increased blood sugar levels while often ignoring many of these other modifiable risks, which are caused by the underlying insulin resistance.”
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This accounts, in part, for the fact that 80 percent of diabetics still die of cardiovascular disease.
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I maintain that treatment of the underlying cause of most diabetes, insulin resistance, is a much better way to confront and control diabetes.
Lifestyle Changes Spelled Out
What many people don’t realize is how simple the lifestyle changes are for treating the primary underlying problem in both diabetes mellitus and insulin resistance. We are talking about modest exercise, eating in such a manner as not to spike the blood sugar, and taking some basic nutritional supplements to improve the patient’s sensitivity to his or her own insulin. When you combine all three of these changes, as you saw in Joe’s case, the results are phenomenal.
Let’s look at each of these ingredients in a healthy response to insulin resistance.
Diet
In my opinion too many doctors make major mistakes in the diet they recommend to their diabetic patients. Since the greatest risk for these patients is cardiovascular disease, the American Diabetic Association has remained primarily concerned with the amount of fat in people’s diets. Therefore, the diet the ADA and many dieticians support is a high- carbohydrate, low-fat diet.
Diabetics have religiously followed the ADA’s recommendations for the past thirty-five years. In the mid-seventies, 80 percent of diabetics were dying from cardiovascular disease. And as we enter the new millennium, 80 percent of diabetics are still dying from cardiovascular disease.
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Shouldn’t this warrant some reconsideration of our approach?
Once we understand that we need to treat the underlying resistance to insulin, we recognize that carbohydrates are the main concern. This is contrary to dietitians who believe that “a carbohydrate is a carbohydrate” and that the source does not matter. This thinking completely ignores the glycemic index (the rate at which the body absorbs various carbohydrates and turns them into simple sugar).
Numerous studies demonstrate that some carbohydrates release their sugars more rapidly than others.
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The more complex carbohydrates (ones with a lot of fiber) like beans, cauliflower, brussels sprouts, and apples release their sugars slowly. When these low-glycemic carbohydrates are combined with good proteins and good fats in a balanced meal, the blood sugar does not spike. This is critical in controlling diabetes. If the blood sugar doesn’t rise significantly after a meal—a major factor in diabetic control—there is no problem of having to bring it back down with drugs.
Dr. Walter C. Willett, chief of nutrition and preventive medicine at Harvard Medical School, proposed in his book Eat, Drink, and Be Healthy that we must rethink the food pyramid the USDA recommends. The bottom rung should be low-
glycemic carbohydrates, while high-glycemic foods (white bread, white flour, pasta, rice, and potatoes) belong at the top of the food pyramid with all the sweets.
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Everyone realizes how bad sweets are for diabetics. But few realize that high-glycemic foods raise blood sugar much faster than eating candy does. When I finally convince my diabetic patients to eat low-glycemic carbohydrates combined with good protein and good fat, their diabetic control improves dramatically, and their bodies become more sensitive to their own insulin.
Basic Diet Instruction
The following are good fats, proteins, and carbohydrates. When you combine these in each meal or snack you eat, your blood sugar will not jump to dangerous levels that need controlling.
The best protein and fats come from vegetables and vegetable oils. Avocados, olive oil, nuts, beans, soy, and so on are great sources of protein and contain fats that will actually lower your cholesterol.
The best carbohydrates come from fresh whole fruits and vegetables. Avoid all processed foods. An apple is better than apple juice. Whole grains are essential, and avoiding processed grains is critical in developing a healthy diet for everyone, especially the diabetic.
The next best protein and fats come from fish. Coldwater fish such as mackerel, tuna, salmon, and sardines contain those fats we discussed in chapter 10: omega-3 fatty acids. These fats not only lower cholesterol levels but also decrease the overall inflammation in our bodies.
The next best protein comes from fowl, because the fat of the bird is on the outside and not marbled into the meat. Even though this is saturated fat, by removing the skin from the meat you still can have a very lean protein meal.
Obviously the worst fats and protein come from our red meats and dairy products. If you are going to eat red meat, at least eat the leanest cut you can. You should avoid dairy products except for low-fat cottage cheese, milk, and egg whites.
If you are going to eat eggs, try to get range-fed chicken eggs, which contain omega-3 fatty acids.
Some of the worst fats that you can eat are the trans-fatty acids. These are called rancid fats because they are so harmful to our bodies. Get used to looking at labels and any time you see “partially hydrogenated” anything—don’t buy it.
These are the basic diet instructions I share with my diabetics and my patients who have developed Syndrome X, like Joe.
The focus of this book does not allow me to get into the fine details of the diet I recommend to my patients. For those curious about diets and Syndrome X, I recommend a couple of books: 40-30-30 Fat Burning Nutrition by Gene and Joyce Daoust, and A Week in the Zone by Barry Sears. These straightforward books recommend the 40-30-30 balance: 40%
carbohydrates, 30% protein, and 30% fat—this is the balance of these macronutrients recommended during a meal. I tend to use more of a 50-25-25 ratio in my office, but the principles are the same.
This is not a high-protein meal program like the Adkin’s diet. This is a healthy diet you can continue the rest of your life. If everyone would eat this way, exercise, and take some basic micronutrients, the diabetic epidemic would be nonexistent.
When you eat this way, instead of stimulating the release of insulin, you stimulate the release of the opposite hormone called glucagon. Glucagon utilizes fat, lowers blood pressure, decreases triglycerides and LDL cholesterol, and raises HDL cholesterol. This is eating for hormonal control rather than calorie control. I tell my patients that they are eating a healthy diet that has the side effect of fat loss.
Exercise
Modest exercise has tremendous health benefits. And exercise is especially critical for the patient with Syndrome X or diabetes mellitus. Why? Studies show that exercise makes patients significantly more sensitive to their own insulin and is, therefore, a critical part of the lifestyle change needed for diabetics and those who have insulin resistance.
The exercise program should include a balance of aerobic and weight-resistance exercise done at least three, and not more than five or six, times per week. It is important that people get involved in an exercise program that they enjoy. No one has to become a marathon runner. Even a thirty- to forty-minute brisk walk three times weekly makes a tremendous difference.
Nutritional Supplements
Several clinical trials have found that individuals with preclinical diabetes or impaired glucose tolerance have significantly increased levels of oxidative stress. Often these same people have depleted antioxidant defense systems. Other studies have revealed that oxidative stress was more significant in those with secondary complications of diabetes, such as retinopathy (damage caused by diabetes to the blood vessels in the back of the eye that can lead to blindness) or cardiovascular disease. The researchers conducting these studies concluded that antioxidant supplements should be added to the traditional diabetic treatments as a way to help reduce these complications.
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Several studies have shown that all antioxidants may improve insulin resistance. It is important that a diabetic take a good mixture of several antioxidants in supplementation at optimal—not RDA—levels (see chapter 17). In my research and medical practice, I have learned that several micronutrients are normally deficient in patients with preclinical and full- blown diabetes: