A Practical Approach to Cholesterol with Dr. Laurie Marbas

you to amazing people like you who are doing great things in the world that I think you should know about. Well, today is the 4th Wednesday of the month, which means it's time for Dr. Laurie Marbas. And today she's going to be discussing a practical approach to cholesterol. Please welcome her back to the show. We love things that are practical, Dr. Marbas.

Well, thank you for having me again. As always, I'm so thankful for you having me on your show anyway. But yes, So many of my patients come to me for advice and getting started. But what I found is simple and practical, and kind of just want to educate people and then help them understand where their assessment should be, some ideas, and then some things that they should really be doing foundationally to improve their cholesterol. And then you go from there. But just kind of a practical guide to your cholesterol management, and you can see some big shifts in numbers. But yeah, let me, let me share my screen.

Nice. People worry about numbers a lot.

Yes, there's a lot of number, a lot of worries about— whoops, where did I go? Here I go. Can you see?

Yeah, I can see perfectly. A Practical Guide to Cholesterol Management.

Okay, there we go. Okay, very good. It had 2 of them open. That's weird. Okay, so yes, A Practical Guide to Cholesterol Management. I'm Dr. Laurie Marbas. I'm a family and lifestyle medicine physician. And I'm gonna share with you something that I share with patients all the time, but I wanted to go a little bit deeper into really understanding what cholesterol is in lipid metabolism, because I think so many people are worried about numbers, but they don't even know really what they're worried about, if that makes sense. We'll go from there. So first of all, what is cholesterol? Like, you can ask people that go, hmm, it's just something that causes illness and heart disease. Well, Basically, cholesterol is a waxy kind of fat-like substance found in all cells of the body. That's just the basics. Make it super simple. But now let's dive a little bit deeper. This is not going to— meant to be a deep biochemical chemistry lecture, but we're going to get a little bit deep just so that we can have a little bit understanding about a few things. Don't get overwhelmed by what you're seeing here, but I just wanted to show you the cholesterol is actually made in the body, but you also get dietary cholesterol. So there's these 2 different pathways that we can obtain cholesterol. And what you're seeing here is the cholesterol synthesis in the liver, right? And so it happens in other places, but, you know, can be in smaller amounts in other cells. But the liver is responsible for producing about 80% of the body's cholesterol. And it's really important for like lots of different biological functions. So in addition to the liver, cholesterol is produced, for example, in the intestines, the adrenal glands, reproductive organs like your ovaries and testes, and they all contribute to the body's overall cholesterol pool. And what do we utilize cholesterol for? Well, they're made to produce essential molecules like steroid hormones, vitamin D, and bile acids, and also, you know, that lipid membrane that our cells are made of. And the bile acids are important for digestion and absorption of dietary fats. So let me move on here. It's my screen. Now let's dive a little bit more into lipid metabolism. And what does that mean? It's just basically, you hear about cholesterol, but what are lipids? Like, what is going on here when you talk about all these things in your lipid profile? We're going to dive into those. Just so you have a really good basic understanding, and then we can talk about things that will actually move the needle, so to speak. Okay, so first of all, what is a lipoprotein, right? So the lipoprotein is basically, it's a little tiny particle, particle, and that's made up of what we call lipids, which are the fats, and proteins. Okay, so these proteins serve really an important role for transporting fats through the bloodstream. Now remember, fats don't dissolve in water, um, so they cannot travel freely like in our blood, and so they need some help. So lipoproteins provide, um, that help by enclosing the fats, um, in a shell made of proteins, which makes them what they call soluble in blood and able to move around in the body. So just like things dissolve in water, like salt or sugar, think about it that way, right? It makes it where it can actually not be repelled but actually traverse in the bloodstream. So the structure of the lipoprotein, what you'll see here is basically there's this inner core, right? So the inner core is made of lipids, remember, which are not soluble in water, which are primarily triglycerides and these little cholesterol esters. And what cholesterol esters are, these are basically the formed a form of stored cholesterol. So that's what's on the inside. Then as you go to the shell or the, the surface coat here, the outer shell is composed of what we call phospholipids. And that's, um, it's a special type of fat that is partially water soluble, um, and free cholesterol. So you can see the free little cholesterol hanging out here. That's this one here. And these other things called other proteins called apolipoproteins, which we'll get to in a minute, which may sound familiar. Maybe you've heard of APOB or Lp. Those are some of the ones we're going to talk about. So this is what's going on here. This is the lipoprotein, which is really important, as I said, because they act as vehicles of transport, right? So they carry the lipids and cholesterol to different things. For energy, for example, they carry triglycerides, which to the muscles can be used for energy. They can carry to your adipose tissue to store triglycerides as future energy