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From The Desk Of Clarence Bass

"There's not one shred of evidence that insulin resistance causes obesity." Gerald Reaven, M.D.

If you have Syndrome X, a low-fat high-carbohydrate diet could give you heart disease.

SYNDROME X, The "New" Heart Disease Risk

Medical science is learning more all the time about the causes of heart disease, and what you can do to lower your risk of having a heart attack. One of the latest discoveries comes from Gerald Reaven, M.D., and his colleagues at Stanford University School of Medicine. It's called Syndrome X, which is a cluster of metabolic disorders that represent a major risk of coronary heart disease. People who have Syndrome X do not respond well to insulin; they are insulin resistant. Their pancreas is forced to secrete excessive amounts of the insulin to dispose of glucose, or blood sugar, by moving it into muscles and fat cells. These people don't have diabetes, because they produce enough insulin to overcome the resistance, but the high insulin levels lead to elevated blood triglycerides (fatty acids), low HDL ("good") cholesterol, high blood pressure and other signs of Syndrome X.

Dr. Reaven's new book Syndrome X (Simon and Schuster, 2000) gives the history of his discovery. In 1968, Dr. Reaven and his colleagues published the first studies on the concept of the insulin resistance. Up to that time it had been thought that the only issue was how much insulin the body could make. Doctors didn't know that people vary greatly in their ability to use insulin. They didn't realize that some people don't respond effectively to insulin and are, therefore, insulin resistant. (People who can't produce enough insulin to overcome the resistance and regulate their blood sugar by definition have Type 2 diabetes.)

More Than 25 Years of Study

After 25 years of additional study and observation, Dr. Reaven published the first paper showing that insulin resistant people, who do not develop Type 2 diabetes, are still at great risk of developing what he called Syndrome X - and heart disease. According to Dr. Reaven, excessive insulin may harm the interior lining of the coronary arteries and trigger changes that lead to heart disease and eventually heart attack.

Dr. Reaven has published two studies showing that Syndrome X raises the risk of heart disease. In one study, he and his colleagues followed 147 individuals (average age 50 and healthy at the start) for five years, and found that one out of seven of the third that were the most insulin resistant had a heart attack during the study. In the third who were the least insulin resistant, says Dr. Reaven, "not a single person had a heart attack." In another study, he followed 650 people for 10 years. In the quarter with the highest insulin resistance, about eight percent had a heart attack. In the rest of the people, only one or two percent had a heart attack.

Reaven estimates that 33 to 40 million Americans, not counting those with diabetes and high blood pressure, are insulin resistant and may have Syndrome X. How can you determine whether you are at risk, and what can you do to protect yourself?

Signs of Syndrome X

Dr. Reaven suggests that you see a physician familiar with Syndrome X, if your: fasting glucose is over 110, fasting triglycerides are over 200, fasting HDL is under 35, and blood pressure is over 145/90. If you are also overweight, inactive and have a family history of heart disease or diabetes, your risk of Syndrome X is substantially increased.

If you're at risk, the first thing to do is lose weight if you are overweight (being fat increases your need for insulin) and become fit (exercise makes you less insulin resistant).

The diet Dr. Reaven recommends for those with Syndrome X may surprise you; it runs counter to the recommendations of the American Heart Association. Cutting back on fat and eating more carbohydrates is good for many people, says Dr. Reaven, "but it's not the best advice for those with Syndrome X."

The Syndrome X Diet

The best diet for people with Syndrome X, according to Dr. Reaven, is 45 percent carbohydrates, 40 percent fat and 15 percent protein. As you'll see, his reasoning is simple and straightforward. It makes sense as long as you keep in mind that the main problem for people who have Syndrome X is high insulin levels caused by insulin resistance.

First, he recommends eating less carbs than suggested by the American Heart Association (55 - 60 %), "because you have to secrete more insulin to handle the carbs if you are insulin resistant." He recommends cutting carbs to 45 percent, because carbohydrates are converted to glucose in the digestive process, and the body must produce insulin to move the glucose into the tissues where it can be stored or used as energy. It's simple: Eat fewer carbs and you'll produce less insulin.

Second, Reaven suggests upping fat intake to 40 percent, because insulin levels do not increase when you eat fat. "Fat has no effect on insulin levels," says Dr. Reaven. "Eat more, eat less, your insulin level will not budge. However, if you substitute fat for carbohydrate, your insulin level will fall." In other words, you must do both. If you increase fat, you must also cut carbs.

There's a caveat, however. "Not any fat will do," says Reaven. He recommends restricting your intake of saturated fat to five - 10 percent. Substituting saturated fat for carbs would be a mistake; it would lower your insulin level, but it would also raise your "bad" LDL cholesterol. What you want, says Dr. Reaven, is unsaturated fat. He suggests 30 - 35 percent mono and polyunsaturated fat. "These 'good' fats keep insulin and LDL under control, which means that this approach guards against the 'new' kind of heart disease caused by Syndrome X as well as the 'old' kind associated with elevated LDL."

Protein Increases Insulin Production

But why keep protein to only 15 percent? Again, Reaven's rationale is simple, if you keep in mind that insulin resistance is the problem for people with Syndrome X. He says diets such as Barry Sears' The Zone, which substitute protein for carbs, don't do anything for people with Syndrome X. "Unfortunately, protein also increases insulin secretion," says Reaven. "Why trade one insulin- raising nutrient for another?" Reaven's explanation will be a shocker for many high protein advocates: "Protein is broken down into amino acids during digestion, and... amino acids stimulate the pancreas to release more insulin."

(This doesn't mean that hard training athletes who have been proven to require more protein than sedentary individuals - and who are not insulin resistant - should restrict protein intake. On the other hand, bodybuilders and other athletes should not overdose on protein.)

Diet Books Are Wrong About Insulin Resistance

Dr. Reaven also maintains that insulin resistance doesn't make people fat, as many diet books claim. "Years ago, we put people with different degrees of the insulin resistance on dramatically different diets. In one study, carbohydrates were either 85 or 17 percent of calories. The only thing that affected their weight was how many calories they ate." ... "There's not one shred of evidence that insulin resistance causes obesity," says Dr. Reaven. In fact, there's no reason to believe that insulin resistance causes obesity. It doesn't make sense, according to Dr. Reaven. "Insulin resistance means that insulin isn't acting correctly. So if you don't have enough insulin or if your cells aren't responding to insulin, you can't deposit glucose into cells. If anything, you would lose weight."

Even though Dr. Reaven's self-assessment quiz suggests that my Syndrome X risk is very low (one on a scale of 1-13), I found his book to be thought provoking and informative. For the general population, I believe the basic message is that people who are overweight and unfit may benefit from a moderate reduction in carb intake and some addition of good fat. They should also lose weight and become more active, of course. And they should keep in mind that calories do count.

Hard training athletes who are lean and fit should probably continue eating more carbohydrates and more protein than Dr. Reaven recommends. Both fit and unfit people alike should avoid refined carbohydrates, and stick as much as possible to whole, natural foods in the "as grown" state. With a few rare exceptions, everyone should eat plenty of fruit, vegetables and whole grains.

I highly recommend Syndrome X. (The book, not the disease.)

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