Parts 1 and 2 appeared in FloridaMD October and November issues
1. Elevated Blood Lipids
The National Institutes of Health (NIH), specifically the National Heart, Lung, and Blood Institute (NHLBI) is responsible for the administration and direction of the National Cholesterol Education Program. A number of years ago,
the NHLBI convened a panel of experts which was referred to as the Adult Treatment Panel (ATP III). The charge for the panel was to develop and publish a consensus document which was called the ATP III Guidelines. This was actually published in May 2001 as NIH Publication No. 01-3305.
This publication, to this day, is the most complete treatise of Blood Lipids ever presented. However, it should be acknowledged that challenges and even changes to the ATP III Guidelines have been made and are even in-progress as this Booklet is written. However, from the prospective of practical preventive medicine, the challenges and changes are minimal. For that reason, the authors have elected to use the ATP III Guidelines for this Booklet and inform the readership of said challenges and changes; we are steadfast in the belief that without an understanding of the initial ATP III Guidelines to enter the debate unarmed, would not be helpful.
The treatment of blood lipids as a risk factor for coronary heart disease and cardiovascular disease in general is clearly complex. This complexity serves to prove and underline the importance of this risk factor, of which its importance and manipulation is still evolving. In the remainder of this section you will find Table 4 which is titled – Understanding, Evaluating, and Managing Blood Lipids. The table is constructed from ATP III. It is intended to give patients a glimpse of Blood Lipids and perhaps provide helpful information to physicians who do not deal in this arena on a daily basis. Anyone desiring to know the very latest should contact the NIH and other sources for the latest guidelines and drug information.
In Appendix 3 of this Booklet you will find in electronic format ATP III Guidelines At-A-Glance, which is the Quick Desk Reference distributed by the NIH National Cholesterol Education Program.
Before closing this Section there is one final word. There are individuals that present with severe atherosclerosis, even heart attack and stroke, without obvious cardiovascular risk factors. When this occurs, abnormal lipids may be the reason. Therefore, in this setting, a more complete Lipid Analysis than presented in Table 4 is indicated.
In less than 1 hour, an individual in the United States with access to the Internet could easily identify 50 different diets promoted by individuals, public organizations, and commercial firms. Despite this array of potential opportunities, two statements can be made without fear of contradiction: (i) obesity is a serious cardiovascular risk factor and (ii) obesity is literally at epidemic proportions in the United States and many countries in the developed world. The term “epidemic” is formally defined as an abnormal increase in disease occurrence and is also related to timing of the process. Our numbers clearly suggest that over 25% of individuals with atherosclerosis have associated obesity.
The cost to society of obesity is so large as to be extremely difficult to measure, further, the process has been long-standing. The following short section, identified by dashes, is the Forward extracted from a major Guideline document sponsored by the National Institutes of Health (NILBI). The entire document is 110 pages long and is very comprehensive.
In June 1998, the Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Evidence Report was released by the National Heart, Lung, and Blood Institute’s (NHLBI) Obesity Education Initiative in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The impetus behind the clinical practice guidelines was the increasing prevalence of overweight and obesity in the United States and the need to alert practitioners to accompanying health risks.
The Expert Panel that developed the guidelines consisted of 24 experts, 8 ex-officio members, and a consultant methodologist representing the fields of primary care, clinical nutrition, exercise physiology, psychology, physiology, and pulmonary disease. The guidelines were endorsed by representatives of the Coordinating Committees of the National Cholesterol Education Program and the National High Blood Pressure Education Program, the North American Association for the Study of Obesity, and the NIDDK National Task Force on the Prevention and Treatment of Obesity.
This Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults is largely based on the evidence report prepared by the Expert Panel and describes how health care practitioners can provide their patients with the direction and support needed to effectively lose weight and keep it off. It provides the basic tools needed to appropriately assess and manage overweight and obesity. The guide includes practical information on dietary therapy, physical activity, and behavior therapy, while also providing guidance on the appropriate use of pharmacotherapy and surgery as treatment options.