use. And then they, for cell functions, they're carrying cholesterol transported to cells for building cell membranes and making certain hormones. So think of your lipoprotein are the trucks on the highway, okay? And they have special ways. It's kind of like if you, like my stepdad was a truck driver and so they had different types of trailers. So think of this as a special type of trailer for this very special cargo. Hope that makes sense there. Yeah. So what are the different types of lipoproteins? Again, the numbers don't matter, but I wanted to show the size, and I wanted, wanted to help you understand the different things. So chylomicrons, these are these guys here. These are basically the largest and what we call least dense. So I always would think about these as like if you ever saw the Macy's Day Parade in New York, you see those big balloons and they're just bouncing around and they're bouncing off things. Those would be the chylomicrons, right? They're just kind of big and fluffy, not causing too much damage. They're primarily composed of the triglycerides, right? So that's about 85 to 95%, 90%, with a small amount of cholesterol. the phospholipids and proteins. They're made in what they call enterocytes, right? These are the absorptive cells of the small intestine, meaning the— these are the cells that take in the nutrients that you consume and bring them into the body, right? They package them up and bring things into the body. So the chylomicrons are most responsible for transporting your dietary lipids, meaning the fats that you consume in your diet. which are absorbed from the intestines to other parts of the— again, for the body for use or storage. And remember, size, the chylomicrons are kind of big. Now we're going to move on to this next one. It's called the VLDL. Okay, now these 3, think of this as the, as the, um, maybe a preteen, teenager, and adult, right? Because this is going to be a transition. This particle here, these, these very by different sizes, but they can transition to one another. Okay, this is the very low density lipoprotein, right? They're produced by the liver, and they carry mostly triglycerides, about 50 to 65%, but also contain some cholesterol and proteins. And then the VLDL transports what we call endogenous triglycerides, right? So these are triglycerides made in the body. And remember, this is from the chylomicrons where your dietary transport— the VLDL is for the ones that we're making in our body. Okay, so that'll help explain those 2 different pathways and how those things come together. So the VLDL transports endogenous triglycerides and cholesterol from the liver to various tissues. Remember, they're smaller because they still have some hydroxycholesterols, but they are smaller than the chylomicrons. Next, you have the intermediate density lipoprotein or the IDL. You don't see this very much on lipid panels, but it's formed from when the VLDL degrades, right? And contains a little bit more balanced triglycerides cholesterol. So the purpose of this intermediate density lipoprotein is it can go either way, right? It can be further processed into low density, lipoprotein or that LDL are taken back up to the liver, um, and then, you know, further, uh, processed from there. Again, it's smaller than the VLDL because triglycerides have been removed, making them a little bit denser. Um, next we have your LDL, right? So this is the low-density lipoprotein. So that's also quote unquote known as the bad cholesterol. Now these primarily carry cholesterol. They're about 50% of its mass, and it contains a lot less VLDL, obviously, because it's smaller. Now the LDL transports cholesterol to cells throughout the body where it's used to build membranes or make hormones. And if you have excess of it, you know, it'll make itself welcome on your artery walls. It's called atherosclerosis. Now the LDL particles are smaller and denser, again, because they have a higher proportion of cholesterol. All right, so that was the chylomicrons from the gut. Here's the VLDL from the liver, and it degrades. And that it talks about, and it's because they're losing triglycerides, getting more condensed with more cholesterol. Then you have your HDL. Now the HDL is high-density lipoprotein. It's called your good cholesterol, right? It is rich in proteins and contains relatively less cholesterol and triglycerides. But it's also made by the liver, right? So this is, this doesn't, you know, this is basically a transitional particle. And then so you have basically 3 different things you're looking at here, kind of the microns, the lipoproteins here, and then your HDL. Now the HDL, it is like a dump truck, it's our scavenger, right? It scavenges cholesterol from the bloodstream, from other lipoproteins, which is gonna be really important here because so many times on, Blood test, you'll see someone with low HDL. We're going to get to the reason why that is here in a minute. I want to explain that to you. Um, and it'll also scavenge from arterial plaque, right? So it'll— and it'll transport that back to the liver for either excretion or to be recycled. And the HDL particles are the smallest and most dense, um, because of their high protein content. Mm-hmm. All right, let me move on to the next one. So that gets just to the final— what you'll typically see on your lipid panel are triglycerides. Again, I don't want you to like freak out about this chemical structure of serum, but I just wanted to highlight what it looks like as I'm telling you about it. So triglycerides are a type of fat, right, or lipid that's found in your blood. It's the most common type of fat in your body. And they are used basically as a major form of energy storage, and they're really important for overall health. But high levels obviously can increase your risk for heart disease or cardiovascular disease. So