Why Cholesterol Is Only One Factor Of Heart Health

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 the 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, my friends at Paleo Valley have come through. They've created superfood bars which are loaded with nutrients without added sugars. Their delicious superfood bars are sourced from only the highest quality organic ingredients while avoiding any harmful sugars you'll see in all the rest. Right now, Paleo Valley is offering my listeners a deal. You can get 15% off the entire store at paleovalley.com/hymen. So be sure to stock up for your food emergencies today. That's paleovalley.com forward slash hymen. I'm excited to share with you about our next partner, AG1, the daily foundational nutritional supplement that supports whole body health. AG1 is truly a game changer when it comes to supporting your overall health. I drink it every day and I've noticed that I consistently feel better and have more energy throughout the day. AG1 is so great because it replaces your multivitamin, probiotic and more in one simple drinkable habit. Their incredible supplement has 75 different nutrients that work together to fill out the gaps in our diet. and if that wasn't enough, the team behind ag1 is continuously working to enhance this formula to deliver the best possible nutritional supplement. They understand that optimal health requires ongoing Innovation and are dedicated to providing ever improving formulations driven by the latest in nutrition science. So if you want to take ownership of your health, it starts with ag1. Get 10 free ag1 travel packs with your first purchase. Go to drinkag1.com forward slash hymen. That's drink ag1 the number one.com hyman.com. And now, let's get back to this week's episode of the Doctor's Pharmacy.

Hi, this is Lauren Fein, 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 Guyer about what functional medicine doctors look for to improve heart health, with Dr. Simeon Margolis about the connection between metabolic syndrome and heart health, and with Dr. Elizabeth Boham 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 challenging.

So 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 Not only do people not meet those habits, but 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, 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, 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. Right. Okay, so a 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, does it 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 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 polypill 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? Why do we have a need for aspirin and inflammation?

Why is our cholesterol all screwed up? and you know what's really interesting? Believe it or not, there's a potential behavioral component for patients who go on a statin and their cholesterol's now normal.

It's good. oh yeah, I can eat my cheeseburger now.

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 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 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 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. 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, and 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, 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 can 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. 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, like if your regular doctor, 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's 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 and all about the inflammation, the 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 were 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 poly pill, everybody gets a 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, you know, we were chatting a little earlier and it's staggering to me as a physician just how poor our metabolic health is. So how healthy are Americans metabolically?

Yeah, not very. So a recent study was looking at the 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 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 that 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%, 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 prediabetes 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, 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 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, 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.

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 risk of 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 oh, 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. It never went over 110 after taking the equivalent of two Coca-Colas. Oh, she's fine. Her A1C was perfect. Her insulin, normally should be under five fasting and under 25 or 30 after a drink. Her insulin was like 50 fasting and 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.

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, but, and by the way, high blood pressure, which just 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 have been some 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 inflam or the cause of inflammation, because it may, you know, like you said, insulin in, 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, but there are other factors that also contribute that 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 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 love to dive into that have a big impact. So can you just share some of the other factors that could drive inflammation?

Well, yet another example where the gut microbiome seems to play a role. So now that we can do more sophisticated gut testing and look at these microbial patterns. There's a so-called microbial signature that strongly predicts insulin resistance, diabetes, and cardiovascular disease. And a couple of general scenarios you see is there's a loss of overall microbial diversity in the gut. There's a loss of a couple of signature species. One's called one of the phyla that produced this signaling molecule called butyrate. Butyrate plays a role as fuel for colon cells to help them replenish and be healthy. And it's also an anti-inflammatory molecule. and another species called 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 created.

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 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.

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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 two diabetes, increased waist circumference, high blood triglycerides and low HDL. Those are the five. If they're three of those are abnormal, you have metabolic syndrome. 66 of people admitted with heart attacks in the US have metabolic syndrome. So three of those are abnormal.

But 75 of them had normal LDL and normal cholesterol. So clearly, what did you just say? Wait, wait, wait, wait, wait, wait, wait, wait, slow down. You're talking fast.

Slow down. You just said that 75 of people.

Admitted to the hospital with a heart attack have normal LDL cholesterol.

Yeah. This is from 2009.

