The Dr. Hyman Show - Cholesterol Is Not The Cause Of Heart Disease with Dr. Elizabeth Boham

Episode Date: October 5, 2020

Cholesterol Is Not The Cause Of Heart Disease | This episode is brought  to you by Perfect Keto We have all heard that the secret to living a long, healthy, heart disease-free life is lowering your cholesterol, but is that really true? The reality is, most of us have little understanding about our cholesterol levels in our blood and the whole topic is much more complicated than we thought. Moreover, the standard cholesterol testing is outdated because it doesn’t check for particle size and particle number, and this information is what is needed to tell what’s really going on with your cholesterol.   In this episode, Dr. Hyman sits down with Dr. Elizabeth Boham to discuss why cholesterol is only one factor in determining your overall health. They also discuss the factors that influence your cholesterol and whether or not statin drugs are the most effective way to prevent heart attacks. Elizabeth Boham is a physician and nutritionist who practices functional medicine at The UltraWellness Center in Lenox, MA. Through her practice and lecturing she has helped thousands of people achieve their goals of optimum health and wellness. She witnesses the power of nutrition every day in her practice and is committed to training other physicians to utilize nutrition in healing. Dr. Boham has contributed to many articles and wrote the latest chapter on Obesity for the Rankel Textbook of Family Medicine. She is part of the faculty of the Institute for Functional Medicine and has been featured on the Dr. Oz show and in a variety of publications and media including Huffington Post, The Chalkboard Magazine, and Experience Life. Her DVD Breast Wellness: Tools to Prevent and Heal from Breast Cancer explores the functional medicine approach to keeping your breasts and whole body well. For more information, please visit drhyman.com/uwc This episode is brought  to you by Perfect Keto. Right now, Perfect Keto is offering Doctor’s Farmacy listeners 20% off plus free shipping with the code DRMARK. Just go to perfectketo.com/drmark, and make sure you try their Nut Butters and Keto Cookies. In this conversation, Dr. Hyman and Dr. Boham discuss: If elevated cholesterol is always a problem The cholesterol test you should be getting (either an NMR Lipid Panel from LabCorp or the Cardio IQ Test from Quest Diagnostics), and why cholesterol particle size matters How diet, lifestyle, environmental influences, and genetics influence cholesterol  The role that insulin resistance, pre-diabetes, diabetes, and metabolic health play in heart disease and overall health  Oxidative stress, free radicals, and their influence on heart health The benefits, side effects, and risks of taking statin drugs Patient cases Additional resources: Why cholesterol may not be the cause of heart disease https://drhyman.com/blog/2018/10/03/podcast-ep21/ The Mind-Blowing Science of Fat-Burning and Insulin Resistance with Dr. Benjamin Bikman https://drhyman.com/blog/2020/09/24/bb-ep154/ Seven Ways To Optimize Cholesterol https://drhyman.com/blog/2016/01/14/7-ways-to-optimize-cholesterol/ 6 Steps to Healthy Cholesterol, Or Why You Should Stop Your Statins Now https://drhyman.com/blog/2013/10/09/6-steps-healthy-cholesterol-stop-statins-now/

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that's D-R-M-A-R-K, and use the code DrMark to get 20% off plus free shipping and make sure you try their nut butters and keto cookies. Now let's get back to this week episode of The Doctor's Pharmacy. Welcome to The Doctor's Pharmacy. I'm Dr. Mark Hyman, and it's a special episode of the doctor's pharmacy called House Call. And this episode is with my friend and colleague Dr. Elizabeth

Boham and we're talking about cholesterol and heart disease and what is the truth and what is fiction and what should we do when our doctor tells us to take a statin, which every doctor pretty much does regardless of our age, sex, or whatever is going on? It's the number one drug sold on the planet and we need to think about why and if it's actually good for us or what we actually should be doing about our cholesterol. So Dr. Bohm is an incredible physician. She's one of my good friends and has been working with me for 20 plus years now, I guess. It's a long, long time. And she's one of the leaders in functional medicine in the world, teaches all over the

place now, mostly from her house on Zoom, but really is a part of the faculty of the Institute for Functional Medicine. She's a huge contributor to the field and is what every doctor should be, which is not only an MD, but she's a registered dietitian and an exercise physiologist. And I'm super jealous of all that. We both went to Cornell, so we have that in common. And it's great to have you back on the doctor's pharmacy list. Thank you, Mark. It's great to be here. All right, let's get right into it. So cholesterol. If you are a person in America and you've been to your doctor, you likely have had your cholesterol checked and you probably have been told you need to get your cholesterol

down and you might even have been told that you should be taking a drug called a statin. So tell us what is this whole hullabaloo about cholesterol and statins and why should we even care about cholesterol? And is it really the thing we should be worried about with heart disease? Oh, such great questions. I mean, it's estimated that 50% of people in this country and in Europe and 40% worldwide have what's considered elevated cholesterol. And obviously, for those 50% of people, not all of them have to be really concerned about

that cholesterol number, right? It doesn't mean that all 50% of us have to be taking a medication to lower that cholesterol. And so people come in all the time with those questions of, is this cholesterol too high? And how do I get it down? Do I need to get it down? And the reason we're really looking at cholesterol is because it's one factor that influences somebody's risk of cardiovascular disease, right? I like how you said one factor, not the factor. Exactly. One piece of the puzzle.

