In preventive medicine, scientists and practitioners are always looking for the origin and causes of disease. In a study of Korean War soldiers 55 years ago, scientists were surprised to find the beginnings of cardiovascular disease in these young men. Today practitioners are watching for cardiovascular risk factors in children. A number of recent studies report that the signs that diabetes is coming on can be detected long before there is a confirmed diagnosis of diabetes.

This phenomenon is called "the ticking clock." The San Antonio Heart Study, conducted in the '80s and '90s, found that many subjects with identifiable heart disease risk factors turned out to develop diabetes in the course of the 15-year study. Ironically, while all indications are that heart disease mortality is decreasing—either because of early detection and/or aggressive clinical and technological treatment—the prevalence of diabetes is increasing and becoming an American epidemic.

In another broad population study of nutritional and behavioral habits in European countries, researchers happened to find a correlation between relatively low hemoglobin A1C markers and mortality risks. The A1C test uses a blood hemoglobin marker to determine the average level of glucose in the blood over a three-month period. An A1C level of 5 to 5.9 % or closer to 6 is indicative of pre-diabetes. A level of 6 and a 3-month average blood glucose of 135 mg/dl indicates diabetes. What this analysis found is that even at A1C levels below 6% there is an increased risk of cardiovascular disease, heart attack and stroke.

In the Nurses Health Study, conducted in the '70s and '80s and involving more than 100 thousand women, the analysts found that women who eventually developed diabetes were at a significantly elevated risk of heart attack and stroke prior to the diagnosis of diabetes (see chart below).

The signs of risk of cardiovascular disease began at least 15 years before the diagnosis of diabetes. That's the "ticking clock."

An Interview with Dr. Vangini on the ‘Ticking Clock' in Clinical Practice

Q: Do you discuss the metabolic syndrome and the ticking clock with a patient who you suspect?

Dr. V: I absolutely do. When I treat many patients in the area of cardio-metabolic prevention, I always tell them I am not only treating them for today but for down the line in 15 to 20 years. I tell them that if they continue with their multiple metabolic risk factors—high blood pressure, visceral adiposity, elevated lipids, and elevated glucose levels—they are at risk for heart attack, stroke, diabetes, Alzheimer's disease and cancer. I make that very clear to them.

Q: What tests do you perform to determine whether a patient is a suspect of the ticking clock?

Dr V: The five tests I always perform from my cardio-preventive and cardio-metabolic point of view are as follows:

1. A carotid duplex, which is an ultrasound evaluation of the carotid arteries in the neck, keeping in mind that 50% of strokes are caused by carotid occlusive disease.
2. A cardiac echo, which determines cardiac performance, valve function, and heart size.
3. A nuclear or stress echo to determine myocardial ischemia or perfusion.
4. Coronary cat-scan testing that will determine premature or advanced coronary disease. Even in the face of a negative stress test, this should be performed on everyone age fifty and over, and on those below age fifty who are at risk.
5. Peripheral vascular evaluation either by a certified physician that can determine peripheral pulses or a non-invasive peripheral study to determine the ankle/arm index.

Q: What treatments do you apply?

Dr V: My treatments are very similar to those used in my cardio-preventive program. I start with lifestyle changes, including the right diet, exercise, stress reduction, prayer, and pharmaceuticals if necessary. I continue with neutriceuticals in accordance with my cardio-nutrition program, using natural therapies geared toward high blood pressure, cholesterol, atherosclerosis, high triglycerides, blood glucose, weight problems and blood vessel wall problems.

Q: How prevalent are these problems (metabolic syndrome and ticking clock) in the patients you see?

Dr. V: Almost every patient I see is involved in some way with an increase in cardio-metabolic risk. Individuals with any type of heart disease—certainly high blood pressure, heart attack, lipid abnormalities—are at a very high risk for elevated glucose and diabetes. As a matter of fact, in the recent American College of Cardiology supplement on the endocannabinoid system, an article indicated (with regards to ticking clock) that individuals have a prolonged period during which their blood vessels are bathing in high glucose levels and high insulin levels, making them candidates for follow-up cardiovascular problems.

Q: Do you find patients with different degrees of these problems? How long does it take to get them under control?

Dr. V: There are many patients coming in with pre-diabetes who are at risk for diabetes, heart attack and stroke. There was a recent article in the February 11 online issue of Diabetes Care naming predictors identifying patients with hypertension and diabetes. The main ones are BMI and fasting glucose. I also find elevated triglycerides are very significant. As a matter of fact, individuals with a family history of diabetes, belly fat, and high triglycerides have a ten times greater risk of developing diabetes. I find the complete gamut of patients, ranging from those who are mildly overweight to pre-diabetes to frank diabetes—which is epidemic at this time—and those with cardiovascular complications. With regards to how long it takes to get them under control, it depends on the severity.

Q: Has your clinical experience convinced you of the validity of the ticking clock hypothesis? Is the hypothesis a valuable bit of information for preventive practice?

Dr. V: Yes, without question. I have followed patients who are not compliant and have seen them develop diabetic and vascular complications. It is not uncommon for patients to come in and say, "Doc, I should have listened to you 10 years ago. You were right."

The ticking clock is one of the key hypotheses that will allow people to start and have a successful preventive program to address insulin resistance, hyperglycemia, hyperinsulinemia and their complications—that include an increased risk of heart attack, stroke, diabetes, Alzheimer's disease and cancer.

About Dr. Vagnini
Dr. Vagnini is ELDR's chief medical advisor. He is the coauthor, along with ELDR Editor-in-Chief Dave Bunnell, of the book Count Down Your Age (McGraw-Hill). To learn more about Dr. Vagnini, visit his website »

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posted at 04:09:15 PM