Search for tag: "hypertension"

Interviewer: For patients that have survived a stroke, there could be some worry that they might be at risk for a second stroke.

Dr. Steven Edgley is the Director of Stroke Rehabilitation at University of Utah Health. Dr. Edgley, what can people who have suffered a stroke do to minimize their chances of having another one?

Dr. Edgley: The most robust way to prevent another stroke or heart disease is to control hypertension. If we put these three things into three buckets, controlling hypertension, its own bucket. It's so important. The second bucket is controlling things like cholesterol or diabetes or if you have AFib, which is an abnormal heart rhythm. So these are other medical factors that lead to an increased risk of stroke and heart disease. And so I mentioned three, the three major factors, but everyone should go to their own and primary care physician to outline and identify their personal risk factors.

The third bucket is lifestyle factors. And we can break those into diet, exercise, and what I would call avoidance of smoking, drugs, controlling your alcohol intake, things like that. So lifestyle factors, away from the doctor's office, things that you would do at home.

Interviewer: How do you best control hypertension? Let's go back to that first bucket. Is that diet and exercise? Is that usually some sort of medication?

Dr. Edgley: Both. Usually, medication works best. But diet and exercise play a role in controlling high blood pressure.

Interviewer: Generally, does a stroke, a person who's had their first stroke, do they have the hypertension that would more likely need medications to control as opposed to lifestyle?

Dr. Edgley: Both are truly important. So, certainly, if you have had a stroke due to hypertension, you need to be on some medication for that.

Interviewer: And then the second bucket, cholesterol, diabetes, AFib, or other medical factors you'd be discussing with your primary care physician. Again, is that medication generally to help control those things, or we do know that diet and exercise, again, can control those factors as well?

Dr. Edgley: Yes. So I'm talking about going to your primary care physician and getting on the appropriate medications. And I think of that third bucket, so it does influence a lot of risk factors. But I think of it as its own bucket, diet, exercise, and avoidance of harmful behaviors and substances.

Interviewer: So when we get to that third bucket with lifestyle behaviors, is it more difficult for somebody who's had a stroke to manage and control their diet and exercise? Is that a little bit more of a challenge?

Dr. Edgley: It is. They may have physical impairments that make exercise really difficult. And they may have physical mobility issues that make activity more difficult and leading to the problem of obesity. And so every one of us is on either an upward spiral or a downward spiral. And it's very, very important to, if you are on a downward spiral, to break that cycle. And a downward spiral means, you know, inactivity, leads to overweight, leads to poor muscle strength, leads to more inactivity and down and down we go. And patients can break that cycle, but it's got to be a conscious choice and an active choice.

Interviewer: So in a lot of ways, what you do, which is help stroke survivors with physical rehabilitation, is really important in breaking that downward spiral. I mean, I can speak from my experience, as somebody who has not had a stroke, I know it all comes out of exercise for me. If I'm exercising, then I tend to eat better. I tend to sleep better. I tend to do all those things. And I don't know if that's the case for everybody, but I would imagine that that physical activity component is pretty important.

Dr. Edgley: Yes. And that's true. And what we really try to do, we can't be everywhere for everyone, but we can set them out on a positive course. And so the most important thing is to be on the right uphill track and not a downward track.

In medicine, we were taught that women were protected against heart attacks until they went through menopause, and then our risks caught up with men's risks. But what if we weren't really protected that well?

For many years, our research into the heart attacks has been focused on men. Even on TV and the movies, something awful happens, and a man clutches his chest and keels over. And we find if it's a police or a medical show, that he died of a heart attack. Most of us could have figured that out before the forensic pathologist told us on the TV show because we know what men's heart attacks look like.

In fact, we understood men's heart attacks and the causes, high blood pressure, smoking, eating red meat and fatty foods, and high cholesterol. Doctors really got on men's cases, and since 1960, men have decreased their smoking. And if their cholesterol or blood pressure is high, and their wives drag them into the doctor, the men were on blood pressure medications and cholesterol-lowering drugs. And meat and fatty foods, they're still Super Bowl yummies and fast food, and they're doing better.

