#20 - Thomas Dayspring, M.D., FACP, FNLA – Part I of V: an introduction to lipidology

Foreign.

Hey everyone. Welcome to the Peter Attia Drive. I'm your host, Peter Attia. The drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions along the way. I've spent the last several years working with some of the most successful, top performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information on today's episode and other topics@peterattiamd.com. Hi everyone, welcome to this special edition of the Peter Attia Drive. This is a special edition because it is the longest podcast ever recorded in the history of podcasts. Maybe it was a seven hour only getting up to P once interview with Dr. Tom Dayspring, who a number of you will immediately recognize by name. Tom is one of my most important mentors and is generally the mentor to the mentors in the field of lipidology. We're breaking this into five parts. So this is going to be the Week of Tom. So today, if you're listening to this in modestly real time, on Monday we're releasing Part one and there will be a part released each day, Monday through Friday. So this seven hour podcast will be released over the course of a week. I'll call it the Week of Tom. And what you're listening to right now is Part one. I'm going to use Part one to give the bio and background on Tom and give you just the insights over what is covered in Part one or Episode one. And then prior to each episode I will just highlight what's going on there. Tom Dayspring is the Chief Academic Officer for True Health Diagnostics, a laboratory company. Tom is a Fellow of both both the American College of Physicians and the National Lipid Association. He's Board Certified in Internal Medicine and Clinical Lipidology. He practiced medicine in Jersey for just under 40 years and in the last two decades he's given about 4,000 domestic and international lectures to lipidologists and cardiologists everywhere, including a little over 600 CME programs on this topic. He's listed in the Guide to America's Top Physicians and is on the Editorial Board of the Journal of Clinical Lipidology. He's authored and co authored more manuscripts than I was able to count, although that's obviously a countable number. And he has received the 2011 NLA National Lipid Association President's Award for Service to Clinical Lipidology I actually spoke to the president of the NLA who gave him that award and he described it as the most important award he had ever given out. Tom's really active on Twitter Rlippid. That's D R L I P I D. And more than anything else, as I think comes across in these interviews, I share just the greatest affection for Tom. He can be rough around the edges. And when I ask Tom a dumb question, boy, do I get an earful about it. And he'll always tell you, I'm sorry, I'm just a Jersey boy. I just don't know how to sugarcoat it. But I don't know how to express my gratitude towards Tom other than the way I probably do so in this podcast. And I really wanted to do this to share so much of the knowledge that Tom has given me with so many other people. There's obviously been such an interest in understanding this space as I think I probably allude to in this podcast. Back in 2011, 12, and maybe even into 13, I wrote a nine part guide on cholesterol called the Straight Dope to Cholesterol. It was about 30,000 words. It was quite a lot of work. Obviously could not have done that without Tom's help. And to this day, Tom is probably the single most important clinical mentor that I have. In this first episode, which is probably going to be a little bit longer than the others, this is where I'm going to really kind of introduce you to what I call the national treasure. And that's just the way I described Tom. He is just a national treasure. And I am not the only one to say that. You ask any card carrying lipidologist who they look to as their go to guy on education and it's going to be Tom. We talk about some of the definitions of things, but we actually start by talking about things about Tom's personal life that most people don't know. His obsessions, firefighting, hockey, and ultimately lipids. And there's a common thread to Tom's obsessions. He's an amazing author and illustrator and we talk a little bit about some of that stuff and his gift to teaching. So in many ways, the first episode is the soft one. This is the one that kind of gets you warmed up, gets you ready to think about what we're about to do. And then in episodes two through five, we get into sort of the more technical stuff. The other thing I just want to say for this episode, as some of you may recall, for the episode with Dave Feldman, we splurged on getting a transcript so that we, you know, really make this technical information available. Tom was so kind to go through and edit and correct all the things that Dave and I had said incorrectly, which is invariably going to happen in a long podcast. And he also did the same thing for this podcast. So when this podcast came out, I want to say it was 80,000 words or 90,000 words. It's basically a book, medium sized book. Tom went through with a fine tooth comb and made all of the corrections there. So what you'll also find in the show notes is sort of an editorialized, corrected version of the transcript. I think it is safe to say that you could learn more in the next seven hours, meaning episodes one through five, than you would learn in a lipid fellowship. And I suspect that many people who are studying in a lipid fellowship will find great value in this. That's the level of detail we go into. And at the same time, if you're a patient, if you're a primary care physician, I think you will still find this incredibly valuable. So this was a little more work than usual to prepare for it, to record it, to edit it, to break it down, to do all of the things we did. But I believe it's worth it. And I am so happy to have been able to have done this because I think of there are a few things that I get more pleasure out of than sharing Tom's knowledge with other people. So with that, welcome to episode one of the week of dayspring. Hey, Tom, how are you?

I'm very good, Peter.

Thank you so much for schlepping all the way up to New York to talk with me.

Not the world's longest journey.

I think a lot of people have been looking forward to this. I think many people have sort of relied on your insights, your knowledge over the years, as I have. And I think what follows, and I have no idea how long this is going to be, but I suspect it will not be one episode. But this will certainly be the master's class in lipidology, but not just for physicians who want to understand this more, but I think for patients too. But there's so much stuff to talk about before we get into that. And I figure if you're willing to talk about it, what I'd love to do is have you explain a little bit about this kind of remarkable physical transformation you've undergone in the last year, which this is actually the first time I've seen you in person in eight months. And I could barely recognize you as you walked down the hall to my apartment yesterday.

Well, many people who have seen glimpses of me on the Internet or whatever, in person, God knows how many lectures I've done across our great country have always known. Geez, for a lipid guy and a cardio metabolic guy, he's kind of obese, so probably doesn't always practice what he may be preaching and everything. So, indeed, I've had the. A long, long experience with obesity and insulin resistance and cardiometabolic disarray and everything, and always had the usual million excuses why I didn't have to do anything about it or so I felt good. Nothing was happening to me, and I just did. Kept ignoring it, but I did keep aging. So for those who don't know, I'm reached 72 years of age this year, 71 last year. And I've been great friends with Peter for a long time. And Peter, of course, has been harping at me to do better nutritionally and everything. And I. I just stumbled into his podcast done up at mit, where he talked a lot about longevity and, hey, the average age of death in the United States. And as an old man, I, you know, I can see a little light at the end of the tunnel, like, Jesus, 80 is the average age of death. How much longer do I got to go? And over the last five, six years, I've dealt with a bunch of morbidities, a lot of them arthritic in the spinal nature. But colecystectomy and fatty liver and things like that were sneaking up on me, even though other than my bone issues, I felt pretty bad. So I just said, you know, since I do see the end of the tunnel and Peter's making a lot of sense, what he's talking about, about longevity here. Maybe I ought to listen to what he's preaching here. And he did raise the topic of intermittent fasting during that talk and everything, I sort of figured I got to do low carbs finally, more than I ever did. But the fasting was kind of new to me, you know, and in further conversations with Peter, he just put me on an incredible regimen he's developed. It's a modified intermitt and fast that I said I can do that, and I did it. And as Peter says, that was 67 pounds ago. Over the last 11 months, I just finished my 11th month of a. I do one week, a month of 700 calories or less. Pretty significant carb restriction. And it's not only the weight has gone off, but, I mean, a bunch of residual orthopedic Symptoms that I was having that I just thought I'm going to have to live with the rest of my life. I've had a hip replacement, several spinal surgeries. I. Almost 90% of the time, 95%, I feel like I've got my normal hip back, my normal spine back. I can walk again.

