Looking beneath the surface of metabolic health

As doctors, we spend much of our time managing the end points of disease. High blood pressure, type 2 diabetes, gout, heart disease, fatty liver disease, high cholesterol and even many cancers occupy a significant part of our working lives.

Sometimes I find myself wondering whether we have become so focused on the destination that we have forgotten to talk about the journey.

When a patient is diagnosed with hypertension, we discuss blood pressure readings. When they develop diabetes, we discuss blood sugar levels. When cholesterol rises, we discuss cardiovascular risk. These conversations are important and often necessary. However, they tend to focus on what has happened rather than why it happened.

Many of the conditions we commonly treat are not isolated problems. They are often downstream manifestations of underlying metabolic dysfunction.

I sometimes think of health as an iceberg.

The conditions that bring people into the consulting room—high blood pressure, type 2 diabetes, heart disease, fatty liver disease and high cholesterol—are the visible tip above the waterline. They are the things we can see, measure and diagnose.

Beneath the surface, however, lies a much larger and often invisible story. Insulin resistance, chronic inflammation, poor sleep, increasing abdominal weight, inactivity, stress and years of small daily habits all contribute to what eventually emerges above the water.

By the time the tip of the iceberg becomes visible, the process that created it has often been developing quietly for many years.

Perhaps one of the greatest challenges in modern medicine is that we spend much of our time treating what sits above the waterline whilst paying far less attention to what lies beneath it.

Type 2 diabetes and hypertension are both key components of what is known as Metabolic Syndrome, sharing many of the same drivers, including insulin resistance, excess abdominal fat, chronic inflammation and changes within the blood vessels themselves. Fatty liver disease, raised cholesterol, gout and cardiovascular disease frequently sit on the same pathway.

However, by the time hypertension has developed, the underlying process may have been evolving for years. The focus naturally shifts towards managing the numbers. Over time, it is not unusual for people to accumulate treatments—one medication for blood pressure, another for cholesterol, perhaps another for diabetes or gout.

Each may be entirely appropriate, but unless we also address the underlying causes, we are often managing the consequences rather than changing the direction of travel

When someone is diagnosed with high blood pressure, the conversation understandably focuses on reducing cardiovascular risk and achieving target readings. Medication often plays an important role and, for many patients, is entirely appropriate.

How did weight gradually increase? What role did sleep play? Was stress a contributing factor? How active is the person? What does their diet look like?

These questions often receive far less attention than the blood pressure reading itself.

Perhaps part of the reason is that these conversations take time. Prescribing a tablet can take seconds. Exploring sleep, stress, nutrition, physical activity and behaviour change takes much longer. Yet those discussions may ultimately have a greater impact on long-term health than many of the treatments we prescribe. The challenge is that modern healthcare systems are often designed around diagnosing and managing disease rather than creating the time and space needed to prevent it.

Targets have an important place in healthcare. Measuring outcomes matters. But good health cannot always be reduced to a collection of numbers on a screen.

Long before blood sugar levels rise enough for a diagnosis of diabetes, long before blood pressure becomes elevated and long before the first heart attack or stroke, the body is often signalling that something is wrong. Poor sleep, weight gain, increasing waist circumference, fatigue, reduced fitness, insulin resistance and chronic inflammation may all be present years before a formal diagnosis is made.

These are not usually the things that bring patients rushing to the doctor. Nor are they the things that healthcare systems are particularly designed to measure. Yet they may tell us far more about future health than many of the diagnoses that eventually follow.

One of the reasons I am passionate about health screening and preventative healthcare is that it gives us an opportunity to look at the whole picture. Not simply to ask, “What disease do you have?” but rather, “Where is your health heading?”

Early health screening can often identify metabolic dysfunction long before a formal diagnosis is made. Blood pressure, cholesterol levels, blood sugar measurements and waist circumference can all provide valuable clues about future health risks.

However, the effectiveness of any health check depends on what we choose to measure. Some of the parameters traditionally used in healthcare may not always give us the most useful picture of an individual’s metabolic health.

For many years Body Mass Index, or BMI, has been used as a marker of health. Whilst it remains useful at a population level, it tells us surprisingly little about an individual’s body composition or where fat is stored. Two people can have the same BMI and very different levels of health risk. Increasingly, measures such as waist-to-height ratio provide a more meaningful assessment of metabolic health because they reflect central abdominal fat, one of the strongest predictors of insulin resistance, type 2 diabetes and cardiovascular disease.

When I talk about earlier health screening, I am not advocating a fishing expedition for disease. Nor am I suggesting annual full-body scans and endless investigations for people who feel perfectly well. In fact, there are risks associated with over-testing. Incidental findings can create unnecessary worry, lead to further investigations and, paradoxically, increase health anxiety in people who are otherwise healthy.

What I am advocating is a more measured and proactive approach to health.

Many of the conditions we worry about most, such as hypertension, can be entirely silent for years. People often feel perfectly well until a diagnosis is made or, in some cases, until a serious event such as a heart attack or stroke occurs. The opportunity lies in identifying risk earlier and helping people understand what those risks mean.

