What you should expect Dr. Jogi to tell you about your labs.

Labs to interpret your metabolic state:  fasting insulin, lipids, AST and ALT. 

1) Triglyceride to HDL ratio is important

Less than 2.5 Caucasians and Less than 1.5 African Americans is the goal. 

If the ratio is higher then patient has too much small LDL and cardiac risk is high and is a good measure of insulin resistance 

HDL goal is more than 60

2) Fasting insulin is important

Less than 10 is good,  less than 7 best. Above 15 not good  and the patient is eating poorly and needs a dietary intervention ASASP. 

High insulin represents diseased fatty liver because the pancreatic vein drains to liver first. If liver fatty then insulin resistance. High insulin is fat storage and inflammatory throughout body. 

3) High LDL is not always bad and statin not always needed. 

The cholesterol is the "cargo". There are two types of LDL cholesterol (LDL-C) . On a regular lipid profile only the LDL-C is measured.  There are two cholesterol transport "vehicles" that carry the cholesterol (1) large buoyant LDL and (2) small dense LDL. The large LDL does not impact cardiac disease. The small dense LDL is the bad actor and can measure directly but costs more to process and regular lipid panel.  

Just use the Trig/HDL ratio 

Where does the LDL come from?

• Triglycerides are the form of cholesterol the the liver produces with the assistance of INSULIN.  

• Insulin stimulates the liver to CONVERT SUGAR TO TRIGLYCERIDES.  (see Fig 1 below). 

• Triglycerides are not created from fatty food intake. They are generated by sugar intake. Then the triglycerides float in the blood stream in the form of VLDL to distant tissues to drop off the cholesterol. 

• Once the cholesterol is delivered to distant tissues (muscles and other organs) then there are two forms of LDL-C  packaging left over: a) large buoyant LDL and small dense LDL and also HDL. 

• The small dense LDL causes heart disease. A high Triglyceride to HDL ratio can indicate high small dense LDL levels. 

 The  small dense is strongly associated with cardiac disease. The large floating ones are less harm associated. You can reduce the small dense with high insoluble fiber diets combined with carbohydrate restriction.

The doctor has to order fasting NMR lipid profiles for getting the particle information. 

QUEST ADVANCED LIPOPROTEIN LABS INTERPRETATION

LDL Particle number: 

Relative Risk: Optimal <1138; Moderate 1138-1409; High >1409. 

Male and Female Reference Range:  1016 to 2185 nmol/L.

LDL Small:

Relative Risk: Optimal <142; Moderate 142-219; High >219. 

Male Reference Range: 123 to 441 nmol/L; Female Reference Range: 115 to 386

LDL Medium

Relative Risk: Optimal <215; Moderate 215-301; High >301. 

Male Reference Range: 167 to 485 nmol/L; Female Reference Range: 121 to 397

HDL Large

Relative Risk: Optimal >6729; Moderate 6729-5353; High <5353. 

Male Reference Range: 4334 to 10815 nmol/L; Female Reference Range: 5038 to 17886 nmol/L.

LDL Pattern

Relative Risk: Optimal Pattern A; High Pattern B. Reference Range: Pattern A.

LDL Peak Size

Relative Risk: Optimal >222.9; Moderate 222.9-217.4; High <217.4. 

Male and Female Reference Range: 216 to 234.3 Angstrom. 

Adult cardiovascular event risk category cut points (optimal, moderate, high) are based on an adult U.S. reference population plus two large cohort study populations. Association between lipoprotein subfractions and cardiovascular events is based on Musunuru et al. ATVB.2009;29:1975. For additional information, please refer to http://education.QuestDiagnostics.com/faq/FAQ134 (This link is being provided for informational/educational purposes only.)This test was developed and its analytical performance characteristics have been determined by Quest Diagnostics Cardiometabolic Center of Excellence at Cleveland HeartLab

Apolipoprotein B

Risk: Optimal <90 mg/dL; Moderate 90-119 mg/dL; High >= 120 mg/dL;

Cardiovascular event risk category cut points (optimal, moderate,high) are based on National Lipid Association recommendations-Jacobson TA et al. J of Clin Lipid. 2015; 9: 129-169 and Jellinger PS et al. Endocr Pract. 2017;23(Suppl 2):1-87.

Lipoprotein (a)

Risk: Optimal <75 nmol/L; Moderate 75-125 nmol/L; High >125 nmol/L.

Cardiovascular event risk category cut points (optimal, moderate, high) are based on Tsimika S. JACC 2017;69:692-711.

