The Dr. Hyman Show - Why Cholesterol Is Only One Factor Of Heart Health

Episode Date: July 3, 2023

This episode is brought to you by Paleovalley, AG1, and Mitopure.  Many people still believe that eating cholesterol and fat, especially saturated fat, causes heart attacks and that taking statin drugs is the only way to reduce your risk of heart attacks, but now we know the science says otherwise. The good news is this: we have a lot more control than we originally thought when it comes to preventing and reversing heart disease. In today’s episode, I talk with Dr. Cindy Geyer, Dr. Aseem Malhotra, and Dr. Todd LePine about why we need to look beyond cholesterol levels to protect our hearts. Dr. Cindy Geyer received her bachelor of science and doctor of medicine degrees, with honors, from the Ohio State University. She completed her residency in internal medicine at Strong Memorial Hospital in Rochester, NY, and is triple board certified in internal medicine, integrative medicine, and lifestyle medicine. She joined The UltraWellness Center in 2021 after practicing and serving as the medical director at Canyon Ranch for 23 years. 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. 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, coauthored 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. Dr. Todd LePine graduated from Dartmouth Medical School and is board certified in internal medicine, specializing in Integrative Functional Medicine. He is an Institute for Functional Medicine Certified Practitioner. Prior to joining The UltraWellness Center, he worked as a physician at Canyon Ranch in Lenox, MA, for 10 years. His areas of interest include optimal aging, bio-detoxification, functional gastrointestinal health, systemic inflammation, autoimmune disorders, and the neurobiology of mood and cognitive disorders. This episode is brought to you by Paleovalley, AG1, and Mitopure.  Paleovalley is offering my listeners 15% off their entire first order. Just go to paleovalley.com/hyman to check out all their clean Paleo products and take advantage of this deal. Right now, AG1 is offering 10 FREE travel packs with your first purchase by visiting drinkAG1.com/HYMAN. Get 10% off Mitopure at timelinenutrition.com/drhyman and use code DRHYMAN10 at checkout. Full-length episodes of these interviews (and links to all the references mentioned) can be found here: Dr. Cindy Geyer Dr. Aseem Malhotra Dr. Todd LePine

Coming up on this episode of The Doctor's Pharmacy. The test that most people get is like an antiquated cholesterol test that doesn't really tell you a whole lot. Hey everyone, it's Dr. Mark here. We all have food emergencies every once in a while when we need some quick convenient calories in between meals and that's why it's a good idea to have some healthy options on hand for when you need them. I do all the time and you might think that grabbing a couple of protein bars would be the perfect portable healthy option, but you know that most quote health food bars on the market today are filled with refined sugar, weird artificial sweeteners, sugar alcohols. There's a serious need for actually healthy protein bars. And thankfully,

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back to this week's episode of The Doctor's Pharmacy. Hi, this is Lauren Feehan, one of the producers of The Doctor's Pharmacy. 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. The good news is that diet and lifestyle choices that support metabolic health and reduce inflammation can dramatically prevent and reverse heart disease. In today's episode, we feature three conversations from the doctor's pharmacy on the real reasons we have so much heart disease and what to do about it. Dr. Hyman speaks with Dr. Cindy Geyer about what functional medicine doctors look for to improve heart health, with Dr. Seemel Hotra about the connection between metabolic syndrome and heart

health, and with Dr. Elizabeth Boehm about various case studies in which patients with heart disease improved their heart health. Let's jump in. This is another one of those conditions 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. And it's a pretty low bar mark. And what are those? What are those four things? It's not smoking.

Okay. 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, a little exercise, and don't smoke. Yeah, that's good.

Simple things to do, but like- We're not even there yet. 3%. Yeah, three percent. 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?

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. 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, 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 entirely. Take 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 in America. Chronic stress, loneliness, isolation, bad sleep. I mean, those things are huge in heart disease. And we often miss the boat on helping our patients really deal with those. So, okay. So the typical person comes in, he's got a high cholesterol, he or she is 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, 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 a C-reactive protein because as I mentioned before, it's like, well, what do we 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 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 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? Why is our cholesterol all screwed up? And you know, it's really interesting.