By the time excess weight has become a significant problem, insulin resistance is often already present. Yet many people have never heard the term, let alone understand why it matters. If we spent more time educating people about metabolic health, insulin resistance and the relationship between weight gain, blood sugar regulation, increased cancer risk, and cardiovascular disease, it would become easier to join the dots. Health would feel less mysterious. People would better understand not only what is happening, but why it is happening.

One of the most common things I hear in consultations is, “It’s in my family.”

Of course genetics play a role. Some people are undoubtedly more susceptible to certain conditions than others. However, genes are not always destiny. For many people, the development of conditions such as type 2 diabetes, hypertension and cardiovascular disease is influenced not only by inherited risk, but by lifestyle, environment and the cumulative effects of daily habits over many years.

A family history is not necessarily a forecast.

Of course, none of this is a guarantee. One of the humbling realities of medicine is that we can do everything “right” and still become unwell. We can exercise regularly, eat well, maintain a healthy weight, avoid smoking and excessive alcohol, and yet still face a serious diagnosis.

Life does not offer guarantees, and neither does medicine.

However, acknowledging that fact should not lead us to conclude that prevention is pointless. Quite the opposite. Whilst we cannot eliminate risk entirely, we can often reduce it significantly. We can improve our chances of remaining healthy for longer, delay or prevent many chronic conditions and improve our quality of life as we age.

Perhaps the goal should not be to avoid illness altogether, but to stack the odds in our favour.

I was reminded of this recently when I met a former NHS patient in my private clinic.

Several years ago, we had one of those early conversations about health. She was concerned about weight gain and rising cholesterol levels, and we discussed lifestyle measures, including nutrition, fasting and ways of improving metabolic health.

Over time, she lost around two stone and many of her blood markers improved.

Unfortunately, life then took an unexpected turn. She was diagnosed with a thymic cancer and required major surgery.

When I saw her today, she reflected on that experience in a way that stayed with me.

She told me that whilst the lifestyle changes had not prevented her diagnosis, she felt that being fitter, lighter and metabolically healthier had helped her cope with the surgery and recovery far better than she otherwise might have done.

Of course, none of us can know what would have happened had things been different.

But perhaps this highlights an important point. Good health is not simply about preventing disease. Sometimes it is about building the resilience needed to face whatever life brings our way.

We cannot always choose what happens to us. We can, however, influence how well prepared we are when it does.

Interestingly, many people only begin to take stock of their health when life presents them with a warning sign. For women, this may be the menopause. For men, it may be erectile dysfunction. For others, it may be mid life anxiety, depression, burnout, persistent fatigue or simply the realisation that they no longer feel as well as they once did.

These moments can feel uncomfortable, but they also present an opportunity.

Sometimes they are the body’s way of asking us to pay attention.

Perhaps this is one reason why health screening can be so valuable. Done well, it allows us to have these conversations before a major diagnosis occurs. It can identify risk factors, highlight early metabolic dysfunction and create opportunities for education and behaviour change.

In many ways, the aim is not simply to detect disease. It is to prevent the end point from occurring in the first place or to identify problems early enough that meaningful intervention remains possible.

Health screening is not really about finding disease. At its best, it is about creating a conversation early enough that disease may never develop at all.

Just as importantly, it allows us to look beneath the surface of the iceberg before the visible tip emerges.

We readily accept the importance of national screening programmes because we understand that early detection improves outcomes. Yet when it comes to broader metabolic health, preventative screening is sometimes dismissed as an optional extra or a luxury.

I would argue the opposite.

When carried out thoughtfully and interpreted within the context of an individual’s life, health screening should not be viewed as a fluffy addition to healthcare. It should be recognised as an important component of healthy living and disease prevention.

Nor should these conversations begin only once we reach middle age.

The earlier people understand how health and disease develop, the greater their opportunity to influence the direction of their future health.

This is why I am such a strong advocate for lifestyle medicine. The six pillars of lifestyle medicine—nutrition, physical activity, sleep, stress management, healthy relationships and avoiding risky behaviours—address many of the root causes of chronic disease.

They are not glamorous. They do not promise instant results. They require effort, consistency and personal responsibility. Yet they remain some of the most powerful interventions we have.

Perhaps the greatest challenge is that most of us pay attention only when something happens. After the heart attack. After the stroke. After the diabetes diagnosis. After the cancer diagnosis. After the warning from the doctor.

Human nature is understandable. When we feel well, prevention rarely feels urgent.

The difficulty is that by the time disease becomes visible, the underlying process has often been developing quietly for many years.

Imagine if we became as interested in maintaining health as we are in treating disease. Imagine if we celebrated prevention as much as we celebrate cure. Imagine if we started at the beginning instead of waiting for the end.

Perhaps the future of healthcare lies not in better disease management, but in helping people stay well for longer.

And perhaps that conversation needs to begin long before the diagnosis arrives.

Because once the tip of the iceberg becomes visible, the process has often been underway for years.

Thank you for reading.

This article was originally posted on Notes from a GP.

If you are interested in taking a more proactive approach to your health and wellbeing, you may be interested in our comprehensive health screening packages.