The Heart Gut Connection with Dr Thaik and Dr Sayana | Free Webinar

Hi, everyone. Welcome to February's webinar here at Cyana Medical. We have old friend and a great guest with us today, Dr. Taik, who is our local holistic cardiologist. She and I are going to give a presentation. She's going to be doing the bulk of it, talking about the holistic framework in terms of looking at the heart. Next slide.

Alyssa.

Before starting on these questions, could people put in the chat what they really hope to learn from this presentation and what questions they really want to make sure that I answer or she answers before the hour is up. So I'll give you guys 30 seconds for any chat questions just to make sure that your questions are answered and your time here is valued.

And my talk shouldn't take up the whole hour. So we'll have discussion. We'll have discussion time afterwards as well.

Perfect. We got a few questions. And if you guys have more questions, thank you. Please drop them in the chat.

Perfect.

And I'll ask her these questions at the end of it and we'll have a discussion so you guys can get the the best answers. And before we have her start, I just thought we'd have a few questions just to see where everybody's fund of knowledge is and wake us up before dinner or after dinner. So here's a question. Which of the following cholesterol, which lipid panel markers, typically increases due to alcohol consumption? We saw this a lot during COVID and the pandemic. Our patients would come in, and this one number was really high. And we asked them, they were like, well, I am drinking a bottle a day. What do you guys think it is? Put it in the chat. Which number do you think is increased due to alcohol consumption? And maybe this is going to answer a question for your own blood work. Good job. Nick said triglycerides.

Excellent.

So excessive alcohol intake can lead to high trisolemia, and it's a risk factor for cardiovascular disease and also can impact the pancreas. Next question.

They're just a few.

Early menopause. This is for the women in the room. Before age 45 increases the risks of strokes and heart disease in women.

Is this true or is this false?

Anyone? It is true.

Go ahead.

Excellent. So women who do experience early menopause do face a higher risk of cardiovascular events due to the loss of the protective effects of estrogen. And that's where seeing a cardiologist, especially a holistic one, becomes super important. Next question. More than 90% of people with heart attacks have high cholesterol. What do you guys think is this true or is this false? Is heart attacks really an issue of the main thing being high cholesterol? Good job.

False.

You guys are smart.

Group of people.

In a study in 2009 where they studied a bunch of people admitted to the hospital with heart attacks, about 50 to 75 of these people had low or excellent LDLs. So as she will explain that heart disease is not a matter of just high ldl. Next question. The risk of cardiovascular disease in postmenopausal women is two to three times higher compared to the women of the same age who are pre menopausal. Is that true or false?

Carnivore.

Similar question to before.

Perfect.

Next slide. Excellent. Same answer, really, due to a protected benefit of estrogen. And then the last question. Which of the following are typical symptoms of a heart attack in women? For men, they typically get chest pressure and have some of the typical symptoms.

Of heart heart attacks.

But for women, which one do you think is the most likely symptom that they might feel? And especially women who are listening, if you have these things and you're postmenopausal, make sure you take them seriously. I got a. I got a B. And given the answer, Alyssa. Actually, all of the above. So women can have achiness in their arms, jaws, upper back pain. They can have fatigue, nausea, and indigestion. They can have flu like symptoms. And this is why a lot of women are dismissed in the emergency room. It doesn't seem like a typical heart attack. So it's important, if you're having these weird symptoms and you're postmenopausal, have some risk for heart attack, make sure you take it seriously. Oh, this is the last question. If I take my statins, which I get, I get this question a lot. I can eat whatever I want because my cholesterol is in control and I don't have to worry about heart problems. Okay, good job, you guys. The answer is.

This is false.

The answer. Perfect. So I'm going to let Dr. Tyke speak about her experience.

And.

And she's a. You know, she wrote an amazing book, which she'll talk about, but she's an amazing cardiologist with a lot of actual clinical experience, and she's really blended conventional medicine with functional medicine. So without further ado, go ahead.

Thanks, Shilpa. Go ahead, Lisa. So when Shilpa and I met almost 10 years ago now, right. We were both super excited. We were expanding our practice and going into functional medicine. At that time, functional medicine was just taking root. We were excited to expand our practice style to take a look at a deeper root cause, for an explanation for why people have the diseases that they have. We've had a great collaboration since then because really, any patients I've seen Dr. Sayana with, whether they're talking about hormone imbalance, whether they have gut issues and are trying to repair their gut, whether it is, you know, metabolic syndromes, they are at risk for heart disease. Right. And on the flip side, any patient that's coming to see me, whether it's for high blood pressure, cholesterol, atherosclerosis, if they want a more complete approach, rather than just sort of masking or treating just the numbers right then, and seeing a really good integrated internist who really understand the integration and the impact of hormone, diet, nutrition, exercise, really will make a difference. And so we've had a really great collaboration. I'm really glad you invited me to come and talk to your audience and, and for my audience to hear from you as well. Why does it matter? Well, heart disease, even this age with all of our advances, still remains the leading cause of death, with unfortunately, cancer actually becoming very close second. While on this talk, we are focusing on cardiovascular disease, any of the underlying root causes that I talked to you about for cardiac disease will also impact risk for cancer, strokes, liver failures, et cetera. You'll see a constant theme throughout that the things that affect our body in terms of its health and its metabolism will impact all systems and increase the risk of all sorts of diseases. Heart disease, one in three have high blood pressure, one in three will die of cardiovascular disease. And it's really sad when you consider that 80% of cardiovascular disease is actually reversible and it is based on lifestyle, a good part of it. And so behavioral modification can go a long way. And little changes, little tweaks, as I know you've seen in your patients, can make a huge difference. Go ahead, next. So this diagram really highlights for me the principle of functional medicine. Right. I like to contrast the fact that traditional allopathic care is what we call sort of top down approach. Right. So you identify the risk factors. So for heart disease, high blood pressure, diabetes, cholesterol, smoking. Right. Obesity. And we have medications and we have relatively good medications. So there isn't a blood pressure I can't treat. You know, there isn't a blood sugar that we can bring down. But the problem with that type of top down approach is really what you're doing is sort of like pruning back to tree branches, right. And as soon as you come off the medication, right and we see this all the time. Patients go on a statin, their numbers are great, so they think they can come off the medication and boom, it goes up again. So top down approaches only are sort of mitigating the symptoms, but it's not treating the underlying issues. Right. And so the root cause. So taking a look at what I call root up medicine, right? And here you have listed things like, you know, hormones, you know, structural imbalance, inflammation, mitochondrial energy production. So it's sort of biomechanics of the body is really where we need to be attacking all diseases Next, when we really look at the risk for cardiovascular disease, There are over 400 identifiable risk factors for cardiovascular disease. So unbelievably overwhelming, right? A person can spend a lifetime with their doctors going check, check, check, and they wouldn't necessarily be address all of those risk factors. Listed here are the top 25 modifiable risk factors. But again, most of these you're going to be attacking from the top down. Drug, drug forward. Right. Next, the approach that Dr. Sayana and I like to take is what we look at are the hidden true risk factors, the underlying common denominator, if you would, for all those other modifiable risk factors. So chronic inflammation, endothelial dysfunction, oxidative stress, all are pretty much part of the same milieu or pathology. And then we'll talk about gut health, gut dysbiosis, intestinal permeability and, and end with metabolic syndrome or insulin resistance.