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 cholesterol is now normal. It's good. Oh, yeah. I can eat my cheeseburger. I can eat my cheeseburger. Or 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. 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 Pepsid because don't worry, daddy, you can eat your peppers and sausage. Just take the Pepsid. I remember that. 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. But, you know, 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 like it's a super fancy doctor they'll measure 100 things like 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. 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 just should just do a quick refresher.

Because the test that most people get, not the one we get here at the Ultra Wellness Center, 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 was a classic example of that, right? So tell us about, and I'll tell you about his testimony, but tell us about the new kind of testing that we're doing. It's not so new because we've been doing it for 20 years, but it's like, 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. 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 for HDL. We've historically thought 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 practically what you see is people come in with what looks like a normal cholesterol. Like this guy yesterday has early dementia. His cholesterol, I think, was 160-something. Sounds good.

Yeah. His LDL was, I think, under 100. His triglycerides 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, you go, oh, that's great, 160. That's a great cholesterol uh they missed the boat because his particle number was was like 1500 it should be under a

thousand wow 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. wow 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 but they were all your cholesterol is fine not an issue and and we also look at a lot of other things besides that. And by the way, you know, in 2021, no one should get their regular cholesterol panel. I mean, you got to insist from your doctor.

You can get it from LabCorp Quest, it's called NMR, 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 test and find, not necessarily what the right thing is. And so with heart disease, 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, all about the inflammation, immune system. And you mentioned earlier that study by Paul Ritker and Libby, in which it was sort of the beginning of the conversation, 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. 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 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 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 the heart disease is a symptom. It's a syndrome.

There are many, many causes. So let's talk about this whole idea of metabolic health. Because, you know, we were chit-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 NAHINES data from 2009 to 2016. Government surveys. government survey.

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%. 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 the interesting piece. Fewer than one third of so-called normal weight people were metabolically healthy. So that's another really important message. Oh, wait, wait, wait, wait, wait, wait. Did you just say that two thirds of skinny people are metabolically unhealthy? Yes. And have prediabetes-like syndrome? Yes. 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%. All right. But we're looking at how strongly it correlated with weight. That's so terrible.

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. 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 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 pre-diabetes 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? It's like, 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 focus on?

When someone comes in with a risk of heart disease or they're concerned about heart disease? You know, 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 pre-diabetes 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 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 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 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 the food it will but yeah yeah yeah and i would say i would say that quality of fat does matter 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. Yeah, so fried foods, trans fats, refined oils, those are nasty. 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. 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. I have a patient, Cindy, that I remember who was at super high risk for heart disease, and she looked like the Tasmanian devil.

And she was 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 risk for heart disease, high blood pressure, diabetes. And I'm like, let's check her glucose tolerance test with insulin. And this was like 20 plus years ago. 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 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 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. Oh, 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 which was making her hungry slowing her tablets putting fat in her belly cells which 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 gonna miss that patient's real problem. And 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 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. 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, 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, like we talked about insulin testing or the cholesterol

or the cause of inflammation, because like you said, insulin in 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 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 are the phyla that produce 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. 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. 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. 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? 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.

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? So of course people want a pill, but there are other things that can potentially achieve

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my friends, I'm super excited about MitoPure. 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. New science is showing that healthy mitochondria also improves immune function too. I've been using it for over a year now, and at 63, I feel stronger and more energized than ever.

Right now, Timeline Nutrition is offering my community 10% off Mito Pure, which you can get in a capsule, powder, or protein blend at timelinenutrition.com forward slash Dr. Hyman. That's T-I-M-E-L-I-N-E dot com slash Dr. Hyman. That's D-R-H-Y-M-A-N. And use the code Dr. Hyman10, just D-R-H-Y-M-A drhyman10, just drhyman10, number 10. 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 will 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. What did you just say? Wait, wait, wait. Slow down. You're talking fast. 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, this is from 2009. Yes, but only 10% had optimal HDL. Yeah, probably. Yeah, that's true.