Yes. But only 10% had optimal HDL.

Yeah, probably. Yeah, that's true.

And I think, I think, I think about 70% had abnormal triglycerides.

Yeah.

Right. 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% 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 triglycerides coming down, HDL 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 of those markers very, very quickly if they adhere to the prescription, the lifestyle prescription that we, you know, 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 study that 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 again, when they go in the hospital, is a low fat, high carb diet. I know. And I'm like, what's going on here? I know. 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 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, absolutely. It's really about looking at the honest accounting of what we know, 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 this, keeping the basics stuff that 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 more than one between 120 and 140 systolic or between, you know, 80 and 90 diastolic then you have pre-hypertension and that that doubles your risk of stroke and also contributes to heart disease so you want to look at the blood pressure HBA1C should be less than 5.7 between five and different I know different countries have different ranges but essentially between 5.7 and 6.4 is pre-diabetic and 6.5 and above is type 2 diabetic so you want your hba1c to be less than 5.7 ideally you want your waist circumference for a Caucasian man to be less than 102 centimeters measured around the belly button and less than 90 centimeters if you're female and then your triglycerides should be ideally less than one millimole to liter which the equivalent I think in the US is I think 150 milligrams of deciliter Mark you would probably correct me on that if I'm wrong I think that's the. 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 is you said earlier on, actually having all those markers in normal range for the average American adult is only about 12% of adults. So 80% of adults in the US don't have those in the normal range, which is very troubling, right? And this isn't just older people, only one in four adults aged between 20 and 40 in the US have those in the normal range. So this is what we're dealing with. But the good news is, again, those are really indirect markers of insulin resistance. If you want to do more, slightly more expensive tests, and people get this in the US more easily than the UK, is you do a fasting insulin level. And there's different units. I won't give you, I won't get it wrong with, but there'll be a normal range. I think it's less than, should be less than six international units, I think, if I'm not wrong, in terms of insulin, fasting insulin, right? So that's another marker that you can use. so once any of those are out of the 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, 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, you know, 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%.

Right.

It's unbelievable.

This is food that comes out of.

A packet that usually has five or more ingredients, a combination of sugar, starch, unhealthy 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 process avoided. 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 refined carbohydrates are like 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 awesome 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 type two diabetic and all your markers are off, then you have.

To be more extreme to see the bigger benefits. Right. So, you know, I might, I'm like, I have my insulin levels are like less than five, pretty much about two. I have a six percent body fat. Yes, I'm bragging, but I'm pretty met about how they 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 gonna like eat whatever and I'm gonna eat the pasta, the bread, I'm gonna 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. Yeah. And it's really, 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. So.

Well, that's a really important point.

Yeah.

I think we have to be aware of that again. We become. And the different people are more sensitive to these carbohydrates as well.

Right. So.

So, I think, 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, yeah, but in the bigger picture for most adult, you know, in Europe, Americans around the world, the big issue is ultra processed food, low quality carbs, as you said. And I think if you get that out of the diet, then it's about patient preference and the values. I'm an advocate for the traditional Mediterranean diet, but minus in the way we're living now, you know, the ultra, obviously the starchy stuff, because there is, as you know, we've talked about gut microbiome as well. The positive side comes from with the best available evidence we have and things evolve. seem to be that there is antioxidants, anti-inflammatory components with whole fruit and vegetables, you know, extra virgin olive oil, nuts and seeds. You want to be getting obviously enough protein, you want to get all your nutritional requirements as well. So you think about, okay, how am I going to get all my nutrition requirements? So I minimize the need for supplements. I mean, I know supplements have a role, but minimize the need for supplements, right? And also reduce the chances of me developing insulin resistance from the diet. And if you focus on that, that's what I do with my patients. then as long as you get the base of the diet right, other things here or there doesn't matter so much. So get the base right, cut out the, the, the crappy stuff, but my language. Right. And then, and then it's about the preference of value. It's different cultures.

Right.

Different types of foods, Indian food, Chinese food, whatever.

There's going to be, obviously, some, some big differences in a lot of the.

Food that people eat.

