Lipids: The Rise of a New Field of Study with Dr. Dayspring (Episode 1)

Welcome back everybody. It's great to be back again. I'm Here today with Dr. Dayspring is a world renowned lipidologist. So I'm going to read his introductory first and we'll kind of grab into it. Dr. Dayspring is an internist who's a fellow of the American College of Physicians who also serves as a social media ambassador to the European Atherosclerosis Society and National Lipid Society. He's practiced internal medicine, lipidology, women's cardiovascular health for 37 years in New Jersey and then worked seven years as a scientific officer for two large cardiovascular biomarker labs in Richmond, Virginia. For the last five years he's been a lipid specialist advisor for early medical, which is Dr. Peter Attia's practice. Great to have you here today to talk to us about.

It's fun to be chatting with a colleague in Richmond.

I know, yeah, it was interesting talking with you before and also watching some of your previous podcasts and things like that. So first I want to talk about how do you go? Because when I was in medical school at MCB here in Richmond, Lipidology, like I didn't know the word lipidologists, you know, so I didn't really hear that term until I started doing my integrative functional training back in 2012 and even practicing locally, I had never like didn't know people actually did this and then come find out you've been doing it for decades. So kind of walk us through how do you go from internal medicine, what your progress was to get to be like literally a world renowned lipidologist?