The Guide was prepared by a working group convened by the North American Association for the Study of Obesity and the National Heart, Lung, and Blood Institute. Three members of the American Society for Bariatric Surgery also participated in the working group. Members of the Expert Panel, especially the Panel Chairman, assisted in the review and development of the final product. Special thanks are also due to the 50 representatives of the various disciplines in primary care and others who reviewed the preprint of the document and provided the working group with excellent feedback.
The Practical Guide will be distributed to primary care physicians, nurses, registered dietitians, and nutritionists as well as to other interested health care practitioners. It is our hope that the tools provided here help to complement the skills needed to effectively manage the millions of overweight and obese individuals who are attempting to manage their weight.
David York, Ph.D. Claude Lenfant, M.D.
North American Association National Heart, Lung, for the Study of Obesity and Blood Institute
National Institutes of Health
Appendix 4 is the entire Obesity Guideline document. The remainder of this section will draw on simple facts associated with obesity. While the scope of this section cannot be complete or even considered broad, what is presented will work for the obese individual – if the individual is appropriately motivated.
The caption for Fig. 6 shown above is true; it is very hard to defeat obesity! Consider how difficult it is to eat when you are not feeling well. The reverse is true in obesity – it is very difficult NOT to eat when you are well and used to eating! Every obese individual should read the following steps:
A. How do you know for sure that you need to lose weight?
Fortunately, the answer to this questions is extremely easy. All that is required is the following: (i) an accurate weight scale, (ii) a method to measure height, (iii) a simple calculation (given below), and simple definitions of the one-parameter finding (also given below).
a. Using an accurate scale measure your weight in pounds (lbs). When making this measurement limit your clothing and take-off shoes. Typical weight in lbs for adults ranges from 90 to 300 lbs.
b. Measure your height in inches. This can be done with a tape-measure and a vertical wall. Make the measurement with your shoes off; the measurement is from the bottom of your feet to the top of your head. Typical height in inches for adults ranges from 55 to 75 inches.
c. Investigators have demonstrated for years that the measurement of Body Mass Index (BMI) is both an accurate and simple what to judge the weight distribution of an individual. The measurement takes weight and distributes the weight over height, using the following formula:
W = Weight in lbs / 2.2 In an individual weighting 200 lbs, W = 200 / 2.2 = 90.9
H = Height in inches x 0.0254 In an individual with a Height of 70 inches, H = 70 x 0.0254 = 1.77
BMI = W / H / H For our example, BMI = 90.9 / 1.77 / 1.77 = 29.01
d. With BMI known, please refer to Table 5. This table determines the weight (i.e. level of obesity) as a function of BMI.
B. What is your current Calorie Intake?
Experience and the Laws of Thermodynamics clearly indicate that for an adult individual, without serious underlying disease, to maintain 1 pound of Body Weight, 12 calories are required over a 24 period. If 12 calories are not consumed over a 12 hour period, the body will take energy from internal storage to maintain the individual’s metabolism. To further clarify, if an individual’s weight has been stable over a period of time (i.e. 4 to 6 weeks), by multiplying the individual’s weight in pounds over the preceeding month, times 12 will reveal the individual’s Average Daily Calorie Intake. For example, a 200 pound individual, on average, is consuming 2400 calories per day to maintain the current weight (200 x 12).
For the record, calorie is essentially a measure of heat, actually the heat of components that compose cells. Would you agree that a heated cell, as in the case of a liquid turned into a gas secondary to heating, would occupy more volume than a unheated cell still in the liquid state? Consider that a car radiator actually explodes when its internal heat causes its contents to change from liquid to gas. The same thing happens in the human cell. If the cell is stimulated by excessive calorie intake, cell volume expansion takes place. Please know that as an individual takes on girth, the number of body cells does not increase, they simply experiece volume expansion.