Yeah, I think that's right. And I think, I think the, the lifestyle stuff is so huge. And, you know, you talked about the Pioppi diet. I talked about the Pegan 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, as a heart, you know, from a heart disease perspective, exercise. I think we've somehow overed 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. There's a, you know, 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 particularly big. I used to be a runner. I've kind you've 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, 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, of another risk factor, like high blood pressure or type two diabetes in terms of this cardiovascular risk. but a lot of people 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 this stuff related to clotting problems, increase in fibrin in the blood, which is involved in as a clotting factor. And what I do with all my heart patients is I ask them, you know, I do a very simple questionnaire kind of on them, and I ask them in, you know, 0 to 10 in the last few years, you know, these are people come, we've already got diagnosed heart disease, some people who've had scans done, they've got some flaring of the arteries. and I say to them, you know, where is your stress levels 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. No. And then I write about in the book, you know, we need better quality data, more data. But what's fascinating, the largest study on heart disease reversal, which was done in India, by a interventional cardiology catheter called the Mount Abu Healthy Heart Trial. Basically, it took patients with significant coronary disease, so well over 100 patients, moderate to severe, so at least 50 to 70% blockage in their arteries. These are people that didn't want to have a bypass operation, they 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 high fiber vegetarian diet. There was some starch in there, but it was very high fiber vegetarian diet. It was moderate exercise. So two 30 minute brisk walks a day. Okay. And then it was something called Raj Yoga meditation, which also wasn't just about meditating. It was like, there was a bit of counseling. It was about reconnecting with your family and your friends and the social aspect, trying to reduce stress levels. Long story short, the end of the, you know, after two years of the trial, then followed 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 that the clogged arteries got better? Yes.

Yeah. They reduced from, say, 70%, 50%, 5%, 30%. I mean, extraordinary, right?

And this is no statin.

No statin. This is pre-statin, no statin. 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, 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 plot formation, it then progresses. You can potentially, it seems, it seems that you can potentially reverse those blockages or reduce But the biggest factor so far, I think, that's been ignored is stress reduction through meditation. And as you know as well, if people incorporate that, then they're also more likely to sustain the lifestyle, the other lifestyle factors in terms of adhering to the diet. But their mental health is better, Mark. So it's quality 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 find it difficult to meditate. just from using an app. I have a Pilates teacher that I started seeing a few months ago that comes to see me once a week. I need to probably do more. It was fascinating within an hour, even that session of Pilates, one hour, which is also, you know, it's a great exercise, but it's meditative. Wow.

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, increase inflammation. Two, it increases cortisol, which is a hormone. that your body makes that actually causes your blood sugar to go up, your blood pressure to go up, causes your lipids to get worse. If you look at 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 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, you know, we are under such a barrage of stressors in our lives, whether it's work, family stresses, financial stresses, COVID stresses, climate change. I mean, the new, I mean, just, I don't watch the news anymore. I just do stress ball for me. and yet it's so simple. It's free, it's accessible. And I've been practicing meditation for years, and it's such a key thing to help regulate your life and your biology in so many ways. It improves the stem cell production, it reduces inflammation, improves neuroplasticity, brain connectivity. The data is just so powerful on this. And if anybody's really interested, you can listen to the podcast I did with Daniel Goldman 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 or 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 chair. And, and through that technique, you're gonna have all kinds of benefits, not just heart disease, but all kinds of benefits. So I encourage people 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 where you take aggressive high dose statin. and Dean O'Shannessy's work showed that there may be possibility through lifestyle interventions to change the course and actually reverse the trajectory.

And Mark anecdotally, I'm getting patients and I will be writing about this soon and hopefully I'll be able to even fund a trial to try and get a bit more definitive in terms of the answers. But I'm seeing patients, many of my patients coming back who have either halted the progression of heart disease, so from imaging, and some have even had some reversal. One patient recently contacted me and I'd forgotten, you know, I was and they said, you know, Dr. Marta, 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 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 reduced your risk. I don't give people false 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, 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, I 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. He was on a statin, a beta blocker, blood thinner.

The whole cocktail, blood.