Men's rates of heart attacks dropped dramatically. And then we noticed that postmenopausal women caught up with men in the rates of heart attacks at about 60. So we sort of got on it and started a national campaign, like the red dress for heart health, to help women understand their risks and the signs of heart attacks. But we were still thinking about women over 50, at least OB/GYNs were. And now comes a troubling study that shows that the rate of heart attacks in young people, people under 50 are increasing and are increasing more for women. This is worrisome. And it's important to look at the communities where this work was done and see what we can learn.

From 1995 to 2014, the ARIC, A-R-I-C, Community Surveillance Study gathered information on almost 29,000 heart attacks. ARIC stands for Atherosclerosis Risk in Communities. And atherosclerosis is the clogging up of the arteries in the heart that can lead to heart attacks.

The communities that were involved in this study were in four geographic areas in the U.S. -- counties in North Carolina, Maryland, Mississippi, and suburbs of Minneapolis. Some of these counties have Americans at risk for heart attacks based on increased rates of diabetes, smoking, hypertension, obesity, and poverty in African American race. Of those 29,000 heart attacks, over the 20 years, one-third in what they called young people, people 35 to 54. Over those 20 years, the annual rate of young men's heart attacks went down some. But women's rates went up to the point that young women, pre-menopausal women had the same rate of heart attacks as young men. These data are alarming, and they mirror similar data from Canada, suggesting that the incidence of heart attacks in young women is rising.

Well, what are some of the risk factors for these young women? Smoking, high blood pressure, and diabetes very substantially increase the risk in women. And black women had very significantly more heart attacks than white women. Seventy-five percent of the young women with heart attacks had high blood pressure, 36 percent had diabetes. And women who had heart attacks were more likely to have multiple risk factors than men.

Young women who had heart attacks were less likely than young men who had heart attacks to have their cholesterol treated or their blood pressure treated. Young men and young women who had heart attacks had a 10% chance of dying the following year. Young women have some extra risk factors for heart attacks compared to men. They're more likely to have demonstrated risk for diabetes by being diabetic in pregnancy. They're more likely to demonstrate risk of hypertension and vascular disease by having preeclampsia when they were pregnant. And they are more likely to suffer the psychosocial stressors of poverty than men.

This information hurts my heart. These young women were mothers of young children and teens. They were at the most productive times of their lives, and they were also at the most stressful times of their lives. So what do we do with this information as women and as physicians? The risk factors in this study are ones that we all know about, risk for heart health, such as smoking, diabetes, and hypertension. But diabetes and hypertension often don't have physical symptoms.

Unless women are getting regular checkups, getting their blood pressure measured, their cholesterol measured, and their blood sugar checked, they may not know. Women used to go to their OB/GYN or their family doctor, get a Pap smear every year, but now they don't. Many women who used to go regularly for their checkups when they were having babies, don't go anymore. All clinic visits, for one reason or another, will have a blood pressure check, but cholesterol or diabetes checks aren't done so often in young women.

Of course, the big risk of smoking cigarettes in an unbelievable 48 percent of the young women who had heart attacks were cigarette smokers, would be addressed by the clinician, if women admitted to it. See our podcast on lying to your doctor.

So all women and men need access to health care. All the women and men need regular checkups at this very busy time of their lives, 35 to 54. All women and men need to have their blood pressure, high sugar, and high cholesterol managed according to national guidelines. And women need to take their medication.

How we manage the stressors of poverty, the stresses of being a minority are issues that we all need to address as a community and as a state and as a national level. So, ladies, please take care of your heart. And thanks for joining us on "The Seven Domains of Women's Health" on The Scope.

updated: September 5, 2019

originally published: February 7, 2014

Dr. Gellner: We usually think of high blood pressure as an adult problem. But did you know that kids can get it too?

Announcer: Keep your kids healthy and happy. You are now entering the Healthy Kid Zone with Dr. Cindy Kellner on The Scope.

