The 4 SIMPLE STEPS To Prevent Heart Disease TODAY! | Mark Hyman

80% of cases of heart disease and diabetes may actually be preventable with diet and lifestyle.

High blood pressure, cholesterol, diabetes, they're seen as separate. They're the same condition.

We know that two-thirds of people who are cardiometabolically unhealthy actually have sleep apnea.

So let's talk about heart disease, because we think we know all about heart disease. Oh, it's cholesterol and statins are the cure, and if that doesn't work, you get a bypass and angioplasty, and you know, if that doesn't work, you get a heart transplant. That's sort of. And then, you know, of course, there's all the normal causes we know, like diabetes and high blood pressure and high cholesterol, but diabetes is a symptom. High cholesterol is a symptom. Smoking is a habit. And yet we're kind of missing the boat, I think, on a lot of the reasons we have heart disease and what we can do about it from a, a more systems perspective.

So.

Let's talk about just what a big deal this is and how few people actually are meeting the simple behaviors that will prevent heart disease.

Yeah, again, this is another one of those conditions 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. Not too much body fat. eating pretty healthy, little exercise, and don't smoke. Yeah, simple things to do, but like-.

We're not even there yet.

3%.

Yeah.

And what's really staggering is that, you know, not only do 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 that 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 ago. I remember that New England Journal of Medicine review paper. Peter Libby and Paul Ridker 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, that'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, things like that, even toxins and bugs in your gut. But stress causes inflammation. Absolutely. Lack of exercise causes inflammation. 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. It 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 that? What do I do with it? Oh, statin and aspirin. And then they're probably gonna treat them with, if they are pre-diabetic or diabetic, they're gonna 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 polypill, the 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? Why do we have an a need for aspirin and inflammation.

Why has 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 eat my cheeseburger. I can eat my fried chicken. Isn't that interesting that people change their.

Diet in an unhealthy way when their numbers back. Oh yeah. 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. And I think they do sell even statins over the counter. And like, you know, it's like, and it's like those commercials for the acid blockers, like, take some Pepcid, 'cause don't worry, daddy, you can eat your peppers and sausage. Just take some Pepcid. And I'm like, no, don't eat the peppers and sausage. So, you know, you kind of mentioned they do instead 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 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 a few things. maybe it's 30, 40 things. Maybe if, like, it's a super fancy doctor, they'll measure a hundred 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 we, 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. Baum. 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 test in a minute, but tell us about, about your, you know, 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 it 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. Triglycerides weren't bad. His HDL was 39, which is kind of low. But we looked at his particle number, even though his LDL, if you regular dog, oh, that's a great 160, that's a great cholesterol. They missed the boat because his particle number was like 1500. It should be under 1000. 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, oh, 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 the regular cholesterol panel. I mean, you gotta insist from your doctor. You can get it from LabCorp Quest called NMR or Cardio IQ. 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, you're 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, it should be called cardioendo immunologists. Because it's all about the hormones, including insulin, all about the inflammation, immune system. And you mentioned earlier that study by Paul Ridker 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 like it was this kind of cohort of women who are probably in their 70s and 80s, who are thin, who are fit. The ladies we see at Canyon 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 I'm 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 heart disease is a symptom. It's a syndrome. It doesn't, there are many, many causes. So let's talk about this whole idea of metabolic health. because 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 NHANES data from 2009 to 2016.

To government surveys.

Government surveys.

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 is 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. Yes. It's like, what's going on with the skinny people? Well, and that's the interesting piece.

Fewer than one-third of so-called normal weight people were metabolically healthy. So that's another really important message. Wait, wait, wait, wait.

Did you just say that two-thirds of skinny people are metabolically unhealthy 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 metabolically unhealthy?

No, no, no, it's still the 88%. 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've 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%, okay, one out of two Americans has pre-diabetes 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 pre-diabetes 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 it's 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. Otezla, Metformin, well that's not gonna 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, 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 wanna 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, 'cause if you think about something that's preventable, you don't wanna wait till they cross that threshold to prediabetes or diabetes. So even in the range of so-called normal glucose Mark, you know this. Somebody who's fasting glucose runs less than 85 is in a very different metabolic place than somebody who's fasting glucose is 95 to 99, even though they're both technically normal. That it's a spectrum of risk and the farther along 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, is causing heart disease? And sugar, the thing that's driving the insulin?

Because fat doesn't cause insulin spikes. Well, there is some, I mean, fat is a player. Fat by itself.

Fat by itself is a player.

If you eat fat with other food, it will.

Yeah.