what are they exactly? Well, they're formed when one molecule of glycerol— here you can see that's kind of the backbone. Whoops, let me get back over here. The backbone, and then that's combined with 3 fatty acid molecules, and that's these things. So if you hear people talk about fatty acids, Now you understand it's the triglyceride. The free fatty acids is when this is broken off. So you have the glycerol, which is the backbone, and 3 fatty acids. That's tri for 3, triglyceride, right? So you see that triglycerides, okay. Um, and basically they are created by the body from the fats in the food you eat or are synthesized by the body from other energy sources, for example carbohydrates, although that's a very small, small, small amount. When you eat, any calories that aren't immediately used by your tissues, for example, can be converted into triglycerides and stored in your fat cells. And then hormones that release triglycerides for energy between meals. And we'll get to those hormones here in a minute. But that's just an important piece here. We're talking about subcutaneous fat is there for a reason. It's there to store fat for days when you aren't going to be— have food. But we don't live in famine ever. We live in feast mode 100% of the time, or say 99% of the time, unless you're doing a dedicated fast on purpose. But, um, but anyway, that's the basics there. The triglycerides, um, again, they can come from your food, right? So when you consume fats in your diet, they're not necessarily directly absorbed into your blood, but instead they're broken down in your digestive system and absorbed into the cells, into the intestinal lining. Remember I was talking to you about those enterocytes? And they're reassembled into these triglycerides. And then the triglycerides are packed into those lipoproteins, remember the chylomicrons, which transport them through the lymphatic system, right? The kind of the fluidy system into the— and then into your bloodstream. So this is where the chylomicrons come in from the digestive piece. Now the liver, the liver can also play a role in triglyceride metabolism. It can synthesize new triglycerides. from other substances like carbohydrates. If again, it's a very small amount, that's called de novo lipogenesis. Again, but it's most of the carbohydrates you consume are utilized for food or for fuel in your body because that's the preferred fuel. The liver can convert the excess sugars, however, into triglycerides for storage. Additionally, the liver produces— remember this— VLDL. Remember that? That's the beginning, right? That's that What I say, preteen of the lipoproteins, which carry the particles, the triglycerides, either to the liver or to adipose tissue for storage. Okay, so you have the liver production, it goes into the VLDL, the triglycerides, and you have the absorption through the colon. So you have these two passageways, and that's one thing I really wanted to highlight here because it gets to an important question: why certain things help. Then you have your adipose tissue. Okay, while they don't necessarily produce like de novo production of the triglycerides. They do play a role in storing triglycerides. And then after triglycerides are transported to adipose tissue, they are stored there until your body calls them into, hey, be released, or the adipose tissue is so full that it cannot take anything else into storage. And that's an important piece to pay attention to when you, you see triglycerides being stored in things called visceral fat, right? So that's the fat surrounding your visceral organs. Also what we call, you could see triglycerides stored into your liver and into your muscles. That's when we start developing insulin resistance. And we're gonna get to that too here in a second. But I wanted to just highlight these 2 pathways. You have the digestion and absorption of the triglycerides, you have your creation and storage of the triglycerides as well. Now, the process of triglyceride synthesis and breakdown is really regulated by 2 hormones that you want to pay attention to: insulin. We all know what insulin is, and glucagon, right? So insulin promotes the synthesis and storage of triglycerides, right? So after meals, so when your insulin levels are high, triglycerides are created and stored. Now, the glucagon stimulates the breakdown of triglycerides into fatty acids and the glycerol. Remember, that's how we break it down here, the glycerol and the triglycerides, and— or the fatty acids, which are then released into the bloodstream as an energy source during fasting or certain types of physical activity. Okay, um, so why are triglycerides important? Again, these are a dense form of energy storage, right? So they're offering more than twice the energy per gram compared to carbohydrates or proteins. However, when you have elevated levels of triglycerides in the blood, that obviously can contribute to atherosclerosis. So, all right, so we got some of the basic stuff, but I wanted— there's some special notes I wanna talk to you about I hinted to earlier about triglycerides, VLDL, and HDL. So this is actually blood that you pull from your body, and if you let it sit, if you have someone who has really high triglycerides, this is exactly what it will look like. You see the the fat floating on top of the blood, and when you see this in real life, it kind of grosses you out a little bit. At least it does me. Maybe not everybody, but that's just me. So elevated triglycerides. There's a there's an interplay between the triglycerides and the lipoproteins. Remember, the lipoproteins are your VLDL, the ones I'm going to be talking about: VLDL, IDL. And LDL, but also the HDL. So those are the— these— all these lipoproteins. But I'm going to stop— talk specifically about— sorry, guys, I have something caught in my throat. One moment.

