The original OMT trials used medications to lower the risk factor that have a greater impact on clinical and financial outcomes than would be expected from lowering the risk factor alone. This one fact is as important as everything else that I have discussed. Usual care is based on the idea that the main goal of managing risk factors like high blood pressure, high cholesterol, and high sugar levels is to get the number down to goal. That is all that matters. OMT recognizes that certain medicines have a greater impact on outcomes than their impact on the target risk factor. ACE inhibitors like lisinopril and ARBs like losartan are prime examples. Researchers noticed that if these drugs were used to treat hypertension, there were beneficial impacts on the progression of chronic kidney disease and heart failure beyond the impact on the blood pressure. The next logical step was to test if they improved outcomes in chronic kidney disease and heart failure in patients who did not have high blood pressure and indeed they did. So, now these drugs are prescribed for patients with chronic kidney disease or heart failure who do not have high blood pressure.
Metformin for type 2 diabetes is another great example. If you achieve the same blood sugar control with metformin as another method, the patients on metformin will have 39% fewer heart attacks and a 32% reduction in all other diabetic complications. If it was all about the sugar, it would not matter how you got the sugar down. We learned about that fact in the mid-90s. I began to study why these specific medications have more impact than other drugs that lower the target risk factor just as well and I arrived at this conclusion. Now we know much more about the reasons that certain medications have a much greater impact on clinical and financial outcomes. Our understanding of the origins of chronic disease are dramatically changed.
Chronic diseases are not due to inherited changes in the DNA code. They are not due to genetics. They are due to DNA regulation or epigenetics. Epigenetics is an extremely powerful new concept, and an example will help you understand. At the moment of conception, DNA from the mother and the father combine in that single fertilized egg whose only function is to become all the other kinds of cells in the body. That process in the fetus is perfectly coordinated. It is like a magnificent symphony with genes being activated and deactivated at just the right time, in just the right place, for exactly the right duration, and with precisely the right intensity to form a perfect newborn child.
There are a set of genes that form a hormone called angiotensin II and that helps us understand precisely why lisinopril and losartan are so much more beneficial in improving clinical and financial outcomes. In the fetus, the genes that make angiotensin II are activated at just the right time and place to form a normal kidney. Angiotensin II is essential to form a normal kidney. That is so important because if a pregnant woman takes lisinopril or losartan, her child will not form a normal kidney. That birth defect is perfectly predictable.
But this insight is even more important. Once the kidney is formed and the child is an adult, the genes that make angiotensin II are much less active as long as the person is young, healthy, and slender. The trouble begins when the adult begins to gain abdominal fat. Abdominal fat becomes the largest gland in the body and one of the things it makes is the hormone angiotensin II, except now it is not perfectly coordinated to make a new kidney. It still supports growth, but it makes the heart bigger and the arteries thicker and that leads to high blood pressure, heart enlargement, congestive heart failure, more rapid aging, loss of function, and –ultimately—death.
The hormone angiotensin II engages its unique receptor on the surface of the cell like a ball in a catcher’s mitt. That interaction generates excess oxidants and subsequent inflammation. Excess oxidants and inflammation are involved in every chronic disease I have studied and they are core factors in the aging process. Here is another proof that losartan in our protocol is more effective than other drugs that reduce the blood pressure equally. Losartan is enough like angiotensin II that it fits in the catcher’s mitt. It does not merely lower the blood pressure. It blocks the production of oxidants and inflammation to make the heart and the arteries more normal It protects every cell and organ in the body. It is a precision medicine.
Here is the key point. Chronic diseases are due to normal genes that are essential to fetal and childhood development, become less active when we are healthy young adults, and then are reactivated later in life by age, cigarette smoking, and abdominal fat. When we are older, those genes generate more oxidants, we lose antioxidant capacity, and that combination results in oxidative stress. Oxidative stress increases inflammation. More rapid aging and faster chronic disease development result from increased oxidative stress and inflammation. Lisinopril and losartan have powerful antioxidant and anti-inflammatory properties. They are antioxidants that work to improve outcomes more than they lower the target risk factor. If you are older with some extra abdominal fat and you have high blood pressure, you want to take losartan or lisinopril. Amlodipine and eplerenone also have antioxidant and anti-inflammatory properties.