What Ails Louisiana

The lovable literary figure Ignatius J. Reilly had textbook medical maladies shared by citizens across Louisiana. When John Kennedy Toole wrote A Confederacy of Dunces in the 1960s, he created a literary character with a medical condition that now plagues Louisiana –– the metabolic syndrome.

The bilious and belching Ignatius was overweight. His mass consumption of Lucky Dogs, popcorn and bakery products from D.H. Holmes department store was consistent with impaired glucose tolerance, a precursor of diabetes. His propensity for heavy cloaks suggested thyroid dysfunction. His radical feminist girlfriend, Myrna Minkoff, hinted at sexual performance problems today labeled erectile dysfunction. Given his family history, he was predestined to develop hypertension and coronary artery disease.

The bronze statue of Ignatius Reilly on the 800 block of Canal Street in New Orleans depicts an apple-shaped body, a classic case of central obesity with the bulk of his excess fat in his upper body. This type of obesity predisposes its carrier to a higher risk of diabetes and cardiovascular disease. Other monikers associated with central obesity are “beer belly,” “potbelly,” “love handles” and plain old “fat stomach.”

The other well-known fat-distribution pattern is the pear-shaped body in which more fat is stored in the buttocks, hips and thighs than in the upper body.

Premenopausal women are more likely to develop pear-shaped bodies due to estrogen-driven fat storage in the thighs and hips. Although pear-shaped persons are not at greater-than-normal risk for cardiovascular disease, they are more likely than normal-size persons to suffer from osteoporosis, certain cancers, varicose veins and hip and knee arthritis complications.

Other obesity complications include increased gastric reflux, which helps explains Ignatius’ constant belching. Of course, Ignatius blames his intestinal problems on his pyloric valve; however, the pyloric valve separates the distal end of the stomach from the duodenum. His stomach problems are more likely due to excessive air swallowing and gastroesophageal reflux of acidic stomach contents into the esophagus through an entirely different sphincter.

Approximately one in four people in Louisiana suffers from at least some component of the metabolic syndrome. A person with full-blown metabolic syndrome has the Ignatius tummy with excess body fat around the waist, higher-than-normal blood pressure, abnormal serum lipids and impaired glucose tolerance. Each of these four conditions individually increases a cardiovascular-risk profile, but all four together make for the perfect storm.

Metabolic syndrome afflicts more than 50 million Americans, but Louisiana has more than its fair share: The most recent national health statistics show that 28 percent of adults in Louisiana are obese. Persons with metabolic syndrome gradually develop arteries clogged with flow-limiting plaque like the pipes in an old house. This increases the likelihood of coronary artery disease and heart attacks, stroke, peripheral vascular disease, diabetes and all the other serious complications that go with these diseases.

The etiologies and interplay among the various conditions associated with metabolic syndrome are complex and not fully understood. There is often a genetic component, as the inheritance of certain genes causes insulin to be less effective, but excess abdominal fat also decreases the effectiveness of insulin. Other factors that fuel the metabolic syndrome are physical inactivity, excess caloric consumption and hormonal changes with aging.

According to the American Heart Association, you have metabolic syndrome if you have three of these five findings: waist circumference of more than 35 inches for a woman or more than 40 inches for a man, blood pressure greater than 130/85, a low HDL or good cholesterol, triglycerides greater than 150 and a fasting blood glucose of greater than 100.

Slowing the Slide
You are dealt your sex and genetic risk factors at birth, but there are ways to stop or slow down the slide from simple metabolic syndrome to frank diabetes and cardiovascular disease. Cigarette smoking accelerates all these risk factors, so smokers need to stop. Period. The prescription drug CHANTIX really works for smokers well-motivated to stop, and I suspect the propensity for serious adverse effects such as suicide are overplayed. Smoking by itself fits the criteria for slow suicide in my book.

Next in importance on the action list is weight reduction, which usually independently brings blood pressure, glucose and triglycerides under better control. There are only two ways to lose weight –– consume less food or burn off more calories with physical exercise.

Most persons who are overweight entirely miss or skimp on breakfast. The lack of new food to fuel the body’s engine sends a midmorning message from survivor genes deep in the brain to the stomach that there is a famine in the land. The pancreas secretes extra insulin, stimulating hunger pains that translate into an urge to consume even more calories.

To lose weight, eat right-side-up and not upside-down. My grandparents practiced this, but modern times have changed eating patterns. My grandfather’s breakfast was eggs, grits, bacon and toast. He walked home about 15 blocks for a huge lunch, but he was lucky to get a bowl of Cheerios for supper. I call this eating right-side-up: more calories are consumed in the morning than at night.

Another way to reduce insulin-stimulated hunger pains is to decrease consumption of simple sugars and starches that also cause insulin levels to soar. Stuff yourself with a sugar- and starch-laden Chinese meal for supper, and you find yourself digging in the refrigerator for the doggie bag or a bowl of ice cream by the time David Letterman finishes his monologue.