It's okay. You know, Dr. Klaper talked about when he saw what made him want to become vegan when he drew blood on a patient one night that ate a cheeseburger.

Oh, yeah. It is like something you've never seen until you literally see that. And it happens within just a few minutes. And it's like, Oh, yeah. I, when I was doing medical school and we had cadavers that we dissected, there was one in particular that they opened up the carotid, which is the artery that goes up to the brain, and it just looked like chicken fat. And I swore off— this was before I was vegan— I swore off chicken for many, many months after that because I was like, nope. Nope. But yeah, but anyway, so when you have elevated triglycerides in the blood, it impacts how those lipoproteins function, particularly that VLDL. Remember, that's your early, you know, preteen LDL and your HDL, right? Your healthy or good cholesterol. Now elevated triglycerides again. cause an increased production of the VLDL. Remember, because VLDL takes triglycerides and helps transport it, right? So that makes sense. Now, there's an exchange of lipids between VLDL and HDL. So when you have VLDL, which is carrying the triglycerides and cholesterol from the liver to various parts of the body, remember that HDL is involved in that reverse cholesterol transport. This is where it's really important. So it takes things back to the liver. So when triglycerides are high, there's an enzyme, it's called CETP, or cholesterol ester transfer protein. So let's think about that cholesterol ester. Remember I told you is a special type of storage form that's hanging out in the VLDL, the IDL, the LDL inside, right? That's the cholesterol ester transfer protein. So now what do we expect is going to happen? that cholesterol ester is going to be transferred, right? So basically, this enzyme facilitates the transfer of triglycerides from the VLDL to the HDL and the transfer of cholesterol esters from HDL to VLDL. So you basically just have an exchange. VLDL is like, hey, I have some fat for you. Here you go, HDL. And the HDL goes, oh, okay, here's my cholesterol that I have. So that's literally, that's that exchange. You have passengers coming on the bus and you have passengers taking off the bus. And now this exchange results in a few things. The VLDL are depleted in triglycerides but enriched in cholesterol, and the HDL are rich in triglycerides but depleted in cholesterol. So now you have a denser VLDL and you have a much fluffier HDL. Okay, so how does this impact your HDL function? Well, the altered composition of the HDL, right, the more triglycerides and less cholesterol, affects its density and function. The triglyceride-rich HDL particles are larger and less dense, and they are cleared more rapidly from the bloodstream. So therefore, the— think about it, if you have this rapid clearance, right, it reduces the amount of HDL available to mediate that reverse cholesterol transport. So essentially, your HDL becomes less effective at transporting cholesterol back to the liver, which is its primary function in reducing your cardiovascular risk. So you have these high triglycerides, it says, yo liver, make some VLDL for me. It's like, okay, here's some VLDL, package up the triglycerides. Now you've got this lots of triglycerides, the VLDL and the HDL have a little conversation and they swap. Now the HDL is big and fluffy, it doesn't do its job very well. The body's like, well, you're not helping me out in excretes it. Now we have low HDL. Okay, hope that makes sense. It's a really— like, I could spend hours and hours and hours going deeper into this, but I really wanted to— again, I really wanted to help explain some of the things that are going on in your body. So when you think about pulling certain levers, why these are important. One other thing I want to speak about is insulin resistance. And as many of you are aware, so insulin resistance is a condition where your body cells become less responsive to insulin. Okay, remember, insulin is that hormone that regulates your blood sugar levels, but it not only affects glucose metabolism, but it's really important. It has some serious implications on your lipid metabolism. And so I'm gonna walk you through a few crucial scenarios here. So first of all, let's talk about your VLDL with the production and secretion. So basically, insulin resistance increases that VLDL production because what's happening is insulin normally inhibits the production of VLDL in the liver. Right? So because the insulin is saying, yo, triglycerides, go and be stored, right? However, in insulin-resistant states, remember, the body's not listening to insulin. You have the inhibition of VLDL being made diminished, right? So now the liver says, I need to produce more VLDL, which are rich in triglycerides, because this This is because the insulin resistance often leads to an increased flux of free fatty acids from adipose tissue. And the reason that happens is because the adipose tissue itself is insulin resistant. So the, the, the fat under your skin is not able to listen to the insulin and say, hey, I need you to store fat. Instead, the, the adipose tissue doesn't see that there's insulin trying to get it to store fat. So there's this triglyceride influx into the bloodstream. So the VLDL is decreased because also the liver's not listening. So now you have this free— all these triglycerides that need to be packaged in VLDL. So basically, you have impaired VLDL clearance also. So insulin also enhances the activity of a certain enzyme that causes the clearance of VLDL, that doesn't happen. And instead of going deeper, I'm going to just highlight the bigger stuff. So there's obviously here you have this insulin resistance piece. It's where the adipose tissue isn't listening, the liver isn't listening, all these tissues aren't listening. So that leads to, again, the basically increased VLDL production, right? You have Also increased LDL production. So think about that, VLDL goes to LDL. You also have what we call reduced LDL receptor activity. So basically, the LDL is not being cleared from the body very well or from the bloodstream. And then you also have decreased HDL levels, HDL levels. And there's a whole reason behind that. You also have elevated triglyceride levels. And then you also have that play I was just talking to you about, the VLDL and HDL, right, where you get HDL increased clearance. So the insulin resistance piece, if you're prediabetes or you have diabetes, type 2 diabetes in particular, what you'll see here is that you will see your lipid metabolism, your numbers will shift as you become more insulin sensitive by doing some things I'm going to mention. You will see your numbers improve. Sometimes what you will see is some individuals, they've been eating a whole food plant-based diet, but their BMI— again, it's not the best measure of body composition, but it is what I have most of the time— if your BMI is bumping up against 25 and you're like, oh, I'm at normal BMI, most of my folks that I see that way still need to lose some weight to get probably around 23 or lower on their BMI. This is a body composition piece, and that's when you start really seeing some more rapid improvement in not only your lipid panel, but also things like hypertension or your glucose management. So those are just some things to think about as well. Let me just talk a little bit now about— let's jump into understanding your cholesterol levels. And I think there's a few numbers