We walked to dinner last night, and you said that that was a walk you would not have been able to do a year ago.

Yeah, a year ago, I could walk a short block and I'd have to sit down and wait for my bones to say, okay, try it again. And now don't have any of those limitations. So it's been miraculous in a lot of way. And I think it's way beyond just the weight loss, too. I think this fasting and whatever else it's inducing in me has just changed a lot of things. And we know that because, look, I work for a laboratory. I can do a lot of sophisticated testing on myself and checking every cardiometabolic marker that pretty much a lab can do nowadays. And there was some ugliness to my report a year ago. And it's. Those who follow the lab I work for know it's reported in red, yellow, and green. And green is you got an optimal level of whatever and went from a pretty yellow red report to a hundred percent green report. So it's not only, geez, I'm feeling so much better biochemically, I'm doing an unbelievable amount. And I mean, I'm happy about all of that. But the disappearance of the aminase levels have been especially impactful.

Yeah. So I'll interject to just add some commentary. So the first thing I would say is you were quite resistant. I recall when we first had the heart to heart. So you called me after you saw the MIT video. I don't even know why you saw it. I don't think I sent it to you.

Think you linked it to. And one last joke about that. You know, I'm good friends with Peter. I don't want to ignore anything he sends me. I send him a lot of stuff, and I know he reads most of it. And I said, all right, I'll humor him. I'll listen to 10 minutes of this lecture, and at least I can be honest. Say, yeah, I listened to it and I put it on, and I'm a busy guy. I don't have an hour and a half to listen to a podcast. And I just couldn't stop listening to it. I went right to the end. I've listened to it one More time. I referred it to many other people to listen to. So it was one of these things in life that somehow it really impacted me on that day, which is interesting.

Because the first 10 minutes are not particularly interesting. So I don't know. Luckily we snuck you through, but. So I'd always had this concern because over the past seven years we've known each other, you know, you see my labs, I see your labs, and I'd always been kind of concerned about those LFTs, and it was like they were getting higher and higher and there were a number of other things I was concerned with. So when you responded to me saying, hey, I want to do something about this, and I said, you know, in the past you've had a hard time just adhering to carbohydrate restriction. I think we need to try something a little bit more extreme. And so what I proposed, as you said, was this idea of doing a modified fast. And this is sort of loosely based on Valter Longo's five day fmd, but we kind of took it a little more extreme. So a slightly higher ratchet up on the caloric restriction during five days. And also doing it every single month, as opposed to quarterly. And also in Longo's version of the fast, it's focusing on the restriction of protein. So it's actually relatively high carbohydrate. We wanted to restrict carbohydrates both inside and outside of the fmd. Well, you expressed enormous reservation just at a practical level, like, Peter, I don't think I can do this. So what I think I wanted to point out was that it was amazing that you took that plunge the first time, because I remember that first one you did last, I think, October.

Right.

And you worked very closely with Nicole, who's our dietitian inside the practice. And she, you know, was just incredible at sort of guiding you through the. The logistics of what does it actually mean to eat 700 calories a day of basically no carbohydrates? And then once you emerge from that, what are you going to do? You remember what it felt like after that first time.

And look, I was highly motivated because of morbidities. I had my age and I'm a time bomb. Something more is going to happen. I sure don't want to go undergo more orthopedic, degenerative arthritic changes. My gallbladder's gone, but that fatty liver. How many liver cells do I have left? My big worry for what I do is cognitive impairment as time goes on. And I was Certainly headed towards ugliness in that direction also. And as you start approaching it, I want to hang around. I got a son, I got a great life, I want to be here for a while. I was super motivated, which 20 years ago, if we even knew this stuff, I don't know how motivated I would have been. So the end was near. And just being so motivated. Even though when I looked at Peter's recommendation and Nicole's, wow, I don't think I can do this. You want me to? To me, the caloric restriction for those five days was you're starving yourself. And I just didn't think my body would allow me to do that. As a guy who's used to nibbling all day long every day of the week and everything. But the motivation made me, I'll try it, you know, if it doesn't work, it doesn't work. But he had convinced me in that talk there was a good chance to shut down a lot of these metabolic pathways that were contributing to my morbidities. So with Nicole's great help in understanding how to put together meals, especially during that week, and with an incredible wife who's willing to prepare my meals and everything, I did it. And you know that first five day fast, you know, by day two or three, the hunger pangs are there and oh my God, can I do it? But I got to do this. And it's kind of funny, like after day three, the hunger disappeared. And on subsequent fasts, sometimes I go five days. I don't even feel hungry during it. Maybe some, like last month, I did it the third day, which was I do it a Monday through Friday, the Wednesday. Oh God, I'm kind of hungry. I feel kind of weak today. But it lasted half of that day and then just passed. So I really tolerate those five day fasts well. And the results are so astronomical. The weight just poured off. We rapidly repeated some of the biomarkers and was there. For a guy like me who's my life is looking at biomarkers in people and seeing it was just so impressive that this has got to be doing good things to my body and symptomize. I just. Symptoms disappeared that I didn't realize, you know, I didn't realize I couldn't walk up a flight of steps without being a little bit dyspneic or things like that. And that's just all gone. So there were a lot of rewards that came quickly. And the fasting wasn't as horrific as I thought it was going to be.

Yeah, I think people who listen to me talk have got the sense that I've become more and more a proponent of fasting as an adjunct to dietary restriction. Of course, dietary restriction, meaning the restriction of certain macronutrients. So carbohydrate restriction would be a form of dietary restriction. Protein restriction would be, you know, meat restriction. For those who choose to, you know, be vegetarian or vegan, that would be a form of dietary restriction. And all of these things can offer benefits potentially. But caloric restriction, the actual restriction of the total number of calories for limited periods of time, I think has to be a cornerstone of what we do because it is simply the most powerful way to deplete glycogen. It is simply the most powerful way to reduce insulin. It is the most powerful way to turn those nutrient sensing organelles and molecules off. And we know that we don't want those things off indefinitely, but we know that our current living environment, where they're basically always on, you have these, you are constitutively fed. It's evolutionarily unnatural. And in the metabolically ill person, it might be the single most destructive thing you can do. And I've said this before, and I'll say it again, Tom, my intentions, I wish I could say it was just altruistic. It was incredibly selfish. My motivation for this. I remember sitting down and saying this to you in October, September last year. I was like, look, Tom, the impact your teachings have had on me personally, and therefore by extension on all of my patients, it can't be measured. And so I started jokingly, and I've been calling you this for a couple of years. I've been referring to you as the national treasure. And I remember saying this to your brother when we had dinner with him a few years ago. And he kind of rolled his eyes at me, I'm sorry, to your son, to Brad. And so I just said, look, this is a selfish motivation that I have to keep Tom around as long as possible. So as long as I can be transparent about that.

