Second Cataract Surgery: January 6, 2016

Although the focus of this blog are issues associated with lipids and heart health, I'd like to bring in other topics as well, in particular, the choices one needs to weigh in choosing the best sight strategy for the kind of lens you choose to embed.

One can go for maximum distance vision in both eyes. But then one almost surely will need reading glasses.

Or one can go for the new "multi" lens, which go for both distance and reading. As with many other compromises, you don't get the best distance or reading correction. At least that's been the story on the street.

Or one can go for "mono-vision" (as I did). This choice takes off from the natural distribution of function your eyes already have. One eye tends to do the "up close" work, the other eye, the distance work. In my case, my left eye naturally gravitates to closer reading, my right eye is my distance eye. My optometrist and I discussed this and set this up with my last several contact lens prescriptions.

Instead of correcting both eyes to 20-20, he corrected my left eye to about 20-40, so that it was easy to read. He adjusted the right eye to the full 20-20 for distance. This worked very well. I could read small text (say on my iPhone) without reading glasses or even squinting. While driving, the brain combined the two different corrections into something like 20-20 (at least during the day). This worked very well and the idea was to continue it with similar embedded lenses when I had cataract surgery.

But cataract surgeries don't typically happen together. The cataract in my left (reading) eye matured faster than the one in my right (distance) eye. So the idea was embed a "reading" lens in that eye.

But I've left out the issue of astigmatism. Both eyes have some astigmatism, which needs to be corrected in some way. My left eye was a candidate for a "toric" implant, a lens which corrects vision, including astigmatism, but costs extra.

My surgeon, who is also a lasik specialist, suggested that he could embed a regular lens and adjust for astigmatism through lasik surgery  at the time of the implant. The idea was to come up with about 20-40 in the left eye to continue my strategy of mono-vision.. This translated to a "backing off" about 1.25 diopters. (There is not necessarily a one-to-one correspondence to the 20-20, 20-30, 20-40, etc. and the diopters of correction. 1.25, 1.50, 1.75, etc. This needs to be actually tested in a standard refraction exam at your optometrist.)

Long story made short is this: while my left eye started out at 20-40, it has continued to "back off" until, almost a year later, it is 20-80. This is no problem of course in terms of reading, but I do feel some strain in combining distance vision, say while reading labels in a museum or driving at night. On a bright day, because the aperture of the iris is contracted, you get the same "depth of field" advantage as you do with a camera, so that my left eye may be even 20-30 at that time and the illusion of a full correction in both eyes is very strong.

The optometrist at the surgeon's office said something like, "The original target was 1.50 but I see that it is 1.75 or more..." I thought the original target was 1.25 (about 20-40) and was afraid the result was more like 20-100 in that dark room, but it was later tested at 20-80, which I think corresponds to 1.75.

In retrospect, I probably should have had a toric lens for my left eye. But my current status is within the acceptable window - as I attested at the office visit.

For the future, however, especially if the left eye backs off further (a real 20-100), then I would get a contact lens for it. The question is then, "At what correction"? From a discussion with my regular optometrist, it would have to have at least 0.5 diopter correction to be worth it. For me, that would mean, I think, a 20-40 "net" correction in that eye.

The question then becomes, does that compromise reading vision. If so, it doesn't appear to be worth it. My optometrist was able to simulate what it would be to have this. I really liked how it helped my distance vision (in the relatively dark room). But I was slightly put off by how I would have to slightly distance (extend out further) my iPhone for optimum reading. A close call.

In the meantime, the surgeon is going for "the best distance" in my right eye and I will get the toric lens. ($$)

Bottom line, after the surgery  and things settle. I'll revisit this.

New Component: Diet

The Scramble

I had an hour-plus meeting with my new endocrinologist's dietitian. Our shared philosophy: "Eat as much as you want, but eat the right foods." Here I remember my experience in China vividly. I ate as much as I wanted, but still lost five pounds a month. At the end of my longest stay there - three months - I lost fifteen pounds. The trick, of course, is to do it here.

She gave me four pages of recommendations, about which I'll be posting in the future. I'd like to highlight here, however, the "Scramble."

This is a variation. I started with  about a half sliced white onion, garlic, part of a sliced yellow pepper, and some sliced green onions. To those I added some already stir-fried ground turkey (just an ounce or so). When those were cooked (but not over-cooked) I poured in enough egg whites (from TJ's) to cover, then waited for that to solidify. I added some chili flakes to warm things up, and some pepper. And just a little fish sauce in place of salt. I then rolled up the scramble, cut it in two and placed it on halves of a round flat bread that I had toasted. Awesome!