And for a lot of people, it's not even an important piece of the puzzle, right? But it is one piece of the puzzle, especially for people who have a really high cholesterol, very like familiar hypercholesterolemia, genetic, absolutely. We're talking about LDLs like in the 190s. And we'll talk more about those numbers, total cholesterol in the 300s. You know, there is a there is an association with vascular disease, it can cause plaque buildup. And that can cause if the plaque is built building up around the arteries around the heart that can cause a heart. Or in the arteries leading to the brain, it can cause a stroke. So for some people, it's something that's very important.

For other people, it's something that's giving us a lot of information potentially about their health and where do we need to focus. And so I think it's an important thing for us to talk about. Like what are all these numbers mean, right? People are so confused. What does this number mean? Do I really need to be worried? So we're going to get deep into all the things you should be thinking about if you want to prevent heart disease, cholesterol being one of them. One of them. And maybe not the most important one, by the way, because two thirds of people who have heart attacks actually have preddiabetes or diabetes, and

it's mostly undiagnosed, that 70% of people who come in have pretty good cholesterol who have heart attacks. About 50% have normal cholesterol. And, you know, it's really striking that we're kind of like wondering about this condition, which is actually not so cut and dried. And I think I want to get into the numbers. Let's talk about cholesterol. Because in my opinion, and I've written a lot about this, the test that you get when

you go to your doctor is antiquated. Absolutely. It's outdated. It's not the cholesterol test you should be getting. And it doesn't give you the right information to make a decision about what to do. So you typically get your total cholesterol, your triglycerides, your HDL, your LDL. Those are fine. But tell us about what these numbers mean and what cholesterol tests we should be doing that your doctor may not be ordering. And that is available through Quest or LabCorp through your insurance.

Absolutely. So when you get your traditional cholesterol panel done, your traditional lipid panel done, they're giving you the LDL cholesterol, the HDL cholesterol, the total cholesterol. And that's one piece of information, like you said, but we're missing a lot of information there. So the, the, it's really important. I love this analogy of the dirt and dump trucks. So dirt and dump trucks, and think of think of all the dump trucks that are going around carrying dirt. And we can make this analogy with cholesterol. So think of your cholesterol like the dirt and the, um, the dump trucks are the particles carrying around your cholesterol. So what we're learning is it's not

just the amount of dirt somebody has that's important. It's the amount of dump trucks that they have carrying around that dirt and that the size of the dump trucks are actually really important. And so when you get a typical lipid panel done, you know, you're just finding out the amount of dirt that you have and how much of it is LDL and HDL and triglycerides. And that's important. And we'll talk about that. But what's even more important, or at least as important, right, is the amount of dump trucks you have carrying around that dirt. And what we're learning is that or what we've learned is that the the if you have small dump trucks, so if you have a certain amount of dirt, you could either have a few big dump trucks carrying around or a lot of small dump trucks carrying

it around. And what we're learning is that those small dump trucks, if you have too many small dump trucks, that that's actually more concerning, that they can get into the artery lining more, they can cause more plaque buildup, they can get that, that it can help that cholesterol get oxidized through oxidative stress. It's much more dangerous. So the size of those dump trucks you have carrying around your cholesterol is critically important and something we look at all the time. I mean, the way I think about it is, and another way I kind of look at it is, the number you get on your test is the weight of your cholesterol. So it's milligrams per deciliter. It's just basically the weight. But it doesn't tell you if that cholesterol is made up of 1,000 particles or 100 particles.

Right. So you could have a cholesterol of 150 and it could be 5,000 particles or it could be 500 particles of cholesterol. And that makes a huge difference in your risk of heart disease. And you can't tell from a regular cholesterol test whether you have a lot of particles or whether they're big particles or small particles. So I think about it sort of like golf balls and beach balls. You know, beach balls are these big, light, fluffy balls that you can bounce and don't

hurt anything. And the golf ball is small, but it hits you in the head and knock you out, right? And the golf balls are the things that are the small particles that are dangerous that bang up against the arteries and cause the plaque to develop and cause heart attacks. So you can't tell that from a regular test. You can have smaller, large LDL, smaller, large HDL, smaller, large triglycerides. And the triglycerides are a little different. It's the big triglycerides that are a problem, not the small ones.

But you can really get a sense from these newer tests what's really going on. Because I've seen people with a cholesterol of 300. Their HDLs, which sounds terrible, right, because you're supposed to be under 200. Their LDL might be 150, which sounds terrible because it should be under 70. Their HDL is like 110. So they have really high cholesterol. They're skinny, they're healthy, and have diabetes, high blood pressure, they don't smoke, they're older.