Oh, you're very kind. And the other good thing about your talk? Look, I'm basically a scientist. I don't try and ad lib and make things up like so many people do to support whatever they believe. There was just so much plausibility and the science behind a lot. What you said seemed very real to me and did a little reading. And so that sort of boosted me too. Peter's just not making this stuff up. It's beyond the theory stage, I think. And if we look at our evolutionary genetic ancestry, and what our human ancestors, the way they ate years ago, it just makes a lot of sense. So here I am, and I'm not giving it up anytime soon.

Well, and I'm holding out hope that my dad is listening to this or will listen to this. I don't think he's ever listened to one of my podcasts, but I might insist that he at least listen to this portion of this podcast, because if I could get my dad to do this, that would be, again, probably for selfish reasons, that would be sort of the highlight of my life. And you generously offered to speak with my dad? Because I don't. He certainly won't do what I would recommend. So it would have to be Nicole and you sort of cajoling him into trying this. And Nicole has also offered to help in any way. So, dad, if I can get you to listen to this, I hope you'd consider doing this. So with that said, thinking a lot about. Well, first of all, just watching the transformation you've just described unfold over the last seven, eight months. It's blown my mind because I've worked with many patients over many years, and I've almost never seen the level of fastidious dedication to adherence that I've seen from you. And I've known you for many years before, and you'd been sort of ambivalent towards this. So it was sort of this question of, once the switch flipped, there was no wavering. Now, I didn't make the connection at the time, but I think more recently I've realized that's just kind of the day spring way. So before we get into lipids, I want you to tell me about the very first obsession you had.

While I've had a few obsessions in my life, there is more to me than just understanding biochemistry and cholesterol and other lipids or so. And probably the first thing in my life was being born to two incredible parents, one of whom was a professional firefighter in the city of Paterson, New Jersey, New Jersey's third largest town. So when you're a son of a firefighter, real early in life, you're visiting firehouses and being exposed to the incredible men who are firefighters and all their glorious machines that are sitting there in the fires, these big red things with bells on them and sirens that, when they start them up, make a lot of noise. Every once in a while, your mom brings you to some major conflagration where you see your dad running in and out of buildings that are collapsing and on fire. So I just developed an unbelievable passion and love of firefighting which remains to this day. I'll put in a plug. I run one of the most viewed and largest historical firematic firefighting websites in the United States. It's pattersonfirehistory.com if anybody like to do it. And you'll see. And there's just thousands of pages of thousands of photographs and incredibly documented data on the Paterson, New Jersey Fire Department, which has very unusual United States. It goes back 200 years. Patterson was formed by Alexander Hamilton right after the Revolutionary War as a mega industrial town because of a giant waterfall that was in the town. So they had a need for firefighting early on. So you can really trace the entire history of firefighting in the United States by focusing on Patterson. And it applies to New York and other towns that have been around for a long while. So I've just had a great passion doing that. So of course I wanted to be a firefighting too. So look, to collect the 30, 40 years of data that is now on my website, you got to be a little bit of a nut job with a passion for firefighting to do that. And I was able to collect that material through, of course, having a father who was well connected in a firefighting world and everything. But I put my heart and soul into it. When I was an adult after med school, I used to go to every antique market around firematic flea shows to collect. I. I collected one of the largest displays of firematic antiquities that were around in the United States outside of a museum. So I didn't even.

That was a word, by the way. I just like the way that sounded.

And there are a bunch of nut jobs like me who are very much into this.

You were recently given an award.

I was, because of my dedication to Patterson documenting all this. They're so proud of it. It's probably the most visited historical fire department website in the United States. The department very much respects what I do. At a certain point, they became very cooperative with sharing some of their archival mater that my father hadn't stolen when he was a chief officer in the department years ago. So the latter years have had dirt cooperation. But they brought me up to a memorial ceremony they had in June recently because I was very much. They have a monument up there where if you make the supreme sacrifice, if you're a firefighter who dies in a line of duty, you get your name on this beautiful bestowed monument outside their fire headquarters. And they've had 28 firemen, unfortunately had their name on that monument over the last couple hundred years. And through my archival analysis in 1938, I found the name of a firefighter who died on the job. He dropped dead as he was carrying a big hose, running to a fire hydrant to hook it up. And it sort of got ignored. Now, in 1930, he obviously died of a heart attack at the scene. He was 50 some years old. Dying of a heart attack while you were fighting a fire was not considered a fireman's death at that time. If a wall collapsed on you, it would have been, but nowadays it certainly is. If you have a heart attack at a fire, you would get your name on the monument, your colleagues would mourn you heavily. So I actually found the data buried deep in the files that this guy dropped dead at a fire scene. I went to the library, got the newspapers that documented that, and I presented it to the department. So lo and behold, they added the 29th name to the monument, Fireman Edward Moore, who died in 1980. So a little belatedly, but his name is there. So I wanted to go up and see that presentation. And the chief said, tom, would you get up and just tell this crowd a little bit about who Edward Moore was? Because none of them will certainly know him. So I made a little three, four minute speech on who he was, what happened to him. And I started to walk back to my seat, and the chief said, no, Tom, don't leave the podium yet. And he said, you know, figured you make a long story short, what you've done for the department. We are, for the first time in a department history, making you an honorary battalion chief. It's the highest honor a professional fire department can ever give to a civilian. They will never give you a rank above a battalion chief, a deputy chief, assistant chief, or a top chief. But me, a battalion chief, my dad was a chief for 30 years in the Patterson Fire Department, starting as a battalion and a deputy and assistant. It was a. I just can't display the emotions that went through me because my life, I always wanted to be a fireman. Dad twisted my arm and said, no, you're going to college and you're going to study whatever you want to study, but you're not joining the fire department out of high school, which I probably really wanted to do. And as tears were in my eyes and there were 400 people in the audience at this big ceremony, I just looked to the skies and. And hoped I was additionally making my father very proud of me. And he was a very proud man of me because of my medical career, of course, but so my love and passion of firefighting got me this. And just to finish that story, because they told me, you're the first person that's ever we've awarded a bad Italian chief to. But they didn't know. I know their history. Back in the 1960s, a woman was made an honorary battalion chief in the Paterson fire department and happened to be a nun at one of the big hospitals in Patterson, A Sister Loretta Agnes. Now, what do you know? One of the major reasons I'm a doctor and had. I trained, actually at St. Joseph's Hospital in Paterson, New Jersey, because I really wanted to practice in that area. She was a friend of the family, a nun, and would visit our house all the time. And she knew I was pursuing a medical career. And she used to always harp on me, oh, you gotta come and visit our hospital. I'll give you the grand tour. And you can hang out there in the emergency room if you want, and just get to know our hospital, Mr. Smartass here. No, I'm gonna go to some big university hospital here in south. I want nothing about a hospital in Patterson, New Jersey, even though it's 700 beds and it's a gigantic hospital with a teaching program. But I took her up on it, and I was a freshman medical student at the time, and she just let me hang out in the emergency room. And I hooked up with a couple of docs who would work. I would go in the evening after finishing classes. I'd go hang out in St. Joe's I don't know. It's a large part of who I am, what I do. It fit in perfect. I'm a fireman. Emergency room is where all the action is happening, happening or stuff. So Sister Loretta had a mega influence, and I did go to train there, and she was a godsend to patient, so I interacted so much. But Sister Loretta was made in honorary battalion chief fighted department because of her care that she extended to every firefighter who was ever brought to St. Joseph's Hospital in Patterson, New Jersey. So the two honorary chiefs in her history are linked in other ways. So it's just kind of spooky there how that turned out, you know, but just a great honor. And on my desk at home, I have a blotter that, you know, is like a plastic top so I can stick things that are important to me underneath it. I have my mother and father's. The little card that was at their funeral that funeral homes put out. I got some pictures of my son there, and I've got a mass card that my wife And I gave to Sister Loretta on her passing. It's just such an impact. Last but not least, the fire department actually now does an annual Sister Loretta Agnes dinner for the clergy in Patterson and stuff. And I kind of laughed. About two years ago, they called me up and said, oh, you know, did you ever hear Sister Loretta Agnes.

