The Pareto Principle (named after the 19th century Italian economist Vilfredo Pareto) states that 80% of the effects generally come from 20% of the causes.
Applied to health, this principle would look like ‘80% of the results come from 20% of the effort’.
For longevity a recent research article came across my desk that strikes me as defining the 80:20 principle for longevity.
Using combined data from 123,219 people followed for 30+ years in two of the best American longitudinal studies, the researchers defined 5 low-risk lifestyle factors:
The results were clear:
For a 50 year old man, adopting these 5 simple lifestyle measures would add 12.2 additional years of life, increasing life expectancy to 87.6 years as compared 75.5 years for someone adopting none.
For a 50 year old woman, these 5 measures add 14 years, bringing life expectancy to 93.1 years vs 79 years.
While this study, focused on lifespan rather than healthspan, it is clear that overall vitality and health would be superior with these same measures.
The rationale behind the measures is clear and compelling:
It was also clear that these lifestyle factors are synergistic - the larger the number of low-risk lifestyle factors the longer the life expectancy benefit.
For most measures the definitions were very clear; for :
In summary - the Pareto for longevity is to never smoke, be moderate with alcohol consumption, exercise regularly, eat well with common sense (eat real food, not too much, mostly plants) and maintain a normal weight.
As I sometimes need to remind the optimizers in our practice - simple lifestyle measures deliver most of the benefit - be sure that you are doing these things first.
At Wellness Garage - we can help you understand and take control of your health. Our comprehensive medical, fitness, nutritional and behavioral assessments give you baseline from which to measure your progress. Our coaching helps you improve your behaviors, one habit at a time.
For more information - please book a free consultation.
Impact of Healthy Lifestyle Factors on Life Expectancies in the US Population - Li et al. Circulation. 2018;138:345–355. DOI: 10.1161/CIRCULATIONAHA.117.032047
Details showing the cumulative effect of 1 or more measures on longevity:
Blood sugar is incredibly tightly regulated.
The average person has a single tablespoon of glucose circulating in their bloodstream.
Insulin, released by the pancreas after a meal keeps glucose in tight control.
Think of what happens when you go out and order a Coke.
A 354ml (12 oz) Coke contains 39g of sugar.
Shortly after drinking it, this 39g of sugar will flood the bloodstream, increasing the blood glucose level rapidly, and resulting in a surge of insulin to quickly pack this away as fat or glycogen and maintain blood glucose in the normal range. (For those of you, deeper into the science, I am ignoring the fructose for now - more on that in a future blog).
Over time, if repeated, your body's insulin receptors will become resistant to insulin, requiring ever higher levels of insulin to maintain tight blood sugars
Some of you may dismiss the fact that Coke contains almost 10X the amount of sugar that normally circulates in the body by pointing out that you don't eat junk food.
But do you realize the effects of other foods on your blood sugar levels?
Glycemic Index (GI) was introduced by David Jenkins and colleagues in order to compare the response of a carbohydrate containing food to that of pure glucose.
The standardized method calculates GI as 100 times the total blood glucose response (area under the curve) for 2 hrs after a meal to a food containing 50g of carbohydrates divided by 100 times the totatl blood glucose response to 50 g of glucose - each performed in 10 people of normal health.
A food with high GI has a greater effect on blood glucose than a lower GI.:
Glycemic Index is very useful to compare foods because it is standardized to the same amount of carbohydrate, but as common sense dictates some foods have more carbohydrate density than others - think of brocolli vs table sugar.
This observation lead to the introduction of another concept - Glycemic Load, which allows the comparison between foods at the usual amounts that we consume.
Glycemic Load essentially answers the two questions that are relevant to determine the glucose response of foods:
Or as David Unwin has so eloquently put it:
A definitive list of Glycemic Load values can be found at http://www.mendosa.com/gilists.htm
While very useful, Glycemic Index and Load are often poorly understood by doctors let alone patients.
This lead Unwin, through his experience as a GP from the north of England, to come up with a new way to express Glycemic Load - as teaspoon of sugar equivalents.
From this perspective, a serving of basmati rice is the equivalent of 10.1 teaspoons of sugar, while the 354ml (12 oz) Coke has 9 teaspoons!
