The Dr. Hyman Show - The Truth Behind Statins: Helpful or Harmful? with Dr. Aseem Malhotra

Episode Date: March 9, 2022

This episode is brought to you by Rupa Health, ButcherBox, and Mitopure. Heart disease is still the number one killer in the world, yet most people don’t actually understand what markers put them most at risk. It’s so much more than just LDL cholesterol. Statins have become the panacea for anyone with LDL that’s just a little off, yet most people (and even many doctors) aren’t fully informed of the risks versus the benefits of this drug, let alone aware of other treatment options for heart disease. Today, I talk to Dr. Aseem Malhotra about the real data on statins, heart disease, metabolic syndrome, and so much more.  Dr. Aseem Malhotra is an NHS-trained consultant cardiologist and visiting Professor of Evidence-Based Medicine at the Bahiana School of Medicine and Public Health in Salvador, Brazil. He is a founding member of Action on Sugar. In 2015, he became the youngest member to be appointed to the board of trustees of UK health charity, The King's Fund. He is a pioneer of the lifestyle medicine movement in the UK and in 2018 was ranked by software company Onalytica as the number one doctor in the world influencing obesity thinking. Dr. Malhotra's first book The Pioppi Diet, co-authored with Donal O'Neill, was an international bestseller and his next book, The 21-Day Immunity Plan, was also a Sunday Times top 10 bestseller. His new book is A Statin-Free Life. This episode is brought to you by Rupa Health, ButcherBox, and Mitopure. Rupa Health is a place where Functional Medicine practitioners can access more than 2,000 specialty lab tests from over 20 labs. Check out a free, live demo with a Q&A or create an account here. For a limited time, new subscribers to ButcherBox will receive 2lbs of 100% grass-fed, grass-finished beef free in every box for the life of your subscription here.   Mitopure is the first and only clinically tested, pure form of a natural gut metabolite called urolithin A that clears damaged mitochondria away from our cells and supports the growth of new, healthy mitochondria. Get 10% off by using code DRHYMAN10 at checkout here. Here are more details from our interview (audio version / Apple Subscriber version):  Statin drugs and our overexaggerated fear of cholesterol’s role in heart disease (9:14  / 6:00) Are heart-attack and heart-disease death rates decreasing? (11:06 / 8:15) Statin benefits for people who have already had a heart attack (16:21 / 13:00)  Statin effectiveness for heart-attack and stroke prevention (20:29 / 17:04)  Why we’re typically looking at the wrong thing when we measure cholesterol (21:45 / 21:05) Targeting insulin resistance as a root cause of heart disease (32:39 / 27:33) Positive and negative effects of statins (36:15 / 33:04) Prediabetes, diabetes, metabolic syndrome, and heart health (45:37 / 40:08) Foods to avoid and eat for heart health (51:41 / 46:33) Exercise and stress reduction for heart health (56:35 / 51:32)  Get a copy of Dr. Malhotra’s book, A Statin-Free Life: A Revolutionary Life Plan for Tackling Heart Disease—Without The Use of Statins, here.

Coming up on this episode of The Doctor's Pharmacy. It's estimated potentially about 1 billion people around the world are prescribed statins. It's also one of the most lucrative drugs in the history of medicine. It's estimated, I think, last year, total revenues from sales of statins have reached a trillion US dollars. Hey everyone, it's Dr. Mark. I know a lot of you out there are practitioners like me helping patients heal using real food and functional medicine as your framework for getting to the root cause. What's critical to understanding what each individual person and body needs is testing,

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a place for conversations that matter. And if you are confused about cholesterol, well, listen up because you will not be by the end of this. And you might have your thinking completely overturned from what the traditional concepts are about cholesterol, statins, what we should be managing, and what the real causes of heart disease and how to prevent them. And we have none other than my good friend, my colleague, a co-revolutionary in transforming the food system and calling out the injustices that exist within our food system that cause obesity and chronic disease, Dr. Asim Malhotra from the United Kingdom. He is a National Health Service trained consultant in cardiology. So he's

a cardiologist. He's a visiting professor of evidence-based medicine in the, I don't know if I'm saying it right, Bahaina School of Medicine and Public Health in Salvador, Brazil. He's a founding member of Action on Sugar. And he also became in 2015, the youngest member to be appointed to the board of trustees for the UK health charity, the King's Fund, which I think is a very important fund. He's always in the media. He's always talking up. He's always telling the truth. And he's called out in many ways for his radical views, but he's testified in front of parliament

and is really doing so much to change thinking about health and wellness in the UK and across the world. He's written many articles in scientific literature, many of which have influenced me. He's become a good friend and colleague, and I am so glad to welcome you, Asim, to The Doctor's Pharmacy. Thank you, Mark. It's an absolute pleasure always to speak to you. Now, you've written many books, The Piappi Diet, One Day Immunity Plan. Your latest book is one I'm most excited about. It's called A Statin-Free Life, A Revolutionary Life Plan for Tackling Heart Disease Without the Use of Statins. And I have always had a love-hate relationship with statins because they are a drug which has some benefits, but what seemed to have happened is that there's been a wholesale

embracing of this class of medication as the panacea for preventing and treating heart disease. And your book challenges that thesis, one, that LDL cholesterol is the problem, which is primarily what the statins do is lower LDL. And two, the statins are not a free ride, that they come with a lot of inherent risks and side effects. And three, they're actually not that effective and that the data we have has been highly manipulated. And it reminds me of a quote from, I think, Mark Twain or maybe Roger Williams. He said, there's liars, there's damn liars, and there's statisticians. And I think, you know, the way that the data get squeezed and manipulated often give the impression of a profound benefit.

But you challenge that whole hypothesis and you challenge us to think differently about statins. So I think it's going to be a very controversial conversation. I'm really excited about it. And I hope to learn a lot because even though I've studied this for the last 30 years, I'm still fricking confused because there's so much data and you've just gone into it. And I'm so happy to have you Asim. Welcome, welcome, welcome. Thank you, Mark. No, absolutely. I think before we continue down this track and more detailed discussion, I think what people need to realize is that we are, I am, we are coming from a position about ethical, evidence-based medical practice

and about giving the right patient the right treatment at the right time with informed consent. So really the book is, premise of the book is really about informed consent. So really the book is premise of the book is really about informed consent. It's about helping and empowering members of the public, patients, even doctors to really have a better understanding of cholesterol and its role in heart disease, but also have an equal, if not more important understanding of the role of statins in preventing and managing heart disease. And I really lay it all out, you know, for the, for the reader based upon the totality of evidence. We all have our own biases and I've done my very best to ensure that I've looked at all the evidence and tried to break it down independently. And at the same time, Mark, also give people an alternative plan,

whether or not they choose to take a statin. And again, I would always argue that's the patient's choice ultimately. But also to not be ignoring something that you've pioneered magnificently over many, many years, the impact of lifestyle, which, as you know, is more impactful in many ways than medications and come without side effects. And, um, mostly lifestyle has a lot of side effects, uh, well-being, happiness, joy, good health, all the side effects are good. Better sleep, better sex, weight loss. That's what it's about, right? Because, you know, we were all going to die eventually,

but we want to have the best chance of having authentic happiness for as long as possible. And of course, our happiness is very much linked to our physical health as well. So this is really the heart of the book. detail, probably over a decade, looking at cholesterol, trying to understand the root cause of heart disease, and trying to shift the conversation and shift the balance towards overall improving individual patients' health, but also population health as well. And I think where we've gone wrong is we've grossly, first and foremost, grossly exaggerated the fear of cholesterol in this role of heart disease. We've then now, because of that fear, the focus has been that the primary way of preventing heart disease is to reduce cholesterol. And the most effective drugs

at doing that have been statins. So widely prescribed, Mark, it's estimated potentially about 1 billion people around the world are prescribed statins. It's also one of the most lucrative drugs in the history of medicine. It's estimated, I think, last year, total revenues from sales of statins have reached a trillion US dollars. So there's a lot of money involved as well. And I think that is important for people to be aware because I think introduces a huge bias into the conversation. A lot of vested interests depend on fear of cholesterol lowering and statins and other cholesterol lowering drugs. So it's like, well, actually, let's just break it down so that people are better informed. And then, you know, one of the things I've also advocated for is something called shared