Next.

So chronic inflammation, right? And heart disease. So whether Covid, whether an autoimmune condition such as lupus, you know, Hashimoto's thyroiditis, whether you're talking about diabetes or metabolic issues, the underlying issue is always inflammation, right? And so what inflammation does to the cardiovascular system is, affects the endothelium. So the endothelium is that lining of that blood vessel and it is responsible really for being the protective barrier not just inside your heart, but inside your vessels. But what that means is that because the vasculature system and the microvasculature system in particular is exist in every organ, whether we're talking brain, kidneys, liver, lungs, it is, you know, has the potential to impact all systems, okay? And so things like diabetes, high blood pressure, etc. And so the endothelium is designed to, you know, regulate blood pressure. Endothelial dysfunction will always lead to hypertension, it regulates blood flow, it is responsible for clotting mechanisms and so forth. Right, right. And so as we talked about and some of the questions that Dr. Seana asked, right, Cholesterol is often put out there in a misleading way as, like, the culprit. The one thing that is the most important thing that leads to atheroscribed disease. And why is that the case? I think that one is a lot of misinformation that's out there. We have an easy drugs. Statins are the most heavily prescribed medications. And so it gives patients a false sense of reassurance that if they're on statins and their cholesterol is lower, that they must be okay. But in reality, you know, cholesterol gets the bad rep, because what cholesterol is at the end of the day is a reparative restorative molecule, which we need it to make hormones. We need it for our neurotransmitter. We definitely need it for our immune system. Just suppressing cholesterol is not the answer. What we need to be really doing is looking for inflammation. Because when you have chronic inflammation, whether it's from blood sugar or infection or autoimmunity, you literally get what we call rub burns on the inner lining of your blood vessel, and the cholesterol is coming. And as a band aid, you know, trying to repair those areas of inflammation. But of course, as it builds up, yes, there's platformation, there's, you know, you know, more immune cells that come. And over a period of time, it does cause a problem. And we do need to address it if the cholesterol is really high and there's evidence for pathology. But at least in my practice, I don't have this reflexive mechanism where I see high cholesterol and automatic statins. And I see that all the time, where patients come and see me. Oh, my doctor, my cardiologist, they want to put me on statins. Is it really necessary? The answer is, for some, yes, it is. But what we want to do is not just treat the numbers, not just treatment the supposed risk factors, but we actually want to treat the disease. We'll talk about a little bit later. But coronary artery calcium scans and CTA artery angiograms are some of the tests that I do in patients who have high cholesterol, in addition to actually breaking up the cholesterol panels into more advanced lipid markers, trying to see if someone has a beach ball type of cholesterol or LDL versus a golf ball type of cholesterol or ldl. So you might have heard these term large buoyant versus small dense. Right. And so if you can imagine the LDL floating through the endothelium, floating through this blood vessel, the large buoyant ldl, and doesn't even matter how many beach balls you have, they're going to float and they're just going to move. Right. But the small, dense golf balls, they're going to sink. So you can have much smaller numbers of an LDL that can be pathogenic and you can have a high number of beach balls that will just float and you won't have any issues. It isn't an absolute that just because you have a high number that you need to be treating it. And in fact, there was an article from Sweden last year where they took a look at. It was a huge number, like 40,000 people. And they followed them over 30, 40 years, looking at various lab parameters. Then at the end of it, they sorted out the people who are octogenarians surviving over the age of 100. So low blood sugar, that makes sense. And we'll talk about metabolic syndrome later, a low uric acid, which again, is a marker of inflammation. But what surprised them was that these patients that were. Or people that were over 100, there was an overwhelming high number of extremely high cholesterol. Right. So that's not to say that high cholesterol will ensure that you'll live long. Right. But what it does point out is that you can't just reflectively think that high cholesterol is going to lead to premature atherosclerosis and premature death, because that isn't worn out. Okay. And so as far as the endothelium, I said it's the lining of the blood vessel, so sort of your skin on the inside. Right. How much endothelium do you think we all have? Right. So if I were to take my body, lay myself down and, and, and line up my aorta, my brachial, my fem rope and stretch it out. Right. Would it stretch a football field? Would it stretch a mile? And the answer is already there. It actually would stretch 60 to 100,000 miles. That is three times around the globe, if you can imagine that.

That's crazy.

It is crazy, right?

Amazing.

And then you take your aorta, slice it open and flail it and lie down. Right. Imagine my body lying down in this small room. We open it, all of the tiny little blood vessels would not only fill this room, it would fill six and a half tennis courts. So it's a massive amount of surface area that then gets exposed to all of our toxins. Right. Because that blood vessel sees everything from hormone disregulation to the In n Out burger to, you know, Blood sugar, acidity, oils, etc. Next. And so this is just one of the tests that we do in our office. This is called the endopath test, where we actually look at blood flow in the tiny little nail beds in the fingernails, right? Now the fingernail is considered an organ, just like the hearts of an organ, the brain, the kidneys, the liver. Now no one really cares too much about the health of the nail beds, right? However, it is a representation of what every vessel in our body sees. And so these are just all different examples. So you can see on the top left of the screen are really big plump vessels, right? And so those two on the, on the left side are considered normal. And then all the ones on the right side are pathologic. And you can see on some of those blood vessels how they thin and narrow they are. This is a representation of blood flow. Now when I see this, I can't tell. I don't know whether those are constricted just purely because of a volume issue. People are chronically dehydrated, they don't drink enough fluid. But is it because of long Covid, Is it because of lupus? Is it because of Renault? Is it because of stress and cortisol and adrenaline that's causing our blood vessels to constrict down? Right. It can be any and all of those possibilities. And this is where an astute clinician like, as I say, I myself are going to go over your history and it's really most of the answer lies in the history.

