Dhru Purohit Show - My Cardiologist Breaks Down My Heart Tests: What Your Cholesterol, Calcium Score & Labs Really Tell You with Dr. Michael Twyman

Episode Date: October 7, 2026

This episode is brought to you by Fatty15, Our Place, Branch Basics, and Dose. Today on The Dhru Purohit Show, we’re revisiting a favorite episode with my personal cardiologist, Dr. Michael Twyman, on overlooked heart disease risk factors and how diet, exercise, sunlight, sleep, and stress management support your arteries. He also walks through my lab results, from genetics and cholesterol to ApoB and omega-3 levels, to show what a personalized approach to heart health can look like. Dr. Michael Twyman founded Apollo Cardiology in St. Louis, Missouri. He combines conventional cardiology with functional medicine, mitochondrial optimization, and cutting-edge biohacking to help patients understand and reduce their cardiovascular risk. With an integrative approach that goes far beyond standard care, Dr. Twyman has helped hundreds of patients take control of their heart health. In this episode, Dhru and Dr. Twyman dive into:  (00:00) Introduction  (6:28) The Biggest Myths in Cardiology (10:09) What Heart-Risk Markers Can and Can’t Tell You (15:56) Heart Disease and the Health of Your Artery Lining (24:13) Is LDL Cholesterol Really Good or Bad? (31:04) What’s Damaging Your Blood Vessels? (35:19) Light Exposure: The Overlooked Piece of Health (38:34) The Connection Between Light, Mitochondria, and Your Heart (56:28) Why Sleep Quality Matters for Your Heart (1:01:30) The Role of Stress in Heart Health (1:08:34) Beyond Cholesterol: Protecting Your Artery Lining (1:10:41) A Deep Dive Into Dhru’s Heart-Health Lab Results (1:43:21) Plant-Based Eating and Lipids: Why Individual Responses Matter (1:48:17) Finding the Right Treatment for You Also mentioned in this episode: Sleep Master Class: How Poor Sleep Makes Us Hungry, Disrupts Our Blood Sugar, And Increases Our Risk For Alzheimer’s Disease with Dr. Sunjya Schweig Boston Heart Diagnostics Cleerly Test  For more on Dr. Twyman, follow him on Facebook, Instagram, X/Twitter, LinkedIn, YouTube, or visit his Websites: Dr. Twyman and Apollo Cardiology. For more on Dhru: Instagram, X/Twitter, YouTube, and KOMI. This episode is brought to you by Fatty15, Our Place, Branch Basics, and Dose. Fatty15 is offering an additional 15% off its 90-day subscription Starter Kit. Go to fatty15.com/dhru and use code DHRU to replenish your C15 levels for long-term health. Reduce your toxic load by upgrading your cookware! Go to fromourplace.com today and use promo code DHRU at checkout to receive 10% off any order. Branch Basics is offering 15% off the Premium Starter Kit; just go to branchbasics.com and use the coupon code DHRU. Support your liver with one simple daily habit. Visit dosedaily.co/DHRU and use code DHRU to get 35% off your first subscription. Sign up for Dhru’s Try This Newsletter *Nothing discussed in this podcast should be construed as medical advice; always consult a qualified healthcare professional regarding your individual health needs. Learn more about your ad choices. Visit megaphone.fm/adchoices

Hi, everyone, Drew Prode here. So a lot of you who have followed me for a long time know that heart disease is something that I care a lot about. Part of this is because cardiovascular disease remains the number one killer for both men and women. A lot of people don't know that, but yes, it's the biggest killer for men and women. But it's also, like many of you, it's personal for me. Heart disease runs in my family.

I've had multiple grandparents pass away earlier than I feel is their genetic potential from heart disease. And interestingly, I learned a few. years ago that my dad, I've always known that he had high LDL, high cholesterol, in the classic sort of medical sense. And it was like when he was 35 years old and my family moved to El Paso, Texas for a few years because he got promoted. But a doctor there, when he was around like 30, 35 years old, he recommended that he'd go on a statin at the age of 35 to manage his high cholesterol. I don't even know if they were looking at LDL then. I'm sure they were. But yeah, he's been on a statin

since he was 35 years old. And now he's 75. That's crazy. So as I got to, got older and was gearing up to turn 40 and paying attention to more of my own numbers a few years ago, I wanted to understand what actually matters when it comes to cardiovascular health. And what is my true cardiovascular risk? Because this space has exploded. There's so many more things beyond just looking at cholesterol, which obviously, we all know, doesn't tell the full story. And even going a little bit beyond LDL, which of course that we've learned on this podcast is important and there's nuances that are there. So the question for me was, what should I be paying attention to beyond a standard cholesterol panel. And how can I look at that cholesterol panel, LDL, and now we're all paying

attention to ApoB? How can I look at that in context? And most importantly, how much plaque do I actually have in my arteries? Because, you know, these are all proxies. Calestral panel is all proxies. They're decent proxies. But how much plaque you actually have in your arteries? So I want to search. That search led me to Dr. Michael Twyman. Now, Michael Twyman, some of you have heard him on this podcast before, but those you that are not familiar, he's a board certified cardiologist. He's a former Navy medical physician and the founder of Apollo cardiology in St. Louis.

And over the years, he's become my personal cardiologist and somebody that have sent multiple members of my own family to. Now, again, I mentioned you might recognize Michael because he's been on the podcast a few times as recently as just a couple of weeks ago. We had him on to talk about

libel protein little A, why it's in the news, why we should be paying attention to it. But the nuances that are there, if you miss that episode, still worth paying attention to. And after that conversation, I thought it was a perfect time

to bring back one of my favorite episodes we've ever done together. So I flew a couple years ago to St. Louis to see Dr. Twyman, and I basically said, give me your program, give me the most comprehensive look at my cardiovascular health that we can possibly get, which was easy, because that's exactly what he takes every patient through. So in this episode, we actually pull all my labs and go through them together.

We took a look at my advanced Boston heart panel, which is one of the most comprehensive heart blood panels that you could possibly do, including my own APOB numbers, my LDL particle numbers, my inflammation, my insulin resistance, my fatty acids, and even markers that can help you determine whether you're producing too much cholesterol or reabsorbing too much cholesterol, which is part of the equation when it comes to heart health. We also look at my genetics, which, by the way, this was one of the most fascinating tests that's

out there. I had never met any other practitioner that was running this test, and Dr. Twyman runs us through the results of this test, and precisely what these results show us about what medication, if I decide to go down that path, what medications might or might not make sense for me when it comes to my heart health. And most interestingly, we pull my clearly CCTV. Now, a CCTV or a coronary CT angiogram lets doctors actually visualize the coronary arteries. And then clearly, which is a software system, uses AI to analyze those images that you get from a CCTV and qualify and quantify the amount of plaque that's there, including both calcified plaque, which is the hard plaque, and the soft plaque that a standard

coronary calcium score or cac score can miss. And soft plaque, by the way, can be one of the most dangerous forms of plaque, especially as we age. And the big reveal is, I give him permission to show you how much plaque was actually in my heart. I was nervous when I did this test originally three years ago. I was nervous about what it would show because I had been on a ton of different diets. And right before seeing Dr. Michael Twyman, I was trying a modified version of a high fat. I won't even say ketogenic, but keto-inspired diet. And I remember one time I went into my doctor at the time, this was maybe like seven,

eight years ago, and I got for the first time my APOB done. And it came back like through the roof. It was like 300. So I was so scared because I thought, man, being on this high saturated fat diet for a while, keto-inspired, putting coconut oil and MCT oil in my coffee, which was a big friend that everybody was doing back in the day. Did I damage my heart? Did I put all this plaque in my heart? And I'm only freaking 40 years old, not even at the time that I was doing this test. And I was worried, what was it going to show? And Dr. Twyman kind of walks you through that. Now, here's the thing.

I love being transparent about my lab results because my goal on this podcast isn't to tell you what to do. It's to show you the questions that I'm asking for my own health or sometimes my parents' health and my family's health and how I'm navigating things, even when they don't look perfect. And hopefully today's podcast will give you better questions to take back to your own medical team. And by the way, if you have the resources and you're looking for this level of cardiovascular testing, which actually isn't like something crazy expensive, it's pretty standard when it comes to if you've ever worked with a functional or integrative doctor. I've had an incredible experience with Dr. Twyman and his team at Apollo Cardiology.

I have no affiliation with this clinic. I'm simply a fan of great doctors. And when I find one, I love telling people and I love letting them know. In fact, I think I hear from Michael ever so often. Most recently I heard of a listener who flew all the way from Australia to go see him. because he and his wife had a history of cardiovascular disease in their family, and they wanted some answers. So, yeah, if you have the resources, check out Apollo cardiology. And if you don't have the resources for this testing, that's exactly why I'm making conversations available like this for

free. So let's jump into my conversation with Dr. Michael Twyman, which was originally run three years ago, but is so relevant, especially if you missed the episode, we're going to tackle some of the biggest myths about heart health. And we're going to set up and do a deep dive into my own cardiovascular your labs and how much plaque I have in my own heart. Stay tuned. Give us a top line understanding of some of the myths that you still see that are out there, right, in the world of cardiology and specifically when it comes to cardiovascular disease. What are some of the top two, three, four myths that you still see out there today that don't take into all, don't take into account all the latest nuances.

that we have because of testing and deeper understanding about both diet, lifestyle, blood work, et cetera. Sure. And there's still a lot of mess out there in the cardiovascular world. You know, unfortunately, cardiovascular disease is still the number one thing that tends to take people out at an early age, especially unexpectedly. And unfortunately, about every 40 seconds in the United States, somebody has a heart attack. Oftentimes, the first time they ever have a sign that they have issues with their heart is

during that heart attack. So most people don't meet a cardiologist until it's sort of too late. You know, they're starting to already have chest pain and short of breath. And so if it's not a heart attack, well, they gets into an outpatient office. And the myth is, well, your EKG was normal. And we did a stress test and it was normal. You're low risk. But all those tests tend to tell you is that you're not at the end stage.

They really tell you nothing about that there's sclerosis, the plaque that's already forming in your arteries. And if you're 40 years older above, there's better chances than not to you're going to already start having some plaque building up in your arteries. And you may not have any symptoms for quite a while, but that plaque is kind of like the boogeyman that's about to pop out at some point if you have a lot of inflammation, if you have a lot of endothel dysfunction, which I'm sure we're going to talk about going forward. So the myth is an EKG and a stress test is enough to rule you out as being high risk.

The other big myth is it's all about cholesterol. You know, cholesterol is heavily debated in social media. Some people think statins should be in the water. Some people think they're absolute poison. and the truth is obviously somewhere in between. Now, there's always going to be cholesterol that's deposited inside plaques in your arteries, but it's a little bit more nuanced. How does it get there?

Cholesterol is a waxy compound that your body produces. It's a critical molecule. Without it, you are not alive. You make your sex hormones with it. You make your bile acids with it. You make your cell membranes with it. So again, without cholesterol, things don't happen. But because cholesterol is waxy, it has to get transported in the blood.

And most people have had their traditional cholesterol panel checked, and it'll give you a number of it says total, cholesterol, H.D.O. cholesterol, LDo cholesterol, and triglycerides. And sometimes that's the only lab that they get. But it's a very crude estimate of what's going on in your blood vessels. You know, it's more about the lipoproteins that are carrying it around. And those watching the video, I always use the tennis balls, the analogy. The cholesterol goes inside the lipoprotein. The lipoprotein is essentially a cargo ship that ferries the cholesterol, the triglycerides, which are energy for the cells. vitamins, the fat-soluble ones, and then phospholipids, which are building blocks of the cell. So the liver will make these phospholipids, these protein lipid carriers, and pump them out and send

the cargo through the blood vessels. The only problem comes in when these things start sticking to the artery wall like Velcro, they can get retained there, and they will basically illegally dock there and drop off their cargo. The cholesterol was not supposed to be going there. It was supposed to be going somewhere else to make a hormone or build bile acids or build shells of your cells. but if it got stuck in your arteries, that's what's going to start that plaque cascade. And this can start in your teens and 20s.