decision-making, which is an approach where you have a more equal partnership when it comes to conversations with patients about any kind of treatment or investigation that they're going to go through, but accept that it's really important that we take into consideration patients' individual preferences and values. So if you look at the evidence-based medicine triad, which is geared towards improving patient outcomes, there are three big components. So you'll use your best available evidence, your individual clinical expertise, and last but not least, patient preferences and values. And what I teach my medical students is if you are adhering to those principles, then you are going to increase your chances of improving your patient's health and well-being. And that's really what it's about. So that's really the

background to the book. That's great. I think that's a very important framework. And what I would like to do is zoom out for a minute and have you answer a couple of key questions. Cause you know, I hear conflicting versions of the data from cardiologists and it seems, yes, number one killer in the world is still heart disease. However, I've heard cardiologists say we're, we're winning the war because death rates are going down. We're better at actually treating the disease. We're better at preventing the disease. Statins have played a big role in that. And we shouldn't ignore that fact. But you suggest that maybe that's not true. And in fact, maybe, you know, that the death rates aren't going down. Maybe heart attack rates aren't going down. So can you kind of unpack

the data for us? And what is the truth about, one, this massive drive to put everybody on a statin if your cholesterol is a little high? Yeah, absolutely. And the fact that maybe it isn't doing all that it's cracked up to do. So talk about that. Absolutely, Mark. So yeah, that's a very good point, right? So let's try and break all of that down.

So death rates from heart disease started to increase in the 1920s. You know, look at data in the US. Let's just look at US data, which pretty much parallels most of Western Europe as well. And it peaked around 1970. And then since 1970,

the death rates have started to drop. But, you know, something I've published on the BMJ before is to, if you break that down to try and see what are the different factors that reduced heart disease the biggest impact actually was reduction in smoking prevalence probably responsible about 50 percent reduction in death rates other factors emergency care emergency treatment of heart attacks so we had thrombolysis these drugs called thrombolytics that help people we had

emergency stenting which in the acute phase in a heart attack certainly is life-saving not in the stable phase that's a different discussion but certainly in the acute phase the development of coronary care units so what a lot of people used to die from heart disease mark because they would suffer even once they're in hospital they would have a cardiac arrest which is more likely to happen within 24, 48 hours of having a heart attack. And we then developed chronic cadence where we could monitor patients and then defibrillate them. They're better at rescuing them from what happens once you get a heart attack. Absolutely.

And in fact, they are life-saving. If you have a cardiac arrest and it's witnessed, then you're in hospital and it's because of a heart attack. Nine times out of 10, you'll be saved from a defibrillator and then you're fine. And your prognosis is the same as somebody that didn't have a cardiac arrest. So all these things are there. Maybe to some degree, the reduction of trans fats in the food supply as well, that also had a role. But when you look at statins, and this is something that's actually recently been analysed, they looked at Western European countries over 12 years, since 2000, 2012, right, to see had an increase in statin prescription for different risk groups, low risk and high risk. Did that correlate with any

reduction in cardiovascular death, death, risk and heart disease? And the answer was no. The question is, well, how can that be explained? So again, let's break the data down. If you look at the average increase in life expectancy from taking statins from industry-sponsored data. We take that with a pinch of salt because industry-sponsored studies, which are most of the statin studies, in general are designed and the results are geared to exaggerate the benefits and minimize the harms. But if we take that at face value, even that industry-sponsored…

I want you to stop there for a minute because it's such an important point. Yeah. Most of the data we have on statins is from drug company funded studies. Yeah. In which they actually often are contracting with research organizations to do the research. They're hiring essentially hit men names to put their name on the study. They design the study, they write up the study, and then they get a bunch of cardiologists to sign off on it. Is that fair to say? Yeah, Mark, absolutely. You're spot on. In fact, just to take a step back for a second, if you look at the issues around health misinformation, you know, we have something

called the health misinformation mess, a quote I from john i need is professor of medicine at stanford yes um and there's something called the seven sins that contribute to misinformed doctors and misinformed unwittingly harmed patients they're rooted in bias funding of research right so research that's funded because it's likely to be profitable not beneficial for patients bias reporting in medical journals, biased reporting in the media, biased patient pamphlets, commercial conflicts of interest, defensive medicine, and an inability of doctors to correctly communicate health statistics to patients and also doctors to not understand health statistics properly. That's something that isn't taught very well at medical school and it's certainly not something we're encouraged to do.

So I've been involved with the BMJ and the medical colleges in the UK in 2015 to try and help revolutionize medical practice through medical education and postgraduate teaching.

But it takes time. I mean, I was reading somewhere that when you try and revolutionize or change an approach to something that's been embedded for a very long time within medical practice, apparently it takes 17 years, Mark, before that change happens. So, we've got to keep fighting

and campaigning for it. But you're right. The issue with statins is not dissimilar to many other drugs. Given that information, given those biases, even if you take all those biases in consideration, best-case scenario, there was an analysis done to look at randomized controlled trials of statins in people with heart disease forget about prevention for a second statins benefits seem to be there much stronger in people who've already had a heart attack or people have been diagnosed with severe blockages in their arteries okay if you look at the if the from those people from the trials who took statins religiously every day for about five years because the trials only tend to last

about five years before they're approved and before it changes practice, the average or median increase in life expectancy is, over a five-year period, 4.2 days. So if we accept that slight increase in life expectancy over a five-year period, and then you add in the real world mark, within a few years of statin prescription, even people at high risk of heart disease, at least 50% of those patients stop taking statins within two to three years. You can understand from a scientific perspective,

from a data perspective, forget about any fraud or any conspiracy theories, just from the data that's already there, you can explain why statins may have not had any impact on reducing uh death rates from heart disease in the population now when you look at individuals um and this is what doesn't often take place in the conversation between doctors and cardiologists and patients and you know to be to be fair and honest on this i mean i think most doctors actually don't even know this information

that's another reason i wrote the book is to educate doctors so they can have better discussions with their patients. If you've had a heart attack, and this is by the way, what I do all the time in my practice. So all my patient letters that go back to general practitioners, all the patients I see, I always put this in there, you know, in the discussion. If you've had a heart attack over a five-year period for an individual, the benefit of a statin taken religiously over five years is it prevents one in 39 of those patients from having a further heart attack and one in 83 in terms of delaying their death or saving their life. Right.

Now, given that already have had a heart attack or are at very high risk. Absolutely. We're not talking. And by the way, for everybody listening, 75% of the prescriptions for statins are not for people who have had heart disease or, or very high risk it's for primary prevention. And the data on that is even worse. And I want you to explain that after you kind of unpack the fact that gee, only one in 83 people have a death prevented. It means, it means 83 people have to take this drug for five years with all the risks and side effects for one death to be prevented.

Yeah. And Matt, so I had a caveat on that. What's interesting is these are also most likely the patients that tolerated the statin and didn't get side effects because those people are somehow weeded out of the trials. Often we have something called the pre-randomization running period before a randomized control trial starts, where patients who don't tolerate the drug or non-compliant, they use this word non-compliant, okay, which doesn't make sense to me because if you're enrolling in a trial and you volunteered, you're likely to be somebody who's enthusiastic about taking a drug, right? So that doesn't make sense to me, but very likely the people with side effects are weeded out within

the first few weeks of a trial. And then you then report on the results of the people who tolerated the drug. Okay. So this is still a bias. So I talk to my patients and say, well, it's more likely those one in 83 and one in 39 figures are people that tolerated the drug and were able to take it for five years. If you add in people who get genuine side effects, and sometimes we don't know whether the side effects they experience are statin or not, and I'll explain what I do with my patients to kind of weed that out.