It's quite been quite a journey for me and I had no grand design to wear up, wind up where the heck I am. I joke. I went to medical school in the Dark Ages, 1968-1972, and never mind the science of lipidology, we barely knew what lipids were. The only lipid being measured in patients at time was total cholesterol and also triglycerides, which were not understood at all. And there were virtually zero lipid therapy. So you know, we were told at what level of cholesterol to worry about, but there was nothing to do about it. Even if somebody had FH back in those days, the worrisome level was if they're above 300, you got a problem and if they're not, don't worry about them. But somehow I got very interested in cardiology because at that time when you were a young stud resident and doing night call and moonlighting and ERs, during your residency, the biggest crisis was acute coronary syndromes. They were ramp, but they were coming in every night. And what did we do for them? We didn't have to CPR them in the emergency room. We put them at bed rest, gave them oxygen, maybe heparin, treated ventricular premature contractions totally unnecessarily. So that's where I started. It's like before the Wright brothers invented their first airplane and now we're watching rockets fly around. So I went into the private practice of internal medicine, still very interested in cardiology because it was the primary pathology that was killing people. By that time we had cured bleeding ulcers with Tagamet. So that wasn't a problem anymore. So early in my career was get on the hypertension bandwagon that can do good to cardiovascular disease. Still no lipid management. And what the rudimentary lipids were measuring, you didn't know what to do with them anyway. But sooner or later, it was in the mid-1980s that some information started to come in that, you know, you can measure lipids and if you can reduce cholesterol in the blood. However you're mentioning, by that time in the 80s we had the calculated LDL cholesterol. We had direct HDL C measurements, so we were a little smarter. Had triglycerides. Still didn't know what to do with them, but at least we knew hey. The first drug that worked was a bile question. It's called a steramine. Pretty much an unusable drug, but it did lower LDL cholesterol a bit and did reduce outcomes in a big clinical trial. Then the first fibre trial came in Gemfibrizole. First primary prevention trial really done, the Helsinki Heart trial where gen fib as a monotherapy reduced events. That was published in 1987. And what hit the market in 1987? Statin being the first guys like me who started to delve into studying lipids in the 1980s of course became major statin users. Probably most of the internists and clinicians at time used statins very cautiously, if at all. Because although they lowered cholesterol, there were no long term safety trials or even outcome trials we were believe in. Hey, Cholesteromin lowered cholesterol. It works. Statins lowered cholesterol more. And of course 1994, seven years after they hit the market, the 4s trial with Simvastatin outcomes beneficial. Very soon, within the year, a primary prevention trial west of Scotland with Pravicol worked. So statins came along. So I was really being aggressive with lipid management by that time. Now back then when you somehow discovered yourself and it was all self studying lipids at the time there was certainly no society of lipids. You just try and delve into the literature and learn what you could. But interesting pharma understood. Here's a doctor up here, he's writing a lot of statins. What does he know that doctors who aren't writing a lot of statins so they sort of hang around with you and they interview you and listen to you and they, they get the feeling that you might know what you're doing. So they give you an opportunity to we would like you to speak to other doctors. Okay. So what they do is they send you out into your local community to basically speak to a few friends or colleagues who know of you who might come to a lecture you're doing. And by luck my self study up to that time I sort of knew a little bit what I was talking about. And the doctors I talked to, better yet, they sort of liked the way I explained how I approach lipids, what I know about lipids. And it spreads like wildfire. If you get the reputation, you're a good lecturer and it's really the pharma people who are monitoring you. Early on at that time, back in the late 80s, early 90s, you start getting invitations to lecture here, there and everywhere. So I love doing it. I started to accept invitations and now you're traveling out of your local community, even out of state. And when you start doing that and sooner or later you're lecturing at medical schools or through faculty doing grand rounds at a hospital, you start to meet the higher ups in lipidology and you get to interface with them a little bit. They get to know who you are. And you start also when you're at destiny, start attending more national meetings. Now there was no lipid meetings to attend but American heart places like that, endocrine societies, and you'd meet more and more of those high level colleagues and before I know it, I was, you know, I grabbed the high level colleagues and I annoyed the heck out of them. But they sort of like the way I do. By that time I had a reputation as being a great illustrator of lipoproteins and lipids in visual mostly powerpointers. So they all wanted to know how I did that. Long story short, I got to meet virtually everybody who's anybody in lipids, became friendly with him and then you start getting invitations to speak at national meetings. Hey, write, publish a chapter here Help me co author this paper here. And here I am. And you know, even when you get to a point where you're so busy doing the educational things, I had to bring in a colleague to assume much of my practice, keeping only the tough cases or some new cases. And then at a point father time gets you. And I really can't keep doing this forever practicing myself. And I have so many opportunities to lecture, write and teach. And then I got the laboratories wanted me to come down as a scientific officer and it was a wonderful opportunity that I just fell into and they recruited me because this guy can understand lipids. He explained lipids and he speaks to clinicians. The laboratorians are not always the greatest people to speak to clinical guys like yourself, they just don't so to speak the same language. But so I got for seven years to hang around with world class clinical laboratorians, became friendly with many of them, started attending their meetings and it helped me better understand their part of the lipidology equation translated to real world guys. And so I just became even better at understanding lipid speaking. The National Lipid Society started just before 2000. By 2004 they decided we want to start a journal and we want to start fellowships for lipid guys. And ultimately we want to create a lipid certifying examination. So the American Board of Clinical Lipidology was formed. I was a little bit in on the ground floor on that. I helped develop a lot of the self assessment programs. I would teach at their masters of Lipidology course. And before you know it, so now they're going to start certifying lipidologists. So they brought a group just under a hundred of us together, I believe it was in Chicago and they had like they put together the first beta trial exam and you know, so they brought in quotes from best and the brightest. We'll give you guys the exam and see how you do on it. Do you like it? Was it fair? Are you guys all going to fail this? So and one feature of that was, hey, if you took the exam they would grant you certification in clinical lipidology. Now again they were recruiting people who were likely going to pass the test no matter. But I took the test. I get it. Underground floor. I have certificate now 28 as far as I don't know what to up there now but in the thousands or so just continued to teach. But now I was into the lab. And the great thing about the lab, I'm called their scientific officer because I know a lot about this stuff. But these labs were Very busy doing hundred of some thousands of assays and you get doctors calling up, I don't understand this, what can I do? So hey, dayspringo get that phone call to try and make it.

Which labs were those that you were doing that?