Insulin surges explain the basic premise behind all the low-carbohydrate approaches to weight loss, from the Atkins diet to Sugar Busters. Various versions of the Atkins diet have been around since the 1970s. Sugar Busters began as a Louisiana craze in 1995 with an emphasis on eating high-fiber vegetables, whole grains and lean meats while avoiding foods with refined carbohydrates or those high on the glycemic index, such as potatoes.

H. Leighton Steward was the chief executive officer of Louisiana Land and Exploration Co. He became intrigued when a business colleague in New York washed down a spinach-and-bacon salad and six lamp chops with generous quantities of red wine while rhapsodizing about all this being on his new diet. After losing 20 pounds on the diet, Steward sought out a Frenchman who had written about a low-sugar diet and got his blessing to spread the word in the United States. Steward teamed up with popular New Orleans cardiovascular surgeon Dr. Morrison Bethea, a gastroenterologist and an endocrinologist to self-publish a book called Sugar Busters! After selling thousands of copies, a major publishing company took over, and Sugar Busters! was on the national bestsellers lists for months. (For more information, go to sugarbusters.com.)

The always-quotable Dr. Edward St. Martin emphasizes the importance of caloric restriction in what he calls “the dog diet”: “Get a Labrador puppy, eat half of what’s on your plate, and give the dog the rest.” This is good advice when coupled with a modified version of Sugar Busters. Simply avoid the white foods –– white rice, pasta, potatoes, white flour and all desserts made with refined sugar.

An estimated one in three Louisiana adults has hypertension, our most common cardiovascular disease. And most never have symptoms unless it goes untreated for years, lending hypertension the title of “the silent killer.” This is an easy disease to diagnose and treat. All it takes is a working blood pressure cuff and somebody who knows how to use it accurately. The commercial units you see at drugstores where a blood pressure reading is free for the sitting are actually fairly accurate.

Between Normal and Hypertension
“My pressure always goes up when I go to the doctor’s office” is a comment primary-care physicians hear daily. But here’s the bottom line on that –– fluctuating elevated blood pressure levels can also be a silent killer. For adults, normal blood pressure is 120/80 or less. Hypertension is a blood pressure of 140/90 or more. Most persons with blood pressures between normal and hypertension will progress to true hypertension with time.

Therapy to normalize blood pressure usually starts with a drug to flush out excess sodium and water or a drug that causes blood vessel walls to relax or both. Effective treatment of hypertension can reduce its well-known complications: coronary artery disease, heart failure, stroke, blindness and kidney failure.

Sleep disorders come in all sorts of styles and colors, from narcolepsy to restless legs syndrome. There are more than 100 sleep-related diagnoses that fuel other diseases and problems, including fatigue, memory impairment, depression, dyslexia, bipolar disorder, anxiety disorders and attention deficit disorder.

Ignatius was a perfect vehicle for obstructive sleep apnea. Just like an abnormal motor noise can signal an underlying engine problem, snoring represents airway turbulence that can cost your partner a good night’s sleep and make you feel miserable during waking hours.

The healthiest humans breathe almost exclusively through their noses at night. The tendency toward obstructive sleep apnea is much higher for nocturnal mouth-breathers compared to nose-breathers because mouth breathing during sleep carries a very significant mechanical disadvantage compared with nasal breathing.

People with sleep apnea and other sleep disorders often do not remember waking up during the night. Signs and symptoms of sleep disorders include snoring, excessive fatigue, daytime sleepiness, irritability (Ignatius was prone to violent outbursts), heartburn, elevated blood pressures even on medications and excessive weight gain. The culprit is a reduction in the REM cycle of sleeping.

Some sleep problems go away if the person lies on his or her side instead of on his or her back at night. Placing a tennis ball in a pocket sewn into the back of a sleeping shirt causes a back sleeper to shift to the side or tummy, improving airflow. Others swear by Breathe Right Nasal Strips readily available at drugstores. But the treatment Ignatius needed –– and that is needed by most persons with obstructive sleep apnea –– is CPAP, a small machine that keeps sagging airways open.

Cancer is not in Ignatius Riley’s differential diagnosis, but Thelma Ducoing Toole, the flamboyant mother of the novel’s author, died of cancer complications in 1984, according to professor Kenneth Holditch, the foremost authority on New Orleans literature.

Louisiana has one of the nation’s highest rates of tobacco-related cancers (lung, oral cavity, kidney and pancreas), correlating perfectly with our high rates of cigarette smoking. Louisiana got some bad press when the parishes lining the Mississippi River between Baton Rouge and New Orleans were dubbed “Cancer Alley,” even though there had been no scientific study showing an overall higher incidence of cancer in this area. We do have five parishes with rising and higher death rates related to these cancers –– Avoyelles, Caldwell, East Carroll, Morehouse and Washington. But these five parishes are not even in the so-called Cancer Alley. (For more information, go to statecancerprofiles.cancer.gov.)

One more tip — if you’re starting to show any of Ignatius’ features, try exercising more. Walking is always good; just stay away from the hot dog stands.