It's highly likely that that benefit is much smaller, if not even potentially non-existent. We don't really know, but there's a chance that it's non-existent. And that's uncertainties. And we have to have those discussions with patients. i think doctors aren't necessarily very good at saying listen there's a lot of things we don't know but let's just tell you tell you what we do know and of course the potential biases and uncertainties and mark in my experience with all the patients i've

had these discussions with even about talking about industry bias and all that kind of stuff patients appreciate that they want honesty from their doctors. Anyway, so that's on the secondary prevention, the high risk. If you look at primary prevention, and you're absolutely right, Mark, most of the people prescribed statins around the world are not high risk. These are people who have got maybe a slightly high cholesterol or even have a risk profile, more importantly, that suggests they may have, say, a 10% to 20% risk of having a heart attack or stroke in the next 10 years. And there are risk calculators. People can go online and look at those risk calculators. If you have a less than 20% risk, if you're not high risk from having a heart attack or stroke

in the next 10 years, then the statin data suggests approximately, convicting data, a 1% benefit. So 1 in 100 in preventing a non-fatal heart attack or stroke over five years, but this is crucial. No mortality benefit. You're not going to live one day longer. And when you look at data and studies looking at when we presented this sort of information to patients in this way, and this is without talking about potential side effects, not even gone there yet. Most of those patients, Mark, would choose not to take the pill. Can you think? It's extraordinary. So if we are actually adhering to the principles of ethical, evidence-based medical practice

and informed consent, in my view, most people who are prescribed statins around the world would choose probably not to take the pill. Now, that's not to say that cholesterol isn't a problem. The question is, how is it a problem and why is it a problem? And it's quite different than what we think. And the overarching narrative has been that LDL cholesterol is the cause of heart disease. And it's convenient because that is what statins do. But it reminds me of that joke of this guy who lost his keys on the street, and he's looking under this lamppost, and his friend comes by and says, hey, what are you doing?

He says, I'm just looking for my keys. He says, where did you drop them? Well, I dropped them down the street. He says, why are you looking over here? He says, well, the light's better here. So we have a drug that can treat LDL, but it actually doesn't deal with the real root causes. And I just want to take a second for people to unpack why we're looking at the wrong thing when we measure cholesterol today, for the most part, most people get a total cholesterol, HDL, LDL triglycerides, but it turns out that LDL isn't even that good of a predictor of heart disease. Absolutely. Yeah. Really good point, Mark. So yeah, absolutely. Let me just finish this thought and the Jupiter trial, which is one of the largest trials looking at statins and heart disease found that if the statin lowered the

LDL cholesterol, but not the CRP, In other words, if the C-reactive protein or the inflammation marker was high and you lowered LDL, it didn't really have an impact, only if the inflammation was lowered. And so we now know that the underlying risks for heart disease are inflammation and insulin resistance, which drive something that we call atherogenic dyslipidemia or a kind of cholesterol profile that makes you prone to heart disease. Hey everyone, it's Dr. Mark. I always say I want it to be 120, but I really only want to do that as long as I'm feeling great and still able to do all the things I love. Aging well requires some mindfulness and intention, but that doesn't mean it has to be hard.

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the doctor's pharmacy. So tell us about a new way we need to be thinking about cholesterol rather than just a simplified, oversimplified dogma of LDL statin, LDL statin, LDL statin, which you hear all day long. What is, what is the things we should be looking at and what, why, and what are those things and what are, what are, what are the causes of abnormalities in the real biomarkers of cardiovascular disease? Sure. Great points you make there, Mark. So taking a step back for a second, just so people kind of understand where we've gone

wrong with the science on cholesterol or why certainly it's outdated. And it's important for people to realize, I think a lot of people have this misconception that medicine is an exact science. And if something is truthful at one time, it must be absolute truth and it can't be challenged. But the reality is 50%. Well, yeah, exactly. But you and I know, I mean, the founder, if you like, one of the founding fathers of the evidence-based medicine movement, David Sackett, said 50% of what you learn in medical school will turn out to be either outdated or dead wrong within five years of your graduation. The trouble is nobody can tell you which half,

so you have to learn to learn on your own. So I bring that concept into how I've started questioning that dogma. And I don't think this was a conspiracy theory or malicious. I think vested interests have taken advantage of what is now outdated science but traditionally when people try to investigate the cause of heart disease up until the you know the 50s 60s 70s um we knew that we found and this is still true is that people with genetically very high levels of ldl cholesterol okay so this would be people uh who not everybody but usually at least have a um have an LDL of more than 4.9 millimoles, which I think in US units is translated to 139 milligrams per deciliter mark, right?

So those people who had at least an LDL of that level, most of those people had the genetic condition which affects one in 250 people. They had a very strong association with the development of heart disease. At the same time, people who had genetically low cholesterol and total cholesterol, certainly we're talking about less than 3.8 millimoles per liter, which I think would be, I can't remember the cutoff, but I think it's probably less than 150, if I'm not wrong, total cholesterol. Those people, one milligram per deciliter, would have less heart disease, although they won't live any longer. But most of the people in the middle, when you looked at that

data from Framingham, which was one of the original big studies that followed up 5,000 people in Framingham, Massachusetts, starting in the late 40s, over several decades, to try and find links and associations with various markers or risk factors in heart disease. In that, they found that there wasn't really a strong association if you didn't have cholesterol at the extreme ends. The next question then is, does lowering cholesterol, if we move fast forward, does lowering LDL cholesterol mark make any significant impact on reducing heart disease? Is there a correlation? I published a systematic review in 2020 in bmj evidence-based medicine we investigated this two other i was co-author with two other cardiologists and we found there's this mantra which comes out from cardiology

societies that there's something with every one you know millimole lowering of ldl you have a 20 percent risk reduction in heart attack stroke stroke, whatever cardiovascular events. It was simply not true. It was not true. We falsified it. We said there was no correlation. So there is no consistent, if I'm being skeptical of my own research, I can say there is no consistent evidence to show reducing LDL reduces your risk of heart attack or stroke or cause mortality. Then you add in the other issue is something other research helps involved in, is if you're over 60, we did a systematic view published in BMJ Open several years ago as a co-author. If you're over 60, there is no association at all between LDL cholesterol development hypotheses and an inverse association with LDL.

Which means that when you're older, if your cholesterol is higher, you live longer. Absolutely. Statistically live longer. Absolutely. Statistically live longer. But let me become founded by other factors. So go ahead. Of course. But one of the explanations is cholesterol has a crucial role in the immune system. And there's a very interesting, so that may be why they're protected.

Okay. People are older with high cholesterol. And actually, if you go look at the 19th century, you go back when our average life expectancy, for example, is about 40 or 50 years. People with FH, genetically high cholesterol, Mark, lived longer than average. And the reason for that is likely because, well, infectious diseases were the biggest cause of death then. So this is really interesting.

It's just something to think about. On the other side of it, the most data published in bmj um and this was last year a danish study looking 100 000 people following them over the 10 years different age groups they found when you look at all causes of death the optimal ldr cholesterol was 3.6 millimoles right which is way higher how would you translate that to american units because yeah it would probably be if if we say that it would probably be in the, in between 200, 250, something like that. It was much higher than what people are recommended to lower LDL.

Sorry, no LDL. It was something like, I think a hundred, 120, something like that. Okay. Okay. Well, people should clarify that. I can't remember the conversion at the moment, but that paper's there and it's translated. So Danish study, maybe we can pull it up later. And it looked at the optimal for all-cause mortality.

What they found is if your LDL was very low, okay, then there was an increased risk of death from cancer. So there is this association with very low levels of cholesterol and cancer, and it could be, again, an immune system mechanism. So it just encourages us to think a little bit differently. We shouldn't be obsessing, as our primary focus in managing heart disease, at the very least, about lowering cholesterol, the lower the better. Now, how do you reconcile this information, Mark, with statins benefits? And you've alluded to this already, is statins, most people aren't aware of this,

is statins have an independent effect. So they may lower LDL, but they also have a slight anti-inflammatory and anti-clotting mechanism. And heart disease is a chronic inflammatory disease exacerbated by something called insulin resistance, which we'll talk about, but also linked to abnormal clotting. And the reason I bring up the clotting issue is when you look, and published on this as well and it's in the book if you look at fh patients so about 70 percent um of fh patients who are female familial hyperlipidemia familial hyperlipidemia genetically very high condition where your cholesterol is like 300 400 really high they will not 70 of those will not develop premature heart disease without treatment about 50 of men right will not so question is, are we able to differentiate in the FH patients, the ones that will develop heart disease and the ones that don't? Now, the first thing that's really interesting is we found there's

no difference in their LDL between the ones that develop heart disease and the ones that don't, which makes you think, well, hold on, then LDL probably isn't even the issue with them. What is an issue, and there is some research on this, is that the people that tend to develop heart disease have some abnormal clotting factors, not your routinely measured ones. There's all sorts of different things that people can check.