So it's never too early to really get screened up to say, hey, I'm really low risk, I'm really high risk. Because unfortunately, still half the people who have heart attacks have no symptoms before that heart attack occurred. That's great. And you kind of talked about it already with stress test, EKG, looking at that. What are some other sort of almost in a way like archaic ways of only looking at our cardio, risk, right? What do people traditionally think about? And on top of the ones you already mentioned, and what are some of the limitations of those, right? So people hear about a CT scan, for example. Can you talk about that? And then some of the other ones, if you have any additional to add in.

Sure. And, you know, frequently people will only focus on the top five risk factors for cardiovascular disease. That's going to be high blood pressure, hypertension, dyslipidemia, abnormal cholesterol particles, diabetes. You're going to know those through physical exam and blood testing. The other ones are smoking, which for the most part, most people are not still smoking, fortunately. And then the fourth one is, you know, being obese. But that just tends to mean you probably are going to have a lot more inflammation, more risk of insulin resistance. So it's kind of, you know, overlaps with the diabetes one. So those are the top five, but there's up to like 395 other risk factors that can drive atherosclerosis or plaque forming in your arteries. So if you only go

looking for five things, you're often going to miss something. And often, the things that are being monitored, they're not doing the more advanced testing. So, for example, hypertension, you know, is your blood pressure over 120 millimeters, over 80 millimeters of mercury? Well, most time, if you go to the doctor's office, you've rushed into the parking lot, you sit down, they slap a blood pressure cuff on your arm, maybe they don't even roll up your sleeve, and they check your blood pressure and say, oh, it's high. Well, you're really supposed to be resting for a few minutes, your heart and your arm should be at the same level. It should be on the bare skin.

It should be ideally used with somebody listening to the, you know, the blood pressure sounds versus just a machine. You know, the machines can be accurate, but sometimes they're not if they're not calibrated. So do you know if your blood pressure is truly accurate or not? Well, there's different ways to assess it. Yeah, we have a device in our office that actually will assess your central blood pressure. That's the blood pressure that comes out of your heart and goes down your heart arteries, up to your brain, to your kidneys.

That's your true blood pressure. Then the lip proteins, we're sure going to. to get into that. If you're only checking a traditional cholesterol panel, you don't have a full picture. You really want to be looking at the number of particles, the size of the particles, something called apolypo-liprotein B. That's going to give you a much better picture into what is actually floating through your blood. And then diabetes is a complicated topic. And by the time somebody's hemoglobin A1C is, you know, above 6.5 and they're now classified as diabetic, it's been going on for a long time for the most part. You know, it's first going to start with higher insulin levels. Your

insulin is going to start spiking first. And then you'll certain things in your lipoproteins will be abnormally. Probably have higher triglycerides, low HDLC, high small LDL, maybe more inflammation will be present. Those are signs that you're really headed towards insulin resistance if you don't do something about it. And kind of for the biohacker crowd, you know, you can get the continuous glucose monitors for under $100 and measure your blood sugar for up to two weeks and then figure out what foods you're sensitive to, or is it stress? Is it blue light? Is it you're not sleeping well? You know, what is breaking your glucose response? And then we were kind of hit upon the smoking. But the side note is the myth is that like the e-cigarettes or the vaping safer? The data is actually

coming out that it might actually be worse. You know, there's other, you know, combustible things that are in the vapes, the heavy metals. All the things really damage the gel coating of your arteries. So those are kind of the newer things that we're starting to look at is just for the five basics. but there's all sorts of advanced lipid testing, inflammatory markers, and then there's the biophysical testing that we offer an office and many offices offer that look at plaque way before, you know, you're going to fail a stress test. So the stress tests are a good test when you're having symptoms. You know, if you're having chest pain, shortness of breath, exercise intolerance,

it's good to put you on a treadmill so you can you recreate those symptoms under a supervised situation. But by the time you fail a stress test, you're typically going to be a test. you're typically going to have to have a 70% blockage of one of your arteries. And again, for the video, that's what your artery is going to look like by time you fail, stress test. But if you pass the stress test, it really doesn't tell you that you're home free. So you mentioned the CT scan. So there's a test that pretty much anybody who's not had an event, basically they've not had a heart attack. Yeah, cardiovascular event.

They've not had a heart attack, a stroke, stints in their heart, bypass surgery. Those people are high risk. This test is not for them. So this is for the people who have some risk factors, family history. It basically called like an amygram for the heart. So CT-corner calcium score or calcium scan, usually about 100 to 300 US dollars, low-dose radiation. It basically takes a picture of your heart, and it looks for calcium in the walls of your arteries.

So calcium is supposed to be in your bones. It's not supposed to be in your artery walls. Calcium in the artery walls is a marker that the arteries have been damaged in the past, and the buyer is trying to take care of that by the body is supposed to take care of that by scarring it down and fibrosing it. So it's a stabilizing factor. Just to pause there just to make sure that everybody's following along. So when you were holding up, you know, the tennis ball, right?

What you're talking about is essentially is that, let's say that there are these lipoproteins that are floating around the blood and, you know, they may have, you know, cholesterol inside of them. So damage, which can come in all sorts of different forms, we're going to go through a whole list of like what are the top things that damage those, that endothelial lining. and then you end up having like sort of like a little bit of a pothole and then these cholesterols, you know, these lipoproteins get stuck there, right? And so that's what you're talking about in terms of like, you know, you have had some damage

and now these lipoproteins that are floating around have gotten stuck in this little, this little divot. Exactly right. And it starts with the endothelial dysfunction. So maybe we'll backtrack there before you go fully into the calcium scar because that's kind of like a late stage finding. So sometimes I'll use an analogy of like subway stations. You know, the first stop is endothelial dysfunction. So to define it, your endothelium is the inner lining of your arteries. It's one cell thick and it coats the entirety of the 60,000 miles of blood vessels that you have.

So that one cell has multiple functions, but one of them is to release something called nitric oxide. Nitric oxide is a signaling molecule. When it's produced on the artery wall, it will cause that artery wall to relax the muscle under the endothelium. So this is going to keep flow normal. This is going to keep your blood pressure optimized. But when nitric oxide becomes low, things tend to start sticking to the arteries. So for younger people, they may not remember what Teflon actually is, but when you have high levels of nitric oxide, the lipoproteins, the white blood cells, the platelets, they just zoom on through the lumen, kind of like a magloft train, and just slide right through. But once you have endothelial damage, the gel code above it, the glycopalase damage, then these lipoproteins start sticking,

there, the white blood cells start sticking there like Velcro, and they may get retained into the artery wall. The body is basically since this is an attack, you know, bacteria is attacking it. So the white blood cells come out, they start gobbling the stuff up, and that starts causing inflammation in the walls of their artery and it starts swelling. You can monitor that with a particular type of carotid skin called the carotid intomeremuteal fitness test. But if that process is allowed to go on, then these kind of like baby soft plaques start rolling, and then eventually the body will start trying to scar it. down. But that, again, may take many years. And once it scars it down, it may calcify it as a stabilizing factor. And that will get picked up on one of these CT-coordinated calcium scans. But again, that's a kind of a later stage finding. So often you'll see on, you know, social media world that

people will say, well, cholesterol doesn't matter because my calcium score is zero. That just means you're not late to the game. You don't have calcified plaques in the artery, but it could have a bunch of soft plaques still building up, and you wouldn't know that unless you want to go looking for it with some of the non-invasive tests I know you've had or doing some other advanced testing that looks at the endothelial health. Yeah, and actually you were the one and Dr. Gabriel Lyon through introducing me to you, you were the one that I recommended this clearly scan. You know, I don't have any affiliation with them. Obviously, it's a test that you guys use in conjunction with a lot of different tests that are there. And we're going to show my results. We're going to kind of walk people through it, which is really cool.

You know, and we'll maybe talk about my, no one test is the full picture, which is why you have a whole slew of different things you work on with patients. But at least this will give you an idea that, you know, just to connect the dots here for people that are in the wellness world, you know, generally zooming out, a lot of people on this podcast, you know, they eat healthy. They're doing a lot of the basics that are there. Sure, they're trying to maybe dial in movement. They're trying to work on that morning light. They're doing that. But they're generally still feeling very confused about what are the things that play into cardiovascular health. And I think I've heard the statistic from you in America alone as the number one killer, it's 700,000 people a year die from heart disease, right?

Like, just think about that in context of, yeah, okay, COVID was bad when it was in its height, but just think about how bad heart disease is. And is it also right that I heard, this fact check me on this, you may or may not know, women die more? They're actually, their rates of cardiovascular disease is higher? Is that true or not? I thought I heard that somewhere. Over enough time, women will have the same.

cardiovascular risk is a man. Estrogen is generally cardioprotective, so they tend to develop cardiovascular disease 10 years later. But often it's a kind of lack of education that cardiovascular disease is still the number one killer of women. You know, breast cancer is still something to be very concerned about and to be screened, but it's something like seven to eight times more common that a woman is going to develop cardiovascular disease than they are breast cancer.

So if you don't go looking for cardiovascular disease in a woman, you potentially are going to miss it until they start having their events. So they eventually will have a boss. the same amount of cardiovascular disease as a man, but they may present kind of more acutely because they didn't go looking early enough. Totally. And, you know, I know you're a fan of Peter Tia and you've mentioned his work before. He has a great phrase. He says, you live long enough, everybody will eventually die of a heart attack, right? Or they'll at least have plaque in their arteries. You don't have to die of the heart attack. Right. You'll have some version of Athloscarosis.

That's there. Correct. So going back to the endothelial dysfunction, which I love this, example that you also, you know, you share is that, you know, especially for the men that are listening today, if you have erectile dysfunction, you have endothelial cell dysfunction, right? Those, the ED is ED. And like, I've shared that with so many of my guy friends as like the first indication. There's many, many practitioners on the podcast that have come on here as well saying that that's one of the earliest markers going back to nitric oxide. You know, we've had Dr. Lou Ignaro on the podcast before about his work, is Nobel Prize winning work around the discovery about nitric oxide as a signaling molecule inside of the body. But that is an important takeaway for men and obviously the women that are in a

relationship with them as well too, is that if you have erectile dysfunction, that's one of, that's the earliest sign of endothelial dysfunction that's there. Is that accurate? That's exactly right. You know, ED equals ED. So 60,000 miles of blood vessels, the ones that tend to get damaged first are going to be the smaller microvessels. So think about your hair. The diameter of your hair could hold about a hundred of these microvessels. And so the blood vessels to your extremities, the penis and men, those blood vessels are more likely to be damaged with high inflammation, high oxidative stress, high insulin, high glucose, spike proteins. Lots of things can damage that gel coating. But once you have subthreshold nitric oxide levels,

your arteries are not going to dilate very well. So you can't bring blood flow into the penis to initiate or maintain an erection. And so nitric oxide, one, the niteroxide, one, the nitercise is Nobel Prize in 1998 for its discovery. There's companies developing medications for hypertension, high blood pressure, that when they gave it to the people, they had more erections. That eventually became Sedinophil, Viagra. So it had a bigger market going down that path than treating hypertension. And guys obviously will pay for that use sometimes. But it is the canary in the coal mine. So I always have this in my intake questionnaire asking people, you know, have they used Viagra, Seales, those type of medications, and it's not a judgment against them, but it's a sign that

if you're requiring those type of medications to maintain an erection, it's that you likely have a nitric oxide issue, and you should really have your heart checked out. Because those medications, the way they work is that they basically prevent the breakdown of nitric oxide, and it keeps it around longer. But it doesn't fix why you have low levels, or it doesn't even tell you why you have low levels. It's somewhat like a band-aid, and it's a good band-aid that can help men be intimate, And that's great, but it just sometimes is a marker that you really need to get your heart checked out. And I'm a cardiovascular specialist. So most guys are coming to me to get screened, but this is often something that people will be talking about with their primary care doctors.

