Most of us plan our medical appointment based on symptoms and complaints, need for check up, schedule and of course, the availability of our physician or health care practitioner. There are only so many early morning openings, and these may be further diminished when doctors make hospital rounds and/or perform surgeries before arriving at the office. If you don’t want to leave home without breakfast in the morning or you have to make a late afternoon appointment, you may not be willing or able to fast for blood tests. (I encourage everyone to eat their breakfast…I won’t leave home without it. This may be the time to mention that individuals who don’t eat breakfast have a shorter life span….fasting from dinner until lunch will result in an overly aggressive i.e., high, insulin response to the delayed meal. Elevated insulin levels can cause fat to accumulate in unwanted places and increase the risk of cardiovascular disease.)

So there you are at the doctor’s office, you have not fasted and you are told that the blood test for diabetes (and perhaps heart disease) can’t be done…Thus is no longer inaccurate. An article just published in the March 4 issue of The New England Journal of Medicine reported that a non fasting blood test called glycated hemoglobin (also known as hemoglobin A1c) will diagnose risk of diabetes just as well or better than a fasting blood sugar (glucose) test and can also strongly indicate risk of cardiovascular disease and death from any cause!

Until recently, the standard measure used for diagnosis of diabetes was a fasting blood sugar. Glycated hemoglobin is a test that reflects your previous 2 to 3 month exposure to glucose and will include spikes that occur after eating. It doesn’t vary from hour to hour or day to day and is not dependent on what you just ate. It is essentially the glucose “truth meter” for what you have consumed and your blood glucose response over the past few months. It has traditionally been used for the determination of glucose control among those who have already been diagnosed with diabetes and are on therapy. But this and other reports will eventually make glycated hemoglobin the test “of choice” for diagnosis and assessment of diabetic risk in everyone.

The Atherosclerosis Risk in Communities (ARIC) is a community -based prospective study of middle-aged adults from four U.S. centers. It was started in the late 80’s and continues to present time. During the study, the researchers measured the glycated hemoglobin in blood samples from 11,092 adults who did not have a history of diabetes or cardiovascular disease. More than 55% of those tested were women. Their ages ranged from the mid-forties to mid-sixties. For the individuals who were found to have glycated hemoglobin of 6.0 to 6.5%, the risk of diabetes (the technical term was multi-variable-adjusted hazard ratio) was 4.48. (Those who had values of 6% to 6.5% were 4.48 times more likely to develop diabetes then individuals used as a reference who had glycated hemoglobin of less than 5.5%). For those individuals who had a level greater than 6.5% the risk was 16.47. The researchers then checked to see who developed coronary disease and stroke. The hazard ratio for a value of 6 to 6.5% was 1.76 and over 6.5% was 1.95 (or a 95% increase over those with low glycated hemoglobin levels.) They also looked at death from any cause and found that the higher the glycated hemoglobin, the greater the risk of mortality. Moreover glycated hemoglobin levels were found to be more predictive of disease than fasting blood sugar levels.

Studies have show that among people in the United States who do not have a diagnosis of diabetes, over 2.4 million have a glycated hemoglobin higher than 6.5% and 7 million have a value higher than 6.0%. This is an ill inspiring number.

Bottom line: A non-fasting blood test for glycated hemoglobin can help determine whether you are at risk for development of diabetes, cardiovascular disease and even early death. Hopefully it will be less than 6.0%. Most of us now know our cholesterol and lipid levels; it may be just as important to know your glycated hemoglobin level. If it’s too high you and your doctor will need to discuss the necessary behavioral changes and therapies that will help you to maintain your health.

I, like most Americans, love salt. My ethnic culinary background has made salt a very traditional condiment. (Think chicken soup, koshered fowl, pickles, smoked white fish, hummus, pitas…then add on American potato chips, processed meats, breads, cookies, sauces and salad dressings). I was going to have a string cheese as a snack while I wrote this….but I looked at the wrapper and it contains 210 mg of sodium (remember sodium chloride is salt). And since a quarter of a teaspoon of simple salt is 1.5 gram or 590 mg of sodium, I guess I also won’t salt those carrot sticks.

An article appeared this February in The New England Journal of Medicine that was titled “Compelling Evidence for Public Health Action to Reduce Salt Intake”. Their projections were astonishing. The authors, from The University of California, San Francisco, used a computer program called the Coronary Heart Disease Policy Model to quantify the benefits of reducing dietary salt by 3 grams a day (or in sodium terms, and that’s what you find on food labels… 1200 mg of sodium per day). This reduction would have a tremendous effect, reducing the annual number of new cases of coronary heart disease (CHD) in the U.S. by 60,000 to 120,000, stroke by 32,000 to 60,000 and heart attack by 54,000 to 99,000 and reduce the annual number of deaths from any cause by 44,000 to 92,000. (And, for the mostly women readers of my website…please note that the projected reductions in stroke would be greater among women than men.) All this could save $10 billion to $24 billion in health care costs annually!