But that seems to be from lab studies and from other studies that suggest that FH people with heart disease have clotting abnormalities. But this is the good news. When you look at the risk,

so what do I do with my FH patients? Well, of course, statins may have a role from anti-inflammatory processes, so you could still prescribe it to them. But we don't have this data about 1 in 39, 1 in 83. There's never been a randomized controlled trial to break down the absolute benefits. So we're presuming there's some benefit. But the people who have low insulin levels and low waist circumference had the lowest risk of developing heart disease, almost only slightly higher than the average person, which is really interesting. The focus on FH patients should be lifestyle that targets insulin resistance, which is basically

your body's getting resistant to the hormone insulin. You've spoken about this, Marco, but because of lifestyle factors, high glycemic index carbohydrates, ultra-processed foods, not getting enough sleep, being overstressed, being inactive, all these things contribute to insulin resistance. So that should be the lifestyle approach. And actually, most of heart disease is rooted, the biggest risk factor, if you like, is insulin resistance. And you asked me the question about what you look in the cholesterol profile, which is a marker of insulin resistance, and that's having high triglycerides and low HDL cholesterol. And the rule of thumb is you want your triglycerides to be lower than your HDL in general, to have your cholesterol levels optimized.

And the way you do that, lifestyle. Yeah. I think it's so important what you bring up, because when you look at the data, whoever looked at, and I wrote an article, which was fat, what I got right, what I got wrong, where I sort of unpacked this a little bit. And I wrote about this in my book, eat fat, get thin, where essentially the, the, um, the biomarkers that are most relevant for predicting heart disease is not just LDL cholesterol. In fact, it's not a very good predictor of when you look at it with the best predictors is the triglyceride to HDL ratio, which you just talked about. And that, and that should be one or less, right. And that goes up when you eat sugar and starch. So triglycerides go up, HDL goes down. Also you get small dense particles. You get small HDL dysfunctional HDL. So even if your HDL looks okay, it might be dysfunctional. And then you

also get dysfunctional LDL, which is the small dense LDL particles. So it's not just that it's just not the total number. When you, when you eat, get a regular cholesterol test, you're just measuring the weight, literally milligrams per deciliter, you know, per 10th of a liter, how many milligrams of cholesterol? It's just the weight when you, when you don't know anything about the quality of that cholesterol. So when you look at particle size and particle number through innovative testing called NMR or CardioIQ, which is developed in America from Quest or LabCorp, those actually help you figure out whether you've got this phenomenon we call atherogenic dyslipidemia, which is far more predictive. And what causes that is not fat, it starts in sugar. In fact, fat can often be the cure for that. It actually raises the HDL.

It can actually lower the triglycerides. In fact, triglycerides are fat made from sugar in your liver, right? Absolutely. So those are the real predictors. So insulin resistance then drives inflammation and inflammation drives heart disease. So when you look at the data on this in America, and I am sure you're catching up in the UK, but 88% of Americans are metabolically unhealthy, meaning they have high blood pressure, high cholesterol, or a high blood sugar. And all of those are caused by insulin

resistance or prediabetes, this whole spectrum of metabolic poor health. And that's really what's driving heart disease. And so statins have become the go-to therapy, but it misses all these other factors. And it's surprising to me how many, you know, cardiologists and how many doctors just don't even look at this data, which is, which I don't, I could not treat a patient if I don't know what their numbers are. Cause I could see someone with a cholesterol 300 and HDL of a hundred triglycerides of 40. And, and they might have very few particles and no small particles and they're fine. Otherwise I'll see someone with a cholesterol of like 150, but their cholesterol, their triglycerides are 300 and their HL is 30. And I'm like terrified for

that person, right? Even though their cholesterol is one 50, which sounds amazing. Perfect. But it's not. So I think, you know, the, the thing about statins to sort of jump back to the statins is that they have what we call pleiotropic effects. In other words, they have multiple actions. One is lowering cholesterol or LDL. Two is lowering inflammation through its effect on nitric oxide synthase, which is a, you know, nitric oxide is what Biagra does. It makes nitric oxide, but it actually also is a great vasodilator, anti-inflammatory, antioxidant. So there's a lot of secondary benefits.

It may affect clotting, but it also has some negative effects, which I think don't get talked about enough. And I'll just, I sort of want to unpack that with you a little bit. The major one is, is a muscle damage. And I love to hear your perspective on this because I read a study once that was a biopsy study where they looked at muscle biopsies. There were two that kind of really terrified me about taking statins. And I want to hear your perspective because I do think statins have a role, but I just think they're over-prescribed. Well, the first study was looking at muscle biopsies and actually found that anybody taking a statin had mitochondrial injury. In other words, the energy factories that produce the fuel that your body runs on actually get damaged and you

get a damaged mitochondria, which you can measure on a muscle biopsy and mitochondria are the key to longevity and healthy aging and metabolic health. So on one hand, you're doing something to help, but you're also maybe harming. Two, it seems to cause insulin resistance, which is kind of counterintuitive because insulin resistance is the thing that causes heart disease. So you've got that. And the third thing is that this is, I think, related to the muscle biopsy study, was it was also a terrifying study where they took two overweight groups of people and they put them on an intensive exercise workout regimen. One group got statin, like 20 milligrams of Zocor, I think.

Another group, nothing. And they actually measured all their fitness markers, their VO2 max, their metabolism, their muscle, all of it. And at the end of 12 weeks, the group that took the statins, despite the exercise program, was worse off than before the exercise program, because they took the statin and the other actually got much more physically fit. So can you unpack that

for us and take us down the road of, of, you know, the pros and cons and, and then take us down the road of, of who should take this? Cause I don't think it's a drug that we should ban or get rid of, but I do think it's overused and we need to sort of focus on one, who should take it and who should benefit, how we measure the benefits and risks. And then, and then we'll talk about the next part of the conversation will be, how do we unpack what are the real root causes of heart disease? What should we really be looking at and how do we really prevent it and

treat it? No, absolutely, Mark. So all really good questions. And the kind of questions that patients ask as well, that's most important. So in terms of the side effects issue, I mean, that's been very controversial over many years. Statins do affect, they can cause many side effects, but the most common that we see in clinical practice is one of muscle aches and fatigue. Other side effects include people with stomach upset, brain fog, erectile dysfunction,

you know, they can affect pretty much every organ system. So the way I approach it is if a patient comes in with a, an unexplained, um, symptom, um, the first thing, I mean, that's been my default now anyway, with all patients, I think, uh, you know, you need to, this is a, so you have to think my mindset is this is a side effect until proven otherwise. Okay. So you look at the medication because because we have a medicated society. And what you often find, what I do is, as a trial and error, from a trial and error perspective, I will give patients information about the potential benefit of the statin and say, listen,

I think most of these side effects generally are reversible very quickly. So you stop the statin. You have an informed discussion. Say, listen, why don't we just stop? You know how you feel. And I ask the patient if they're complaining of a side effect, and often they already have this in the background anyways. Is it interfering with the quality of your life?

