The Dr. Hyman Show - Prevent And Reverse Heart Disease Using Functional Medicine with Dr. Cindy Geyer

Starting point is 00:00:00 Coming up on this episode of The Doctor's Pharmacy. We know that two-thirds of people who are cardiometabolically unhealthy actually have sleep apnea. And our perception of how sleep-deprived we are doesn't always match the reality of what we find when we screen people. Hey everybody, it's Dr. Mark. Now one of today's episode sponsors is ButcherBox. I love this company because they make eating high-quality meat and seafood accessible, affordable, and most importantly, really delicious. When I talk about high quality animal protein, that means caring for the lives of the animals and the livelihoods of the farmers, reducing our impact on the environment and the climate, and feeding our bodies real food

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Starting point is 00:03:16 Welcome to The Doctor's Pharmacy. I'm Dr. Mark Hyman. That's pharmacy with an F, a place for conversations that matter. And if you have heart disease or you know someone who's had heart disease, which is probably everybody listening to this podcast, then you should listen up because this conversation is going to matter to you because we're going to talk about heart disease, the number one killer in the world. But in a way that might surprise you because a lot of the thinking about heart disease is just plain wrong. And a lot of the root causes are being missed. And that's what we're going to get into today with none other than Dr. Cindy Geyer who's back on our special episode of The Doctors Pharmacy called House Call. Cindy and I have known each other for decades she and I

Starting point is 00:03:56 worked together at Kenya Ranch for years I hired her to be one of the doctors there and she ended up taking over the place and became medical director and has been teaching all over the world as one of the leading lights in functional and integrated medicine she's triple board certified in integrated medicine functional medicine i mean internal medicine and lifestyle medicine and she's recently joined the ultra wellness center as one of our key staff and we're just so happy to have her. She's got, gosh, a quarter century of experience in functional medicine, integrated medicine. It's just one of the smartest docs I know. And Cindy, welcome to the Doctors Pharmacy Podcast. Thanks, Mark. Glad to be here. Okay. So let's talk about heart disease because we think we know all about heart disease. Oh,

Starting point is 00:04:40 it's cholesterol and statins are the cure. And if that doesn't work, you get a bypass and angioplasty. And if that doesn't work, you get a bypass and angioplasty. And, you know, if that doesn't work, you get a heart transplant. That's sort of. And then, you know, of course, there's all the normal causes we know, like diabetes and high blood pressure and high cholesterol. But diabetes is a symptom. High cholesterol is a symptom. Smoking is a habit. And yet we're kind of missing the boat, I think, on a lot of the reasons we have heart disease and what we can do about it from a more systems perspective. So let's talk about just what a big deal this is and how few people actually are meeting the simple behaviors that will prevent heart disease. Yeah, again, this is another one of those conditions

Starting point is 00:05:25 that the debate is, well, it's in my family, so I'm doomed to get it. But we know that 80% of cases of heart disease and diabetes may actually be preventable with diet and lifestyle. And despite that really powerful message, fewer than 3% of the US population is meeting the core four basic characteristics that predict low risk.

Starting point is 00:05:44 And it's a pretty low bar, Mark. What are those? What are those four things? It's not smoking, getting the minimum recommended 150 minutes of exercise a week, eating in the top two quintiles of what's considered a whole foods diet, and having a healthy body fat percentage. Fewer than 3%. I still find that shocking. So not too much body fat, eating pretty healthy, little exercise, and don't smoke. Yeah, that's good. Simple things to do, but like- We're not even there yet.

Starting point is 00:06:12 3%. Yeah, 3%. And what's really staggering is that not only do the people not meet those habits, but that there are some really other big factors that we are just so bad at in America. Our whole society is set up to actually cause heart disease. Absolutely. What are those things that really are these risk factors besides cholesterol?

Starting point is 00:06:37 Well, of course, it's inflammation. I mean, you and I were working together back at Canyon Ranch when that pivotal study came out. I think it's been 21 years now. I remember that. New England Journal of Medicine review paper. Yes. Peter Libby and Paul Ritker showing that cardiovascular disease is an inflammatory process, that it's not just about cholesterol, but there's ongoing inflammation. And as you've talked about many times on this podcast, inflammation is not, it's also a symptom that it can come from a lot of different places because in our paper our local paper when that article came back out i don't know if you remember this

Starting point is 00:07:11 it said president bush's doctors measured his crp which is the common marker of inflammation and they don't know what to do about it right right so it's one thing to say well we know inflammation matters it's another one entire aspirin take aspirin and a statin, right? But it's another to say, well, what are the root causes of inflammation? Well, it's true. And there's a lot of them. And some of the things that we don't typically think of as causing inflammation, we know infections and allergens and things like that, even toxins and bugs in your gut. But stress causes inflammation. Absolutely. Lack of exercise causes inflammation. Yeah. Bad sleep causes inflammation. Loneliness and isolation cause inflammation. And those are pandemics. Yes. In America. Chronic stress, loneliness, isolation, bad sleep.