Dr. Gellner: High blood pressure or hypertension is something adults deal with all the time. However, an estimated 3.5% of all kids in the U.S. have it too. It often goes undetected and thus untreated. Sometimes it goes undiagnosed for years and can lead to problems like coronary artery disease in adulthood. To try to identify more about blood pressure issues in children, the American Academy of Pediatrics recently came up with a report to give pediatricians a simple screening table to follow to figure out when a child's blood pressure needs further evaluation.

First, let me explain what blood pressure is. It's actually two separate measurements. The systolic blood pressure is the highest pressure reached in the arteries as the heart pumps blood out to the body. And the diastolic blood pressure is the lower pressure from the arteries when the heart relaxes between beats, so it can take in blood coming back from the body. If either or both measurements are high, that's hypertension.

In kids, it's tricky to diagnose hypertension because the ranges change based on height, age, and if they're a boy or a girl. Also, if a child is in pain or has a fever, it might be high. But we are more concerned about what their blood pressure is when they are healthy. That gives us our best measurement.

We start doing blood pressures when a child is three, usually at their three-year-old well-child visit. If your child's blood pressure is indeed high, we have you come back for a recheck in about a week. If they have high readings for three consecutive visits, that's when red flags start popping up for us pediatricians, and we need to evaluate further.

Most kids don't have any symptoms when their blood pressure is high. For most kids, especially after age seven, more than 50% of hypertension in kids is due to obesity. That rises to 85% to 95% in teens. The treatment for hypertension due to obesity is the same for kids and adults --healthier eating, lower salt diets, and plenty of physical activity.

Usually, if hypertension in child is due to another cause, such as kidney disease or hormone problem, your child will have other symptoms that your pediatrician will be able to pick up on quickly with blood or urine tests. In these cases, your pediatrician will refer your child to a specialist who can manage the underlying cause and that will help manage the hypertension. So, if you have a family history of high blood pressure, or your child is over three and your child's blood pressure isn't taken at the well-child visit, speak up and ask your pediatrician to check it. This isn't something you want to miss.

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Interviewer: Treating chronic thromboembolic pulmonary hypertension, also known as CTEPH. We're going to find out more about that surgery next on The Scope.

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Interviewer: You've been diagnosed with CTEPH and we've already learned about the condition, its symptoms, and stuff like that in our earlier podcast. But today, we want to talk about the surgery that treats it. Dr. Craig Selzman is a heart surgeon and one of the directors of the Chronic Thromboembolic Pulmonary Hypertension Program at University of Utah Health Care. So in case somebody didn't hear the first podcast, just briefly sum up what's going in the heart that causes this disease?

Dr. Selzman: It's actually, believe it or not, it's in the lungs and so the lungs are sandwiched between the right side of the heart and the left side of the heart. And so what CTEPH is, we'll just call it CTEPH, it is a form of what we call pulmonary artery hypertension. So pulmonary artery hypertension is high blood pressure in the pulmonary circulation. And there are a number of causes for it for which CTEPH is one of them.

This particular situation is a form of PAH, pulmonary artery hypertension, that is related to having blood clots that come from your legs or the lower extremities usually and get lodged into the lungs. We call that a pulmonary embolism. It's very highly morbid, causes a lot of problems, and it's lethal. It's one of several leading causes of cardiopulmonary death that can happen acutely.

And so what happens also inside the lungs is that the lungs actually start to remodel. You could almost imagine like you have some stuff in your sink and it gets into drains and it's kind of there, but you could imagine that a year or two later, it kind of forms and becomes part of the wall of the pipes. And that's what's happening inside your lungs and it becomes very hard for them to do their job, which is to take in oxygen and get rid of carbon dioxide.

Interviewer: So then over time, is it the stiffness that's causing that problem, that build-up of stuff in there that's causing the stiffness?

