From Cath Lab to Longevity: A Cardiologist's Shift from Intervention to Prevention

So guys, joining us today is Dr. Sanjay. He is a board-certified cardiologist in the longevity space, and he is leading us today with just the voice of wisdom when it comes to cardiovascular health. We got to meet him in September at a Mindshare Summit that Lori and I attended and instantly knew that we needed to connect again on the podcast. So thank you so much for being here today.

Oh my gosh, thank you guys for having me, and, uh, and it was equally an honor to meet the two of you and just so excited about the work that you guys do as well.

Thank you. Thanks for taking time out of your schedule. So we always have to start the same way. Give us a little insight about who you are, what you do, and who you serve.

Yeah, so I am by conventional training, so I'm an MD physician, so went to medical school, and was a conventionally trained interventional cardiologist. So for those of you who aren't familiar, interventional cardiologists, we are the procedure-based cardiologists. So for a living, I was putting in balloons and stents, and then, progressed into putting heart valves into people all through the arteries in the legs or arteries through the wrist. And for about 20 years, I was the front line of cardiovascular disease, like literally that last line between life or death. So you had a heart attack at 2 in the morning, I would get called in, come in, open up your blood vessels. And in that space, very rewarding, right? Very few things in medicine that give you that instant gratification, that instant hit of serotonin. But I got to a point in my career where we were starting to get repeat business. And in almost any other business that you're in, you know, like if you watch Shark Tank, they're like, what's your return customer rate and all these things. But in cardiovascular medicine, repeat business means someone's had a second heart attack or progression of the arterial disease and they need a second, you know, stent or heart bypass surgery or whatever it may be. And that's not really something that you want. And so in about the 10 to 12 year point in my career, I was seeing people that I had fixed earlier on come back with the same issues despite having, you know, what we consider the conventional world optimal medical therapy, meaning conventional medical world. So blood sugar was great and cholesterol was great and blood pressure was fine and all the quote unquote controllable things seemed okay. And I realized, man, there's gotta be something more. Then it was right around that time that I got an introduction email from some supplement company into the functional medicine approach to hypertension. And it was, you know, free lecture online. This was before the COVID And so Zooms were kind of weird and webinars weren't quite as facile. But I said, you know what, you know, I can just forget watching another episode of Law Order or whatever and watch this. And it blew my mind because all of the things that we were not addressing in the conventional world mindset, emotional health, activity were so central to the role of, or the approach with functional medicine. So, you know, that, that was on a Thursday night. And on Friday, I started talking to patients about diet, lifestyle, all of these different things. And I saw this shift in not just their numbers, but also their whole approach to life and, you know, happy humans are just better than unhappy humans, right? I think it was Elle Woods in, in, uh, was it Legally Blonde where she said happy people don't kill people, right? But it's so true. Happy people are better. And when your body is working better, when you feel it balanced, when you feel like your healthcare practitioner is actually listening to what you're having to say and giving you advice that is tactical, that just creates a better relationship for health, right? So I think in all of those ways, functional medicine just kind of fit what I thought was then going to be this next chapter of my career, which is getting out of the cath lab and really leaning into these integrative and functional modalities for heart health because they are central. It's just not a conversation a lot of cardiologists know how to have.

So interventional cardiology—

you're—

you— I'm a numbers person. Okay, so give us some insight to about how many procedures you were honestly doing a week in the cath lab.

Yeah, so probably between all the things— so I was, I was within cardiology, I did a lot of different things. So I basically, from the neck all the way down to toes. If there was a blood vessel, I would stent it, heart valve procedures, things. I was probably doing anywhere from 8 to 10 cardiovascular procedures a week. That includes emergency and scheduled. So it was a lot. And again, as you, as you accumulate these numbers over the years, you kind of divine the commonalities in between. And so much of it was diet, lifestyle conversations that people weren't— like conventional doctors just don't know how to have.

Right. And I'm asking that question because I think sometimes people don't truly understand the rate to which you all are doing these and the cost and the expense associated with that economically in healthcare.

Yeah. I mean, you know, I always say being healthy seems expensive, but being sick is definitely expensive, right? So, you know, eating the organic food and, and taking that vacation so you can unplug from your environment seems expensive, but in the long run it's actually much cheaper. So cardiac— so if you came in with a heart attack, generally that's a 3 or 4 day hospital stay. On average, anywhere from $80,000 to $120,000 for that hospital stay gets billed to insurance. So it is not an inexpensive thing. And considering, yeah, let's say, you know, one of the heart valve procedures I do, if you're cash paying that, that was easily $150,000 to $250,000. So these are expenses that, you know, generally because insurance is paying for it, people don't think about it. But in the ecosystem of healthcare, these are being charged to insurers. These are being charged across the board. So, you know, we have to really, you know, as I say, we have to get away from this intervention mentality into a prevention mentality, right, where we're preventing disease from happening. The best way to manage a heart attack is to manage to never get one in the first place. And that starts with diet, that starts with lifestyle. And that starts with the understanding that heart disease really begins the moment we're born. And so we have to look at our kids and how they're eating and their activity levels and get them outside instead of behind video games. Same goes for adults, you know, get outside, don't watch TV, don't be sitting around all the time, be active, do things that humans were designed to do, because that's really the easiest road to maintaining health.

