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Heart Health

What’s Your ABI? Peripheral Vascular Disease

ABI normal ranges for ankle-brachial index

Knowing your Ankle-Brachial Index (ABI) can not only help you determine your risk of cardiovascular disease but helps you prevent major complications of peripheral vascular disease. What’s your ABI?

Measuring Your ABI

The easiest way to measure your ABI is with a manual blood pressure cuff and a handheld Doppler.

Not all clinics can do this, but any vascular office can do this for you. Many of our patients will perform this themselves if they are at risk for peripheral vascular disease.

Peripheral Vascular Disease

Cardiovascular disease often manifests with atherosclerosis which can lead to calcification and/or hardening of the arteries.

This stiffening of the vessels will often cause the ABI (ankle blood pressure divided by arm blood pressure) to be low and, in some instances, too high.

Stiffening of the arteries in the lower extremities, which is the hallmark of Peripheral Vascular Disease (PVD) can present with weakness in the legs, cramps, or pain.

ABI normal ranges for ankle-brachial index

The ideal ABI is in the 1.0 – 1.4 range. Any value of 1.4 could indicate stiffness of the arteries. If the value is below 0.8, it would indicate blockage of the arteries in the lower extremities.

ABI Testing at Home

The best way to test your ABI at home would be to purchase a manual blood pressure cuff and obtain a handheld Doppler, which measures fetal heart rate.

Both of these are quite inexpensive and you can purchase them online or at most medical supply stores.

Inflate the cuff to make the arterial sound disappear, and release pressure until the sound reappears. This is the systolic reading for both the arm and the leg.

Great ABI Video from Standford

The following video shows how to measure your ABI in the ambulatory (outpatient) setting to determine someone’s risk for PVD.

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Blood Sugar Diet Heart Health

Stubborn Fasting Blood Sugars

You’ve lost weight, improved your activity level, changed your diet, and that stubborn fasting blood sugar won’t get below 110.

In this article, I’ll share how we approach such outcome discrepancies in our Heart Health Coaching practice. With the most important caveat that any improvement is a massive step in the right direction; and that perfection is the enemy of progress.

Elevated Fasting Blood Sugar Troubleshooting

In this case presentation, we assume that you are actively involved in improving your blood sugars whether you are a non-diabetic, prediabetic, or type 1 or 2 diabetic.

For some reason, your actions have made a huge improvement in your A1C percentage and your postprandial sugars but the morning fasting sugars remain high.

1. Data Error

The CGM (continuous glucose monitor) our client is wearing might show elevated morning sugars, but is it accurate?

Confirming any values with a handheld glucometer and serum fasting blood sugars is best. As a bonus, we also recommend our clients check their fasting insulins.

2. Body Composition Issue

Some of our clients are underweight, and others are overweight. Is there excess visceral fat in the body?

A DEXA scan will tell us if the client has too little muscle mass or too much visceral fat.

3. Stress & Sleep

If there is undiagnosed sleep apnea or elevated stress levels, the fasting blood sugar will be hard to control.

Managing sleep and stress is just as important, if not more, than diet or exercise levels.

4. Dietary Extremes

A few clients, especially those in their 70s, seem chronically undernourished. A low dietary protein content combined with androgen deficiency leads to rapid loss of muscle mass, which is necessary for proper fasting blood sugar regulation.

5. Exercise Balance

Are you doing too much cardio and not enough resistance training?

We see too much cardio and not enough resistance training. It’s only been in the last decade that science has pointed toward the importance of weight lifting.

6. Excess Fasting

What does time-restricted eating do to your blood sugar long-term, not just short-term?

Some will do great with fasting, but many will experience glucose desensitizing during the fasting state and experience massive spikes upon waking, resulting in stubborn fasting blood sugars.

Improvement May be Enough

We remind clients that improving blood sugar profiles may be more than enough. Rarely do we recommend long-term use of blood sugar measurement via handheld glucometers or CGMs.