Tests Pending for February 2016 Assessment

Seeing my new endocrinologist has led to a variety of tests and consultations to establish diagnoses that my previous doctors suspected and prescribed for without necessarily testing for. For example, my excellent Kaiser doctor suspected that I might have "fatty liver syndrome" (NASH) but didn't test specifically for it, or made his judgment on the more standard tests. He also suspected some "insulin resistance" and talked of my being "pre-diabetic".  But my A1c test was typically normal, so those diagnoses were put on the back burner after attaining and holding a good lipid profile.

Often heard, "Yes it would be nice to have additional tests results, but because they would not change your treatment regime, there is no need to do them." A follow-up heart scan was not indicated because it wouldn't tell us anything we don't already know - and are treating for. (In addition, it would introduce additional radiation, something I did not need after the IMRT treatments at RCOG in Georgia for my prostate cancer.) The VAP test is expensive, and the results would be interesting, but they would not affect what we are already doing for treatment.And so on. I've continued to take my medications, exercise, and eat reasonably well.

Yet ferritin levels continue to be high. A younger family member has had two strokes. A cousin died in her forties from atherosclerosis. My Dad had this disease as well and suffered at least one very bad stroke. So it is perhaps not surprising that my new endocrinologist is specifically testing for these assumed diagnoses.

I've consulted a second specialist for the NASH - "fatty liver syndrome." There are a set of labs which are grouped under this heading "NASH". I've taken the test and will get the results back when the specialists reports back to my endocrinologist.

In January, I'll take the "VAP" lipid profile (equivalent to the Berkeley Labs lipid panel), then meet with my new endocrinologist. The VAP panel will help diagnose the "small-LDL-trait" - where one's LDL is small and gritty rather than large and buoyant. It is perhaps the best predictor of stroke. The smaller and grittier, the greater is the likelihood of a stroke or some other heart incident.

In the meantime, I've started shifting to the foods recommended by the dietitian in my endocrinologist's office. I'm intrigued with the possibilities. The idea is not to eat less food, but to eat different food. The result should be weight loss, the last piece of the puzzle. I am enthusiastic because this has worked for me in China where I lose 5 pounds/month eating all I want. More about this in a separate posting.

I'm taking milk-thistle, a supplement which is supposed to detoxify my liver. We will see from the VAP and liver tests in late January where this helps ferritin levels, or the slightly high/low scores of my liver enzymes.(See this earlier post.)  I'll have an ultrasound of my liver before Christmas to see whether there are any anomalies there. More about these tests later.

Nor have my kidneys escaped notice, though I haven't identified any tests specifically directed at them.

It is likely that the ferritin, NASH, insulin resistance, small-LDL-trait (and throw in Hyperlipoproteinemia Type IIb see this) are all part of the same syndrome that can be addressed by essentially the same medications, loss of 15 pounds, and a shift of diet.

Heart Scan Scores: Then and Now

November and December have and will be filled with a variety of tests, on which I'll be commenting shortly. But I've had a second heart scan and can compare the results to those of the Orange County scan from January, 2010. (The January, 2010 is in the middle, designated with "OC". The November, 2015 score is on the right, designated "MI" for "Millennial Imaging" where the scan was performed.)

First note that the actual number of lesions went down from 10 to 8. (This may, of course, be an artifact owing to different equipment.) Note also that the Calcium Score for the Left Anterior Descending Artery (LAD) actually went down from 283 to 258.2, although the number lesions is the same.  (Again, this could be because of different equipment.)   

For the Right Coronary Artery (RCA), however, although the number of lesions went down from 5 to 3, the score increased from 552 to 654.4. 

While it's my belief that these scores are in "standard form," Orange County included an additional interpretation from 0-100:

0-20 Low
21-40 Moderate
41-70 High
71-100 Very High

On this scale, OC assigned a number of 58, which falls the "High" category.

I am naturally curious about whether this initial risk has changed.  If proportions hold, this risk would increase about 8% in proportion to the increase from 835 to 903.6 or 63, which is still in the "High" category,  but not quite in the "Very High" category. Of course, risk assignment is tricky and may not be linear.

So how do I interpret the two scores, five years apart? I would not make too much of the "fewer" lesions. I am more mindful of the 8% increase in the total  score. I am appreciative of the 9% diminution of the LAD score. I was hopeful that this would be across the board. But this is offset by at nearly 16% jump in the RCA score.  