Does it bear shit in the woods?

Actually, on our website now, I have a whole page dedicated to her and what she's done for the fire department and everything. So it's kind of funny.

Well, we could probably spend another hour talking about that. And I know that our listeners would actually appreciate it. But that said, there are a couple other things I want to get to even before we get to the lipid stuff. The other thing that we connected on pretty early was I realized you were a hockey fan. Of course, I grew up in Toronto, and I don't think you can grow up in Canada without being a hockey fan, without playing hockey and being obsessed with it, you know. And certainly when I was at really young kid, probably till I was about 13, it was hard to think of anything but hockey. And it turns out you kind of just as you had this sort of light switch moment with it, you know, all these things we've talked about, you had kind of that flip of the switch moment in hockey too, right?

I sure did. And it was very easy to grow up in New Jersey in the 1950s and early 60s without knowing what ice hockey was, or even ice skating, per se, other than a month or two on a pond, maybe in January. You know, when I was a young boy, a defining moment in my life was the first visit. My dad picked me up in a car and brought me to Yankee Stadium. And I walked into, probably in the early 50s, into that stadium and the green grass and these Yankees running around in their white uniforms and pinching. So I became a mega baseball fan growing up in a New York Yankee Die Hard, which I remain to this day. And that was a transforming moment. To be sure, it's the sport we played as a kid, Wiffle ball all the time, me pretending I'm Mickey Mantle, and the pitcher would be Whitey Ford throwing to me and everything. But in 1962, while in high school, my best friend was another young man who also had firefighting as a passion. I always joke, I think I became his best friend because he knew my father was one of the fire chiefs in Patterson, and he wanted to hang around with a fire chief son talking about, who cares? I love the guy. And we grew, we became so close in High school and everything. But some reason he was a hockey fan or son. He says, I want you to, you know, I go to Madison Square Garden occasionally. I'd like you to come with. Why not? You know? So I went over and I remember to this day, it's probably 1962, maybe freshman, sophomore in high school. You walk into the. Oh, and I'm talking the old garden up on 8th Avenue, 49th Street. It was a dark, dingy place. You're walking in, you almost need night vision goggles. But all of a sudden you walk into a spot where the glow of that white ice strikes you. And out come these guys in red, white and blue, the New York Rangers, who at that time were wearing no helmets. And you really. And the other team, there are only six teams there, so the competition was unbelievable. So I just fell in love instantly. One game I knew I just have to start following this sport. And I told Peter, within the year, not only did I say, I have to watch this, I went out and bought myself a pair of skates, which wasn't easy to do back in those days. And me and one other buddy at night, in the winters, we started going to a local pond we knew about. We're the only two people out there, and we just taught ourselves how to ice skate, bought some hockey sticks, started playing. One thing led to another, convinced a few others young friends to do it. And within a year or two, we knew the one or two rinks that were in 50 miles of our house. So we would drive down there and rent the ice for an hour. So I became a pretty decent hockey player, considering I didn't grow up in Canada and everything, at least playing against New Jersey competition and over time joined men leagues. And some of my best friends in life now are not doctors. There are guys I played men's league ice hockey with beer hockey, as they call it nowadays, or whatever, because after you're done with the rink, you know where you wound up for a while. And I played until I was 50 years old. And the last part of my hockey story, of course, when I was so lucky, my wife and I to have a child who turned out to be a boy. When he came home from the hospital, my wife and I drove him home, brought him upstairs, put him in this wonderful bedroom we had put together with a crib in it. And what was laying in his crib, a small hockey stick that was about four feet long. And I wanted him to imprint on it like the ducklings do to mother duck. And as it turns out, my son Turned out to be an incredible lifelong hockey player at every level, youth hockey, high school and college.

And he was a team captain in college, wasn't he?

He's just had leadership abilities. I credit that to my father. And yeah, he was probably the captain of every team he was ever on from might up through high school and into college and so very proud of him. So a large part of my life was not only playing hockey as I grew up watching hockey, but when he started getting every night of my life, I was at a practice watching him. And so again, some of my best friends were other hockey parents and stuff. Again, I wasn't hanging out with all the docs and going to the document doctors balls and that kind of stuff. They never saw me. And in practice for 37 years, I just had a godsend of a fellow from a brother, really my associate who just covered my tail every time I wanted to run to a, hey, I gotta go to practice with Brad or I gotta play hockey. Just covered the practice and it was made my life easier. So. So yeah, that's the other super passion of mine when I say dedicated to hockey. Even when I was in med school, when class was over, I was going to a rink or someplace or I'd show up in my greens because, hey guys, cover for me for a few hours. We got a game tonight. And that's how crazy I was. In my medical school yearbook, you'll see a picture of Tom Dayspring and the class voted. You know, we're going to predict what everybody's going to wind up. And I was predicting, of course, to be the future New York Rangers team physician, which I never did achieve, but close enough.

Well, it's not too late, so we should add that to the list of things that we might try to figure out how to tee up. You know, it's so funny because I grew up in Toronto. Of course, the Maple Leafs were also one of the original six. Now I grew up in the 70s and 80s, so by then the league had expanded. And I very quickly fell in love with the Edmonton Oilers, who would very soon go on to become the most dominant team of the 80s. But even watching them come up before they became that most dominant team, they were just electrifying. Thanks to of course, Wayne Gretzky, but also guys like Mark Messier, who would go on to become captain of the New York Rangers and finally bring glory back to the Rangers after one of the longest hiatuses in Sports. It was 94 when they won the Stanley cup again, right?