Even with some elevated values, health improvement is exponential as long as the changes are happening in the right direction.

Instead of obsessing over the last 10 mg/dl we encourage our patients to figure out their Heart Health Risk Score and aim to minimize other health risk factors.

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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.

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Heart Health Prevention

The Heart Health Risk Score

I don’t know of any other health coach who creates a Heart Health risk score for their clients. I came up with this because most of us understand risk and know how to work with percentages.

Perhaps the most important point is that prevention is the most powerful tool against cardiovascular disease.

The objective is to push a heart attack, heart failure, peripheral vascular disease, valvular disease, or a stroke as far down the road as possible.

Heart Health Risk Score Criteria

In a previous article, I discussed the overview of risk stratification. In this article, I want to dive deeper into the anatomy of this score.

I have broken the risk score up into the following categories. It’s a constantly evolving tool that must be revisited often.

1. Age

You might think age isn’t much of a lever, but I disagree. If you are reading this article and taking action now, you have decided to prevent heart disease earlier than your future self.

2. Family History

A parent who suffered a heart attack at 49 is a powerful risk contributor to the heart risk score. While an uncle who suffered heart disease at 79 may not tell us much about this risk.

Your mother’s health and the environment in which she carried the pregnancy portend future risk.

3. Comorbidities

Comorbidities include conditions and diseases which accelerate atherosclerosis or elevate the coagulation response in case of an unstable plaque.

Sleep apnea, hypertension, diabetes mellitus, obesity, elevated lipid profile, systemic inflammation, and certain lifestyle factors.

4. Exercise Capacity

While some variables increase the risk of heart disease, others are protective and lower the overall cardiovascular risk score.

A healthy VO2 Max and a higher than average HRV are indicators and may be protective. In fact, exercise improves these metrics and is independently protective against cardiovascular disease.

5. Mental Health

Living in an area with high pollution, loud noise, or being under constant stress negatively impacts heart health. More so in those who don’t have compensatory coping mechanisms.

Ongoing financial stress, poor sleep, childhood adversities, and relationship stress also elevate the risk score.

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Heart Health

Mental Health and Heart Health

With enough medications and interventions, achieving perfect blood pressure, blood sugar, cardiac output, and vascular health is possible. But that’s not a sustainable way of managing Heart Health. For many, their mental health has to be addressed.

Mental health includes stress, anxiety, depression, and sleep. These things are related to our careers, relationships, and childhood events.

With a healthy psychological state, the autonomic nervous system is more balanced. Even the AHA has directed its marketing on the topic of emotional health.

Resistant Hypertension

My blood pressure is quite sensitive to my stress levels. This is likely related to my adrenalin levels in the sympathetic nervous system (SNS). We use epinephrine or forms of norepinephrine as a way to bring up the blood pressure of patients in the ICU.

With longer-lasting stress or constant low-level stress with which I can’t cope well, my hypothalamic-pituitary-adrenal (HPA) system is activated. The hormone cortisol causes changes in certain cell channels, which increase blood pressure.

Despite several medications, a patient’s blood pressure can remain elevated if their stress level doesn’t normalize.

Heart Health and Mental Health

Those who deal with a lot of depression and anxiety or face other major societal pressure tend to have much worse cardiovascular outcomes than less-stressed peers.

We can’t change job security, income security, or our upbringing. But how a person can cope with some of these mental health factors can help improve Heart Health outcomes.

Meditation, psychological intervention, breathing techniques, certain body movements, and dietary changes can help improve mental health.

My goal as a Heart Health Coach is to help identify the factors which require more immediate attention. Sometimes, it’s our psychiatric state which needs to be addressed first.

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Heart Health Hypertension Treatment

Blood Pressure Goals

As with all things in medicine, there is much debate about ideal blood pressure goals. 120/80 or under 140/90?

And as with all things in medicine, it’s an individualized approach. Some patients have enough risk that a 120/80 value makes the most sense.

