037 - Why normal Cholesterol can still kill you with Kevin English

I just said, it is the stuff that ends up in the blood vessels, whether it's in the neck causing stroke, in the heart, in the legs causing what we call peripheral arterial disease. Every single one of those plaques is a hunk sticking into the wall of the vessel. At that point, the disease is so far advanced that we probably need stents and balloons and surgery and all the mechanical things that if we found it earlier and treated it medically with diet, exercise, lifestyle, not smoking, and of course we have a ton of medicines, tools, To affect plaque as well, then heart disease as we know it, which includes stroke as well, right? You get a blockage in the heart, we call that a heart attack. If it's in the neck, it's a stroke. So it's really the same disease. It's plaque. But if we applied this and started doing this on a routine basis, heart disease as we know it, strokes and heart attacks, balloons, stents, bypass surgery, catastrophic cardiovascular events that seemingly come out of nowhere, although the plaque has been there for decades beforehand, just not causing symptoms. that heart disease, strokes, all the things that come from that, heart failure, cardiovascular death, sudden death, all those things could be eliminated. As your insulin levels rise, and I'm sure you have explored this thoroughly, as your insulin levels rise, your body literally pulls in more sodium. It doesn't pee it out in the urine, it pulls more in sodium. So now you're basically, that's how you get high blood pressure. So sodium, which is the ultimate cause of it, but also a high carb, high simple sugar, high Simple starch approach without fiber, without, you know, good protein, good fat, also is another factor that contributes to sodium or salt retention and ultimately translates to the high blood pressure too.

Welcome to the Over 50 Health and Wellness Show. I'm your host, Kevin English. I'm a healthy aging expert and founder of the Silver Edge, and I am on a mission to help men and women just like you build strong, healthy, amazing, capable bodies they love For the rest of their lives. All right, folks, buckle up. We got a fun one today. If you've ever been told, hey, your cholesterol looks normal, nothing to worry about, or conversely, hey, your cholesterol is looking a little high, let's get you on some statins, then today's episode might just change your life. Because here's the truth: a huge percentage of people who suffer heart attacks were told their numbers were quote unquote And for those of us over 50 who want to stay strong and active and fully engaged in life, that's a risk we simply can't afford to ignore. So today we're diving into why normal cholesterol doesn't always mean a healthy heart, what's actually happening inside your arteries long before symptoms show up, and how modern medicine can help us see heart disease decades before it becomes deadly. My guest today is Dr. John Osborne. He is one of fewer than 50 physicians in the United States who is triple board certified in cardiology, hypertension, and lipidology. He's Harvard trained, he's nationally recognized in preventative medicine, and he has personally interpreted over 25,000 advanced heart scans, proving that heart disease is predictable, preventable, and very often reversible. Dr. Osborne is also the co-founder of Clear Cardio, where he's leading a national effort to stop preventable heart attacks before they ever happen by finding plaque early and changing the game from reaction to prevention. So if you are over 50, feel pretty good, but you want to stay lean and vital for decades to come, this is an episode you need to hear. So whip up your protein smoothie and let's meet Dr. Osborne.

So I was 4th, 5th grade. My dad was a pilot in the Air Force, retired Air Force, by the way. And so my first Plan A for my life was to be a fighter pilot. So, 4th, 5th grade, I found out I had to wear glasses. I knew that was not gonna be a successful pathway. So, then I went to— my mom was a nurse. So, then I said, I think I'll go the medicine route. And so, started really young. And that really was the path ever since then.

Is that right?

I went to medical school and I was so intent on going to medical school. That's where I wanted to go, right? Undergrad, all that stuff you gotta go through was just kind of a barrier. So, I found a program. This is a number of years ago now, back in the '80s, where you could get— apply to Penn State, where I grew up, and go to Penn State for a year. And if you did well, then you could go to medical school the next year. So, it was a 5-year undergrad MD program. So, that's what I did. So, kind of skipped out 3 years and saved a lot of time and all that. And then, when I got to medical school in Philly, I was—

Yeah.

19, I couldn't drink. Most everybody else there could, obviously, in the medical school class. So I thought maybe I'll do some research, talk to my mentors. And they said, well, if you're gonna do some research, get into our MD-PhD program. That way you'll get 2 pieces of paper during medical school. And I said, oh, that's brilliant. So I did that. And so by age 26, I'd done my undergrad, my MD, and my PhD, and then went up to Boston and Harvard where I did the rest of my internal medicine and cardiology training.

So right on. And I was poking around on your website here preparing for this interview and you've got quite the papers, as you say, right? So quite the pedigree to talk about what we're going to talk about.

I have a lot of expensive wallpaper. I like to put—

You have a lot of expensive wallpaper. Yeah.

Yeah.

So, all right. Well, that makes, makes you qualified to be our guide to talk about this. So let's, so obviously always interested here in medicine. You knew that was the path. It sounds like you excelled at it, fast-tracked it. You got a lot of certifications here. Why cardio health? How did you become an expert in this area?

Yeah, so it, it, so I went to Harvard at Brigham and Women's Hospital where I did all my training, which arguably I'm gonna say is the best. It's an arguable point, but it's the best place to train and do cardiology cuz that's where I wanted to go. In fact, when I started my whole pathway, even in medical school, I said, I wanna go to the Brigham, right? It's like Babe Ruth pointing out, I'm gonna put the ball back there, right? So as it turns out, I was able to get there, did my training there. And remember, this is back in the '90s, so We had fairly limited tools for diagnosis, right? So we had stress tests, which we still do today, and lots of different kinds of stress tests. And we had the heart cath, right? Which a lot of my colleagues would say is the gold standard, right? So we put tubes or catheters up in your heart, inject dye, right? Invasive, expensive, risk of complications. And in fact, when we did heart caths, the technology was, it was actually filmed on 35mm film. Not digital. It's out now.

Yeah.

You would actually take the pictures, run the film, develop the film, and then we could actually review the film on these little devices that showed us films. So, what was interesting is, at the Brigham and Harvard, we get people coming from all over the place, right? Different countries, all the different states, and they come in and they get their heart cath done, right? Because they were worried they had heart disease or blockages. So, we do the heart cath. And we go, it looks fine, right? Well, as I was looking at it, I go, well, there's some little lumpy, bumpy stuff there, right? It's not completely smooth, right? It's got some lumpy, bumpy stuff, but we call it normal. Go home. It's all good. No problems. But that kind of stuck with me. I'm going, I think that lumpy, bumpy stuff that we're seeing is important. Well, as it turns out, critically important. So that really was my genesis back in the—

2000s.

mid-'90s of, wait a minute, plaque is something that starts decades before we have symptoms, chest pain, angina, flunk a stress test. Shouldn't we be detecting it early? That's kind of where I came up with the concept of, shouldn't we be thinking about, is there a way to do what I call, and you may laugh at this, I make the analogy to colonoscopies, right? Everybody gets this, right? Everybody gets to be screened.