Starting point is 00:08:00 I mean, those things are huge in heart disease, and we often miss the boat on helping our patients really deal with those. Right. So, okay, so the typical person comes in, he's got a high cholesterol, he or she has a high risk for heart disease, maybe family history. Typical doctor does sort of what workup and what kind of treatments? So a typical doctor might measure a glucose and an A1C to look at their blood sugar status. And they would do a standard cholesterol profile, which interestingly enough, calculates your LDL cholesterol, the one we usually think of as being the lousy cholesterol from a formula, doesn't even really measure it. And base most of the decisions on that. If they have symptoms,

Starting point is 00:08:45 they might send them to a cardiologist for a stress test. If they have chest pain. If they have chest pain, right. Or shortness of breath on exercise. It's already kind of down the road. Right. But most doctors don't measure C-reactive protein because as I mentioned before, it's like, well, what do we do with it? What do I do with it? What do I do with it? Oh, statin and aspirin. And then they're probably going to treat them with, if they are pre-diabetic or diabetic, they're going to give them metformin or medications to lower blood sugar and probably a statin to control the cholesterol. How often do they actually talk to them about those root causes such as diet and stress and sleep? Maybe not. Yeah. They're talking about this poly pill as a treatment, which is this combo pill of an

Starting point is 00:09:27 aspirin, a statin, and a blood pressure drug. Yes. Put it in the water. Just like give it to everybody. It'll prevent heart disease. I'm like, yeah, okay. Well, why do we have high blood pressure? Why do we have a need for aspirin inflammation?

Starting point is 00:09:40 Why is our cholesterol all screwed up? Yeah. And you know, it's really interesting. There's, believe it or not, there's a potential behavioral component for patients who go on a statin and their cholesterol is now normal. It's good. Oh yeah. I can eat my cheeseburger. I can eat my cheeseburger. My fried chicken. Isn't that interesting that people change their diet in an unhealthy way when their number's better? One of the worst things I ever read was there was a bunch of cardiologists advocating for selling statins over the counter at McDonald's and fast food restaurants. Oh my gosh.

Starting point is 00:10:12 I think they do sell even statins over the counter and like, you know, it's like those commercials for the acid blockers. Like, take some Pepsod because don't worry, daddy, you can eat your peppers and sausage. Just take the Pepsod. And I'm like, daddy, you can eat your peppers and sausage. Just take the Pepsod. And I'm like, no, don't eat the peppers and sausage. So, you know, you kind of mentioned they do it sort of a cholesterol profile, but there was a hint of a subtext in that sentence where they really weren't measuring the right thing. So we tend to look at things that we're used to looking at that are easy to test and measure.

Starting point is 00:10:47 But one of the things that I think people forget, and I think doctors honestly forget, is we get trained in this panel of tests. And it's your blood count, your metabolic profile, and your cholesterol. And we measure like a few things. Maybe it's 30, 40 things. Maybe if it's a super fancy doctor, they'll measure 100 things.

Starting point is 00:11:09 And they think they're kind of checking everything. Oh, your tests are fine. Everything's great. You look good. And the truth is that they're missing a huge amount. There are literally tens of thousands of different molecules in your body, all doing things all the time, every minute, every second. And we ignore most of them.

Starting point is 00:11:32 And in fact, we may ignore some of the most important ones. And when it comes to cholesterol, we've covered this on the podcast with Dr. Bohm. We went really deep into this. We should just do a quick refresher. Because the test that most people get, not the one we get here at the Ultra Wellness Network, but the test that most people get is like an antiquated cholesterol test that doesn't really tell you a whole lot. And I have a patient yesterday who's a classic example of that, right? So tell us about, and I'll tell you about his testimony, but tell us about

Starting point is 00:11:58 the new kind of testing that we're doing. It's not so new because we've been doing it for 20 years. And the discovery that allowed for the testing was 50 years ago. Yeah. So the focus has been on amount of cholesterol, but we want to know the quality of the cholesterol. So we know, for example, LDL, that's typically labeled the lousy cholesterol, there's big, fluffy, puffy pattern A LDL cholesterol, which is less easily made into a plaque in the artery, less prone to inflammation and oxidative stress and rupture. So it's a less risky LDL, whereas somebody could have small, dense pattern B LDL, and that's the really risky LDL. So quality matters.

Starting point is 00:12:41 And if you have two people with a calculated LDL of 130, one of them could all have pattern A low-risk LDL, and they're actually fine. Somebody else could have lots of those dense particles that's not captured by the calculated LDL of 130. So the quality matters. The same is true of HDL as being the good healthy cholesterol, but size matters there too. Small HDL doesn't seem to be as able to cart out the bad LDL and get rid of it. So we want to know the quality and the size of both the HDL and the LDL. And we want to know what other remnant particles are floating around, like very low density lipoprotein and intermediate density lipoprotein. And those don't show up on a typical panel. Yeah. So, so, so practically what you see is people come in with what it looks like a normal cholesterol. Like this guy yesterday has early dementia. His cholesterol, I think it was 160 something. Sounds good. Yeah. His LDL was I think under 100.

Starting point is 00:13:42 Stranglisterides weren't bad. His HDL was 39, which is kind of low. But we looked at his particle number, even though his LDL, like if you're a regular doctor, oh, that's great, 160, that's a great cholesterol. They missed the boat because his particle number was like 1,500. It should be under 1,000. Wow.

Starting point is 00:14:03 And his small particles, which should be like zero, or less than 300 is, you know, you can live with, but anything over that is high. His was 900. So he was like, and he was a skinny older guy, was 84 years old and had, you know, lost muscle, belly fat, you know, underweight, over fat. And he was pre-diabetic, and that was driving some of his dementia.