Whereas we know its takes 12 calories over a 24 period to maintain 1 pound of Body Weight, we also know it takes a 3500 Calorie Deficit for an individual to lose 1 pound of Body Weight. Consider this number and concept carefully as it will be used in the next step of this process.
C. What must be done to lose weight?
The answer to this section’s title is relatively easy to understand. The individual, through the combination of reduced Calorie Intake and increased Activity must produce a Calorie Deficit. You were told in the previous section that a 3500 Calorie Deficit will result in the loss of 1 pound of Body Weight. Since a day is a typical period of time to use in this discussion and a week is composed of 7 days, if we take the 3500 Calorie Deficint number and divide it by the number of days in a week, the result is a 500 Calorie Deficit per Day to lost 1 pound of Body Weight in a week. To make this more clear.
If an individual wanted to lose 1 pound in a week, without increasing Activity, and the individual weighed 200 pounds, the individuals Calorie Intake would have to be decreased from 2400 calories per day to 1900 calories per day. If the individual wanted to lose 2 pounds per week, the Calorie Intake would have to be reduced by 1000 calories per day or 1400 calories.
The Summary here is that weight can be lost by reducing Calorie Intake and that a 500 Calorie Deficit will result in 1 pound being lost in 1 week. A safe weight-loss-rate is between 1 pound and 1.5 pounds per week. This is a daily calorie reduction range of 500 to 750 calories.
D. Can increasing Activity hasten weight loss?
The answer to the title of this section is a resounding YES! However, there are clear limitations which must be understood. Many individuals fail to understand the degree to which exercise will hasten weight loss. The first issue is that overweight individuals rarely have been currently active in a formal exercise program and further, are rarely physically able to participate immediately in extensive exercise or other taxing activities. This argues that reducing Calorie Intake initially will take on very significant proportions.
Consider the following, if a standard sized individual walks, jogs, or runs 5 miles, approximately 500 calories were be expended. If an individual played tennis at the professional level for 1 hour, approximtely 1000 calories would be expended. Table 6 illustrates the positioning of Activity versus Food Intake and points out the necessary bias toward reducing Calorie Intake over increasing Activity in successful weight loss programs.
E. Calorie Counting
The odds are good that any individual needing to lose weight has failed at previous attempts. This is another way of saying that the individual is most likely not an expert in weight loss and clearly needs help. Consider an individual that is asked to drive a vehicle from a current location to a city within the same state for which the individual has no idea as to its location. It is quite logical for that individual to seek advice to complete the desired trip. This advice may come in the form of referring to a paper map or performing a MapQuest Search on the Internet. The important point is that to be successful, the non-expert MUST obtain additional information. This is just as true in losing weight. Here the reference is simple – know exactly what the individual is putting in his or her mouth! This is easily determined and learned rapidly by using a book or computer program that displays the relationship between food and calories. Consider in a complex road trip, information source can be used as a constant monitor of success.
Accurately counting calories must be done to be successful and can be accomplished by anyone with a little patience (The Calorie Counter. 6th Edition – Karen J. Nolan, PhD and Jo-Ann Heslin, MA, RD, CDN – Amazon.com – $7.99 or The Complete FOOD Counter. 3rd Edition – Annette B. Natow, PhD and Jo-Ann Leslin, MA, RD, CDN – $7.99).
F. How to set-up your Program
The answer is to follow Table 7 given below.
The individual’s initial weight and BMI are known parameters. The Weight Goal and BMI Goal are inputs. It is suggested that reachable goals be selected. Whereas an individual may need to loss 60 pounds, this could be divided into phases. The first phase must be something the individual is confident can be obtained. Future phases will take care of themselves. For a first phase, do not select a Weight Loss Desired that exceeds 50 pounds and consider the individual’s BMI in selecting the goals.
From the Weight Goal the Weight Loss Desired is easily calculated, by subtracting the Weight Goal from the Weight Initial.
Select a Weight Loss Rate between 1.0 and 1.5 pounds per week. Individuals that select rapid schedules have more difficulty in achieving goals and may experience symptoms secondary to rapid weight loss. The Program Period is determined by dividing the Weight Loss Desired by the Weight Loss Rate per Week.