Yep.

We don't want anybody getting cancer. The whole purpose of a screening colonoscopy is find the polyp, take care of the polyp if you have them, and we don't get cancer. Everybody gets that, right? We screen everybody. But that then raised the question in my head, is there a cardiac colonoscopy? Is there a tool? Is there a way to visualize early plaque long before it causes blockages, long before we have symptoms, chest pain, angina, long before we have or flunk a stress test? Can we detect this, the polyp version of plaque, literally years before we get in trouble? So, that was really my light bulb that went on 30 years ago. So, I started out as we called the— we called it back then, we call it non-invasive cardiologists, right? So, I didn't do stents. That was my interest. I was on the preventative side. So, we did stress testing, echocardiography, ultrasounds, nuclear cardiology. So, all of those non-invasive tests to try to figure out what's going on. And so, we were called the non-invasive guys, right? Now, I found out about, eh, 15, 20 years ago, I was actually a preventative cardiologist. I just didn't know what to call myself. So, then we evolved that into preventative cardiology, which basically uses imaging, which we'll talk about. What is the state of the art of, of that imaging to do essentially what I like to call the cardiac colonoscopy to find the early plaque long before we get in trouble? I would argue, I'm gonna be a little controversial here, Kevin. If you think of heart disease like cancer, right? With that analogy, I would argue in the world of cardiology, in the world of atherosclerosis or plaque, I will argue we really understand it well. There's always stuff to learn, but we really understand it well. What causes it, what contributes to it, how to fix it. And we have an incredible array of proven therapies that stop, and not just stop, but reverse plaque, right? Those are here today. Our problem, if you think of this as cancer, is I'm going to say we have the cure for cancer, but we're not looking for it. We're waiting till it shows up as a symptom, as a chest pain, as a stroke, as a flunk, as an abnormal stress test, where that's never early detection. That is really— late detection. And that's kind of—

yeah, by then the damage is done and we're reacting.

At that point, the disease is so far advanced that we probably need stents and balloons and surgery and all the mechanical things that if we'd found it earlier and treated it medically with diet, exercise, lifestyle, not smoking— of course, we have a ton of medicines, tools to affect plaque as well— then heart diseases, we know, which includes stroke as well, right? You get a blockage in the heart, we call it a heart attack. If it's in the neck, it's a stroke. So it's really the same disease. It's plaque. But if we apply this and started doing this on a routine basis, heart disease as we know it, strokes and heart attacks, balloons, stents, bypass surgery, catastrophic cardiovascular events that seemingly come out of nowhere, although the plaque has been there for decades beforehand, just not causing symptoms, that heart disease, strokes, all the things that come from that, heart failure, cardiovascular death, sudden death, all those things could be eliminated.

Yeah, I love this analogy to colonoscopies or even breast cancer screening, right? So we have these very preventative things in the world of cancer.

Right? We do colonoscopies, pap smears, mammograms, right? We now do low-dose CT in smokers to identify early lung cancer with a proven mortality benefit. Cancer kills hundreds of thousands of people in the U.S. However, heart disease, strokes, and heart attacks kill more people than the next 7 causes of death combined. And what are we doing to find it early? Nothing.

Interesting. All right. So let's— I want to put a pin in the, in the technology piece of this, because we're going to come back and pull this all apart, the preventative piece and the imaging, all that. But let's just back up a little bit because you just mentioned, I think most of my audience probably has heard by now that heart attacks are what, the leading cause of death worldwide, and certainly here in the United States, right?

Roughly about a million or so in the US every year, year in, year out. In fact, the only thing that killed more people over COVID was heart disease, right? It's the most common cause of checking off this, checking out of this mortal coil. And worldwide, again, leading cause of death, 20 million people every year, year in, year out, will die of preventable strokes and heart attacks.

Strokes and heart attacks. Okay. So let's start here before we dig into the fun stuff, the nerdy stuff. I'm gonna call it what lifestyle— let me back up. What's caused— why are so many of us having— why are a million of us dying of heart attack and A whole bunch of us are building up plaque without knowing it. What are the main causes of stroke and heart attacks?

So kind of, kind of 4 big modifiable factors, right? I'm going to tell you a secret. The major contributor to heart disease that no one ever talks about is, as I call it, birthdays. It's age, but that's not modifiable. I can't fix that. So, I'm going to focus on things I can fix. And as you'll see, as I walk through these, very simple, straightforward. A lot of these, this is where you come in, right? This is good choices, diet, exercise, being height-weight proportionate, not using tobacco. All of those things can dramatically change your trajectory towards Plaque, strokes, and heart attacks, right? So the big 4 factors, and there is overlap obviously between all these, right? We have tobacco use, right? And I say tobacco broadly and generally, it's not just smoking, it's the nicotine. So if you vape, yeah, it, that there, there are no safe form of nicotine, right?

Right.

So, right, as I like to say, I don't care whether you smoke it, chew it, snort it, inject it, rub it on your skin, use as a colonic. You're getting nicotine in your body. It literally turns your vessels from Teflon into Velcro. One does not want sticky vessels, and that's a beautiful way to accelerate or cause the deposition of plaque in your blood vessels.

Okay?

The other two— so obviously tobacco, you know, just please don't go there. Okay? If you do, seek help, work it. Because in fact, I'll tell you, If you quit smoking— now, most of the data we have is smoking, so I'll say smoking, but again, I'll say leaf tobacco. But if you quit smoking, wonderful data, in 1 year, simply by quitting smoking, right, doing nothing else, you will lower your risk of a stroke or heart attack by 50%. So that's 50% off in a year by simply not doing that. So there you go. Now, hopefully, I—

maybe you're I've got to go out on a limb here and say most of my folks here tuning in are not smokers. But there you go. I mean, another way to say that, though, is smoking will increase your chances of dying of a heart attack by 50%. Is that fair?

Absolutely. So it's a major risk factor, right?

Yes. Hopefully you don't.