Often little old ladies have this really high cholesterol. They're skinny, they're healthy and have diabetes, high blood pressure, they don't smoke, they're older. Often little old ladies have this kind of cholesterol. There's no evidence that these people are at risk of heart disease because they have large light fluffy particles. They might have no small particles. They might have the perfect size and shape of all their cholesterol markers and their risk is really low. And I remember talking to a colleague, well more of a mentor, Dr. Peter Libby, who's the chief of cardiovascular medicine at Harvard, has written the textbook, you know, on heart disease

at all, cardiology study. And I said, you know, Peter, I have these patients, these little ladies, they cholesterol is 300 and they have this and that. Like, this was like 20 years ago. I mean, like, would you treat these people with a statin or a drug? He said, absolutely not. You know, there's no evidence that these people are at risk even though their cholesterol is so abnormal. So you can't just go by the cholesterol test that your doctor does. Right. Right, so you need something called what?

Like particle size testing. It's telling us about those things that are carrying around your cholesterol. Yeah, so LabCorp does NMR. Yep, NMR. And Quest does something called CardioIQ. Yep. Which is similar. And you can ask your doctor

for these and you shouldn't stand for any other test, but these tests. And then they tell you so much. So tell us, how do you get a profile that is with these small, dense, dangerous HDL and LDL? Well, you know, it's interesting. So there's a lot of lifestyle that impacts the size of your LDL particles, right? The size of those, you know, are they small and dense and dangerous, or are they big and fluffy and not so dangerous? I mean, there's always a genetic component, right? There's a genetic component, but then there's our lifestyle. And we know that that that metabolic syndrome where people are insulin resistant, gaining weight around the belly. They typically have lower HDL. They typically have higher triglycerides, but they also typically have

more of these small dense LDLs, which are more concerning. And so lifestyle makes a huge impact on the size of those LDL particles. And which part of your lifestyle? What's the biggest thing? The diet. Your diet. What diet causes you to have the dangerous kind of cholesterol? That sad diet, the standard American diet, right? That's the one that, you know, that full of carbohydrates and sugar and refined and processed foods and lots of alcohol and, you know, simple sugars.

It's the starch and sugar that drives it. What does that do to the body that causes these particles? and lots of alcohol and, you know, simple sugars. It's the starch and sugar that drives it. And what does that do to the body that causes these particles? And it actually leads to the high triglycerides, the low HDL, the small particles. It's that whole process of insulin resistance. And it results in this really unhealthy pattern. And so, you know, we sometimes get clues of that with a standard lipid panel, right? We sometimes get clues when somebody has a low HDL. That's the one, the HDL is the one you want higher.

And for men, you want it at least over 40. And for women, at least over 50. And then if that triglycerides are over- I'm like 50 and 60. I'm more aggressive than you. Yeah. Well, that's really true. Like what's optimal, right?

What's optimal, right? If your cholesterol's HDL is 40, probably not optimal. It should Yeah, well that's really true. Like what's optimal, right? What's optimal, right? If your cholesterol, HL is 40, probably not optimal. It should be over 50. It really should. It really should. You're right. It's not optimal. I'm a tough customer here.

And then the triglycerides, you want at least under 150 or what would you say? What's optimal? 70. There you go for triglycerides. If your triglycerides are over you're you're definitely flirting with danger and there are you know there's some genetics involved we'll talk about the genetics in a minute but but it is usually a sign of increased carbohydrate load like not and i don't mean broccoli i mean like flour and sugar absolutely right so so you know you can get some sense

of if somebody has is prone to metabolic syndrome insulin resistance with that. But then the particle size testing also gives us a lot of information. The NMR, for example, gives you something called your insulin resistance score. So you can get a sense based on the analysis of the particles of cholesterol that you have, how at risk you are for insulin resistance. So it's just one more piece of the puzzle. And I see people with a cholesterol of 150 who have like 2,000 particles of LDL, which should be under 1,000, who have like 900 particles of small LDL, which should be under 300 ideally, probably less than 90 is perfect. And you see that often. And yet their doctor, well, your cholesterol is 150, it's fine. And so you really can get duped by just looking at the total numbers.

If it's 300, it might be fine. If it's 150, it might be highly dangerous to you. And it's not so easy without looking at the specific tests. So it's super important. And so what you mentioned is that insulin resistance is the driver of this, which is prediabetes, metabolic syndrome. And to some degree or another, 88% of Americans are metabolically unhealthy and have some degree of this.

50% have prediabetes or type 2 diabetes. Like every other American has diabetes or prediabetes. That's crazy. 75% overweight. And every one of those people is some degree of poor metabolic health. So if this is true, what else does this diet do that accelerates heart disease? Because we now know that it's not just the cholesterol. Like I said, you could have cholesterol 300 and be fine. There's a special ingredient you need in order to cause the heart

disease. What is that special ingredient? So it's inflammation and oxidative stress, right? So inflammation seems to cause everything these days, from depression to cancer to heart disease to diabetes to everything else. So what is the cause of the inflammation in these patients with insulin resistance? So a lot of times, I mean, there's many things, right? But it's our belly fat, because we know that that fat around our belly, when we get insulin resistant, we gain more weight around our belly, and we know that visceral fat or weight around the belly, when we get insulin resistant, we gain more weight around our belly. And we know that visceral fat or, or weight around the belly, the apple shape is more inflammatory. It secretes all these inflammatory markers and increases inflammation in the body. And so when people, when they, when we get them to, when they help, when their weight around their belly goes down,

when we get that waist hip ratio better, that inflammation goes down. So basically what you're saying is, is that fat around your belly is down. When we get that waist-hip ratio better, that inflammation goes down. So basically what you're saying is that fat around your belly is not just holding up your pants, that it's an immunologically active organ. It produces these molecules we call adipose cytokines. You've heard of the cytokine storm with COVID. Well, it's that same chronic cytokine storm that's being released from these fat cells

in your belly. They're not just average. I mean, you have fat in your legs or your butt. It's not going to do that. These fat cells in your belly are super inflammatory. So then you get the inflammation, which leads to oxidative stress, which then causes what problem with the cholesterol? Right.