Still, if the proportions hold, then I would remain in the "High" category and am - in some sense at least - holding my own. One assumes it would be worse without my efforts over the past five years, very likely slipping into the "Very High" category.  But click here for my cardiologist's take five years ago. His thalium stress test actually looks at the blood going through these arteries.  His comment, "no obstruction."

That is, of course, the problem. I am asymptomatic. I am trying to guard against something that statistically could well happen. It goes back to indirect measurements. We don't see the plaque, we see the calcium in a calcium scan. We do see the blood moving in a thalium stress test. "No obstruction" he said.

Artery	# of Lesions OC	Calcium Score OC	# of Lesions MI	Calcium Score MI
LM	0	0	0	0
LAD	5	283	5	258.2
CX	0	0	0	0
RCA	5	552	3	654.4
Total	10	835	8	903.6

Measuring REM Indirectly

REM (or Rapid Eye Movement) sleep is not only when you dream but repair as well. If you don't get your REM sleep, overall health can suffer. I'm concerned about this because I use a CPAP machine. Does it prevent me, for example, for getting enough REM. I've puzzled over this from the time I started using my CPAP machine.

The "direct" measurement of REM is by detecting the electrical patterns in the brain during rapid eye movements. This done in sleep studies and requires hooking up a lot of equipment and being monitored overnight. I vividly remember doing this because of the discomfort I experienced being hooked up in that way. Here is what Medline says about polysomnography. A bit of a hassle.

But suppose you didn't have to do anything? Except wearing your watch to bed. Then waking up the next morning to view a graph of your previous night's sleep states, including REM. The new Basis Peak does this indirectly, using heart rate, skin temperature, and algorithms that they have built into their watch.

REM sleep is the light blue at the top, running about 25% total sleep time. Light sleep is below it, followed by Deep sleep in the darker green. This is a typical night and typical proportions. I am getting enough REM, but I'm making it a point to get at least 8 hours a night, which means going to bed a little earlier than I normally do.

The identification of REM sleep is tricky. Some CPAPers believe they can tease REM sleep out of the CPAP data. I'm inclined to believe they can, but I can't do it myself at this point, but I do have the Basis data, which is based on algorithms which correlate with polysomnography data just as closely as Polar's OwnIndex is correlated with actual VO2 Max studies, or as closely as Benno Fricke's preference data predictions correlated with actual SAT results. Seems like magic, but isn't.

VO2Max: Indirect Measurement

Imagine that you are on a treadmill working hard, being pushed to the limit in fact. Not only that, but you have a face-mask and air-tube hookup so that all of the gases going through your lungs are being measured. When you are about ready to conk out, you hear the welcome, "Okay, you can stop." This is how to determine one's VO2 Max directly.

It is both costly and invasive. At least, I wouldn't do it if I didn't have to. But it is the gold standard for determining fitness. The higher the score, the more fit you are. A top athlete may have a VO2 Max in the 70's or even 80's Lance Armstrong sported one of 85. Miguel Indurain may have had one as high as 95. A very fit 70 year old male would have one in the 40's, as would an average-age male of average fitness.

Okay, now suppose you could get the same result by lying on a bed for five minutes relaxing. The same result! (Okay, maybe a couple of percent one way or the other. At my age, I'm not competing on my bike) Wouldn't it be a no brainer?

Well, it is possible. In fact there are several such indirect measurements. But I was intrigued by Polar's "OwnIndex" which is their term for their indirect measurement of VO2 Max. Polar uses the same units so 45 VO2 Max units are the same as 45 OwnIndex points. For a discussion of the units see Wiki's article here.

Here is Polar's description of how to perform the test and (below) a table for interpreting the results. Here are the reliability results offered by Polar. In particular,

"Validity of a test means that the test measures what it is supposed to measure and not something else. The Polar Fitness Test was originally developed on 305 healthy Finnish men and women in a study, where VO2max prediction was developed using artificial neural network analysis. The correlation coefficient between the laboratory measured VO2max and the neural network prediction value was 0.97 and the mean error in the VO2max prediction was 6.5 % which is good compared to any other predictive tests of VO2max."

I'm partial to Polar's OwnIndex because it takes into account HRV (Heart Rate Variability) as one of the predicting factors. But there are a variety of indirect VO2 Max predictors, as it turns out.