So we think about all the changes that have happened since COVID And one of the biggest changes we saw was this onset of inflammation that was more recognized and more honored, honestly, post-COVID, and increase of cardiovascular deaths, right? We saw more people have events and then not survive the event than ever before.

And COVID was interesting for a couple of reasons. You know, as a virus, it made people more inflamed, and that led to hypercoagulability, meaning your blood would be stickier and clot faster. And, and that's part of that cascade. But what most people, and even a lot of cardiologists, I don't really, don't really appreciate so much is atherosclerosis. That's what we call plaque building up in the arteries. Is really atherosclerosis. That -itis suffix indicates inflammation. So when you're looking at these cells of plaque under a microscope, they are— it's an inflammatory situation. It's an inflamed situation. And anything that, that revs up inflammation in the body is also going to rev up inflammation in these plaques. And that's why we saw that uptick in cardiovascular events. That's why we saw people with cardiovascular morbidities fare much worse with COVID infection because their bodies were just amped up. And now, these plaques are growing, they're exploding, we call it rupture, leading to heart attack, right? But so many different things. And to your point, inflammation was really a topic that we knew about, but we weren't talking about, but it came to the fore because we realized that systemic inflammatory response syndrome and all these things were long COVID and long post-viral syndromes or whatever we're calling it nowadays exists because we have to ramp down the immune system. It gets so revved up, you kind of actually have to cool it down as well. Otherwise, it starts attacking us in weird ways and all sorts of things happen.

Yes, our listeners are listening. They're really tuning into that inflammation discussion. Like, they want to know more. They want to know what they can do to help themselves, not just short-term but long-term. Like, what is— what are some strategies? What do they look like in today's world for calming that immune system And because we don't want to suppress the immune system, right? We just want to calm it down. So what do you find the best strategies to be?

I mean, I think that the most— the probably the cheapest one is sleep. Honestly, getting adequate sleep is a big deal. Um, so, you know, inflammatory markers like IL-6, IL-1B, TNF-alpha, um, will be increased in people who are chronically sleep deprived. And, and, you know, that's the The awareness of sleep as a public health intervention, I think, hasn't reached where it needs to be. So really just getting adequate sleep. If you do have a sleep partner or bed partner or whatever, who is snoring a lot, get evaluated for sleep disordered breathing because you can be asleep but not getting that rested phase, that phase 3, phase 4 REM sleep where the brain starts to clear itself. So I think that is one of the easiest easiest things to do in terms of inflammation. Mental approach to things and mindset also, people don't realize, affects inflammation. So if you're, you know, a negative person who, oh my gosh, you know, I won the lottery, but I only won $1 million instead of $5 million, you know, like these things, these mindset things have been shown in the cardiovascular literature to increase inflammatory markers as well. Food, you know, what are the types of foods that you're eating? And so for your audience that may be dealing with a lot of autoimmune conditions, probably a lot of people realize that, but if you have intolerances to high histamine foods like nightshades, things like that, or even foods that you don't realize aren't healthy, like I run a cardiometabolic program and one of the things that we do is look at not just healthy foods, but what are the foods that are healthy for you as an individual? And all the time we'll be surprised by things that people react against like asparagus, or I had someone, salmon. Someone reacted to chocolate. You know, those are things that the chocolate person decided ultimately she was going to do the time for the crime. So she didn't give up chocolate, but she just realized that that's something that affects me. But in a lot of different ways, the foods that we eat promote inflammation as well. And then, you know, the standard gut health and all those things that we talk about are foundational, but really operationalizing 3 things that we don't talk about too much: the foods that we eat, the mindset that we have, and the sleep that we're getting and we're not getting are relatively, you know, that 80/20 kind of rule, change 20% of the things and get 80% of the benefit. Those are probably the 3 that I point to the most often that you can change tomorrow and start to see a benefit within a week or 2.

And being in the cardiometabolic world, I'm just curious, that is my space, my world, that's my entry into functional medicine. We all have our story.

Sure.

I can imagine that you often see blood sugar dysregulation as a primary driver of cardiovascular disease. I would love to hear how frequent you see that. And then what is your— is, is there, beyond those three, are there specific tips for those individuals that have that blood sugar dysregulation?