Before I share a really useful infographic - let me share two thoughts:
So for anyone trying to lose weight, and especially for anyone with diabetes (or pre-diabetes) understanding the glycemic load and avoiding the sugar equivalents is a great strategy.
In Part I of this series, we reviewed the extent and impact of the diabetes epidemic and noted that the traditional approach to diabetes was clearly not working to prevent or reverse diabetes.
In Part II, we dove into the science to show that we have had evidence that Type II Diabetes could be reversed through bariatric surgery. What was most interesting was the fact the improvements in blood sugar control and diabetes emerged well before the weight loss resulting from the surgery. The trigger theory of the twin cycle postulates a mechanism behind this dramatic and immediate improvement and suggests a path where therapeutic diet interventions could accomplish the same effects as bariatric surgery.
From this theory, the key to diabetes reversal lies in improving liver function and decreasing the liver’s role in diabetes by changing the fat flows from the liver - the key steps:
Here the evidence is mixed between evidence from diets of varying:
The DIRECT study (http://www.directclinicaltrial.org.uk) in the UK - took 298 Type II diabetics people through a randomized controlled study:
The results were dramatic:
VIRTA Health has recently (https://www.virtahealth.com) research published the 1 year results of their study of 300 Type II Diabetics
What is interesting is the difference in composition of the VIRTA diet:
The VIRTA study included longstanding diabetics and those on insulin while the DIRECT study spefically excluded these populations.
Both studies clearly show that therapeutic nutritional intervention can reverse diabetes.
In both studies, changes in blood sugars came before weight loss and correlated with changes in liver function - suggesting similar mechanisms: reducing the metabolism of carbohydrate into fat by the liver, and reversing the flow of fats from storage to utilization.
In my opinion, the biggest practical difference between these approaches is calorie restriction vs carbohydrate restriction and which is easier to sustain over time.
This is where a ketogenic approach may have advantages. It has been proposed that there is a metabolic advantage to ketosis whereby a 'calorie is not a calorie'. In other words ketogenic diets cause a greater expenditure of energy than non-ketogenic diets. Scientific evidence for this is limited, and if there really is an advantage, the effect is likely small and would not explain why people lose weight when carbohydrates are restricted to the point of ketosis. This common observation of sustainable weight loss with ketosis is more likely explained by three attributes of nutritional ketosis:
How can these findings be applied to diabetics today?
At Wellness Garage, we will soon be launching a Diabetes Remission and Reversal program that:
In part I, we discussed the impact of Type II Diabetes on our health and the extent of the epidemic of diabetes in Canada and the world:
The traditional approach can be summarized as:
Yet we have clear evidence that diabetes can be reversed.
The first hint of this reversal comes from the outcomes of bariatric surgery. In 1992, Pories et al. showed that blood glucose levels normalized in obese people with Type 2 diabetes who had undergone bariatric surgery and that almost 10 years later 90% remained free of diabetes.
The effect of bariatric surgery to reverse diabetes has been replicated in numerous studies with rates of remission ranging from 30 to 70% depending on the procedure and trial.
Overall the long term remission correlates with the amount of fat loss achieved and maintained.
But this correlation may be misleading when it comes to causation.
The changes in insulin resistance and blood sugar happen well before there is any significant loss of fat. Initially there was belief that these early effects were mediated through incretin hormone secretion.
Closer analysis shows that real change happens through the initial rapid decline in caloric intake at the time of surgery. This creates a sudden reversal of traffic into fat stores that brings about a profound change in the intracellular concentration of fat metabolites. This effect happens first in the liver and other ectopic (visceral) fat storage sites.
These changes represent a sudden and dramatic reversal of the proposed cause of insulin resistance.
With this evidence that Type II DM can be reversed by bariatric surgery and that the effect results from the immediate reversal of the intracellular changes that cause insulin resistance and diabetes in the first place, the next question is can this be done through diet - without the cost, risk and complications of surgery. The simple and resounding answer is YES:
Type II DM can be reversed through dietary interventions.
