Monday, January 27, 2014

A Heart-Smart Strategy for Post-Menopausal Women

Heart disease is rare in premenopausal women. Once women go through menopause, though, everything changes. To reduce the risk of diabetes and heart disease, women need to take a good look at their lifestyle. Favorable cholesterol levels don’t insure women against heart disease. Instead, a holistic approach is needed.

One of the drivers of heart disease is obesity (defined as having a body mass index greater than 30). It's no secret that the United States is suffering from an obesity epidemic. In fact, around 66 percent of Americans are classified as being either overweight or obese. Obesity results from and contributes to insulin resistance and eventually, to Metabolic Syndrome. This can, in turn, result in diabetes, cognitive decline and heart disease. Post-menopausal women are at greater risk. Metabolic Syndrome is the real cause of women dying of heart disease.

“Syndrome X” as it was originally called, dysmetabolic syndrome, and "Metabolic Syndrome" (MetS) are the names given to the following cluster of signs: elevated blood pressure, elevated blood sugar, high triglycerides, low HDL (aka “good cholesterol “) and excessive abdominal fat (a waist size of 35 or more inches in women and 40 or more inches in men). MetS puts a person at a much higher risk of developing life-threatening health problems like cardiovascular disease and diabetes. Insulin Resistance (IR) is the primary cause of MetS.


The Role of Insulin Resistance
“Insulin resistance” means that a patient has chronically elevated insulin levels. Insulin is released from the pancreas after a meal. As insulin facilitates transfer of sugar into cells and the blood sugar drops, the insulin level comes down. This is the body’s normal response to a rise in blood sugar (glucose) after a meal.

IR occurs when the body's cells stop recognizing insulin. The pancreas has to produce more and more insulin to get smaller and smaller amounts of glucose into the cells. The cells are hungry for nourishment, but glucose can’t get to them. People with IR are HUNGRY—their cells are hungry! So they overeat, blood sugar rises, then insulin levels increase, blood sugar stays high, so more insulin is secreted, etc. It’s a feed-forward cycle. This is followed by “glucose intolerance” (GI), which means chronically elevated glucose levels. Eventually, when these levels rise to over 125 mg/cc (fasting level), one is diagnosed with type 2 or adult onset diabetes mellitus.

To complicate matters further, fat cells never lose their sensitivity to glucose, so they continue taking up glucose and making it into more fat. As a result, people with IR, MetS, GI, and type-2 diabetes usually have big waistlines. Abdominal fat produces chemicals called cytokines which make the person even more insulin resistant. Another feed-forward cycle: abdominal fat also produces cortisol independent of adrenal production. Cortisol breaks down muscle, raises blood pressure, increases glucose, and… increases abdominal fat cells. Rinse and repeat.

IR can have a number of contributors—many of which are also general risk factors for MetS. They include:
  • Obesity, especially increased abdominal fat (an “apple” figure)Lack of exercise (loss of lean muscle speeds the process)
  • Consumption of refined carbohydrates, especially high-fructose corn syrup (excess refined sugars and white flours also promote IR)
  • Consumption of excessive saturated fats in grain-fed beef, and saturated and trans fats in fast foods and processed foods
  • Excessive caloric intake
  • Hormonal imbalances (hypothyroidism, adrenal stress, and menopause)
  • Environmental toxicities, particularly exposure to lead and arsenic, bisphenol A in hard plastics, ammonium perfluoro-octanoate (Teflon®), phthalates in soft plastics and “fragrance” in personal care products

Why Post-Menopausal Women Are Affected
Women tend to gain an average of one pound a year after menopause and also devote less time to exercise. Women also gain about 15 pounds before their last period.

The hormonal shifts that occur during menopause are also to blame. The hormone levels of post-menopausal women tend to show higher testosterone, low or high estradiol, decreased sex hormone binding globulin, low thyroid function, and higher cortisol. The reduction of estrogen production in most post-menopausal women increases the risk of abdominal obesity, increases fibrinogen levels, reduces HDL (“good cholesterol “) and increases LDL (“bad cholesterol”) and triglycerides.

Inflammation goes up as post-menopausal women gain weight around their waists. Cytokines and other inflammatory markers increase.

Another risk factor for MetS is vitamin D deficiency. Low levels of this vitamin are common in post-menopausal women. Also heavier women tend to have lower levels than slender women. Vitamin D is fat soluble so fatter women need a lot more of it. Most obese women are very low in Vitamin D because they need so much of it. Low D causes hypothyroidism too.