But, you know, it is surprising, though. People say, well, I just chew, it's fine. Or I just do vapes, it's fine. No, no. Yeah. Literally lining of the vessel, the endothelium, as we call it, Literally has nicotine receptors. When those receptors get stimulated, it starts a whole genetic cascade that turns your vessels from Teflon, or as my partner says, a slip and slide, into Velcro. We do not want sticky Velcro.

Not a good situation.

Smoking.

Okay.

We beat that horse. The other big things, and this is particularly where diet, exercise, lifestyle is dramatically effective. High blood pressure. And diabetes, both of which ultimately cause you to have sticky vessels, right? As far as high blood pressure, strikingly, let me give you a few striking statistics that I think are, your audience can determine. High blood pressure affects half of US adults. So I, and I'm talking anybody over 18 has high blood pressure. Okay.

Hmm.

Many do not know it. It is the silent killer. So your blood pressure could be high. You feel fine. You have to measure it. It is terribly underdiagnosed. Even those that are diagnosed, it is not well treated. And even those that are diagnosed and treated, only 20% actually have good control of their blood pressure. So, it is a massive public health issue. And frankly, even if you're height-weight proportionate, you work out every day, do all the good stuff that you've been You know, talking about encouraging, motivating, all that stuff. Great to prevent high blood pressure. Great if you have it to lower it. However, a lot of blood pressure happens to do with genetics, DNA ancestry, who, who your parents were. Okay. Or as I like to say to many of my patients, right, who do all the right stuff, who follow the Kevin Protocol, I say, the problem is, my friend, you chose the wrong ancestors.

Okay.

Right.

Yeah.

But if you don't want to get high blood pressure, or if you have it and want to treat it non-pharmacologically, again, the Kevin pathway, right? It's fantastic. It's highly successful. However, sometimes genetics catch up with you. The other thing is birthdays, right? From the age of 40 onwards, and Kevin, one of these days you'll hit 40. From the age of 40 onwards, the lifetime risk of developing high blood pressure in the US is 90%.

Say that again.

From the age of 40 onwards, the life risk of developing high blood pressure in the U.S. is 90%. Wow! Nine zero, not nineteen. Nine.

Wow! Nine. So look, I'm so I'm Steve. I've got great blood pressure. I'm beating the odds. Yeah. You're you're yeah. Okay.

You're already in the in God bless.

I'm in the ten percent club. All right, guys. That's our goal here, right? I think everybody here. Should certainly— I had no idea it was that prevalent. We happen to have one of those little collar things my wife bought at the drugstore. Yeah, they're, they're not expensive. They can— you can do it at home. It's really easy to test.

Blood pressure monitoring, because one of the pieces of, of paper, the expensive wallpaper, you can actually get certified in clinical hypertension. No one does. No one used to do it, but I love it, and it's absolutely critical to preventative cardiology. So it's one of the little things I did in the past, right? So, I'm a huge blood pressure hawk, right? So, home blood pressure monitoring is more accurate. Tell this to your doctor or your provider, is more accurate than what we call seated cuff blood pressure in the office. It is more accurate.

Yeah, I get it, right? Yeah. I might be nervous in medical environments.

Light colors.

All of that, right? There could be a number of reasons.

And you're going to get a lot more numbers at home. Than the time that we just check it once in the office.

The once, once a year for most of us.

So, home blood pressure is the secret. It's cheap, it's effective, it's fantastic. It is the best way to measure in a practical way what your blood pressure is, or if you have high blood pressure, are, are we controlling it adequately? Adequately. And, you know, these monitors, they're slick, they're, you can link 'em to your phone, Bluetooth enabled. They save all the data there. They'll chart it, graph it, do all kinds of crazy stuff. And it's a $70 investment.

Yeah, well worth it. I had no idea it was that prevalent.

And lastly, Kevin, I'll say, so big picture, right? If you think about the entire US population, if we eliminated high blood pressure tomorrow via diet, exercise, medication, however we do that, if we just eliminated it tomorrow, we would tack on to everybody's lifespan just by doing that alone, 3.2 years. Okay.

Wow.

Which is a lot. And to put that in frame of reference, women getting mammograms, which they absolutely should. Okay. But if you look at the net benefit across the entire population, obviously men don't benefit from that. But, but if you spread that benefit across everybody, what additional lifespan does that give the average person in the US by doing mammograms for women? It adds 1 month. Do we get mammograms? Absolutely.

Much bigger impact by simply— yeah, right.

By high blood pressure, underappreciated, underdiagnosed, Silent disease. We don't know we have it unless we measure it generally, and even then is still poorly treated and controlled. So that's my 2 cents on high blood pressure.

Well, thank you for sharing that for us, cuz I think a lot of us learned a bunch right there. A, the just prevalence. And then for those of you that don't have a home testing kit, just go get one. Go out to a, to a drugstore. They're pretty easy. I'm sure they're online.

I will tell you, I dunno if it's okay, but the, the device I recommend, it's It's great, accurate, it's small, it's got a Bluetooth thing. If you're interested, there's a lot of great devices out there, but I like this when people say, what should I get? It's called Omron. That's a big manufacturer of these blood pressure devices. O-M-R-O-N, Omron. And they make a device called the Evolv, E-V-O-L-V, Evolv 7000, Evolv blood pressure cuff. Go to Amazon, wherever, or your local pharmacy, Walmart, whatever. But that's my favorite. But But basically home blood pressure devices, and there's a ton of 'em, they're, they're all quite good. But that, that's the one if someone wants my specific recommendation. I love that device. It's great.

Got it. Okay. Thank you for that recommendation, folks. I will throw that, a link to that. I'll track it down and throw that in the show notes. You guys can find that on whatever app you're listening to this on. So yeah, thanks for that.

All right.

So, so far we've gotten through tobacco. I think we were ready for that one, right?

Yep.

Yep.

Diabetes, blood pressure. There are genetic influences, right? There, I run into people, everybody in my family has diabetes, right? So there clearly are genetic influences. But there's a huge amount that lifestyle plays a role, right? Even if there's a really strong family history of diabetes, with the stuff that you recommend and diet and exercise and eating well can dramatically lower that risk. And having diabetes again is a terrible disease, not just for the heart, leading cause of blindness, leading cause of dialysis and kidney failure. And of course, a leading contributor and cause to strokes and heart attacks. Yeah. So diabetes is a really bad thing. In fact, I, you know, very, very careful on all my patients to monitor that. And even if they start developing, quote, prediabetes, which we can detect before they ever develop diabetes with some very simple markers, right? By the way, blood pressure is one of those markers, right? High blood pressure precedes diabetes in the vast majority of people.