And 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 in itself, if it's made from whole food sources and nuts and seeds and avocados and all that- 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, right? I have a patient, Cindy, that I remember who was a super high risk for heart disease and she had, I mean, she looked like the Tasmanian devil. She was just like a round apple ball like this and her belly was like big thing. And I'm like, this woman is in big trouble. And she's inflamed. She's a high score heart disease, high blood pressure, diabetes. And I'm like, let's check her glucose tolerance test with insulin. And this is, you know, this is like 20 plus years ago, and no one was, like, looking at this. Even today, no one's looking at this. It's like, so hard. I mean, it took 50 years from the time the guy said, hey, we should wash our hands before surgery for us to wash our hands. You know, McKinley died, President McKinley, because he got shot in the belly, and the doctor, mcburney, stuck his finger in the wound to check it out without washing his hands. You so 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, you see 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, like. 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 was 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 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 were basically inflammation factories, and leading 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 that showed me so much because you can even do a normal glucose tolerance test.

If you're not measuring against.

Perfect. And if you were super hyperinsulinemic, you're gonna miss that patient's real problem.

And you know, it's interesting, Mark, because that scenario is also associated with that cholesterol profile we talked about with the small dense LDL and low HDL and the sequelae that we usually link to diabetes, fatty liver, peripheral neuropathy, all these other organs that are affected, and it can happen with the high insulins alone before the sugars go up. It's a metabolic imbalance.

So that's really the take home here is that heart disease is really a hormonal issue around insulin and insulin resistance and an inflammation issue. And unless you address those two things, not with aspirin and statins, which will work to some degree or metformin, which will work to some degree, but, 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, pre-diabetes, 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, exercise, sleep, stress, all those, we've covered those on the podcast, 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 love to dive into that have a big impact. So can you just share some of the other factors that could drive inflammation.

Well, yet another example where the gut microbiome seems to play a role. So now that we can do more sophisticated gut testing and look at these microbial patterns, there's a so-called microbial signature that strongly predicts insulin resistance, diabetes, and cardiovascular disease. And a couple of general scenarios you see is there's a loss of overall microbial diversity in the gut. There's a loss of a couple of signature species, one's called one of the phyla that 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 Akkermansia muciniphila, 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 Akkermansia 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, yeah, I was gonna ask you that.

Like, 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 Akkermansia, and a rebound of those butyrate species.

With metformin.

With metformin, which I think is fascinating, right? The way we think drugs those are working may actually be completely different.

We call those side effects, but they're not.

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 acromania, like polyphenolic foods, berries, deeply pigmented berries and greens and garlic and onions and cranberries, right? Of course, people want a pill, but there are other things that can potentially achieve the same thing.

Interesting, yeah, there's a new company that came out with an acrylamide product. Yes.

Pendulum. The Pendulum.

And it's fascinating. They're not saying this is a probiotic that's healthy for your gut. This is a tool to control your blood sugar. Isn't that funny? And I think, you know, we don't even think about that, that a lot of insulin resistance can start in the gut. I had shared the story recently on a podcast, but I'll share it again. I had this patient who was diabetic, very brittle diabetic. He was kind of a type 1e2e, but he wasn't on insulin, but he was just all over the place. Put him on a keto diet, sugar's dramatically improved dramatically, but still not like going from like 250 to like, you know, 120, 130 better, but not like more where I want them. And then one day he called me up and said, you know, Doc, my stomach's been bothering me. I got the worst gas and I just feel so bloated and uncomfortable. I said, well, we have to get to the bottom of it and maybe have bacterial overgrowth, maybe have this, maybe have that. But like in the meantime, you're so miserable, why don't you just try some charcoal tablets, see if it gives you some relief of your symptoms. And he comes back and says, I don't know what happened, Doc, but my sugars went to normal. Like I'm in the 80s now because I took charcoal. And I'm like, oh my goodness, this is it. This is these toxic bacteria and they're producing toxic molecules. and charcoal is like a sponge for toxins. So when something comes in the ER and they swat a bottle of pills, we make them drink a bottle of charcoal and they have black teeth. But it works to absorb all these other bacterial toxins. And I was like, wow. And so often the pathway to fixing heart disease might not be through the heart. It might be through the gut or other factors like toxins. We know the role, for example, pollution and the particulate matter in a lot of urban areas, huge correlation with heart disease, right?

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

They've also shown- so all my jogging and running outside in China and Beijing in the middle of winter when the skies were gray, probably wasn't a good idea?

Probably wasn't a good idea. You can even show that those arteries will spasm acutely in response to stress. in response to a Burger King meal.

So- Not McDonald's.

Well, not mine. Let's say a Burger and Fries meal. So if we understand what keeps that endothelium healthy, that can actually clue us into how we keep ourselves cardiometabolically healthy.