Thanks.

Honestly, absolutely.

80%. That's why our initial appointments are like two hours. It's all there, right? And it's like, oh, I know exactly what I think you have. Let's do the lab work to confirm.

Exactly, exactly. And I think that part of the problem that exists currently in our modern day system is you go to the doctor and you get five minutes, 10 minutes, you barely have a chance to sort of just think the problem, right? And, and so patients oftentimes are left feeling frustrated that they didn't get hurt, that that's, that they weren't, you know, the physician wasn't really listening to all the issues. Right.

Or they get tested and everything says normal, but you've tested so little, how can you say everything's normal? And a lot of patients are like, wow, I just felt really dismissed.

Exactly. And think even the word normal needs to be taken into, into context. Right. Because I know Dr. Sean does this as well, but for myself there is, quote unquote, the normal range. Right. And then when we look at things from a functional lens and when we look at things serially, even when like say the TSH is still in the normal range, but you see that it's been climbing from 1 to 2 to 4 to 5, you know that there's a trajectory.

Exactly.

And those are the things that we would look at.

Next.

Okay, so what are the causes of inflammation and oxidative stress? The list is a mile long, right? And so rather than just sort of listing this off, I like to sort of give five key ways for patients to think about this, right? So nutrition. And, and this can apply to those of you sitting at home. Maybe your issue is in cardiovascular, maybe it is hormonal or gi, right. Or neurologic. But you can apply these five principle to any of your symptoms and you can almost be your own D diagnostician. Okay? So nutrition, right? And, and all of us say we know what we should eat, right? But truthfully, be careful about the word I know, because that keeps you stuck, right? What you're, what you're actually doing, what your mirror is reflecting back at you. So if you're overweight or you have like, you know, acne, right? What the mirror reflects back at you is really what your body knows, right? And so you really have to think about eating living food, right? Or am I eating dead food, right. Am I eating food that was never alive, right? Versus, you know, plants and even, you know, so. And when I say live food, right. I don't just mean, you know, plant food, right? Because there's a lot of benefit that does come from eating animal proteins, right? And so I always find that people are very passionate about whatever they believe, right? Yes. So there's, you know, vegetarians, vegans, right? Versus the Paleo, the ketos, right? And everyone believes that what they are adapting to is the right thing for them. But in reality, when we talk about the need for diversity, right? What each individual need is whatever they are not actually eating, right? So those are people who have been plant based for the last decade. They actually need animal protein, they actually need Omega fish oil, right? And then for, obviously for the people who've been mainly doing Paleo and keto, they need the fiber, they need the, you know, phytochemicals, etc. And so, you know, again, I always reach back to my Buddhist roots or middle of the road, right? Ne on neither extreme, right? So nutrition. And I want to. Can't stress the importance of water in that. In nutrition, right? Exercise, you want to be doing a modest amount of exercise. Both you know weights as well as aerobic. But guess what? To my gym rats that spend hours in the lab, in the, in the, in the gym, that exercise is the most, you know, the thing that leads to the most oxidative stress, the most inflammation. So you have to be careful about that, right? It has a lot of benefits, but it, it's really stressful to the heart, right? So we got, we did nutrition, exercise, sleep. Sleep is the time when we do our most. We might be resting, but our body internally is doing its most work. The liver is super active, the immune system is super active. And so we need a good amount of sleep for our bodies to repair. You have sleep disturbance, if you have sleep apnea, that will lead to inflammation, that will lead to oxidative stress. Stress itself. A lot of people, they think they are stressed, but they can't do something about it. You absolutely can do something about it. And not only that, you must do something about it. Cortisol, the adrenaline system, the epinephrine, norepinephrine, are two of the most potent neural hormones that leads to inflammation, oxidative stress, metabolic disturbances, insulin resistance. Those first four, any individual without a physician can tackle them by just looking at their own lifestyle and behavior. Then the fifth one is the only one that you really need help of someone like Dr. Sayana and that's looking at toxins, infectious inflammation, your gut, your balance, heavy metal, things of that nature. You need a student physician to take a look at that. But that really encompasses all things that will lead to inflammation, oxidative stress, increase your risk of cancer, heart disease, liver issues and so forth. There are specific lab work that I do and my patients with heart disease or when I assess for risk of heart disease. And it isn't just the basics. So I'm not looking just as glucose, I'm not just a cholesterol. But I want to know how are, you know, I want to look at markers of inflammation. I'm going to look for oxidative LDL to see if there's evidence for free radicals. I want to take a look at my Omega 3 to 6 levels to see if there's an appropriate balance. Because even though omegas in general are important and they are anti inflammatory and both play a role, Omega 3, especially EPA and DHA are the ones that are protective for the heart and the brain. And you can only get that from animal sources. And Whereas like the Omega 6 more from plant sources can be inflammatory. And so you want to, you know, be taking a look at that and being mindful about that and we'll talk about various solutions later.

What supplements? I think that slide is cut off there.

Yeah, so. So in terms of supplements that I recommend in general for. For. For cardiovascular health, and in no particular order. Right. Methylated B complexes, I think are really important. Multivitamins, not so much. Especially if you're eating a good, you know, nutrient rich diet. Right. But if you have a methylation issue, if you're not able to methylate your B complexes, this will lead to, among other things, increase in an amino acid called homocysteine, which we can measure. And homocysteine is associated with increased risk of heart disease and inflammation. So methylated B complexes, vitamin D along with vitamin K2. So in this day and age, with the knowledge that we have, with the science that we have, no one should be on just a D3 alone. Now, when I say that, yes, if you're 20 years old, you could be on just a D3, but D, what D does is indiscriminately pushes calcium into tissues. Yes, we want it in our bones, but we don't want it in our valves. We don't want it in our blood vessels. We don't want them in our brain. So.

And the prescription kind doesn't have D in it. Right. So you just tell people to take a supplement.