Dr. Selzman: That's right. We want our lungs, you know, you want your lungs to look like the sponge that you just bought out of the store. You open it up, it's this very light, airy, and it's just . . . you could kick it and it would maybe go up in the air, but it's not this heavy wet sponge that you've just finished cleaning the dishes with. That's what you want your lungs to look like. And you want all those little holes because all those little holes allow oxygen to go back and forth. But if you don't have good blood vessels that go to all those little holes, all of the ability of your lungs to do that work become compromised.

Interviewer: So during this surgery, what do you do to fix it when you go in there?

Dr. Selzman: So believe it or not, this is a roto-rooter operation. What we do is we have to do this, it's a major heart operation in the sense that we have to open up your breastbone. We do have to open up the pulmonary arteries. And then what we do is we open up the pulmonary artery and we actually peel out the inner layer of the blood vessel wall.

And so, sometimes, there's actual blood clot that you remove, but it's not really just the blood clot. It's you have this really thick rind that's layering out along the blood vessel wall and you have to remove this whole rind in order to allow the blood flow to get out to the periphery of the lung where it does all of its work. In order to do this, it's a major operation, you have to go on the heart-lung machine.

We actually have to take the body temperature very low because there's a lot of blood that gets in the way when you're doing this and so you need to be able to see. And so, sometimes, we actually have to even turn the circulation of the patient off and the only way to do that is to take the blood temperature very, very low to protect the brain and other organs. So it's not something that we take lightly. It's a very relatively conceptually, straightforward operation but has some pitfalls if you don't do a lot.

Interviewer: How long does it take for an average for you to do the procedure?

Dr. Selzman: Probably three to six hours.

Interviewer: Okay.

Dr. Selzman: And a lot of that time, the nitty-gritty work is actually only maybe less than an hour, but the prep time to get ready and to take the temperature down and then to bring it back up, it does take some time.

Interviewer: And you're able to go in and get most of that, if not all of that, usually cleared out?

Dr. Selzman: We are fortunate because we have really good preoperative testing so it might be that all of the lung is affected, but sometimes, it'll be just half the lung or, you know, three-quarters of the right lung and two-thirds of the left lung. And so we can kind of target that.

There are some disease processes with these pulmonary embolisms and the CTEPH that is stuff that we cannot fix. And that is the stuff that gets way, way deep out into the periphery of the lung and we just physically can't do it. When people have pulmonary hypertension related to that kind of disease, there' really only one out outside of medical therapy and that would the lung transplantation.

Interviewer: Got you. So I think you just answered who makes a good surgery candidate. If it's affecting the outside part of your lungs not so much, but if it's more in the main part.

Dr. Selzman: Yeah, I think that's a good way of thinking about it, you know, from a technical aspect. The more proximal or the less further out into the periphery defines some of the patients that we would just not even think about doing.

Interviewer: Got you. What kind of preparation does the patient go through leading up to it? Is it just typical surgery preparation, you just want to be healthy?

Dr. Selzman: Yeah. Unfortunately, you know, some of these patients aren't so healthy.

Interviewer: Because they have a hard time breathing, right? Which makes it hard to exercise and move.

Dr. Selzman: Exactly. And, you know, and also risk factors, which led them to have developed blood clots in their legs. You know, it's sometimes the blood clot is the classic traveler across country on an airplane and they're not moving their legs and they get the blood clot in the leg and then they later that day they walk around and then they get acutely short of breath and they might not even know that they had something happen.

As a matter of fact, about 40% of patients that have pulmonary embolism don't even know that they have it and a lot of CTEPH comes without an antecedent diagnosis of pulmonary embolism. And it's just something that happened that nobody . . . you just didn't know you had it. It's kind of like the silent heart attack. "Oh, I didn't know I had a heart attack, doc." It's the same kind of thing. "I didn't know I had a pulmonary embolism, doc." And so that can happen and it can be kind of very sublime, if you will, the development of the disease.

Interviewer: Got you. And then what's the recovery time look like after the procedure normally?