people are always looking at, like, what do you recommend on what should my labs look like? Well, first of all, there's some essential labs I think you might want to to pay attention to, these are the ones that I pay attention to, are your total cholesterol, right? Preferably under 150, but even still it could be a little bit higher and still see some optimal numbers here. You want your LDL cholesterol under 100. And if you have a history of heart disease, you probably wanna be under 55. Your HDL, it really will depend on the person. You will see some decreases in some very healthy numbers. So you may see just HDL lower because you don't need as many. But when you look at the data, we're talking again about standard Americans who are eating a standard American diet. They really like to see that HDL above 60. But again, you might see it lower just because you have so low LDL. And that's a different story. That's a different scenario. And then triglycerides, you definitely probably want to see them actually under 100. You'll see in most labs it'll say 150. But I have found that honestly, when you see that triglycerides under 100, the triglycerides are not wreaking havoc and causing as much trouble as we kind of discussed. And then your non— excuse me— non-HDL. So remember, there's lots of different things that can be here, but this number is basically, it's your total cholesterol minus your good cholesterol, your HDL. And so it includes your LDL and then the other types of cholesterol like your VLDL. Then you have your ratio of total cholesterol to HDL. which is you just divide your total cholesterol by HDL. And so the higher that ratio is indicates a higher risk of heart disease. You have those apolipoprotein B. So remember when I was looking at— when I showed you the picture of the lipoproteins and I said those are those lipo— those little proteins? These are the ones I'm talking about. So basically the ApoB, it's the main protein that's found in your LDL and VLDL. And it serves as a framework for cholesterol and is kind of a really important player in plaque buildup in arteries. So high levels of ApoB can be a stronger predictor of cardiovascular risk than just the calculated LDL. And then you have the lipoprotein little a or Lp. That is a lipoprotein linked to also to an increased risk of cardiovascular disease. It is similar, but Anyway, it's just another factor that's genetic risk factor. I think there's still— I haven't dove deep into more recent research on the Lp, but it is typically not so much modified by lifestyle. Sometimes it can. I've heard— I spoke to Dr. Kim Williams about this— maybe like 10%. Some medications can actually increase the Lp. So again, but not typically affected hugely by lifestyle. The other thing that we always want to think about, and it's a little bit outside of your lipid metabolism, is inflammation. So I would encourage you to check your hs-CRP. Now, this is really showing increased risk of cardiovascular disease if it's elevated, especially above 3, but you definitely probably want it less than 1 is optimal. And it's just chronic inflammation. It really is critical in creating atherosclerosis. So the lower that is, the better. And I don't want you to— I really want you to look at this as a snapshot, right? That these numbers don't— they're not meant to be emotionally provoking. And so many people, they freak out about one particular test. They're like, my cholesterol was great last year and now it's high. I'm like, well, let's look what's going on. And a few things can change. And that goes the same for the hs-CRP. If you have an infection like a dental infection or you had COVID or you had the flu, you might see the hs-CRP rise for a small period of time and come on back down. And there's some other things that can also affect your cholesterol levels as things change in your life, and I'll get to those here in just a second. But remember, this is just a snapshot. There are things that can be done to improve these. I'm not going to go deeper diving into too much anyway about other things you should be doing, like a And no coronary calcium score or CT angiogram. That's a discussion to look at you as a whole, your past history and other factors. But what we're talking primarily about today is your lipid panel. So let's talk a bit about the power of lifestyle and cholesterol management. And the reason I wanted to highlight this is because so many people don't even do the basics right, and they're thinking, well, I primarily eat a plant-based diet. And then you start talking, they're like, Well, you're eating a lot of other things on the weekends. They're binging, their weight's not moving, there's a lot of inflammation. You need— if you want to see the most change, and if this is really about— you need to be adherent to a healthy lifestyle as possible. And we'll get into the details of that here in a minute, but I just wanted to highlight what— just because you think you're doing a little bit of it doesn't mean you're going to make big changes. You're— it's It really is. If you want to see big changes, you got to move the levers big sometimes. So especially if you've been sick for a long time and you're in your 60s and have high cholesterol, you're not going to be able to just see overnight changes. It just doesn't happen. So let's start with the foundation of health. So really, we're going to talk about 3 different things. And of course, I'm going to be showing you the plant-based diet, right? So why are these helpful? Well, remember, plants are rich in fiber, which we talk about a lot, which reduces your LDL cholesterol, the bad cholesterol, and increases your HDL. So these are going to be different foods, and I'll get to the 10 foods that you want to think about here in a minute. But they also can have an impact on that ApoB, right? So again, eating no cholesterol will be great because that decreases your cholesterol pool, right? So if you're not eating animals, you're not eating cholesterol. Now you have these foods and different mechanisms and how they work, which we'll get into a little bit on a plant-based diet that will further lower your cholesterol that you're creating. So the important thing to understand is that you want to reduce your saturated fats and eliminate trans fats. So trans fats are banned in the United States. But doesn't mean you can't get trans fats in your kitchen though, right? If you're cooking different things. or adding different oils and such. Or the other things is the saturated fats, which come primarily from animal products, but they can also be found in certain high quantities of, you know, certain palm oils and coconut oils. If you hear someone's like, oh, coconut oil is healthy for you, like, oh no, you know, let's not do that. That's high in saturated fats. And then goes along also for like coconut milks, Coconut yogurts. Now, the whole coconut, I think you'd be okay. But again, just pay attention to the coconut. And it doesn't mean that you can't partake on occasion. I think I have some low-fat coconut milk in my cupboard. Once every 6 months, I might create a curry or something. But that's not too often because honestly, I focus on the saturated fats. It kind of freaks me out. Yeah. So these saturated fats, they raise your LDL and lower your HDL. So again, go backwards from where you want to go. Let's talk about physical activity. We want to do a few different ones. You want to do aerobic and resistance. Now, the aerobic obviously is going