So when your LDL cholesterol gets oxidized- And what is that? Think of oxidative stress like excessive free radicals or rusting in the body. But you know, we're always making free radicals in many different cellular processes in the body. But when there's too many of them, or you don't have enough antioxidants to squelch that oxidate, those free radicals. So if your diet's not rich enough in the polyphenols or those phytonutrients or your

vegetables, then what happens is you get more oxidative stress. And that oxidative stress can shift that LDL cholesterol. And it's that oxidized LDL that's more damaging and more likely to cause plaque buildup and that will lead to heart disease. So it's basically rancid cholesterol in your bloodstream that's the problem that gets oxidized, which is like you said, rusting or apple turning brown or your skin wrinkling from too much sun. These are all signs of oxidative. But this happens inside of you.

And it leads to this inflammatory process, this oxidative stress, and that's what causes the heart disease. And I, you know, some of the interesting studies I've seen, like the Jupiter study, very big trial from Harvard on heart disease. It's fascinating to me that people had high LDL, but no inflammation, had very low risk. Yes. People had high inflammation, but kind of okay cholesterol, they were at risk risk and those with high cholesterol and high inflammation had the most risk so i think we have to be focused on inflammation what's causing that and it may it may be that you know the statin drugs turns out the the benefits may not have a lot to do with cholesterol lowering but they're anti-inflammatory they're very powerful

anti-inflammatory drugs which is quote a side side effect. But it actually works. Now, there's a lot of better ways to get rid of inflammation besides taking statin drugs. And so when you're talking about people's cholesterol, how do you decide what to do for each patient? How do you decide from a functional medicine perspective, how to work these patients up to decide whether that should go on a drug or whether you just do lifestyle? How do you figure that out? I mean, it is a complex process, right? Where we're taking a really detailed history and we're looking at more than just those numbers. We're looking at what are their markers of oxidative stress? You know, we can measure those. We can measure oxidized LDL. We can measure 8-hydroxydeoxyguanosine and lipid peroxides. All of these biomarkers that give us a sense

of is there oxidative stress? And by the way, these kinds of tests are not things you'll typically get at your regular doctor. You know, at the Ultra Wellness Center here in Lenox, Massachusetts, we do functional medicine, which takes a deeper dive into the root causes, into these diagnostic tests, which are not available usually through your traditional doctor. They may not be interested in or know what to do or how to interpret, even fasting insulin, which they don't even do.

So we really are excited to help people figure out how to look at their risk and design a strategy that's personalized for them using functional medicine. And we see people from all over the world at the Altra Wellness Center doing Zoom consults now. So it's pretty easy to get access. You know, and it's fascinating because there's so many pieces to the puzzle. And so when you find somebody with high oxidative stress, you ask that question, why? Why is there high oxidative stress?

Is it their poor diet? Is it inflammation? Is it their microbiome? Is it their microbiome? Is it a toxin? Heavy metals. Heavy metals, like a toxin or some other- Yes.

All this smoke that wildfires in California, that increases risk of cardiovascular disease. Absolutely, absolutely. So it's really important to think about all the different things that can lead to oxidative stress and inflammation, and then try to tease out what is it for that individual person that we need to focus on. So I think that's important for some people and a lot of Americans, there's so much that's lifestyle related, right? But for some people, their lifestyle is great. And it's more, it's more toxin related that we really need to work on that. Or, or like you mentioned, the microbiome is this is a is an area that's

fascinating. We're learning so much about how it influences inflammation in the body. Yeah. You know, microbiome in your gut, as well as microbiome in your mouth, right? And gingivitis, and how much that we know, we've known for years that that impacts risk of heart disease because of its inflammatory properties. So those are important things that we need to really investigate and look at. Yeah, so true. You know, I'm just thinking about, you know, how we work with these patients. So we look at all these diagnostic tests that may not be looked at. We look at their

overall cardiovascular risk, their family history. We may look at diagnostic tests. We may send them for a heart scan, look at calcium, product ultrasound, look at particle size, look at inflammation markers, oxidative stress markers,

the microbiome, heavy metals. We might look at other factors like homocysteine, which looks at B vitamin status. We look at lipoprotein A and a bunch of other factors that give us a more rounded picture of what's going on. So we're not just focused like a laser on cholesterol. And the reason it seems to me that we are so hyper-focused on cholesterol is we have a good drug to treat it, right? So it's all pharmaceutical driven, whereas when you look at the data, two-thirds of all