Yes, I tell people to take a supplement. And a multivitamin doesn't have enough D. So vitamin D should be about 5000 unit, vitamin K2 about 180. What K does is like those people in the. On the airport where they say this plane goes here, this plane goes there. Yeah. K will actually tell the D where to put the calcium. And it can also help to remove calcium from where it doesn't belong. So if somebody, particularly if you haven't done a coronary artery calcium scan and you know that you have a high calcium, you should be taking K2 in order to decalcify the blood vessels. Omega 3 for inflammation. It acts as a protective coat on those blood vessels. Probiotics. Right. And so those are usually my core products I recommend for everybody. And then if someone has like metabolic syndrome or other issues, then berberine, alpha lipoic acid. I have different cocktails for cholesterol in terms of red yeast, rice plant cereal. Berberine will also help with lipids. And so those are sort of nuances that we can talk about. Go ahead. Okay. So Dr. Mark Houston said that there can be hundreds and thousands of insults to our body and to our blood vessels, but from a blood vessel standpoint, there's only the same mechanisms of reaction, that it works to protect against whatever might be the insult. And unfortunately, part of what the body does to protect itself against the invaders against the enemy, unfortunately, then leads to pathology, right? So when we have mast cells and macrophages, and then, you know, there's inflammation, then they become foam cells, and then the lipids gets into them and then get oxidized. And over time, that can cause a lot of issues, right? And so I always try and remind patients that when it comes to pathology, right? Like, say, for example, Covid, we can blame the COVID you know, virus, we can blame the COVID vaccine. But obviously there is biological divergence, right, where some people didn't even feel anything and other people got horribly sick and a good many died, right? So, yes, it is the infection of the COVID but it is the underlying immune state of the body, whether they have autoimmune conditions such as lupus and other vascular issues, and then also how robust their immune system is, because unfortunately, it was that robustness of the immune system that actually led to the worst pathology, right? And so one has to really be careful and cautious about that. And so, again, this is why it's so important that you actually protect yourself against those insults, because you don't want your body to get into that immune inflammatory state next. So understand that whether it's a physician treating you or you taking care of yourself, right? You should be taking care of the entirety of you and the entirety of you. Only 10% of the entirety of Cynthia is actually human synthesia, and 90% is others, the microbes. And there are millions and millions of bacteria, viruses, fungus, that actually resides within us and are commensurate with us and control our neurotransmitters, control our immune system, control our hormones, right? And so when we call the gut our second brain, right? When we talk about our gut and all the microbes in our gut really sort of controlling us. If you guys remember that Disney movie Inside Out, I always think about that, right? All those little critters that are, like, controlling our emotions, controlling our thought processes, controlling our focus, right? And so from a cellular perspective, only 10% of our cellular material is human. From a genetic standpoint, less than 1%. So 99% of our body is foreign to us, is microbial, right? And so when we talk about what we feed ourselves, yes, it's important for us to feed the human us in terms of the nutrients, but we should also be thinking about what are we feeding the microbes. And it is beneficial to the microbes or not beneficial to the microbes. And when we take medication, particularly when I get so many patients actually like friends right now, call and say, like, I have a call, can you write me for some Z pack? Right. And I really have to try and like dissuade them from that. Right. Because you feeling less symptoms two days earlier is not worth you literally like, you know, Hiroshima, the atomic bomb and wiping out your entire microbes. That could take you not days or weeks or months, but literally years to recover and repopulate.

We see this all the time. If we treat people's guts, people with chronic anxiety gets much better. People are chronic depression, it improves. Inflammation gets better. Autoimmune numbers and markers go down.

Absolutely.

So feeding those gut bugs is.

Critically important. Next. Okay, so this is just a pictorial of things that would be good for the gut microbes versus bad for the gut microbe. And at the end of the day, what it does to the, to the gut, you know, those bacteria and whether they are healthy bacterias or not, will determine your gap junction. So those are basically the junction between the cells in your gut lining. Now, remember, the gut is supposed to let nutrients in, but there are microns in terms of size, and that's what, you know, supposed to let amino acid in as opposed to tertiary protein structures. Right. It's supposed to let you know, the micronutrients as opposed to the macronutrients. But when you have gut dysbiosis, when you have bloating and belching, right. And you have a descending gut. Yes, you know, yes, the air might come up the top and it might come up on the bottom, but where it mostly goes is into our blood vessels. Right. The same way that nutrients would. But instead of micronutrients, now you got big chunks of proteins which can lead to autoimmunity. You got bacteria going into our blood system and that will lead to inflammation. And so I know that anybody who has GI distress or anybody who's on an H2 blocker, you know, with miprozole, Zantac, if they have a history of having antibiotics, if they're on non steroidals, I know that they're going to have some form of intestinal permeability. And I'm going to be looking for endothelial dysfunction, chronic inflammation, and it's only a matter of time before that shows up in the body. Whether it shows up as headaches or brain fog, whether it shows up as chest pain or palpitation, or whether it shows up as, you know, arthritis or you know, inflammation and it all feeds back on each other.

Exactly. Makes total sense.

Yeah, totally. Next. So this is just, you know, listing why it's important to have a healthy gut microbiome. Everything from blood sugar regulation to nutrient support to immune system regulation to obviously, you know, having a healthy endothelium, not having hypertension, etc. Next.

And a healthy gut microbiome really helps you. If we are giving you any hormones, process those hormones so that your liver is ready for like tomorrow's prescription. So it's so important in terms of giving any hormones to any patients. We always like, what's your gut?

Yes.

It's so critical to look at that.

Yes. And so no matter what I, or particularly Dr. Sayana does, right. You need that healthy gut to help support your body. And so we're always thinking about, you know, what is the gut and what is the gut microbe need, etc. As we think about our patients. Right. And so for the same reason that the gut can support us, it can harm us. Right. And so there's always this, like, gut part axis and this gut brain axis.

Right.

And we call the gut our second brain. Right. The gut has, produces more neurotransmitter. There is more connections going from our gut to our brain and to our heart than the opposite direction. The vagus nerve is a connector that signal that, you know, sends signals from our gut to, you know, to heart and our brain. And so when there is gut issues or when there's gut dysbiosis, people oftentimes develop autonomic dysfunction. Right. They will oftentimes, like you said, have anxiety, depression. So a lot of mental health is tied into gut health and inflammation. Right. So depending on whether you have the right set of microbes or not. Right. Tmao, trimethylamine oxide is one of the metabolites that we can measure from the blood. And when we find that in our blood system, that is a sure sign that you have evidence of leaky death because that metabolite is produced by the gut. Right. So if it's produced by the gut, by the bacteria in the gut, but we can draw blood and find it in our blood system, then that's already telling you you have intestinal permeability.

Right.