And, you know, if you're listening and you say, oh, it equals ED, then you can start doing some of these more novel blood test or testing of the arteries at an earlier stage and then get them on the right path of kind of healing themselves so that they don't go down the path of developing severe atherosclerosis. That's great. We'll break down nitric oxide and, you know, what is harming it and then what can help it. We're going to talk about that in a minute. But still sticking on this topic of endothelial cell dysfunction. You know, I didn't really finish my thought that I was hearing before. So I'll just connect it again. Most people in this podcast, they're doing a lot of things that are there that they feel, you know, are helpful for them. But they're still often very confused because they hear a lot of mixed messages when it comes to the world of especially diet. And a big part of your message is it's not just diet. Yes, diet is an important part of it, but there's all these other things that are completely

underrated that connect to endothelial dysfunction, atherosclerosis, and eventually, you know, making you more prone to heart attacks or less prone to heart attacks. And we're going to unpack that all. But going back to the listeners, so often people will hear versions of, hey, you want to keep your LDL low, and then they'll hear another side say, well, there's danger. to keep your LDL low, then they'll hear another, the same side, you know, another side, but somebody may be a little bit more sophisticated saying, well, still in general, when you look at these big observational data and these studies that are there, generally people who had lower

LDL as one of the primary markers that are there, you know, had a correlation with having less heart disease, right? So talk to us about at least LDL. I think there's a lot of people that understand like cholesterol is not the full conversation. You know, it's not the problem itself. But then there's still some people that are stuck on that sort of LDL component, and they're hearing from different sides, and they're just like, I actually don't know what to believe now. If we want to stay strong and resilient as we get older,

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Check out Our Place today. You're exactly right. It is somewhat of a complicated, complicated topic in ways, but to break it down, you know, think of like three levers that you can pull. First is, can you do something about the endothelial glycochalix and the endothelium? That's the nitric oxide story. If those levels are low, figure out what's breaking it and support the body to get more optimal levels. After doing that, second is look at the inflammatory cascade.

So we're all supposed to have inflammation when we have a virus or we have an injury. You want your immune system to kick on, take care of the problem, and cool back down. So start with those two things first, because those are the things that are necessary for plaque to start forming. I think still the commensal cardiology world does very good work in emergencies, but sometimes it's a challenge trying to get the message out there because it does require education. And fortunately, the message got to be like, LDL cholesterol is bad and HDL cholesterol is good. It's too simplistic of a message, and it's not actually physiologically right. Cholesterol is just cholesterol.

And there's just different lipoproteins, different cargo ships carrying things around. So when we go back to it, your liver is making the majority of cholesterol that's in your body. You're not necessarily getting this from your diet. So your body makes the cholesterol to make hormones, to make bile assets, to make cell membranes, but it'll put it inside the lipoprotein. The LDL particles are for the most part taking things from the liver and delivering the cargo to your muscles, your other organs. And then the HDL's job is to pick things up and shuttle back to the liver.

So it's kind of like different, you know, cargo ships. essentially, that have different roles. HDL has other roles involving the immune system. But it's essentially about the APOB containing particles because they are the ones that will drive cardiovascular risk. This is out of the like Pramingham offspring study, looking at the LDL particle size being more predictive of risk than the actual LDL cholesterol.

So more particles, more risk. Now they're now just thinking about it's like shots and goal. The more of these that you just got circulating around in your blood vessels, the more chances they're going to interact with your artery walls and get retained there. So cholesterol by itself is not the problem. But if you have an artery that has endothel dysfunction and a lot of inflammation going on because whatever else is in your life is going on, you have sleep apnea, you smoke, you don't exercise, you eat horribly.

These lipoproteins, they're going there to kind of clean up the mess, but they're getting stuck there. And that's the problem. Yeah. So I think that's a perfect place to really go through. What are the top things that are damaging our endothelial? cells that are so crucial and are the first step in us eventually ending up with, you know, heart disease at some point in time and then eventually, unfortunately, so many people dying of a heart attack or at least having a heart attack.

Sure. And, you know, I will always kind of layer it into like the four pillars of health, you know, major pillars, you know, there's exercise, there's nutrition. And most people will sort of stop there. And they are very important pillars. But if those are the places where you stop and forget the. other two, the table's still going to fall over. The third pillar is your stress management. We all experience stress every day, you know, you exercise, that's physical stress. There's mental

stress. But how well do you bounce back from it is really the key. So I sometimes use an analogy of like, you know, the gas and the brake. You know, your sympathetic nervous systems, the gas, you need to go sometimes. You need it to be fight or flight time. But how fast can you pull it back? How far can you break it down when you need to? And that's all about stimulating the parasympathetic nervous system, you know, stimulating your vagus nerve. So this is where meditation, deep breathing exercises, yoga, you know, the biohackers can do, you know, Apollo Neuros and interbalance and all that stuff that they want to do to simulate the vagus nerve. So you have to deal with your stress. And then the big pillar is really your sleep. And we'll probably talk much more about sleep

at coming up. But if you don't manage those four things, that's going to drive a lot of oxidative stress and inflammation. And it's those three, you know, it's inflammation, oxygen, of stress and autoimmune dysregulation. Or, you know, people are developing Hashimoto's, Crohn's, you know, your immune systems turned up. You're carrying different compounds through your blood vessels when those things happen. And then the blood vessels are sort of getting damage as innocent bystanders. So I said earlier that the endothelium is one cell that can coach your entire arteries.

But in the past few years, it's become more evident that the real structure to focus on is the endothelial glyco-Kalax, the EGX for short. It's basically a sugar coating or a gel coat that lines on top of the endothelium. You can almost think of it like a seabed, the moths of the seabed, just sensing what's floating through the riverbed. There are so many things that will damage this gel coat. The most common things, high blood sugar will definitely damage a gel coat that's made of sugars and proteins, high insulin, high sheer stress. So if you have high blood pressure for numerous reasons, that little moss essentially is going to take a hair. It's going to get damage.

Heavy metals. You know, there's certain things in the diet that definitely will do it. You know, so if you have LPS, the lipopolysaccharides, you know, coming from, you know, basically leaky gut, that's going to damage it. You know, there's the spike proteins. Spike proteins will damage the glycocalyx. And then when that happens, endothelium laying below that is not going to be able to pump out nitric oxide at normal levels.

So there's lots of things that will damage it. Unfortunately, there's things that can also help you prepare it. Yeah, that's great. And it's like, you know, I think we're in Los Angeles right now. I'm in Los Angeles. And it's been raining a ton. And with all this rain, these roads are not used to it. And so you see these beginning formations of these potholes all over the city.

And, you know, you have a natural cargo, which are these, cars that we're all driving in. And then these cars are driving through and cars are good. We don't say cars are bad. You know, you have to get from one place to another, just like we're saying, like cholesterol has to do its job inside of the body. You know, one car hits this pothole. Potdle gets a little bit bigger. Another car hits a pottle. It gets a little bit bigger. Another car hits a pottle. It gets a little bigger. And if you're not repairing these things, you don't have good maintenance on the road, you're going to end up in a place where a small, tiny, tiny pot hole can become a really big problem and can cause a lot of damage down the line and even

like an accident. I know it's not a perfect analogy, but in a way, you're talking about our endothelial cells being disrupted, beaten up through all these other lifestyle components. And the one that I feel like you are most passionate about, probably because you've done the work yourself to look into this and how it's connected, is also about light and one of the reasons that you're wearing the glasses that you're wearing right now. So talk about the role that light and photo, what was it again, photo biomodulation? You got it, yeah. Yeah, photobiomodulation.

Tell us about the role that that plays and how that has become an underappreciated aspect of health, specifically connected to cardiovascular disease. So it's a great question. And, you know, sometimes I get asked like, well, how did I get into talking about photo modulation or why do I wear the blue black and glasses? Well, back in 2017, I was traveling to Asia and it was going to be like a 14-hour flight. and I knew the jet lag was going to be pretty significant. So I just started researching, you know, what can you do to help mitigate jet lag other

than just take melatonin and came upon some articles talking about these blue blocking glasses. And I didn't really read the science behind him. I just heard that it potentially worked. Bought the glasses, jumped on the plane, flew over to Asia, and the jet lag was present, but it was about a third as bad as I'd experienced in the past. I was like, that's crazy. I have no idea how that worked. So then when I got back, did, you know, some deep dives and came positive some people that

put me on the right path and read Dr. Sacken Panda's information. There's Alexander Woonch out of Germany that has a lot of information on how light affects your biology. I was like, that is fascinating. Why didn't I learn this in medical school or any of my training? And then to start understanding that, oh, we all evolved under full spectrum sunlight. We were supposed to be outside the majority of the day. When did most chronic diseases really start flaring up? When we all start moving inside and spending 8, 12 hours a day, and then especially in the past 15, 20 years, an explosion and all these autoimmune conditions and diabetes, because we're all drawn inside onto technology. We're not getting the proper light signals throughout the day. So if your body doesn't know what time of day it is,

your body has different clock genes that are programmed by light, programmed by timing nutrients come in, your body gets confused. And when it's confused, there's going to be more inflammation. There's going to be more damage happening that you're going to have to recover from. So I wear these blue black and glasses, partly so I can educate people about it, but I'm also trying to be a good steward of like, I need to protect my melanopsin receptors in the back of my eyes, so my brain knows what time of day it is. So my sleep is going to be optimized because sleep is when you repair all the good things that you've done throughout the day. So you go out and exercise and you eat clean, but you don't sleep well. It's like putting real premium gas into an engine that you never tune.

You have to sleep well to get the benefits. And controlling your light environments is really that first step. So circadian rhythms, there's different clock genes in the heart that determined that you should exercise more likely in the afternoon to have peak performance. There's certain cardiac cells that are more active at nighttime, that your blood pressure will start rising between 3 a.m. and 5 a.m. That's getting ready to go outside and hunt or gather whatever you need to do throughout the day. So the body always has these different rhythms, but we sometimes just get lost and, you know, paying attention to how they're really supposed to be tuned up. It's fascinating and, you know, really, I've heard that, you know, the heart is one of the largest concentrations of mitochondria, but you have a whole other, you know, more detail on mitochondria

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So sometimes my name's Mito-Myke. But the mitochondria, you know, we all learned in like, you know, high school biology, you know, the powerhouse of the cells. Well, the mitochondria do a lot more for your body than just make energy. but it's a pretty important thing. So your mitochondria, you have multiple mitochondria inside your cells. The heart and the brain are the two organs that tend to have the most mitochondria. And each heart cell has somewhere between 3,000 and 5,000 mitochondria.

Those mitochondria take in the food stuff that you eat. And this is why sometimes on, you know, social media, I kind of get, quote, bored with the food war. It's because, you know, food is energy and information. The easiest way to break it down is like if it's not man-made food in a lab and it's made from a vegetable or it's an animal product that you're eating, you're basically breaking down sunlight energy. Photosynthesis grows your food and you go eat it and you digest that sunlight in your mitochondria. That's the basic way to think about it. It's not perfect, but the mitochondria are breaking that stuff down into protons and electrons. And that's what generates the energy, the ATP, the water, the carbonodocus.

and the heat on the other side of the mitochondria respiratory chains. So the heart and brain, because they have so much energy demand, those are the places where most chronic diseases happen. You can think of it as like a brownout. You know, if you, you're in California, there's rolling brownouts at times. If you don't have energy, things don't work well. If you don't have enough energy in your brain, you're more prone to things like Parkinson's or Alzheimer's. If you don't have enough energy in your heart, you're more prone to things like

age of revelation or coronaryarthoscrosis or a cardiomyopathy, a weakened heart. So I kind of focus almost everything back down to circadian rhythms first and then focus on mitochondrial optimization. And that's mainly getting people to sleep better and putting the right inputs into the mitochondria. That's great. And, you know, our mitochondria, just to make the connections, the connection there, our mitochondria are very sensitive to light, which is why I wanted to talk about mitochondria in the context of photo biomodulation, right?

Is that part of your work as well? Correct, correct. And it's evolutionary thought that mitochondria were their own standalone organisms at one point and there's a symbiosis and then we kind of made a deal with them like, hey, make us energy and we'll protect you. And so because they're not put together like a, you know, you carry out cell, they have a thinner cell wall so they're more sensitive to light, like you said, and they have different cytocrams in them.

those cytochromes are different light detectors. So photo biomodulation is a term that's been used since about 2015. And prior to that, it was known as low-level light therapy or low-level laser therapy. But this is a type of therapy that has been present in Europe and Russia since the late 1960s. And it's only since the late 1990s, early 2000s, is again a little bit more prevalent in the United States. But what is photo biomodulation? It's basically using light to modulate your biology, change your biology. So, even in old Egyptian days, there was heliotherapy.

People would go outside and they would soak up full spectrum sunlight. Photo by modulation usually will use different wavelengths of light. And the majority ones that people are going to utilize in kind of the consumer-facing world, it's generally going to be the red and infrared spectrums of light. because those will penetrate a little bit deeper into the skin, and the mitochondria are very sensitive to both red and infrared light. So when the red light penetrates into the mitochondria, it will help the mitochondria make energy more efficiently.