people entering into an emergency room with a heart attack have either prediabetes or diabetes, and most of them are undiagnosed. Right. So when you say- So two-thirds of heart attacks are from sugar, not cholesterol issues. And we're just focusing on cholesterol. It seems like we're missing the mark here. We often are. And when we're saying, okay, this is high, I mean, so many people come back with high

on their lab work, and it doesn't necessarily, like you said, mean it's anything to be concerned about. Right. And then there's so many people who come back without that H, that high level, and they do need to be concerned. Yes, very much so. Yeah. Yeah, and I think, you know, statins have a role, but let's talk about the statins for a minute,

because it's very controversial. You know, like any drug, there are benefits, there are risks, there are side effects, and there's the right patient for the job, right? So how do you come to sort of decide what you should do with a patient? Yeah, I mean, you really want to get a good detailed family history. I think that there are some people who are at very high risk of vascular disease. And for people who have a strong family history, which means that if you have a first degree relative, which would be a parent or a sibling who has had an early heart attack.

So for a man less than 55 or a woman less than 65, that means they've had diagnosed heart disease because of plaque at an early age. You know, those people who have that type of family history need to be more careful. Or were they smokers? Were they very overweight? Did they have diabetes? Like what are the other factors? So I always look at that as well because- You have to. I remember my grandfather, you know, everybody in his family, like I think he had nine siblings, everybody had heart attacks in their 50s. You know,

they all had bypasses heart attacks and they weren't like significantly overweight but they were pretty high risk uh as a family and he was deaf so he couldn't hear so he really he really couldn't get a job like a white-collar job so he had a blue-collar job which was basically loading new york times big bundles of new y York Times onto the trucks from the conveyor belt. So he was constantly working out all day long and was very, very strong and healthy. And every night he would go out in Queens and he would walk down the street and feed all the alley cats. So he walked every night after dinner, which we now know is a very good way to

improve your health. And he didn't really get heart disease until his 80s, right? And they all got it in their 50s. And his diet wasn't the best, right? But still, even with simple lifestyle things, it can make a big difference. Absolutely. So right. So you bring up a great point that genetics and family history is just one piece of the puzzle. It's not what makes us make all the decisions in the world, but we take that into account as well as all their other risk factors, like you mentioned, like type two diabetes and are they a smoker? And so we really have to pay attention to all of those lifestyle factors. And high blood pressure, a lot of high blood pressure is a big factor in heart disease. But

again, high blood pressure is usually caused by the same thing, which is insulin resistance. So often. So when I sleep at me, yeah, it's very, very common. Yeah. And, you know, I just sort of recall a patient. I'd love to hear any cases you'd like to share. But I just remembered a patient I saw who was about 50 years old. And he came to see me.

And he had a little bit of belly fat, maybe 20 pounds overweight. He'd had a heart attack, had a stent, and was freaked out, you know, at 50 years old to have his heart be at risk like that and he was on a pile of medications when i saw him he was on a statin a beta blocker blood thinner you know the whole cocktail blood pressure pills you know pretty much everything and i said well listen are you willing to sort of make some changes and so we looked totally revamped his diet we got rid of all the junk out of his diet. Very, very low sugar starch diet.

Lots of good fats. Lots of fiber. Got him on some basic supplements, you know, B vitamins, folate, and also fish oil. Got him on an exercise program. And over the course of a year, know he lost i think i don't know maybe he was more overweight i think he lost almost 50 pounds he he was able to normalize all of his numbers and his blood sugar was high his insulin was high he wasn't quote diabetic but he was pre-diabetic and no one they completely missed it yeah like they i mean it's just staggering to

me that after 30 years that I've been doing this, that the literature has been there, that doctors don't check for prediabetes on a regular basis, which affects basically one out of every two Americans or more. And so you check that by measuring insulin, A1C, a glucose tolerance test with insulin. There's ways to look at it and look at particle number, particle size. And he lost the weight and he was able to reverse all of his numbers and he was able to get off all his medication, including statins. And his numbers were better off the statins than they were on it by fixing all these lifestyle factors.

And he's been heart attack free for the last 20 years. So I just, yeah, I think we are so stuck in this paradigm of treating the symptom, the cholesterol, instead of the cause. Absolutely. That's critical. That's a good story. You've had some patients too, right? So what-

Yeah, so, you know, the first one, you know, I wanted to bring up the two cases I wanted to talk about today were people with this in-between cholesterol, like where they were, they really, they really wanted to know what to do. They weren't crazy high risk, but they were told they should go on medication. And they came to me to say, well, is that the right decision or what else can I do? So the first one was a 45 year old gentleman who was who was told his cholesterol was too high. He didn't have a strong family history of heart disease. But his total cholesterol was, what, 225. His good

cholesterol's HDL was 37. Which is low. It's too low. His triglycerides were 185, fasting. Which is high, right? Too high. Should be ideally under 70. And his LDLs were 145. So, you know, his doctor said, you know what, I think you should start some medication. And he said, well, you know what, I want to see what else I can do. So he came to see us, which was great. And because, you know, a lot of times with patterns like this, we can make a huge change. So we did that special, we did an NMR lipoprofile. So we looked at those particle sizes and we saw that he had a lot of the small dense LDL particles. His pattern, they sometimes