It should be noted that women who undergo natural menopause may be at a lower risk for developing MetS than women who undergo surgical menopause. A study in the journal Endocrine Today found that 47 percent of women who had a bilateral oophorectomy before natural menopause developed MetS. The study discovered that only 36 percent of women who went through natural menopause went on to develop the disorder. Both of these numbers are too high.


Increased Risk of Cardiovascular Disease
MetS is more than just a grouping of signs and lab results; it's an indicator of health issues to come—in particular, cardiovascular disease.

The hormonal and lifestyle changes caused by menopause and the subsequent connection to insulin resistance and MetS are why women's cardiovascular disease risk increases after menopause. While cardiovascular disease is rare in women under 50, the rates catch up to men by about age 71.

Research suggests that almost half of post-menopausal women develop MetS. 80% of these develop diabetes and 9/10 of these have serious complications such as heart disease, renal failure, and retinopathy within six years. 1/3 die within 6 years of diagnosis. Elevated cholesterol may also contribute, but MetS is the primary driver of cardiovascular death as women age.

Research has shown that MetS may increase C-reactive protein in post-menopausal women. The elevated levels of C-reactive protein put these women at an even higher risk of experiencing a cardiovascular event.

In addition to cardiovascular disease, post-menopausal women with MetS are also at a heightened risk for additional health problems. Studies suggest that these women have a 66 percent increased risk for developing cognitive impairment (brain fog or memory problems) and a 40 percent increased risk of needing gallbladder surgery.

In this country Mexican American women have the highest risk of developing MetS, followed by African Americans, then Caucasians.

Evaluating for MetS
A doctor can diagnose MetS in women by evaluating five factors:
  •  Waist circumference: > 35 inches
  • Elevated triglycerides: > 150mg/dl after a 12-hour fast
  •  Low HDL: < 50 mg/dl
  • Hypertension: ≥ 130/85
  • Fasting glucose: ≥ 100mg/dl and < 126mg/dl (Diabetes) Some people get “white coat high blood sugar” caused by cortisol and adrenaline surges due to stress responses and caffeine on the way to the doctor’s office; so, many doctors prefer using Hemoglobin A1C (Hgb A1c)           
 Other labs that are useful for detecting and treating the causes of MetS are:          
  • Hgb A1c: Optimally 5% or less (> 6.5% is considered diabetic)
  • Fasting insulin and glucose
  • Ferritin: Elevation is an early sign of fatty liver
  • Thyroid functions to include TSH, FT3, FT4, reverse T3
  • Vitamin D: Optimal range is 65-85 ng/dl
  •  Liver function (to screen for fatty liver), including GGT
  •  Salivary cortisol x4 (morning, mid-morning, afternoon, evening) or 24-hour urinary cortisol
  • Sex hormones and DHEA-Sulfate
  • Homocysteine, HS-CRP, and fibrinogen

           
Treating MetS
If MetS is confirmed, there are a number of ways it can be reversed. These include:
  • Weight loss
  • Dietary changes

o   Reducing or eliminating refined carbohydrates
o   Reducing or eliminating saturated fats and trans fats
o   Eliminating high-fructose corn syrup
o   Consuming fewer carbohydrates in general
o   Brief periods of fasting
o   Eliminating gluten

  • Stress reduction
  • Improved sleep
  • Detoxification
  • Prescription drugs
  • Supplementation
  • Bioidentical hormone replacement therapy

Studies have shown that losing just 7 to 10 percent of your body weight can play a major role in stamping out MetS. So, for someone who weighs 200 pounds, just a 20-pound weight loss can make a huge difference.

An important component to achieving weight loss is making dietary changes. Since most post-menopausal women with MetS have a high amount of abdominal fat, cutting back on carbohydrates is a crucial step. This means eliminating all refined grains and sugars—and most whole-grains as well. Add more good proteins and oils and, whenever possible, eat organic. Despite standard recommendations from the government and conventional doctors for a high carb/low fat diet to lose weight, in the case of MetS one will get the best results with lower carbohydrates and higher (healthy) fats and proteins. The Mediterranean and Paleo diets can both be platforms for achieving this. Generally within one week of starting a low carbohydrate diet, hunger pangs will subside. IR measures can improve in as quickly as two weeks.

Many integrative physicians endorse short fasts to help lose weight. Dr. Mark Houston at Vanderbilt suggests a 12 hour overnight fast 4-7 days a week.