Dr. Selzman: Usually, in the intensive care unit for two or three days and then up on the floor for several days. Everybody is a little bit different how they do this. In the more severe cases, you can actually be in the hospital for several weeks because there's part of the lungs that aren't used to having seen blood flow and we acutely remove this stuff and then we get what's called reperfusion injury, which means of the lungs which hadn't had a lot of blood flow all of a sudden gets this rush of blood that comes to it. And that's called reperfusion and sometimes that can be very troublesome to deal with.

And so, yeah, this is not an easy physiologic process for the patient. I mean, the lungs are going through a lot of stuff. Obviously, it's very central and core, you know, heart and lungs. And so, you know, if the lungs are working good, then the heart works good. But if the lungs aren't working good, then it affects the heart and it can be a problem.

Interviewer: So you're taking a little bit of time off from work?

Dr. Selzman: Oh, yeah.

Interviewer: Probably.

Dr. Selzman: This is a major heart operation, but the cool thing about this as, you know, as big as of a procedure as it is, we just have some great stories that come back. I mean, you see these people that are on oxygen at home and then two weeks after surgery, they come and see you in clinic and they're off of oxygen and they say that, "Wow. I haven't been able to take a deep breath like this in years." And then you see them a year later and they're just so thankful because they can breathe because we see this in lung transplant.

You know, at the University of Utah, we're kind of lucky because we're one of the, we're really the only lung transplant center in the entire region. You know, you have to go to Denver or Phoenix or in California. And so we see great stories and when you see people that can't breathe, you know, just imagine you're down swimming and you're underwater. I mean, that's what these people are. And so when you allow the folks to actually take a deep breath and also the plastic hose of the oxygen just gets really old. And so it can be an incredibly gratifying thing to do for a patient.

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Interviewer: CTEPH is a hard to diagnose disease that about one in 1,000 people will develop. And because it is relatively rare, many patients and even doctors haven't heard of it. The symptoms can easily be confused with other diseases and what makes it even harder to detect is many people don't have any symptoms or the symptoms that they do have are mistaken for other illnesses. Dr. John Ryan is a cardiologist, one of the directors of the Chronic Thromboembolic Pulmonary Hypertension Program at University of Utah Healthcare. So it's so hard to diagnose, how do people even find out they have the disease.

Dr. Ryan: No, it's really tough. So it is, as you describe, Chronic Thromboembolic Pulmonary Hypertension so it is a cause of pulmonary hypertension. Pulmonary hypertension is elevated pressures in the lungs. So, oftentimes, if people are short of breath, if they're fatigue, if they have some leg swelling, they might get an ultrasound of their heart, and then that might show that they have high pressures in their lungs. And that's where the pulmonary hypertension is.

So then, when you look at the causes of pulmonary hypertension, a lot of pulmonary hypertension is caused by problems with the heart, a lot of it is caused by problems with the airways, such as emphysema, COPD. Some of it is caused by exposures to things such as methamphetamines. And rarely, within pulmonary hypertension, you can have it caused by chronic thromboembolic disease or chronic pulmonary embolisms.

The reason this is complicated is because some people won't know that they've had a previous pulmonary embolism. So if we want to talk about pulmonary embolisms, because I think that will be the first thing to talk about and then we can go into the chronic pulmonary embolism or chronic thromboembolic pulmonary hypertension, the abbreviation for this is CTEPH. So pulmonary emboli are common and pulmonary embolism is common, you have a clot in the lungs.

A lot of folks will have family members who have this, sometimes they themselves have had it. It can happen after a hip replacement, it can happen after a long-haul flight, which is something that you've come across before, and that's where you have a clot in your lungs. In 97% of people who have clots in their lungs, that's a classical way they head back to their regular everyday life.

In 3% of people, that's not the case. In 3% of people, they end up with this chronic pulmonary embolism, which can either be recurrent pulmonary embolisms, so they have one and they have another and another. Or it can be that the clot doesn't actually go away. Whereas, 97% of the time, the clot dissolves. In 3% of people who have pulmonary embolisms, the clot may not dissolve and therefore, they're left with this blockage in their pulmonary vasculature.

