Blood Sugar Heart Health Metabolic

How To Use The HOMA-IR Formula

HOMA-IR stands for Homeostatic Model Assessment of Insulin Resistance. It’s a formula used to estimate insulin resistance in the body. Insulin resistance is a condition where the body’s cells don’t respond effectively to insulin, a hormone that regulates blood sugar (glucose) levels. This can lead to higher blood glucose levels – a characteristic feature of conditions like type 2 diabetes.

HOMA-IR Formula

The HOMA-IR formula typically involves measuring fasting blood glucose and fasting insulin levels and then plugging these values into the equation below.

HOMA-IR = (Fasting Insulin (μU/mL) × Fasting Glucose (mmol/L)) / 22.5

This calculation gives an estimate of how well the body responds to insulin – how efficient the body is at utilizing insulin and blood sugar values. A higher HOMA-IR value indicates greater insulin resistance.

Using the Formula With Clients

First, we’ll say that it’s rarely necessary to use this formula since many other signs and symptoms can be used to estimate someone’s insulin resistance.

However, when we use it, we obtain a fasting insulin level and fasting serum glucose (not a finger stick) and track someone’s progress over time.

It doesn’t matter much what the actual value is; more important is how well we can manipulate the value to improve someone’s longterm cardiovascular outcome.

High Insulin Resistance

Someone with a high HOMA-IR value will have more insulin resistance, which increases their risk of Type 2 Diabetes and cardiovascular disease – specifically, the atherosclerosis associated with heart attacks and stroke.

Fortunately, insulin resistance is something easily manipulated by lifestyle factors. Well, we say easy, but habits are among the most immovable objects in the world.

Alternatives to HOMA-IR Calculation

Many of our clients don’t have access to this test, so here are some alternative methods to estimate if someone is insulin resistant:

1. Fasting Blood Glucose

Whether by a fingerstick test or a blood test, elevated values are suspicious for insulin resistance and metabolic dysregulation.

2. Elevated A1C

The glycosylated hemoglobin value, the A1C, when elevated, often indicates someone is insulin resistant.

3. Glucose Tolerance Test

Often, this is done by having the person eat a sugary drink that has an exact measurement, and multiple blood tests are done to see how the person responds to this glucose challenge test.

4. CGM Measurements

A Continuous Glucose Monitor, often worn on the arm, estimates the serum blood glucose, and high spikes often indicate insulin resistance.

5. Increased Waist Circumference

There are various cutoffs used, such as 35″ for women and 40″ for men. These elevated numbers indicate visceral adiposity, which is associated with insulin resistance.

6. History of Gestational Diabetes

Those with prediabetes, gestational diabetes, or a strong family history of diabetes may be insulin resistant. But of course, this should be confirmed since it’s just a risk factor for this condition.

7. Acanthosis Nigricans

This rather common skin condition is often associated with insulin resistance. It can happen in many parts of the body, not just the neck.

Reverse Your Insulin Resistance!

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Experts: Our Heart Health experts understand the complexities of insulin resistance. We provide personalized strategies tailored to your unique needs.

Proven: We’ve helped countless individuals reverse insulin resistance, leading to improved energy levels, weight management, and reduced risk of diabetes.

Holistic: We believe in addressing the root causes of insulin resistance, not just its symptoms. Our comprehensive approach includes addressing all lifestyle factors and the habits needed to see positive results.

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Heart Health Metabolic Treatment

Uncovering Sleep Apnea

Sleep apnea is one of the factors we use for a Heart Health Risk Score and address to decrease the risks from such a condition.

Briefly, this is a condition in which the body doesn’t get enough oxygen which can lead to brain and tissue injury.

Sleep Apnea Testing

Traditionally, patients have quite a journey when trying to have their sleep-disordered breathing diagnosed. In fact, quite a few primary care physicians can’t get easy insurance approval for sleep studies.

The idea of in-lab sleep testing, where you spend 1-2 nights in a sleep laboratory, is daunting. While an alternative to this is in-home testing, it’s not that much easier.

Is a sleep test necessary?