In short, salt reduction would be as beneficial as interventions that reduced smoking in the US by 50%, a 5% body mass reduction in all obese adults or the use of drug therapy for people with hypertension and hyper cholesterol levels. Moreover it is probably as important as reducing trans fats in all foods and increasing our consumption of fruits and vegetables. The authors of a commentary in the same issue also point out that salt reduction may reduce risk of gastric cancer, kidney disease, congestive heart failure and osteoporosis.

It turns out that we are a population of salt eaters ….consuming more than in many other developed countries. Although the current guideline for salt consumption by The Departments of Agriculture and Health and Human Services is less than 5.8 g of salt (2300 mg of sodium) with a lower target of 3.7 g of salt per day for persons over 40, blacks and persons with hypertension; the average man in the U.S. consumes 10.6 g of salt per day and the average woman 7.3g per day. And statistics have shown that the amount of salt we consume is on the rise.

So what can we do? Certainly look at labels.  Seventy-five percent to 80% of the salt in the U.S. diet comes from processed foods. Our government (doesn’t it always seem to come back to them) should probably begin a program of regulations on the salt content of processed food, make labeling clearer and work with the food industry to reduce salt….it worked for trans fats. And it behooves us, the consumers, to look at those labels, choose less salty alternatives (begin with cans of soup and breads and hey potato chips and pickles may have to go) and of course start using foods that are not processed. (Well at least try in some areas of food preparation….it may be difficult for most of us to bake all our breads or raise our own fowl and meat.)  And let’s not forget to diminish the salt intake of children. Between their processed snacks, cereals and the children meals at takeout and eat –in restaurants they are being inundated with salt.  Hypertension and plaque build up starts at a very young age as does the preference for salt.

Studies have shown that as salt intake is reduced, children and adults prefer food with less salt. Our taste receptors change over the course of just weeks or a few months. Taste is an acquired sense that can be changed. I for one will try to continue to enjoy what I eat sans excessive salt. (There goes the salt rim on the Margarita glass, oh well….)

One last encouraging note; the article pointed out that even if there was a more modest reduction in our salt intake by as little as 1 g a day there would be a significant projected decline in the annual rates of cardiovascular events and deaths. So if you can’t go salt free try for salt “freer”

We have all heard the weight gain formula: 3500 calories that are not burned off will add 1 pound of fat tissue. So if that’s the case 1 extra cookie that has 60 calories, when consumed daily, will add 0.5 pounds monthly or 6 lbs a year. Now let’s say you eat that cookie daily for a decade….does that mean you will gain 26 lbs, or if you eat it for 4 decades, you will gain more than a hundred pounds? Add to this the distressing fact that our basal body metabolism decreases by about 5% each decade…By now that cookie could make us look like sumo wrestlers before we get to take advantage of Medicare! (The last phrase is not meant to be an ad for Medicare Advantage.)

Well according to a very relevant commentary recently published in JAMA, this is not the cookie’s (nor you body’s) destiny. Weight gain does occur when your caloric intake increases above your energy expenditure, but it doesn’t continue indefinitely. The increased initial weight from that cookie requires more calories for maintenance. (It’s physics again, a heavier body needs more sustenance to stay heavy.) Eventually your weight will stabilize after several years of extra cookie consumption at approximately 6 lbs. But once you are in a steady weight state and you up your cookie consumption to 2 extra cookies, the process will begin over again.

The author of the JAMA commentary brought up some additional weighty information. If a young adult woman adds 1 oz of a sugar sweetened beverage and walks 1 minute less a day, she will have a temporary caloric excess of about 13 calories, leading to a weight gain of 1.4 lbs in one year. If she repeats nutritional and exercise changes of this nature on an annual basis for 28 years she will have a 370 calorie energy gap and a 35 lb weight gain. And she will not be alone in her caloric overage. The estimate is that the average per capita energy intake in the U.S.A since the 1970’s has increased by up to 500 calories. Our readily available food supply and mass encouragement to eat more and sweeter (for less money) has worked and contributed to our ever increasing girth. Obesity will overtake cancer as a cause of premature death! Future health care will have to start with food care, but now I digress.