Patients should experiment with a gluten free diet. Underlying gluten sensitivity, even without typical lab findings of Celiac Disease, has been found to contribute to obesity and inflammation which can cause MetS.

Additionally, do not underestimate the role exercise plays in weight loss. A Johns Hopkins study of fifty-five to seventy-five year-olds found that those who exercised (aerobic and anaerobic) 60 minutes three times a week lost 20 percent of their abdominal fat. Nine of the patients completely resolved their MetS. Another study by Northwestern Memorial Hospital found that women with MetS who exercised lost their elevated risk for cardiovascular disease. Aim for seven days a week and meet a goal of exercising at least five of those days. Work up to a combination of strength training and aerobic exercise for 40-60 minutes a day. Exercise brings down blood pressure, decreases triglycerides, and decreases depression too.

Lifestyle changes including stress management and improved sleep will also help. Sleeping less than six hours a night increases a person’s risk of obesity by 235 percent compared to sleeping seven hours a night. Mindfulness practices like meditation, yoga and tai chi stimulate an innate healing response when done for 20 minutes daily. In addition, stress reduction reduces cortisol levels.

Avoiding or at least reducing exposure to toxins is critical today. Go to www.ewg.org or www.breastcancerfund.org to learn how to reduce exposure to these toxins which increase everyone’s risk of obesity. Also avoid all Roundup Ready® genetically modified foods and conventionally grown grains. These foods are laden with glyphosate, the herbicide in Roundup®. Glyphosate damages our friendly gut bacteria, thus generating inflammation… which raises cortisol. Also, glyphosate binds up (or chelates) trace minerals in the food, causing the body to need even more trace minerals, so people are driven to eat even more calories to get the nutrients they need. Eat organic as much as possible, and avoid processed foods.

After reducing exposure, try a detoxifying cleanse. A one-week or 28-day detox may be helpful to jumpstart weight loss. Or, if one hits a plateau, a detox can help blast through it. Many toxins are stored in fat. During the fat-burning process, fat cells release stored toxins and the body is poisoned a second time. This can contribute to an inability to lose weight even when doing everything “right”.

Individuals having trouble achieving any of these strategies on their own should ask their doctor for advice. A doctor can also help determine whether prescription treatment is appropriate. Drugs which are used off label to treat MetS include metformin and exenatide.

Another important treatment option for MetS is supplementation. The right combination of supplements, used in conjunction with a proper diet, can help enhance cell functioning, reduce glucose levels, provide appetite control, reduce blood pressure, regulate cholesterol, and provide anti-inflammatory protection. Commonly recommended supplements for MetS include:
  • Multivitamin: not one a day, usually three to six daily
  • Fish oil
  • Insulin Resistance (IR) formulas containing some combination of chromium, zinc, vanadium, Gymnema sylvestre, Momordica charantia, ginseng, holy basil, and cinnamon
  • Antioxidants like alpha-lipoic acid, green tea extract, N-acetylcysteine, other botanicals, flavonoids, proanthrocyanidins: curcumin, resveratrol, bilberry or blueberry, hawthorn, gingko, Silybum marianum
  • Lecithin
  • Vitamin D3 and calcium
  • Probiotics: 25-50 Billion CFU daily are a must
  • Fiber: 25-40 grams daily if not obtained in food
  • Garcinia Cambogia may help with carbohydrate cravings and satiety
  • Trace minerals


Bio-Identical Hormone Replacement Therapy: An Important Treatment Option
To specifically treat insulin resistance and MetS in post-menopausal women, bio-identical hormones may be needed. One study found that women with low estrogen who didn't receive hormone replacement therapy (HRT) were more likely to have high cortisol levels—an imbalance that leads to increased abdominal fat. With HRT, these women were able to reduce their cortisol levels and their abdominal fat.

Studies have shown that transdermal or vaginal HRT may be more effective and have fewer side effects than oral HRT when it comes to the treatment of IR and MetS.

In Summary
Before initiating any treatment, a doctor will perform a comprehensive workup to evaluate the risk for MetS and determine the best treatment options for an individual’s unique health needs. To fully tackle MetS, a commitment to appropriate lifestyle changes and prescription/supplementation regimens is crucial. HRT may be especially helpful in women with persistent hot flashes and/or bone loss. The rewards for doing so are a healthier body and heart.

Sources:
Morstein, Mona. "MetS and the Menopausal Woman." Townsend Letter. February/March 2012

Houston, Mark. “For Women with CVD, Lipid-Centric Strategies Often Fail” Holistic Primary Care. Winter 2013