One of them (use this link) has a predictor which uses only your resting heart rate! I've tried it and it is not too bad. Polar shows my OwnIndex as of today as 41. The first test on this site returns 36 for me. 1/3 of my current heart rate of 66 is 22. Enter that and 36 is returned. But other factors such as age, weight, HRV or previous level of aerobic activity are obviously not taken into account, so I would go with Polar's. (Aside from the fact that is is higher and therefore better.)

Others from that site use more exercise-intensive tests. The second has you walk a mile, then key in your age, weight, time and pulse rate. At some point I will try this one and compare it to Polar's.

There is a 3-minute step test, but you need to find 16.5 in steps. I'd bet that you could do this on a StairMaster

BTW the site has expanded VO2 Max Fitness tables as well. (Polar doesn't include 70 year olds on the tables I've seen.). Click here to view the expanded tables.

With a score of 41, I'm right on the cusp between "Excellent" and "Superior" for males between 70-79. Or, looking at it another way, with a score of 41, I have a comparable VO2 Max to men 50-59 in "Good" condition (38-42). Or 20 years younger.

Anyway, I'd like to think so. Unless and until getting on a treadmill to do a direct VO2 Max test,  don't hold your breath!

Three Indirect Measures of Important Things

In this and the next postings I'm going to identify three important things that can be known about oneself which can be measured indirectly. If measured directly, there can be considerable hassle, as in the case of measuring one's O2 Max, a key fitness indicator, or in the case of REM sleep, where EEG leads need to be placed on your scalp.

Some might wonder about a direct measurement of intelligence. There is probably no "magic bullet" to do this. That's why we have intelligence tests and even aptitude tests which purport to give some indication of brain power. But what if there were a way to predict performance on an aptitude test, say the verbal part of the Scholastic Aptitude Test (SAT) not by answering questions about difficult paragraphs, but on the basis of what you prefer; in effect, on the basis of a preference test. It would seem no cognitive test is being given (nor is it), yet this preference test can predict results on aptitude tests.

That's what triggered an interest, many years ago when I was a college freshman at the University of Michigan. I had just answered a series of preference questions (Agree or disagree: "I like cooked carrots rather than raw carrots," or "My stools are black and tarry.") These questions went on seemingly forever (actually, there were only 396 or them), but on the basis of these preferences, it was possible to predict my verbal SAT score almost exactly. I suspect that they could do the same with the math part as well. And maybe they did, but I to remember the verbal part. I was quite intrigued by this.

I had just taken what was affectionately known as Benno G. Fricke"s "Raw Carrots" test, which seems magical, indeed, because it could predict skills and aptitudes which would seem to have nothing to do with the chosen preferences. (I notice that Dr. Fricke was defending his 396 question test as late at 1975 in this Michigan Daily article.)

Just how this feat was accomplished I leave to colleagues far more versed in statistics than I am. But the basic idea is simple enough: you run correlations between student responses to the preference questions and what the same student got on his SAT test. (Michigan had all of this data, and the willingness to crunch it before computers went big league.)

Patterns would emerge. Perhaps on a subset of the preference questions. It might have worked this way: a set of responses to the 396 questions would emerge that correlated with top performance on the skill or aptitude test; another set with a less stellar performance, and so on. Within the grouping (all college freshmen), stable correspondences could be found. The test would not work, for example, on a random set of the US populations - I would think.)

So within this population, the predictions about aptitude, based simple on preference, would work and would seem magical.

The utility of the preference test does not matter. Some might say, you have the aptitude test results. What do you need the "predictor" tests for?  Good question. What if someone didn't have a SAT score. No problem. Fill it in with a really good estimate. Or perhaps, just perhaps, it would be interesting to see whether the preference test could predict skills in artistic perception or spatial perception, say in Gardener's 16 "intelligences. But this is for another time. For the present, note the ability to predict SAT scores indirectly.)

Okay. Enough about raw carrots. Now to the first of two measures that are important in assessing health: the indirect O2Max measure and the indirect REM measure.

Five Years Watching: Status Report

I began this Blog early in 2010, so a five-year "Snapshot" is in order.

My lipid profile remains good, with borderline "low" HDL readings. Exercise is good, with a recent 44 on Polar's OwnIndex, which correlates very well with the O2Max test, the gold standard in aerobic fitness.

This result puts me in the top category for those in the 60-65 age-range. At 74 I would think this is a good reading, but they haven't included us oldsters in their table.

I have also added the Basis Peak to my collection of health gadgets. More about this later, but it can track REM sleep. Preliminary results are excellent with on-target REM results.

Weight, however, remains an issue. It is steady at about 204 without clothes. In recent years, I've gotten it down to 189, but it creeps back up.