It helps make ATP. It decreases reactive oxygen species, so it lowers oxidative stress, it lowers inflammation. But what it also does is when that red light penetrates the mitochondria, there's five respiratory proteins in the mitochondria. So you can almost think of them as like, stepping stones. So it's like hopscotch or I should say kind of like the old game of Pac-Man. I should say, Frogger, let's go with Frogger. So it's the Frogger game. You're kind of bouncing around.

So you're passing an electron down the chain. At the fourth one, nitric oxide, our friend in the arteries to dilate it, it acts as a handbrake. It's actually slowing energy down in the mitochondria. There's reasons why, because anytime you're making energy in the mitochondria, you're also going to make reactive oxygen species. You're going to rust with that extra energy making if you're not ready for it. So the body will use nitric oxide to kind of slow energy production, but we're in energy production to come back on with photo-bomodulation, the red light therapy goes into mitochondria, knocks nitric oxide off that four-sidocrine, and then energy flow continues. And then that nitric oxide is free to diffuse out to your blood vessels and dilate your blood vessels.

So this is why, you know, you can have improved athletic performance, you can have improved blood pressure utilizing photo bar modulation. That's fantastic. And I think that a lot more people are aware of through the work of a lot of really great people that are out there, like Andrew Hoobman, about the power of morning sunlight. And if we wanted to give some actionable tips on top of that, because you are a huge fan of morning sunlight,

I love to follow you on social media because it's always that reminder if I haven't gotten my morning sunlight to like, hey, make sure you get it the next day. So morning sunlight, you know, and again, feel free to clarify on that, like, you know, your approach to it. But then another one that you really big on is that, you know, really winding down the lights at night and especially because they're not that expensive, getting a good pair of, you know, blue light blocking glasses, like the dark red ones, right, that are really good at pretty much getting rid of all of that blue light around you and really starting to use those at night when you start to wind down for bed. Probably, you know, it's always, you know, you have to balance out social and everything else like that that people are doing. but what would you say at least like you know two or three hours before sleep at least an hour before

bed as usually I tell people if they're just kind of get their feet well with this but once you start noticing the improvement in your sleep quality you tend to want to know like well what else can I do what else can I do and then you know for myself I just made it a habit that like if I'm inside and I'm not controlling the light environment then I'm protecting my eyes at least so I kind of lead you through like what a quote optimal day would be but essentially this is what your great great grandparents would have had. They would have generally woken up somewhere near sunrise, whatever environment they were at. The first light that they would have seen, unless they lit a fire in the morning, would have been the sun. Your body evolved to that sun signal. So, I, you know, having missed a full sunrise in many,

many years, sometimes traveling, I don't see it right when it breaks the horizon, but I try to be outside at the time that the sun rises. The light hits the back of your eyes. So no glasses on, no sunglasses, there's a receptor back there called melanopsin. It's a blue light detector. So when that hits back there, the body's like, oh, daytime, cortisol will start to increase. But you're going to make other neurotransmitters. You're going to make dopamine, serotonin. There's something called pompsi. It's going to have beta endorphins, so it's going to make you feel better. So that morning light sets the clock for your rest of your organs. There's a master clock behind your eyes called the supercosmic nucleus. that gets that signal and says, oh, daytime, tell the organs, let's go. Then live your life. If you're

inside a lot, you know, try to mitigate the light when you can. So I will wear kind of these day pair of blue blockers if I'm going to be in front of a screen because your screens are basically dialed in at the same color as solar noon. So if you're staring at your screen when it's solar noon, that's fine. But if it's 9 p.m. at night, you're now giving me your signal to your brain. It's still daytime. So you're going to keep it. your cortisol levels very high at that point. And that's going to be an alerting factor. Stay away, go hunt. And you're going to keep suppressing melatonin. And melatonin is a hormone. It's not a supplement. Melatonin is a hormone that your body's making throughout the day, but it only gets

released when there's about three to four hours of darkness. So until they invented the light bulbs in the late 1800s, at nighttime, you had fire or it was dark. And once it's dark, your body will start setting the clock that, hey, you're probably going to start going to sleep in three to four hours. So if you really have trouble sleeping, start working with your light hygiene at night. And there's different companies that make the darker glasses. I don't recommend people have to get the darker ones. I can start with these ones and use it more during the day and see how they affect it. But if you're really deep down the rabbit hole, well, at nighttime, there's glasses that will block 100% of the blue spectrum of light, 100% of the green spectrum of light. I basically

say it's like midnight for your brain when you put these things on. You just feel your brain cooling down. And it's very rare that if I put those on, that I'm still awake half an hour or an hour later. So I usually fall asleep with them on and then take them off go to bed. But they're my favorite kind of hack when I'm traveling is that like you're on a plane and you need to quickly get over jet lag. If it's nighttime to wherever you're flying, you're saying on the plane, you wear the red glasses, you're going to have a lot better jet lag experience on the other side. And to zoom out again because, you know, a lot of folks in this podcast have heard or maybe listen to other podcasts where they've heard a lot of people talk about

blue light, morning light, all these components. But you are really strongly connecting these principles, habits, and larger ideas back to cardiovascular health. And that's the part that, and you're not saying that it's a nice bonus. You're saying that it's one of the central things that you talk about because, and feel free to add to it, our photo biomodulation impacts our sleep. It impacts our mitochondria, which are largely concentrated in our heart and our brain. And again, to repeat what you shared, that's the center of a lot of chronic diseases long term. So before we get into diet, and of course there's a role for strength training and movement inside of this as well,

if you are not paying attention to the light aspect of your day, you're going to be going and working uphill, and it's going to be that much harder for your heart to do the work and for your endothelial cells to repair and not have damage. Is that accurate? Anything you want to add to that? No, that was a great review, and that's exactly right. I was trained as a cardiovascular specialist and took care of a lot of

sick people in the hospital having heart attacks and, you know, shocking people getting them out of bad heart rhythms. And there's always going to be a place for that. But I got much more interested in like, well, how do we stop this? And then basically we look upstream or I should say back at least 10 years and be like, okay, if we do this, this person's never going to have a heart attack. But eventually you get to the point of, you get to a certain point of life, you're like, maybe I should start thinking about longevity. You know, how do I keep healthy for a long time, not just prevent people from my heart attacks? So then you fall down deep rabbit holes and you find different people with podcasts and you know, you optimize this and that, but it really comes

back down to like, oh, if it really comes all down to the mitochondria, what do I need to do to take care of those guys? And the mitochondria, one of the fun facts is this was discovered by Dr. Doug Wallace at the Children's Hospital of Philadelphia is that the mitochondria or only inherited from your mother, comes from your maternal lineage. And if you've done 23 and me or one of those ancestry type tests, you usually can find on the test. What I'll say is your maternal. haplor type. That's essentially where your original maternal mitochondria came from. And this is kind of a starting point sometimes I talk with patients is like depending on where your original mitochondria came from, where you're more equatorial. You know, that means those people tend to really need a lot of sunlight to

kind of power up those mitochondria or are these mitochondria more northern European? Well, when people moved out of East Africa and went north, one of the kind of evolutionary things that happened is that the mitochondria became less efficient at making energy because during the process of moving north, it got really cold. And instead of wanting to freeze to death in the winter, the mitochondria would basically become less energy efficient and there would radiate heat. That heat would then keep you from freezing to death. So people who have a northern European type, papalotype, they can go down to Mexico in the summertime

and do fine. And then they can also do fine when they're up in Finland. But if you take somebody who's supposed to be optimized at an equatorial, latitude and then you move them up to Detroit, they're basically have mitochondria that you can never fully charge. And they're much, much more likely to get a chronic issue. So you have to kind of match the person to their environment. Again, we'll get in nutrition a little bit, but I always want to focus on the mitochondria at first. So, you know, think about what your engines need. They need proper light signals. They need proper sleep. And then you get into the fuel that you put into them.

Totally. And there's obviously, there might even be some people that are literally at the beginning. steps of their journey. And for them, you'd say, of course, still sleep matters, getting away from ultra-processed foods matters, you know, your relationships matters, and some form of movement in your life, right? Some form of walking. And if that's, you're at the beginning, focus on those, right? Now this is a conversation for obviously people that are not just at that beginning stage and are not dealing. And of course, you mentioned smoking and some of other risk factors there too. And kids these days. It's crazy. Do you have kids? No kids. Okay. I don't have kids yet, but that's definitely in the future for my wife and I. I'm so amazed at the level of vaping that's going on with kids.

It's so the norm right now, and it's really scary, especially from everything that I've learned from you about it and how it can damage the endothelial lining. Yeah, it's pretty scary. But, okay, moving on from there. So we talked about light, right? What's the next big branch when you are teaching your patients and newsletter subscribers? You have a whole, you have a newsletter series, right? It's called heart attack proof, which I love, right? You're constantly putting out new information that's out there.

Photo biomodulation, we talked about that. What's the next big pillar that you want to chat about? Probably sleep, because I think that's one that gets the least focused. from the non-biohacking world is like, you know, people think like, well, I put my head down and I get up, you know, six, seven, eight hours later, and that's probably good enough. And unless they have, like, sleep apnea, they don't really think about their sleep quality. So I don't necessarily recommend everybody, you run out and get a sleep tracker. But if you're not performing at the level that you want, you know, if you don't feel that your brain's a 10 out of 10 the next day when you're at

work or you're not having the best exercise that you want, you should really focus back on the sleep because sleep is one of those mitochondria engines repair themselves. So you want to sleep like in the top percentile for your age. That's kind of like the new status symbol in my mind. It's like if you can sleep better than somebody else, that's much more impressive to me that you can run faster than that person. So what are the big drivers asleep? It's going to be the light that you got in your eyes during the day,

how you block the light at night, when you kind of cut off your meal timing so that the liver and gut can go to sleep. They basically want at least three to four hours to shut off. and then setting up your kind of sleep cave. You know, for those that have kids, you know, you can't just take your kid and, you know, pick them up and say, we're going to bed. Like, there has to be this routine. So you want to have kind of a sleep hygiene routine. So if you just want to block your blue light the hour before you go to bed or wind down on your technologies, that is a good starting point.

And then your bedroom really should be your sleep sanctuary. Like you're going to your bedroom for sleep or, you know, intercourse. Like, those are two things you should be doing in your bedroom. You shouldn't be in your bedroom, watching TV, reading books. All those things are stimulating to the brain. And you want your brain to be thinking, like, if I'm going to this room, I'm going to sleep to recover. So go to your room when you're tired. The bedroom should be dark.

You should be, can't see your hand in front of your face. You know, there's multiple reasons for that, but you also have these blue light detectors on your skin. So if you've ever tried to sleep in a brightly lit room, you probably did not have the best sleep, even though your eyes were closed because the body is sensing, well, maybe it's still day, time. I'm not really sure what's going on. Your bedroom should ideally be quiet. That's pretty easy or, you know, totally fine with people having fans or, you know, white noise and stuff like that. But you definitely don't want to be falling asleep to a TV because the TV, you know, irrespective of what, you know, noise it is, you know, you don't want your subconscious programmed with whatever's on

the screen. Like, you just want it to be, you know, neutral noise at night. And then cold, the colder that you're basically keeping it, the better your deep sleep tends to happen. You usually have better sleep onset as well. So kind of the biohack is, you know, do a sauna an hour or so before bed and cool off or, you know, there's where people are doing, you know, cold plunges, cold baths, you know, cold showers and then jump into bed. Their sleep quality tends to improve. So dark, quiet, and cold, they're usually kind of the recipes to help augment better sleep. Amazing.

We just did a doc, a deep dive on sleep, like a two and a half hour masterclass that our audience can listen to as well with a friend of mine, Dr. Sunjai and you know we'll link to that inside of the show notes there a lot of the same principles you guys are very simpatico in some of uh you know the messaging and everything that's there okay so sleep important part because sleep is not just about rest it's about uh so many of aspects are hormone production our satiety our increased levels of hunger the next day if we don't sleep well and also i just saw this recently with the interview that dr suchin panda did with uh Dr. Andrew Huberman, that shift work is classified as somebody waking up and doing either something physical or mental at least once a week in the middle of the night, even for, I think, like 30 minutes

or an hour. And there's a lot of people, including there was a period of time myself. I'm just starting to get the hang on it right now where I kind of had this thing. I think it was related to lower levels of serotonin inside of the body, early serotonin metabolites. and a few things that I needed to optimize and sort of my diet and life and everything and some supplementation that I ended up taking that fixed it. But I was kind of waking up in the middle of the night and I'd be up for like an hour. And that would happen like two to three days a week.