Pressure pills, pretty much everything. And I said, well, listen, are you willing to sort of make some changes? And so he 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, you know, B vitamins, folate, and also fish oil, got him on an exercise program. And over the course of a year, you know, he lost, I think, I don't know, maybe he was morbidly, 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 diabetic, but he was pre-diabetic. They completely missed it. It's 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 pre-diabetes 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 men 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 were, 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.

Too low.

His triglycerides were 185 fasting.

Which is high.

Right? Two. and his LDLs were 145. So, you know, his doctor said, you know what? I think you should start some medication. And he said, well, you know what? I wanna 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 lipo profile. 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 Risks 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 of about five. It's over one.

Not great.

If it's over two, you're in trouble. It 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, you know, a total of 150 triglycerides of 300 HDL of 29. I'm terrified for these patients. Absolutely.

In total, cholesterol is 150 and it's absolutely 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 where 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 and your heart artery.

Right, and that's really often what we see when somebody has a sudden heart attack, right? That blockage is 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 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. 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? 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. 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 you also focus on giving him more of the omega-3 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 FDA approved as a drug.

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 is 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 lipo profile and he went from having 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 things 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. 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 five percent 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 is, you know, depending on the person, their responses are very different to diet. Yes. And I've talked to Dr. Ronald Krause, who's one of the world's experts in cholesterol in 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, 260. It was pretty high. A lot of small particles, a lot of overall particles, just weight loss 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 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 like, 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 and super healthy. And his cholesterol wasn't great. and 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 and said, let's try just do more of a ketogenic diet, see what happens or more saturated fat. His cholesterol turned in 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 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 UltraWellness Center, we can on an individual basis really come to learn what is the right thing for this particular person.

That's so 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, you know, our nutrition intervention. And I think what you mentioned with the first woman, the reason we saw such, 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 on 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? 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, for the most part, and the one guy it wasn't because he was so fit and there was genetic variations, but for most people out there, it is really the most common thing. But 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. Because by the time your blood sugar goes up, you're down the road, way down the road. It's a late stage phenomena. You even have your blood sugar going up fasting and then two hours after sugar load, you see a little earlier. But I've been doing these tests for decades. I just see this pattern over and over again. You're gonna have perfectly normal sugar, perfectly. I mean, I had this one woman who really overweight. She 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. Her fasting blood sugar was normal. Her average blood sugar was normal. Her one and two hour blood sugar test, normal. Her fasting was in the 80s after it was like 110. but I measured her insulin. Now normal insulin should be under five. It's 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 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. Yeah, 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 at Cleveland Clinic where I also work, one of the leading doctors there, 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 hyper-laser 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 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 the second case I had, she was not at risk for insulin resistance significantly. 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. 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 looked 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 particle size testing on her, and she didn't have not 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? Let's bring down, 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 protein is really important as well when we're talking about cholesterol because there's some vegetable proteins that.

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 Pegan 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 conda meat as you speak about. So, I think that's a really important area to focus on. She with three months or so, the weight came down and when we rechecked her, we saw that LDL cholesterol come down to like 130. And her HDL even went up higher, which was great to see. So, 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'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 starches, 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 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 konjac. 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. 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 this drug. We'll see you later. And people often get a false sense of security. So, oh, I'm taking my statin. I can have the fried food. I can go to McDonald's or, I mean, they were talking about it selling Lipitor at McDonald's, which I thought was insane. But I think we really have to understand that heart disease is a complex sex 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, 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 I, it's been so satisfying for me. And I've had patients who, you've had a heart 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. Thanks for tuning in to the Doctor's Pharmacy. I hope you're loving this podcast. It's one of my favorite things to do and introducing you all the experts that I know and I love and that I've learned so much from. And I want to tell you about something else I'm doing, which is called Mark's Picks. It's my weekly newsletter. And in it, I share my favorite stuff from foods to supplements to gadgets to tools to enhance your health. It's all the cool stuff that I use and that my team uses to optimize and enhance our health. And I'd love you to sign up for the weekly newsletter. I'll only send it to you once a week on Fridays, nothing else I promise. And all you have to do is go to DrHyman.com/picks to sign up. That's DrHyman.com/picks, P-I-C-K-S, and sign up for the newsletter and I'll share with you my favorite stuff that I use to enhance my health and get healthier and better and live younger longer.

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