Starting point is 00:14:30 But they were, oh, your cholesterol is fine, not an issue. And we also look at a lot of other things besides that. By the way, in 2021, no one should get their regular cholesterol panel. I mean, you've got to insist from your doctor. You can get it from LabCorp Quest. It's called NMR or CardioIQ. It's so important to do. And I guess, you know, the problem is most doctors won't know what to do with it once they find it. There's no drug for it. Like, oh, your LDL is high. We'll give you a statin. It's like we treat what we can easily

Starting point is 00:14:59 test and find, not necessarily what the right thing is. And so with heart disease, you know, it really is a metabolic issue. They shouldn't be called cardiologists, they should be called cardio-endo-immunologists. Right. Because it's all about the hormones, including insulin, and all about the inflammation, the immune system. And you mentioned earlier that study by Paul Ritker and Libby, in which it was sort of the beginning of the conversation.

Starting point is 00:15:29 A lot of the follow-up studies, like the Jupiter trial, they found that if patients had a high LDL, but they didn't have a high CRP, their risk of heart disease was negligible. But if they had a high LDL and a high CRP, that was the problem. So independent of inflammation may not be an issue. And also you can get falsely confused by cholesterol tests.

Starting point is 00:15:49 You've seen these patients who were, and I don't mean to stereotype people, but it was this kind of cohort of women who were probably in their 70s and 80s, who were thin, who were fit. The ladies we see at Kenya Ranch who like exercise, eat well, don't smoke, normal blood pressure, no diabetes, and their cholesterol is 300, and their HDL is 100, and their LDL is like, I don't know, maybe 150 or something. And they have no small particles, and they have

Starting point is 00:16:18 all these large fluffy things, and they're in really no risk for heart disease, and they don't need a statin, right? I even asked Peter Libby, who's the chair of cardiology at Harvard, like, do these women need a statin? And they're like, no, they don't. We don't have any data to say that they do. And I'm like, oh, that's interesting. So we kind of have to be really personalized

Starting point is 00:16:35 in our approach. And that's the other feature of functional medicine, not like one size fits all. Everybody gets the polypill, everybody gets the statin, aspirin and blood pressure pill. Like, no, we have to start to think about what's the cause. And heart disease is a symptom. It's a syndrome.

Starting point is 00:16:49 There are many, many causes. So let's talk about this whole idea of metabolic health. Because, you know, we were chatting a little earlier, and it's staggering to me as a physician just how poor our metabolic health is. So how healthy are Americans metabolically? Yeah, not very. So a recent study was looking at the NAHANES data from 2009 to 2016. It was a government survey.

Starting point is 00:17:15 Government survey. All of our blood tests and health records and everything, right? And trying to say, well, how many people are what we would call metabolically healthy? And if you're not familiar with it, for people who may not be familiar with that term, it's sort of meeting the optimal numbers for a blood pressure less than 120 over 80, HDL levels being in the high range, a good range, greater than 40 for men and 50 for women, having triglycerides that are low, having a glucose that's less than 100. And they found that 12.12% of Americans- 12.2%.

Starting point is 00:17:51 12.2%. Thank you. 12.2% of Americans were metabolically healthy. Which kind of means that almost 88% of Americans are metabolically unhealthy. And since 75% of people are overweight, there's another 13% there. It's like, what's going on with the skinny people? Well, and that's the interesting piece. Fewer than one third of so-called normal weight people were metabolically healthy. So that's another really important message. Wait, wait, wait. Did you just say that two thirds of skinny people are metabolically unhealthy and have prediabetes-like syndrome? Yes.

Starting point is 00:18:26 Two thirds. That's mind-boggling to me. Okay, so that means that what, like 95% of Americans are metabolic? No, no, no, it's still the 88%. But then we're looking at how strongly it correlated with weight. That's so terrible.

Starting point is 00:18:41 So just having a body mass index that's less than 25 is not a guarantee that you're metabolically healthy. So if you're a skinny sugar and bagel eater, don't think it's fine because you're skinny. Exactly. It's basically the bottom line. Exactly. Because foods have other impacts besides just what they do with cholesterol anyway.

Starting point is 00:18:59 Foods directly impact the elasticity of the arteries, for example, which is another key player. You mean food is more than calories, Cindy? Food is information, Mark. You said that for years. It talks to our genes. It talks to our systems. Yeah. Wow. So you're talking about how the food impacts our metabolic health. And we're not really good at diagnosing metabolic dysfunction. I mean, 90%... I mean, okay, one out of two Americans has prediabetes or type 2 diabetes. And if you look at this new study, I would argue that nine out of 10 Americans have some degree

Starting point is 00:19:32 of prediabetes or type 2 diabetes, like 90% of Americans. So when you look at that data and you also look at the parallel data that 90% of Americans with prediabetes are not diagnosed by their doctor. Right. That's terrifying, especially because this is a 100% reversible, preventable, treatable condition. And it gets worse and worse over time. And people just don't even know they have it and doctors miss it because there's no pill to take. Oh, tecmetformin. Well, that's not going to help, right? And so what are the kinds of ways that we look at these patients differently? What are the tests that we do? What are the things that we really