And that's a crucial thing. If it's like an occasional niggle here or there, nothing much of an issue, then you still have the informed discussion, but there isn't necessarily an urgent requirement to stop the stat unless of course the patient's now fully informed and they're like doc you know what given that information i don't really i want to take this drug fine okay yeah we've had an informed discussion but if they've got say fatigue or memory disturbance or something else and by the way i do this i've been doing this for a very long time with many many patients now so i've got a lot of, certainly a lot of anecdotal evidence in my practice of this,

that usually the patient's side effects, if it's a statin, disappears within a few days to a couple of weeks. And people are amazed about how they feel their energy's back, all that kind of stuff. And then the question is, well, do they want to go back on the statin or a different statin? And then you can try a lower dose, say they're high risk, and they're kind of like, well, you're actually less likely to get side effects at lower dose. So say, for example, you've got 80 milligrams of atorvastatin, which is the highest dose you give people who have heart disease.

You can then say, well, so let's try you on a lower dose. And I explained that there's a slight anti-inflammatory mechanism, for example. Let's try it on a lower dose, see how you tolerate that. Be reassured, most of these side effects are reversible. If this comes back again, we just stop it, for example. So that's my approach to it. In terms of the prevalence, Mark, it's very interesting. I mean, you know, data varies from, say, anything from, you know,

if you trust the industry-sponsored trials, they say like 1% of people may get muscle aches or fatigue. And then, you know, in my practice, I don't know. I mean, it goes from 20%, 30%, whatever. That's like one in five people taking the drug have pain muscles and they stop it, right? 75% don't take it after a year. Well, that's another interesting thing. In the real world, when you look at studies and surveys, in one study in the US, a statin usage survey, 75% of people stopped taking the pill within a year of prescription.

And when you ask the patients why, 66% of those said it was because they had side effects. So that makes you think, hold on a minute, there's something that doesn't add up here. And I don't think it's about, you know, they talk about something called nocebo effect. If the patient is going to be aware of a potential side effect, they'll imagine it. And of course that exists. But a lot of the awareness of side effects of statins, Mark, in the mainstream only came out really in the last several years. I mean, they were prescribed for a very long time under the belief that those side effects didn't really exist. So I don't think these patients were imagining it. I think it's more likely they genuinely suffered side effects. I think that's

really important. But either way, I think doctors should be aware, patients should be aware that these potential side effects, which aren't serious or life-threatening at all, but interfere with the quality of life, and that's, of course, very important for people, are very common. And you shouldn't be afraid of discussing with that doctor and having a trial period, potentially, after discussing with your doctor off them. The other thing that we didn't mention is that when we talk about all this issue about management of heart disease with statins is that for many people, it gives them the illusion of protection.

So they think, I can eat what I like. my cheeseburger and whatever as long as i want to they continue to gain weight you know and there was one study in jama internal medicine a few years ago that showed if you followed people of similar risk profiles who were on statins and ones that weren't on statins over a 10-year period the ones on statins gained more weight and the reason for that probably is to some degree the illusion of protection. So again, this is about educating informed patients to learn. Or maybe because insulin goes up and insulin makes you gain weight. Absolutely.

Absolutely. And we also know it does now, it's been established about 1% of people who take statins will develop type 2 diabetes because of the statin. Right? So that's another except so there's a lot of information that people aren't being told and would change the decision-making process and that's really where we you know we need to change the conversation across the whole of medical practice and it's taking time i think people are becoming more aware doctors are becoming more aware i think one of the concerns and issues i've had and i've campaigned on in the uk is that when you financially incentivize doctors to meet certain targets of cluster or lowering or targets of treating certain people at certain risk, then it's more likely to bias the conversation. And the patient really is the one that suffers at the downstream because they're not really getting involved in fully informed consent.

And that, for me, is ethically dubious. Yeah. I mean, the challenge is that, you know, most doctors are very busy and they are seeing patients and doing good work and they want to do the right thing. And they don't have time to go into looking at all the data and analyzing and sifting through it and sorting through it. And so they're hearing the sound bites. They're hearing the sound bites that generally come from continuing medical education. And I was once skiing and I joined a chairlift and I sitting on this chairlift with this woman. I'm like, Hey, what do you do? She's like, well, I'm in pharmaceutical marketing. I said, Oh, really? I said, what do you do? She's like, put on

conferences for doctors. So essentially a lot of the medical conferences are funded by the pharmaceutical industry and they are putting their speakers on, they're having their spin on the data. And so the average doctor really is very hard pressed to actually get to the nuances of what all this data shows. And it's really unfortunate because they're missing the boat. And the other problem is, you know, in medicine, we don't like to feel disempowered as doctors. And when most of us have zero training in nutrition or lifestyle medicine, and the biggest cause of heart disease is insulin resistance, which is a lifestyle driven disease where, for which there's really no good medication.

I mean, metformin maybe a little, but it's kind of marginal and doesn't work as well as lifestyle. And that's been proven many times over in the diabetes prevention trial and other trials. So like you're, you're, you're, you're, you want to do something right. And so as a doctor, I want to help some, you want to help your patient, but this is all they know how to do and they don't even know how to diagnose insulin resistance. 90% of people with prediabetes are completely undiagnosed.

And the one study I read from, I think it was from the UK about, if I get the numbers right, I think the two thirds of everybody coming into the hospital with a heart attack had either diabetes or undiagnosed prediabetes. That was the biggest driver. Yeah. So two thirds of people admitted, there's a large US study several years ago that showed that two-thirds of people admitted to hospital with heart attacks had metabolic syndrome. So that's the worst type of poor metabolic health. You've got five markers, which we'll go through. And if you have three of those abnormal, which basically is linked to high blood pressure, pre-diabetes or type 2 diabetes, increased waist circumference, high blood triglycerides and low HDL. Those are the five. If three of those are abnormal, you have metabolic syndrome.

66% of people admitted with heart attacks in the U.S. have metabolic syndrome. So three of those are abnormal. But 75% of them had normal LDL and normal cholesterol. So clearly- What did you just say? Wait, wait, wait, wait, wait, wait, wait, slow down. You're talking fast. Slow down.

You just said that 75% of people admitted to the hospital with a heart attack have normal ldl cholesterol yeah yeah this is from 2009 yes but only 10 had optimal hdl yeah probably yeah that's true i think i think i think about 70 had abnormal triglycerides yeah right yeah yeah so so the question is at that time, so why have we not changed things? I think one of the things you say, you hit on the nail on the head there about lack of awareness of nutrition and that kind of stuff.

One of the things that's also, there's a huge lack of awareness is about how rapid lifestyle changes with diet at the forefront. But the other things of course are crucial, um, can improve those risk markers and metabolic syndrome. So one study showed that in uh you know 50 of people with obesity that had a dietary change which in this particular trial was low

carb okay reverse their metabolic syndrome within 21 to 28 days mark right that's massive right so those risk markers are tried this right it's coming down hr coming up even blood pressure coming down some degree getting out of p, getting out of type 2 diabetes. They start to have an effect. And that's why I wrote this. It wasn't gimmicky. I mean, 21-day immunity plan was also based upon those principles. And the same thing I talk about in this book as well, is that people will see the improvements

in those markers very, very quickly if they adhere to the prescription, the lifestyle prescription that doctors prescribe for them that really focus on insulin resistance. That's it. If you focus on insulin resistance as your end goal to improve fat through various lifestyle mechanisms, but dietary change alone is the only intervention mark from any lifestyle study that can rapidly improve those markers. What's really striking to me is even at major, major heart hospitals around the world, the heart disease prevention diet, the cardiology diet, again, when they go in the hospital is a low fat, high carb diet. I know. And I'm like, what's going on here? It's like, we're living in the, in the dark ages and the data that's now here is not getting

incorporated into the practice of medicine, which is really unfortunate. So I love your work because what you're doing is you're, you're is you're not just taking things at face value. You're looking under the hood. You're looking at the data and you're creating nuanced conversations that aren't black and white. It's like statin's bad. You know, it's really about looking at the honest accounting of what we know and what we don't know.

And actually, where should we be looking? So as a cardiologist, what really is the best predictor of heart disease if it's not LDL? And what can we do lifestyle-wise to both prevent, treat, and reverse the risk and even the status of actually having heart disease? Yeah. So Mark, so I think, again, I would come back to keeping the basics, stuff that is relatively simple to measure, inexpensive. Okay.

