Framingham and the Muddy Waters Jeffry N. Gerber, MD Denver’s Diet Doctor

“Those with cardiovascular disease not identified with diabetes… are simply undiagnosed” - Dr. Joseph R. Kraft

Dr. Joseph R. Kraft - diabetes-epidemic.com

FBG>100 mg/dl (5.5 mmol/l) screening 2hr OGTT>140 mg/dl (7.8 mmol/l) HbA1c Standard Methods Inferior

Gold standard based on RIA insulin (uIU/ml) 14,384 subjects, 5hr glucose plus insulin Defined 5 distinct patterns 3 patterns of hyperinsulinemia – Diabetes In-Situ Redefining diabetes at its earliest stage Dr. Kraft 5hr Insulin Assay

Image curtesy Ivor Cummins BE(Chem) CEng MIEI Pattern 1 - Euinsulinemia

Image curtesy Ivor Cummins BE(Chem) CEng MIEI Patterns 2,3,4 - Hyperinsulinemia

Image curtesy Ivor Cummins BE(Chem) CEng MIEI Patterns 5 - Insulinopenic

Hyperinsulinemia before Hyperglycemia Catherine Crofts M.Phil, B.Pharm, NZRegPharm, PhD Candidate Public Health. Images curtesy Ivor Cummins BE(Chem) CEng MIEI

Glucose vs. Insulin Data recompiled from Kraft J. R. Diabetes Epidemic & You. 2011

Euglycemia

Hyperglycemia

NHANES prevalence 2015: 49%-52% in the US now pre-diabetic or diabetic UCLA 2016: 55% of Californians are pre- diabetic or diabetic Kraft would predict that many more have hyperinsulinemia Predicting population risk Menke A, et al. JAMA. 2015;314(10): doi: /jama healthpolicy.ucla.edu/publications/search/pages/detail.aspx?PubID=1472

Diabetes Paradox? Despite more diabetes & obesity there’s less heart disease Morbidity & mortally not to be confused with incidence and prevalence Diabetes Care March 2003 vol. 26 no doi: /diacare

Atherosclerosis is a metabolic disease Missing pre-diabetes and diabetes also misses cardiovascular disease Dr. Kraft on CV risk

Gerald M. Reaven, MD Diabetes December 1988 vol. 37 no doi: /diab Slide curtesy lipidsonline.org

Lipids, Smoking, HTN, Diabetes Guidelines, risk calculators Lowering cholesterol Diabetes risk buried Framingham Distraction

Hyperlipidemia requires remedy Mechanisms remains elusive Diet-heart hypothesis unproven Statins provide small benefit Lipid Lowering Therapy

Get with the Guidelines 2009 Towards a Paradigm Shift in Cholesterol Treatment 2015 Debunking the Lipid Hypothesis

Mark A. Creager et al. Circulation. 2003;108: Hyperinsulinemia and blood vessel damage

Framingham risk calculators: CV risk increased 2-3 fold (middle risk population) Diabetes alone: CV risk increased 6-8 fold Framingham vs. Diabetes Risk Circulation. 2002; 105: e132-e137 doi: /01.CIR

Atherosclerosis is a symptom of diabetes Focus insulin excess, IR, and inflammation Many at risk are missed Diet and lifestyle, not medicine It’s the Insulin Stupid!

Low carb best Eliminating processed food Eating less Movement & activity Smoking cessation Proper sleep & happiness Diet and Lifestyle

Early level of suspicion FBG & HbA1c - are poor screening tools alone 2 hr OGTT including 1hr glucose <155 mg/dl (8.6 mmol/l) Insulin - fasting, 5hr assay, 2hr <30 uIU/ml Inflammatory markers, lipid quality, etc… Clinical assessment doi:

Heart catheterization CIMT IVUS CT angiogram Coronary artery calcium score Cardiovascular imaging

CAC Score J Am Coll Cardiol Img. 2015;8(5):

CAC Progression Arterioscler Thromb Vasc Biol. 2004;24:

Diabetes is a Vascular Disease

Hyperinsulinism, Inflammation & Adiposity