Starting point is 00:20:10 focus on when someone comes in with a risk of heart disease and they're concerned about heart disease? What's our approach? It's not just looking at the typical cholesterol and even CRP. Yeah. So we would look at those, of course. We would also want to know what is somebody's insulin. Most doctors measure glucose, but not insulin. I personally like to look at somebody's glucose trends over time. Because if you think about something that's preventable, you don't want to wait till they cross that threshold to prediabetes or diabetes. So even in the range of so-called normal glucose mark, You know this, somebody who's fasting glucose runs less than 85 is in a very different metabolic place than somebody who's fasting glucose is 95 to 99, even though they're both technically normal, that it's a spectrum of risk. And the farther along

Starting point is 00:20:57 you march that spectrum, the higher the risk of heart disease and diabetes. So if somebody's glucose used to be 85, and then it was was 91 and now it's 98, we're going to talk to that person right off the bat about all the things they need to put into place to prevent it from progressing because they're already on that spectrum. We also want to know insulin levels, not just a fasting insulin, but sometimes the insulin response to food because the other thing that's emerged is insulin is a player. And way before somebody's blood glucose goes up, they might be pumping out tons of insulin to try to keep it in a good place. And insulin by itself contributes to inflammation and more weight gain around the middle, that

Starting point is 00:21:39 visceral adipose tissue. So we want to know their insulin, both fasting and in response to a challenge. So wait, wait, wait. Are you saying that sugar, not fat, that's causing heart disease? And sugar, the thing that's driving the insulin? Because fat doesn't cause insulin spikes. Well, there is some, I mean, fat is a player. Fat by itself. Fat by itself is a player. If you eat fat with the food, it will. Yeah. And I would say that quality of fat does matter.

Starting point is 00:22:05 And we can talk some more about that, but I think fat plays a role with artery elasticity, which is another component of vascular risk. So fried foods, trans fats, refined oils, those are nasty. Absolutely. Absolutely. But fat itself, if it's made from whole food sources and nuts and seeds and avocados and olive oil. Might actually be beneficial.

Starting point is 00:22:24 Actually beneficial, yeah. So what you're talking about is a set of diagnostic tests that are so important but mostly ignored. So the particle size and number, which nobody's doing. And the second is not just measuring your blood sugar A1c, which may be perfect. And you may be in really bad trouble. But measuring also insulin in response to drinking like a couple of cokes right i i have a patient cindy that i remember who was a super high risk for heart disease and she had uh i mean she looked like the tasmanian devil and she was

Starting point is 00:22:58 just like a round apple ball like this and her belly was like this big thing and i'm like this woman is in big trouble and she's inflamed she's a high school heart disease high blood pressure diabetes and i'm like let's check her glucose tolerance test with insulin and this is you know this is like 20 plus years ago and no one was like looking at this even today no one's looking at this it's like so hard i mean it took 50 years from the time the guy said hey we should wash our hands before surgery for us to wash our hands. You know, McKinley died, President McKinley, because he got shot in the belly. And the doctor, McBurney, stuck his finger in the wound to check it out without washing

Starting point is 00:23:34 his hands. You know, that's like crazy. It took 50 years from the time the guy said, let's do a stethoscope so we don't get lice jumping into the doctor's hair to start using the stethoscope because the doctor used to put their head on the patient. So it takes forever. And we've been doing this. Anyway, this woman, I did this test. I gave her this drink.

Starting point is 00:23:52 And it was the most shocking thing I'd ever seen. And it taught me so much about what we miss in medicine. Her blood sugar was perfect, like 80. And she took the sugar drink and it was like perfect. Like it never went over 110 after taking like the equivalent of two coca-colas you know she's fine her a1c was perfect her insulin normally should be under five fasting and under like 25 or 30 after a drink her insulin was like 50 fasting wow and like 250 after a drink so her body was just pumping out insulin

Starting point is 00:24:26 which was making her hungry slowing her tablets putting fat in her belly cells which were basically inflammation factories and leading to this perpetual cycle and she was able to lose 50 pounds like that when we cut out starch and sugar. And I just feel like, you know, that showed me so much because you can even do a normal glucose tolerance test. And that looks perfect. And if you were super hyperinsulinemic, you're going to miss that patient's real problem. And you know, it's interesting, Mark, because that scenario is also associated with that cholesterol profile we talked about with the small dense LDL and low HDL and the sequelae that we usually link to diabetes, fatty liver, peripheral neuropathy, all these other organs that are affected and it can happen with the high insulins alone before

Starting point is 00:25:17 the sugars go up. It's a metabolic imbalance. Yeah. So that's really the take home here is that heart disease is really a hormonal issue around insulin and insulin resistance and an inflammation issue. And unless you address those two things, not with aspirin and statins, which will work to some degree, or metformin, which will work to some degree. And by the way, high blood pressure, which goes along with all this stuff, they're all seen as separate. High blood pressure, cholesterol, diabetes, they're seen as separate. They're the same condition. They're manifestations of the same underlying biology of insulin resistance. And unless you really know how to look at the metabolic pathways in the right way,