I think about 70% had abnormal triglycerides. Yeah, 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 can improve those risk markers of metabolic syndrome so one study showed that in 50 percent 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

trying, this ride's coming down, HL coming up, even blood pressure coming down to some degree, getting out of pre-diabetes, 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. Well, what's really striking to me is even at major, major heart hospitals around the world, the heart disease prevention diet, the cardiology diet they get 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, 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 statins bad, you know? Uh, it's, it's really about, 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, you know, 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 between 120 and 140 systolic or between 80 and 90 diastolic, then you have prehypertension. And 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%. I know different countries have different ranges, 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

um 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 HDR 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 88% of adults in the US don't have those in the normal range, which is very troubling. 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 slightly more expensive tests, and people get this in the US more

easily 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. 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, okay?

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 the ultra-processed sub-oil, 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 lack 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, what, you know, I have my insulin levels are like less than five, pretty much about two. I have a 6% body fat.

Yes, I'm bragging, but 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, you know, it was, so even if you are extremely healthy, if you start to eat more of that stuff, you're going to start

accumulating that. And, and it's really, uh, you know, unless you're just like doing a marathon every day it's really tough to keep up with that carbohydrate load that we have sure so well 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 that an ounce of prevention is worth a pound of cure. Absolutely right. So I think I think. Right. So I think with the pain, I think, yeah, but, but the bigger picture for most of adult,

you know, in Europe, Americans around the world, the biggest shoes, 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 preference and the values. I'm an advocate for the traditional Mediterranean diet, but minus 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,

with whole fruit and vegetables, um, you know, extra virgin olive oil, nuts and seeds. Um, you want to be getting obviously enough protein you want to get all your nutritional requirements as well so you think about okay what how am i going to get 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 um and and also reduce the chances of me developing insulin resistance from the diet and if you focus on that so 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 to 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 the lifestyle stuff is so huge. And you talked about the Piappi diet. I talked about the Pagan diet. It's essentially focusing on quality. So whatever you're eating, the key concept is it should be high quality, meaning nutrient dense, unprocessed, 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. Absolutely. So that, that really covers a lot of the diet side of stuff. And then obviously the 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, you know, 30 minutes of moderate activity a day. And you can do different things. You do Pilates, you do yoga, you do cycling. You know, I'm not a particular big, I used to be a runner. I've kind of shifted more to cycling now because, you know, running on the road generally is not particularly good for your knees. I mean, I do sprints once a week, I do hits, right?

So all these things are there, but do enough, but don't overdo it, right? With the exercise. And then the big thing mark um something i've discovered in the last few years which certainly has a big impact in 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 type 2 diabetes in terms of cardiovascular risk but a lot of people aren't managing that not realizing how important it is and of course it links to inflammation um there's a lot of emerging aren't managing that, not realizing how important it is. And 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 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, nought to 10 in the last few years, you know, these are people who have 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 in 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 10, right? For the last few years. And they've not done anything about it. And then I write about in the book, you book. 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, didn't 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 a very high-fiber vegetarian diet. It was moderate exercise, so two 30-minute brisk walks a day. 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, after two years of the trial, then followed up for five years, they found that 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?

Yeah. They got better. They reduced from, say, 70%, 50%, 50%, 30%. I mean, extraordinary, right? This is no statin. 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 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, you get a plaque formation, it then progresses. You can potentially, it seems that you can potentially reverse those blockages or reduce them. But the biggest factor so far, I think, that's been ignored is stress reduction through meditation. As you know as well, if people incorporate that, then they're also more likely to sustain the other lifestyle factors in terms of adhering to the diet. But their mental health is better, Mark. So it's quality of of life it's not just about something potentially being helped within the long term within a few weeks when people do this and some people need more help you know i i i find it difficult to meditate um just from using an app um i have a pilates teacher that i 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 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, increased inflammation to, 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 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 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 medication 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 in 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, 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, you know, sit on the floor or a chair. And, 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, the, the data you presented on the reversal is quite interesting because most of us don't think we can, unless we 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, reverse the trajectory. And Mark, anecdotally, I'm getting patient,

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. One patient recently contacted me, and I'd forgotten, you know, I was in the set, you know, Dr. Marger, I saw you in 2019. She'd suffered a TIA, a mini stroke, she'd had a blockage 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 is 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 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 practices. I just remembered a patient I saw was about 50 years old. And he came to see me.

