WHAT ARE THE MOST COMMON REASONS FOR A WARBIRD PILOTS TO LOSE THEIR MEDICAL

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WHAT ARE THE MOST COMMON REASONS FOR A WARBIRD
PILOTS TO LOSE THEIR MEDICAL ?

• AND HOW TO AVOID THEM
• Michael Schloss M.D.

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Diabetes
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Risk Factors for Cardiovascular Disease in Pilots
Obesity
Dyslipidemia
Age
High Blood Pressure
Inflammation
Diabetes Insulin Resistance
Sedentary Life Style
Cardiovascular Disease
Family History
Smoking
Heart Attack
Heart Failure
KidneyFailure
Stroke
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THE LIPID PROFILE
TOTAL CHOLESTEROL
HDL CHOLESTEROL
TRIGLYCERIDES
LDL CHOLESTEROL
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THE LIPID PROFILE
DESIRABLE LEVELS

• TOTAL CHOLESTEROL
• LDL CHOLESTEROL (increases risk)
• HDL CHOLESTEROL (decreases risk)
• TRIGLYCERIDES (increases risk)

45 (males) 55(females)

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ATHEROSCLEROSIS IS A PRODUCT OF HOW MUCH
CHOLESTESTEROL IS GOING INTO AN ARTERY VERSUS HOW
MUCH IS COMING OUT
CHOL
ARTERIAL WALL
CHOL
CHOL
CHOL
LDL
CHOL
CHOL.
HDL
CHOL
CHOL
CHOL
CHOL
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THE TOTAL CHOLESTEROL DOES NOT TELL THE WHOLE
STORY

• One half the heart attacks in the USA occur in
  individuals with Total Cholesterol Levels below
  200mg/dl.
• Two thirds of heart attacks in men less than 55
  years of age have Total Cholesterol Levels below
  200, Only 15 have very high cholesterol levels
• 60 of them have low HDL cholesterol

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NOT ALL LDL CHOLESTEROL PARTICLES ARE CREATED
EQUAL
NORMAL LDL PARTICLE
SMALL DENSE LDL PARTICLE

HIGHER RISK
1 Apo-B
1 Apo-B
M. Schloss 2002
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At the same level of total LDL cholesterol,
people with small, dense LDL particles have a lot
more particles than people with large LDL
particles
LDL C 100 Apo-B 90
LDL C 100 Apo B 160
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How Can You Tell If You Have This High Risk Type
of LDL (a lot of small dense LDL particles
without a markedly elevated LDL cholesterol
level)???
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Increased of Small Dense LDL Particles

• THEY CAN BE MEASURED DIRECTLY ( Apo-B or
  Lipoprofile)
• BY THE COMPANY THEY KEEP Low HDL
  Cholesterol, Elevated Triglycerides Obesity
  (waist 40 inches in men or 35 inches in women)
  
  High blood pressure ( 130/85 )
  Family
  History of Diabetes or Glucose over 100mg/dl
• Evidence of Inflammation (elevated Hs-CRP level)

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THE METABOLIC SYNDROME (any 3 of these 5 risk
factors puts you a high risk)
RISK FACTOR
DEFINING LEVEL
1. Abdominal Obesity
Waist Circumference
Men
40 inches
Women
35 inches
2. High Triglycerides
150mg/dl.
3. Low HDL Cholesterol
Men

Women

4. Blood Pressure
130/85
100mg/dl.
5. Borderline Blood Sugar
ATP III JAMA 20012862486-2497
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Prevalence of the Metabolic SyndromeIn the U.S.
by Age
8,814 US adults aged 20 and up
Prevalence,
Age, y
Findings From the Third National Health and
Nutrition Examination Survey,
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Prevalence of the Metabolic SyndromeIn the U.S.
by Age
8,814 US adults aged 20 and up
Prevalence,
Age, y
Findings From the Third National Health and
Nutrition Examination Survey, Ford, JAMA, January
16, 2002 - Volume 287, No. 3 pg. 358
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CARDIOVASCULAR DISEASE MORTALITY IN THE METABOLIC
SYNDROME
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Cardiovascular Disease Mortality
10
CUMULATIVE RISK OF DYING FROM A CARDIOVASCULAR
EVENT
Metabolic Syndrome
5
No Metabolic Syndrome
0
12
0
2
4
8
10
6
Years Of Follow Up
Lakka et.al. JAMA 20022882709-2716
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Insulin Resistance

• Cause A reduced sensitivity in the tissues of
  the body to the action of insulin
• Effect A higher level of insulin will be needed
  to keep your blood sugar normal.