Current Clinical Guidelines

Clinical guidelines are useful concepts in Western Medicine that allow clinicians to follow similar algorithms for patients.

However, no two patients are alike, and guidelines, when they must be followed or when they become the standard of care, leave many patients and clinicians on the sidelines.

The AASM linked above recommends that, ideally, an in-lab polysomnography be done in a sleep laboratory for a proper sleep apnea diagnosis. Alternatively, an in-home sleep test can be done but with many limitations.

The AASM recommends against the use of clinical questionnaires for the diagnosis of sleep apnea.

STOP-BANG Questionnaire

The STOP-BANG questionnaire screens for the potential of obstructive sleep apnea (OSA), a subtype of sleep apnea. In fact, OSA is the most common type of sleep apnea by a landslide.

This validated questionnaire is more than enough to establish a very high suspicion of an OSA diagnosis.

Of course, whenever possible, we like to make sure. As in, clients are advised to obtain formal in-lab polysomnography (PSG) or, at the very least, an in-home sleep test.

As health coaches, we cannot advise individuals what to do or not do. But our philosophy is that guidelines should be followed unless immediate harm is possible from having untreated sleep apnea.

For our clients, we recommend that they speak to their physicians to decide if an auto-titrating positive airway pressure (APAP) is appropriate for them even before any testing can be performed.

Once treatment has begun, it’s still possible to undergo testing.

Highest Risk Patients

In our experience, individuals at the highest risk for sleep apnea or complications from sleep apnea are those with:

  • heart failure
  • hypertension
  • obesity
  • dementia
  • older age
  • kidney disease
  • COPD
  • heavy snorers
  • daytime fatigue
  • insomnia

If you’re looking for a hassle-free way to get treatment for OSA and want to take a home sleep test, there are companies like Empower Sleep that make the process easier.

For less than $200 you can purchase your own home testing device to diagnose OSA.

Sleep Apnea & Heart Health

There are plenty of articles linking sleep apnea and heart health; no need to dive too deep into that topic again here.

We approach the topic of sleep apnea and cardiovascular health by educating and empowering our clients. These two conditions have a bidirectional relationship; sleep apnea increases inflammation in the body and elevates blood sugars, and cardiovascular disease can make it harder to oxygenate the body.

Is OSA permanent? Not necessarily; certain underlying conditions can be treated to help reverse sleep apnea.

Can OSA treatment improve heart health? It seems that those who have their sleep apnea managed properly with a CPAP machine drastically improve their cardiovascular health.

The Magic of Masks

A properly fitted mask makes all the difference. Too often, people give up on their machines because they have difficulty tolerating their masks.

Finding a mask with the proper fit makes all the difference. Not only are they more comfortable, but they are also more effective.

We recommend working with a good sleep apnea technician or a great salesperson to help you find the full-face or nasal mask that fits you best.

Making the Habit Stick

Our clients fall into 2 categories:

  • those who stick it out with their machines
  • those who give up after 2 weeks

Any new habit takes time to cultivate. There will be setbacks before the habit becomes part of your routine. With tiny, whisper-quiet devices these days, you can travel with them with ease and help the habit stick.

Commuting to work, exercising, brushing before bedtime – none of these were intuitive habits until you did them enough for them to stick.

The goal is to work with the setbacks and ask:

  1. What went wrong?
  2. What can I do differently next time to improve?

Sleep Apnea Health Coaching

Our role as health coaches is to support clients in achieving their ideal health goals by helping them overcome doubts, fears, and hurdles related to changing habits. We leave clinical decision-making to the clinicians.

The goal as always is to prevent major health consequences from cardiovascular disease. We achieve this by focusing on:

  1. managing sleep apnea successfully and consistently
  2. measuring potential outcomes changes based on treatment
  3. adjusting other relevant risk factors to decrease cardiovascular morbidity risk
  4. empowering individuals with knowledge and self-confidence
Heart Health Metabolic

Ideal Body Composition by DEXA

A DEXA scan is traditionally used to measure bone mineral density (BMD) and body composition to delineate body fat content and muscle content.