Starting point is 00:25:56 like we talked about insulin testing or the cholesterol or the cause of inflammation, because, you know, like you said, insulin and resistance is probably the biggest cause. So probably the biggest cause of inflammation is diabetes, prediabetes, and the starch and sugar that we eat about a pound of each every day in America. That's the problem. But there are other factors that also contribute that people don't think so much about, especially cardiologists. So those are the big ones. And, of course, you know, exercise, sleep, stress, all those. We've covered those on other podcasts, relationships, connection, community, really important. But there's some other factors that are a little unusual that we look at in

Starting point is 00:26:33 functional medicine that I'd love to dive into that have a big impact. So can you just share some of the other factors that could drive inflammation? Well, yet another example where the gut microbiome seems to play a role. So now that we can do more sophisticated gut testing and look at these microbial patterns, there's a so-called microbial signature that strongly predicts insulin resistance, diabetes, and cardiovascular disease. And a couple of general scenarios you see is there's a loss of overall microbial diversity in the gut. There's a loss of a couple of signature species. One's called one of the phyla that produced this signaling molecule called butyrate. Butyrate plays a role as fuel for colon cells to help them replenish and be healthy. And it's also an anti-inflammatory molecule, and another species called Acromantia mucinophila.

Starting point is 00:27:26 And you can kind of tell from the Latin mucin base that it's a mucus-loving bacteria. So that pattern of low diversity, loss of butyrate, and loss of acromantia correlates with loss of integrity of the gut lining, more absorption of unwanted things into the bloodstream, more calories and more inflammation that in turn exacerbates insulin resistance. So the question is, is it chicken or the egg? Because we know that pattern also shows up in response to diet, of course.

Starting point is 00:27:56 The standard American diet creates that pattern, right? Why do you don't have the good guys and why do you have too many bad guys? It's because of what we're eating. It's because of what we're eating. It's because of what we're eating. That microbiome is influenced by the foods that we feed it. But what's really fascinating is even our thinking about how medications work. You mentioned metformin earlier, right?

Starting point is 00:28:15 And we used to think that metformin helped our cells respond to insulin better, but it also has a microbiome effect. Interestingly enough, there was a study that found that people who took metformin, you saw a rebound of microbial diversity, a rebound of acromantia, and a rebound of those butyrate species. With metformin. With metformin, which I think is fascinating, right? The way we think drugs are working may actually be completely different.

Starting point is 00:28:43 We call those side effects. We call those side effects, right? But we also know in functional and integrative medicine that we can achieve the same thing when we encourage people to eat a diverse array of plant-based, colorful plant-based foods and foods that are really good for rebound of acromantia, like polyphenolic foods, berries, deeply pigmented berries and greens and garlic and onions and cranberries. Right.

Starting point is 00:29:07 So of course people want a pill, but there are other things that can potentially achieve the same thing. Interesting. You know, there's a new company that came out with an acromantia product. Yes. Pendulum. The pendulum. And it's fascinating.

Starting point is 00:29:19 They're not saying this is a probiotic that's healthy for your gut. This is a tool to control your blood sugar. Isn't that funny? And I think, you know, we don't even think about that that a lot of insulin resistance can start in the gut i i haven't shared the story recently on a podcast but i'll share it again i had this patient who was diabetic very brittle diabetic uh he was kind of a type 1 e 2 e but he wasn't on insulin but he was just all over the place put him on a keto diet sugar's dramatically improved dramatically but still not like going from like 250 to like you know 120 130 better but not like where i wanted them um and then one day he called me up said you know doc my stomach's been bothering me i got the worst gas and i just feel so bloated and uncomfortable

Starting point is 00:30:02 i said well we have to get to the bottom of it and maybe have bacterial overgrowth maybe have this maybe that but like in the meantime you're so miserable why don't you just try some charcoal tablets see if it gives you some relief of your symptoms and he come back says I don't know what happened doc but my sugars went to normal like I'm in the 80s now because I took charcoal and I'm like oh my goodness this is it this is these toxic bacteria and they're producing toxic molecules and charcoal is like a sponge for toxins so when Sun comes in the ER and they swat a bottle of pills

Starting point is 00:30:35 we make them drink a bottle of charcoal and they have black teeth but but it works absorb all these other bacterial toxins and I was like wow and so often the pathway to fixing heart disease might not be through the heart. It might be through the gut. It might be through the gut. Or other factors like toxins. We know the role, for example, of pollution and the particulate matter in a lot of urban areas. There's a huge correlation with heart disease, right? I think part of that, too, is if we look upstream, even before correlation with heart disease, right? I think part of that too is if we look

Starting point is 00:31:05 upstream, even before people form plaques, they can start to have problems with the elasticity of their small arteries. And in fact, that's a more typical pattern for how cardiovascular disease shows up in women, that it's small arteries that have lost their elasticity as opposed to big arteries full of plaque. And we can think of that artery, that endothelium, as the canary in the coal mine. And they did studies of measuring people's artery elasticity as they were jogging through urban environments with high air pollution counts.