The current standards consider normal values to be under 120 systolic and under 80 for the diastolic value.

Avoiding hypertension is an important part of ensuring proper Heart Health and avoiding strokes, heart attacks, erectile dysfunction, heart failure, and kidney disease.

Current Approach to Blood Pressure Checks

My patients have their blood pressure checked when they come into the clinic. Or worse, they check their BP at home when they have a headache, feel dizzy, or have nausea.

At best, in this current approach, we’re measuring someone’s blood pressure only 2-3 times per year. At worst, we check blood pressures when they likely will be high due to pathologic factors.

So, the old method is outdated – too little data or dirty data from which a proper decision cannot be made.

Average Blood Pressure Readings

In comes the average blood pressure. This is a far better approach and method to guestimate someone’s baseline blood pressure.

Baseline, meaning this is the blood pressure they are walking around with when not stressed, when not doing a strict meditation routine.

The goal for this blood pressure should definitely be low – closer to 120/80.

The average blood pressure can be taken with a cough which you set to inflate every 30 minutes using a timer. Your doctor can also prescribe an ambulatory blood pressure monitor, which achieves the same automatically.

Interventions That Lower the Blood Pressure

When you’re stressed, your blood pressure goes up. Logically, if you can calm yourself down, your blood pressure should and does indeed decrease.

Blood pressure goals can be achieved with lifestyle changes alone. Weight loss, dietary changes, stress management, better sleep, and correcting underlying pathology such as sleep apnea.

The next step is medications. There is a lot of fear when it comes to medications. It’s understandable. Big pharma can’t always be trusted – perhaps. But they do some good, as well.

It’s important to understand that any chemical is a tool, and when used correctly by the right people, it could be a proper solution.

Otherwise, to achieve the desired blood pressure goals, herbal medications or supplements can also be tried.

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Heart Health Hyperlipidemia Treatment

Should We Be Testing for Lp(a)?

No doubt those with elevated Lp(a) have a higher risk of ASCVD, but the question is whether testing for Lp(a) is beneficial if we don’t have effective therapies for lowering it.

Lipoprotein (a)

It isn’t the best nomenclature, but this word refers to a low-density lipoprotein containing a particular molecule called apolipoprotein(a) or Apo(a).

The blood levels of Lp(a) are affected by a few factors, one of which, of course, is the LPA gene that encodes this molecule. Dietary habits, age, or sex don’t seem to affect your Lp(a) values.

It’s important to check for Lp(a) in the same lab for monitoring levels, but it may not be the best way to work with this lab value. Most experts will check this one or two times in the patient’s lifetime because it’s meant to be an indicator of overall risk.

Lp(a) is made up of a liporptein plus ApoB and Apo(a). The Apo(a) portion can independently elevate the risk for clotting.

Lp(a) & Disease Association

We know from observational studies that those who walk around with higher Lp(a) levels tend to have a higher risk of ASCVD, coronary heart disease (CHD), cerebrovascular disease (CVD), and aortic stenosis.

This molecule is also an acute phase reactant, so those with inflammation will have higher values. Meaning also it shouldn’t be checked during times of inflammation.

From a UK study of half a million individuals we know that for levels above 20 nmol/L there was an increased association with ASCVD. Which translates to a 10% higher risk for each 50 nmol/L increment above this value.

Lowering Lp(a)

Unlike someone’s LDL values, we don’t have good tools to lower a patient’s Lp(a). At least, that’s the current widespread consensus. Some experts believe there are treatments (medications) in the pipeline that will lower the serum level of Lp(a) but as much as 80%.

The next question is whether lowering Lp(a) levels would change someone’s health outcome.

With HDL and homocysteine levels, we have seen that changing the value of these in the blood through directly targeted medications doesn’t have an actual cardiovascular disease outcome.

So, we’ll see if medications that lower Lp(a) will change a person’s ASCVD. Some of the upcoming clinical research should reveal that.