Yeah. So the interesting thing is, over the course of my career, we went from a population that used to smoke smoked a lot, right? And I trained in the Midwest, so in Indiana and Chicago and Detroit. So, a population that smoked a lot to now a population across the United States where most of us are metabolically insufficient, meaning we're insulin resistant. In fact, there was a study that came out of University of Utah or one of the Utah universities probably about 2 years ago that said 93% of Americans over the age of 18 are metabolically unhealthy, a staggering number. Much more lethal than COVID, right? But being in the cath lab during this time, I got a very interesting insight to be able to see the cardiac consequence of this. So back in the good old days of smoking, and I know that sounds absolutely crazy to say, but in the good old days of smoking, when I'd have to go in and fix someone's artery, it was a very discrete lesion. So you can imagine this blood vessel like a pipe, and there's just 2 or 3 millimeters of disease that I would need to put a short balloon or a short stent in and fix. And that was the, the MO of, of smoking as a risk factor. And what I saw is smoking rates went down and metabolic disease went up is a completely different pattern of disease inside the arteries. So now instead of having one small little area that's affected, which would be presumably by damage from the chemicals and whatnot in smoking, because insulin resistance and blood sugar elevations and all these things are systemic, what we started seeing in the cath lab now was much more what we call multivessel disease. So rather than being just one vessel out of the three main vessels of the heart, it would be splotchy in different areas. But we also saw a much more diffuse pattern. So now instead of putting in a 12mm stent, which is a fairly short standard size, we'd be putting in 30, 40, 50, 60mm sometimes of metal, right, because we'd have to reconstruct the vessel. In fact, we call it a full metal jacket when we have to do that in the cath lab because now we're seeing such diffuse disease. And the reason that's of concern from a cardiac standpoint is, you know, heart bypass still has a role in what we do and is one of the mainstays. But when you have this much stent, there's nowhere to plug a bypass into, right? So you're starting to limit options, you're painting yourself into a corner. And, you know, metal does not belong in your arteries, and it has diseases of its own. We call that restenosis and thrombosis and all these different things. So now you are taking a bad situation, making it kind of better, but kind of not for different reasons. And so the consequences of metabolic disease from a cardiac standpoint are, number one, a completely different pattern of disease, but then we have to rethink our approach, right? Because now it's not just about cholesterol. We really have to zone in on sugar, right? And, you know, where I was at a conference in Las Vegas a few months ago, and And I hate going to Vegas for conferences, but one of the things is that you can still smoke inside there, right? Like, I've lived in California and it's just weird for me. So when you see someone smoking, you can kind of give them a crappy look and that just disdain look, and they feel bad for a hot second, they go back to puffing. But there's a social almost intolerance to smoking, but we don't have that when it comes to ultra-processed foods and high fructose foods and sweets, right? Like, it's a sweet treat, right? It's like a reward for something. And so it's much more difficult to take away. And socially, the pressures, you know, if I show up to an office party with a thing of veggies as opposed to like donuts, right, like that's going to be a very different thing, right? We reward kind of these sweet treats, which is great. And I have nothing wrong with sweets in moderation. However, we're overdoing it, right? And now we're seeing, I think, in the cath lab, we're now seeing the consequences of this, that tide, that wave kind of starting, and it's only going to get worse over the next 10, 15 years, right? Because now We've got kids with adult onset diabetes, right? We used to call type 2 diabetes adult onset. Now we're seeing it in kids as young as 8, 9, 10. And I get so nervous about their vascular health over time. And so we really need to get in— getting back to what the original question was, was what are some of the interventions that we can take, right? So number one, I think, you know, let's get the ultra-processed foods out of our diet, which I know is difficult to do, but do the best you can. Food should really just have one ingredient on the label, right? What are carrots made out of? Carrot. I don't know, right? Like, what is meat made out of? Meat, right? There's no monosodium glycinate and kind of all these things that you need PhDs in biochemistry for. So I think really zoning into diet becomes really important in terms of things that we can do. Avoiding sugars almost at all cost. I mean, I'm not saying that I never have sugar, but sugar in its more natural form. So apples and grapes and because that sugar is balanced by the fibers, right? Maybe not so much in grapes, but certainly apples, blueberries, and that sort of thing become important. Daylight regulation, nighttime regulation, eating with your circadian clock, not overeating, intermittent fasting. I'm a huge fan of, Lori, probably you as well. I mean, I've seen so many people do so much better just narrowing that window, doing a time-restricted eating, and metabolically, it just puts our bodies in a much better state. So yeah, there's a lot of things that we can do from a functional medicine standpoint. But, you know, I think getting rid of the ultra-processed foods and intermittent fasting or time-restricted eating are probably two of the most powerful things that I've seen in my patients.