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

also fish oil, got him on an exercise program. And over the course of a year, he lost, I think, I don't know, maybe he was more overweight. I think he lost almost 50 pounds. He was able to normalize all of his numbers. And his blood sugar was high. His insulin was high. He wasn't, quote, diabetic, but he was pre-diabetic. And no one, they completely missed it.

I mean, it's just staggering to me that after 30 years that I've been doing this, that the literature has been there, that doctors don't check for prediabetes on a regular basis, which affects basically one out of every two Americans or more. And so you check that by measuring insulin, A1C, a glucose tolerance test with insulin. There's ways to look at it and look at particle number, particle size. And he lost the weight and he was able to reverse all of his numbers and he was able to get off all his medication, including statins. And his numbers were better off the statins than they were on it by fixing all these lifestyle factors. And he's been heart attack free for the last 20 years. So I just, yeah, I think we are so stuck in this paradigm of treating the symptom, the cholesterol, instead of the cause.

Absolutely. That's critical. That's a good story. You've had some patients too, right? Yeah. So, you know, the first one, you know, I wanted to bring up the two cases I wanted to talk about today were people with this in-between cholesterol, like where they really wanted to know what to do. They weren't crazy high risk, but they were told they should go on medication. And they came to me to say, well, is that the right decision or what else can I do? So the first one was a 45-year-old gentleman who was told his cholesterol was too high. He didn't have a strong family history of heart disease. But his total cholesterol was what? 225. His good cholesterol's HDL was 37.

Which is low. It's too low. His triglycerides were 185 fasting. Which is high, right? Too high. Should be ideally under 70. And his LDLs were 145. So his doctor said, you know what, I think you should start some medication. And he said, well, you know what, I want to see what else I can do. So he came to see us, which was great.

And because, you know, a lot of times with patterns like this, we can make a huge change. So we did that special, we did an NMR lipoprofile. So we looked at those particle sizes. And we saw that he had a lot of the small dense LDL particles. His pattern, they sometimes give you a pattern. Are you pattern A or pattern B? Pattern B being the more concerning, you have too many small dense LDLs. And that's what he had. He looked like he had a high risk for insulin resistance, which we knew even before

we did the test, but because his waist to hip ratio was too high, his HDL was too low, his triglycerides were too high. So it was obvious, but that test confirmed that, right? It said you have a high risk for insulin resistance based on your cholesterol panel. And we also- Before you go there, I just want to point out, because this is really a very easy, cheap way to check to see if you have insulin resistance. And it's a far better predictor of your risk of heart attacks than your LDL, which is your triglyceride to HDL ratio. And this guy had a ratio about five. If it's over one, not great. If it's over two, you're in trouble. He was five. And that pattern

of high triglycerides, low HDL is what you see in these patients with prediabetes, even though they might have a normal cholesterol. I mean, his was 225, but I've seen people with a total of 150, triglycerides of 300, HDL of 29. I'm terrified for these patients. Absolutely. Even though their total cholesterol is 150, and it sounds ideal. Right.

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

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

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

We needed to work to lower those carbohydrates, to lower the sugar. You know, we know that triglycerides really decrease when you cut out juices, sugars, alcohol. And they're basically fats that are made in the liver when you eat sugar and starch, right? Yes. They're not produced by eating fat. Nope. Nope.

Sugar. And you can really, you can lower your triglycerides pretty quickly when you pull out the alcohol, the juice, the lots. If some people doing too much fruit. Flour and sugar. Flour and sugar. Absolutely absolutely sugar, sugar, sugar. So when you cut that out, you can bring your triglycerides down really pretty substantially, pretty quickly. So we really focused on lowering his carbohydrate load, you know, all the bad carbs, right. And, um, and you also focus on giving him more of the omega

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

So we made that switch with his diet, you know, and what was amazing, and what I love to see is when in like three months, we repeated that NMR lipoprofile and he went from having the too many of the small dense LDLs to having, he was now considered pattern A. He had more of the big fluffy LDLs, his HDL improved. Now it wasn't yet optimal, but I think it got up to like 47 in three months. His triglycerides came down to 120. So maybe not, you know, this was just three months of doing this. We can see really quick changes in people's bodies with making these changes in lifestyle, which is phenomenal.