Yeah.

In fact, patients with diabetes, 90% have high blood pressure.

Yeah, that's not surprising.

They all begin to clump together, right? So being height-weight proportionate, exercising, watching the sugars, starches, the white stuff, the processed foods, right? Really, really very, very beneficial. Change that trajectory over the course of our life to prevent diabetes. And along the way, all those things. Particularly sodium on the blood pressure side, or salt, will really help to lower your risk of developing that, or maybe prevent it, or even if you have it, will make it much easier and better to control. So diabetes—

Well, hey, yeah. Okay. Thank you. I, let's, I wanna, cuz you mentioned salt in context of blood pressure, and now that I've got an expert here, I'd love to ask this question cuz it seems to me like high blood pressure and say the DASH diet or low sodium type diets are often prescribed. And is it the case, for example, I don't suppose anybody's causing high blood pressure by over— putting too much Himalayan rock salt on their grilled chicken breasts and broccoli. I suspect it's because if I'm having a high sodium diet and I'm eating the standard American diet, there's this— Now all of a sudden, not only am I eating high sodium, but I'm eating a whole bunch of probably ultra-processed crap that's not serving me from a health perspective. Is that fair? What is the role? I've often wondered how much is, is salt, say, causative of high blood pressure? Have we pulled all that apart?

It's a very large part of that. Again, there could be other factors and genetic factors and, and, right? As far as things we can fix, salt plays a very big role. And there's 2 Kind of levels. First of all, 85% of the sodium, the salt, sodium chloride in our diet is literally already baked in, put in the foods we're eating, particularly if they're—

So you mean the processed foods, right?

But not all foods.

Yeah.

Baked, baked goods. Goods are pretty high in salt. Even diet soda, by the way, is fairly high, believe it or not, in salt. Okay. Cheese. I love cheese, but cheese tends to be high in salt. But 85% of the food we eat, or the sodium that we get in general, unless you're careful, read labels, et cetera, 85% is literally already in the food there. 11% is what we add. Okay.

Got it.

And interestingly, yeah, meat, right? And, and this matter, poultry, pork, red meat, whatever, all of that is low in sodium. It's what we do to the meat.

Yeah.

It's the processing. that we're adding a huge amount of sodium to it. Makes it very yummy, but—

Yeah, so take that turkey and you turn it into sliced deli turkey. Now all of a sudden I'm done. So yeah, I've done some crazy things, right?

So we should be shooting in general— this is for everybody— below— here's a number— 2,300 milligrams of sodium a day, right? So if you read labels, it'll say here's your sodium milligrams, whatever. observing.

Yeah.

So we should shoot for everybody, if you have high blood pressure or want to prevent it, should be below 2,300 milligrams. Okay. One, one sub has 3,000 milligrams of sodium.

Yeah.

So there you go. So read labels.

Yeah.

Lots of sneaky salt out there. I will tell you, here's a, a great solution. Okay. At home, we've done studies where we replace table salt, which is sodium chloride, With a mixture of what we call low salt. So it's, it's about or so sodium chloride, table salt, your Himalayan salt basically. And then we replace about 25 to 30% of that with potassium chloride. Potassium lowers blood pressure, sodium raises it. So we've actually done studies with this, very large trials. These are actually outta China, right? Where they consume a large, large amount of sodium.

Right? Mm-hmm.

Uh, and if we simply replaced the sodium in their homes with low salt, which is potassium chloride and sodium chloride, it both lowered the risk, lowered blood pressure, and translated to a lower risk of stroke and all-cause mortality. And this is a trial about 50,000 people done in China. One village randomized to that approach, the other village not, and then followed out over several years. So even simple stuff like that, the low salt stuff, which you can buy on Amazon, Yeah. Or, you know, at your, at your store can be a really effective, helpful tool to, to help meet that blood pressure. The other thing is, so there's sodium, but the more carbs we eat, the more simple carbs, right? The sugars.

Yeah.

The simple starches, the processed foods causes us to make more insulin. Insulin causes us to pull in more sodium. So, whatever sodium you're taking in, as your insulin levels rise, And I'm sure you have explored this thoroughly. As your insulin levels rise, your body literally pulls in more sodium. It doesn't pee it out in the urine. It pulls more in sodium. So now you're basically— that's how you get high blood pressure. So sodium, which is the ultimate cause of it, but also a high-carb, high-simple-sugar, high-simple-starch approach without fiber, without, you know, good protein, good fat, also is another factor that contributes to—

Yeah.

sodium or salt retention and ultimately translates to the high blood pressure too.

Yeah. And unfortunately, that's the standard American diet that you're describing there. That, that just those, those, the, that the simple carbs and high sodium, ultra processed foods.

That's, that's yummy. Oh, yummy. Right. Which is why I moved from Boston, where we're reasonably healthy in Boston, to Texas 28 years ago, because here I'm in the land of, and I'm sorry, my, my Texas, but You know, I moved from Boston, which is— we do reasonably well there, smoking, diet, exercise, sodium, and all that, to Texas, where we have smoking, barbecue, and no sidewalks. Yeah, they needed me in Texas.

Yeah.

So that's why.

Right. They needed you down there to help evangelize. Right. All right. Well, Dr. Osborne, we— so I think we got it. Tobacco, blood pressure, diabetes, certainly a very nuanced conversation there as well. Moving on.

Okay. And, and I would tell you the 4th thing is very special. Asymptomatic. I feel fine. Right. The 4th critical factor, modifiable factor, and there's lots of others, but, but these are the big ones, right? Is cholesterol. Okay.

Right on. That's where I wanted to go next anyway. So, yeah, hit us.

Yeah, exactly.

Let's talk about cholesterol.

Yeah.

'Cause can't talk about, right. Can't talk about heart disease without talking about cholesterol.

Because cholesterol is a little different than the other factors. Because cholesterol literally is the stuff that gets into our blood vessels that causes the plaque. It literally is at the scene of the crime every time. There is no such thing as plaque in the absence of cholesterol. Okay? However, cholesterol gets pretty complicated. We'll walk through this. We'll make it simple. And here's the thing though, and here's the cholesterol paradox. I just said it is the stuff that ends up in the blood vessels, whether it's in the neck causing stroke, in the hearts, in the legs causing what we call peripheral arterial disease. Every single one of those plaques is a hunk sticking into the wall of the vessel. However, I can show you people— here's the cholesterol paradox— who have high cholesterol, high LDL, and who have no plaque.