Before we look at the therapeutic nutrition trials that are now providing evidence that diabetes is reversible, I want to step back and look at the mechanism and time course of insulin resistance, as this will help us understand what approach an individual looking to reverse diabetes should follow.
Insulin resistance is a process by which muscle, fat and liver cells no longer respond properly to insulin and thus cannot easily absorb glucose from the bloodstream. As a result, the body needs higher levels of insulin to help glucose enter cells.
The liver is the key player in the development of diabetes, as it is the hepatic production of triglycerides from excess carbohydrates that is at the root of the disease process.
Interestingly, it is the reversal of insulin resistance in the liver that occurs during the immediate hypocaloric response to bariatric surgery.
The trigger theory for the twin cycle explains the mechanism for both the development and reversal of Type II DM, and provides the foundations of a strategy for a new paradigm for diabetes management.
This theory postulates that:
These changes in the liver also lead to
The key is to understand at what the point the trigger is activated in the liver, that is the point at which liver fat accumulates along with the corresponding trigger level at which adverse metabolic effects of fat on the pancreas occur. The goal of any therapeutic effort to reverse diabetes would then be to reduce the liver and pancreas fat below the personal trigger levels.
The key here is the liver: we have known for some time that insulin resistance in Type II DM correlates with liver fat - decrease the liver fat and the diabetes improves.
How do we decrease liver fat?
If bariatric surgery’s immediate effect on diabetes results from this hypocaloric induction – can this be done through diet alone, without surgery.
In Part III, we will explore some of the new and powerful evidence for therapeutic nutrition that demonstrates that Type II Diabetes is in fact reversible through dietary interventions.
In medical school we were taught that Type II DM is a chronic progressive disease - once diagnosed, it could potentially be managed, controlled, but never cured.
The primary thrust of diabetic cares has been to try and control blood sugar with a goal of decreasing the risk of macrovascular (heart attack and stroke) and microvascular (kidney failure and blindness).
Conventional wisdom has been that 90% of diabetics require medication treatments that need to intensified over time to effectively prevent complication and that "delays in intensification of are common and may be due to unrealistic patient expectations." (1)
Evidence is accumulating that conventional wisdom has been wrong.
The Massive Toll of Diabetes
Diabetes rates globally are rising, driven by the obesity epidemic.
In Canada, 9% of the population is diabetic - this has grown from 3.3% in 1998 and is expected to grow to 12% in 2025.
Perhaps even more alarming, an additional 22% of the population are pre-diabetic, 90% of whom do not realize it. Over 70% of pre-diabetics will go on to develop diabetes.
Diabetes reduces lifespan by 5-15 years and accounts for over 10% of deaths in Canadian adults.
People with diabetes are:
Diabetics have a 25% greater chance of developing cancer. Diabetes is moderately associated with cancers of the:
Diabetes and depression create a self-enforcing viscous cycle: 30% of diabetics have clinically relevant depressive symptoms, people with depression have a 60% increased risk of developing type 2 diabetes.
Adding to this massive clinical toll, the cost of diabetic care is staggering - in Canada we currently spend $15B on treatment and management of complications. With the rates of diabetes climbing the cost trend has been called an economic tsunami, with an expected doubling by 2025.
Looked at from both the clinical and financial perspective, it is clear that diabetes is the biggest healthcare challenge of our generation.
Stepping back, we can see that our traditional approach:
... is not working, for the simple reason: our current approach does not address the cause of diabetes.
The chronic and progressive nature of diabetes may have more to do with our management than of the disease itself.
In part II and III of this blog series, I will look at the powerful new evidence that Type II Diabetes can be reversed through a comprehensive lifestyle approach.
At Wellness Garage, we believe that the answer to optimal health and vital longevity lies in our lifestyle behaviors. We use comprehensive, evidence-based, precision health assessments to gain deep understanding of an individuals current health and behaviors. We then use this information to come up with a behavioral plan to address underlying illness and risk, while optimizing health.
If this approach makes sense to you, book a free consultation with us and we can help you get started.
In the coming months, Wellness Garage will be launching a comprehensive diabetes program aimed at disease reversal and remission based on evidence from powerful new studies. Part II and Part III of this blog series will explore this evidence and detail the Wellness Garage approach.