I started with Health Diagnostic Lab, which was an incredible lab. And again, world class laboratorians. Ultimately, laboratories get into trouble with third party payers because they're always going to be accused of unnecessary testing and third party payers don't like to pay for it. One of those third party payers is the government through Medicare and Medicaid. And they surely when they see a lab is really creating a lot of bills, they come down with their investigators and you know, unnecessary testing. Every test was ordered by a doctor practicing medicine. It's not what laboratorians say, but they'll say, hey, do you really need this many of those tests? So ultimately they stopped paying them and the labs fold. So HDL ultimately went into bankruptcy after a decade, but they were bought at Biops at the bankruptcy sale by Truth Health Diagnostics who came in? They kept me. They wanted me to continue as a scientific officer. They kept a lot of the people, they narrowed down the group but ultimately ran into the same trouble. After four or five years, they're being investigated for unnecessary testing. The screws are put on them and they have to fade away too. That was 2019. I joined HCL in 2012. And then my friend Peter Attia said, tom, I know the labs are not here. What are you doing? I said, well, I guess I'm retired finally. And I was into my, I guess late 60s at that time, early 70s. And Peter says, but you know, I have this very specialized practice and you know, I've leaned on you for the last decade. I knew Peter for a long time and we interacted on lipids a lot, me trying to teach him and help him solve. So he gave me an opportunity to be the lipid specialist in his practice. Now I don't practice there, but I look at lipids. He's got internists working for him who do the practicing and prescribing himself. But I will talk to them. If they get a lipid thing, we'll talk in a group. Here's what I think is going on here are possible solutions to it. Peter, as you know, does a lot of education with his podcast, writing weekly emails. So I get involved in any of them that are lipid. If you go through his podcast library, you'll notice a dozen of the world's top lipid Thought leaders. I've done eight of them with Peter, but there are many, many more. I recruited most of those speakers to come and speak to because I know all the guys. And the last thing I'll tell you is at a certain point when I started to slow down a little before I left the labs, I got involved with social media. Twitter was invented and it was there ultimately LinkedIn. So I started going on Twitter and started publishing there, writing little tweets and put all my teaching slides, which people love. So before I know it, I got like 37,000 followers on Twitter. Not bad for somebody who just tweets all the time. LinkedIn. I only accept if you're a professional. You know, there's a lot of laymen and who knows who following me on Twitter. But now all of a sudden, you're recognized far more globally than you were. I've done a number of talks around the world, but I still didn't have a high level recognition. But once I hit social media. You mentioned I'm a social media ambassador for European athletes. I've never heard that before because they contacted me. And we love the way you're educating on social media and we'd like you to copy us on some of the tweets or help us with some of our endeavors. So why wouldn't I? And now all of a sudden I way more connected globally with the top five thought leaders in the world. Then I was mostly connected in the United States and now it's globally. So it's been wonderful.

That's a great summary. I haven't actually heard all those different things put together with your store. So it's really great to hear that. It's kind of interesting, the whole lab thing, because I, as a priority as a clinician, I have the exact same issue where it's like, this lab is paid for by this insurance. This lab is not paid for by this insurance. This one is a cash base. And so I have to create my own ecosystem where it's like I want to do Cleveland heart labs, which has the NMRS and all the advanced stuff we'll talk about here in a little bit. And you realize, hey, that's going on a different pathway. If you use certain labs, like doctor's data, don't accept insurance. If it's a certain carrier, I'll use it for that. And so I almost have to become like an insurance expert. And I've actually gotten some letters from certain carriers which I won't mention here just in case their representatives are listening. Whose immius have sent me cease and desist letters that if I keep on ordering this lab, they might drop me from their insurance. And so in the way my practice is set up right now, I do like a membership and insurance that allows me to use insurance for labs that are appropriate. It also allows me to use the patient's resources for labs that are outside their scope. But yeah, you gotta stay on your toes because if not, it's terrible.

I don't know how anybody practices the type of medicine you do, or even run of the mill internal medicine or family practice, because everybody's trying to put handcuffs on you with no recognition that you're a well trained physician, you have your own CV that shows you're not some dummy who's discovered testing here and there and you're doing it appropriately. But they don't want to pay for it. They want to maybe pay for a lipid profile, a glucose level, even fight some people on a 1Cs. And good God.