But the "presenting" issue of the past several months has been ferritin. My GP flagged this earlier this year. He was afraid it might indicated hemochromotosis. However, the two genetic tests were negative. At least I didn't have to be "bled" as in the Middle Ages.

But the ferritin is clearly tied into the constellation of factors that caused me to embark on this health project and this blog five years ago. I needed to become more pro-active.

I've now visited a highly-recommended endocrinologist, who has researched my past lab results, interviewed me thoroughly, and has recommended a battery of tests to complete, including another round of VAP tests. I'll also have another heart scan which we can compare to the earlier one done at Orange County, so we can see whether the level of obstruction has been stable. It is even possible that it has been rolled back slightly.  My risk level was "High" in 2010 with a score of 58. See this post.

I am reminded of the issue of whether the risk level remains high even with treatment that reduces cholesterol, etc. The Orange County results implied a 20% chance of heart incident, presumably if untreated. Does it remain at 20% if treated? What are the differences in percentage between treated and untreated cases. I assume my risk remains "High" even if treated. But my GP seemed to disagree. Well, I assume he would, otherwise, what's the point of treatment? I puzzled over this earlier.

So I will head to the labs next week to see what's up. At the five year point, this is a good thing to do. It is ten years since my serious look at my lipids at the time of my prostate procedure. I'll be able to revisit my VAP results, including the "small LDL trait"  that puzzled me first time around. I'll also be able to follow up by doing another calcium heart scan and checking progression. And deal with my diet. Good to be doing this.

Looks like some attention will be paid to my liver too.

I have appointments with my GP and cardiologist upcoming as well.
Stay tuned.

No Celtic Curse, but NASH still an Issue

I've had high ferritin readings for some time, but this time my GP referred to to a hematologist to check it out. He was worried that the high level could indicate hemachromatosis, which overloads the liver with too much iron. There is a cure for this (or a way to manage it), but it is a hard one to believe. The patient is systematically bled, as in the Middle Ages, though then for more pedestrian afflictions.

This is done to lower the amount of iron in the liver. A build-up of iron can damage the liver. Bleeding the patient from time to time prevents this from happening.

People of Irish and Scandinavian descent are genetically predisposed to the disease, when, "The Celtic Curse" is derived. A blood test can tell you if you have this predisposition.  I took it, waited three weeks, saw the doctor, and was told I didn't have the predisposition. Whew!

But what about the elevated ferritin? My Kaiser doctor diagnosed me with "fatty liver" syndrome, which is typically referred to as NASH. My hematologist speculated that the causal sequence is the other way around. Something triggers a release of ferritin in the liver. What that something is, is not clear.
"The hematologist did offer a suggestion: fast once a week. That might "detoxify" the liver. I've started doing this and will check back in month with him and see whether the levels have changed at all.

Yearly Doctor's Visit - Holding, but with a Flag

Had my yearly check up a couple of weeks ago and my lab work done a couple of days ago. Just talked with my Dr. on the phone with the lab results. Okay on lipds, pretty much as expected. Sounds like a little high on the LDL's. I heard something like 116, but will pick up the results in the next day or so.

Big picture is that I have almost achieved the goals I set out at the beginning of this Blog. No way I can get my HDL much above the mid-forties, but the rest are pretty much in line. My doctor is satisfied however.

The flag? My ferritin is on the high side. I heard something like 600, but it has been high. My doctor is concerned that too much iron is ending up in my liver. Hemochromotosis is the specific condition. It is treated by blood letting. Shades of the Middle Ages! I'll check with a specialist, whose name I'll pick up with the lab results.My take? I've long had "fatty liver" syndrome. That was my Kaiser doctor's diagnosis twenty years ago. My current doctor, being cautious, wants to rule out hemochromotosis. Me too.

I noted that my ferritin level in 2014 was 678. The upper end is supposed to be 300 or so. It's probably been near 600 since it stopped being monitored in late 2008. It was quite intensively monitored in 2007, with 4 separate tests, averaging 572. It averaged 500 in 2008.

I think the high ferritin is associated with my familial lipid dysfunction (Hyperproteinemia IIIb) rather than with hemochomotosis. We'll see.

My Ownindex topped out at 43 recently. My CPAP is working well. I put in about 50 miles week cycling and will do more hiking.

I'll cut down on red meat. And try to lose 10 pounds. Maybe go vegetarian a couple of days a week. Maybe fast most of a day one day a week and increase that to two if it works. This is important but I do love to eat and snack!