Yep.

But it's the same experience. I remember the first time my dad took me to Maple Leaf Gardens, which, of course, is not where they play anymore, but was it. It was this old, sort of historic, kind of dingy arena. And I remember one game because there was like, gold seats were the best then. Red, blue, green and gray. And, you know, we could afford the grays. But I remember for an exhibition game where the tickets were a bunch cheaper, the Oilers came to play the Leafs and we got gold seats. And I mean, I couldn't. I couldn't believe what it was like to sit 10ft, maybe a bit more, maybe 20ft from the glass and actually see. You know, at the time, there was a goalie named Grant Fuhrer who was like, I was a goalie. I played goalie in hockey. So Grant Fuhrer was actually the guy that I was trying to emulate. And to see these guys, you know, Yari Curry, Glenn Anderson, Paul Coffey, Mark Messier, Wayne Gretzky, I mean. Yeah, it's just. It was a very special thing to do as a kid, and. And I can certainly relate to that. And the older I got, the more I realized that the experience I had was basically going to be shared by every kid growing up in Detroit, Chicago, New York. I mean, the stuff that you would have seen. Montreal. Never mind. I mean, you might argue that it was even more fanatical in Montreal than any other place.

Let me just expound that. Peter is right. If you ever have the opportunity, I mean, any hockey game is great, but if you can get such a seat. And way back when we were kids going over to the Garden, you know, the lower, best seats, a lot of them were corporate, you know, those who couldn't afford those seats. But they didn't always show up, those guys. So almost always by the third period, we'd be sneaking down there and sitting there as young kids. And the ushers wouldn't give you too much trouble if you were showing up in a third period there. And it's just a different game back then. And look, I love the military. Nothing can be like in a foxhole when you're fighting for your life. But when you see what those guys with the way they look at each other and the way they hit and at top speeds, wow. It's a different sport.

Yeah. It's funny you bring that up. I totally forgot. But as a kid, that was my M.O. was we'd get the gray seats, which I think were $5, maybe $9, but they were, you know, that was what we could afford. And we would just take binoculars and lock eyes on seats where we thought people had left, and then we'd weasel our way down. And it's the same thing. It was just a different era. Back then. They weren't electronically scanning tickets. So usually by the end of the game, you were sitting close. Very, very close. Yes. Oh, God. Just special memories. Well, let's get to what everyone really wants to hear. I'm sure nobody wants to hear us bullshitting about hockey and stuff like that, but like I said, I don't even know how we're going to organize this. I mean, we've talked very briefly about kind of like a loose framework for what we want to talk about. I don't want to put any restrictions on time. I just want to go as long as we got to go. I've set aside an entire day, which for me is almost impossible to do. I think I'm seeing one patient all day today. And then we'll divvy this up in the end. So let's just start with kind of definition. What's a lipid? What's cholesterol? What are these things?

Before we even do that, let me tell you how I wound up in. In this world or so. Now, look, I went to Med School, 68 to 72, residency in internal medicine for three years after that. And I've already told you, I've done an extensive amount of time working in emergency rooms, you know, where everybody comes in. In those days, acute myocardial infarction was, you know, very, very common. You didn't spend the night in the ER without seeing a couple of them people coming in and fulmin pulmonary edema and everything. And, you know, I just recognized early on that atherosclerotic heart disease and its clinical endpoints are bad news. And a lot of those people were young and dying way too prematurely. And in those days, when you came in, even if we got you through your acute coronary syndrome, pulmonary edema, I mean, it's 50, 50. Most of them were dead by morning, or those that survived then had this morbidity they had to deal with. So I grew up in an era when it was rampant. The acute episodes that I don't think they see anywhere near with the frequency that I did back then. And I just latched onto it, and I was lucky. Those were the days when the concept of a coronary care unit was invented. Mason Sones invented coronary angiography at that time. And our hospital developed a big. One of the probably first departments in. In New Jersey that was doing coronary angiography. And that's the world I decided to start hanging out in. My electives in medical school were all spent in the coronary environment. One year of our residency, the third year was pretty much elective, so all I did was hang in the angiography lab or the coronary care unit or the post coronary floors providing care. My first opportunity going to practice a cardiology group actually brought me in to, hey, you manage our hypertension, you do stress testing, which I had done a lot of as a resident. And of course I'd be taking call every fourth night in that group too. And you know, it dawned on me, God, every night I'm being called back to the hospital at 2, 3 in the morning. It's another acute MI, for God's sakes. So I jumped really on to the prevention strategy. It would be far better to prevent heart attacks than getting up at three in the morning and praying you could help them survive this episode that they at least made it to the hospital with. So early on in life I just said, what's involved with atherosclerosis? And early in my career, hey, please don't smoke, try not to be fat, which I was not the best example of. And let's attack your blood pressure aggressively.

I want to pause for a second here because you said something really interesting that I just hear so often from physicians of your generation, including a physician I'm really close to here in New York who I share office space with. And he's, you know, he's about your age, runs a very nice concierge practice in the city. And he basically said the exact same thing you just said, which is, we just saw mis all day, every day, non stop. You know, a week couldn't go by where one of his patients didn't have an mi. And then he contrasts it with today. He's like, I don't know the last time I saw one, I don't know the last time I saw a Q wave mi. I just, you know, he doesn't recall.

I get that all the time from young docs, residents or physicians who've been in practice. But they're not in a baby boomer of my age or anything. And they've all seen obviously acute cardio coronary syndromes or. But it's a different type of acute coronary syndrome. They don't see these people coming in and fulminant pulmonary edema. They just don't know what it's like. The massive transmural mis with Q waves developing, dropping Dead before your eyes. Because they're rushing them right to the cath lab now and dissolving their clots and everything. Never do. So how these people survived or didn't. So I was talking to Peter La last night and it would not be unusual during my residency if you were the first year resident where you covered every admission in our 700 bed hospital. There were nights where I'd get a dozen admissions to the coronary care unit, a dozen of some sort of exacerbation or a clinical event related to atherosclerotic heart disease, most of them of our most horrific nature. And I just don't believe that they see that nowadays. Yes, they see acute coronary syndromes, but they don't see the type of acute coronary syndromes we saw back then. So it has changed. And look, we got a long way to go to still eliminate this heart disease. I think if we all jumped on prevention much earlier in life, we'd end this disease. But yeah, it was a different world back then, surely was.

Is there one person that would sort of be your first mentor, the person that specifically got you not just interested in cardiovascular disease, but pointed you towards lipids? Like something about these lipids matter?