Yeah, it was interesting also heavy metals have become an interesting phenomenon. And many heavy metals are exposed to lead, mercury, arsenic, and so forth. Arsenic's been linked to diabetes, and things. But, the lead story is fascinating to me because from our perspective in functional medicine, it's relatively easy to diagnose and treat, but it's been mostly ignored. And, if you look at the American Journal of Cardiology, they put out major papers that show that, for example, if your lead level is over two, which is considered normal, which is about 40% of the population has a lead level over two, which is a lot of people. That the risk of having a heart attack or stroke or dying was far greater than if your cholesterol was abnormal. And yet, what doctor is checking your blood levels or checking your body burden of lead or chelating you as a treatment for heart disease? And yet, I think it was called the TACT trial, which was a $30 million randomized controlled trial of chelation therapy using EDTA, which chelates lead, actually was effective in heart disease. and yet it doesn't matter what the research shows because we don't have research evidence-based medicine. We have reimbursement-based medicine. We get paid for doing angioplasty is not chelation. So that's what keeps getting done even though the data is there, which is kind of amazing. This is an NIH government study showing that it worked. I was like, okay, well this is very slow to pick up, but we see this. I think the take home here is if you have heart disease, Don't just assume it's high blood pressure, smoking, cholesterol, diabetes. It could be a lot of other factors. It could be your gut microbiome. It could be nutritional deficiencies. It could be environmental toxins along with.

Lack of sleep and stress and so forth. And Mark, you know my passion about sleep. I would put a sleep study very high on the radar for anybody who's got cardiometabolic imbalances because we know that two-thirds of people who are cardiometabolically unhealthy actually have sleep apnea. And our perception of how sleep deprived we are doesn't always this match the reality of what we find when we screen people. I had this guy.

I remember him. He was a lawyer. Came to Canyon Ranch years ago, 50 plus pounds overweight, desperate to get healthy and lose weight, trying to exercise, eat better, doing everything. Nothing was working. So I'm like, tell me about your life. He says, well, I'm a lawyer. I work really hard, a lot of hours, and I, and I work at a stand-up desk. I'm like, oh, that's great. I said, why do you work at a stand-up business? This was like, you know, before people were working at sea. He's, well, if I sit down, I fall asleep. I'm like, oh, no, you know, you probably have sleep apnea. And we did a sleep study, and he had sleep apnea, for sure. And we got him on a CPAP machine. He lost 50 pounds and reversed his pre-diabetes his cholesterol, obviously, his weight, blood pressure. And, and most, you know, most people don't realize that, that, you know, it's a, it's a it's a bi-directional thing. So if you're overweight, it can cause sleep apnea, but if you have sleep apnea, it can cause you to gain weight. And it's very hard to lose weight. And he was able to lose 50 pounds just by getting on a sleep program with a sleep machine that helped him sleep. I was like, wow, this is interesting. Had many people like that. Yeah. So it's, you know, honestly, Cindy, I don't know about you, but, like, I've learned way more from my patients than ever. Medical school. Absolutely. And the challenge in, you know, being a doctor is you get trained in this paradigm and it's taught to you as if this is a monolithic truth, like this is a table and that's all it is. There's no questioning that this is a table, right? But the truth is we are just learning so much about the body and all of our old ideas are sort of breaking apart. But unfortunately people really aren't accessing them and it just breaks my heart to see how slow medicine is to adopt the emerging science that we're talking about, whether it's around checking for lead or insulin resistance. I mean, insulin resistance is not even like a controversial thing. It's not like heavy metals or the microbiome, which seems weird. I mean, like, insulin resistance is a well-described known phenomena. It's just doctors clinically are kind of clueless because the treatments are going to be primarily lifestyle interventions. There's no drug.

Oh, your cholesterol is not going to give you statin.

Your insulin resistance, what do I do?

Oh, we'll give you metformin, but that's not the answer. Or even think of the terminology of borderline blood sugar.

Oh yeah, I hate that. Yeah, I do too. Oh my God, it reminds me of the story. It's this patient comes in, it's like blood sugar's like 120, right? One high, 118, like high, 126 is diabetes. Like, so have you seen your doctor about your blood sugar? Because it's kind of high. And he's like, well, yeah. I'm like, oh great, what did your doctor say? He says, well, I said, we're gonna watch it. I said, watch for what? He said, well, watch it until it gets to be in the diabetic range, and then he's gonna give me medication. And I'm like, ah, no. You know, it's like, it's so terrible. So tell us about a patient of yours, Cindy, that you had, a woman, you know, post-menopausal woman who really struggled and, and you helped with this kind of a functional medicine approach.

