Avoiding Heart Disease

This summer my uncle went to see a doctor after complaining about experiencing shortness of breath. He's an officer in the Indian army and has a regular medical checkup every six months so he wasn't expecting to hear anything too shocking. This time, after some prodding from a cardiologist family friend, the doctors did a more extensive checkup. They told him that four of his coronary arteries were severely blocked. It was amazing he hadn't already had a heart attack. He underwent a quadruple bypass and thankfully is recovering well now.

I happened to be traveling in India at the time and learnt from my family that my grandfather had a fatal heart attack around the same age my uncle was now (mid 50's). He was also an officer in the army and seemingly in good health. I began wondering if a similar fate lies in store for me. The more I considered it, the more ridiculous it seemed. How could someone spend years thinking they're in good health with no idea that they're actually a ticking time bomb?

I decided to be proactive about managing this risk. I wanted to know what data I should be looking at and tracking over time so I could avoid being completely blindsided one day. I went to see a doctor and explained everything above. Her response, "you're young and healthy, come in for a physical once a year to check your cholesterol numbers and don't worry about it - just eat well and exercise regularly". I found this quite frustrating for two reasons:

  1. My cholesterol numbers came back fine (just like they were last year) but I knew cholesterol couldn't be a sufficient indicator of a healthy heart. My uncle had cholesterol numbers that were fine too.
  2. The advice to "eat well and exercise" didn't seem particularly insightful. To me it felt a lot like saying "don't worry about things for now, come back in 20 years when you have some actual symptoms".

So I started doing my own research into predictors of heart disease risk beyond monitoring cholesterol numbers. I came across three blood tests that seemed important; Apolipoprotein_B (ApoB), High Sensitivity C-Reactive Protein (hs-CRP) and Lipoprotein(a) (Lp(a))[1]. There appeared to be evidence[2] that all three taken together could provide a more accurate overview of heart disease risk than cholesterol alone.

I ordered these tests[3] and found that my levels for all three were elevated and fell into the "at risk" category.  There were a few conclusions I drew from my results:

  • While it's not exactly good news discovering that you have an elevated risk of heart disease, it made me feel better that I wasn't flying totally blind anymore. My mind immediately switched to researching ways to improve these numbers.
  • There seem to be fairly clear guidelines on how to go about reducing Apo(B) and hs-CRP numbers e.g. exercising reduces Apo(B) (though interestingly not LDL ("bad") cholesterol) and eating omega-3 fatty acids reduces inflammation.
  • Lp(a) seems trickier to manage. It appears to be mostly hereditary and I can't find a clear consensus on how to reduce it. It occurs to me that while I thought I wanted to gather data on every aspect of my heart, perhaps what I actually wanted was just the data about the things I can control.
  • My cholesterol numbers were checked again during these tests, in just two weeks my total cholesterol had dropped 14%. It seems incredible that such an important number can fluctuate so much over a couple of weeks and yet most people only measure it once a year, at best.

I've been thinking about whether taking this approach to managing my health is a good idea or not. It's certainly a slippery slope. There's always a new study to read indicating some additional marker or factor that should be taken into account. After a while it can seem somewhat overwhelming. I've been wondering though why didn't I have this level of discussion with my doctor? There are of course the obvious practical reasons. Doctors are busy and explaining heart disease risk to a healthy 28 year old isn't  viewed as a priority. Also running blood tests costs money and it's hard to see the insurance companies being willing to foot the bill for tests that aren't deemed necessary.

Ignoring these for a moment though, I've been thinking about the possible philosophical objections to treating managing your health as a data project. Here's what I've come up with so far:

Heart disease is complex and there's still debate about the validity of these additional markers
There's also debate about how useful linking cholesterol with heart disease risk is and yet that's still a standard test. There certainly appear to be enough studies and trials arguing that hs-CRP, ApoB and LP(a) are important so surely these numbers can't be completely irrelevant. If I want to take a proactive and preventative approach to managing my health, surely gathering the most information possible to form a plan of action seems reasonable?

The advice i.e. manage diet/exercise/stress is still the same. You should be doing it anyway.
True but I find that tying actions to specific numbers/metrics is better e.g. it's easier to lose weight if you weigh yourself regularly. Generic advice to eat well and exercise is not as effective as having a specific number you're trying to improve on e.g. lowering your ApoB count. Being specific also allows you to create a more personalized plan of action.

Optimizing for specific factors before fully understanding them can have unforeseen consequences
An example would be the conclusion by Ancel Keys in the 50's that animal fats caused heart disease, resulting in the American Heart Association pushing the idea of low fat diets to the public. By promoting fats as evil, the real danger of sugar and refined carbohydrates were ignored[4].

I'm not advocating pushing any particular theory or medical opinion on people. What I want is a system where I can choose to have access to my data with the explicit acknowledgement that the behaviour of the human body is inherently complex and uncertain. It's then my decision what course of action I want to take, taking the informed opinion of my doctor into account.

Numbers are constantly fluctuating, monitor them too frequently and you'll get stressed
This is actually a direct quote from my doctor. In my opinion it's still not a reason to ignore the numbers. I can opt out of knowing them if I wish but if I want access to that data, why should anyone but me have the right to make the decision? The role of a doctor should include telling me what fluctuations are normal and which ones aren't, rather than just checking in with me once a year.

I'd really like to hear more about what people think about this. Am I missing other major downsides to taking a more proactive approach to managing my own health?  Are there other things I should consider looking at to get a complete picture of my health?


[1] ApoB: This is a protein found on the surface of LDL ("bad cholesterol") particles. A regular cholesterol test tells you how much cholesterol is contained within the LDL particles but doesn't tell you either the number or size of these particles themselves. Each particle contains one molecule of ApoB i.e. ApoB count == the number of LDL particles you have. This means you can also make an inference as to their size. If you have a high ApoB value, your LDL particles are likely to be small and dense which are believed to be a stronger indicator of heart attack risk. There seems to be some debate both for and against the importance of ApoB as a heart disease risk indicator that's more valuable than just measuring LDL. The existence of the debate alone seemed reason enough for me to add it to my list of data to track.
hs-CRP: This is a protein found in the blood and its presence is a sign of inflammation in the body, which is a risk factor for heart disease.  While testing for hs-CRP alone isn't more predictive of heart disease than a regular cholesterol test, it does provide valuable additional information. If your hs-CRP level is higher than 3.0mg/L you're at high risk for cardiovascular disease, according to the American Heart Association.
Lp(a):This is a different form of LDL (Low Density Lipoprotein - also known as "bad" cholesterol) which attaches to a protein called Apo A. It's apparently unclear what Lp(a) actually does but if your level is greater than 30mg/dL it's deemed an increased risk factor for heat attack.

[2]http://www.lipidjournal.com/article/S1933-2874(11)00606-4/abstract, http://circ.ahajournals.org/content/108/12/e81.full, http://www.medscape.com/viewarticle/714264

[3] I looked into how I'd get these tests ordered myself and found these options:

  • WellnessFX: A nice looking website that has various packages of tests you can run. The cheapest package that included hs-CRP, ApoB and LP(a) was their Baseline (http://www.wellnessfx.com/baseline), priced at $149. It also includes a variety of other tests
  • Directlabs: A dated looking website but offering the option of a la carte tests. Total cost for these three tests: $205
  • Health Tests Direct: Another dated looking website, again with the option of a la carte tests. Total cost: $115.50
I decided to go with WellnessFX since for marginally more money I could get a variety of other tests too.

[4] The opening chapters of Good Calories, Bad Calories contain a detailed explanation of the history involved.