No, I sort of discovered lipids by myself. As I said, it was evolving. I wanted to be a preventionist. So I was on the hypertension bandwagon and it became pretty obvious after a lot of the big epidemiologic trials started coming in with more data. Framingham, Mr. Fit that Lipids, specifically cholesterol was the one they sort of focused on early on, was a real big player in here. So I realized, and I'm a self education guy and most of the things that, all right, I'm as up to date as I can be on hypertension in the 1980s. Now it's for me to start doing some lipid education. So I started doing a lot of reading and stuff. And first course I ever went to take lipids to a different level was out there at the Cleveland Clinic. But the guy that I hooked on earlier that really became a major mentor, a good friend was Dan Rader down in Philadelphia, who turned out to become a world high density lipoprotein expert. But just an expert in my mind in all things lipid. He was so far ahead of the curve. So Dan was one of the real early ones. Others I had jumped onto were Tony Gado and Virgil Brown and Alan Snyderman and Ron Kraus and people like that who are really doing the type of investigations that when you started doing lipid reading, you'd find, yeah, all roads keep.

Pointing to these guys.

Yeah, really did. And they were gifted enough also that you could semi understand what they were writing about and talking about. I told Peter, he said, how long did it take you to MA? It was 10 years of serious reading. Anything you could get your hands on. I think the first five years was you read something, you didn't even know what you read. But I was just motivated to keep going back sooner or later. And one day I woke up and it sort of, sort of all made sense or so. So it took a lot of education and I think it's easier nowadays because there are phenomenal reviews have been put together by a lot of people. They just didn't exist in those days. You had to sort of discover it yourself if you didn't spend. Spend two years at the NIH doing research on it and you would be exposed to it that way or so.

Well, you've also played a big role in that. I mean, when I now get to think about how I got into this interest, you know, what sparked my interest was there wasn't a single moment. But I do remember reading a single document that you had written in 2011. And I think I was introduced to it by. Remember that guy Greenie up in Greenoff? Yeah. So I think Greeny had sent me a document you wrote. And it was the first time I'd even heard of nmr. I mean, I knew what NMR was from chemistry, but I didn't know what NMR was with respect to lipids. And so he sends me this document. It was like a PowerPoint but with notes embedded. So it was printed as a vertical. You know, I printed it as a vertical. And each. So each page had a slide which I would learn to go on were like famous Dayspring figures. At the time, I didn't realize that. And then, you know, just great text and prose explaining it. And it was 26 pages long or something like that. And it was dense, like you can't imagine. Well, you can imagine because you made it. But it was. There was a density to it that I was like. And I'm thinking, okay, I know I'm just kind of a dumb surgeon. So it's not like I ever knew this stuff. But it was just so. It was just so captivating. I was like. It was like there was a whole other world that I didn't know existed and these particles mattered. And I never. I remember feeling like, how did I not want to know this when I was going through medical school and training, you know, I was just, you know, I guess when you go down that surgical path, you're not thinking about this stuff. You're thinking about, you know, the surgical ways to address these problems. And I mean, I read it so many times because the first few times I was kind of frustrated. I was like, I don't know what the hell is going on here? Like, I really have no clue what he's talking about. And what are these APO this and APO that. And I, I just kept getting confused by the concordance and the discordance between all these particles. But that, you know, mid-2011 was kind of when I just, I don't know, I guess that was just the bug that bit me too. But to your point, I think so many people today, whether it be physicians, patients, anybody who wants to understand this topic better, really can look to you and your work as a great way to synthesize the work of these luminary folks that you've alluded to.

It's kind of funny because who could have ever imagined that when I started my lipid journey, I just was a real world internist with a big practice in northern New Jersey. My only real goal was to be a better internist to my patients, most of whom were getting atherosclerotic or co cardiovascular events. So rather than mastering ulcers and GI bleeds, I just went where the money was. Atherosclerotic heart disease. And I invested all my time and effort on learning this. With no grand design that hey, I'm. Hey, Dave Spring. Whether you know it or not, within 10 or 15 years you're going to be the most requested lipid educator in the United States. How did that ever happen? And it just happened because I self taught myself as a dumb real world internist made it understandable to my brain. Part of the dayspring learning curve is visual.

You said you used to draw.

I draw graphics as I'm reading this stuff initially and I have no artistic skills whatever. If I draw a human being, it's that stick figure with a circle as a head. But Path PowerPoint came along and there are tools there which are not that hard to master. So I was able to draw and I'm now known as one of the best lipid lipoprotein illustrators in the country.

We're going to probably not probably. We will unquestionably link to maybe your 50 finest diagrams in this podcast, which is to say about 1% of what you've produced. But I remember the first time you sent me one of your PowerPoints, I was like, oh, it's really interesting. Like either Tom has contracted with an illustrator to do this or he's found somebody else that's already done these. And when you said you had done them, I was blown away because you have to remember I cut my teeth in PowerPoint at a place like McKinsey, where we're PowerPoint ninjas. I could do anything in PowerPoint. I couldn't do what you had done simply because I couldn't. I didn't have the time. Like those were such complicated figures that like if I ever came across something that was that complicated that I needed to make a slide for, I would just get the illustrator to do it. I wouldn't actually be able to sit there and make it happen. So I couldn't believe it. And I think the listeners who aren't familiar with your illustrations are going to find themselves incredibly surprised and grateful for that sacrifice.

So illustrating things made me understand. I mean look, my illustrations got better and better as time went on. Early on they were a bunch of colored circles and stuff. And then I learned shading and making them move and animate on the slide. So I've really progressed there. But I just learned by illustrating. I've since had serious educators tell me the human brain just understands things better by seeing pictures and graphically they're and reading thousands of words put together. And there is no doubt my gigantic success as a lipid educator were I could dumb down the talk and try and make you understand complex enzymology or anything else, the APO proteins and how to interact. But as I'm saying it in my dumbed down version, you were looking at it moving on a screen with a graphic. So it made comprehension of advanced lipid related areas much easier for either a layman or certainly a physician to understand. Or so so just the part of who I became. And then somehow because of all my intense prepper writing slide notes, as Peter said, I became pretty good at putting together prose. So I've done a little bit of research in my time because the places I wound up on and have authored a research publication. But most of the things you'll find in the literature with me are reviews and discussing this, trying to make you understand concepts. Then you can go read the geniuses studies and you'll understand what they're talking about and everything. So I just evolved into that. And actually the first guy it was a cardiologist down in Florida, Michael McIver. He's the first guy I ever saw use PowerPoint for literally lipids. And I just used him and he shared a lot of his early stuff on and I learned off of him. And it's made my life as a well known lipid educator. I've got opportunities to start doing lipid education. And if you go out and you're lucky enough to have some people come and listen to you, you better be good at what you do or they're going to badmouth you and you'll never be invited back. Or if you do want to come back, they're going to like you, they're going to be in touch with you. And I just developed ways of explaining lipids and illustrating lipids that became huge. Just to finish is Mike Davidson, who's one of the all time gods in the lipid world in Chicago, still a university professor there. One of the big founders of the National Lipid association did at one time during his presidency bestow their presidency award to me which is given to people who make contributions to lipidology. But this is the top lipid organization in the country. How does some real world internists with no formal lipid training ever work his way up to an award like that? Or so Mike told me. We pulled out of the NLA and a lot of people joined this organization because they heard a Tom Dave Spring lipid lecture. And Mike was a big advocate of you teach through illustration. And I've illustrated many things from Michael over the years. And so he's right. And that's my claim to fame. I hope some of you follow me at drlippid because Twitter is the way to get a lot of my graphics nowadays.