give you a pattern. Are you pattern A or pattern B? Pattern B being the more concerning. You have too many small dense LDLs and that's what he had. He looked like he had a high risk for insulin resistance, which we knew even before we did the test, but because his waist to hip ratio was too high, his HDL was too low, his triglycerides were too high. So it was obvious, but that test confirmed that, right? It said you have a high risk for insulin resistance based on your cholesterol panel. And we also- Before you go there, I just want to point out because this is really a very easy, cheap way to check to see if you have insulin resistance. And it's a far better predictor of your risk of heart attacks than your LDL, which is your triglyceride to HDL ratio. And this guy

had a ratio of about five. If it's over one, not great. If it's over two, you're in trouble. He was five. And that pattern of high triglycerides, it's over two, you're in trouble. He was five. And that pattern of high triglycerides, low HDL is what you see in these patients with prediabetes, even though they might have a normal cholesterol. I mean, his was 225, but I've seen people with a total of 150, triglycerides of 300, HDL of 29. I'm terrified for these patients. Absolutely. Even though their total cholesterol is 150 and it sounds ideal.

Right. That's where we get really nervous because we know that's such a pro-inflammatory process. And what we know about heart attacks, especially sudden heart attacks, right? There's typically, it's, you know, I always sort of draw this picture for my patients of the inside of the artery. And so often we think when somebody has a heart attack, the plaque just keeps building, building, building, building, you know, they're 50% blocked, and then they're 90% blocked, and then they're 100% blocked, and they have a heart attack. But where we know is that sometimes you're only 30% blocked, but if that's inflamed,

if that blockage is inflamed, kind of like that can rupture and then cause a significant blockage. It's like a pimple popping that then your body protects by making a blood clot and you're harder. Right. And that's really often what we see when somebody has a sudden heart attack, right? That blockage just ruptures. And so it's often missed. People aren't necessarily coming in with years of chest pain and shortness of breath, those things that we see as people get older. They just have a sudden rupture of that plaque.

So yeah, those are the situations you get really nervous. And a lot of times you see a lot of inflammation. So we also did an oxidized LDL with him, which was high and concerning. That's the rancid cholesterol. Yep, that's that rancid cholesterol. Yep. That's that rancid cholesterol. So, you know, we really, for him, with all those signs of insulin resistance, metabolic syndrome, the diet for him was that really low glycemic diet. We needed to work to lower those carbohydrates, to lower the sugar.

You know, we know that triglycerides really decrease when you cut out juices, sugars, alcohol. And they're basically fats that are made in the liver when you eat sugar and starch, right? They're not produced by eating fat. Nope. Nope. Sugar. And you can really, you can lower your triglycerides pretty quickly when you pull out the alcohol, the juice, the lots, if some people doing too much fruit, flour and sugar, flour and sugar, absolutely sugar, sugar, sugar. So when you cut that out, you can bring your triglycerides down really pretty substantially pretty quickly. So we really focused on lowering his carbohydrate load, you know, all the bad carbs, right. And, and you also

focus on giving him more of the omega three3 fats because we know those omega-3 fats are really anti-inflammatory and they can, two to four grams of omega-3s a day can lower your triglycerides and raise up that HDL. And this is FDA approved as a drug, quote, a drug, which is fish oil, which is a prescription that you can buy to lower your triglycerides. And you can get it from food, right? Like a can of sardines, three ounces of sardines has about two grams, has about two grams of the omega-3s in it. That's what I'm having for lunch. That's my favorite lunch, sardines on a salad with some walnuts, very heart healthy. So we made that switch with his diet, you know, and what was amazing and what I love

to see is when in like three months, we repeated that NMR lipoprofile and he went from having too many of the small dense LDLs to having, he was now considered pattern A. He had more of the big fluffy LDLs, his HDL improved. Now it wasn't yet optimal, but I think it got up to like 47 in three months. His triglycerides came down to 120. So maybe not, you know, this was just three months of doing this. We can see really quick changes in people's bodies with making these changes in lifestyle, which is phenomenal. Yeah. And I think one of the other thing I want to talk about, this is a great case, but you know, you're able to change his diet and improve things. But you know, one of the things

that we're really bad at in medicine is personalizing care. And there's no place that's more important to personalize your care than dealing with your heart attack risk and cholesterol because it's different for different people. That's very true. And what I've seen, I'm sure you've seen this over the years, is people respond dramatically differently to the same diet. So typically we're told by the American Heart Association that we should have less than 5% of our diet is saturated fat. Although breast milk is 25% saturated fat, so maybe we should ban breast milk according to the American Heart Association. I don't know about that. But it's really important to get saturated fat in your diet because it's a building block for cholesterol,

which is not necessarily a bad thing. I mean, your cholesterol makes your hormones. It makes the nerve coverings for your nerves. It's part of your brain. I mean, it's really important. A lot of your hormones are made from cholesterol, your sex hormones. And what I found was, you know, depending on the person, their responses are very different to diet.