Yeah. And I think one of the other thing I want to talk about, this is a great case, but, you know, you're able to change his diet and improve things. But, you know, one of the things that we're really bad at in medicine is personalizing care. And there's no place that's more important to personalize your care than dealing with your heart attack risk and cholesterol because it's different for different people. That's very true. And what I've seen, I'm sure you've seen this over the years, is people respond dramatically differently to the same diet. So typically we're told by the American Heart

Association that we should have less than 5% of our diet as saturated fat. Although breast milk is 25% saturated fat, so maybe we should ban breast milk according to the American Heart Association. I don't know about that. But it's really important to get saturated fat in your diet because it's a building block for cholesterol, which is not necessarily a bad thing. I mean, your cholesterol makes your hormones. It makes the nerve coverings for your nerves, it's part of your brain. I mean, it's really important. A lot of your hormones are made from cholesterol, your sex hormones. And what I found was, you know, depending on the person, their responses are very different to diet. And I've talked to Dr. Ronald Prowse, who's one of

the world's experts in cholesterol on this. He says, yeah, there's a lot of heterogeneity. And I've seen this, just two cases come to mind. One was of a woman who was overweight, who was clearly pre-diabetic, whose triglycerides were 300, which is really high. It should be under 70. Her HDL was like 30, which is terrible.

Her total was, you know, probably, you know, 250, 60. It was pretty high. She had a lot of small particles, a lot of overall particles, just way high. Red box syndrome. Yeah. And she struggled with weight loss and diet. So I put her on a high saturated fat diet. I put her on basically high saturated fat diet. I put her on basically butter and coconut oil and almost a ketogenic diet.

And it was striking. She never could lose weight. She dropped 20 pounds like that. Her cholesterol dropped 100 points. Her triglycerides dropped over 200 points. Her HDL went up 30 points. And you just can't get that result with a drug. Nope.

And so I did that with her and saturated fat was the cure for her cholesterol not the cause but another guy was this super fit mid-50s biker would bike 50 miles a day i'm super healthy and his his cholesterol wasn't great and he he had a genetic issue with his cholesterol and had this sort of more of these small particles. And so I put him on, I tried to say, let's try just do more of a ketogenic diet, see what happens, or more saturated fat. His cholesterol turned terrible. So we had to totally change gears and get him off saturated fat. I think we'll soon be able to do a test, which is a cheek swab or a drop of blood, measure your genetics, and figure out which one are you. Are you somebody who should be eating more fat and saturated fat or more carbohydrates

or more of the right foods, different kinds of fat? We're not quite there yet, but I think in functional medicine and here at the Altria Wellness Center, we can, on an individual basis, really come to learn what is the right thing for this particular person. So I think it's really important. That's so important because what's really key with diet is personalizing it, right? That's when we get the most benefit from our nutrition intervention. And I think what you mentioned with the first woman, the reason you saw such an improvement with the ketogenic diet is you lowered her insulin so much, right? So we know that the carbohydrates that you eat cause your insulin to spike. So when your insulin is high and you can't lose weight because your insulin is high, because it's causing you to put down weight around the

belly, when you change to a diet that doesn't cause your insulin to go up, which is like a ketogenic diet. I mean, that's the extreme, right? But you can do some things in between too. But then that insulin doesn't go up and that's when we can see huge benefits for some people in that situation. It's really true. I mean, insulin, you know, for the most part, and like the one guy it wasn't because he was so fit

and there's genetic variations. But for most people out there, it is really the most common thing. And, you you know aside from getting the NMR particle test getting a measure of your fasting insulin really great if you can get an insulin test after you have a sugar load that's even better yeah because by the time your blood sugar goes up you're down the road way down the road yeah it's a late stage phenomena even have your blood sugar

going up fasting and then two hours after sugar load it's you know you see a little earlier but you know I, doing these tests for decades, I just see this pattern over and over again. You can have perfectly normal sugar, perfectly. I mean, I had this one woman who was really overweight, had a giant belly and clearly she was metabolic syndrome. She had high triglycerides, low HDL, the same pattern. But when I measured her glucose tolerance test

and her A1C, perfectly normal. Like her fasting blood sugar was normal. Her average blood sugar was normal. Her one and two hour blood sugar test, like normal. Like her fasting was in the 80s, after it was like 110. But I measured her insulin. Now normal insulin should be under five. So over 10, kind of in trouble.