So the things I always go through with my patients, like, so let's go through these five markers. What's your blood pressure? You want your blood pressure ideally to be less than 120 over 80. Now the diagnosis is if it's more than one between 120 and 140 systolic or between you know 80 and 90 diastolic then you have pre-hypertension and that that doubles your risk of stroke and also contributes to heart disease so you want to look at the blood pressure hba1c should be less than 5.7 percent between five and different i know different countries have different ranges, but essentially between 5.7% and 6.4% is pre-diabetic and 6.5% and above is type 2 diabetic.

So you want your HbA1c to be less than 5.7% ideally. You want your waist circumference for a Caucasian man to be less than 102 centimeters measured around the belly button and less than 90 centimeters if you're female. And then your triglycerides should be ideally less than one millimole per liter, which the equivalent, I think, in the US is, I think, 150 milligrams per deciliter. Mark, you would probably correct me on that if I'm wrong. I think that's the range. It should be less than 150. And the HDL to be similar.

So when you're above 150, right? So greater than one millimole per liter. And if you have those all in range, which as you said earlier on, actually having all those markers in normal range for the average American adult is only about 12% of adults. So 80% of adults in the US don't have those in the normal range, which is very troubling, right? And this isn't just older people. Only one in four adults aged between 20 and 40 mark in the US have those in the normal range. And this is what we're dealing with. But the good news is, again, those are really indirect markers of insulin resistance. If you want to do more, slightly more expensive tests, and people get this in the US more

easier than the UK, is you do a fasting insulin level. And there's different units. I won't get it wrong, but there'll be a normal range. I think it should be less than six international units, I think, if I'm not wrong, in terms of fasting insulin. So that's another marker that you can use. So once any of those are out of the normal range, then you've got some degree of insulin resistance.

So the question is, what can you do about it? And then it's, well, let's just go back to very basic principles. I keep it simple. So avoid ultra-processed foods. So avoid ultra-processed foods. What are ultra-processed foods? Well, the data now, and I know you've been a big advocate for this, Mark, in recent years as well, and writing about this, is that more than 50% of the UK diet, more than 60% of the US diet is now coming in terms of calories from ultra-processed foods. I think kids are 67%. 67%.

Is that right? It's unbelievable, right? This is food that comes out of a packet that usually has five or more ingredients, a combination of sugar, starch, and healthy oils, usually with additives and preservatives. And that's a very simple rule of thumb. So I tell my patients, if it comes out of a packet and has five or more ingredients,

it's ultra-processed and void. And that includes even packaged bread, right? So these are the things to cut out. And then low-quality carbohydrates. So minimize sugar and low-quality carbs. So these are refined carbohydrates and fiber. Your white breads, your pastas, your rice, your potatoes. Now, it doesn't mean you have to completely eliminate it. It depends where you're starting from. So a lot of people have also metabolic health already who are generally doing this stuff, right. 80% of the time probably don't need to be as strict, but if you're starting from a position where you're a type two diabetic and all your markers are off, then you have to be more extreme to see the bigger benefits. Right. So, um, you know, I, I, I, I, I, I, I,

my insulin levels are like less than five, pretty much about two. I have a 6% body fat. Yes. I'm bragging, but I I'm pretty metabolic healthy exercise a lot. I eat really healthy. And I went to Sardinia last summer and I'm like, you know, here I am for a week. I'm just going to like eat whatever. And I'm going to eat the pasta, the bread, I'm going to drink the wine. And I went, I, you know, I was treated well and had a very, you know, abundant diet and I gained like five pounds and I got the belly fat. And so even if you are extremely healthy, if you start to eat more of that stuff, you're going to start accumulating that. And it's really, unless you're just like doing a marathon every day, it's really tough to keep up with that carbohydrate load that we have.

Well, that's really important point. up with that carbohydrate load that we have. So that's really important point. Yeah. I think we have to be aware of that. Again, we become, um, and different people are more sensitive to these carbohydrates as well. Right. So I think, uh, you know, one of the, there's a quote in the book from Dean Ornish. I quoted him just to give people a concept to understand a bit of nuance with this management

mark is that it takes more to reverse disease than it does to prevent it. Well, I think he was borrowing from Benjamin Franklin, which says an ounce of prevention is worth a pound of cure. Absolutely right. So I think, yeah, but the bigger picture for most adult, you know, in Europe, Americans, around the world, the big issue is ultra-processed food, low-quality carbs, as you said. And i think if you get that out of the diet that it's about patient preferences and values i'm an advocate for the traditional mediterranean diet but minus in the way we're living now you know the ultra obviously the starchy stuff because there is as you know we've talked about gut microbiome as well. The positive side comes from, with the best available evidence we have and things evolve,

seem to be that there is antioxidants, anti-inflammatory components with whole fruit and vegetables, you know, extra virgin olive oil, nuts and seeds. You want to be getting, obviously, enough protein. You want to get all your nutritional requirements as well. So you think about, okay, how am I going to get all my nutritional requirements? So I minimize the need for supplements. I mean, I all my nutritional requirements? So I minimize the need for supplements. I mean, I know supplements have a role, but minimize the need for supplements, right?

And also reduce the chances of me developing insulin resistance from the diet. And if you focus on that, that's what I do with my patients, then as long as you get the base of the diet right, other things here or there, it doesn't matter so much. So get the base right,

cut out the crappy stuff, pardon my language, right? And then it's much. So get the base, right. Cut out the, the, the, the crappy stuff on my language. Right. And then, and then it's about preference of values, different cultures, right. Different types of foods, Indian food, Chinese food, whatever. There's going to be obviously some, some big differences in a lot of the food that people eat. Yeah, I think that's right. And I think, I think the, the, um, the lifestyle stuff is so huge. And, and, you know, you talked about the POPI diet. I talked about the vegan diet. It's essentially focusing on quality. So whatever you're eating, the key concept is it should be high quality, meaning nutrient dense, processed, whole real food. And you can kind of go up the chain, you know, eating a feedlot steak is better than eating, for example, you know, a bunch of bread, right. But it's not as good as eating

wild elk or eating a grass-fed steak. So you can keep going deeper in the quality chain. The second is to really understand that food is medicine and that everything you're eating is regulating your biology in real time. And three, it's personal. Everybody's biologically different. And some people may be more carbohydrate tolerant than others. Some people may be more fat intolerant than others. And there are ways to figure that out, which is really important. Absolutely. So that, that really covers a lot of the diet side of stuff. And then obviously there's a heart, you know, from a heart disease perspective, um, exercise,

I think we've somehow over-ended it. The most important message is keep moving, do what you enjoy, be careful of overdoing it. A lot of people get injuries, they overdo it. Especially if you're stressed out and you're doing more than, say, 60 minutes of moderate to vigorous exercise a day, more vigorous side, that can actually worsen your stress. So the data really says that 30 minutes of moderate activity a day,

and you can do different things. You can do Pilates, you can do yoga, you can do cycling. I'm not a particular big fan. I used to be a runner. I've kind of shifted more to cycling now because running on the road generally is not particularly good for your knees. I mean, I do sprints once a week, I do HIITs. So all these things are there. Do enough, but don't overdo it with the exercise. And then the big thing, Mark, something I've discovered in the last few years, which certainly has a big impact on my patients, is stress, psychological stress, chronic psychological stress, which in its own right,

and I write about in this book, is the equivalent of another risk factor like high blood pressure or type 2 diabetes in terms of its cardiovascular risk. But a lot of people aren't managing that, not realizing how important it is. Of course, it links to inflammation. There's a lot of emerging data. There's stuff related to clotting problems increase in fibrin in the blood which is involved in as a clotting factor and what I do with all my heart patients is I ask them you know I do a very simple questionnaire kind of on them and I ask them in you know naught to ten in the last few years you know these are people come they've already got diagnosed heart disease some people who've had scans done they've got some flaring of the arteries

and I say to them you know where is your stress levels the last two or three years i know it's obviously been pandemic time so it's a bit skewed but in general most of them say you know that they are stress levels are kind of eight nine out of ten right for the last few years and they've not done anything about it no and then i write about in the book you know we we need better quality data more data but what's fascinating, the largest study on heart disease reversal, which was done in India by an interventional cardiologist called Satish Gupta called the Mount Abu Healthy Heart Trial. Basically, it took patients with significant coronary disease,

so well over 100 patients, moderate to severe, so at least 50% to 70% blockage in their arteries. These are people that didn't want to have a bypass operation. They want to have stents. And he put them through his healthy lifestyle plan. Now in India,

there's a lot of vegetarians. So it was a very high fiber vegetarian diet. There was some starch in there, but it was very high fiber vegetarian diet. It was moderate exercise. So two 30 minute brisk walks a day okay

and then it was something called raj yoga meditation which also wasn't just about meditating it was like there was a bit of counseling it was about reconnecting with your family and your friends and the social aspect trying to reduce stress levels long story short the end of the you know after two years of the trial then followed up for five years they found that uh in the people that adhered to the lifestyle program, there was a 20% reduction on average in the stenosis of the arteries, which is unheard of, right? You mean the plaque, the clogged arteries got better? Yes. Yeah.