Okay.

It is necessary.

Interesting.

It is essential. It is mandatory. However, it may not be sufficient. Okay.

Got it.

Yep. Conversely, I can show you lots of people whose cholesterol looks perfect, looks average, or even well below average. Who have extensive plaque. So, this is the cholesterol paradox, okay? And here's what's happening. There are really 2 factors, which we already talked about. Cholesterol is the stuff that ends up in the blood vessel, okay? But it's going to interact with factors that give you sticky vessels. Inflammation contributed to by tobacco, high blood pressure, diabetes, prediabetes, right? Those factors will give you sticky vessels, right? So, you want your vessels to be Teflon, not Velcro. If you smoke, if you have high blood pressure, not controlled, diabetes, prediabetes, not taken care of, those vessels will migrate from Teflon as they should be where nothing sticks, a slip and slide, they will migrate into Velcro and things stick. That's how you can have average cholesterol levels, right? Because remember, the cholesterol we measure simply measures how much cholesterol is floating through our blood vessels. Tells me nothing about is it sticking. So that's how you can have average or even below average cholesterol, but in the setting of sticky vessels, you can form plaque all day long. And then the the reverse that I can show you people with high LDL cholesterol, right? That's that's really high. Like you need a drug right now last week, right? High LDL cholesterol when we actually look at the blood vessels, they don't have plaque. Because their vessels, because of diet, exercise, good choices, choosing the right gene— right ancestors, all those factors, right? Yeah. Doing all that they would tell you to do. Their vessels are so much more like Teflon that even though the cholesterol is high, it bounces off. It doesn't stick.

So is that maybe with, like, for example, carnivores seems to be a thing now, right? There are people that have been fit, very strong, very athletic in our age demographic that only eat meat. And that seems crazy. Could that is maybe happening there? They're, they're, I'm guessing their cholesterol's probably through the roof, wouldn't it be?

And there's a lot of genetic differences between these individuals, right? Sure. Some people do carnivore, cholesterol's fine. Some people do carnivore, particularly if it's preexisting high and it can rocket it through the roof. Now the, the theory concept, there's a lot of research going on. I'm gonna say it's not completely settled at all. Okay. It's just, sure, it's a great research. That's right. I'm very, very fascinated by it as well. But the hypothesis is that we can consume a high-fat diet, particularly saturated fat. That's what drives the cholesterol. By the way, here's another interesting factor. Cholesterol in your diet has nothing to do with the, the cholesterol that we measure in your blood. Cholesterol in your blood is made by you. It's made by your liver. Okay. Dietary cholesterol.

Yeah.

And I'm quoting the guidelines is, quote, not a nutrient of concern.

Really?

Yes. Now, saturated fat in some people can drive the LDL, the bad cholesterol up, but dietary cholesterol has essentially no impact upon the cholesterol that we measure in your blood. The cholesterol we're measuring in your blood, 85% of that is made by your liver, largely as a function of who your mom and dad were.

Okay. So really the, the determining for on What I eat and my cholesterol is less, less than I thought it was. It has more to do with, again, my, my genes, I suppose.

Genetic, right?

It's a lot more genetic.

Okay. If you look at studies, we've done all these over the last several decades, that if you look at diet and exercise, right, doing all the right stuff, we can lower your cholesterol in the range of 5 to 10%. Fairly small, fairly modest. Now, if you have plaque and we need to stop and reverse it, We're gonna need over a 50% reduction. Now, I will take 5 and 10% all the, all, all day long.

Sure.

And when you see a cardiologist or someone and they're talking about cholesterol and they say, start with diet and exercise, let me tell you the secret. This diet exercise in the setting of high cholesterol is so that you don't develop high blood pressure, you don't develop diabetes, you don't develop sticky vessels.

Makes sense. Okay. Gotcha. We know it's that we keep coming back to these safety principles, right?

You've really gotta move the needle on cholesterol. But it's great to help prevent sticky vessels, right?

Got it. Got it. Yep. This is starting. Sorry, I'm so dense here, but yes, this is all coming full circle here. I see what you're saying here.

There's a mythology about cholesterol out there.

There is.

Right.

By the way, look, there's—

Another piece of paper on the wall. I've been a 20-year member of the National Lipid Association. Yes, there's a small group of us. This is what we love. We're lipid nerds. Board certified in lipidology, served on the board for 8 years, all that stuff. So I love lipids, right? And there's a lot of just confusion, misunderstanding, and all that out there. More than we frankly have time to talk about today, just on that topic alone. But I think we got people well up to speed about the reality of cholesterol. The paradox of cholesterol is every time, if there's a plaque, cholesterol is there. It is the ultimate culprit. Okay. In fact, right, if you do not smoke, don't have diabetes, exercise, do all the right stuff, high blood pressure, blood pressure, right? If you have plaque, and you certainly absolutely may, this is my real estate analogy, right? It's cholesterol, cholesterol, cholesterol. Plaque, in the absence of those factors, is a cholesterol issue. Even if your cholesterol appears normal, for you, it's too high. Somebody else could have much higher cholesterol and have no plaque. But if you have plaque, in the absence of those, those big modifiable factors we talked about, you have a cholesterol issue. And when you get into that, there's LDL, there's ApoB, there's Lp, there's lots of other species. I won't bore anybody or get too deep in the woods about that, but I will say the, the main outcome is if you have plaque in the absence of all those other modifiable factors we talked about, and you're doing all the right lifestyle stuff, you have a cholesterol issue.

Very interesting. Okay, so that number that I get when I go to my annual physical, cuz we all, the blood lipid panel's done every time you go, right? Especially in this age demographic. We're gonna get our total cholesterol, we're gonna get our LDL, LDL and HDL. We have to remember which one's the good one and which one's the quote unquote bad one. Now, ApoB is a big thing, right? Because I think, I don't know, Huberman or somebody has been talking about that on podcasts as well. So now that's in our vocabulary. We got to worry about that one as well. But it seems to me that that number and that reference range has a lot less to do with my likelihood of developing heart disease than The fact of whether I've got slippy slidey, what you call 'em, slip and slide vessels, or if I've got the Teflon vessels, right? Yeah. So it's a, a plaque issue. Yeah. All right. So then in that case, let's go ahead. Let's transition. Let's talk about plaque. So what is plaque? Is it a cholesterol molecule? And I, I know you talk about the difference between hard and soft plaque. Let's do a Plaque 101.