And I was like, wow, basically, you know, I was kind of like participating in a form of like shift work, which the World Health Organization calls shift work, you know, a probable carcinogen, right? And there's countries out there like Denmark that if you get cancer and you were a shift worker, there's compensation that's given to you because you most likely ended up with that cancer or how to increase risk because of your shift work. I learned that from Dr. Sanjay. So it's crazy. You know, what happens when we don't take our sleep seriously? All right. So you talked about sleep, talked about light. Let's go to the next one. Let's do stress management. I don't think it's a

well enough understood topic by most people. You know, people are like, you know, I feel stressed out. like, what does that really mean? You know, stress is not necessarily bad. You need stress to, you know, thrive. But it's when people kind of get stuck in that fight or flight response, they have a problem. Now, if you have a tracker, you know, a ring, a watch, you know, you'll see the number of the heart rate variability. So the heart rate variability is the inverse of your heart rate. So your heart rate is just the number of beats that your heart is pumping out each minute.

But if you use a piece of technology that's measuring, what's known as your RR interval, it's measuring the time in milliseconds between each heartbeat. And as you're activating your vagal nerve through diaphragm stimulation, you're breathing essentially, you're going to have a differential

in your heart rate. So your heart rate's going to expand and contract as you breathe in and out. So the better that you have heart rate variability basically means the better you're able to take your foot off the gas and pump the brake when you need to. You're not all gas. So lower heart rate variability, and I sometimes see people like freaking out about their low heart rate variability, sometimes it is genetic and you're just going to be set with a low heart rate variability.

But if you had what you're considered your normal baseline and then you start dropping your heart rate variability, you're either over training or you're maybe potentially getting sick or there's just something else in your environment that is stressing your system out. It's like the check engine light went off and then you've got to go figure out what's going on with it. So heart variability is a good metric of, you know, how much stress is your body sensing right at this moment? Again, like you said, stress is ubiquitous. Everybody's going to have it. You're hopefully going to have some physical stress. That's what happens when you exercise. You physically stress the body and you let it recover and then you have to adaptive change.

You know, you should be using your brain to do some mental activities. So mental stress, you sleep, comes back down or meditate or whatever you like to do to kind of bring your stress levels down. So I'm not telling people they need to be, you know, Zen masters or anything like that. but they do need to kind of modulate their stress when they need to. So connecting these first three here, light, sleep, stress, in your clinical practice and connecting this to your earlier conversation about is not the cholesterols. And with the conversation with LDL, okay, it's part of the story,

but it's these lipoproteins. And one of the main ones that, you know, you talk about testing and a lot more people are talking about now is, you know, lipoprotein B, have you seen patients in your practice who generally are keeping their diet the same in one way or another, depending on, you know, what their approach is? Maybe they're having less plant, you know, having more plant food, maybe they're having more carnivore type diet. Have you seen patients in your practice just focusing on light, stress, and sleep reduce these lipoproteins which are these shots on goal that you're talking about.

Can working on just these three things alone reduce your risk of these lipoproteins, or is it more that these three things are focusing on the endothelial layer? And so they may not directly impact the lipoproteins, but they're going to make sure that there's Teflon coding. We don't want actual Teflon in our body, but in a good sense, We don't want these lipoproteins to stick. So these things are protecting that coding that's there.

So even if you have some genetic variation, it probably seems that I do based on my labs that we're going to go over in a little bit. So even if you have higher levels of APOB or these other lipoproteins that are there, you're going to be more resilient because you have that coating. It is definitely that latter. And that is such a unique approach to thinking about cardiovascular risk. is again, you know, it's more complicated than good cholesterol versus bad cholesterol. But I think if you want to go to true root cause medicine, it really comes down to how healthy

is the endothelium in the glyco calyx. If you can keep that coating healthy, I'm not telling it doesn't matter that you have high lipoproteins, but it's less of a concern. And so if you're sleeping well, if you're getting proper light signals, or you're augmenting with photo balm modulation to kind of keep inflammation down, you're managing your stress through. whatever means, exercise, meditation, you're preventing the inflammation, the oxidative stress that's going to damage the glyco calyx that's going to oxidize and damage the lipoproteins floating through the system. They're not necessarily going to lower the APOB particles. That's probably going to be a little bit more through physical activity and nutrition. But again, unless,

I'm not going to say that nutrition does not matter for this, but people sometimes will overestimate the amount of change that could make and have a difference, there's a lot of genetic moving parts that affect the lipoproteins. Now, once somebody's kind of dialed in their exercise, their sleep, their stress, and they're already eating a clean diet, whatever that means to them, you know, going the full 180-degree opposite diet from where they're at is probably not going to have a major difference on their lipoproteins. It's probably a genetic issue at that point. But, you know, I like the way you said. It's like, you know, focus way upstream on things, and then maybe these lipoproteins aren't as big of a deal.

Yeah, which it seems, you know, I'm teasing to it, but we're going to get into it in a minute. That seems to be the case for myself. You know, my lipoprotein B and some of my other markers would traditionally, a cardiologist would look at them, even somebody that's more functional inclined, and they would be very worried about them. They would, you know, be very worried, and especially with my South Asian background, and South Asians being more prone to insulin resistance and all those things that are there. But through a combination of some testing, which we'll go through today, there maybe seems to be some element of knock on wood. At least so far, I'm doing a good job with the endothelial support system through the lifestyle factors, light, sleep, meditation.

Sure, I referenced my sleep earlier or my sleep has been off during periods, but generally I sleep pretty good. generally I see actually really good. And way before it was popular to wear red light, I would just naturally, you know, probably for the last like 10, 15 years, I would always dim the lights down at night. And I try to avoid overhead light. And I would be very mindful of those things.

And then, of course, you know, community and all those things play a role into it too. But so here I am somebody that would look at my traditional blood work if I'm looking at my blood work alone. And I could get very worried and sort of anxious, which there could be reasons to be worried and anxious for people that are there. But if you can have access to some additional testing, it could give you more of a complete picture as to where you stand. Very much so. And yes, you're right. If you look at

just your traditional lipid panel, people are going to say this person has phymeolial hyperlipidemia until proven otherwise, which one in 500 people will have a genetic abnormality that's going to give their traditional lipid panel this type of pattern. And that panel is having a total cholesterol over 300 milligrams per deciliter and an LDL cholesterol, all over. for 190 milligrams per decilator. Now, again, it's a check engine light. I'm always going to be like, oh, that's interesting. You know, the first thing you need to look at is,

is this something that's always been there? You know, so if you've had blood work since you've been 18 years old, then now you've checked it and it's always been about that, it's highly likely it's going to be a genetic, you know, contributor to it. But now there's some, I'm not calling an extreme, but there's some people that will go, you know, they're eating, you know, a standard American diet or even a Mediterranean diet or paleo, and then they go carnivore or, you know, full keto.

Well, some people will have a pattern where they hyperabsorb so much sterols from their intestines that their lipoproteins are going to look at the exact same as somebody with FH. And so this is where, you know, the nuance comes in is that, you know, cholesterol does matter, but it matters how many of these lipoproteins are sticking to the endothelium. So thinking about, again, the endothelium is being a negatively charged Teflon-coated. If you can keep that level of sulfation and negative charge high on your glycopalix,

then the lipoproteins, which are also negatively charged, negative repels negative, be like a maguletraint or a magnet just slides on through there. It's not going to stick. But if that glycopalics gets damaged, the negative charge in that glycoccalyx goes down. Now there's a more positive charge there. The negative lipoproteins are going to be attracted to the positive charge. That's how they actually stick there. It's a quantum reason.

why. So that can be the reason why you can have the lipoproteins that you have, and the reason you do not have advanced atherosclerosis in your case, because you've done whatever you needed to do and kept that gel coating healthy for as long as you've had. Fantastic. All right, what should we go into next? Should we go into the next pillar, or do we want to kind of go into some test results? I'll let you decide how you want to go and, you know, through the test results, we can talk about food, diet, nutrition, et cetera. But, you know, it's up to you to decide how you want to proceed from here. Let's show them what you got, I guess. So let's see. Okay, great. So which, what test do you want to go to first? Do you want to, yeah, which test do you want to go to

first? Because we've done my Boston Heart Labs through you, and we've also done this clearly, clearly scan, which you know, you and Dr. Lyon turned me on to. So let's actually look at the blood work stuff first, because that's what people are most used to thinking about, and then we'll look at the images. This was done with a company called Boston Heart Diagnostic. They're one of the companies that does some of the advanced cardiovascular testing. They just have a very good panel that looks at different metrics of risk from a cholesterol standpoint. So in his traditional cholesterol panel, you know, a total cholesterol of 329, an LDO cholesterol of 214, that looks like familial hyperlipidemia to proven otherwise.

Now, the people on mine will always note first, well, what is, you know, your HDL cholesterol and your triglycerides, you know? You know, is that ratio, if you divide your HDL and your triglycerides, is that ratio less than two? If it is, then that person is less likely to be insulin resistant. But some people get a little bit too bent out of shape that that's the only thing that matters, is that their triglyceride and HDL ratio is low, so it doesn't matter that their total cholesterol, elder cholesterol, are elevated. So for you, we keep moving on.

Okay, well, he has, quote, high cholesterol. What is carrying that cholesterol around? And that is going to be the LDL particles. So the LDL particles are essentially the tennis ball that I've been showing. So he's got 1986 of them. Traditionally, you really only need about 1,000 of these particles. More particles, more shots on gold. On the outside of a tennis ball is a white stripe.

That white stripe is basically apolyproproteen B. ApoB is a structural protein. It keeps that lipoprotein in a sphere, but it also acts as something called like a ligand. So one way to think about is when this tennis ball is floating through your blood vessels, the receptors will have to grab onto it. Where does it grab onto? It grabs onto that white stripe on the tennis ball, the APOB.

So the more EPOBs you got, the more chance that these things are going to interact with that endothelial lining. So if people have, you know, advanced cardiovascular disease, their target APOB is generally going to be less than 80. The other metrics that you would look at would be the HDL side of things, the HDL particles. They have maybe 200 rolls in the body. One of them is reverse cholesterol transport. So this is basically the cleanup crew.

In most cases, if you have more HDL particles and not allow inflammation, that is generally a better sign that the body may be able to clean up some of the cholesterol deposits in the artery wall, but not a guarantee. And then in your instance, your level is so borderline, I'm not 100% convinced that this is going to be high long term, but you may have high levels of lipoprotein L.A. Lipoprotein LLA is present in up to 20% of the population. LPLA is very similar to LDL particles. It looks almost identical. So it has this APOB protein on it.

So it's got the white stripe on the outside of it. But it also has an extra protein on the outside. It's kind of like a corkscrew. that corkscrew digs into that glyco calyx more aggressively. And when that happens, the blood is more likely to clot and the arteries are more likely to get damaged. Because LPA is carrying oxidized fossil of its basically toxic waste. It's trying to get it through the system.

And now it's basically getting stuck in the arteries and illegally dumping it into the arteries. And the nice thing about the cholesterol balance test, it tells us, well, where is this issue potentially coming from? So there's two compounds, Lantosterol and Desmosterol. These compounds are made in your liver. This is also where cholesterol is made. Your levels of Lantosterol and Desmosterol were normal.

So this tells me that this is not likely an overproduction issue. It's not that your body's making too much cholesterol. Now, that's one lever to look at. This is the lever where statins would tend to work. If the liver is overproducing things, you give a medicine to slow down the production. Then there's a layer in between, which is not a direct test for. So once the liver pumps out these tennis balls, they eventually got to return to the liver.

The liver is going to put out some called the LDL receptor. It's like a catcher's mitt. It will grab onto that receptor and the lipoprotein and pull it back into the liver. This is the location where the PCSK-9 inhibitors work. This is where Repatha and Pralium work. And then there's an oral one that's being evaluated, hopefully to come on the market in a year or two. So once the lipoproteins are into the liver, the body will break them down, put it into the bile, put it into the intestine, and you eliminate it through the gastrointestine tract. But in some people, up to 20% or so, there's basically a door that will open back up.