to be great for helping raise your good cholesterol. It can be helpful in lowering your LDL, but resistance training— what's wonderful about this is it also makes you more insulin sensitive. And when you improve your overall metabolic health like that, remember, your muscle is your metabolic furnace. That's only going to help you altogether. So again, that body composition piece is really, really important. So resistance training and aerobic exercise. How much should you be doing? You want to aim for around 150 of moderate intensity or 75 minutes of vigorous intensity. And muscle strengthening, you want to do 2 or more days of the week, preferably probably 3. And again, there's lots of different ways. It doesn't have to be one big fell swoop activity. You could break it up into maybe, you know, 3 10-minute sessions throughout the day. It doesn't have to be some formal type of exercise. It literally could be doing— oh heavens— walking from up the stairs instead of taking the elevator. Maybe you walk at a little, you know, faster pace than you normally would during, you know, going between meetings. Lots of different ways to do that instead of, you know, ordering your groceries from Amazon. Guilty here as well. But, you know, go to the grocery store and see how, you know, practice lifting the, the— I'm just coming up with in my head— bags up and above your head and how many times you can do that and walk you know, park further and carry your groceries up the stairs, or like, I don't know, whatever you can do to make more movement in your day, the better. I'm just throwing out some ideas for you. Again, when you're taking— it's really important to take mini breaks also from your sedentary job. If you sit at the desk and look at a computer like so many of us do throughout the day, that's a really important piece as well. And then I think finally it comes to weight management, and I kind of mentioned earlier Really want to think about body composition, as much muscle mass as you can, decreasing your fat composition. Of course, you need some healthy fat stores, but BMI hitting around 23. If you've been really struggling with numbers, you might want to talk to someone about, okay, what is— what would be the best numbers that I should be looking for? So I know you guys will always ask, like, what are the foods? How much should I be eating? These are the foods I would suggest. Just because they have certain types of elements that are really helpful. Oats and barley, they have certain soluble fiber and like beta glycans, excuse me. And the oats, you might, you can, interesting, just skimming the research, you know, if you're thinking about at least a cup or so of cooked oats, you can maybe lower your cholesterol about 5%. Barley, again, A cup of cooked oats, maybe 5 to 7%. Beans, again, like kidney beans, black beans, chickpeas can also decrease LDL. You'll see nuts and seeds, probably about an ounce and a half per day. That's maybe a little bit over a handful, which honestly is great because you're also going to get other minerals and things. Soy products, really helpful when you look at different research. I encourage patients to consume 2 soy products per day, preferably the whole soybean, such as the soybean, like in a can or cooked. You can cook them yourself. You could also do tempeh, which is a fermented soybean, and/or edamame. They have more of the isoflavones that are actually really helpful for other things too. Avocado, you have your ground flaxseeds and your chia seeds. Again, they have Some amazing lignans. Of course, you have your fruits like apples that have pectin that lower cholesterol, and you also have other vegetables like broccoli and Brussels sprouts, carrots again, and whole grains that have these different types of fibers that work differently in helping you lower your cholesterol. They grab hold of the cholesterol and they escort them out the door, literally. So, and we're gonna dive into that a little bit deeper here. What are some of the 6 things that you'll see that plants do to lower your cholesterol? Well, then again, we talked about the high fiber content, especially that soluble fiber. And the soluble fiber, kind of think of it like a gooey gel-like substance. It binds the cholesterol and the bile acids and prevents their absorption, and heads out the door. Then you have things called phytosterols and stanols. So plant foods contain these. They're They're naturally containing compounds. And basically, they compete with the cholesterol for absorption in the intestines. And they reduce the absorption of dietary cholesterol, which is not a big deal if you're eating a plant-based diet because you're not going to be eating cholesterol. Healthy fats— again, when you look at research, the monounsaturated and polyunsaturated fats have shown to lower your LDL. Antioxidants. Plant foods are abundant. Obviously, we're aware of antioxidants we talk about all the time, like vitamin C and E and flavonoids and polyphenols. They really reduce with the oxidative stress and inflammation, which we talked about. You have phytochemicals such as flavonoids, carotenoids, and the phenolic compounds. They also have shown to be decreasing cholesterol by inhibiting cholesterol synthesis. And enhance a few other things. Again, I don't want to go deeper into this, but again, you also have lower saturated fat content, which we talked about, will also help decrease your triglycerides from getting so high. So we could spend an hour just on these 6 things alone, but I really just wanted to share with you why those things are so helpful, as I do get a lot of the questions like, well, how much of this should I be eating? Again, I have a whole lower cholesterol lowering protocol that I share with patients and we go into that more specifically. But I just wanted to highlight kind of on a, you know, looking at the whole forest here. So there are some other things I wanted to speak to about what can affect cholesterol beyond lifestyle. And things include genetics, right? So there's, some people may have a genetic predisposition to high cholesterol. So you even, it's even more imperative that you maintain a healthy lifestyle. But there are things like familial hypercholesterolemia. And you'll see these are kids, right? These kids will end up with high cholesterol in their early teens or sometimes even earlier. Again, there's genetic mutations occurring there. Age and gender. Cholesterol tends to increase with age, particularly that bad cholesterol. And we'll talk a little bit about menopause. You'll see women typically have lower LDL cholesterol than men at the same age. However, after menopause, women's LDL may rise, and that could also include perimenopause, perimenopause being the time around menopause. Hormonal factors, for example, your thyroid. So if you have hypothyroidism, it can absolutely lead to an elevated LDL. I've been hypothyroid for 28 years, and I will definitely say when my thyroid's off and I need to increase medication, you'll see my LDL increase. Okay. In addition, other things like medical conditions. Let's see here, you have chronic kidney disease, liver disease, metabolic syndrome can be an issue, prediabetes, diabetes, certain medications like corticosteroids or anabolic steroids, diuretics. Some immunosuppressants can affect it. We talked a little bit about body weight and body composition, why you want more lean muscle mass. And then ethnicity and race, right? So certain ethnic and racial groups