So plaque is what causes heart attacks and strokes. It is the stuff Sure. That forms in our blood vessels. And here's a couple things about it. When plaque starts, think of a donut, okay? If you're in New York, we'll say a bagel, okay? But, but think of a donut, and we have a donut hole, and we got the donut or the bagel itself, right? Plaque always, always begins in the wall of the vessel, in the donut itself. And what will occur over years to decades, which in some ways is good, is Is it's good in the sense that when plaque starts forming, developing, which is deposition of cholesterol, the cholesterol comes out of the bloodstream, enters into the blood vessel wall, particularly if the vessels are sticky— tobacco, diabetes, high blood pressure, right?

Yep.

There are other factors too, but I'll keep it simple. It'll start in the wall of the vessel, and what will happen is the donut will literally go outward. So, there is no impact upon the channel, the lumen. That's where the blood flows. All of this occur— is occurring in the wall of the vessel, and the vessel now turns into a warehouse for cholesterol. It doesn't say anything.

Right.

Doesn't notify you, doesn't give you any symptoms, but it's saying, okay.

Yep.

I got too much cholesterol for me, which again, your cholesterol could be high, average, below average. None of that tells you, is it forming? Is it, is that process begun? So, the good news is it grows outwards, right? Doesn't notify you, doesn't cause symptoms, doesn't grow inwards, and it will do that literally for years to decades. In fact, the whole donut, if you think of the wall of the vessel, literally the vessel itself can literally double in size as all that cholesterol is being warehoused in the wall of the vessel before it ever begins to grow inward. Now, in a sense, that's good. We're delaying the inevitable. The bad news is— The process starts 20, 30 years before we ever have symptoms, chest pain, angina, flunk our stress test, right? So, if we wait till we have a blockage, and by the way, our vessels are bigger than they need to be. We have tremendous reserve, right? We can put up with, we can afford up to about a 70% blockage in the vessel before it restricts blood flow.

Hmm.

So, we have lots of reserve, which is great. The bad news is—

That is great.

By the time we start having symptoms, chest pain, angina, let alone have a heart attack or stroke, Or flunk a stress test, we don't have a little plaque. We have extensive plaque that literally has been there for decades, growing, festering without symptoms, without any knowledge of it. So getting back to that issue, I said, I, I, I like to say, if you think about the knowledge of the disease of plaque, the tools we have to treat plaque and proven tools, not just do they lower cholesterol or lower blood pressure, but yeah, these things. have been shown to ultimately reduce what we want to, which is balloon stents, bypass surgery, heart attacks, strokes, cardiovascular death, those things, right? So we have an incredible array of tools, multiple dimensions of tools, multimodality of tools that stop and arrest plaque. Our problem is we, as I say, we have a cure. We've had the cure for cancer. It is true. I'm not wearing a tin hat. We have the cure for cancer. Our problem is We're not looking for it. We're not doing the analysis.

We're not doing that early screening. Right. Yeah.

Right. That is part of the major problem because it literally will show up decades and could be seen and visualized and detected decades before we get in trouble. But we're not doing it unlike what we do in the world of cancer.

So, so for an example, a 40-year-old, if they were screened for plaque, regardless of what the numbers they got back on their annual physical set on the plaque issues.

Right.

But we could do a screening and we could tell whether they are at risk for a heart attack at 50 or 60 by what we're seeing there. And you're saying we have the tools then to not just arrest, but to reverse that, that plaque at that point?

We do. Okay. Yeah.

We're just not catching it.

We have the cure for heart disease. We're just not finding it early. We wait until the machine breaks. No preventative maintenance, no changing the oil, right? We just wait till it breaks and then we go, oh my gosh, the machine broke after 50 years. Hopefully it's not permanently broken, right? And then we stent you and bypass you and do balloons and all those mechanical things because we have now such extensive disease that has been developing over decades. And then we apply all the tools and drugs. Of course, given the foundation of all this is to prevent the first, or if you have it. The diet, the exercise, you know, all of those good things that you, you know, proselytize. We wait until the machine's broken, then we say, oh my gosh, it broke. Who'd have thunk? Right? Hopefully you survived that.

Right?

Half of men, two-thirds of women, the first symptom of heart disease plaque is you die. So historically, we've basically sacrificed half the men, two-thirds of women from a disease that's been there for decades that we never detected. Their first symptom is they get a toe tag. The survivors, the lucky half of men, the lucky one-third of women, then they get stents and balloons and bypass surgery because they have extensive disease. Then we say, oh, well, let's take care of your blood pressure. Let's treat your diabetes. Let's treat— and I'm talking drugs, right? Uh, treat your diabetes, your blood pressure, your cholesterol, which is great. But we should have done that a few decades earlier after we detected that, yes, you have polyps, to use that analogy. Let's take care of the polyps. And unlike my GI colleagues, right, if they find polyps, they do not have drugs to stop or reverse polyps. In my world of plaque or atherosclerosis, we have pharmacologic draino, but we're only applying it after the event, which is crazy. We do that for cancer. Why do we do it for heart disease, which is the leading cause of death in the US and worldwide?

All right. So let's, let's talk about what I'm assuming We have technology then that can screen. I figured we were going there. Yeah, we, that technology exists. However, you know, when I turn, I guess what, probably when I turned 50, my, my doctor said, happy birthday. Here's your colonoscopy prescription. Go get this done. Yeah.

Great.

Right. But he did not hand me anything like, hey, let's, let's go get arteries. Let's go get that plaque checked, Kevin. It just doesn't happen. Why do you think that is?

Several things. One, sort of medicine is very, very conservative. It's very slowly. Okay. As an example, aspirin, right? Prevent heart attacks to save lives, right? We did those studies in the early '80s before aspirin was widely, broadly recommended and used, right? With a drug that has no barriers, over-the-counter, safe, well-tolerated, highly effective with a drug that has no barriers to access. It took 17 years. So, we move very, very slowly, right?

Yeah.

So, one is organizational institutional apathy and inertia. Part of it is training. When I trained in the '90s, we learned stress tests and heart casts and all that stuff. And I'm going to tell you, I'm going to stick my neck way out, right? I will— I'm willing to suffer the slings and arrows of outrageous fortune and the criticism of my colleagues. Stress tests and heart cath are 20th century technologies.