And we know that TMAO is associated with risk of hypertension, vascular issues, atherosclerosis, et cetera. Right. Meanwhile, another type of metabolite that some of the gut bacteria makes is small chain fatty acid. And those have a beneficial effect. So how can we get our gut to Produce one versus another while controlling what we eat. So even though I said, again, everybody has their favorite in terms of food, we know that protein, animal protein, eggs and so forth will lead to a higher production of tmao, whereas like fermented food, fibrous food, et cetera, prebiotic, probiotics will lead to more of the small chain fatty acid. And that can actually really have a huge impact on both your heart health as well as your brain health. Right? Yes. Yeah. And, you know, a talk on heart disease wouldn't be complete about without addressing insulin resistance and metabolic syndrome. Insulin resistance is for sure the number one leading metabolic disturbance that is tied into a huge range of disease condition. Even infertility, right. You know, from erectile dysfunction to pcos can be tied to insulin resistance. Insulin resistance absolutely leads to hypertension, leads to arterial stiffness. Insulin resistance leads to brain pathology. We call diabetes, you know, diabetes, or we call dementia type 3 diabetes. Right. A more appropriate term might be insulin resistance of the brain. There are some estimates, some studies that show that 80%, up to 80% of all individual at some point or another has had signs of insulin resistance acutely. Insulin resistance. Three main factors that will lead to insulin resistance. Stress. So I talked about that before. Cortisol, as well as the adrenergic nervous system, epinephrine, norepinephrine. When we are stressed, when we have that fight or flight, we need energy, we need glucose. And so the body secretes the glucose and so forth. Insulin level goes up and then oftentimes insulin resistance occur. Inflammation is another big trigger to lead to insulin resistance. And then the third thing is insulin itself leads to insulin resistance. So it's sort of like the more you have of something, you develop that. What's the term I'm looking for, you know, resistance. Right. So you just, you know, stop responding as much. Right. And so when we think about how a lot of people eat, right, there's like small, frequent meal, you, you get up, you have your coffee with sugar, then a couple hours later you get your donut and then you're like snacking on chips and so forth. So we're always constantly dosing ourselves with food that is usually of a high glycemic nature, spiking sugar, spiking insulin. Right. And so the body subsequently develop insulin resistance. So insulin resistance as a definition is when the cells stop seeing insulin or stop responding appropriately to insulin. And insulin is supposed to be the key that lets glucose into the various cells, into the muscle cells, into the brain, into the liver, but not Only does it let the sugar in, but it tells the cells, that particular cell, what to do with that sugar. So in other words, how to use that energy. Right. Whether to store it as fat, whether to utilize it for energy, etc. And so when you have too much insulin, that leads to not only fat storage, but to the wrong type of fat storage. It leads to the. You know, we talked earlier about the LDL being large buoyant versus small dense. It leads to this shift, so you get more of that small dense particle. It leads to high triglyceride. Dr. Sienna asked about if you drink too much alcohol, what's the one parameter that goes up is the triglyceride. And I think that all too often when we look at the lab parameters, we focus on total cholesterol, we focus on the ldl because we have drugs like statins to treat the ldl, we don't focus enough on the triglyceride. But in reality, the triglyceride, because it is an absolute marker of insulin resistance, is a much more strong corollary to your risk of developing atherosclerotic disease. Right. So just everyone should ask your doctor to get advanced lipid panel to break it down so that you can see your particle size. You can sort of see what your cholesterol is looking like. And I don't care if that's because you have an LDL180 or an LDL110. Right. Even when you have a relatively normal cholesterol or ldl, you should still be interested in knowing how those particles are broken down. As a poor man surrogate, if your doctor is not willing to order it or you haven't been to your doctor, you can all take a look at your current labs that you have and take a look at your current just regular liver profile. If you do a ratio of your triglyceride to HDL, that ratio should be less than 1.5. Okay. If it's anything higher than that, and definitely if it's higher than 2, that is a guarantee that you have insulin resistance and are starting to develop metabolic syndrome. Okay. And oftentimes what do I see? I see triggers. Right? So 240 to an HDL 30. Right. That's an 8 to 1 ratio. Right. And so not even close. And really what you should also be asking your physicians to do is check an insulin, you know, just an insulin level, because understand that insulin and glucose are sort of biofeedback indicators. Right. And so when we eat and our blood sugar is up, insulin is there. To bring your blood sugar back down. As we develop insulin resistance, we need more and more insulin in order to keep our blood sugar down. But for as much as a decade, our pancreas will put out insulin, and our cells will still be responsive enough so that that blood sugar remains low. Right. So when you're checking standard glucose or you're checking hemoglobin A1C, it still looks good. And how often have you heard family members or friends say, you know, I was really good last year, and then all of a sudden, just overnight, I developed diabetes. But that's not the case because for 10 years, they've seen this insulin level rising but had not known about it because it was in check. And then all of a sudden, my insulin can't do its job anymore. Then all of a sudden, the blood sugar goes up. Right. So one, check an insulin just to see how much metabolic syndrome or insulin resistance you're developing. But recognize that insulin, in and of itself, apart from glucose, has a lot of negative effect in terms of what it does to the lipids, what it does to the liver, in terms of lipid storage, what it does to the brain, what it does to the gut, what it does to hormone. Right. And so addressing insulin and insulin resistance, which, again, much of that can be done through diet. You can also use supplements such as berberine.

Yeah, we see a lot of patients in that perimenopause menopause phase, or andropods for men, where their insulin was normal six months ago, but now they're fully into perimenopause or andropause, and suddenly the insulin is higher, and we see the correlation with lower testosterone. So really trying to increase resistance training, take natural things to really balance your hormones so the insulin doesn't jump suddenly, even though you haven't changed your diet, you're seeing these markers change.

Right. Go ahead. And so in our office, when we evaluate a patient beyond the standard testing that we do, which is just an ekg, icg, echo, we rarely do treadmill testing these days. In the past, every patient almost annually would get an echo and a treadmill or stress test. But the nature of coronary disease is shifting, and. And most patients are not coming in with the 90% lesions and so forth. Unless the patient has symptoms, there's almost no reason to get a stress test because it's going to be low yield. But I do check endothelial function to take a look at that blood vessel inner lining, because that will give me an early clue as to whether they're developing vascular Inflammation. And then I do check in patients in the right age group with the right risk factor or family history, coronary artery calcium testing, because I want to know if there's pathology forming, if there's pathology already forming. I'm going to take a different approach to their lipids versus if the corneal calcium score is zero. And then I will always break down the lipids into the fraction to risk, stratify them to know whether they have a genetic lp, whether the apob, which is a more atherogenic protein on the lipids, is present. And then I will look for other markers of inflammation or oxidative stress. I will always check a vitamin D level. A lot of patients tell me they're on vitamin D. And I look and, and they're not. Or, or, you know, they say they, they eat enough fish and they don't want to take, you know, supplemental fish. Well, but then I see that their Omega 3 is really low.