Yeah, I first ran into that when I was in the military. And that was before, this was 2004, before Medicare was paying for screening colonoscopies. And so the United States military filed the same standards as Medicare. And it's this common knowledge, if you're in the military, just being in the military increases your risk for Parkinson's, als, the chemicals you're exposed to. First Gulf, second Gulf, you're Vietnam, we know these veterans are getting bladder cancers, all these things. So like all my guys that came and see me, it's like everybody gets a colonoscopy. Sure. Insurance wasn't paying for it. So I have this colonel or general, a sergeant, you know, have you, you know, do you have blood in your stool? And they'd say, no, it's okay. Have you ever in your life ever had blood? When I was 12, bingo. And I get the insurance to pay for it. And all of a sudden it's this game where like I know you're high risk because of your history. I know it's becoming more common. I had to massage the system and five years later, it's now considered okay for screening. And now as of like a year or two ago, now it's okay to screen a 45 year old to 40 for colon cancer.

They're catching up. What you knew 20 years ago?

Yeah, well, that's kind of, that's a great transition because it sounds like your entry into this foray, so to speak, was a ton of self study. Like there was no board. You predated the board. You actually were part of the board helped form all this kind of stuff. And so now at this stage in your career, you have this history and we'll probably talk about what's cholesterol and you this. But it's like interesting how like in the modern day of evidence based medicine, people forget there's sometimes a 20 year lag between data and clinical stuff. And you literally have lived that. That's been your experience.

It's funny, when I was working at the lab, one of my jobs was because they were calling up the lab all the time, stop offering this test. What the heck would you even. Why are you asking this? And I would be brought into those phone calls as someone, somebody who had a high level knowledge of appropriate use. But you'd be talking to a bunch of accountants bean counters, somebody who they directed as medical director who had a very limited knowledge on any of these things. And I would give them the scientific A, B, Cs and Ds as to why each test is very appropriate in one ear there and out the other.

I kept.

Finally I got to the point in lesser. A waste of time being on these phone calls. My credentials mean nothing, my experience mean nothing. They don't want to hear it.

What's interesting.

So it's so tough. One thing, last thing, I'll say I was one of the reasons I left medicine after 37 years. For most of my 37 years, I had nobody over my shoulder restricting me. They respected somebody's expertise. But then it got to the point where you had to have little algorithms for who, who can get this. And that's it. If I have opportunities, people want to give me other employment, goodbye private practice.

It's unfortunate there's a whole generation of physicians like you. And actually it was pretty standard 25 years ago. That physician would work till they're 75, maybe 80. Sometimes they'd work until they're actually like, you know, you're kind of old, you come to work in a cane, you forget you need to retire. And now we have people retiring. You know, this happened with the pandemic where a lot of people in the local environment were like, I'm done. 55. Couple GI doctors hiring at 55. It's almost like you're removing 15 to 20 years of a physician's no career.

If I didn't get the lab opportunity and after the lab, Peter, I'd have been in a rocking chair a long time ago. We got enjoying a retirement. I sort of love my retirement now, which is still teaching lipids, because I love it. But but you were looking for ways to get out of the private practice.

In medicine and heart disease. A lot of interesting statistics like quoting heart disease is the most common cause of death in our country. If you're a female diagnosed with breast cancer, heart disease is still the most common cause of. So it's one of those things that something as basic as cardiovascular disease and obviously lipids are one of the major risk factors. It's a bigger deal, I think in 1900 cardiovascular disease was uncommon. By the 50s it was the most common cause of death in our country. And 74 years later, it still is. So let's make a little transition. One other thing you mentioned when all, everything you mentioned where in that. Because there's a bunch of different credentialing societies now where in that this lifestyle, diet, exercise, where in your journey in lipid medicine do those? Because in the functional medicine world, we always, the, the foundations are always like diet, exercise kind of stuff.