The bouncer just opens the door and says, well, we made this, we would like this back. So in your case, you're hyperabsorbing the beta cytosterol and that compostrol. The cholesterol will also be in there. So the cholesterol then comes back through the portal circulation. So it's going back to the liver. The liver's like, welcome back. It has to make a new lipoprotein to wrap up that cholesterol and sends it back through the cycle again. So you may have an issue with your Neiman 1-Pick-like receptor, one of the ABC binding cassettes.

So we're going to do some further genetic testing and figure out what's exactly causing some of this hyperabsorption. But this is the location that if medication therapy is going to be utilized, azetamide is a better option. Azetamide basically keeps the trapdoor closed so that these sterols don't come back into the port of circulation. Sometimes this is the magic bullet for these type of people. One medication completely fixes the issue. Then after the lipoproteins, you want to look at the inflammation in oxidative, of stress. So in his panel, high sensitive VCRP was normal, so the liver was not inflamed.

LPPLA2 activity. This is an enzyme that's present when plaque is inflamed and basically growing and more likely to rupture. So if LPPLA2 is high, that person's at higher risk of a heart attack. That person's at higher risk, that plaque is still actively growing. The oxidized phospholipid on April B was a little bit elevated at 3.6. This is essentially the white stripe on the tennis ball is inflamed. And once it's inflamed, it's more likely to send out a signal to the immune system that the immune system is going to grab onto. So this is the stuff that is more likely to get stuck in the artery walls and contribute to more plaque formation if plaque is being deposited. And is that is that a marker? Just to just interrupt here, is that a marker?

Because I don't think I have a reference of doing that. I have my APOBs from previously, you know, I have my normal sort of things. I don't know if I have this marker because I didn't do the Boston Heart labs, but is that something that could also, is that a lifestyle component? Is that a genetic component when you weigh it out and you look at sort of bringing it out of that elevated level? That's a great question. So right now this type of test is only available through Boston Heart.

So it hasn't had a long history. So there's not a lot of things that you could track from two, three, four years ago. But it's one of the most sensitive markers that the lipoproteins are getting modified. And those are the things that are more likely to contribute to further plaque progression. In your case, the likelihood that yours are high is mostly because you just have so many of them floating through the blood at any one time. And as you're sitting here talking to me, you're breathing oxygen, that oxygen is going to cause some oxidative stress through your system. and some of it is damaging those lipoproteins that are floating through the system right now. Got it.

Makes sense. Then the myloproxidase, your MPO, this is an enzyme that's normally found in white blood cells. This is basically bleach. So you have a bacteria. The white blood cell goes out, dumps this out on bacteria to kill it. But if you have high myelproxidase, it can actually damage your HDL. And then your HDL particles don't work. So this is somewhat to have a marker of the HDL functionality, which that would really be a great test

if they eventually can figure out how to monitor what the HL is doing in the body. That's kind of the other analogy is like, you know, these tests are static in many cases. This is what your blood was doing right when they stuck the vinyapuncture needle in there, hold out the sample and said, what's in here? But that's a picture. What would be great to have would be a video. Where do these things all go? Are these just being delivered to your muscles and then they're making a trip back to the liver?

Cool. Or are they rolling and getting stuck on the individual? the endothelial function, or should the endothelium, you're getting retaining the arteries. They don't just have that kind of technology yet, but hopefully that would be something in the future. You could say, like, this is a problem, yes or no, just based off of the levels here. Of the H-DL, I should say. The fibrinogen is a marker essentially how sticky the blood is. I tell people you want your blood to be like red wine, not so much like ketchup.

So the higher the fibrinogen, the more likely the blood is the clot. And in this next test, I think it's possibly going to be an artifact in you. We're going to have to recheck it. But interleukin 6, this is a compound that the immune system makes when there's a marker, I should say it's an interleukin that damages the endothelium when it's high. This is the interleukin that was monitored in COVID patients. The higher it was, the sicker they tended to present with their COVID episode. So I use it in the cardiovascular world that when it's high, that person is more likely to have endothelial dysfunction. Right.

And you were saying that, you know, it could be related to. to, did I have an infection or something that I was dealing with at the time? And we're going to be retesting in like three months or so to see if it goes down naturally. And then it was just something that I was dealing with in the moment. Correct. Correct. And, you know, if the person was asymptomatic, it's not a concern. But if, like, you know, they were, you know, very fatigued, night sweats,

and their weight loss, unexpected, you know, GI issues. Okay, maybe that's true, and you have to repeat it in a couple weeks. But if the person's asymptomatic, just repeat in a couple months, when you're looking back at everything else. And then your metabolic test, you know, you said, you know, with your heritage, you're probably more at risk of insulin resistance. But at this point, nothing really jumped out of me that, you know, your body was working too hard to keep your glucose optimized.

And so on a traditional panel, most people's eyes will dart right towards the hemoglobin A1C, and your level is 5.4, which is considered normal, but optimal is 5.1. But everybody has a little bit of variability of how long the red blood cells last. Most red blood cells are going to last about three months. But if people have a thalassemia trait, those red blood cells can last maybe 120 days or even longer in some instances. The longer red blood cells are circulating around the track, the more glucose or glycolation is going to happen, and you're going to caramelize more of those red blood cells. And then the A1C goes up.

But the person's not truly insulin resistant or diabetic. You have to look at the other metrics. So is he pumping out a lot of insulin? No. So your body's not working really hard right now to keep your blood sugar down. and C-peptide is also a marker of how all your body is using insulin to control your blood sugar. And then all your insulin risk is, to the scores for the most part, are pretty good. So nothing really concerning on your glucose disposal right now.

And where do you like to see the fasting insulin? You know, you'll have different sorts of things. We'll say five and lower, but is there an optimal one that you're looking at? And here, I think my fasting insulin is three. Yeah, your insulin is three. I usually shoot for that five or less. You know, I'm pretty happy if most people are under 10. Okay, got it.

And then the other thing that is nice that the Boston art panel will look at is some called the fatty acid balance test. This will look at essentially how you're absorbing the different fats that you're eating in your current diet. So this is a great test for somebody who's on a carnivore diet or doing a high fat ketotype diet. As I can tell you how are you absorbing those fats. So at this time, you were not having an issue with the way your body was handling the saturated fat that you're getting in your diet. The trans fats, you know, for the most part, people are not trying to add these to their diet. The trans fats are going to be the modified fats. This is going to be margarine.

There's going to be things that are fried. You know, the sources for most people, it's going to be in packaged foods. It's going to eat out. So it's going to be the oils that their food gets fried in. But one of the hidden places is often it's going to be the salad dressing. So you just have to be careful and read labels when you can to make sure that there's not a lot of the stuff in your food stuff because the trans fats will make your cells very stiff. When your cells are stiff, they don't communicate well with each other.

The omega-3s, which are found in the cold water fish for the most part, they make the cells very flexible. Flexible cells or pliable cells, they're able to communicate with their neighbor better. So it's kind of like the whole game of telephone. You know, how fast can you talk to the person next to you and they can send the message, send the message, send the message. Well, the more omega-3s you have, that message can be transmitted quicker. the more trans fats you have, that message slows down.

And it's very inflammatory to the system. And one question for you. I do eat out occasionally, but generally, like, I'll be eating at home. And I was trying to really think about, you know, what's my exposure to the trans fats? And I avoid fried foods, you know, like that's, it really messes at my throat. I feel like not the greatest. So I pretty much avoid fried food. So I was thinking, are there instances like, you know,

where you could have, like sometimes I mainly have my chef working with, like, who will provide some meals with me. They'll cook in like avocado oil, but I recently found out that they were like using expeller, expelar pressed avocado oil instead of like the virgin, you know, avocado oil. I know there's like a whole thing about avocado oil and like, is it all pure and there's so much like fraud that's in the world. So could you have sort of tainted versions of other oils that are out there that are also

creating extra exposure to trans fats? It's possible. I have not seen that clinically, but it's definitely possible. And I've not seen it in the avocado, but in the olive oil world, there are definitely cases where it's getting caught with vegetable oils. So you want to be working with somebody, you know, at least in California, there's very strong, you know, nutrition guidelines. Standards.

So if the, you know, the olive oil is coming out of California, it's going to probably be what it says it is, but I have learned that, like, a lot of times when they're importing certain oils, you know, places like Italy, they're going to keep the best stuff for themselves. And so you're getting like the second cut. Well, it depends on what happens once it gets here, if it's going to get cut again with vegetable oil or something like that. So yes, it is buyer beware on some of these things. But you would be able to pick that up in some cases because I've seen people have these higher omega-6 levels than they would expect or there's trans fats. They're like, I just do not eat out. Like, I never eat out. And then they go back and look at things and they, some,

sometimes can uncover these type of things. But for you, it's not popping up as, oh, that's a problem with what you're currently getting. Got it. So some detective work, but, you know, just something to be mindful about. Sure. And then the thing that I really look at on this panel is going to be your omega-3 fatty acid index. So the mega-3s are mostly the cold water fish. So salmon, tuna, herring, those are the main things that most people are willing to kind of eat.

But it's mainly about the EPA and the DHA content of those. EPA is really important for artery health. The DHA is really important for brain health. Your nerves are coated with DHA, like the insulation. So I sometimes use an analogy of DHA being your cell phone charge. The more DHA you have, the more energy, the longer things are going to last. When your DHA is low, the more likely things are going to break down sooner. So DHA is critically important for brain health.

And so you're doing really well on the DHA side. Maybe you could stand to eat a little bit more seafood, but you weren't far off from optimal levels. Yeah, you know, it's interesting. This is also, these tests are great because you get a chance to sort of check in. And pretty much since last August, I've been working out with a new training group here in Los Angeles called Ultimate Performance. And I've moved away from the amount of salmon that I used to have. You know, I've done a mega index test before through a mega quant. And I would always be in the optimal category to see that I dropped below optimal over here.

And I also wasn't having a regular high quality fish rail supplement. But when we reviewed these labs, I was like, okay, if I'm going to step away from some of the cold water fish and salmon, I really got to make sure. that I take a high-quality fish oil because I'm now starting to drop out of the optimal category. Right. And it's all about balance, honestly. You weren't far off from it. You know, you didn't have significant inflammation. Those are the cases where you really got to start pushing it more through diet and, you know, maybe supplementation because that can help lower high sense of UCRP in certain cases. But if you skip ahead a little bit and look at it's more about your omega-3 to omega-6 ratio. Other companies will do omega-6 to omega-3 ratios. You've got to kind of

of invert the math. So usually you want to see the ratio under 4 to 1 if you're doing 6 to 3 ratio. But on the Boston, you basically only see your ratio 0.1 or higher. So the omega-3s tend to be more anti-inflammatory. The omega-6s are not all bad, but when they're out of balance, it tends to be more pro-inflammatory. So I don't really see two concerns with the way you're doing that at this point. And the test isn't really dialed in for the monocetate fat to be truly accurate of like your recent exposure to monocetri fat, but the monocetriot, fat, that's going to be the olive oil and the avocados. So people are like, I'm eating a ton of that stuff and their level's low. I'm like, that's okay. Sometimes it doesn't really fully track. But for some of the patients,

when, you know, they had, quote, normal libel proteins, they switched to a keto diet and they say, I'm not going to switch back. You know, I feel great on this keto diet. Well, sometimes you can get by by cutting back on some of the saturated fat and have them isoclerically increase their omega-3 and or increase their monon saturate fat, and sometimes their lipoproteins will improve as well, because some people are more sensitive to the volume of saturated fat that they're getting than others. Great. So anything else in this test?

Side note, once it's homocysteine. This is extremely important for people, is that if your homocysteine levels north of 10, you may have a methylation issue, and if you have a methylation issue, you're more prone to having high homocysteine. High homocysteine will cause high asymmetric dimethylacine, and if you have high levels of that, you have low levels of nitric oxide. So roundabout way they're saying that if you have high homocysteine, it may affect that endothelial function. Yeah, so zooming out big picture just with that lab, right? And obviously, this is just me.