Adapted from Reaven GM. Diabetes/Metabol Rev.
19939(Suppl 1)5S-12S.
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INSULIN RESISTANCE
Genetic Predisposition
AGE
Obesity
Physical Inactivity
Rising Blood Sugar Rising Blood Pressure Abnormal
Lipid Profile
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INSULIN RESISTANCE
If your fasting Blood Sugar (glucose) is over
125mg/dl you are diabetic If your fasting
Blood Sugar is between 100 and 125 you are
Pre-Diabetic Normal is 99mg/dl or less. The
two conditions are the same disease (prediabetes
and diabetes) , only the prediabetic is at a
slightly less advanced stage. The underlying
condition is the same, just get a little older, a
little fatter, and do a little less exercise and
the label changes.
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30
2008
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After a  two year loan to the United States ,
Michelangelo's  Statue of David is being
returned to Italy . . .
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His Proud Sponsors were
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Waist Circumference, Non-Fatal Heart Attack and
High Blood Pressure
Women
Men
RLATIVE RISK
Waist Circumference (Inches)
High Blood Press. Non-fatal Heart
Attack
Compiled from Nurses Health Study (women) Health
Professionals Follow-up Study (men)
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Waist Circumference and Diabetes
Women
Men
RLATIVE RISK
Waist Circumference (Inches)
Compiled from Nurses Health Study (women) Health
Professionals Follow-up Study (men)
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Abdominal Fat Is Not Just The Bodys Way of
Storing Energy
High Blood Pressure
Inflammation CRP
Heart Attack Stroke Diabetes
Dyslipidemia (High Trig. Low HDL)
Insulin Resistance
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HIGH SENSITIVITY C-REACTIVE PROTEIN
(Hs-CRP)

• A MEASURE OF INFLAMMATION (A SIGN THAT YOUR
  IMMUNE SYSTEM HAS BEEN TURNED ON)

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Inflammation (Hs-CRP) Correlates with Abdominal
Fat
N 159 men, mean age 43 years
Waist circumference
44






42

40
Inches
38
36
CRP quintiles
P 3
Lemieux I et al. Arterioscler Thromb Vasc Biol.
200121961-7.Després J-P. Eur Heart J Suppl.
20068(suppl B)B4-12.
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C-REACTIVE PROTEIN (HS-CRP) LEVELS PREDICT
CARDIAC EVENTS IN APPARENTLY NORMAL MEN
1086 Men Followed For 14 Years


RELATIVE RISK FOR HEART ATTACK

0.56-1.14
2.10
1.15-2.10
PPRidker et.al.NEJM 1997336973-29
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JUPITOR TRIAL
17,602 Patients with LDL-C 2.0
Randomized to Statin vs. Placebo
Heart Attack, Stroke, or Cardiovascular Death
Coronary Bypass, Stent or Hospitalization for
Unstable Angina
P P 0.05
0.06
Placebo
Placebo
0.05
0.04
0.04
- 47
0.03
Cumulative Incidence
Cumulative Incidence
- 47
0.03
0.02
0.02
Rosuvastatin
Rosuvastatin
0.01
0.01
0.00
0.00
0
1
2
3
4
0
1
2
3
4
Follow-up (years)
Follow-up (years)
Ridker et al NEJM 2008
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RELATIVE RISK VALUE OF BLOOD MARKERS FOR
CARDIOVASCULAR EVENTS
5.91
5.9
4.2
RELATIVE RISK FOR STROKE, MI OR CAD DEATH
3.11
3.1
2.8
2.0
1
Hs-CRP
LDL PARTICLE NUMBER
LDL-C
SMALLLDL
P Blake et.al. Circ. 20021061930-193
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The next time your Doctor asks you to get blood
tests ask him or her to get an LDL Particle
Number (Ideal is below 1000) Or An Apo-B level
(Ideal is less than 90) Hs-CRP level (Ideal
less than 1.0)
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Cardiovascular Mortality DOUBLES With Each 20/10
Increase in Blood Pressure
RR X8
RR X4
175/105
Increasing Cardiovascular Risk
RR X2
155/95
135/85
RR X1
115/75
Age 40-69 years n1,000,000
Lewington et.al. Lancet 2002601903-1913
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EVEN IF YOU PASSED YOUR MEDICAL (FAA requires a
BP INCREASES YOUR RISK FOR HEART ATTACK AND STROKE
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What Kind Of An Exercise Program Will Help You To
Keep Your Medical?
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Walking the dog
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The Key a Successful exercise program is to do
it regularly