could have different profiles due to genetic and environmental factors. For example, certain individuals of South Asian descent may tend to have higher rates of heart disease just because there's some cholesterol difference in cholesterol metabolism. And you may see someone who is thinner develop type 2 diabetes, for example, or have insulin resistance at a smaller weight. Again, that's where it's so important to focus in on all of the lifestyle factors that you can because we're all dealing with different predispositions. I wanted to highlight just a little bit about the menopause and why that happens. They're like, this isn't fair. It's like, I understand, but what's going on here? So you have decreased estrogen, right? So it really plays a role in cholesterol levels by increasing the production of HDL, right? So as estrogen declines, you'll see a production of your HDL may decrease. You'll also see changes in other lipoprotein levels, right? So you'll see alterations in the distribution and composition. Specifically, you'll see a rise in your LDL. Which is just great. Also, you'll see a shift in body fat disposition, and I think this may be related to the time in life where people are in their activities. It doesn't necessarily cause the weight gain, but you'll see a shift in where that weight is being distributed. So it goes away from like the subcutaneous fat to more visceral fat, which is that abdominal obesity that we talk about. Again, it causes increased inflammation. You also see insulin resistance, which is associated with that shift in body fat composition or body fat storage, and just change in lifestyle habits, right? So you're decreasing exercise, maybe you're drinking a little bit more wine, not exercising as much as you are— should. So, or maybe you have— you're sick or you've been injured. Lots of things can shift around that middle life Time. All right, I'm gonna, I'm gonna go over this very quickly. There's just a few things I wanna speak to about medication, and I know you're like, oh, this is lifestyle we should be talking about. Well, sometimes you need particular medications, and I wanna highlight when that conversation comes up, at least for me and my patients, is when you have high levels of LDL, right? Especially if they've remained above 190. And you've done all the lifestyle factors or you're seeing changes in your coronary calcium score or CT angiogram, or you have a history of cardiac disease, that's something to consider. You have elevated ApoB, remember it makes, it's just a stronger predictor of cardiovascular disease. You have high levels of Lp and you're still struggling to get the other numbers down, that might be another something to consider. And if you have increased hs-CRP. So remember, I understand cardiovascular disease is multifactorial, but there's so many things going on here. There are certain points that you might want to consider medication. And if you've done all the foundational stuff and you're still struggling, again, my hope is that we have you live as long as possible with the least medications, and preferably none at all. But sometimes that That is a consideration you might want to think about. And there's lots of different medications— statins, niacin, fibrates, the PCSK9s, zetamide— lots of different things you could do. And which ones would be better for you, depending on side effect profile, other medications you're on, how much they could lower your cholesterol, how much you should be taking, again, should be talked about with your doctor for your specific cases. All right, so how can we assess your risk, right? So taking into all this account, I just wanted to highlight there is a tool that you and your doctor should use together to make a decision, and you're gonna— it'll take in your lifestyle, age, your labs, your history, and give you a risk profile. This is for someone who has not had heart disease. And so when you think about the This comes from the American College of Cardiology, and it's really looking at the atherosclerotic cardiovascular disease. That's that ASCVD risk estimator, and it puts in all these different factors: your age, your gender, your race, your total cholesterol, your HDL, your blood pressure, your if you've had diabetes or smoking or hypertension. So it's looking at it as a big picture, and what it's done is it's. Looking at different research and studies and giving— weighting each of those based on the research, and then formulating a score and giving you an idea of what is the risk of you having an event in the next 10 years. This is a really great tool to utilize to start the conversation. So you know where you are. I'm a big fan about assessing where you are. You have some education now. Now you can assess where you are, and now you have where you want to go. And what is that delta like? What is— what do you have to do to get there? But it's really important, you know, where you're starting from. And this is just one tool of many, looking at your lipid numbers, looking at your risk. What are your preferences? You know, what are your— what's value— most valuable for you? Again, it's just part of the conversation. This is no definitive like, oh, this is what you gotta do. But these are just some ideas for you. And so finally, I just want to highlight that how often should you be getting checked? Well, they recommend if you're healthy, let's say a young adult, getting checked every once, you know, every 4 to 5 years, you know, checking your cholesterol levels, kind of those labs that we talked about. But if you have cardiovascular disease or you have a higher risk factor, let's say you had family members like myself, my biological father had his first heart attack at 38. My mom's dad died at 46. I'm more— I'm super paranoid about cardiovascular health, so I've already had a coronary calcium score. It was zero, by the way, just last summer. So I'm looking at that, really trying to be proactive in my health. That will depend on those things for you as well. But I would say at least every once every 4 years if you're healthy, maybe once a year or even more recent if you're doing things to change and you're really wanting to see things move, or definitely if you are perimenopausal, menopausal, I would— and you haven't had one in a few years, I would absolutely encourage you to get one done. A fasting lipid panel, hs-CRP, your ApoB, your Lp, and then have a discussion with your doctor about what those mean for you. Maybe run that risk calculator and think about where can I do better in those foundational things, your lifestyle, your diet, your exercise. And of course, I didn't dive deeper into stress and sleep. But of course, those affect other pieces like your hypertension and all those metabolic health. It's all interplayed together. But the bigger levers, I would say, are exercise, weight, and your plant-based diet. Those are the big levers. If you can manage those, a lot of things will work themselves out. So it's a really big topic. For my Healing Kitchen members, if you are part of the Healing Kitchen, it's right around with Brittany Drudy. Monday, I'm going to be doing a deeper dive into cholesterol management. That's going to be the workshop. So, but you have to be a member of the Healing Kitchen to see that. But I just want to throw that out there for my Healing Kitchen members. And you want to learn more about that, you can go to drmarbas.com. Whoo! That was a lot. So hopefully, let me stop sharing. And that was good.