LABCORP ADVANCED LIPOPROTEIN LABS INTERPRETATION

** INTERPRETATIVE INFORMATION- PARTICLE CONCENTRATION AND SIZE

                   <--Lower CVD Risk                  Higher CVD Risk-->

 LDL AND HDL PARTICLES   Percentile in Reference Population

 HDL-P (total)        High     75th    50th    25th   Low

                               >34.9    34.9    30.5    26.7   <26.7

 Small LDL-P          Low      25th    50th    75th   High

                                <117     117     527     839    >839

 LDL Size   <-Large (Pattern A)->    <-Small (Pattern B)->

                                 23.0    20.6           20.5      19.0

Small LDL-P and LDL Size are associated with CVD risk, but not after LDL-P is taken into account. 

INSULIN RESISTANCE MARKER

                              <--Insulin Sensitive    Insulin Resistant-->

                                   Percentile in Reference Population

Insulin Resistance Score

                          LP-IR Score   Low   25th   50th   75th   High

                                                     <27   27     45     63     >63

LP-IR Score is inaccurate if patient is non-fasting.

                                          .

How does the PANCREAS-> LIVER portal blood flow work?

Portal system flow diagram:

heart -> aorta -> artery -> organ 1 (pancreas)  -> vein  -> organ 2 (liver)-> inferior vena cava -> heart 

Why is fatty liver a problem?

Fatty liver occurs due to sugar intake which manifests as small dense LDL. When you get fatty liver your liver does not work properly. The pancreas will have to make more insulin to tell the liver to work correctly. The pancreas makes insulin and the liver the the primary target.  Insulin is good at reducing sugar BUT everywhere else in the body insulin is damaging (chronic diseases of prostate, brain, blood vessels, cancers).  

4) ALT more than 25 indicates you have a fatty liver

Normal ranges have increased to 40 or less because  the population is now unhealthy. The "normal" ranges are based on population averages and keep increasing. "Abnormal" is more than 2 standard deviations above the population mean.  In the 1970s then normal range of ALT was 25 or less. 

ALT more Than 25 is a problem =fatty liver. 

If uric acid concentration in blood is high it is a proxy of fructose metabolism. Less than 5.0 is best. 

AST is minute to minute depends on a recent meal

ALT is a more stable way to understand liver metabolism

5)  Fix fatty liver

• Intermittent fasting and diet changes

• No processed food

• No alcohol 

Labs to evaluate diabetes mellitus type 1: hemoglobin A1c, CBC, lipids and microalbumin to creatinine ratio, and AST and ALT and creatinine, and CGM

1.  See section about metabolism above

If any of the metabolic markers above are off, then a type 1 patient may have developed metabolic syndrome on top of their type 1 lack if endogenous insulin. Diet Diet Diet is the best intervention. Exercise is useful. 

2.  Hemoglobin A1c is a 3 month average of your blood sugars:

A1c should be less than 7.0-% in patients with diabetes less than 10 years who do not have heart disease. Less than 8.0% in patients with CAD and more than 10 years of diabetes or those with advanced age or limitations on the ability to handle hypoglycemia. Also the goal in type 2 diabetes to cured the diabetes with a1c less than 5.5% without medication, using dietary changes alone. The A1c can be wrong in certain patients especially if a patient's hemoglobin is abnormal or if the creatinine is elevated. 

A1c alone is not a great indicator of a patient's health or blood sugar control. 

3. Urine microalbumin to creatinine ratio more than 30 suggests a problem with kidneys

Higher than usual ranges suggests that your blood pressures or blood sugars have been too high, leading to early changes of kidney failure.  Changes in diet and medications, such as adding ACE inhibitors or ARB medications can repair the kidney.

4. Continuous glucose monitoring is the safest way to monitor blood sugars while on insulin.

Dr. Jogi believes a continuous glucose meter is mandatory for all patients on insulin and patients that are afraid of wearing the device need to rethink their priorities. Also once on insulin the only way to change your diet to get off diabetes medication is with a CGM like dexcom or libre. 

5. GAD and fasting c-peptide tell us the future

If your GAD antibody is positive it means a patient is at higher risk to develop an autoimmune reponse to the pancreas leading to a lack of insulin production and resultant type 1 diabetes. A nonfasting cpeptide of less than 0.9 with concurrent blood sugar more than 150 is a sign that you are on the way to having type 1 diabetes. Less than 0.1 means you probably do have type 1 diabetes. 

Labs to evaluate diabetes mellitus type 2: hemoglobin A1c, CBC, lipids and microalbumin to creatinine ratio, and AST and ALT and creatinine, and CGM

1. Metabolic syndrome is probably the root cause. 

If you have type 2 diabetes, even if you are not fat then you really need to pay attention to the section on metabolic syndrome. 

Read everything in section on Type 1 diabetes, it applies

Labs to evaluate all other conditions read here