We're not giving anybody medical advice. You know, I wanted to share. I actually think, you know, Michael, I'd love to get your idea on this, thoughts on this idea. I think anybody that actively talks about nutrition and is recommending one way of eating over another, which I don't do. do, but I'll talk about nutrition and interview different experts. I think everybody should be required twice a year and there should be like an independent nonprofit that just facilitates the test. And it's like, hey, great, everybody can argue for however they want to eat, their lifestyle

components, but just like you have to have your blood work out. And you know, I know my lipids are not optimal and they're maybe even problematic. Now, is it genetic? Is it not genetic? That's some of the stuff that we're digging into. But, you know, people should be able to like, you know, show where they're at. What do you think about that idea? I kind of like it.

I mean, I'm pretty transparent of the testing that I do on myself. You know, I'm a pretty good biohacker in that, like, I'm not willing to put patients under certain testing unless I've done it myself or one of my loved ones have done it. You know, so that clearly scan, I was the first one to do it. I did it first and saw what the process would be like. I'm like, okay, this is how much radiation you soak up. This is what's like to take a beta blocker before you do the test. You know, this is what's going to feel like to get IV contrast. Okay.

Now I can explain it to the patients better. So I'm not usually far off. And I'm happy to share what I have sometimes. And that is true in ways is that, you know, I don't claim to be an expert in all things. I'm really good at endothel health and some of this photo bomb modulation. So I don't have a lot to sell you on this audience. Like I'm not to sell you any supplements or anything. Like you have the opportunity to work with me if you want to work with me.

I'd be happy to work with you. But I'm not selling anything. So if somebody's trying to sell you something, well, what is their bias? You know, if it's that, you know, that their way of the diet is the only way to work, well, they have to show us that more than just them and everybody else that they're, you know, working with that they actually got the benefit. And so, you know, if you go through the kind of the program that you went through and can show that your arteries are as healthy as you are, then whatever your current diet you're doing is not doing that harm. I can feel pretty confident,

like you're eating the way you say you're eating. Yeah, I mean, I don't have anything to sell on. I mean, I've adds to my podcast of companies that I like endorse, but I'm not here to argue keto over this or that, you know, I have no. skin in the game. I'm trying to learn. I'm definitely not an expert. I dropped out of college. I'm just trying to ask good questions, and I happen to know people like yourself. Okay, great. So, you know, we mentioned the clearly. Is it worth going through that, you know, for a second? Sure. So the clearly scan is a very interesting, relatively new to the market type of technology. So the scan utilizes a CT coronary angiogram. So in traditional cardiology, the CT angiogram,

is mainly going to be utilized to look at people's risk of stenosis in their arteries. It's going to look at how blocked up their arteries actually are. So, you know, if patients show up to the emergency room and they're having chest pain and they're not going to go for a stress test, they may do a CT angiogram quickly. Okay, there, you know, no calcium in the arteries, there's no significant plaques in the arteries, discharge home because up to 75% of time people show up to the ER with chest pain. It's not due to their heart and it's not something that is life-threatening. But chest pain is a concerning thing.

And if it's a heart, you want it to be treated. But the CT angiogram sometimes is a good tiebreaker. Nope, those low risk, send them home. They get the workup as an outpatient. But what clearly has done is that they've used AI and machine learning to take the images from a CT angiogram and then do an analysis. So instead of just looking at the degree of stenchristian, or blockage in your arteries, it's looking at the plaque characteristics.

So it's looking at the plaque in the walls, voxel by voxel. So it will give you a total plaque volume. So previously we talked about a CT Corneur calcium scan. Great test. But the downside of that test is it only assesses calcium, which is the late stage finding. You know, that calcium is usually stable, but you're always concerned about the soft plaque that comes with it. And you're not going to see that on a CT corner calcium scan.

But with the clearly scan, you can actually see the soft plaque. And it will quantify it into, is it kind of normal soft plaque? Or is it very low density soft plaque? And that very low density soft plaque is more necrotic. It's basically more on fire. You can take it as more the vulnerable plaque, the plaques that are like a volcano ready to rupture. If the plaque is more calcified or more solid, yes, that plaque is something you want to be addressing, but that's not the five alarm fire in the artery, and that person isn't as high.

risk. So clearly scan can kind of put people into different risk buckets. And at this point, in my estimation in many kind of the preventive cardiologists, this is the best non-invasive test to tell you this. Now, we can take people to the cath lab and do angiograms on, but even an angiogram is probably not as good of a test as this, because an angiogram, in most cases, is only going to be looking at how much stenosis you have. Synosis is interesting if you're having symptoms, but otherwise, Not really. Stenosis dictates symptoms, but if you have a 50% blockage, you can still have a heart attack. You're just not going to get a stint for that blockage. That clearly will tell you who is that high-risk person. Somebody who has a lipoprotein panel like yourself, if they have a high risk

clearly, then aggressive pharmacological agent should be initiated relatively quickly. If they're clearly scanned as more low risk and they're not already doing all the right lifestyle modifications, well, start there first and then repeat their blood work and see what's left over. So the scan that you had done kind of helps put you into that risk bucket. Overall score for years was extremely low. This was one of the lowest scores I had seen in the man who's done this scan, which is great. So there's three stages. And listen, I'm not, I'm not putting you on the spot, but I think you said that this is the best score you've seen of any person that is a man of my age. Is that accurate? That is accurate. That's accurate. You've

actually beat my score. So I'll put it out there. My score is not as good as yours right now. But I will be a little, I'm a little younger than you, I think, right? I'm 40. How old are you? Okay, I'm 47 now, so maybe that's a different. So you have a few years on me. Yeah. So your stage was very low.

So there's three stages according to clearly. Stage one is lower risk. Stage two is intermediate. Stage two is very high risk. And the main number that you would look at is this total plaque volume. So in all your corner arteries, they look at it voxel by voxel, slicing it up. And you only have 10.8 millimeters cube. a plaque that's very low. But I've also told you that as of yet, every person over the age of 40

that I've ever done the scan on, they've had some amount of plaque in their arteries because this test is so sensitive to it. So I'll put it out there. I've done three calcium scores test on myself before. They've been normal. I've done cradid intimately medium-thickness scans on myself. At one point, I had a higher inflammation on my left artery than my right artery. I think it was from my days being in the cath lab and I was giving radiation to that side. And I call inflammation in the artery. And then a couple years ago, I stepped out of the cath lab and focused more on prevention. And so doing the things that I'm talking about with you guys today, I've shrunk it back down, and now my artery age is back down to like 37. So my arteries are 10 years younger than my

biological age. So I do know what I'm doing, and I'm going to do to myself first for the most part. But my calcium score has always been zero. My CT angiogram read by the radiologist was red as normal. But then when it was uploaded to clearly, my total black volume was sub 200, but it was not 10. So did make me frustrated, and I've gone to more extreme measures to take care of that, and I'm going to repeat the scan, probably within a new year, and we'll show you that I can actually stabilize it, and ideally get that stuff to shrink down. And what are just a couple of top-line things that you think that you're going to do to shrink it down from where your test score was before? I really started heavily focusing on glyco-calyx restoration. There's novel supplements

in the market that can kind of help support the glyco-calyx. And, then also boost nitric oxide. So I have access to, obviously, I'll have the toys in my office to not to basically test my arteries whenever I want. And I just make sure that the arteries are very elastic. And if everything's elastic, then I know my endothel function is healthy. And then the body can get to work at repairing any of the underlying issues. And then, yeah, so usually, you know, at least every four to six months,

I'm doing these type of blood work panels as well and trying to make sure that keeping everything optimized. I've never really had any issues with the inflammation or the oxidation or anything else. It's always been paperbee particles have been borderline. line high and never high enough to say, oh, yes, definitely start pharmacological agents because all the traditional testing, calcium scores, carotid scans. Nothing pops up that says you should start this person on medication. But once my clearly wasn't normal, I debated it for a bit. But I said, let's do a couple more things, focus on the endothelium, like, okay, like it's first. And then I'll

repeat the scan and see what I want to do personally. Got it. Thank you for that. And then on your plaque volume, it was very low. You have no calcified plaque. So when you, I should say it was 0.1. So I know you've done the calcium score test was always read as 0, so they're going to tell you you don't have any hard plaque in your arteries. This gave you, you know, 0.1. I don't know if that's an artifact or not, but the non-calcified plaque, this is the soft plaque.

The soft plaque is the stuff that you hope to over time either calcify and it becomes solid or you want to delipitate it. You want it to shrink down and go away. So nothing that is really concerning with the total plaque volume. And I want to board people with all the details of this. but I will show you what it actually is interesting, is looking at one of the coronary arteries. So the coronary arteries are the arteries that sit on the outside of the heart,

providing oxygen nutrients to the heart muscle. So on this scan, this is looking at the right coronary artery. This is the artery that wraps around the side of the heart and feeds blood to the bottom portion of the heart. And where the white is, this was the lumen. This is where the contrast is flowing in your artery, and this is what they allowed you to be able to see any of the plaque on the artery walls.

So the contrast flowed all the way through your artery, and normally your artery looks like a big C, and it's a moving object. What clearly does is they stretch it out, and it looks like a roadmap is how I kind of quantified or think about it, is that when I look at this, I would say there's no blockages in this artery, and that's what they say. But you do in this middle portion of the vessel have an early plaque buildup. So basically, this is like a little pimple building up on the artery wall.

the plaque is positively remodeling, meaning where the lumen is, where the blood flows, there's no obstruction or blockage, but the plaque is growing in the artery wall. So if you think of like a garden hose, and you slice the garden hose in half, the plaque is growing inside the garden hose. It's not growing where the water would be flowing.

And that's how it normally goes. It's kind of like an iceberg as well. The iceberg is way below the surface for a long period of time until it pops up over the, you know, into the lumen. So this plaque is very, very mild at this point. And there's things that you can do, you know, keep the endothelium healthy. And then ultimately, we'll probably think about something, the lower the AP will be particles using the right kind of targeted agent. And then the body can get to work at shrinking these things down.

But for the most part, you already look fantastic. So, but that's the nice thing that the clearly does is it really quantifies it. How much stenosis? But really, what is this plaque? Is it calcified? Is it soft? or is it the stuff that you're really concerned about the low density non-cals by plaque and you don't have that type of stuff?

So, you know, when we connect the dots on the two tests, and again, these are just two tests of a whole litany of different things that are out there and ways to look at sort of your overall cardiovascular list. But I think that these two, you would say, are probably like your one and two, right? And the markers that are included with like the Boston Heart Labs and clearly, you have a pretty good idea of somebody's risk for arthroscopis in the future. right, and if they're on the right direction to sort of be heart attack proof. Is that fair to say?

Very much so. And, you know, I just think the limiting step is not necessarily the test. It's just knowing that the test exists and having access to actually go get it done. You know, all in these tests, you know, the blood work sometimes is covered by medical insurance, but all in this test combined should be less than $3,000. you know, that's an insurance policy. You know, if you know that, you know, your heart attack proof, they can keep going out there and live in your life the way you want to live it.

You can be a triathlete. You can, you know, be a high-level executive, you know. But if you have a time bomb in your arteries, then that's what got to hit the timeout, what's causing this, cool it down, and then go back to living your life the way you want. And that's what I love doing about my practice is helping these people figure out, do we have a problem learning your guy just now or nope, good to go, keep going. Right. Now, I think that just while I have you here, if you have a few more minutes here, just to kind of contextualize some of the stuff that we're talking about.

Now, some of the more I would call it the plant-based world may look at my lipids and say, hey, you're rolling the dice with that level of LDL and APOB. And just so everybody's clear, I've talked about it on the podcast before. I grew up vegetarian, kind of an unhealthy vegetarian, then I became vegan. And then for many years, I actually was like a raw foodist if you're familiar. with like the whole raw food world. You know, I was a raw foodist. I don't recommend it, you know. That was just something that I kind of got into.