In further detail, we look at how much of that fat is around vital organs and how much of it is centrally located, and a few other factors.

The critical takeaway of this article is that a DEXA report for body composition tells us if your skinny frame is healthy or harboring ominous fat around organs. And, vice versa, if your larger frame has most of its fat subcutaneously and not anywhere near visceral organs, which would be more protective.

Ideal Body Composition by DEXA Scans

The following report is that of a 29 yo female at 5’5″, 127 lbs.

Reports will vary from person to person and from different companies, but they will have all the data to make the necessary conclusions.

Another sample report can be found here. BodySpec, a favorite DEXA company of our clients at Heart Health Coach, provides this report.

1. Bone Mineral Density (BMD)

Your BMD is reported using a T-score and Z-score, depending on age, and compares you to others in your average age group.

If a compression fracture happens because of low bone density, it will happen in areas such as the hip or lumbar spine.

2. VAT

DEXA for body fat will report the total body fat that encapsulates the fat around the viscera and the fat found under the skin.

We pay close attention to visceral fat since this is the leading inflammatory cause of many metabolic diseases we encounter in practice. It’s this factor that we try to manipulate in our Heart Health practice.

If you are age 50, the ideal total body fat would be around 30%. If you are 25, 27% would be more ideal.

With the main goal of having a total body fat in the 50% percentile and below.

The VAT in grams should be 200 grams for the 50-year-old patient and around 0 for the 25-year-old.

3. Appendicular Lean Mass Index (ALMI)

Lean mass goes down with age, and preserving this is quite protective.

We use ALMI to accurately estimate the amount of lean muscle mass in your body. Each body part – arms, legs – has its own lean mass index.

4. Fat-free Mass Index (FFMI)

FFMI can be used the same as the ALMI, but when there is a discrepancy, we rely on the ALMI. That’s mostly because the FFMI includes the organs and bone and is factored into your height.

The goal would be to stay north of the 97th percentile, but not everyone can achieve this. Your genes may never allow you to reach a 97th percentile of muscle mass, so we approach your health individually.

Addressing Results from a DEXA Body Report

There is a lot of data, and it can feel overwhelming. The main questions to ask are:

  1. Am I overweight?
  2. Do I have excess fat around my viscera?
  3. Do I have enough muscle mass?
  4. Is my bone mineral density adequate?

The actionable items are:

  1. More resistance training
  2. More cardiovascular training
  3. Increasing protein consumption
  4. Decreasing insulin resistance

We can manipulate these last 4 levels at Heart Health Coaching, always with the person in mind, aiming to manipulate factors that will result in the biggest gains.

There isn’t a perfect but perhaps ideal body composition by DEXA which should be a second goal. The primary goal is to feel better and lower the Heart Health Risk Score.

Diet Heart Health Metabolic

Approaching Weight Loss

The topic of weight loss is both a medical topic and one that is emotionally charged. Many of my health coaching clients blame themselves for their weight problems and believe that more willpower will lead to better outcomes.

Being overweight or the diagnosis of obesity is a medical condition the same way pneumonia or back pain is a diagnosis. If gaining weight is done simply by eating more then eating less should result in weight loss. And this discrepancy is precisely why weight loss is more complex.

My approach to weight loss is unique as I’ll highlight below. For those whose weight negatively affects their cardiovascular health, we create an individualized plan and tackle obstacles to obtaining an ideal weight.

Reductionist Thinking

In western medicine reductionist thinking is abundant. If you have a urinary tract infection you must take an oral antibiotic. If anyone has diabetes they must be started on medications.

Reducing any concept down to one easily explainable idea is a pitfall. It prevents more insightful thinking.

I don’t reduce obesity down to a calorie issue. This makes sense on paper in a calorimeter but the human body is agnostic to our mental models.

Weight Loss Drivers

There are several factors that affect weight loss. I see this in my clinical practice when a patient unintentionally loses weight. Below are examples.