Her fasting insulin was like 30. Yep. And then we did a sugar load and her insulin went up to 200, 250. Yep. And it should be under 30 after sugar load. So she was like 10 times normal. And it was keeping her blood sugar normal, but it was driving all this weight gain and inflammation and abnormal cholesterol.

So you really have to dig in in a different way than your traditional doctors are digging in. Absolutely. Those people can't, they have such a hard time losing weight, especially if you don't pull the carbohydrates too low. I mean, she lost 50 pounds like that. Once you pulled the carbohydrates out. It's so easy. I feel embarrassed about it because, you know, it's like what we're telling people to do is so simple. But when you understand the biology, which is what functional medicine really is about, it's understanding each of our unique biology, looking at things that traditional doctors don't look at, at function, at differences in the responses to different

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

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

insulin resistance significantly. You know, her insulin, I don't really remember what it was, but it wasn't that concerning to me. But she was also concerned about her cholesterol. You know, she was 55. Her doctor had just checked her cholesterol. Her LDL cholesterol was 160. And so he was recommending some medication. She didn't have a strong family history, but when we look deeper or when we, you know, her cholesterol also showed her triglycerides were okay at 90, her HDL was 55. Again, maybe not perfect, but you know, it was really that LDL cholesterol I was a little more concerned about. We did, we did particle size testing on her and she didn't have too many of those small dense LDLs. She was more pattern A, more of the big fluffy LDLs,

which made me happy to see. But she's like, you know what, I want to bring down this LDL cholesterol. And so with her, the focus in the diet was a little bit different. She was about 10 pounds overweight, so she wanted to lose some weight. So we focused on that. And then we also really focused on her protein because, um, because protein's really important as well. When we're talking about cholesterol, because there's some vegetable proteins that can help with lowering, they can help with lowering that LDL cholesterol. So beans and legumes, nuts and seeds, these are vegetable sources of protein that have plant sterols in them, and they can help bind to the cholesterol in the gut and lower your LDL cholesterol. And, you know, so when I have a situation like this, you know, I really talk

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

It's not just what you take out of your diet, like sugar and starch, it's what you put in your diet. Yes. And using compounds that are naturally found in plants, like plant sterols that come in beans and nuts and seeds and high fiber, you can really have a big impact. And I think, you know, one of the things I like to use is extra fiber as something called PGX, which is basically from a root of a Japanese vegetable called cognac. It's not like the alcohol. It's K-O-N-J-A-C. And it's a fibrous root.

You can actually make noodles out of it. There's these shirataki noodles. So you can have pasta, in a sense. But it actually is zero calories. It's all fiber. And it blocks the absorption of cholesterol from your gut. So adding more fiber plays a huge role. Yes.

Changing the quality of your diet, increasing the good fats like olive oil or the avocado oil, and also improving the overall content of phytochemicals in your diet, all helps to reduce your risk dramatically. And I think we're really not focused on that in medicine. We're just like, here, take the struggle, see you later. And people often get a false sense of security. So, oh, I'm taking my stat and I can have the fried food or I can go to McDonald's. I mean, they were talking about selling Lipitor at McDonald's, which I thought was insane.

But I think we really have to understand that heart disease is a complex disorder. It's not just about cholesterol. That from a functional medicine perspective, we do much more detailed workups, looking at inflammation, oxidative stress, looking at the particle size and number, looking at even your gut, heavy metal toxins, other factors that relate to nutrition like homocysteine. And we get a really good sense of what's going on and we then personalize the treatment. And it's very, very different approach to reducing your risk. And it's been so satisfying for me. And I've had patients who have had heart attacks. And then we follow them for 20 years.

And they're just great. And they're healthy. And they have no risk because they really have changed the cause of their heart attack. I hope you enjoyed today's episode. One of the best ways you can support this podcast is by leaving us a rating and review below. Until next time, thanks for tuning in. Hey, everybody. It's Dr. Hyman.

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