In two earlier blog posts (I and II), I outlined a fairly common extra articular complication of rheumatoid arthritis called metabolic syndrome which is associated with increases in insulin resistance, type II diabetes and cardiovascular disease. Although all of the connections are not fully understood, it is clear to researchers that the systemic inflammation brought about by RA can contribute to metabolic malfunctioning (see this scientific review).
Since I was writing about these topics, it should come as no surprise that metabolic syndrome has become an issue for me. This originally came to the surface when I was receiving Actemra infusions every month. One of the listed side effects of Actemra is an increase in blood pressure and lipids. My rheumy began regularly checking these parameters and we began to see an increase in hypertension and the lipid test results were high and rising over time. I already knew that my cholesterol was borderline going into the use of Actemra. But the dramatic changes, coupled with the lack of efficacy of Actemra in treating RA, were enough to cease using it after five months. But even after stopping Actemra and going on a low fat diet to try to lower cholesterol, the test results kept coming back high. At their peaks over the past few months, my total cholesterol was 293 (target is below 200), high density lipoproteins (HDL) or “good” cholesterol was 33 (target is above 40), low density lipoproteins (LDL) or “bad” cholesterol was 226 (target is below 100), and triglycerides was 469 (target is below 150). The fact that triglycerides were high points to the fact that sugars were going unused and were being converted into long term storage molecules. Insulin resistance was occurring and I was headed towards type II diabetes as my general practitioner pointed out.
My rheumatologist and general practitioner both agreed that metabolic syndrome was a real danger and we developed a comprehensive plan to treat it. I did not want to develop type II diabetes and I felt like a ticking time bomb for a heart attack or stroke. This all seemed surreal as these issues don’t run in my family and I was not really overweight. My body mass index (BMI) was 24.4 which is still in the low category – albeit at the high end (see this simple online BMI calculator). The major culprit must have been the systemic inflammation caused by RA.
My general practitioner commented that eating a low fat diet does not do much to lower cholesterol and that since my triglycerides were high and insulin resistance a real threat, he suggested cutting back on sugars and starches. After much investigation, I found an excellent book on insulin resistance diets. I began to analyze my eating habits and found out that I was eating far too many processed sugars and starches. I’ve learned to keep total carbohydrates to about 30 grams per meal, balance quality carbs with low fat proteins (about a 2 to 1 ratio of carbs to proteins), and snack regularly when hungry. I’ve learned that American diets are full of processed sugars and starches that can wreak havoc on someone with metabolic syndrome. There’s been a complete change in mindset in how I eat. I avoided Atkins, South Beach, and Paleo diets as they are not necessarily designed for insulin resistance and may be difficult to follow long term. A balance in macronutrients – quality carbs from whole grains, proteins, and fats – seems to be the best approach. Of course, I can eat all the green vegetables I want.
Exercise is another way to stave off insulin resistance as muscles can burn through large amounts of unused glucose in the bloodstream (see this article). RA patients often have trouble remaining physically active that was the case with me over the past few years. While RA is currently active and not under control, I have attempted to go on walks several times a week and started doing some fairly light resistance band exercises when my joints and energy levels permitted. The only medication that was used was a daily dose of the cholesterol lowering statin drug atorvastatin (Lipitor).
At my most recent blood tests last week, the cholesterol and triglycerides are finally within normal parameters – total cholesterol = 136 (target below 200), HDL = 46 (target above 40), LDL = 70 (target below 100), and triglycerides = 99 (target below 150). Cholesterol was down and insulin resistance was no longer an issue! In addition to the dramatic decreases in lipids, my blood pressure has decreased and I’ve lost 10-12 pounds in two months. The spare tire from my waistline is disappearing and my BMI is decreasing. My general practitioner wanted to make sure that I was not prediabetic so he ran a fasting blood glucose test and it came back within the normal range. Thyroid function was also tested since it has so much to do with metabolism and everything came back normal. While it’s impossible to pin the improved metabolic markers on any one treatment or prevention, the systematic and aggressive approaches are probably acting in concert with one another.
Unfortunately, these metabolic syndrome treatments and lifestyle changes have not had a dramatic impact on RA symptoms as they remain uncontrolled. In fact, I predict that if systemic inflammation from RA gets under control, it will help with metabolic issues. But that is another battle that my rheumy and I are systematically tackling right now.
If you have RA, it is critical that you and your doctor regularly monitor your blood pressure, lipids, body weight, and glucose levels to make sure that metabolic syndrome is not running amok. If problems persist, then please be proactive by treating and preventing these extra articular symptoms from having a serious impact on your health and life span.