Sure.

I stopped doing them 20 years ago, right? We have better tools, far better tools, right? The other thing is, to be honest, stress tests, the revenue is very, very good. The cath, the diagnostic heart cath, we do 2.5 million of those every year in the US, generate tremendous revenue. Okay. Why do you think your hospital built a new building, a new heart hospital?

Yeah. Because it's, it's a cash center.

Yeah. It's not to prevent disease. It's because they're detecting it late. $20 for a heart cath, $50 to $70 for stents, $150, $200 for bypass surgery. So, if you're not an MD, but a CFO, what industry do you want to invest in?

Prevention? Yeah. There's pretty— there's a— there's an ugly financial reality the way that our whole medical pharma system is set up.

And then I'll tell you, I trained 30 years ago and you know, older cardiologists, you know, we learned about stress testing, heart casts, and most of my colleagues, that's what they do because that's where they're trained. When I came outta my training, cardiac CT, which we'll talk about, which is the magic tool, wasn't even a thought. It, it wasn't even a glimmer in somebody's eye, right? Only roughly about 2000, 2001 did we begin to use very early crude machines that began to show us plaque. Before you ever had symptoms, before you had a heart attack. Those machines, like your iPhone, have evolved from the rotary phone to the touch phone to the iPhone 1 to the iPhone 17, as you can imagine, over the last 25 years. So, but to do that, I had to self-train, right? There was no training. There was no, I mean, no one taught me because it didn't exist in the '90s. So I had to self-train. So for me, if I can do something better, that gives me better outcomes for my patients, it's done. I'm going to do it, right? But a lot of my colleagues admittedly, they go, well, this is what I learned. They taught me how to screw the nut on the bolt. I'll do that for 20 or 30 years and then I'll retire. If there's new stuff that comes out or technology, well, I don't know. That's good. Maybe the youngsters will pick that up. But I, you know, this is what I do, right?

So, it's been working for me.

Yeah. And frankly, the money, certainly hasn't been a factor that, that broke through that, that ceiling either. Right. Yeah.

Okay.

It's really pretty cheap in the big picture to treat heart disease. That's where the money is. Okay. The Willie Sutton rule.

Yeah.

Well, why do you rob the bank, Willie Sutton? Because that's where the money is.

That's where the money is. Yeah, that's right. And you're, you're saying treat heart disease. I mean, we're, we're not really, we're, Managing it, right?

And when it's like you said, I, when it's in the, if you think of oncology, our current tools, stress tests, heart cath, can really only detect disease when it's stage 4. If you would think about the sort of widely metastatic, advanced, whatever.

It's not picking up that, that plaque buildup. Yeah.

Plaque cancer of the coronaries. I like to say in stage 3, 2, or 1, unless you use imaging technology that I've been using for 25 years.

Okay. So this, this technology exists. If somebody's, I'm interested right now, hey, I'm curious about my, my plaque. What would I do? Would, is there a, is there obviously not my med tech, but are there places around?

You can ask, but I'll tell you, so for your audience, right? The magic tool for early detection that detects all of this literally years before we get in trouble can say, oh, okay, I got some, again, your cardiac colonoscopy. As we talked about colonoscopy, cardiac colonoscopy. And by the way, colonoscopies, the goal is to prevent and prevent colon cancer, right? But it's an invasive, expensive day of your life, general anesthesia, 0.1% chance they perforate your colon, which is great. And we should do it, right? In fact, we went from 50, now it's 45. It'll probably be 40 for everybody to get screening for colonoscopy. Colon cancer kills 2 to 3% of Americans. Cardiovascular disease, strokes and heart attacks kills about 40% of us. What do we do to find it early?

Nothing.

Yeah. Okay. So, the real best tool out there right now is cardiac CTA or CCTA, cardiac CTA coupled. And the, and, and we've been doing this time. This is not a new technology. I've been doing it for 25 years. Okay. I was one of the very early, first early guys to do it. Started doing it. They're going, What the heck is this, right? Well, yeah, guess what? You know, now people are beginning to jump on board, which is great, and replace heart casts and stress tests and all that. So, cardiac CT, but the big, big advance, what I call cardiac CT 2.0, is taking that cardiac CT data done with a CAT scanner, by the way, not an MRI, but a CAT scanner, literally with the newest machines that we use. The scan itself literally takes a fraction of a second.

Okay.

I put an IV in your arm. That's it. Okay. It's cardiac CT, but now coupled with, as you can imagine, AI. The AI literally can see plaque that we cannot see with our eyes and will quantify it very precisely down to a 10th of a cubic millimeter, which is almost an infinitesimal volume. And for the first time ever, we can now track plaque. So not only are we exercising, not smoking, we're losing weight, our cholesterol's better, whatever, blood pressure's great. But we can now say, for the first time ever, we can say, here's how much plaque we had in 2022. Here's how much plaque we have in '25. Is it getting better? Is it the same? Is it improving? That was impossible to do until we had the combination of cardiac CT and now AI. Now we do, uh, we have amazing machines. Our machine, by the way, is a 640-slice machine. Really very, very cool. I started out 20 years ago with a 64-slice machine. iPhone 1, iPhone 17, 640-slice machine. Our particular machine, and I don't know if I should say who it is, but anyway, it's a phenomenal machine. We were the very first installation of this machine in North America. There's now 8 in the US. So it's a really phenomenal machine. But other machines, which are not as slick as ours, not as low a radiation and all that, but can do cardiac CT. We just have the Ferrari of those machines, but there's lots of—

Gotcha.

Tauruses and Camrys out there. Okay, they're fine. But the other thing to do is now couple that data, get the scan, upload to the cloud, and then do the AI analysis. It is absolutely amazing, right? That is the start, the state of the art as far as early diagnosis for heart disease. And the AI tool we use is something called Cleerly, C-L-E-E-R-L-Y. Amazing. So, it's really the coupling of cardiac CT, simple non-invasive test, fairly inexpensive, a 10th of the cost of a heart cath, by the way, of which we still do 2.5 million in the US. I stopped doing them 20 years ago. By the way, we do 10 million nuclear stress tests a year, which only detect severe advanced disease, will miss severe advanced disease 25% to 40% of the time. That's a false negative. And they will be inaccurate and call it present when it's not, which then would buy you your heart cath for another $20,000. We'd go through that process over weeks to months, and then, you know, you're freaking out. Do I need stents, bypass surgery? I'm gonna kill over dead. They go through the process because the stress tests look funky. You then get a cath and it's fine. So we don't do that anymore.