And then what does that look like? If you could just explain to the listeners a coronary calcium score is a bundle radiology, what does it look like would be any pain patient.

Yeah. So the CAC scores were developed, gosh, almost 20 years now. Right. And I used to practice in Santa Monica. And so at that time, when it was first available, I would have these execs coming to me and they'll say, you know, I have the score and what do I do? Et cetera. Right. And so, quite honestly, I wasn't an early adapter to the technology because I still believe at that time that dynamic testing was more important. And at that time, we also didn't really understand or know the correlation between calcium spore, which signified calcified plaque, which means a sunny side up, or egg yolk that is solidified. That's what a calcified plaque would be, versus a non calcified plaque or a mixed plaque, which is more like the sunny side of egg yolk. Right. And so, so the sunny side of egg yolk plaque with a thin fibrous cap that's not calcified is more at risk than the calcified plaque. Right. Because hypertension, sheer stress inflammation would essentially be like me putting a fork into that egg yolk and then it'll spill out, and then the platelets will come and the mast cells and the foam cells will come, the macrophages and foam cell, and then that will cause acute rhombus formation. Right. But now, 10, 15 years later, when we have so much data from all these patients who have gotten the calcium score and Then subsequently either gone to have a heart attack or not. And now we have AI with large language modeling, we're able to more risk stratify and really know if someone is at risk or not.

So just a CAT scan.

It's just a CAT scan. And then the other difference is that it used to be eighteen hundred dollars, all self pay, not covered. Now we get have a lot of coverage for it. Right. And the prices has dropped down. So even if your insurance is not going to cover it, there's a lot of centers that will do it for 150, 200.

Amazing.

Right? So that's definitely what we're doing. So you have a high calcium, you have a high cholesterol, but your calcium score is zero.

Yeah.

Then you can read a sigh of relief and you can take the time to figure out why that cholesterol is high. Looking at hormones, looking at inflammation, looking at stress, gut health, etc. Right. Now if you have a high cholesterol, as many of my patients do, where they say like, there's no way I'm not going to take statins no matter what, and then their calcium score comes back at 800, then I really have to say to them, okay, you can be on your soapbox and say, I don't want to take this medication, but is that really what the risk of having a heart attack or stroke? Right. I said to a patient just today, right, if you have breast cancer or ovarian cancer or pancreatic cancer, your oncologist is going to say, I'm going to give you a drug that's going to make you lose all your hair, make you puke, be sick as a dog, lose weight, and you say, when can I start?

Right, right, right.

Where I live. Yeah. But when we say like okay, let's take a blood pressure medication so you don't have a stroke, then patients are like, I don't know. Right. But you have to balance. You know, at the end of the day it's all about risk benefit ratio. Yes, absolutely. Every drug is going to have side effects. Right. But drugs do have benefits as well. And so you have to sort of figure out what your risk is. Right. The problem with statins in general actually is that we, we put way too many patients on statins that don't need to be on it. And so as a result you have a huge amount of patients who have side effects. Right. And so that then influences those small subset of patient who would truly benefit from a statin, from wanting to be on a statin and so what do.

You think of the injectable type medications? I think a few people.

Yeah. And so for me again, I tend to look deeper, be a slower adapter. I do think that statins are still if indicated, the way to go. Right. I, I think that most people who say that they have statin intolerance, it really is not the case. And, and we, you know, we've done, you know, there's been studies where it's been know, placebo minded cross, you know, cross control, which means is that, you know, patients are giving either placebo or s, but they don't know what they're getting. Right. And, and you and I both know, right, the power of the mind. Right. If you believe it, you're going to feel it. So if someone is drug adverse, believe me, their body will create the physiology to, to manifest the symptoms. Right. But when you take a double blinded cross reference, then the patient is left having guessed, okay, is this a statin, is this a placebo? And we find that people have as much side effects from the placebo as they do from the statins. If they truly don't know which one they're getting.

Makes sense.

Right. But if they know they're getting statins and they don't want to be on statin, then yes, they're going to end up, you know, having brain fog or whatever else. Right. Remember, brain fog is going to come when your cholesterol gets too low, right?

Yes.

So as long as you control it. Well, meaning don't over medicate, don't over treat.

We have a lot of patients on here who are over treated by the cardiologist LDL of like 30.

20, 30.

Yes.

Crazy.

How are we going to make hormone if your cholesterol.

Absolutely, absolutely. And I see patients who have a calcium score of 0 who are on.

You know, aggressive medication.

Aggressive medication, Absolutely.

And so what's the difference between a CT and jirogram versus a cavernary?

So, so I always start with a C8 calcium score so that all that is, is a, is a radiographic CT scan. You're literally in, in the machine for like all of five minutes. And, and so the technology is such that it's so easy to do now that they can offer it for such a low price. And all it's doing is the cone CT and we're figuring out how much calcium is in that area. There are caveats that the patient needs to be aware of when they do that comb thing and they say there's X amount of calcium, say in the LED distribution isn't necessarily identifying whether that calcium is extraluminal, intra, you know, intra luminal, or in the vessels. Right. So. So it's just giving you a ballpark idea of whether you have vascular inflammation, because calcifications and come about as a result of inflammation. So it's just sort of generally defining is your vascular healthy or not? Is there, you know, calcium or not? If there's no calcium, that doesn't mean you don't have soft plaque. However, I think data is really strong and correlating that you risk. You buy yourself at least 10 years of not being, like, having to worry. Right. But if you have a calcium score of 400, 600, 800, then yeah, absolutely, you need to do something about it. Right. And if someone has a modest cholesterol, then I know that they have blood sugar issue, they have insulin resistance, that there is some pathology. And oftentimes, like I said, cholesterol is the innocent bystander that ends up being the mechanism by which atherosclerosis happen.

Right.

So you see atherosclerosis, you have to look for inflammation, you have to look for oxidative stress, you have to look for an unhealthy gut, you have to look for hormone issues or immune or autoimmune. You got to look for those deeper root things. Right. Because just lowering the cholesterol, if I say to you cholesterol is actually the band aid, doesn't make sense. Right. You've got to lower the underlying nitus for which the cholesterol is building up.