We have touched on the importance of sleep many times in this blog.
Research implicates poor sleep as a risk factor for obesity, metabolic dysfunction, diabetes, heart disease, stroke, traumatic accidents and overall increased mortality. Lack of sleep adversely affects our immune system, increases inflammation and upsets the balance of our autonomic nervous system (sympathetic:parasympathetic).
More practically - great sleep leads to greater energy for doing the things we want to do.
Today I want to focus on 'sleep hygiene' - simple rules for getting the most recovery and benefit from sleep.
If you have any of the following symptoms, you should seek further evaluation of your sleep:
If you think you need help with your sleep, please reach out and book a free consultation with us.
50% of Americans have high blood pressure according to the new guidelines from American College of Cardiology and the American Heart Association.
Lost in the debate about whether this makes sense to label so many people with a disease was the recognition that normal blood pressure is now defined as 120/80 and the acknowledgement that the risks from blood pressure increase progressively, and linearly from levels as low as 115/75 in people from 40 to 89 years of age.
For every increase of 20 mmHg systolic and 10 mmHg diastolic there is a doubling of mortality from both heart disease and stroke.
Here is the Wellness Garage strategy for high blood pressure:
1. Know your blood pressure:
2. Know whether you have insulin resistance:
3. Get moving - exercise is key
4. Eat better - lose weight
5. Salt - stop eating packaged food and decrease how much you eat out - see #3
7. Sleep - develop a great sleep routine
This 7 step strategy will allow you to take control of your blood pressure and do everything you can to either avoid medication or take as little as possible.
Backgrounder on Hypertension:
What is it?
How is it defined?
Why is it important?
What causes it?
At Wellness Garage, we believe that good health comes from good habits and behaviors.
Specifically there are six core behaviors that are the pillars of vibrant health - if any one of these pillars collapse, your general health will suffer:
It sounds so simple - master a set of habits for each behavior and you optimize your health.
So why does it feel so hard?
Two words explain it: Evolutionary Mismatch
Simply put - our evolutionary design did not prepare us for the modern world.
Evolution through natural selection adapts organisms to their past environments and has no ability to foresee the future.
Across the six core behaviors:
Looked at this way - it is no wonder that the diseases of evolutionary mismatch are the chronic diseases that afflict us and imperil our vital longevity:
At Wellness Garage, we believe that everyone needs a strategy to address these mismatches.
Our programs systematically help people to find their own path to vibrant health by addressing the six core behaviors through the 18 principles we have outlined here.
The answer to evolutionary mismatch will be unique for each of us, but it will lie in our own behaviors.
If you need help with any of your core behaviors, please reach out and book a free consultation with us.
Wellness Garage is now open...
Not Your Average Doctor's Office
Wellness Garage is unlike any doctor's office you've been to before and includes a gym, cafe, scanning room and stress reduction space.
If you haven't had a chance to stop by for some kombucha and conversation we invite you to do so!
We are located at 15165 Russell Avenue, White Rock
If you think that you could benefit from a Lifestyle Medicine approach to your health, please reach out to us and book a free consultation, we can help you come up with a strategy for your vibrant health.
Many of you found this to be a bit deep in the weeds of science, so I thought this week's post would back up a little bit and provide an overview of fats with some take-home practical advice (and of course some science).
Let's start with definitions:
For humans there are two essential fatty acids (fatty acids that we need for our health and cannot synthesize ourselves therefore we must consume in our diet), both are PUFA:
Both Omega 3 and Omega 6 FA’s are important structural components of cell membranes, incorporated into phospholipids where they are affect membrane function. Increased dietary levels of Omega 3’s result increased membrane content of Omega 3’s with resulting improvement in membrane fluidity, flexibility, permeability and the activity of membrane-bound enzymes. DHA is selectively incorporated into retinal and neuronal membranes highlighting the important role it plays in vision and nervous system function.
It is worth noting that these membrane-bound HUFA are damaged by free radicals released by mitochondria under oxidative stress - this mechanism may be a contributing factor in the development of insulin resistance, the process whereby the membrane bound insulin receptor loses its ability to respond to insulin efficiently.