Yeah. And there's a lot of stuff that we'll make sure we link to. But the Lipaholics Anonymous you used to write a lot more into. I used to read those case reports constantly. We'll have to make sure we can pull all those things out of the archive because there's some amazing cases there. But yeah, we'll make sure people know where to find you on Twitter and all that stuff.

Because quickly on that. When I was on this giant lecture tour for 10, 15 years of my life, I did generate a weekly newsletter called Lipidaholics Anonymous where they were one case discussion all real world that were in my practice or sent to me by other docs. And I would just take it into the next level. So I would explain it basically and then I would like, I'm talking to a lipidology illustrator. It became immensely popular. I had several thousand people it was free. I sent it out each week in a group email. But it really enhanced my. And it found itself on a lot of desktops, you know, so that's a big part of who I was, you know, And I do have most of them still there. But I'm really. People give me all. Because I don't want you to know what I was saying in the year 2000 because it's mostly all wrong nowadays because we've evolved so much. But if you want to see what we were talking about in the lipids in 2002, they might have some historical interest.

Yeah. Well, you just touched on kind of an important point, which is I like to say facts, all facts have a half life. And some of them are really, really long half lives. You know, the earth being round is. We would call that an incredibly long half life fact. We're going to, you know, the half life is nearly infinite on that. But elevated levels of HDL cholesterol are necessarily a good thing. That's a fact that I think it used to be deemed a fact based on the epidemiology of Framingham. I think today anyone who's serious about the study of lipidology would say that's grossly oversimplified, potentially incorrect.

That's certainly one of the all time facts that really disappeared. I personally think it's a waste of time to even put it in the lipid profile other than it's used in certain calculations that are popular nowadays, like non HDL cholesterol. But I encourage no one to ever make a judgment on any human's cardiovascular risk based on their high density lipoprotein cholesterol level, or think, you know, what you're doing to a human being if you somehow change that HDL cholesterol metric in that patient. Has nothing to do with anything, to be honest.

All right, so now I'm chomping at the bit. We gotta get into this. So where do we even begin? Do we want to start with what's a lipid? What's cholesterol? What? Let's. And then I want to, you know, let's explain what these things mean. HDL C and stuff. Sure.

Well, a lipid is basically a molecule that is not soluble in water. It might be soluble in certain organic solvents, but not in water. So it's a hydrophobic compound. Compound. And oils and fats are what everybody thinks of as a lipid. Some, you know, cholesterol is in there. I never liked calling cholesterol a fat, but it's a Lipid fats to me are fatty acids and combinations of fatty acids or so glycerides. So that's what lipids are. And different lipids have different degrees of solubly. Some are in extremely hydrophobic because both ends of the molecule that can be seen in water, some lipids have a one end is a little bit water soluble, hydrophilic, and the other one is. And that would be where cholesterol fits in, phospholipids fit in. So that's what a lipid is. And there are several types of lipids in your body, but the ones that those of us who live in a clinical lipidology world are focus on our cholesterol, basically two types of cholesterol. And there are fatty acids. But fatty acids stick to a lot of things and it's sticking is called esterification in the world of lipids. So they can bind to carbohydrates, cholesterol. A3 carbon sugar called glycerol is the most common thing they bind to. So if you have one fatty acid on a glycerol, that's all a monoacylglycerol. If you have two, that's a diacylglycerol. If you have three fatty acids stuck on your glycerol compound, that is called a triacylglycerol, which most people would call a triglyceride. If you're as old as me, you're not used to hearing those terms and you're used to hearing triglycerides, but initially they were just called glycerides. And glycerides would be the whole family of monoaceous and triacylglycerides or so. And it's basically the way in which the human body transports fatty acids or stores them. It transports them in the plasma or stores them in various tissues in case you need a fatty acid for a certain purpose, be it energy or a structural purpose, then the fatty acids would disconnect from its glycerol backbone. That would be called de esterification. And that fatty acid could be used to whatever what a cell wanted to do with that fatty acid. Or so if the cell didn't need it, could store it till when it did need it as a glyceride. So those are your basic definitions. But the one glyceride that is of incredible importance, maybe in the future, the one we're going to be looking at most seriously and the one that nobody ever looks at or even brings into the discussion nowadays are our phospholipids. And phospholipids are simply glycerol compounds. So you got your three carbon alcohol, sugar there, and there's two fatty acids attached to it. And there's a lot of fatty acids in the makeup of every phospholipid might have the same two fatty acids, different fatty acids. Fatty acids come in different lengths, different types of double bonds. And then they got a head group which is usually got a phosphorus moiety in it. And that's what a phospholipid is. Phospholipids are kind of cool because part of it is water soluble, part of it is hydrophobic or doesn't like water. They're called amphipiles. Ampipathic is the name. And that allows them to sit in certain positions in our body where hey, their hydrophobic lipid tails, the fatty acids can exist in a lipid enriched environment inside the cell, inside a core of a lipoprotein, which is all hydrophobic lipids. But its hydrophilic surface can interact with plasma. So where do phospholipids exist? On the surface of our lipid transportation vehicles, lipoproteins or on our cell membrane. Every cell membrane in your body is phospholipids. And what nobody seems to know is, is most of your phospholipids are made in the liver or they're made in the small intestine because the intestine absorbs fatty acids, repackages them into glycerides, phospholipids or triglycerides, and then they become part of lipoproteins that enter your lymphatics from the gut chylomicrons. Or your liver gets fatty acids and as phosphorus, it makes phospholipids. And your liver makes, makes lipoproteins and excretes them. So few people know that a gigantic. Everybody talks of lipoproteins as if they're delivering cholesterol all over the place. That's what we have lipoproteins for. That's probably the last reason we have lipoproteins. Because every cell in your body makes every cholesterol molecule. It needs to do what it has to do, with a few rare exceptions. So if I'm a nose, I don't need some lipoprotein to come and deliver cholesterol to my cell because I need cholesterol in my nasal cell membranes. That cell will make cholesterol. Every cell has the genetic power and the protein, the enzymology to make cholesterol to its heart's content. The tragedy is what we eat. Most of our cells make way too damn much cholesterol, which becomes then not a, a absolutely life sustaining molecule needed in your cell membranes, but a cellular toxic molecule because it crystallizes and kills that cells. So evolution has given our cells incredible powers to evict, efflux out cholesterol so they don't suffer cholesterol toxicity in those cells. And that will be certainly something we'll get into. How do cells get rid of all this cholesterol that because of what we're eating are making too much of our cell? It's not that lipoproteins are delivering too much cholesterol to most of these cells, although they can in certain areas. Some people do get cholesterol builds up in their skin, xanthomas and things like that.