Starting point is 00:31:35 And you could see the arteries lose their elasticity in response to that. They've also shown... Oh, so all my jogging and running outside in China and Beijing in the middle of winter when the skies were gray probably wasn't a good idea. Probably wasn't a good idea. You can even show that those arteries will spasm acutely in response to stress, in response to a Burger King meal. McDonald's. Well, let's say a burger and fries meal. So if we understand what keeps that endothelium healthy,

Starting point is 00:32:08 that can actually clue us into how we keep our, ourselves cardiometabolically healthy. Yeah. It was interesting also heavy metals have become an interesting phenomenon. And many of the, many heavy metals are exposed to lead, mercury and arsenic and so forth. There are sticks been linked to diabetes and other things,

Starting point is 00:32:24 but the lead story is so fascinating to me because from our perspective in functional medicine, it's relatively easy to diagnose and treat, but it's been mostly ignored. And if you look at like the American Journal of Cardiology, I mean, they put out major papers that show that, for example, if your lead level's over two, which is considered quote normal, which is about 40% of the population has a lead level over two which is a lot of people that the risk of having a heart attack or stroke or dying was far greater than if your cholesterol was abnormal wow and yet what doctor's checking your lead levels or checking your body burden of lead or chelating you as a treatment for heart disease.

Starting point is 00:33:05 And yet, I think it was called the TAC trial, which was a $30 million randomized control trial of chelation therapy using EDTA, which chelates lead, actually was effective in heart disease. And yet, it doesn't matter what the research shows, because we don't have research evidence-based medicine. We have reimbursement-based medicine. We get paid for doing angioplasty, it's not chelation. So that's what keeps getting done, even though the data is there, which is kind of amazing. This is an NIH government study showing that it worked. And I was like, okay, well, this is very slow to pick up.

Starting point is 00:33:40 But we see this. I think the take home here is if you have heart disease, don't just assume it's high blood pressure, smoking, cholesterol, diabetes. It could be a lot of other factors. It could be your gut microbiome. It could be nutritional deficiencies. It could be environmental toxins along with lack of sleep and stress and so forth. And Mark, you know my passion about sleep. I would put a sleep study very high on the radar for anybody who's got cardiometabolic imbalances because we know that two-thirds of people who are cardiometabolically unhealthy actually have sleep apnea. And our perception of how sleep deprived we are doesn't always match the reality of what we find when we screen people.

Starting point is 00:34:20 I had this guy. I remember him. He was a lawyer. Came to Kenya Ranch years ago. 50-plus pounds overweight. I had this guy, I remember him, he was a lawyer, came to Kenya Ranch years ago, 50 plus pounds overweight, desperate to get healthy, lose weight, trying to exercise, eat better, doing everything, nothing was working. So I'm like, tell me about your life.

Starting point is 00:34:34 He says, well, I'm a lawyer. I work really hard, a lot of hours. And I work at a stand-up desk. I'm like, oh, that's great. I said, why are you working at a stand-up desk? This was like, you know, before people were working at a stand-up desk. He said, well, if I sit down, I fall asleep. And I'm like, oh, that's great. I said, why are you working at a stand-up business? This was like, you know, before people were working at a stand-up business. He said, well, if I sit down, I fall asleep.

Starting point is 00:34:48 And I'm like, oh, no. You know, you probably have sleep apnea. And we did a sleep study, and he had sleep apnea for sure. And we got him on a CPAP machine. He lost 50 pounds and reversed his prediabetes, his cholesterol, obviously his weight, blood pressure. And most people don't realize that it's a bidirectional thing. So if you're overweight, it can cause sleep apnea. But if you have sleep apnea, it can cause you to gain weight.

Starting point is 00:35:16 And it's very hard to lose weight. And he was able to lose 50 pounds just by getting on a sleep program with a sleep machine that helped him sleep. I was like, wow, this is interesting. Had many people like that. You know, honestly, Cindy, I don't know about you, but I've learned way more from my patients than I ever learned in medical school. Absolutely. And the challenge in being a doctor is you get trained in this paradigm

Starting point is 00:35:37 and it's taught to you as if this is a monolithic truth. Like this is a table and that's all it is and like there's no questioning that this is a table right but the truth is um we we are just learning so much about the body and and all of our old ideas are sort of breaking apart but but um unfortunately people really aren't accessing them and it's it's just breaks my heart to see how slow medicine is to adopt the emerging science that we're talking about, whether it's around checking for lead or insulin resistance. I mean, insulin resistance is not even like a controversial thing. It's not like heavy metals or the microbiome, which seems weird.

Starting point is 00:36:16 I mean, like insulin resistance is a well-described known phenomenon. It's just doctors clinically are kind of clueless because the treatments are going to be primarily lifestyle interventions. There's no drug. Oh, your cholesterol is how I give you statin. You're insulin resistant. What do I do? Oh, I'll give you metformin. But that's not the answer.

Starting point is 00:36:33 Or even think of the terminology of borderline blood sugar. Oh, yeah. I hate that. Yeah, I do too. Oh, my God. That reminds me of this story. This patient comes in and says, blood sugar is like 120, right? One high, 118, like8 like high 126 is diabetes like so

Starting point is 00:36:48 have you seen your doctor about your blood sugar because it's kind of high and he's like well yeah i'm like oh great what did your doctor say he's well he said we're gonna watch it i said watch for what he said well watch it until it gets to be in the diabetic range, and then he's going to give me medication. And I'm like, ah, no. You know, it's like, it's so terrible. So tell us about a patient of yours, Cindy, that you had, a woman, you know, a postmenopausal woman, who really struggled and you helped with this kind of a functional medicine approach. Yeah, this was really interesting because this drove the point home