• Bare bones minimum 30-40 minutes of brisk
  walking daily
• Ideal 30-40 minutes of aerobic exercise to a
  level that you perceive as moderately difficult
  with a 3 minute warm up and a 3 minute cool
  down (3-4 x week)
• Resistance training (weights etc.) 2 -3 times per
  week, ideal 10-12 reps, at a moderately hard
  level , try 10 different exercises to get most
  major muscle groups (1 set each)

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FRENCH FRIES
6.9 ounces
How much exercise do you need to do to burn off
the calories from this one order of Fries?
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FRENCH FRIES
610 Calories
Walk Briskly 1 hr 30 Minutes 45-60 minutes on
the treadmill
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What Is The Best Diet to Keep Your Medical?

• Reduce carbohydrate intake (restrict rice,
  potatoes, bread, pasta etc.)
• Increase intake of salads, vegetables and nuts
• Dairy products should be skim milk products
• Avoid fried food or gravies
• Use plenty of olive oil or canola oil
• Eat more fish, White meat turkey and white meat
  chicken (dont eat the skin)
• If you eat red meat, make it as lean as possible
• Bring your own food to airshows !

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ALCOHOL AND THE RISK OF CORONARY HEART DISEASE
87,938 Male physicians, followed for 5.5 years
P for Trend 0.001
RELATIVE RISK OF CARDIAC MORTALITY
NEVER/ RARELY
MONTHLY
WEEKLY
DAILY
ALCOHOL CONSUMPTION
Ajani et.al. Circ. 2000102500-505
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WINE vs. BEER EFFECTS ON CARDIOVASCULAR AND
TOTAL MORTALITY
36,250 FRENCH MEN 40-60 YEARS OF AGE - BEST
PROTECTION WITH 2-3DRINKS OF WINE AND 2- 3 BEERS
PER DAY
-1
DECREASE IN EVENTS

-29

-33

-40
Wine
-68
Beer
CARDIOVASCULAR
ALL-CAUSE
MORTALITY
MORTALITY
Renaud et.al. Arch. Int. Med. 19991591865-70
P 43
WINE vs. BEER EFFECTS ON VIOLENT DEATHS AND
CANCER

• 1-3 glasses of Wine per day was associated with a
  decreased rate of violent death by 51 compared
  to beer drinkers (decreased homocide , assault
  and automobile accidents)
• Drinking 2-3 glasses of Wine per day was
  associated with a 22 reduction in death from
  cancer
• Once you get above 2-3 ounces of alcohol per day,
  the rate of high blood pressure starts to
  increase.

Renaud et.al. Arch. Int. Med. 19991591865-70
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WHAT CAN YOU DO TO KEEP YOUR MEDICAL?

• Exercise Regularly
• Stay thin (Less abdominal fat)
• Keep your intake of saturated fat low
• Keep your LDL cholesterol low (below 100mg/dl),
  Apo B
• Keep your blood pressure low (less than is optimal)
• Dont Smoke!

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WHAT CAN YOU DO TO KEEP YOUR MEDICAL?

• If one of your close relatives had stroke or
  heart attack at a young age, get your risk
  factors evaluated and treated.
• If one of your parents or siblings has diabetes,
  make sure your blood sugar is
• Just because you take meds for blood pressure
  does not mean your blood pressure is well
  controlled.
• Just because your Total Cholesterol is below 200
  and your LDL is risk, you need to know your HDL, Triglycerides
  and Hs-CRP
• Your FAA medical is not the time to get your
  annual checkup. See your own doctor first and
  take care of any issues you may have, before
  going for the FAA exam.

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WHAT CAN YOU DO TO KEEP YOUR MEDICAL?

• You wouldnt fly without knowing how much oil and
  fuel you have .
• Dont leave your next Physical without knowing
  what your risk factors are and if they are being
  effectively treated.

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Visceral Fat
Normal
Insulin Resistance, Metabolic Syndrome or
Diabetes
Courtesy of Wilfred Y. Fujimoto, MD.