How To Treat Elevated Lp(a)

Some countries, such as the UK, regularly test their patients for Lp(a). But all countries are still waiting for final results to figure out which Lp(a) lowering treatments will actually lower the risk of atherosclerotic heart disease.

It’s important to recognize that statin therapy can sometimes elevate Lp(a). Again, this is the tough part of understanding the complicated interplay between the different key players in heard disease.

Fortunately, despite the rise in Lp(a) caused by statins, those at risk will still benefit from statin’s independent anti-inflammatory and LDL lower effects.

1. PCSK9 Inhibitor

Though PCSK9 inhibitors seem to lower Lp(a) values, it’s unclear whether they can lower the risk of heart attacks in those with high Lp(a) values.

2. Lipoprotein Apheresis

Similar to dialysis, though not as severe, this can be used weekly to lower Lp(a) values by 70% or more.

3. Antisense Therapies

Some antisense oligonucleotide treatments are being researched to lower patients’ Lp(a) levels.

4. Inclisiran

Leqvio is a medication for those with elevated ASCVD disease risk who may not be candidates for standard treatment alone.

This molecule works in the synthesis pathway of the PCSK9 protein.

Serum Lp(a) Values

Serum values above 165 nmol/L seem to be associated with the highest risk such as coronary heart disease death, heart attack, or needing immediate vascular intervention.

Some believe values above 125 nmol/L equate to elevated risk, and other experts set that bar at 50 nmol/L. The patient’s clinical history obviously matters a lot.

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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.

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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!

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Diet Heart Health Hypertension

Carbs and Blood Pressure

The human gut benefits from a balanced diet. It can withstand quite a poor diet for short periods. But, in the long run, there has to be a balance; otherwise, we suffer health side effects. Carbs and blood pressure are an example of this improper balance.

Carbs and high blood pressure correlate closely. It doesn’t mean you have to cut out carbs, but it’s important to choose carbs wisely and get plenty of fiber or protein in the diet.

Blood Pressure and Diet

It’s not that you are trying to hurt yourself, but some of your diet decisions may not be ideal for your unique physiology.

Functional nutrition is a branch of medicine focusing on each person’s unique physiology and microbiome. One person does well with a lot of processed carbs, while another suffers health consequences from the same diet.

I have patients whose blood pressure isn’t affected by salt. They might suffer other issues, such as vascular stiffness, but their blood pressure doesn’t falter.

Carbohydrates – specifically processed carbs – seem to affect most of us negatively over the long term. Carb consumption has a reasonably direct relationship with our blood pressure.

Carbs and Blood Pressure

Fortunately, it doesn’t mean you have to adopt a ketogenic or carb-free diet.

The balance of your macronutrients could help protect against the downsides of a high-carbohydrate diet that is mostly processed.

Certain foods have carbohydrates that digest slower than other carbohydrates. You can test it out by wearing a CGM or checking your blood sugar every 30 minutes after certain meals.

Some carb-rich foods will spike your blood pressure. A continuous blood pressure monitor is helpful for this. But checking your blood pressure every 30 minutes will be as effective.

A Balanced Diet

Some nights I eat a late meal that’s heavy in processed carbs. For example, it might be a homemade burrito with white flour and white rice.

The timing of this late meal, combined with the high glycemic index, often leads me to snore heavily at night, wake up congested the next day, and raise my systolic blood pressure by at least 10 points.

But if the tortilla is a whole-wheat tortilla and I have brown rice with plenty of veggies and go easy on the salt, my body handles it much better.

Heart Healthy Diets

There is no single diet out there that works for everyone. Many argue that diets as a concept of achieving health don’t make sense.

Chances are there are many foods you can eat and remain healthy. However, a dietary adjustment may be needed to achieve Heart Health once you are dealing with a particular cardiovascular disease.

Schedule a session with me today to discuss how to experiment with your diet to figure out what foods are best avoided and which to consume more of.