Yeah, this, this was really interesting because this, this drove the point home that you can't rely on body mass index or weight to predict somebody's risk. Now, she had a strong family history of heart disease. But she came in and I did her cholesterol profile, the advanced one that we talked about, and I was blown away because she was not overweight. She did not have high blood pressure. Her triglycerides were 600. That is through the roof. Normal is like less than 70.

Over 100, I start to worry.

Yeah, she had a lot of the small, dense LDL particles. I'm like, this doesn't fit with the person in front of me. But when you measured her waist to hip ratio, it was elevated. So she wasn't overweight, but she had just a little bit extra here. Belly fat.

Belly fat.

We actually did a body composition on her and confirmed that she had some visceral adipose tissue.

Okay, wait, wait, what's a body composition?

That sounds interesting. So it's a DEXA scan. It's the same kind of technology you use to do a bone density, but you can actually do it for a body composition. And it tells you your muscle mass.

Your fat-free mass, and it tells you how much deep belly fat, whether you.

Have fat under your skin or deep in the belly.

Yeah, so basically it looks at how much body fat but where it is.

Where, right. And that's important because you had mentioned your patient with the cholesterol of 150 who was skinny. Yeah. But I bet if you did a DEXA on him, he had very little muscle mass. For sure. Very little muscle mass. And those are the ones that can fly under the radar. So what was interesting for her is we did find some underlying issues. She turned out to have Hashimoto's thyroiditis and she was hypothyroid, so that can affect cholesterol. Said, okay, let's fixed the thyroid first. She was vitamin D deficient, which can affect cholesterol, so we're working all these other pieces. And the biggest thing for her, interestingly enough, is she really got engaged in fitness. So she had a poor fitness level as we measured it with something called a VO2 max, maximum oxygen carrying capacity. And she got on an exercise program and she came back and her cholesterol was much better. her fitness was much better. She improved her muscle mass. She still had a pretty high, she was still not where we wanted her to be from a cholesterol standpoint, and she still had some elevated inflammation. Her CRP was high. So it's yet another incidence where, okay, she's got some bloating, she's got some digestive issues. So we then did a breath test and she ended up having small intestinal bacterial overgrowth. So we addressed the small intestinal bacterial overgrowth and her inflammatory markers got better. fast forward 10 years. She's now got great cholesterol. She hasn't, has maintained her high level of fitness. She's become passionate about exercise, and she is cardio metabolically healthy. Yeah.

But what's interesting about her story, Cindy, was that you did a lot of the obvious things, but you also kind of tweaked a lot of things that played a role that aren't typically thought of. She was gluten sensitive, so you got her off gluten because that was.

Got about that part, too. Yes.

She was a little bit low thyroid. Yes. And that can affect your cholesterol and definitely increase the risk of heart disease for women. And a lot of times the way we look at thyroid is kind of screwed up. We don't actually look at the full thyroid panel. We under treat people who are borderline, you know, like, I mean, when you think about what's normal, like the normal ranges are from 2 to 92, right? Basically, I mean, kids range a little different. But let's say, you know, you're a teenager till you're 100, as the same reference range. and it doesn't tell you what's optimal. It tells you what's normal. Like if you were a Martian and you landed in America, you go, oh, it's normal to be overweight because 75 of people are overweight. So that's normal. It's abnormal to be thin in this country. That doesn't mean it's optimal. Right. And so with thyroid, the same thing. So you, you probably tweak that. And then you, you also, you know, helped with her, her vitamin D deficiency, which is an interesting factor because vitamin D plays a role in inflammation, plays a role in metabolism, and insulin resistance and your thyroid function and everything. So you kind of have to think about functional medicine. It's almost like taking your car in for a 100,000 mile, 100 point checkup. So you're checking, you're just kind of tuning things up. So maybe it's not broken, but it's like a little off. And in and of itself, it may not be the thing, but you add all these things together and you tweak everything. and then people can enter a life of energy and vitality and in ways that they just typically would not do by just, okay, you have a heart disease risk, here's a statin, I'll see you later. Or try to eat better and exercise more. Good luck with that. What does that mean? Eat better.

I don't know. Watch your glucose and come in next year.

Yeah, right. You want to know my secret for living a long and happy and healthy life? Well, all I have to do is check out my weekly newsletter, Mark's Picks, where I share my favorite tips for health, longevity, well-being, and lots more. Check it out and link below. And so we also look at other things with heart disease that we typically don't look at. I guess we also look at the particle number. We look at the CRP, but we look at other things that mark inflammation like LP, PLA, and we look at.