Yes. And I've talked to Dr. Ronald Prowse, who's one of the their responses are very different to diet. Yes. And I've talked to Dr. Ronald Prowse, who's one of the world's experts in cholesterol on this. And he says, yeah, there's a lot of heterogeneity. And I've seen this, just two cases come to mind. One was of a woman who was overweight, who was clearly pre-diabetic, whose triglycerides were 300, which is really high. It should be under 70. Her HDL was like 30, which is really high it should be under 70 her hdl was like 30 which is terrible her total was

you know probably you know 250 60 it was pretty hot should a lot of small particles a lot of overall particles just way box syndrome yeah and she struggled with with weight loss and diet so i put her on a high saturated fat diet. I put her on basically butter and coconut oil and almost a ketogenic diet. And it was striking. She never could lose weight. She dropped 20 pounds like that. Her cholesterol dropped 100 points. Her triglycerides dropped over 200 points. Her HDL went up 30 points. And you just like, you just can't get that result with a drug. And so I did that with her and saturated fat was the cure for her cholesterol, not the cause. But another guy was this super fit mid fifties biker would bike 50 miles a day,

super healthy. And his, his cholesterol wasn't great. And he had a genetic issue with his cholesterol and had this sort of more of these small particles. And so I put him on, I tried, I said, let's try just do more of a ketogenic diet, see what happens, or more saturated fat. His cholesterol turned terrible. So we had to totally change gears and get him off saturated fat. I think we'll soon be able to do a test, which is a cheek swab or a drop of blood, measure genetics, and figure out which one are you. Are you somebody who should be eating more fat and saturated fat or more carbohydrates or more of the right foods, different kinds of fat?

We're not quite there yet, but I think in functional medicine and here at the Ultra Wellness Center, we can, on an individual basis, really come to learn what is the right thing for this particular person. So I think it's really important. That's so important because what's really key with diet is personalizing it, right? That's when we get the most benefit from our nutrition intervention. And I think what you mentioned with the first woman, the reason you saw such an improvement with the ketogenic diet is you lowered her insulin so much, right?

So we know that the carbohydrates that you eat cause your insulin to spike. So when your insulin is high and you can't lose weight because your insulin is high because it's causing you to put down weight around the belly, when you change to a diet that doesn't cause your insulin to go up, which is like a ketogenic diet. I mean, that's the extreme, right? But you can do some, some things in between too, but then that insulin doesn't go up. And that's when we can see huge benefits for some people in that situation. It's really true. I mean, insulin, you know, for the most part, and like the one guy,

it wasn't because he was so fit and there's genetic variations, but for most people out there, it is really the most common thing. And, you know, aside from getting the NMR particle test, getting a measure of your fasting insulin, really great. If you can get an insulin test after you have a sugar load, that's even better. Because by the time your blood sugar goes up, you're down the road, way down the road. I mean, it's a late stage phenomena. You even have your blood sugar going up fasting and then two hours after a sugar load, it's, you know, you see a have your blood sugar going up fasting and then two hours after a sugar load, you see a little earlier.

But I'm doing these tests for decades. I just see this pattern over and over again. You can have perfectly normal sugar, perfectly. I mean, I had this one woman who was really overweight, had a giant belly, and clearly she was metabolic syndrome. She had high triglycerides, low HDL, the same pattern. But when I measured her glucose tolerance test and her A1C, perfectly normal. Like her fasting blood sugar was normal. Her average blood sugar was normal. Her one and two hour blood sugar test, like normal. Like her fasting was in the 80s after it was like 110. But I measured her insulin.

Now, normal insulin should be under five. It's over 10, kind of in trouble. Her fasting insulin was like 30. And then we did a sugar load and her insulin went up to 200, 250. And it should be under 30 after a sugar load. So she was like 10 times normal. And it was keeping her blood sugar normal, but it was driving all this weight gain and inflammation and abnormal cholesterol. So you really have to dig in in a different way than your traditional doctors are digging in. Absolutely. Those people can't, they have such a hard time losing weight, especially if you don't pull the carbohydrates too low. I mean, she lost 50 pounds like that.

Once you pulled the carbohydrates out. Yeah, it's so easy. I feel embarrassed about it because, you know, it's like what we're telling people to do is so simple, but when you understand the biology, which is what functional medicine really is about, it's understanding each of our unique biology, looking at things that traditional doctors don't look at, at function, at differences in the responses to different insults like diet and toxins and various things. So we have a really different scope.

And at Cleveland Clinic, where I also work, one of the leading doctors there, cardiologist Stan Hazen, has done incredible work looking at the microbiome and how the environment and the gut can increase your risk of heart disease and how certain foods increase certain problems. And it's just fascinating to think here at the number one heart hospital in the world, they're going, wait a minute, maybe we should be looking at poop. And. Right. And so the paradigm's breaking down, right? The hyperlaser focus on cholesterol, which we're talking about today, is only one small part of the story. And getting into the nuances is really important in order to really look at your

risk and design the right program for you. And that's what you do here at the Ultra Wellness Center. It's what we do. We've been doing it for decades. And I think it gives people a chance if they're concerned about their heart disease risk to come up with a personalized plan that can help determine their best outcomes and reduce all these factors. Yeah. So the second case I had, she was not at risk for insulin resistance significantly.