Yeah. And there's another. Some good studies showing the higher levels of lead is associated with coronary artery disease. And we had lead levels over 100 times normal a few weeks ago with the fires miles away. So for people who don't detoxify, well, it's important to. To measure those levels. So that's like a atypical risk factor.

Absolutely.

We need to know, and we have the technology to measure this. So you just have to kind of find the right doctor to partner with.

Right, right. And, you know, with. Especially with all the fires, like, you know, inhalants. Right. Like, that's a major toxin. Microplastic.

Yes, right.

The estrogen disturbers. Right.

Like.

Yeah. So there's so many things that I think that if you truly understand or get educated.

Right there stuff you can do. Good. Next slide, Melissa.

And we actually really sort of COVID this already. I mean, the nutrition, exercise, sleep, stress, and then seeing someone like Dr. Seana to go over toxins, be able to measure it, take A look at your nutrients and so forth and then the supplements we talked about. So Q and A. Yeah, do those.

Questions and I would say you can go to the next slide too. I'm going to answer those questions.

It's just my book and I can.

Just get that on Amazon.

Yes. Awesome.

And then the next slide, I think that's it.

Oh yeah, perfect.

So if you want to work directly with Dr. Thy, that's a QR code you can pull up. I think the next one has both of our respond there. Is it a long wait list to get in with you, Dr. Paige? People can get in with you.

Yeah, yeah. Because we take insurance. I do.

Okay. So they can get this stuff coming. And you said 150 to 200 for the corporate transfer. Yeah. That's amazing.

At this point, I think that any, you know, most people, once you reach the right age, you know, postmenopausal. Right. So later for women than for men. But you know, just one time.

Right.

Just to establish what your coronary disease important is.

Okay. I have some questions. How do you lose weight post menopause?

That I would say the most important.

In my book is to really look and see why. So postmenopause your insulin goes up as we talked about. And once your insulin goes up, you are going to gain weight mainly around the belly and the thighs. So it's important to understand why and look at your sources of inflammation. Is your gut, is it toxins, what's happening and how you can actually reduce.

Those before trying to do some sort.

Of diet intervention or some sort of program that really pushes you to lose weight.

Hydration is so important. If you do not drink enough water to detoxify to take all those toxins out. Right. So understand that when it comes to toxins within our bodies, Right. We have water soluble toxins and fat soluble toxins. Right. And so water soluble toxins you just need to get out of your body. But unfortunately most of the toxins that we're exposed to are fat soluble. So that's why we accumulate more and more visceral fat because that fat acts as a protector. If you would. Right. It would rather you be fat than you be toxic.

Yes. And we see that a lot with the use of the GLP1 is people lose a certain amount of weight dramatically and all this toxin is released into their body. And then like now I have an autoimmune disease. And there was an interesting study that just came out recently saying that GLP1s may put you risk for arthritis and that may mean a mechanism, it's how quickly you're losing that weight. Somebody asked, what are statins? I think you have a good sense of that Shreya. Now they are used to treat cholesterol as a medication. And John asks, is obesity the major challenge facing us? What are your thoughts about the GLBs?

So I think they have a role, but like Dr. Siana said, right, neither one of us are drug forward, right? So you're going to want to understand and know your biology and physiology. It isn't just, oh, let's just go ahead and grab that drug, right? You want to know first of all the underlying issues, right? Because if you just take a GLP and meanwhile you have insulin resistance, right? And, and these molecules, you know, what they do is they actually, you know, they're glucagon, like, you know, peptides, and they actually raise insulin to try and lower your blood sugar and do its feed and so forth. And so if you already have high insulin, and I said insulin can in and of itself be a factor in causing illness, then you have to be really careful about that, right?

You really do. And another thing is doing them, it's so easy to get them at lots of different places that are not medical facilities. I think that's just really dangerous. In bad medicine, you need to partner with somebody who's going to be watching you, monitoring you. If you have a bit of pain and you think it's just a side effect of the drug, it could be a severe kind of pancreatitis. So it's important to monitor.

Having said that, I, you know, our office, we sat on the sideline for many years and not doing it. But right now we are offering it to our patients as well. Right. And so again, you want to really be like, have it be individualized for you. I mean, GLPs can have benefits. There are, you know, you know, reports of it having some immune benefits. Definitely from a cardiovascular standpoint, can be protective. So again, it comes to that risk benefit ratio, right? You have enough risk if obesity is exponentially increasing your risk and increasing your mortality and morbidity and you're not able to lower it. Absolutely. I feel like we now have drugs and it can be absolutely game changer.

And make sure you like, maybe stay on the lower dose and not just quickly escalate, because that's where I see people get into trouble. So even though that's the guideline, keep escalating, just maybe stay on the lower dose for longer. And we do see a lot of nutrient deficiencies in The GLP is because you're not eating. So just make sure you're nourishing your body even though you're not hungry.

Remember from the pharmaceuticals perspective, they want you to, you know, dose, escalate once that they make more money and then, and then there's more resistance and so then you have to go up on the higher dose. But there's a lot of research now and patients for microdosing and I think microdosing just to help with the neurodivergence, our thought processes can be really beneficial. And then patients still need to then do all the things that they need to do from a lifestyle.

Yeah, I've seen people like stop smoking on them. Alcoholics get alcohol, they are amazing drugs. But just use them with some sort of caution. We answered this question, I think already about restorative sleep and how it relates to inflammation. And then Dina asked, why do the endopath on small women? Would they have narrow vessels anyway?

Absolutely. Absolute. Great point. So, so men, because of the bigger bodies will have a, a larger, you know, measurement or relative vessels. So women tend to, you know, show vessels that are maybe half to one third of the, of the size of a male. Okay. But you can still see the difference between in a women where there's reasonable flow versus when they're really constricted.

So it's still valid?

It's still valid to get it. Absolutely, yes. And then, but to that point, right, we hearing, you know, for the last decade, you know, in the, in the literature and lay press about women having small vessel disease. Right. Like you know, when you do an angiogram and so forth, you know, oftentimes you might not find, you know, actual atherosci blockages. Right. But people still have prince mental angina, people still have abnormal stress tests with documentation of ischemia. And those are all due to small vessel microvascular disease. Right. Makes more sense. Yeah.

And then for Rashti asks for someone who's been mostly plant based for years, is there a recommended type of animal protein to occasionally add within the diet that you think would be beneficial?