So you don't do that anymore? Yeah.

Refer to the cardiologist. I'll make it very simple. If you get referred to a cardiologist, And they say, oh, let's start with an EKG, a stress test, whatever. I'm gonna be very honest, run. That, that's 20th century technology. It's, it's so bad. It's so terrible. Which is why, although we have made major advances in cardiovascular death from the '60s, which is peak cardiovascular death, year after year after year, the total numbers of cardiovascular deaths fell. That period of time till 2011. The bad news in 2011, we're getting grayer, which we will, and unfortunately fluffier, right? Since 2011, the, the instance of heart disease deaths actually reversed and going back up.

Started going back up.

And we're still doing 10 million nuclear stress tests a year. Hasn't had done nothing to lower that. In fact, the numbers went up. Starting 15 years ago.

So as a person who's interested in optimal health and healthy aging, I, I suppose it's gonna be tough for me to go to my general physician and, and get this test. Am I, am I going outside of the— because I'm finding more that those of us that want to live above the means, the current medical system and the insurance system is not our ally. It's not our friend. And so is there a way for me to go around the medical system? And just go straight to a cardiac CT plus AI solution, which I'm paying out of pocket?

Yeah.

Gotcha.

That's what we do. Now, I will tell you, cardiac CT has been around a long time. The AI is the latest wrinkle, which is amazing. But I will tell you, as far as the American Heart Association, American College of Cardiology, as of October of '21, okay, now I started doing it 25 years ago, but as of October '21, this tells you how slow we are in early adoption of new technology. If you have symptoms of chest pain, uh, of angina, chest pain, or we think you have heart disease, or maybe shortness of breath, we call that an anginal equivalent right now. I can't move on. I could do it 3 months ago, whatever. But symptoms that might suggest that you have heart disease, cardiac CT, not necessarily with AI, but cardiac CT is what we call a Class 1A indication. What that means in real speak is It is the standard of care, right? Anything other than that, like stress testing, is now no longer standard of care. Has it bent the needle much as far as what we do practically in the world of cardiology? We still do 10 million nuclear stress tests a year and 2.5 million heart cath, alas, right? But I will tell you, so it is changing. It is out there. But I think part of this is that your, your listeners can know what to ask, right? There's the unknowns, right? So if one is worried about heart disease because of symptoms, chest pain, shortness of breath, or just your cholesterol's high, your family history, or whatever, diabetes or blood pressure, the state-of-the-art these days is cardiac CT with AI. Anything other than that is frankly a waste of time and money and terribly inaccurate.

Got it. Now, I don't want to wait until I actually have real chest pain though, because by then, yeah, right. So what I might want to do is go, hey, Doc, oh gosh, you know, I've been feeling this tightness in my chest here lately. I know what's going on. Is— I mean, would that at least get me that referral?

Yeah, absolutely.

And I stay inside the system.

Depends upon who you see.

If you're having those symptoms, yeah, it's highly variable.

Your local cardiologist say, well, let's start with a stress test. I'm going to be honest.

And as it As a consumer, can I just say no?

I don't think you can because I see people in your community, right, who are using cardiac CT. Now they should be using AI with it. If you want more details, obviously this is what we do. I'm a preventative cardiologist. I've been doing this for 30 years. The nice thing is everybody else, the rest of the herd, is now finally catching up with me, which is good. We still have lots of opportunities there, but they're catching up with me. If you want more interest information about The tools we use, the state-of-the-art cardiac CT, AI pictures, all that kind of crap. Go to our website, clearcardio.com. That's just C-L-E-A-R cardio, C-A-R-D-I-O, clearcardio.com. We also are on YouTube. We have a channel, Power Prevention, clearcardio.com. Just go YouTube, Clear Cardio. You'll see all our videos and stuff. So I think those are great instructional videos. Now, I'm not soliciting anybody. I'm not going to sell anything. But I'm telling you, if you want some more information about what is really the state of the art of both detection, we, we talked a little bit about prevention, but we have an array of tools there. Uh, you know, there, there's some resources that you can check and, and get educated, as we say in Texas, edumacated about how do we detect heart disease before we get in trouble.

All right, folks, let's get edumacated then here. I will throw all of Dr. Osborne's information, that website, the clearcardio.com. The YouTube channel and his other social channels. I'll put all that in the show notes. You guys can find that whatever app you're listening to this on. Of course, you can hit us up on our website as well. But Dr. Osborne, I want to thank you so much for coming on, taking the time to share this enlightening information with us. I want to go out on a limb here and say we all learned a lot today, even those of us that maybe are considered ahead of the curve when it comes to just preventative health, et cetera. So, man, thanks so much for the work you're doing, and I just encourage you to keep up the great work.

Thank you. Thanks for getting the message out. Thanks for having me, Kevin. And, and what I always finish up with anybody, right? I always, 2 things. One, my ultimate goal is to eliminate heart disease, right? And I need everyone to help me to do that. There are 33,000 cardiologists. There's 600 preventative cardiologists in the US.

Mm-hmm.

And by the way, no one who has my pedigree and expensive wallpaper. Again, I, not that that matters, but this is what I have dedicated my life profession to and my passion. So, A, help me eliminate heart disease. I can't do it alone. Please spread the word. So, thank you for letting me spread the word today and, and et cetera. And ultimately, I'm gonna ask you, Kevin, please work, put me out of business. Okay?

Yeah. Amen. Let's go, folks.

You heard it. Okay.

Let's do it. We're gonna put him out of business.

Out of business. Let's, let's eliminate heart disease. And, and what I do is irrelevant. And that'll be great.

Would be great. Be perfect for retirement, right? That's our show for today, folks. If you are interested in learning how the SilverEdge Collective program can help You feel lean, strong, and confident again. You can find a link to learn more in the show notes for this episode. You guys can find that on whatever app you are listening to this on, or head over to silveredgefitness.com/403. As we wrap up our time together today, you can show your support for this show in 2 important ways. The first is to tell a friend about this podcast and encourage them to— The first is to— the first is to tell a friend about this podcast And encourage them to give it a listen. The second is for you YouTube folks to please click the like and subscribe buttons, and for you podcast folks to please give this podcast a 5-star review on whatever platform you listen to podcasts on, and be sure to subscribe and follow so you don't miss any future episodes. I really appreciate you spending your time with me today, and until next time, stay strong.