Starting point is 00:37:23 that you can't rely on body mass index or weight to predict somebody's risk. Now, she had a strong family history of heart disease, but she came in and I did her cholesterol profile, the advanced one that we talked about, and I was blown away because she was not overweight. She did not have high blood pressure. Her triglycerides were 600. That is through the roof. Normal is like less than 70. Over 100, I start to worry. Yeah. She had a lot of the small, dense LDL particles. I'm like,

Starting point is 00:37:57 this doesn't fit with the person in front of me. But when you measured her waist-hip ratio, it was elevated. So she wasn't overweight, but she had just a little bit extra here. Belly fat. Belly fat. We actually did a body composition on her and confirmed that she had some visceral adipose tissue. Okay, wait, wait. What's a body composition? That sounds interesting. So it's a DEXA scan. It's the same kind of technology you use to do a bone density, but you can actually do

Starting point is 00:38:16 it for a body composition. And it tells you your muscle mass, your fat-free mass, and it tells you how much deep belly fat, whether you have fat under your skin or deep in the belly. Yeah. So basically, it looks at how much body fat, but where it is. Where. Right. And that's important because you had mentioned your patient with the cholesterol of 150 who was skinny. Yeah. But I bet if you did a DEXA on him, he had very little muscle mass, very little muscle mass. And those are the ones that can fly under the radar. So what was interesting for her is we did find some underlying issues. She turned out to have hajimotus thyroiditis, and she was hypothyroid. So that can affect cholesterol. So okay, let's fix the thyroid

Starting point is 00:38:54 first. She was vitamin D deficient, which can affect cholesterol. So we're working all these other pieces. And the biggest thing for her, interestingly enough, is she really got engaged in fitness. So she had a poor fitness level as we measured it with something called a VO2 max, maximum oxygen carrying capacity. And she got on an exercise program and she came back and her cholesterol was much better. Her fitness was much better. She improved her muscle mass. She still had some elevated inflammation. Her CRP was high. So it's yet another incidence where, okay, she's got some bloating, she's

Starting point is 00:39:38 got some digestive issues. So we then did a breath test and she ended up having small intestinal bacterial overgrowth. So we addressed the small intestinal bacterial overgrowth and her inflammatory markers got better. Fast forward 10 years, she's now got great cholesterol. She has maintained her high level of fitness. She's become passionate about exercise and she is cardiometabolically healthy. Yeah. But what's interesting about her story, Cindy, was that you did a lot of the obvious things, but you also kind of tweaked a lot of things that played a role

Starting point is 00:40:09 that aren't typically thought of. She was gluten sensitive. So you got her off gluten because that can cause inflammation. I forgot about that part too, yes. She was a little bit low thyroid. Yes. And that can affect your cholesterol. Yes. Definitely increase the risk of heart disease for women. And a lot of times, the way we look at thyroid is kind of screwed up. We don't actually look at the full thyroid panel. We undertreat people who are borderline, you know? Like, I mean, when you think about what's normal, like the normal ranges are from 2 to 92, right? Basically. I mean, kids' ranges are a little different. But let's say, you know, you're a teenager until you're 100. That's the same

Starting point is 00:40:43 reference range. And it doesn't tell you what's optimal it tells you what's normal like if you were a martian and you landed in america you'd go oh it's normal to be overweight because 75 percent of people are overweight so that's normal it's abnormal to be thin in this country that doesn't mean it's optimal right and so with thyroid the same thing thing. So you probably tweaked that. And then you also helped with her vitamin D deficiency, which is an interesting factor because vitamin D plays a role in inflammation, plays a role in metabolism and insulin resistance and your thyroid function and everything. So you kind of have to think about functional medicine.

Starting point is 00:41:25 It's almost like taking your car for a 100,000 mile, you know, 100 point checkup. So you're checking, you're just kind of tuning things up. So maybe it's not broken, but just like a little off. And in and of itself, it may not be the thing, but you add all these things together and you tweak everything. And then people can enter a life of energy and vitality and in ways that they just typically would not do by just okay you have a

Starting point is 00:41:49 heart disease here's a statin I'll see you later or try to eat better and exercise more good luck with that what does that mean eat better well I don't know watch watch your glucose and come in next year yeah right and and so you also look at other things with heart disease that we typically don't look at i guess we also look at the particle number we look at the crp but we look at um other things that mark inflammation like lp pla and we look at uh we look at we look at myeloperoxidase yeah myeloperoxidase which is a measure of oxidative stress or oxidized ldl we look at uh whether there's good cholesterol absorption or increased absorption or production

Starting point is 00:42:28 of the liver. So are you an absorber or producer of cholesterol? We can look at particles of HDL and whether classes are good. We can look at so many things. We mentioned body composition testing. We can look at metabolic health through stress testing and cardiovascular fitness like VO2 maxes and heart rate variability. So there's so much that we do.

Starting point is 00:42:48 It's a 360 sleep studies. So when we think about heart disease, we think way bigger than just cholesterol, high blood pressure, smoking, or diabetes. It's like a very big container. And when we do that, the interventions are usually sort of driven through lifestyle and diet. So I have a question for you. You know, when we started at Kenya Ranch, we were still back in the kind of food pyramid-y, low-fat era, right? This was the food pyramid-y, 6 to 11 servings of bread, rice, cereal, and pasta.