Here come the “I am going on a diet or at least not eating that cookie” facts. As you loose some of that fat from your body, you also need less fuel to maintain that loss. Your weight recalibrates at a new steady state. Your body also “misses” some of that weight and strives to conserve whatever calories you do consume. So to continue to loose weight you have to further restrict your diet (much more than that cookie) and/ or really increase your energy output (i.e. exercise). Walking one mile a day expends just an additional 60 calories when compared to resting; the minimum to make up for that cookie. But to lose more you have to do more, and consume less. Unfortunately you can’t just rest on early weight loss laurels and resume your old diet and restricted physical routine. If you do the weight you lost will just come back. That New Year resolution has to be one that goes on and on and on…

We like our sweets…If I really wanted to impress you with scientific taste I would phrase that differently and point out that the taste receptor for sweetness, T1R2/RIR3 detects sugar at a concentration of 1 part to 200 and “notifies” the brain about this pleasurable sense. But as great as our fondness for sweet tasting foods, we are much more aware of and put off by bitter substances, which can be detected in the range of a few parts per million! (I will spare you the receptor details.)

When refined and concentrated sugar (usually sucrose and high fructose corn syrup) is consumed in large amounts, it immediately causes a rise in blood glucose. In order to stabilize elevated blood glucose levels the pancreas will, if functioning, produce insulin. Elevated insulin then causes an increase in triglycerides, fat deposition (in unwanted parts of our body), inflammatory factors, and oxidative radicals….all of which are associated with coronary heart disease, diabetes and obesity.

In an effort to please our taste buds without suffering the consequences of too much refined sugar many of us use artificial sweeteners, especially in our drinks. According to an article in the American Journal of Clinical Nutrition, our per capita diet drink intake has increased from less than 1 ounce per day in the 1960′s to about 4 ounces per day in this decade. Moreover, among regular consumers of diet drinks, intake is now greater then three 8-oz servings per day.

I switched from diet colas to water about 2 years ago, but admit I still indulge in ice tea and (when my reflux lets me) coffee, both sweetened with artificial sweetener. After all, there are currently 5 types of synthetic “no-calorie” sweeteners as well as Stevia (a natural extract) that have received FDA approval. They all are more potent than sucrose and elicit a sense of sweetness in very small concentrations. It’s so easy to just tip a pink, yellow or blue packet into a drink. (And the manufacturers of all those diet sodas do it for us.)

A recent commentary in The Journal of the American Medical Association pointed out some disturbing concerns that I thought we should all consider. The author (who is an MD and PhD in the Department of Medicine at Children’s Hospital in Boston) pointed out that calories displaced by artificial sweeteners may be replaced over time with other fattening sources. (I immediately thought of my dinners with friends…we put sweetener in our coffee and then smugly order a calorie intense dessert.) He also stated that “frequent consumption of hyper-intense-sweeteners may cause taste preferences to remain in or revert to, an infantile state”. This can cause individuals to pass up less intensely sweet foods such as fruit and indeed avoid foods that are unsweet. (There go the vegetables and legumes!). An overly stimulated sweet tooth may end up sabotaging the type of healthy diet that prevents weight gain.

The author then went after diet drinks which, as we know, have no calories and no nutrients. If they are consumed instead of other foods, they can produce a disassociation between sweet taste and caloric intake and hence “disrupt the hormonal and neurobehavioral pathways regulating hunger and satiety”. He cited an experiment in which rodents fed saccharine compared with those fed glucose, increased their overall caloric intake and gained weight. Another study compared rodents’ preference to cocaine versus saccharine…and surprisingly, they preferred the latter! This would seem to show that the taste and desire for sweetness (at least among rats) was more addictive than the desire for abused drugs.

Although he admits that there are no long-term prospective studies of diet drink consumption and body weight in humans, he does cite an observational study: The San Antonio Heart Study found a relationship between diet drinks and measures of adiposity over a 7 year period among 5158 adults. Those that consumed more than 21 servings of diet drinks per week (if you haven’t done the math, it’s 3 a day or what the average diet drink consumer now imbibes), had a 2-fold increased risk of becoming overweight or obese. And in another study of 6814 individuals (The Multi-Ethnic Study of Atherosclerosis), daily consumption of diet drinks was associated with a 36% increase risk for metabolic syndrome (high blood pressure, high triglycerides, high blood sugar, excess weight around the waist and ultimately high risk for coronary heart disease) as well as a 67% greater risk for type 2 diabetes when compared to non diet drinkers.

So what are we to take away from all this? I don’t think the current data constitute a mandate against any diet drink consumption. We certainly don’t want our children (or ourselves) ingesting a major portion of their calories from refined sugars and corn syrup. However, if artificially sweetened drinks replace unsweetened drinks or less sweet food, the result may be weight gain as well as the absence of the nutrition needed to maintain good health. So when you reach for that diet drink or sweetener, why not reconsider and try quenching your thirst with water (flat or carbonated), non fat milk or even tea or coffee sweetened with just 2 teaspoons of sugar. Or, if like me you can’t reach for that sugar, use that yellow, pink or blue packet, but as rarely as possible.