The analogy I kind of give among other analogies, which at least people humor me and tell that my analogies are very good, but the analogy that I give here is that a clot in your lung is like a car crash on the freeway. All the blood flow stops. And then, eventually, the crash gets cleared. In chronic thromboembolic pulmonary hypertension, that crash does not fully get cleared, you're instead of having four lanes, you're now down to one lane. So you end up with just this one trickle amount of blood going through because the clot has never gone away. Or the vessel has changed in response to that clot and folks get short of breath.

However, what makes it hard, and the thing you've asked me in the beginning about, you know, why is this so hard to pick up, what makes this hard is, first of all, it is in . . . of all the causes of pulmonary hypertension, it's least common. Fifty percent of people who have it don't know that they had a blot clot sometime in their life. They think this was never picked up or it was missed clinically.

But the importance of it is that it is a curable form of pulmonary hypertension so you can get treatment. And that's what our program specializes in here. We specialize in the management, the surgical and medical management of chronic thromboembolic pulmonary hypertension. We're the only program to do that in the [Inaudible 00:04:03], one of the few programs in the country. And you can, again, cure people of their disease by medically managing this or surgically managing this, most particularly. And that's a pretty positive thing.

Interviewer: I'm still confused as to how I would know that I had it. I guess the first thing is . . .

Dr. Ryan: The first thing you'd be short of breath. You'd be short of breath with fatigues.

Interviewer: Those symptoms, yeah.

Dr. Ryan: So you'd have symptoms similar to heart failure. The symptoms themselves are not that dissimilar to heart failure. And then at some [inaudible 00:04:29] along the line, someone will do an ultrasound of your heart and they would do an echocardiogram. And on the echocardiogram, you would see that the pressures in your lungs are high.

Interviewer: Okay.

Dr. Ryan: So then you have pulmonary hypertension. And then, as a workup for pulmonary hypertension, people look to see, did you ever have any blood clots, either by asking you specifically or there are some scans that you can do on the lungs to see if there are any signs of old blood clots.

Interviewer: So you can actually see those also?

Dr. Ryan: Yeah.

Interviewer: So it's a little bit of a detective game that you've got going on.

Dr. Ryan: It is, yeah. I mean when you have the diagnosis, first of all, when you have a diagnosis of shortness of breath or when you have a diagnosis of fatigue, that's obviously, as you alluded to, when the detective game starts. And then, once you get diagnosed with pulmonary hypertension, then you start looking into the different cause of pulmonary hypertension. So a lot of these are going on all at the same time.

When you have pulmonary hypertension, people start looking, it is caused by the heart, it is caused by the lungs, it is caused by the airways, it is caused by the vessels in the lungs, it is caused by clots. So all of these things are being looked at, at the same time. And then, if you find that there are clots in the lungs that have never gone away, in some regards it's almost kind of a eureka moment. You've found the cause of this pulmonary hypertension and now you can treat it.

Interviewer: So if you continue to have these symptoms and they're not just going away and you've received treatments for other forms of pulmonary hypertension, then that's when you consider, "I could be in this 3%."

Dr. Ryan: Yeah. Hopefully, before you get treatment of your pulmonary hypertension, people have figured out what type of pulmonary hypertension you have. The analogy that we use for this is pulmonary hypertension, in many regards, is similar to cancer. There are lots of different types of cancer. There are lots of different types of pulmonary hypertension. We don't treat all cancer types the same. Bowel cancer is very different to leukemia, say, and so on. So that's the same idea that we do with pulmonary hypertension. You find the cause of pulmonary hypertension, then you treat it.

Now that being said, of the people who have pulmonary hypertension, 1% of them will have chronic thromboembolic pulmonary hypertension so it's the least common form of pulmonary hypertension. That being said, it's the most curable form or pulmonary hypertension. So in some programs, in some practices, we'll guess and you can be . . . you're right, 90% of the time or 99% of the time, you might be right. But if you or me are that 1% who don't have these other forms of diseases, then you're getting the wrong treatment.

