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What is Health and How to Measure It.
I am not a fan of chasing lab tests. But, we need a measure of how our health is progressing. What SHOULD we measure?
As you well know, I don’t think about health like most of my colleagues.
With respect to measuring health, looking to lab values and other diagnostic testing (e.g. radiology) as confirmation of health or disease is an often misguided endeavor.
Labs can be “within normal limits” while you are sick. Conversely, they can be “abnormal” while you are healthy.
Before we address how to measure health, we must give thought to what we measure.
Which naturally leads us to our first question.
If we want to measure and track our health, we should know what health is.
What is Health?
Health is often thought of as merely “the absence of disease.”
A tad circular, if you ask me.
The World Health Organization has “improved” on this definition:
…a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity.
Not much of an improvement.
Both of these “definitions” have an air of subjectivity and malleability.
Worse, it doesn’t empower people to have a concrete way of knowing if they are healthy.
They must rely on the opinion of medical authority to determine when they are sick, and when they are healthy. I see it in the medical setting all of the time.
Someone comes in with no health problems for some sort of screening test. A typical situation would be an adult gets an annual exam, and the blood test reveals “elevated” cholesterol. Otherwise, this patient looks and feels healthy.
What does medical authority do? Prescribes a statin to lower their cholesterol.
Before this encounter, this patient looked and felt healthy.
Even those in the health-conscious space who promote healthy living have trouble defining health. So, let’s give it a shot.
One of the first things we learn in human physiology is the concept of homeostasis - the natural tendency to maintain the optimal conditions of the organism.
Homeostasis is brought about by a natural resistance to change when already in optimal conditions, and equilibrium is maintained by many regulatory mechanisms; it is thought to be the central motivation for all organic action.
You can think of homeostasis as the natural drive of an organism to resist dysfunctional changes to its being.
Spike in blood sugar? The body adjusts.
Increased demand for blood in a given organ? The body adjusts.
High-stress situation? The body adjusts.
In those with optimal health, the homeostatic drive is appropriate, effective, and minimizes collateral harm to the organism itself.
From this universal physiologic phenomenon we can attempt to derive a definition of health or of ‘being healthy.’
“The body which is in optimal health is able to adapt to any disturbance of its state without harming itself.”
Sometimes the stressor can be so severe, that the response can put us out of commission for a short period. For example, an inflammatory response so strong that we become febrile and weak. Particularly in children, this sort of response can lead to seizures and many worried parents.
These things happen, as many factors can lead to an overall depletion of homeostatic capacity. However, when something like this happens it should signal to us that we need to support and improve our homeostatic capacity.
Let’s look at common disease to illustrate.
Diabetes is defined as an inadequate response to a load of sugar (via glucose tolerance testing), or a chronically elevated blood sugar (via hemoglobin A1c %).
There are several mechanisms contributing to the maintenance of normal blood sugar which we wont discuss today.
The normal response to a sugar load is the release of insulin, which signals to cells of the body to extract sugar from the blood stream.
Diabetics have a problem. For a multitude of reasons, their body has been depleted of the capacity to appropriately and effectively response to a moderate elevation in blood sugar. Either the rise in blood sugar is not sufficient to trigger an insulin release, or the release of insulin is not enough to result in an appropriate removal of sugar from the blood. In reality, it’s likely an interplay of both.
Thus, the diabetic is one who has depleted the body’s capacity to sense and respond to fluctuations in blood sugar appropriately, efficiently and without harming itself.
Loss of adaptability to the ‘stress’ of elevated blood sugar. Loss of homeostatic capacity.
How to Measure Health
Now that we have clarified the difficult part, we move on to measurement.
How do we measure adaptability? Resilience? Homeostasis?
You may recall that almost every lab test you have gotten does not make reference to any of these qualities of health. Some look for mineral deficiencies, others for blood concentrations, and so on…
Further, most people get labs performed once per year. Hardly enough data to make judgements about the impact of yours choices on health.
Let us continue with the example of diabetes. In part because diabetics tend to get rather frequent checks of their blood sugar.
If they are self-administering insulin, they check their blood sugar multiple times a day. Their doctor will also order a hemoglobin A1c (average measure of blood sugar) every 3 months.