And then I was still vegan for a little while after that. And then I started for the first time of my life, not that it's about, again, it's not the diet wars, just giving context for the people that are listening. And I started eating some chicken, fish, and eventually, you know, having some beef and red meat inside of my diet. And that was about when I turned like 28 and I'm four. 40 now, like 28, 30 years old. So some of the more traditional plant-based world may look at my lipids and say,

look, you're rolling a dice, and we do know that higher concentrations of saturated fat, you know, would potentially be raising these APOBs in particular, right? But what I'm hearing you also say is that in my instance, which is not everybody, it could be more genetically related. So, sure, could I go down that path? go super aggressive and maybe remove certain food categories from, you know, my diet and we could see, you know, does it make a difference? But you're balancing that out with the fact that my clearly results look really strong. Is it is the is the is the is the pros of that potential

intervention worth the cons of now having to practice a lot more of a sophisticated diet to try to figure out your protein sources and other foods that you might enjoy now and going back to the work of our mutual friend, Dr. Gabriel Lyon, you know, and does that have some downsides along with your string training program that you've kind of doubt in? Is that how you would look at it right now? Exactly. Is that, you know, I will, you know, we're over an hour and a half in here. And, like, nutrition has been around the edges. Like, nutrition is very important. And I will not tell people that it's not. But when people sit down with me in the office, it's not the first thing that I'm addressing. We've been talking about light and photo biomodulation and sleep and stress and

into the health because that is truly more important than nutrition. Nutrition is information and energy. It's sunlight. So I'll give you my kind of quick tips and then, yeah, I'll dial into your question a little more. The best tips are eat during sunlight hours. That's when your body's optimized for your metabolism. So wherever you're right in the world, son up, to sundown is your optimal feeding window. You can play around with the time in there if you want to. Try to eat seasonal for your environment. Your mitochondria are supposed to be decoding the food that would have grown in the environment that they're at currently. So where I'm out of the Midwest, there's four seasons. There's a part of the season where nothing is growing here. So this is the

part of the year that you would be more catotic or you'd be more protein heavy this time of year because carbohydrates are not as prevalent. And then in the summer when vegetables and fruits are more prevalent, you would eat more of those things. Just do what your great grandparents had access to as one of the simple metrics. But you're right. Back to our young major friend, Dr. Lyon, if you don't get your protein right, you're not going to get your muscle health right. And your muscles are your metabolic engines, as she talks about, you know, your muscles handle 80% of your glucose. So if you're really concerned about your body composition, you're trying to reverse insulin resistance, you really got to focus on the muscle health. And can you do it plant-based?

Yes, you can. It just takes a lot of planning. And people sometimes are not willing to do the planning, and they go subthreshold on the protein every single day, and they don't trigger muscle protein synthesis. And you start losing muscle mass over the years, and if you're not trying to gain it, and you start losing it, it's a lot harder to gain it as you get 45, 50, 60 years old. So it's much better to hold onto it at an earlier age

by optimizing your protein every single day. Yeah, and one other layer that I would add into it, too, is like if Peter Tia was eavesdropping on this conversation, you know, he may say, okay, listen, I understand you may have a familial, you know, cholesterol situation that's there. Still, I'm not super comfortable with the APOB that's that high. And so I would recommend some sort of aggressive intervention. And obviously that's some stuff that, you know, we're talking about once I get my genetic

test back done and we'll update my listeners on it. But potentially, in my instance, you know, statins would not work. And they would come definitely with, you know, everybody's weighing out the pros and cons and risks of those. but in my situation, it wouldn't work because of some of the things you mentioned previously, but there could be some other drug interventions that could help me potentially lower the floating levels of lipids in the body. Can you expand on that? Correct. And, you know, I, you know, I learned a lot from a lot of podcasts that Dr. Atia did with Thomas Day Spring. And I've been found in Thomas Day Spring for many years, you know,

one of the world lipid experts. And, you know, it is a lot of, you know, it is a lot of about, you know, just getting to educate out there that you need to first start looking at the lipoproteins in APOB in particular. So start with that. So cholesterol can get very esoteric at times. People are fighting about, you know, best agents for things. But know, like, where your numbers are at. If you're going to make an intervention, if you have a test like this Boston Heart and then some of the genetic tests that you're going to do, it's going to laser guide focus.

You're like, okay, if he's already doing the dietary interventions and he's already doing reasonable resistance training and cardio, well, what, you know, pharmacological, agent is likely to work best for this individual. So looking at the way your panel looks right now, stands are probably not the first tool. You do not have advanced plaque already in your arteries. You're not a hyperproducer of sterols. So are you going to get the same benefit using that? No, probably not. So what we know so far, it's probably going to be a PCSK9 inhibitor, which we're just going to help the LDO receptor stay out longer to clear these APOB particles, or it's using a medication like a Zetamide to close the trapdoor in the gun. And it's going to be a and block the reabsorption of these sterols.

So it's not saying that you should not be on some type of therapy. It's just more like, what is the one that's more optimal for you that you're likely to tolerate without side effects? And part of this too, you know, you've listened to a lot of same podcasts that I've listened to, but you're the expert as here, is that we also just don't have enough information. So everybody's weighing out the pros and cons of all these approaches.

We don't have enough information of how generally healthy people that are radically focused on, you know, getting the lifestyle factors that you're talking about, stress, light, sleep, you know, strength training, et cetera, and then a cleanish diet that's personalized for you. We don't have enough examples of those individuals doing this over the long haul that might have elevated lipoproteins and do those things matter, right? That doesn't mean that we can, I understand that public health has to make recommendations. You know, the tests that you mentioned, there's not a lot of people. Most people are living, paycheck to paycheck. They're not going to be able to afford these things. They may not have the money

for a consultation to work with somebody like you or another functional medicine doctor. I totally get that. That doesn't mean that we can't lean into the age of personalized medicine because yes what, you know, the insights that we learn, somebody then goes starts a company that helps, you know, lower the cost of these things and, you know, tools become more affordable for people. So just because not everybody has access to personalized interventions doesn't mean that the folks that do have access shouldn't go down that route. Right. I think that's an important thing to understand. But I do want to acknowledge that sometimes these things are expensive. And at the end of the day, I'd much rather drive a not fancy car. I'd much rather live

in a not fancy house. I'd much rather not take that extra vacation and spend that money on my health because health truly is wealth. And if cardiovascular disease is the number one killer of all of us, men and women, that seems like a good area to spend some money to get to the root of. Very much. I'm going to talk about investing in your health. I mean, you know, a lot of busy entrepreneurs, you know, they will sacrifice their sleep, you know, they're going to work long hours, they're going to be high stress, you know, they've got to, you know, burn the, you know, candle at both ends. And, you know, when they get to be 40, 50 years old, they're like, they put their head up for a second. They're like, I probably should get checked out.

And then they're oftentimes surprised that they got more black than you would expect. But they were kind of burning the candle at both ends. But it's not too late, you know, until they put you in a box or do whatever you do when you pass away, there's still time to intervene on improving endothel function, cooling down inflammation. So, yes, if you want to very personalized, you know, working with the best doctors, best lab companies, it's going to be a little bit costly for some people. But the basic test, if you could do this, a CT coronary calcium score over the age of 40, it should not cost you more than $300 wherever you're at.

You know, in St. Louis, it's $125. So that will give you a rough estimate. If your score is zero, you're still in that low risk bucket. If your scores over 400, you're high risk. If you're over 1,000, you're very high risk. I recently had a gentleman who was doing Peloton for, you know, 45 minutes a day, said he had no symptoms, you know, eating clean diets. His score was the highest had ever seen. Wow.

And, you know, his scores over 7,000. We had to, like, double check, make sure that was even possible and repeated it at one point. And yes, it definitely was. So now with that guy's on a very aggressive regimen to try to stabilize this and cut down his risk of having an event. Unfortunately, we found him early enough. But if you can use that test, that is great just to know what's going on with arteries. And then the blood test, an APOB test, if you do it at any lab, and if you had to pay cash, it should cost you no more than $20 U.S. dollars.

So those two pieces of information will give you a lot of what we've been talking about today. Yeah, and I would just say, you know, because I see a lot of carnivore people, you know, posting their CT score and everything. And it's like, really go get a clearly test because you could have a false sense of confidence that what you're doing is working for you. And to add on to what you were saying that you told me is that some of the damage to your end up the oil lining that could have been very heavy, it could have happened in your, you know, 20s and 30s. You know, people have hardcore partying days or they might have been smoking or they might

have been, you know, having other sort of lifestyle habits that had major damage. And even though they cleaned a lot of things up, they still could be sort of dealing with that damage. It doesn't mean it can't get better. But then you add on top of that a diet that might work for somebody, but then with all the damage you have doesn't end up working for you. And you have a ton of. a soft plaque even though your, you know, hard plaque score, your CT score is zero. Correct. Exactly right. And that's kind of the analogy that I learned. You know, it's test don't guess. That's why I'm not in any dive camp, you know, I'm going to work with the patient in front of me and what their goals are. And we're going to look and say, okay, based off your

genetics, what you're trying to do, what your current glucose tolerance is, you know, what your current fat intake is. This is what we're dealing with. This is how much endothel dysfunction you have. This is how much inflammation you have. And then we have a guided conversation like which way would you like to go? It's never, you know, paternalistic with me at this point. That's not where I have, you know, stands or tools. Do I use them on occasion, you know, for the right population? But, you know, if a person's standard versus or they've had myopathies on sands,

there's a lot of other tools that we can be using to lower APOB if we need to. So I don't want people to get, you know, the mindset that like, you know, diet doesn't matter that, you know, like I'm anti-carnavore or anti-ketos. Like, just test and tell me what's going on with your heart. arteries, and then I can kind of educate you on what's going to be your options going forward. Okay, last question. If you're a betting man, because this is another area that's highly debated, because all the observational studies and even some of the human studies that have been done on seed oils show

that seed oils aren't inflammatory, right, from like the top line level, right? But then there's a whole other camp that argues that, you know, like they are inflammatory and they're the devil and they're the ones that are. causing so much of this challenge that's there. In your experience, what would you, what would you say if you had to go one way or another? Do you have a strong, you know, feeling about it? Two points on it is that I think it's important, but I don't think it's to be all end all of vascular health. It's about balance. You know, if you're eating tons of seed oils and super high omega-6s and no threes, that's going to be pro-inflammatory that person. But I don't know how much time you have left,

But the real details come down to how much deuterium is in those omega-6 oils that you're consuming. Deuterium is heavy hydrogen. That hydrogen basically plugs up the mitochondria's machinery and making energy. That's the problem with this stuff, is you're overloading the body with deuterium. Great. And the flip side of that is also true. It's also about balance because there's people on the plant-based side that say, listen, we're not pro-seed oils.

We don't want people consuming a lot of them. We're concerned about what they're going to replace them with. Well, why are they concerned because of these big observational studies of LDL and the risk association with these lipoproteins and APOB? But even then, it's within the context of endothelial health, which is what we've been talking about over here. So really, this is a conversation at the end of the day. I wish for everybody to hopefully in the future, you know, if somebody's listening to this podcast,

it gets excited and goes starts a company to make these tests cheaper, more accessible, world of people. We need more personalized medicine. We need to get out of the diet wars. We need to figure out what works for everybody individually. And if all that sounds confusing, you know, just move a little bit, get better friendships in your life, get away from ultra-processed foods, dial in your sleep, and, you know, get your morning sunlight. 100%. Those are great tips. Dr. Michael, thank you so much for coming on the podcast. I've used up a ton of your time. If people are interested in working with you or your clinic or, you know, checking out some of the resources that you have, where should they, where should they follow you or check you out?

Well, first off, thank you for the opportunity to talk to you. This was a fantastic conversation. You know, we went deep into the science on endothio health, mitochondria, some of my favorite topics. If people are interested in learning more about the way that I practice medicine, my website, Dr. Twyman.com is probably the best resource, those links to those, you know, four pillars of health, some of my videos that have explained this are on that side. And I'm intermittently on Instagram, Monday nights, I will do some IG Lives, hit some AMAs, talk about some of these biohacking topics on occasion. So those are the best places to find me in on Instagram.

I'm at Dr. Twyman. Well, thank you for your work, your research, all the great clinical work that you're doing that's out there. You're definitely helping me head in the right direction. And I hope to have you back on in the future. Thank you. Hi, everyone, Drew here. Two quick things.

Number one, thank you so much for listening to this podcast. If you haven't already, subscribe, just hit the subscribe button on your favorite podcast app. And by the way, if you love this episode, it would mean the world to me. And it's the number one thing that you can do to support this podcast is share it with a friend. Share it with a friend who would benefit from listening. Number two, before I go, I just had to tell you about something that I've been working on that I'm super excited about. It's my weekly newsletter. And it's called Try This.

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