Interviewer: Got you. And you said surgery is the treatment?

Dr. Ryan: Yeah.

Interviewer: How effective is it?

Dr. Ryan: Surgery is the cure. Yeah, so it's really rewarding that you can go from being very debilitated, very short of breath, very fatigued, not able to do the things you want to do, and you undergo a major surgery. It's an open heart or open lung surgery where the clots in the lungs are removed and you're on bypass. Your chest is opened and the clots in the lungs removed and that changes the blood vessels are fixed. And then you come to the ICU afterward, you come to the floor after being in the ICU, you enter into a rehab program. But down the road, you'd then do very, very well and you go from being very, very sick to essentially having a normal life expectancy and doing very well.

Interviewer: Are there consequences for not treating?

Dr. Ryan: The disease progresses without treating so you got sicker. The strain on your heart gets worse and, ultimately, the heart can go into heart failure, which is what drives a lot of the symptoms. And then, of course, you can have future PEs as well, or future pulmonary embolisms on top of it. So you can have your disease and then have another pulmonary embolism. So those are kind of the consequences of not treating it.

Interviewer: Any final thoughts for somebody that's experiencing these symptoms and thinks they might have it?

Dr. Ryan: Yeah, so two things. One, surgery isn't actually for everyone. There are some people who, even in 2017, still have inoperable forms of chronic thromboembolic disease. That doesn't mean you're out of options, it just means surgery, right now, is not an option for you. But there are other medicines available that can help you do better. They're not a cure, but they can help you do better.

And so I think the main thing is to ask your doctors, "Do you need to look to see if this is blood clots?" Again, oftentimes, as I said, people don't look fresh. It's rare, it's uncommon, there are much more common causes and people don't know that they have blood clots. I think people also assume that they would know if they had blood clots, that you and I would know if we have blood clots. So I think it's worth asking your doctor, "Did you check for blood clots." And this is an easy, straightforward, low-cost test.

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Interviewer: Someone who is thin can end up with diabetes. And yet an obese person may be surprisingly healthy. Why is that? We'll talk about research today that addresses that question.

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Interviewer: I'm talking with Dr. Scott Summers and Dr. Bhagirath Chaurasia, in Nutrition and Integrative Physiology at the University of Utah College of Health.

You know, I thought one way we could start talking about this is that this type of research has a personal connection for you. If we're talking about thin people who get diabetes, which is kind of not the stereotype, that's something that you've faced in your own life. Not with you personally but with a family member?

Dr. Summers: Yeah. I was 14 years old when my father, somewhat precipitously, developed diabetes. He was 38. He was a fairly athletic individual. And to be honest, after he got diagnosed, he became sort of an exercise addict, and this was the way he would control his diabetes.

But despite all of his efforts and the fact that he was incredible fit and won countless road races, his diabetes worsened and became quite severe. So that was sort of the impetus for me to study diabetes in my career.

Interviewer: Right. So that profile is a surprise, right? Because what's more typical?

Dr. Summers: Yeah, he's an unusual diabetic, but he's not the only one. There's actually a fair number of people that can develop diabetes. We have kids that develop it, a classic type 2 when they're obese and we have adults that develop diabetes when they're thin. I think, actually, what we're learning is that distinction of type 1 and type 2 is much muddier than we realized and there's a lot of types in-between.

Interviewer: So often I think of diabetes as being a problem with the body's management of sugar. It turns out that's part of it. But what you two are looking at is the role of fats in diabetes and maybe it's sort of a mismanagement of the way fats are stored?

Dr. Summers: Yeah, I think so. I think the issue is really what's the type of fat, right? So fat has a lot of different terms, right? Sometimes when we're referring to fat we mean the tissue and sometimes we actually mean the food we're eating. But at the end of the day when fat is eaten, it's converted into something called fatty acids which are then taken up into cells and then they're restored in fat tissue as something called triglycerides.