Her insulin, I don't really remember what it was, but it wasn't that concerning to me. But she was also concerned about her cholesterol. She was 55. Her doctor had just checked her cholesterol. Her LDL cholesterol was 160. And so he was recommending some medication. She didn't have a strong family history, but when we look deeper or when we, you know, her cholesterol also showed her triglycerides were

okay at 90, her HDL was 55. Again, maybe not perfect, but you know, it was really that LDL cholesterol I was a little more concerned about. We did, we did particle size testing on her and she didn't have too many of those small dense LDLs. She was more pattern A, more of the big fluffy LDLs, which made me happy to see. And, um, but she's like, you know what, let's bring down, I want to bring down this LDL cholesterol. And, um, so with her, the focus in the diet was a little bit different. You know, she did, she was about 10 pounds overweight, so she wanted to lose some weight. So we focused on that. And then we also really focused on her protein because, um, because protein's really important as well when we're talking about

cholesterol, because there's some vegetable proteins that can help with lowering, they can help with lowering that LDL cholesterol. So beans and legumes, nuts and seeds, these are vegetable sources of protein that have plant sterols in them. And they can help bind to the cholesterol in the gut and lower your LDL cholesterol. And, you know, so when I have a situation like this, you know, I really talk to them about balancing where they're getting their protein from. More of that vegan diet, right? Where they're getting some of their protein from a vegetable source like beans and legumes,

healthy forms of soy, nuts and seeds, and some of their protein from an animal source, but maybe not, you know, more of as that condom meat as you speak about. So I think that's a really important area to focus on. So she with, you know, three months or so, the weight came down. And when we rechecked her, we saw that LDL cholesterol come down to like 130. And her HDL even went up higher, which was great to see. So she had a nice improvement with shifting her diet. But we just focused a little bit differently than we did with the first gentleman.

You're right. I think you bring up a lot of very important points. It's not just what you take out of your diet, like sugar and starch. It's what you put in your diet. And using compounds that are naturally found in plants, like plant serols that come in beans and nuts and seeds and high fiber, you can really have a big impact. And I think one of the things I like to use is extra fiber as something called PGX, which is basically from a root of a Japanese vegetable called cognac.

It's not like the alcohol. It's K-O-N-J-A-C. And it's a fibrous root. You can actually make noodles out of it. There's these shirataki noodles. So you can have pasta, in a sense. But it actually is zero calories. It's all fiber.

And it blocks the absorption of cholesterol from your gut. So adding more fiber plays a huge role. Changing the quality of your diet, increasing the good fats like olive oil or the avocado oil, and also improving the overall content of phytochemicals in your diet, all helps to reduce your risk dramatically. And I think we're really not focused on that in medicine. We're just like, here, take this drug, we'll see you later. And people often get a false sense of security.

So, oh, I'm taking my stat and I can have the fried food or I can go to McDonald's. I mean, they were talking about it selling Lipitor at McDonald's, which I thought was insane. But I think we really have to understand that heart disease is a complex disorder. It's not just about cholesterol, that from a functional medicine perspective, we do much more detailed workups, looking at inflammation, oxidative stress, looking at the particle size and number, looking at even

your gut, heavy metal toxins, other factors that relate to nutrition like homocysteine. And we get a really good sense of what's going on and we then personalize the treatment. And it's very, very different approach to reducing your risk. And it's been so satisfying for me. And I've had patients who have had heart attacks and then we follow them for 20 years and they're just great and they're healthy and they have no risk because they really have changed the cause of their heart attack. So taking a statin doesn't change the cause of why your cholesterol is messed up. That's very true.

And I think it's, you know, I want to say heart disease is not a statin deficiency, right? Right. So thank you so much, Dr. Bohan, Liz, for being on the Doctors Pharmacy podcast. If you suffered from heart disease, if you are having issues with cholesterol, if you're concerned about it, someone in your family's struggling with these issues, I really encourage you to dig deeper. Don't just accept at face value that you should take a statin. Cholesterol is the problem. It's often more complex. And find a doctor

or practitioner who can help you. We're at the Ultra Wellness Center here in Lenox, Massachusetts, happy to help anybody. We're doing mostly Zoom and virtual consults now so we can take care of anybody from anywhere. And it's just really satisfying to see how quickly people respond and fix these things and get off the medications and fix their numbers. And more importantly, they get better. They feel better. Because I don't really care about the numbers as much as how do you feel? What's your vitality, energy?

And I think the side effects of these medications are not benign. And so I'm just so excited we got a chance to talk about this on The Doctor's Pharmacy. You're just a wealth of information and knowledge. And I'm so excited that we get to do these house call podcasts and get people information about things that often they're struggling with and have questions about that are kind of obtuse, but that in functional medicine, we really do a powerful job in fixing. Thank you, Mark. So if you've been listening to this podcast and you loved it, please share with your friends and family on social media, leave a comment. We'd love to hear from you and have you fix your

cholesterol and subscribe wherever you get your podcasts. And we'll see you next time on The Doctor's Pharmacy. Hey everybody, it's Dr. Hyman. Thanks for tuning into The Doctor's Pharmacy. I hope you're loving this podcast. It's one of my favorite things to do and introducing you all the experts that I know and I love and that I've learned so much from.

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