If you are a healthy person without insulin resistance and you eat a carb-loaded meal, your body should respond appropriately and effectively without disturbing your body.
Not delayed. Not inadequate. No over-correction.
If you had a continuous glucose monitor (CGM), the non-diabetics blood sugar through the day should look something like this:
Notice a few things:
Except for heavy meal or snack, the blood sugar fluctuates calmly between 70 and 90 mg/dL
Fluctuations are smooth and timely
On the other hand, if you are diabetic…your CGM tracing might look like this:
Again, let’s notice a couple of things:
Wide fluctuations in blood sugar, ranging from 100 to 180 mg/dL
Sharp changes, instead of smooth and calm adjustments
Though not pictured here, diabetics who take insulin risk over-correcting into hypoglycemia
Insulin resistance is characterized by an inadequate and inappropriate response to a load of sugar. The body struggles to appropriately and effectively adapt to this stress.
An unpopular though emerging metric for understanding blood sugar trends is glycemic variability (GV).
Essentially, GV tells us how much blood sugar varies across time. Looking at the two graphs above, we can see that the healthy person has low GV and the diabetic has relatively high GV.
There are many ways to measure GV, depending on which points along the graph you choose to use as reference points: compare peaks and troughs, differences between consecutive peaks and troughs, averages across time, or time-dependent standard deviations.
I am not so sure it matters how you measure GV, as long as you do it consistently.
Because, we are not concerned with short-term GV but rather the trend of GV across time. This trend is what we use to guide how we manage our health.
For example: If we implement a low carb diet and observe a reduction in GV across time - then that tells us something very important.
What does GV tell us?
In this article exploring the concept of glycemic variability (GV), the authors point to research which shows a correlation between minimizing GV and improving insulin resistance.
In my opinion, the authors fails to make a critical connection between GV and insulin resistance.
Glycemic variability is a projection of insulin resistance.
You can think of GV as a marker by which you can track insulin resistance.
In the healthy person, you do not need a large rise in blood sugar for a small secretion of insulin. This person is very sensitive to sugar and insulin.
However, in the frail diabetic - not only does consumption of sugar result in a large rise in blood sugar, but it also requires a large dose of insulin to correct the blood sugar.
This should be a revolution in diabetes. But, few talk about it.
Most mainstream doctors and their patients are on a wild-goose chase of correcting the next blood sugar reading without ever considering the broader picture.
Hemoglobin A1c is one way that medicine has tried to adopt long-term strategies to ‘managing’ diabetes. However, this is a rather blunt instrument as it is a reflection of 90-day average blood sugar.
You can have an A1c that is, for example 6.2% - a reasonable target. But, if you were to look at this persons CGM tracing you may see wild fluctuations in their blood sugar - aka high GV.
Is this person healthy? Will they suffer from complications of diabetes?
From the article:
Note: macrovascular complications = stroke, heart attack or death
Note: FPG = Fasting blood sugar variability metric
Note: DPN = Diabetic peripheral neuropathy
…reducing glycemic variability may provide a potential new therapeutic strategy
Beyond Glycemic Variability
The importance of this perspective on lab-work and measuring our well-being cannot be overstated.
Current medical practice acts on the basis of instantaneous data or visual projections of reality (i.e radiologic imaging).
To be able to fine-tune our habits, our choices, and our lifestyles on the basis of data that is almost as “alive” as our bodies could be revolutionary.
Even if it is just used to test new intervention strategies.
For example, you want to know how a carnivore diet impacts GV and insulin resistance.
An easy way to do this would be to use a CGM, and test this diet for a month or two.
Then, simply compare the CGM tracings of your regular and carnivore diet.
How else can we measure our bodies adaptive capacity?
Few additional examples off the top of my head would be:
This emerging way of looking at health and disease is only limited by your imagination.
But, it opens the door to appreciating the impact and value of “conservative” treatment options like lifestyle modification.
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The ultimate manifestation of reduced capacity to adapt, is physiologic exhaustion.
The more we refine the stressors in our lives, the more we exhaust our capacity to adapt.