And I want to just interject for a moment to go back and clarify something for the listener. So we talk a lot about fats, but many people are familiar with the term saturated fats, monounsaturated fats, polyunsaturated fats. You, you touched on it very briefly, but just so that they understand the broader context. A saturated fat means a fatty acid hydrocarbon that has no double bonds in it. A monounsaturated fat has a single double bond in it, and a polyunsaturated fat has two or more. And of course, depending on the position of the first double bond with respect to its carboxyl group. That's where we get into these omegas and things. But the point here is when people talk about saturated, monounsaturated and polyunsaturated fat, they're referring to the positions of these double bonds within these long hydrocarbons that also can be of variable lengths. So for example, a saturated fat can be very short, 6, 7, 8 carbons in length, or it can be much longer. Each one of them has its own name, and the same is true with the monos. So once you get into the monos and the polys, the nomenclature starts to get complicated because you're describing both the position of the, the double bonds and the length of the hydrocarbon. Now these things have all of these complex properties, but in many ways it still pales in comparison to the complexity of the cholesterol system because those fatty acids can also mean, even though they're not soluble in water and therefore they can't float around, willy nilly, they have the luxury of being transported on albumin. Right? Which is, which is another protein in the plasma that can hide this hydrophobic part of them in an ability to transport them through. But yet, why can't we transport cholesterol, which you've just explained is not soluble in water, it's hydrophobic. Why can't we transport cholesterol or phospholipids in albumin, something that's so ubiquitous and benign?

Well, you can. Cholesterol can attach to albumin. And just before I answer your current question, what I was explaining before is, you know, the lipoproteins, everybody thinks their purpose is to deliver cholesterol to tissues. That's their last purpose. They don't do that. They are. The real purpose of our lipoprotein, our lipid transportation system, is to develop, transport energy to tissues that need them. That would be triglycerides, the fatty acids which our cells oxidize to create ATP. So they are brought to tissues that are very good at extracting triglycerides from lipoproteins muscle cells. But if your muscles, because you're not using your muscles, don't need any energy, today, those triglycerides will be dumped in an adipocyte to be stored as your fatty acids until you need them. But what nobody talks about is what else are the lipoproteins delivering? That cells cannot be a cell without they're phospholipids. And what is the surface of every lipoprotein? Phospholipids. Where do the phospholipids come out of? Lipoproteins produced in the intestine or the liver. So what are the biggest lipoproteins? Because they would have the most gigantic surface area, kylo microns coming out of your gut, very low density particles coming out of your liver. So we all talk about our delivery cholesterol. They're delivering maybe triglycerides, because they're very triglyceride with they're delivering phospholipids.

So just to clarify, again, the spherical lipoprotein has an inside which carries the cholesterol ester and the triglyceride. But the phospholipid isn't carried inside that central cargo. It's actually embedded within the structure of the lipoprotein, and therefore the chylomicron being the largest, followed by the vldl, the very low density lipoprotein. The larger the surface area of these things, the greater their capacity to carry phospholipids. Since the phospholipid is carried in the wall.

Correct. And when these gigantic Triglyceride rich particles go to your muscles or adipocytes to deliver their triglyceride in their core, very hydrophobic. In that core is a special type of cholesterol that has a fatty acid to it, cholesterol ester, incredibly hydrophobic. Also those two tissues that I talked about have very powerful triglyceride dissolving enzyme called lipoprotein lipase which starts hydrolyzing the core triglycerides. Now these big dump trucks full of triglycerides like that, they start to shrink when the triglycerides undergo hydrolysis de esterification. The particle as it shrinks. That's called lipolysis. Removal of a lipid from a lipoprotein. So you can imagine these big fat balloons full of triglycerides. If you could suck water out of a balloon, it becomes a smaller balloon too and it would get wrinkles on it. Well, lipoproteins don't become wrinkles, they just evict their surface phospholipids, which can immediately attach to a contiguous cell where the decrease in diameter of the lipoprotein is occurring. Or they just jump on a protein that evolution has given us called phospholipid transfer protein, which then takes all those phospholipids and brings them to cells that say hey, I need phospholipids. Or the only lipoprotein that is not made in the liver or the intestine but grows itself, matures itself in the plasma. High density lipoproteins. You couldn't change a baby APOA one, which is the structural protein of an HCL into a, a big fat mature large HDL if you weren't supplying it with what Phospholipids. Where would an HDL get phospholipids as these big triglycerides rich particles shrink and they extrude them. Phospholipid transfer proteins is here little baby hdl. Here's your phospholipids and they can mature into it.

So it's just, I love anthropomorphizing these things, little babies, HDL and all these other.

It helps. So that all being said, I want everybody to realize nobody because we don't measure them, because it's complex on how to measure them. And there are so many different types of phospholipids based on the exact fatty acid makeup, the length of the fatty acid. Remember glycerol has three positions. They're called stereospecific number one, number two and number three, everything depends. The lipases attack various fatty acids on different positions. So it's really complicated. So the phospholipids affect a lot of functioning, since phospholipids are making up not only a surface of lipoproteins, basically because they're water soluble and it allows these dump trucks to float around in plasma in the cell membrane, what Peter was just talking about, that fatty acid makeup in the phospholip has become so crucial because saturated fats are straight, they're rugged, they don't bend. So it gives some structure to a phospholipid. If your phospholipids can't contain a lot of saturated fat, you got a strong cell membrane there that's hard to get through. But the real reason cells function and interact with the rest of the cells of your body is they signal each other. And signaling occurs because some something occurs at a certain area of the lipid cell membrane that we're going to call a lipid raf, which is a specialized collection of special phospholipids with a little bit of free cholesterol interspersed. But the structural positioning that a phospholipid takes up, if you have several double bonds in that thing, if you've ever seen a 3D view of a phospholipid that's got a several double bonds and it takes up an incredible amount of space, so it's two legs spread out and you change the structure of the cell membrane. And that structure of that area called the lipid raft allows certain cellular proteins to locate there. And those are all our receptors that pull things into cells or extrude things out of cells.

So the fluidity of the membrane is highly high, highly dependent on the nature of the fatty acids in the phospholipids.

Fluidity and the ability to shelter or let certain proteins be expressed in that area. If I'm an LDO receptor or some immunoreceptor, there's certain areas of cell membrane I could never locate to because the phospholipids wouldn't allow it. But there are other areas. They say, welcome, here's where you're supposed to be expressed. And cells know that and they construct their lipid membranes, hopefully, if you have the right type of phospholipids and everything. So as we start to talk and those who study and investigate membrane physiology, it's one of the more advanced areas in lipidology. But as we also are starting to understand some of the qualities beyond just measurements of various lipoproteins, their phospholipid makeup is going to be crucial. And as we talk about HDLs, we're going to start throwing around the word HDL functionality and a giant part of HDL functionality. What a specific HDL particle does in your body, what it might be capable of accomplishing or not accomplishing, is due to the fatty acid makeup of its phospholipids. And one day I think we're going to be analyzing the lipidome of various lipoproteins and we're going to have a lot more insight of what lipoproteins do or don't do do.

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