They got better. They reduced from, say, 70%, 50%, 50%, 30%. I mean, extraordinary, right? And this is no statin. No statin. This is pre-statins. No statin. This is pre-statins, no statins. And then when they tried to look into what was the most important factor by far of all the lifestyle factors that contribute to the reversal, it was 40 minutes of meditation a

day. Wow. Right. So this is a big missing area, I think. And I think the other thing about the stress reduction, which links to chronic chronic inflammation that's the mechanism is that we think now heart disease these plaques that develop these blockages they're dynamic processes so you get some inflammation um you get a plaque formation it then progresses you can potentially it seems it seems that you can potentially reverse those blockages or reduce them but But the biggest factor so far, I think that's been ignored is stress reduction through meditation. And as you know, as well, if people incorporate that, then they're also more likely to sustain the lifestyle, the other lifestyle factors in terms of their adherence to the diet, but their mental health is better. So it's quality of life.

It's not just about something potentially being helped within the longterm, within a few weeks when people do this and some people need more help. You know, I find it difficult to meditate just from using an app. I have a Pilates teacher that I started seeing a few months ago that comes to see me once a week. I need to probably do more. It was fascinating. Within an hour, even that session of Pilates, one hour, which is also, you know, it's a great exercise, but it's meditative as well. You feed your stress levels. You just feel like a different person. Yeah. Yeah. It's true. I mean, I think that, you know, the mechanisms are interesting when you look at stress, what it does is a number of things. One,

as you mentioned, increases inflammation. Two, it increases cortisol, which is a hormone that your body makes that actually causes your blood sugar to go up, your blood pressure to go up, causes your lipids to get worse. If you look at a race car drivers before and after a race, their cholesterol goes up a hundred points just from the stress. And not only that, but it actually, uh, it actually causes your fat cells to store more fat. So if you eat under stress, there's nerve endings that innervate your fat cells and the stress response communicates through your nerves and your autonomic nervous system to your fat cells and the stress response communicates through your nerves and your autonomic nervous system to your fat cells and tells them to store the fat. So it's kind of a big deal. And I agree with you. I think that, you know, we are under such a barrage of stressors in our lives, whether it's work,

family stresses, financial stresses, COVID stresses, climate change. I mean, the new, I mean, just, I don't watch the news anymore. It's just too stressful for me. And, and yet it's, it's so simple. It's free. It's accessible. And I, I've, I've been practicing meditation for years and it's such a key thing to help regulate your life and your biology in so many ways. It improves the stem cell production, it reduces inflammation, improves neuroplasticity, brain connectivity. The data is just so powerful on this. And if anybody's really interested, you can listen to the podcast I did with Daniel Goleman about his book, Altered Traits, which studied advanced meditators using very advanced imaging technology, looking at their brain function and their brain waves and see what happens when you have somebody who's

been meditating for a long time. But it really doesn't, you don't have to be a professional meditator where you're living in a cave for nine years, just 20 minutes a day or 20 minutes twice a day is very powerful. And I personally use a technique, it's called Ziva meditation, Z-I-V-A meditation. You can look it up online. You can take an online course, learn how to do it. It's super easy. And you don't need any special equipment except sit on the floor or a chair. And through that technique, you're going to have all kinds of benefits, not just heart disease, but all kinds of benefits. So I encourage you to take heart to what you're saying, because I think it is one of those neglected factors. So diet, exercise,

stress reduction, sleep. I think the data you presented on the reversal is quite interesting, because most of us don't think we can unless you take aggressive high dose statin. You know, Dean Orr's work showed that there may be possibility through lifestyle interventions to change the course and actually reverse the trajectory. And Mark, anecdotally, I'm getting patients and I will be writing about this soon. And hopefully I'll be able to even fund a trial to try and get a bit more definitive in terms of the answers. But I'm seeing patients, many of my patients coming back who have either halted the progression of heart disease so you know from imaging and some have even had some reversal uh one patient recently contacted me and i was i'd forgotten you know i was in the said you know dr marjorie i saw you in 2019

um she'd suffered a tia a mini stroke she'd had a blockage in in one of her blood vessels of 75 and she emailed me back saying, I've followed your lifestyle protocol. And I was shocked, Mark, to receive this. I had to read it again. And she said, I've repeated the imaging. And now the reduction has gone to less than 50% within two years. I mean, and I'm just doing what the data, you know, I'm saying the very least that's reduced your risk. I don't give people promises and say, you know, there is some potential here, but your quality of life is going to be improved. We, let's reduce your risk. I don't give people promises and say, you know, there is some potential here, but your quality of life is going to be improved.

We're going to improve your risk factors. And hopefully, you know, there may be some reversal, but at least we can help stop progression at the very least, you know, according to what would happen normally. And the feedback is extraordinary once people follow it. So we need to try and get this more data, of course, but we need to get this more inculcated into medical practice as well across the board. I mean, the behavior change factor is a huge thing. That's a separate topic, which we could spend hours on.

I've had BJ Fogg talking about behavior change and I talked for the Daniel Planet Behavior Change. So the power of community and the power of group support or medical group appointments or shared medical appointments can be very, very effective. And we we've seen this at even getting people to change their lifestyle is, and outcomes are almost three times better using groups than actually one-on-one doctor visits. We've done that at Cleveland clinic. It's really quite interesting data to see. Yeah. One last question before we wrap up, I want to talk about what's a

hypothetical patient because, you know, for me, let's just say my cholesterol would be a little high and I do a cornea calcium score, which is a way of measuring calcium deposits around the heart and the arteries, which by the way, calcium is the body's bandaid where there's inflammation, calcium goes. And so it's an indirect marker of potential plaque. However, there's some questioning of the data around the benefits of coronary calcium and there's new imaging techniques, like a coronary angiogram with a CT scan that looks at soft plaque. There's a company called Clearly that looks at the analytics. They use sort of artificial intelligence. And how do you use that technology to help influence your decision about how to treat the patient and which patient would benefit from a statin and which wouldn't? Because one of the things we're talking about with these levels, these numbers, I mean,

abnormal cholesterol is not a disease, right? but but it but it's a predictor potential predictor but it's it's it's you know drawing a one-to-one correlation with any one patient is very difficult right so but when you look at their when you look at the actual plaque burden and not just the calcified plaque but soft plaque which is the more vulnerable plaque to rupture the more vulnerable to actually cause a heart attack how do you sort of navigate that decision tree with a patient and who would get what? Yeah, so great question. It's all individual-based.

I think we have to walk before we can run. So you've alluded to the issue of calcium scores, which in themselves are still very, very predictive and very good in terms of their risk stratification. So they supersede all the other risk markets in terms of heart attack risk, high blood pressure, type 2 diabetes, whatever else. If you get a calcium score that's zero,

close to zero, less than 100, then your risk is very, very low of having a heart attack in the next 10 years, despite what's going on. Although I would always tell my patients, listen, you're lucky where we are right now. It hasn't caused any significant damage, but if you're carrying as you are,

probably this calcium score is going to increase. So at least we need to sort your lifestyle out. And often I will repeat calcium scores in a year and give them some reassurance of what they're doing is having, making a difference. So that's some one way it can be used. So sequential calcium scoring. Can you see regression of calcium? Can you see? Yes. Yeah. Lowering the calcium score. Absolutely.