56-year-old Mary

Mary is a 56-year-old woman who always carried an extra 50 lbs, as she put it. Her kids had grown up and she got laid off which was the perfect excuse to move to a remote city in Mexico where her husband found a job with an electrical company.

The type of food she had access to was very different there. Busy with getting settled in she didn’t pay any attention to her weight until her clothes started being too big. Without pizza, pasta, ice cream, or bagels her weight was coming down rapidly.

The activity levels she always wanted to engage in like riding a bike or hiking suddenly were much easier. It was her lower weight that made it easier for her to be more active. This, in turn, made her lose even more weight.

44-Year-Old Jesus

Jesus got diagnosed with an inflammatory bowel condition which caused him severe diarrhea and bloody stools. He was about to lose his health insurance so he decided to not start on any new medications but he met with a nutritionist who suggested a diet to help prevent further flare-ups.

Jesus was petrified of the blood in his stool and was committed to never seeing that again. Though stressed about work he bought those college-style bound notebooks and kept a food journal and meal planned as instructed by this nutritionist.

He was told to eat fish, olive oil, fruits, nuts, seeds, oats, and legumes as much as he wanted. The items to avoid were bread, white rice, alcohol, pasta, desserts, and anything fried.

Jesus was never worried about his weight and felt that for his height he had a normal physique. At 5’10” and 205 lbs he described himself as stocky but not fat or skinny/scrawny, which was what kids teased him about when he was in grade school.

9 months later when he found a new job and could afford health insurance again, he saw me for the first time and was quite concerned about his weight loss. He had lost around 27 lbs and believed it was due to the inflammatory bowel disease.

Foods that Help with Weight Loss

It’s clear from the examples above that changes in what we eat impact weight loss. For some individuals certain foods are obesogenic – they cause a high spike in blood sugars which results in fat deposition and more hunger.

But there is no one diet that helps every person lose weight – human physiology is simply not the same from person to person.

I, for example, can eat a lot of fruit without gaining weight. Trying the same diet for some of my patients results in rapid weight gain. Therefore, it has to be individualized. But some generalizations can be made.

1. Slow Carbs

Slow carbs are whole grains and seeds such as 100% whole wheat or brown rice, quinoa, barley, oats, etc. These tend to not cause a sudden spike in blood sugars which helps curb hunger later in the day but also signals decreased weight retention.

Slow carbs versus higher glycemic load or glycemic index carbs seem to also help lower high blood pressure. Something Jesus also noticed from the example above.

2. Fiber

Fiber is filling and helps many maintain healthy gut flora. Though some believe that fiber is not needed many of my patients do well with it, anecdotally.

Avoiding it is generally a bad idea. But it’s easy to overdo it. Beans, generally quite high-fiber, can be well tolerated by some but someone else can only handle 1/4 cup without getting a lot of GI symptoms.

3. Healthy Fats

Certain fats are more obesogenic. Milk and fatty meats seem to not be ideal food choices for weight loss.

Olive oil, fish, avocados, nuts, and seeds are better fat/oil choices for someone trying to lose weight.

Some physicians recommend avoiding fats altogether and eating more starches. Perhaps you have the kind of physiology which would respond well to this. Experiment and find out.

4. Plant Proteins

Animal foods tend to be a bit more calorie-heavy but less nutrient dense. As in, they satisfy your macronutrient needs but may not have enough micronutrients.

Obtaining proteins from plants is a good option for many of my Heart Health coaching clients. Does this work for everyone? Absolutely not. We are all unique and our response to certain foods must be taken into consideration.

5. Nuts

Without brown rice or something oily, it’s hard for me to feel satiated. Nuts and seeds are ideal for me after a lighter meal. It’s my dessert and helps me feel full.

I could also feel full with a fatty whip cream or ice cream dessert but the weight and health consequences from that aren’t worth it.

Heart Health Metabolic Prevention

The Body Mass Index Limits

The Body Mass Index has had its fair share of troubles because it’s open to interpretation. Those who are muscular are comfortable being in the upper limits of it, and those who exercise a lot are comfortable in the lower ranges. Let’s discuss body mass index limits to avoid any confusion.