Please use the following formula to determine Calories Allowed per Day:
Calories Allowed per Day = (Initial Weight x 12) – (Weight Loss Rate per Week x 500)
For Our Example:
Calories Allowed per Day = (200 x 12) – (1.0 x 500) = 2400 – 500 = 1900
The Calories allowed per Day MUST be carefully monitored by CALORIE COUNTING!
When the Goal is reached the individual enters a Mantainance Phase and should adher to the Maximum Calories Allowed per Day, calculated by multiplying the Current Weight by 12. As in the Table 7 example, the Phase 1 Weight Goal is 180 pounds, therefore, the maintainance calorie level is 180 x 12 or 2160 calories per day during maintainance.
Before closing this section, we will leave the readership with an additional fact. Please look up Kleiber’s Law. You will find that Dr. Kleiber in the 1930s studied mammal metabolism. He found that the Metabolic Rate (MR) of mammals extending from mice to whales was related to the Mass (M); mass is weight of the mammal, by the following simple formula (MR ~ M3/4). Using a 200 pound individual and increasing weight in 10 pound increments, the amount of calories, to support that weight gain may be calculated using Kleiber’s Law. Further, the amount of calories to sustain the increasing weight may also be determined (Table 8).
Here is the take-home message from Table 8. Your weight can balloon from 200 pounds to 270 pounds by increasing your daily Calorie Intake by only 605 calories and that weight will be maintained by consuming 840 additional calories when compared to baseline. The 605 figure can be added by eating the equivalent of a Big Mac Sandwich and a 10 oz Coke over a 24 hour period. The 840 calorie figure can be added by simply eating the equivalent of a Big Mac Sandwich, Snickers Bar, and a 10 oz Coke over a 24 hour period. This clearly demonstrates how we gain weight and how we must COUNT CALORIES if we are to be successful in losing unhealthy weight.
Jeffrey K. Raines and Zoraida Catherine Navarro
Professor Jeffrey K. Raines was responsible for the Soteria Cardiac Platform including its design and module development. After attending Harvard Medical School and training in the Surgery Department of Massachusetts General Hospital, Dr. Raines received a PhD in Engineering from MIT. His thesis title was Diagnosis and Analysis of Arteriosclerosis in the Lower Limbs from the Arterial Pressure Pulse; this work outlined the construction and testing of a new medical device called the Pulse Volume Recorder (“PVR”). This device was built and distributed by Life Sciences, Inc. and became a central device in the diagnosis of peripheral vascular disease and in the development of vascular diagnostic laboratories around the world. Dr. Raines was Chief of Research at the University of Miami Department of Surgery until his retirement in 2004 and Director of the Miami Vein Center from 2004 to 2010. Dr. Raines has developed Soteria’s technology over a period of 43 years and now that it has FDA clearance, he looks forward to expanding the use of the Platform worldwide. Dr. Raines is Emeritus Professor of Surgery at Harvard Medical School and the University of Miami. Dr. Raines is a Senior Member of the Society of Vascular Surgery, was elected to American College of Cardiology in 1975 and the Harvard Surgical Society in 2006. Dr. Raines lives in Homestead, Florida with Glo, his wife of many years; they have four children and five grandchildren.
Zoraida Catherine Navarro, MD practices at the Vein Center of the Palm Beaches and Navarro Dermatology Skin & Vein Care. Dr. Navarro earned a B.S. from MIT and medical degrees from Boston University School of Medicine and later, the University of Miami School of Medicine. As a member of the Palm Beach County Medical Society, she helped establish the Women Physicians Medical Society. In 1986, after a year as Director of Medicine for the Wellington Regional Medical Center, Dr. Navarro established the Vein Center of the Palm Beaches in West Palm Beach, an internal medicine solo practice with specialties in varicose vein sclerotherapy, skin care, and holistic approaches