But I think the other thing is, Mark, you're right about soft plaque. So the calcium score can sometimes miss soft plaque, but it's still very reliable. So we come back to the basics of the history, right? What is at risk from the risk factors and an individual patient based? And if they're also getting like, for example, you know, I've seen some patients that have got quite typical symptoms of angina but think that they should just have a calcium score you know and it's you know often the calcium score could come back and being relatively low but you do a ct corneal angiogram i think that's what you're kind of referring to some in which actually look more detail and we'll see soft

plaque and you can see a significant soft plaque they're relatively less common common. So I think it's something to be aware of. I think calcium scores still have a very important role. But if there is doubt, then of course, you can just go for the full CT coronary angiogram, and then you can see both calcified plaque and non-calcified plaque. So I think they have a role, but I think still calcium scores still should be used

much more frequently than just the CT coronary angiograms based upon all the different risk profiles of that individual patient. Yeah, very important. And I think some patients, for example, with a high calcium score or soft plaque, they might be candidates for statins, right? Yes. And again, the data that I've read most recently suggests that the ones with a calcium score more than than 400 but then you're already automatically into the high risk group anyway which was talked about which is the one in 39 benefit from non-fatal heart attack over five years 183 so it's pretty consistent still with what we know um about and but but people with the calcium score of less than 400 there doesn't seem

to be any big benefit from statins i think one of the other slightly confounding factors is statins also increase coronary calcium. So they can potentially stabilize blocks, but increase coronary calcium. So you've got to also think about that in the context of patient come back two years later, oh my God, why has my calcium gone up? Well, actually it may well be the statin, but then it could be this progression of disease. So in that situation, Mark, you could then say, well, maybe we should have a CT coronary angiogram and actually look in more detail to make sure there's not been any significant stenosis

or soft plaque or whatever else developing. That's the way I would approach it. But I think overall, in terms of where we're going with this and trying to make sense of what's going on in the world with ill health and everything else, I look at things also philosophically and and rationally you know and uh i always think about my purpose and our purpose as doctors ultimately is is to improve patient outcomes but you know what do we do for that we use knowledge and the ultimate purpose of knowledge is to reduce human suffering

and but that knowledge needs to be based on the complete totality of evidence on the truth. And one person I've recently, I'm just going to throw this in there, that I've been very fascinated with, and I follow his work. I know he's a bit of a controversial figure, but I like what he says, is Jordan Peterson, the clinical psychologist. And, you know, ultimately, we need to speak the truth, we need to speak the truth we need to know the truth and if we move away from the truth then we're really going to increase suffering and we're in his words you know we are going towards hell we need to redeem the world from hell and by not speaking the truth and that also also requires courage at times you know people speaking out doctors when there's

misinformation being propagated from vested interests we have a role to actually speak the truth from a rational perspective, because if we don't, the situation is only going to get worse. And even if we're avoiding conflict in the short term, we're going to increase further damage down the line, if not for us and for our kids and the kind of environment and their futures. So I also have to look at this from a philosophical point of view as well, when you come into the whole issue around trying to help people understand what's going on. And I think everybody knows Mark,

you just look around you. In the last 10 to 20 years, you know, ill health is getting worse. Mental health is worsening. You know, there's a whole issue on a separate discussion about, you know, and I'm not going to go into any detail on this, but even our management of the pandemic,

about COVID, about vaccines, about informed consent, all of that's there. And if we don't speak the truth and we don't get access to the truth then the whole of the world and society is going to suffer and you combine that with hostility and division people taking being becoming very tribal about statins or whatever else then um we're based and exacerbated by social media. We are also losing, my concern is losing our capacity for empathy, as well as access to the truth. And that's sending us down a very, very, to a very, very dark place. So our job now is to reverse that.

Yeah. Well, thank you for your work. And thank you for being one of the really leading voices in showing us what the data actually say for taking the time, which is precious to do the hard work of looking at these studies, going back to the original data, dissecting them, making sense of them, and actually sharing with people what we know and what we don't know. And being honest and transparent about it. You're not anti-stat and you're just pro-truth. Yes. And I think, I think just to, just to,

just to kind of summarize, cause we unpacked a lot and then we'll, we'll close up the, the, the most important thing people need to realize is that heart disease is not a statin deficiency. Number two, that it's primarily driven by lifestyle and primarily by the amounts of carbohydrates that we're eating, sugar and starch, flour and sugar. And three, that the over-focus on LDL is misguided. And then in fact, it may be other biomarkers, such as triglycerides and HDL or the total cholesterol to HDL ratio, or the inflammation biomarkers or oxidative markers around cholesterol or the particle number, particle size, things that we're not typically looking at insulin. I mean, if I had one test to look at heart disease, actually a risk, I would do a glucose tolerance test, measuring insulin fasting and one,

two hours later, because that I was going to tell me almost more than any of the other tests. And it's something that most people don't do. So, and then the, the other thing we kind of covered was that we need to do the right cholesterol profile, which is the NMR or Carter IQ test from LabCorp Quest, which you can get from your doctor. It's a much better way of looking at the total picture along with the other biomarkers of blood sugar, insulin, A1C, inflammation markers, and so forth. And that, and that the good news is that according to the Epic trial and many other studies, 90% of heart disease could be prevented by simple lifestyle changes, eating a whole foods, real food diet, exercising a little bit, not smoking, keeping your ideal body weight. I mean,

that's pretty simple. And yet on meditation, you might even get a better benefit. That's a 90% reduction, right? It's actually really relevant. And yet statins, although they are good for certain patients with high risk conditions or with lots of plaque or with heart attacks, they do form part of the toolkit, but I would just sort of emphasize, I saw this one sort of medical journal that said lifestyle doubles the benefits of statins. And I'm like, oh God, that is such a poor framing. You know, in fact, lifestyle may be all you need if you are aggressive enough. And I, and I have patient after patient, I'm sure you do who are on all the medications. They're on high blood pressure medication. They're on statins. They're on aspirin. They're on all kinds of cardiology medications. And they've had a heart attack. And their numbers are better off the statin once we fix the underlying lifestyle issues. Actually, their whole profile looks better.

So that's to say that you need to have a more nuanced view around statins and nuanced view around heart disease to deal with the root causes of it. And I really encourage everybody listening to get a copy of Asim's new book. It's called A Statin-Free Life. And it's such a good summary of the data and the research. He's done the hard work. He's told us actually what we need to be thinking about in a way that is really refreshing. It's coming from a cardiologist. And of course, you're an honest broker. You don't have any vested interest. You're not getting any funding from pharma. You're often vilified in the press. You're taking a lot of arrows in your back, but you're telling the truth. And I think for

people listening who are on a statin, who have high cholesterol, whose doctors told them to take a statin, this book is really important whose doctors told them to take a statin, this book is really important. A Statin-Free Life, a revolutionary life plan for tackling heart disease without the use of statins, available anywhere you get your books. I want you to get it and read it. And if you know somebody who's got some issues,

send it to them too as a good present. And if you love this podcast, share it with everybody on social media, subscribe wherever you get your podcasts, leave it with everybody on social media, subscribe wherever you get your podcasts, leave a comment, how have you managed your risks? How statins helped you or not? Or what side effects have you had? Tell us about your story.

We want to hear. And we'll see you next week 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. And I want to tell you about something else I'm doing, which is called Mark's Picks. It's my weekly newsletter. And in it, I share my favorite

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and get healthier and better and live younger longer. Hi, everyone. 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 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 or other professional advice or services. If you're looking for help in your journey, seek out a qualified medical practitioner. If you're looking for a functional medicine practitioner, you can visit ifm.org and search their Find a Practitioner database.

It's important that you have someone in your corner who's trained, who's a licensed healthcare practitioner, and can help you make changes, especially when it comes to your health.