And it has to be. But look, we're at the point in lipidology now where we believe anybody who does show up with a lipid disorder, there's an abnormal genetic process behind that. If you had a perfect genome, if that even exists, but at least say a perfect lipid genome, the genes that influence lipids, some of them minusculely, some of them disastrous, but we're created from billions of genes. So if you've got a few even minor genes by themselves, but oh, they start pairing up in you, you will have what we call an abnormal lipid phenotype. That means the blood tests come back abnormal, whatever, they're measuring yourself. So like everything else. So if we all have genes that are sending us down to abnormal lipids, what it really influences a gene's what it's going to do to that phenotype. It's the environment that a gene gets exposed to. So in the lipid world, what are the environments of concern that lipid drugs are going to be influenced by? And clearly you start with lifestyle. And what does lifestyle include? Well, of course it's your nutrition, but it's your activity, your exercise, it's your sleep pattern patterns. God forbid you're exposing yourself to toxins like the soldiers you talk about or the smokers that we encounter all the time. So it's genes plus environment, environment, lifestyle. Now part of the lifestyle is nutrition. So obviously if you have a lipid disorder, somebody should be advising you on if you're an expert in lipids, the type of nutrition you or the nutritionists that you influence or work with or Respect might come up with a nutritional plan that would probably or likely be beneficial to a lipid disorder. The one thing you will find out and I think you have to be open minded on nutrition. There is no such thing as I'm going to memorize one diet, that's it for everybody and I'm done. That is absurd, you know that. So you do have to individual, individualize a nutritional plan based on not only whatever lipids you get other biomarkers you get, other historical things, physical examination, you're assessing their activity and their muscles, blah blah blah. And you're going to come up perhaps with solutions with all of them. You're certainly going to stop smoking. Despite no randomized bonded trial.

Evidence based medicine. There's no like, what's your evidence? Like common sense.

Same as for parachutes, no evidence but most of them.

Did you read the, did you read that BMJ article about that?

That's a great line. So anyway, nutrition is part of it. But no matter what, even if you're an expert and you say aha, you're insulin resistant, you're not. Here's the nutritional plan. I'm coming up where you've been eating too much saturated fat. You have to try your nutritional plan with addressing all the other things, sleep, muscles, blah blah blah. But if it doesn't work, you have to be prepared to abandon your nutritional plan and try something else. Even though what you suggest might work in the majority of people, you're going to find out diets can be funny. You know, as far as solving a lipid disorder, I will then go on to whatever lifestyle changes you do come up with. And I've listed four or five that you'll approach to if you still have a lipid disorder that puts the patient at cardiovascular risk. You must work on pharmacology into the world. And now that we're realizing the lipid or lipoprotein concentrations that are really necessary to say with this amount of certain biomarkers it is impossible to get atherosclerotic cardiovascular disease. Our goals of therapy over the years I told you when I started it was 300 total cholesterol. Now we're into LDL cholesterol or LB, LDL P if you're beyond lipid markers. Boy, every 5, 10 years the bar keeps getting lowered on what is an acceptable, what is an appropriate goal of therapy. Goals of therapy have always come in two directions for the very high risk and for those who are not at high risk, basically. And of course you'd be more aggressive with the goal of therapy and the very high risk. But really those goals of therapy emerging, what's good for one is certainly probably good for the other. The one who's already had a heart attack, you're trying to prevent the next one. But in the other ones, primary prevention, we're now calling it primordial prevention. Let's get your lipids, lipoproteins in balance so we can take the leading global cause of morbidity, mortality out of your picture. Concentrate on the other things I have to worry cancers in you or arthritic things in you, bowel diseases in you, and you can zero in on that. So the lipid management is nutrition and lifestyle and ultimately pharmacology. And the good thing, in the year 2024, there is almost nobody outside of rare genetic lipidosis, that you cannot get to a pretty good goal of therapy to eliminate atherosclerosis. But those people do require drug treatment. We basically have four drugs that you can use other than we're not talking about pediatric homozygous fh, where they have drugs that you're never going to use as an adult. Four drugs. So there's not a lot to master, even with the pharmacology notice.