Starting point is 00:43:18 Fat was at the top along with sugar. You know, where are we coming? And what do you think we should be doing now? Because a lot of the thinking before was you should be on extremely low fat diets for heart disease, like Carlo Esselstyn at Cleveland Clinic. He's recommending not even any avocados, no nuts. I mean, this stuff that's really been shown to be heart healthy. So what's your take on that? Yeah. So it's interesting, Mark. I think you've done a tremendous job of just raising the awareness across the world about the importance of nutrition as one of the most important things we can do for our health because it talks to our

Starting point is 00:43:55 cells. It talks to our DNA. It's really information. And fat also provides information. So if we come back to that artery elasticity, we know that certain kinds of fats can actually help us feel satisfied and full, but they have benefits with artery elasticity. You mentioned avocados. It was a study a few years ago that found an avocado a day, this high fat food, lowered LDL cholesterol 20 points. So it's this paradox, right? Don't forget the apple a day, it's the avocado a day. It's the avocado a day, which I like because I love avocados. Nuts and seeds, they have benefits on endothelial function, on artery elasticity. Extra virgin olive oil, rich in polyphenols,

Starting point is 00:44:35 is an antioxidant, anti-inflammatory, benefits on the artery elasticity. So I think there's a range of fats that people can really thrive with. But I do believe for artery elasticity and artery health in particular, emphasize the ones from fish, nuts, seeds, avocado, extra virgin olive oil is the primary source of fats. And the other thing about most traditional diets throughout the world through eons, they all share in common a foundation of colorful fruits and vegetables and plant-based foods. So I'm less concerned, to be perfectly honest, about the percentage of those macronutrients, the 10%, 20%, 30%, 40%, and more concerned about the quality. I think that really makes the biggest difference.

Starting point is 00:45:21 I mean, it was interesting in the Virta study, which is a company that was developed to treat diabetes and reverse diabetes virtually using a ketogenic diet, which is 70% fat, including saturated fats, that not only do they reverse diabetes in 60%, get 90 plus percent off insulin, a lot of diabetes drugs, and 100% off the main diabetes drug, not only do they have an average of 12% weight loss, which is staggering compared to most studies, which five is like a heroic weight loss for people. But when they looked at all their cardiometabolic numbers, all these like lipid numbers, cholesterol, everything got better and they were eating 70% fat. Wow. Now that's not to say that if you're not diabetic, if you're a thin, healthy athlete, that if you do the same thing,

Starting point is 00:46:04 you might get into trouble if you do that. So it's really about personalization. It is. And it's interesting that you say that, Mark, because there's this concept of metabolic flexibility. And I love that idea. Because if you think way back when we were gatherer hunters, we had to be able to pivot to whatever food sources were available to us. Some days we might just, well, not me personally, but might just be nuts and seeds and fruits or whatever we could forage. And then we might get some game and gorge on it and then fast for a bit. So this idea that our metabolism, when it's healthy, can flex back and forth and handle whatever macronutrient load it's given, we've lost

Starting point is 00:46:45 that metabolic flexibility. And in essence, insulin resistance is a loss of metabolic flexibility. The only reason I exercise so much and eat good is because sometimes I want to do bad things. And I feel like I could get away with it. Maybe not. But, you know, occasional ice cream or, you know, like, but I, you know, it's like, I just, I think it's true, that whole idea of

Starting point is 00:47:07 being metabolically flexible and resilient is the key to health. Yeah. And if you look at the three things that have the best data for restoring metabolic flexibility, the ketogenic diet sorted down the path, it's really polyphenols, which is interesting. Those are those deeply pigmented foods like berries and pomegranate. Periods of fasting, we didn't really talk about that, but fasting may also play a role with cardio metabolic health. I just blanked on the other one. Polyphenols, fasting, and exercise.

Starting point is 00:47:38 Exercise. Yes. Yeah. You know, it's funny Cindy, we were talking earlier about the poly pill. Yes. And there was a great paper that was written looking at all the research on food and talked about the poly meal, which was essentially like wild salmon, berries, chocolate, red wine, and dark green leafy greens. Dark leafy greens? Pretty much sounds like what I eat.

Starting point is 00:48:03 I just don't have the wine that much. But this has been such a great conversation I think we have way more to talk about I'm looking forward to having you back on the house call at the doctor's pharmacy podcast if you've been listening to this podcast and it helped you and you learned something and you want to share with your friends with heart disease

Starting point is 00:48:19 or who may be at risk please do I think it's important people understand this story at the ultra wellness center here in Lenox, Massachusetts, we take patients from all over the world. We do virtual care. We've got a waiting list, so hopefully you can get in. But we're really working on how to help people even through virtual support for groups and so on.

Starting point is 00:48:36 So we're going to be able to help you. And I think you should for sure think about getting these other kinds of tests, if not here, then somewhere else. And of course, subscribe to here, then somewhere else. And of course, subscribe wherever you hear a podcast, leave a comment, and we'd love to hear how you've improved your numbers

Starting point is 00:48:51 through whatever you've done, because there's always something to learn. And hopefully we'll see you next week on The Doctors 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

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Starting point is 00:49:57 I hope you enjoyed this week's episode. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical

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The Dr. Hyman Show - Prevent And Reverse Heart Disease Using Functional Medicine with Dr. Cindy Geyer

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