Listen To The Patient

He was new to my practice; four months. I want to talk about just one of his tests, one which all or most of you have had tested in the past. It is not an exotic one. Triglycerides.

The thing about this patient is he actually does what he and I agree he will do between blood tests. We come up with a proposed behavioral change and by golly he does it. He is precise enough that the interval changes in test results are not random and tell us very precisely how well he has followed the agreed upon behavior. He was borderline diabetic, tending to daily fatigue, and serious about feeling better. Initial testing revealed, unknown to him, severe coronary artery disease and osteoporosis. Still, I am going to talk only about triglycerides.

When he left the office last week he said, actually shaking his head, “its amazing how much you can tell from blood tests.”

When he first came to see me his triglycerides were high at 220 mg/dl. Not remarkably high but high. Now with all of the background issues of heart disease and weak bones we opted for the fast track; I stripped his dietary behavior back to my baseline strict diet and his triglycerides quickly fell to 75. Great, right on track. He said he missed fruit so then  we did an experiment; we added in 1/2 cup of Northern fruit a day and rechecked his triglycerides; they jumped to 121 which is more than I would have expected with such a limited dietary change though, for some genetic types, not all that remarkable. So we probed some more. I will get to that.

The reason triglycerides matter so much is that they are produced by the liver in response to a relatively small number of dietary choices. Alcohol and fruit sugar drive this number more than starch and other sugars. Triglycerides are a fat produced by the liver under the influence of these dietary components and more importantly they stimulate the liver to make small dense LDL particles which are the deadly kind. Large low density LDL particles are not much of a problem but the small ones are killers. Recent IVUS studies (Intravascular Ultrasound) have shown directly how the triglycerides transported by small dense LDL penetrate the walls of arteries and harm them. Triglycerides are bad; pretty much period. You don’t want zero but you don’t want much; certainly less than what your lab says are ‘normal.’

In the case of my patient under discussion here we know that his triglyceride range when first I met him was typical of him as we had several of his previous tests. Written neatly across the test results thoughtfully mailed to him by his doc were the instructions “eat right and exercise.”

So we started talking: he was sure he had not gone back to alcohol and was eating no starch and only the agreed upon 1/2 cup of fruit. We talked some more and thought through his days of meals and snacks. Oops, he had started drinking no cal soda once or twice a week, he was adding vanilla extract to his yogurt because he didn’t like the astringent taste of a good organic yogurt without sugar or fruit. Little by little we found several sources of fructose and sucrose that he had added back into his diet. And of course his fasting glucose which had fallen dramatically had also risen slightly. He had done remarkably well; still, the slippery slope had already started to get steeper and more slippery. Back to the drawing board. His next triglycerides will come back below 100. I know, I’ve done this thousands of times.

Now I pick this simple blood test and this simple story to illustrate how precisely you need to work through your blood tests. “They are normal” is the most useless assessment of tests possible. Plus or minus two standard deviations outside of the mean is ‘normal’ and tells you little more than nothing about how you are doing today or will be doing tomorrow.

My patient was neither lying to me or his self; life is complex and the corners we cut all look like straight lines to our goal. Precision measurement, iterative testing, and caring about the results is the difference between life and death; maybe not today but someday for sure.

That’s just triglycerides!

Get to work. It matters; somebody loves you!

God Speed,

Dr. Mike

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