We look at- Myeloperoxidase?

Yeah, myeloperoxidase, which is a measure of oxidative stress or oxidized LDL. we look at whether there's good cholesterol absorption or increased absorption or production of the liver. So are you absorber, producer of cholesterol? We can look at particles of HDL and whether their classes are good. We can look at so many things. We look at mentioned body composition testing. We can look at metabolic health through stress testing and cardiovascular fitness like VO2 maxes and heart rate variability. So there's so much to be do. it's a 360 sleep studies. So when we think about it, heart disease, we think way bigger than just cholesterol, high blood pressure, smoking or diabetes. It's like a very big container. And when we do that, you know, the interventions are usually sort of driven through lifestyle and diet. So I have a question for you. You know, when we started at Kenyon Ranch, we were still back in the kind of food pyramid, low-fat era, right? This was the food pyramid eat 6 to 11 servings of bread, rice, your own pasta. Fat was at the top, along with sugar. You know, where we come and what do you, what do you think we should be doing now? Like, because a lot of the thinking before was you should be on extremely low fat diets for heart disease, like card, a Colorado esselstyn at Cleveland Clinic. He, you know, he's recommending not even any avocados, no nuts. I mean, this stuff that's really been shown to be heart so what's your take on that?

Yeah, so it's interesting, Mark. I think you've done a tremendous job of just raising the awareness across the world about the importance of nutrition as one of the most important things we can do for our health because it talks to our cells, it talks to our DNA, it's really information. And fat also provides information. So if we come back to that artery elasticity, we know that certain kinds of fats can actually help us feel satisfied in full, but they have benefits with artery elasticity. You mentioned avocados. It was a study a few years ago that found an avocado a day, this high-fat food, lowered LDL cholesterol 20 points. So it's this paradox, right?

Don't forget the apple a day.

It's the avocado a day. It's the avocado a day, which I like because I love avocados. Nuts and seeds, they have benefits on endothelial function, on artery elasticity. Extra virgin olive oil rich in polyphenols is an antioxidant, anti-inflammatory benefits on the artery elasticity. So I think there's a range of fats that people can really thrive with, but I do believe for artery elasticity and artery health in particular, emphasize the ones from fish, nuts, seeds, avocado, extra virgin olive oil as the primary source of fats. And the other thing about most traditional diets throughout the world through eons, They all share in common a foundation of colorful fruits and vegetables and plant-based foods. So I'm less concerned, to be perfectly honest, about the percentage of those macronutrients, the 10%, 20%, 30%, 40%, and more concerned about the quality. I think that really makes the biggest difference.

I mean, it was interesting on the, in the Virta study, which is a company that was developed to treat diabetes and reverse diabetes virtually. using a ketogenic diet, which is 70 fat, including saturated fats, that not only do they reverse diabetes in 60, get 90 plus percent off insulin and a lot of diabetes drugs and 100 off the main diabetes drug. Not only do they have an average of 12 weight loss, which is staggering compared to most studies, which five is like a heroic weight loss for people. But when they looked at all their cardiometabolic numbers, all these, like, lipid numbers, cholesterol, risk everything got better and they were eating 70% fat.

Wow.

Now, that's not to say that if you're not diabetic, if you're a thin, healthy athlete, that if you do the same thing, you might get into trouble if you do that. So, it's really about personalization. It is.

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

So the only reason I exercise so much and eat good is because sometimes I want to do bad things. And I feel like I could get away with it. Maybe not. But, you know, an occasional ice cream or, you know, like, but I, you know, it's like, I just, I think it's true. That whole idea of being metabolically flexible.

And resilient is the key to health. Yeah. And if you look at the three things that have the best data for restoring metabolic flexibility, the ketogenic diet, sort of down the path, it's really polyphenols, which is interesting. Those are those deeply pigmented foods like berries and pomegranate, periods of fasting. We didn't really talk about that, but fasting may also play a role with cardiometabolic health. I just blanked on the other one. Polyphenols, fasting, and exercise.

Exercise, yes. Yeah, you know, it's funny, Cindy, we were talking earlier about the poly pill.

Yes.

And there was a great paper that was written looking at all the research on food and talked about the poly meal, which was essentially like wild salmon, berries, chocolate, red wine and dark green. Pretty much I was like what I eat. I just I don't have the wine that much. But hey YouTube, if you like this video, you're gonna love the next one. Click on it to check it out today.

Genetics and family history is just one piece of the puzzle. It's not what makes all, you know, make makes us make all the decisions in the world. But we take that into account as well as all their other risk factors like you mentioned, like type 2 diabetes and are they a smoker and so.