Yeah, So I think Omega 3s are really important. So having, you know, fish I think would be good. I think that there is value to animal proteins as well. I'm not a nutritionist, but from what I'm told, like, you know, red meat actually is more nutrient dense. I see it then, then, you know, so I know a lot of people, they, they, they go to chicken and so forth, but you know, that's probably not as favorable as red Meat, so good piece of steak.

Like, it's so many good nutrients.

Yes.

But anything with fish, is that mercury. Just watch and monitor.

Yes, absolutely. Yeah.

And then a few people ask, is there a great brand of vitamin D with K2 that you guys love?

I'm a big ortho. Right. I think you guys use that and you know, in the therapeutics. I think the way that, you know whether a, A brand is good or not, at least for me, is if they're smart enough to pair the two. Right. If they have their vitamin D with K2, then it's like, okay, they know they're following the science, they know they're taking a look at that. I often look at my multivitamin. If it doesn't have methylated B complexes, then I'm going to say like, hey, that's just a sort of like the run of the mill multivitamin. If it's going to be a nutraceutical in this day and age, they're all going to be methylated. I look for things like, you know, when I look at the label, if, if this has dot, dot, dot and they don't want to tell you what the ingredients are.

Yeah.

Then I'm not going to believe it. Right. So you oftentimes see like, you know, like, I don't want to like call out a brand, but if you go to Costco, Right. You know, I'll say a thousand in the front for Omega 3. But you turn around, look at the label, and you look specifically at EPA and DHA, which are the only two fish, Omega 3, that has like, you know, value from a medical standpoint. It shows, it says 250. Okay. That means now you have to take four times what they're recommending to get the 1,000 milligram. But more importantly, if you do that, what are the other 750 of their thousand milligrams of omega? Those are usually the omega 6 and omega 9 that are not going to be as beneficial.

Exactly. And that's with the Costco. You know, watch for the Kirkland blend. It has a little bit more lead in it than the other ones. So you can shop at Costco, just pick your brands. Well, and exactly what you said in terms of reading the ingredients.

But at the same time, if you can afford it, then you might, you know, get the, get the good.

It's your health at the end of the day. Right. If you're, if you are a healthy person, you may have many problems, but if you're a sick person, you only have one. So really try and nourish your body. Any other questions before we do our raffle? But you guys have been so patient. In the end, one lucky person gets orthomolecular omega ortho omega, which is a pretty good fish oil, I take it. I don't like swallowing things so I just bite it and then I spit out the COVID But if you don't mind swallowing things that are a little bit on the bigger side and oh, here's one more question. Yes. Everybody's going to get a copy of the recording. We'll make sure we email them out. And it says, what are your thoughts on fasting for extended periods of time for reversing the things we touched on seeding?

Yeah, so we didn't talk about that much. But fasting is really good to help with insulin resistance. Right. So anytime that you can just like lower your blood sugar. Right, right. And so I'm not really a big believer in like the small frequent meals. I think that even if you're not going to do extended fasting, doing time restricted eating, making sure that you have a long period of time from your, your evening meal till when you break fast.

Right.

So the, you know, when we talk about breakfast being the most important meal of the day, what it means is that when you break your fast, that's the most important meal. Right. And you don't want to do it with sugar, you do not want to break your fast with sugar. So you want to break with protein, healthy fat. Right. So time restrict eating, which is not fasting. So fasting has to be over 24 hours, but time restricted eating, which is what a lot of people refer to as their fasting, is just, you know, that you extend that period of time in between your meals. Right. But in terms of the data on prolonged fasting, 24 hours or more. Right. There's a lot in the literature about apoptosis or program cell death. Right. This notion of building up and breaking down my metabolism of anabolism, which is building up and catabolism which is breaking down and recycling those cells. Right. I think the data is really clear that that's associated with longevity. And I'm not going to get into it, but there's specific genes that are considered to be part of like the longevity genes that get turned on with fasting, like mtor.

It's a good thing to do overall if you can.

Yeah, absolutely.

Two more questions that I think are important. What do you think of a solely plant based diet? Like I am plant based, but I Do take like IV iron. I take B vitamins. I wish I could eat meat. I just can't.

What do you think of it? Yeah.

So are you a vegetarian? Maybe vegan patients out there? I do eat dairy and eggs.

Yes. So when measured. Because when we've done like cellular measurements for inflammations. Not doing that anymore. But when we were doing it fairly robustly. Right. Like, you know, looking at brain inflammation, etc. Some of my most unhealthy profile patients were my vegan. Vegan patients. Right. And. And so I always end up asking them, are you plant based vegan or are you carb based vegan?

Such a good question. Right.

So. So it's because they're not equivalent. Right?

Yeah.

And so most people are defining being vegetarian vegan as not having animal protein, but they're having pasta and bread and rice and so forth.

Right.

But if you're really doing whole food plant based and you're knowledgeable. Right. You know what you're deficient in. Right. Because there are certain nutrients that you can only get from animal protein. So then you just have to supplement.

You have to test and know, like, what's going on with your body.

So whenever I have a patient who's vegetarian vegan, I always try and get them to a nutritionist. I always like, say, do you really know? Do you know what you're deficient in?

That makes sense. Last question. Thoughts about the dangers of calcium and supplements and it causing artering.

Wow. Yes. Great question. Right. Go Vicki. I always say to a patient, I don't want to contradict what another physician might have recommended. Right. However, I'm very clear to say to the individual, as cardiologists, we do not like calcium supplementation. Not at all. Right. Because it's going to end up in all the wrong places. Valvular disease. Right. If you look at patients who end up with aortic stenosis, aortic valve replacement, mitral valve issues, regurgitation, etc. It's always, you know, an overabundance of calcium. Right.

Giving all these women on so much calcium residency.

Yeah. So my feeling is, and you will know more if you take vitamin D and vitamin K2, we take in enough dietary calcium that there's plenty of calcium around, as long as we don't put it in the wrong place. Right. So you definitely don't need to be supplementing with calcium. That makes sense.

No, I agree. Okay. I think that brings us to the end. And then the winner of today's raffle. Thanks, Alyssa, for picking it up. Is Michelle Fisher. So, Michelle, just drop your address to Alyssa, who's moderating today's webinar. And we'll be sure to mail you a free fish oil. And hopefully you can swallow them or at least chew them. And if you have any questions, feel free. These are both QR codes to discovery calls or to book directly with Dr. Dyke. There's any questions you have, please feel free to ask us. And you're very welcome. Everybody said, thank you.

Thank you. Take care.

You guys have a good. Nice. Thanks for staying with us for so long, and hopefully it was informative.

Bye.

Bye.