Body Mass Index Examples

I’m around 165 lbs and 6′. This brings my BMI to 22.4. My friends consider me too skinny when they look at me. In fact, I could lose more weight around the midsection and still would be healthy.

Unaccounted for here is that I could gain 18 lbs, and my BMI would still be normal at 24.8. So I would be okay?

Unfortunately, no. The extra 18 lbs would increase my metabolic disease risk, negatively impacting my heart health.

Using the BMI

There are limits to using the body mass index to monitor your health. But I use it as an assessment of my patient’s initial health.

My BMI of 22.4 is a good start. Knowing other factors, such as my cardiovascular risk factors, activity levels, and genetic factors, is essential.

The CDC states that a BMI between 18.5 to 24.9 is a “Healthy Weight range,” which isn’t true for everyone, as seen in the example above.

Other Weight Factors

I like to know how much weight my client has gained and over what period of time.

Equally important is the location of the majority of the weight. Central weight versus more spread out makes a difference.

Blood pressure, snoring scores, energy levels, basal heart rate, and heart rate variability can also be helpful when considering someone’s BMI.

Book a Heart Health consult with me today!

Heart Attacks Heart Health Metabolic Statins

Atherosclerosis and Inflammation

Coronary plaque undergoes a specific transformation that ends up causing a blockage of the vessel and eventual ischemia. In this article, I will discuss the basics of how atherosclerosis and inflammation play a role in heart health.


Plaque is the buildup inside an artery, leading to decreased blood flow and sometimes complete lack of blood flow – obstruction. It begins far deeper in the vessel wall before you see anything protruding through into the lumen of the artery.

With obstruction comes ischemia – lack of oxygen to the nearby tissue, not just muscle but the vessels themselves, the nerves, and connective tissue.

You need cholesterol to form this plaque. With a total cholesterol value below 150, achieved naturally without medications, it’s rare to see someone develop much plaque in their arteries.

Another ingredient for plaque buildup is hardened vessels and increased pressures or turbulent blood flow through those vessels. Hypertension can cause this; lack of exercise or inflammation can also contribute.

Unstable Plaque

Let’s lay the cards flat on the table – we know little about inflammation. Astute clinicians can recognize inflammation when they see it. There are specific biomarkers that are helpful as well.

Inflammation adds to the problem of atherosclerotic and negatively affects heart health because it leads to unstable plaques.

A plaque is like a scab on a wound. If it’s the right time for it to come off, it’ll fall off without any bleeding. Rip it off prematurely, and you’ll get fresh blood.

Fresh blood will clot in the artery and create an unstable plaque that is prone to rupturing and exposing those raw surfaces. Suddenly you go from a tiny plaque to a massive clot that halts all blood flow in that artery.

Measuring Inflammation

Several biomarkers can tell us there is inflammation. But it’s not biomarkers alone we use in our risk stratification.

Some people with inflammation in their bodies may never develop unstable plaque. And some with inflammation may not have much plaque to begin with.

If someone has atherosclerosis, the goal is to increase their exercise capacity – both cardiovascular and anaerobic. Next, we want their systemic inflammation to be as low as possible.

Examples of inflammatory biomarkers are below. Some are nonspecific markers, and others are specific to the atherosclerotic cardiovascular disease.

Atherosclerosis and Inflammation

In regards to heart health, atherosclerosis isn’t a death sentence. Most of us will develop it, and less than half of us will suffer heart attacks or other complications because of it.

Preventing atherosclerosis is what we encourage in our Heart Health program. But most of those who come to us already have atherosclerosis.

Plaque and inflammation have an essential relationship in Heart Health which we address with this second group. We want to decrease their total body inflammation to allow newly formed plaques or old plaques to stabilize.

Statins lower inflammatory markers independent of their lipid-lowering effects. Perhaps this is another reason why they are effective and reducing cardiovascular death.

In a meta-analysis of 26 randomized controlled trials involving over 160,000 participants, statins were shown to reduce the risk of all-cause mortality by 10% and the risk of cardiovascular mortality by 15%.