Ceramides is another way that those fatty acids get metabolized. Instead of getting stored effectively or burned for heat, they sort of spill over into this and they conjugate with a certain protein derivative, protein metabolite. So it's just this different type of fat and metabolite that accumulates and it seems to have a whole series of actions that really are almost part of a universal stress response and a lot of the damage they do seems to be relevant to most of the diseases associated with obesity.

Interviewer: And do we have any idea why one person might be more able to store the fat as triglycerides versus going into that ceramide pathway?

Dr. Summers: Not as much as we need to. No, we really don't. When fat makes the decision to either be stored, burned, or go to ceramides there are some regulatory factors. We know that inflammation, infections will drive it into the ceramide pathway. We know that cortisol stress will.

We don't know as much about the dietary component as we should. We know ceramides are made from saturated fat and a certain type of protein that's a conjugation of those two. We don't as much as one would think about how much you eat, whether that influences it or not. And there may be a genetic component, too. About 20% of Utahans have a mutation in a ceramide synthesizing gene and those that do tend to have diabetes or hyperglycemia.

So I think there are a lot of factors that are driving it and we're trying to . . . that's sort of the holy grail of our research is to figure out those two questions - how ceramide works and what's driving its synthesis.

Dr. Chaurasia: Yeah, and that's exactly the next steps that we are following onto.

Interviewer: So you did some research in mice. What did that work show you? You had too many ceramides in mice.

Dr. Chaurasia: So what we showed is that if you delete out one of the initial enzymes required for ceramide synthesis, specifically in the adipose tissue, these animals tend to be more insulin sensitive. They tend to burn more calories and they tend to deplete out what we call the bad fat, white fat, into something called brown fat which actually turns them to other [inaudble 00:04:30] fat, actually and which allows them to burn more calories. And that's why we think that these animals are much more skinny and much more metabolically healthy.

Interviewer: Okay. And those are the ones where they had less ceramides?

Dr. Chaurasia: Those are the ones where we have less ceramides. And also we found in both the mouse cellular models as was the human cellular models is that if you treat them with increasing concentrations of ceramides, they tend to down-regulate, the expression levels of certain genes which are required for browning and increasing energy expenditure.

Interviewer: Which is actually helpful?

Dr. Chaurasia: Which is helpful, exactly.

Interviewer: Yeah, because it takes that away from white fat which is the more toxic fat.

Dr. Chaurasia: Exactly. Yeah.

Interviewer: Okay. Are you looking into ways to maybe manipulate those pathways to see if that can be used to treat diabetes?

Dr. Summers: Yeah, absolutely. So we've known before that if you treat with . . . there are drugs that you can give to mice but not to people and if you give that to them it prevents diabetes, it prevents fatty liver disease, it prevents hypertension, and cardiomyopathies, and things.

And so we're trying. You know, a part of our lab is trying to develop new drugs that will mimic that. We're testing some natural products that actually are out there that people can eat that might be able to deplete ceramides. And we're looking at dietary interventions, as well. Or we'd like to at some point, at least, look at dietary interventions to see if we can try and modulate this in addition to looking at the genetic components.

Interviewer: And so you think interfering with the ceramide pathway has a potential to help a lot of people?

Dr. Summers: I do. I mean, we've been working on it for a long time now. So it's been 15 years plus.

Interviewer: You're pretty motivated.

Dr. Summers: So, yeah, I'm still a believer at this point. You know, there are a number of things that can prevent diabetes in mice. So the fact that we can do it with this is there are other people that can do it, as well. And turning that into an effective therapy, I'm rather convinced ceramides can contribute to the development of diabetes.

Whether we can actually target that safely in a person is unclear because the reality is ceramides are actually . . . they do good things, too. So it's only when they get above a certain threshold that they become toxic. So can we titrate them in a person? Can we get them to make just, you know, not too little, not too much and remain healthy, is going to be a challenge for us.

But this is what we're trying to do and what I believe passionately we should do.

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