I feel like, I feel like it was a mini medical school.

Oh my goodness. I didn't know how to stop. Like, I was like sitting there going, okay, oh, I should mention this. Just based, you know, based on my experience with my patients, there's so many questions that if they would just have a basic understanding, at least a high level, I think it makes the conversation easier for everybody. Yeah. So I think that That was really fast too. I could have spent much, much more time on

it. It was like a really deep dive.

Yeah, I hope it was helpful.

Well, I think so. This is something people are really concerned about.

Yeah, as they should be. It's a, you know, heart disease is the number one killer of Americans, men and women. And yeah, but there were some special things too that I think around the menopause piece and the insulin resistance piece that we don't highlight or talk about enough. And Those are very, very important things to think about as well.

A lot of times people worry about their HDL, though. And I've heard from other doctors like Dr. Klaper that the analogy that if you don't have garbage, you don't need garbage trucks.

Right. That's exactly right. And that's why I was highlighting, like, if my really healthy, clean, plant-based eaters, you'll see a lower HDL. But many times, though, even in those folks, if they really have a strenuous exercise program, You'll see an elevated— it'll go up even with that, even with those folks. So exercise is the mover there.

OK, I see a question that was submitted in advance from Melissa on the topic. And she said, can you please ask Dr. Marbas about the rise in cholesterol during menopause? Does she have any advice for someone that eats whole food, plant-based, low oil, and is positive for lipoprotein little a?

Yeah, so that is a discussion. I think it's, it's really a matter of you'd want to look at how much did it shift. And there are some things that you could incorporate. Some women, if they're really suffering, you know, hormone replacement therapy might be an option that you might want to consider. That is certainly on the table for discussions, and you will see it shift there. So just by replacing your estradiol, there are certain formulations that you'd want to consider. For example, transdermal patches or something like that, and there's reasons for that and the different types. That setting that aside, you could also consider. I've seen some great improvements with incorporating a few different things: amla powder. I didn't even go into the supplement stuff. There's some interesting research on that, but the the amla powder you could do about half a teaspoon a day. Split that up and take it with your lunch and dinner. You could do. Berberine. Again, you want to talk to your doctor about, you know, if it doesn't interact with certain medications. But berberine has been really helpful. 500 milligrams with each meal, 3 times a day, up to 1,500 milligrams. You could see some slight improvement with Brazil nuts. You do one a week. I wouldn't do more than that just because there's so much. Ground flaxseed, make sure you're doing— or chia seeds. Adding those soy products, getting the weight down, increasing your muscle mass, those will be the shift in the drivers that you'll see after menopause and seeing some improvements in your numbers.

That's great. Thank you. And there's another question from an Instagram viewer on the same topic and also relating to menopause. And they're asking, what is the biochemical mechanism that causes the elevation of cholesterol in peri- and postmenopausal women?

Yeah, so it's multifactorial and I kind of listed them very briefly, right? So you're seeing a shift in adipose tissue storage, right? So the adipose tissue changes, right? It goes from subcutaneous fat to more likely be in the visceral. Then you can increase insulin resistance. You'll see that in and of itself will cause increased inflammation, which feeds upon itself. And again, there's other lifestyle factors that shift as we get older. That's just part of the life. But again, the hormones can cause a shift in it, and you will see some improvement with hormone replacement therapy. I've absolutely seen that multiple times. So there is some shift as far as the biochemical nature. Oh, I'd have to do a deeper— I'm doing a menopause workshop for my Healing Kitchen folks next month. I'll probably go into that a little bit deeper.

Nice. Thank you. And here's a question from Bruce. If your lipid— or in cases, if my lipid panel is normal except for high triglycerides, should I be worried? And I'm asking them if they can clarify the number. 4.70 mmol/L.

Is he out of the country?

A Canadian.

Canadian. I don't know what that is in American. So what was the number again? Let me Google it.

4.70. I could even Google it. 4.70 mmol/L. What do they use, like the metric system or something? Yeah, it's a different Those crazy Canadians. No, I'm just kidding. I'm making a joke because, I mean, I remember ever since I was in first grade, they kept saying we're going to get on the metric system. And now, you know, 60 years later, we're not on the metric system.

Right, exactly.

And I still don't know it. So 0.54 centimeters per inch. That's about all I can remember.

That is so great. What is it again? It was 4.7? 4.70.

What would that be in American triglycerides?

That would be to triglycerides convert. Oh, 415. That's high, right? Yeah, that's really high. Um, I would ask, number one, why is that high? Um, alcohol can drive it, uh, your weight, certain medications. Um, yeah, so I would really pay attention to your diet. Are you consuming a lot of refined products like, um, baked goods, refined flours, high sugary drinks. What is going on in your diet and in your weight and potentially hormonally that could be driving it? So I would, I would do a deeper dive there.

What, what are there, are there actual impacts to having high triglycerides?

Yeah, so the high triglycerides, one, cause increased inflammation. They are drivers of atherosclerosis in and of themselves, and they lower your good cholesterol. And they increase your VLDL because they have to be transported, which then will go further to LDL. So when someone says they have normal cholesterol, I don't know what that means optimal. Normal doesn't mean optimal because people will have normal cholesterol and they're surprised when they have a heart attack the next year. So yeah, triglycerides absolutely can be a driver for heart disease.

Thank you. Well, this was fascinating. I'm going to— I mean, this isn't something that I luckily suffer with, but for people that do, this is like, you know, like mini— like I said, mini medical school. You and Dr. Rogers, you know, you guys really thoroughly research your PowerPoints, and I appreciate it. And please tell people, in case this is— we could have started with this too— if this is the first time they're being exposed to you, how you can see patients, because I think you might be the only one that is certified in all 50 states, right?

Yeah, I'm licensed in all 50 states and DC, and I see patients via telemedicine. So any state, and I can see people internationally as well. I just can't order medications. It's more of a coaching environment. But at drmarmas.com, and all that information is there. I really interact a lot with folks in the Healing Kitchen with Brittany. It's membership-driven. We meet weekly live and we cook together and we talk and we answer questions and then we— then I do a deep dive workshop every month.

What are you going to do when she has a baby?

We're going to get Chloe Stein to take her place for a month or so.

That's nice. I think she's been on the show.

Yeah, Chloe's amazing. Yeah.

Great. Well, thank you. This is so wonderful. Thank you, Dr. Marbas.

Thank you for having me.

It's always a pleasure. And thank you all for watching another episode of Chef AJ Live. Please come back at 11 AM tomorrow for