Other Inflammatory Markers

Even without serology, we can tell if someone has inflammation. More importantly, how much more actionable information do we get beyond the basic inflammatory markers?

The following are inflammatory markers I use based on signs and symptoms:

  • obesity
  • acne
  • rosacea
  • seborrheic dermatitis
  • joint pain
  • fatigue
  • sleep disturbance
  • agitation
  • sound sensitivity
  • GI changes
  • heavy menses
  • concentration issue

As you can imagine, these are rather subjective. Even if you have a little bit of all of this, it doesn’t mean there is inflammation.

We use these data points as a guide. With them, we change our diet and lifestyle and reevaluate. If these markers decrease, then inflammation is likely.

Interventional Steps to Consider

First, where’s the fire? What we mean by this is that the person likely isn’t about to have a heart attack or die from their inflammation.

Let’s figure out why the inflammation is there; stress, insomnia, too much exercise, dairy, wheat, or environmental exposures.

Next, we recommend testing those values, which are the most sensitive markers of inflammation, and see if there was any change.

Nattokinase or curcumin decreases inflammatory markers such as the commonly tested hs-CRP and fibrinogen.

Normal LDL Levels?

Imagine the LDL-C levels of a person are normal. How could we predict what their heart attack and death from heart attack risk would be?

Paul Ridker et al. did a wonderful study highlighting this relationship and showed that hs-CRP would be a bigger predictor of a heart attack or death when a person has normal or even high LDL-C levels.

Heart Health Metabolic

Obesity and Cardiovascular Health

In my practice, I focus on obesity and cardiovascular health only when weight clinically affects heart health. Obesity, in isolation, if all else is optimized, offers only slight improvement if corrected.

Obesity has become a sociopolitical topic rather than a medical one. In my practice, I don’t focus too much on obesity unless it is a unique contributor to my client’s heart health.

Obesity in Healthcare

In western medicine, the patient is considered sick if their BMI is over 25. The patient will always have an ICD-10 code stuck somewhere in their medical chart.

It’s hard to know why conventional medicine manages patient health in such a way. Perhaps it expedites care and makes insurance billing simpler.

It is true that carrying extra weight puts most people at increased risk of insulin resistance, joint problems, sleep apnea, certain cancers, and other metabolic issues. But not everyone.

A person can be obese (BMI > 25) and relatively healthy. They manage their stress well, they are active, and their diet is optimized for their individual needs.

Vice versa, a person can have a normal BMI and not have an ideal metabolic profile. They can still have sleep apnea, hypertension, insulin resistance, and increased cancer risk.

Personal Perspective on Weight and Heart Health

I have clients who carry extra weight but live a good life. They have a diet that fits their individual needs, and they aren’t suffering in any significant way due to their weight.

For such individuals discussing obesity is clinically unnecessary. The minor percentage points of health advantages may not be worth the effort needed to change their weight.

If weight is an important topic, however, affecting their heart health, then we make that a priority. Think of sleep apnea or insulin resistance.

Obesity And Heart Health

I’ve worked with many heart health coaching clients and many of heart risk factors due to their lifestyles. Much more so than due to their body mass index.

We work together to improve their diet, stress, exercise, breathing, chemical exposures, and relationships that change their heart disease risk and improve their heart health.

If my client has the ideal diet, lifestyle, clean environment, sleep, and social support but remains overweight or obese, then we perform calculations to assess their ongoing risk.

This final risk score is how we determine if a weight reduction would add meaningful results; if it would improve this person’s heart health.

The Current Obesity Research

Look, all else equal, it’s potentially better to have a lower BMI – up to a point, of course.

However, we’re talking about an individual and not the population. The current research, just like most research, uses statistics to draw general conclusions. And it generally states a strong correlation between obesity and cardiovascular health.

General conclusions don’t define you and must be carefully applied to individuals. Otherwise, it’s easy to do a lot and not get results.

Most individuals who suffer from obesity also tend to have poor diets. They tend to be sedentary and, therefore, strongly correlate their weight and heart health.