Dear friend Quentin,

Good day Quentin. As always you bring new dimensions to my discoveries.
What you have found this time is an article that is easy read for most
of us yet connects most often neglected part of our discussion here:
The effect of diabetes on our heart. Specifically I liked the way the
term "Metabolic Syndrome" was introduced and explained. I have noted
following points that made great sense to me and feel they may appeal
to wider audience here. Do not think this as an effort to jump ahead of
you! Its more t o share with you what I picked up from your wonderful
find of the day!

Point 1:
The two major underlying risk factors for the metabolic syndrome are
obesity and insulin resistance; exacerbating factors are physical
inactivity, advancing age, and endocrine and genetic factors. The
condition is progressive, beginning with borderline risk factors that
eventually progress to categorical risk factors. In many patients, the
metabolic syndrome culminates in type 2 diabetes, which further
increases risk for cardiovascular disease.

Primary treatment of the metabolic syndrome is lifestyle
therapy-weight loss, increased physical activity, and
anti-atherogenic diet.

Point #2:
Insulin resistance can be secondary to obesity but can have genetic
components as well. Several factors further exacerbate the syndrome:
physical inactivity, advancing age, endocrine dysfunction, and genetic
aberrations affecting individual risk factors.
The increasing prevalence of metabolic syndrome in the U.S. and
worldwide, however, seems to be driven largely by more obesity
exacerbated by sedentary lifestyles.

Point #3
In patients with the metabolic syndrome, relative risk for ASCVD ranges
form 1.5 to 3.0 depending on the stage of progression. When diabetes is
not yet present, risk for progression to type 2 diabetes averages about
five-fold increase compared with those without the syndrome. Once
diabetes develops, cardiovascular risk increases even more.

Point #5
First, epidemiological studies strongly suggest that multiple risk
factors raise risk more than the sum of accompanying single risk
factors;[45-48] risk rises geometrically instead of linearly. This
phenomenon is called multiplicative risk.
Second, several metabolic risk factors are not included in standard
risk algorithms; but all of them seemingly impart independent risk for
cardiovascular events. These are a prothrombotic state,[49-51] a
proinflammatory state,[52,53] and elevated triglyceride.[54,55] This
additional risk exceeds that which can be explained by standard risk
factors.
Third, some of the risk attributed to established risk factors (e.g.,
hypertension and low HDL) probably can be accounted for by unmeasured
risk factors. For example, blood pressure-lowering with drugs fails to
reduce risk as much as predicted from epidemiological studies;[56] a
portion of the epidemiological risk attributed to hypertension likely
is subsumed by unmeasured risk factors.
Likewise, the robustness of low HDL to predict ASCVD risk almost
certainly is due in part to the fact that it is a marker for other
metabolic risk factors.[57,58]
And fourth, because metabolic syndrome often progresses and culminates
in type 2 diabetes, the syndrome's long-term risk is underestimated at
any one time.

Point #6
Lifestyle Modification is the Primary Therapy of the Metabolic Syndrome

The ATP III embedded the metabolic syndrome into cholesterol guidelines
to reinforce clinical lifestyle therapies. These therapies consist of
weight reduction, increased physical activity, and an anti-atherogenic
diet; smoking cessation in addition is mandatory. Lifestyle
intervention unfortunately is often neglected in routine practice. It
has the potential to reduce the severity of all metabolic risk factors
at every stage of progression as well as to slow their progression

Drug therapies of established risk factors alone are not sufficient to
completely reverse risk associated with the syndrome (i.e., risk for
either ASCVD or diabetes). Clinical trials consistently show a
substantial residue of risk that cannot be reversed with drugs.[

Lifestyle modifications are one way to cut into this residual risk. In
addition, institution of lifestyle therapies early in the syndrome can
delay risk-factor progress and the need for drug therapies.

Note the point>> Clinical trials consistently show a
                      >>  substantial residue of risk that
                      >> cannot be reversed with drugs.

There is plenty here to feel humble about. But over I felt that making
evry possible effort to stay disciplined is not just a way to deal with
diabetes but may well be the the only way to keep it from encroaching
too fast. Some of us who have been just introduced to this have to
realize that we are indeed in honeymoon period here but length of that
period will much depend on how big a lifestyle change we are going to
accept and how fast!

There is also some thing that this article made me once more aware of.
When one takes statin drugs and prophylaxis drug line aspirin, one
looses the ability to monitor important markers. One can no more use
the LDL/HDL/Trig numbers to find the damage caused by the Metabolic
Syndrome! I can not see hs-CRP level and say my CVD risk is now lower.
Because all I have done is put a duct tape on the meter that tells my
health numbers. Yes I am over simplifying things but at least at the
early stage in this game maxing out lifestyle changes should be allowed
to take its effect before rushing to go for the silver bullets. Don't
you think so?

Anyway I am once again feeling good about the progress I have made but
article like this help me remain focused and acutely aware that my
enemy is far more capable and I will need a rather large reservoir of
mental discipline to truly keep it at bay.

If it is not too much to ask may I once again request all of you to
read the book "The China Study" by T. Campbell. I am sure you can find
it in the local library. Please do not think I am doing it as a favor
to any specific way of thinking. I want all of you to fight the battle
with all the guns you can use. There is no such thing as being over
prepared. But using the right tool for the job will make a big
difference in distance you will travel before you encounter the enemy.

Once again I want to thank you Quentin from the bottom of my heart for
sharing such a wonderful paper.

Wishing you all the best for all finding and using guns you can use!

Anil