Under the influence of hormones and cytokines, membrane bound Omega 3 and Omega 6 FA’s are metabolized into multiple classes of PUFA-dervied bioactive lipids involved in inflammation and immune function.
Only ALA and LA are essential - all other Omega 6 and Omega 3 HUFA's can be derived from these precursors.
LA is common to many vegetable oils (corn, soybean, sunflower)
ALA can be derived from plants sources - flax, chia seeds, green leafy vegetables, soybean oil, canola, and importantly from fish.
In general compounds derived from the Omega 6 pathway are inflammatory and those from the Omega 3 pathway are neutral, anti-inflammatory or even promote resolution of inflammation.
Evidence supports that increasing intakes of long chain Omega-3’s (EPA and DHA) decrease the risk of cardiac disease by:
Studies show that long chain omega-3 FA’s (DHA in particular) have a protective effect in the development of Alzheimer’s Disease through
Omega-3 and Omega-6 FA’s also modulate the expression of genes associated with fatty acid metabolism and inflammation by interacting with transcription factors.
Omega 3’s suppress NFkB a transcription factor associated with inflammation; as well as suppressing SREBP-1 which decreases fatty acid synthesis. In this way Omega-3 PUFA functions as feedback inhibitors of fatty acid synthesis.
There are two challenges to Omega 3 metabolism from ALA to EPA and DHA:
So for all effects and purposes, we must consume EPA and DHA from our diet - if we want to ensure we want to get the Omega 3 health benefits.
EPA and DHA are most commonly consumed from cold water fish or fish oil. The actual compounds are synthesized by algae and are preserved in the food chain in fish oil, so it is possible to get algae derived EPA and DHA (important for vegans, and probably the most ecologically sustainable).
The key to getting the health benefits of the essential fatty acids is to get a proper balance of Omega 6 to Omega 3.
From an evolutionary perspective, the ratio of Omega 6 to Omega 3 in the diet was 1:1. Since the introduction of cheap, industrial vegetable oils - corn, soybean, safflower etc. into the Western diet - this ratio has sky-rocketed to 25:1. At these levels, Omega 6's act as pro-inflammatory agents and likely are a significant contributor to obesity, insulin resistance and heart disease.
These industrial oils are pervasive in packaged foods and restaurant prepared meals and should be avoided.
The easiest substitution is to use extra virgin olive oil or avocado oil instead. These oils are predominantly monounsaturated.
At the same time, increasing Omega 3's, either through the consumption of fish or through Omega 3 supplements.
Research suggest that an Omega 6 to Omega 3 ratio of 2:1 may guard against certain cancers, reduce inflammation in rheumatoid arthritis, and potentially decrease the risk of heart disease and Alzheimer's
The relative amount of EFA requirement is relatively small - about 1% of daily energy requirements from each of these two classes. 1% of 2000 calories = 20 calories - 9 calories per gm of fat = 2.2 g each of Omega 3 and Omega 6.
For more precision you can measure how much Omega 3's you need to consume by measuring one of two metrics:
What fats to eat?
Since the requirements for essential fats is small in both a relative and absolute sense, we come back to the question - what fats to eat?
One line of thinking when it comes to dietary fat, it to consume fat in the form that the body likes to store:
Composition of fat stored in adipose tissue:
But isn't Saturated Fat bad for you ? Probably not - see this blog post.
Current evidence does not support that dietary intake of saturated fat increases risk of CVD.
While increased levels of circulating SFA does correlate with increased risk of CVD and Diabetes - dietary intake of fat does not determine circulating SFA. In a fat adapted individual (someone who is burning fat for energy), dietary SFA will be quickly consumed as fuel. The real danger is the combination of high fat and high carbohydrate intake, where both dietary intake and insulin action will increase circulating SFA. What does get confusing is evidence that replacing saturated fat with PUFA improves CVD risk.
Summary and Recommendations:
Our view is not conventional wisdom – but we believe that it does represent the emerging consensus view
At Wellness Garage our approach is personalized:
If you think that you benefit from a personalized approach to cardiovascular risk - please reach out to us and book a free consultation, we can help you come up with a plan to address your health needs.
Dr. Brendan Byrne