Yeah, I love what you just shared about the cath lab and what you're seeing, the difference between what you used to see as one of the primary drivers of cardiovascular disease in history and then what you're seeing with the dysmetabolic insulin-resistant patient. And, and I just want to say, Kelly and I don't really like traveling to Vegas either. It's completely disruptive of sleep for beyond reasons, right? There's so many reasons.

I wore so many, like, the sounds and the lights and the stale air. And, you know, this was the American Academy of Anti-Aging Medicine, which is really hilarious, A4M, that they have that conference there. But I had to go outside to breathe fresh air, and even the fresh air outside doesn't feel fresh, right? It's just so many different—

yeah. So what ruined us going to Vegas was actually wearing our Oura Ring. So we track a lot with Oura data, right? So wearing that to Vegas, we could see that HRV flattens low and flat, right? And then it would take 3 or 4 days to recover. So we were going to Vegas every single year for A4M for years, probably for 15 years. And then 2 years of wearing the Oura Ring. The first year we just said, okay, well, maybe we shopped too much, maybe we had a little too much wine, maybe that steak late at night wasn't good. The second year we did everything perfectly. We ate early, we went to bed early, we got hydrated. I even got an IV while I was there. It was the same picture, no difference in my HRV.

And that speaks to, you know, environmental cues. And that's something we don't talk a lot about in cardiovascular medicine. But, you know, light, right? Like the wavelengths of light and the directionality of light that we get at nighttime. And, you know, you can certainly wear the blue blocker glasses, but, you know, if you've got can lights that shine, you know, I'm in my office right now, I've got can lights here and I don't use them at nighttime. I turn the temperature of my light down to about 2,500K to mimic the evening shades of sunset, right? Noise. So one of the things that I did this year was I walked around with my noise-canceling headphones because you don't realize how much that background noise really causes stress on your body. Air, right? Sleep. But one of the great things about that is connection, right? Is that we see so many people. And so I don't want to be completely negative Nelly about those kind of conference different situations as well. But in our day-to-day existence, even in our houses, we need to start looking at the air we breathe. Are you opening up your windows every so often? I know in the winter it can be difficult. I'm from Chicago originally, and nobody's opening unless you're in one of those old Chicago apartments like I had in college where you had a radiator. And so it was either just blazing hot as the sun or not, and you had to open your window to a certain length to get the cold air in to modulate the temperature. So are you getting air exchange in your house? 'cause over time you can actually accumulate carbon dioxide from breathing. And so you have to get fresh air in the house, looking at off-gassing and the cleaning chemicals that you're using and the directionality of light and trying to get some floor level or eye level incandescent bulbs. I don't know if I can say the I word anymore because they're so unpopular, but finding those older bulbs that don't have the same blue light spectrum as those energy efficient LED bulbs bulbs have. We just have to think about these things in so many different ways that it actually does make a difference. And being mindful of this, not overwhelmed, and making those 1%, 2% changes is manageable but also tactical and can lead to benefits of health. I know my sleep has improved significantly since I stopped using overhead lights. Just such a simple thing, right? My body doesn't think it's noon at 9:00 PM anymore.

So can we go back to the discussion on heart rate variability?

Oh, yeah.

Are you measuring that in your patients? I know a lot of our listeners wear devices to measure, right? Whether that's the Whoop, whether that's the Oura Ring, but they love tracking that. So what are your thoughts on measuring?

And I love heart rate variability, and I think it is one of the most easily understood metrics, right? So When we talk about heart rate variability, what we're talking about, as you may know, is these beat-to-beat millisecond variances within, within your heartbeat. So when you have a heart rate of 60 beats per minute, it's not like a metronome clicking exactly at whatever, 1,000 milliseconds, but rather there are these beat-to-beat variables, and that kind of gives us insight into the fight-or-flight and the cooldown system, that parasympathetic-sympathetic tone, um, and HRV scores like basketball, not like golf. So you want higher numbers, not lower numbers. So I, in my cardio metabolic program that I run, that's one of the first things we talk about is HRV. Why? Because it's not just emotional stress that drives HRV up and down, it can be inflammation. So, you know, if you have a glass of wine or a beer, you can see your HRV drop, right? If you're eating a food, and that's one of the things that I teach, a food that's inflammatory to you milieu, you will all of a sudden see your HRV drop. In fact, that happened for me with peanuts, right? Peanuts are known to be inflammatory. I love peanuts. I grew up on peanut butter, and I would have handfuls of peanuts every night. And I saw that those few nights where I didn't have peanuts, I slept better. I got more in-depth sleep, and my HRV had about a 15-point swing. And I'm like, no, that can't be just from peanuts because, you know, food doesn't affect your inflammatory milieu, right? Why would that work? And then sure enough, I started avoiding the peanuts and, you know, my sleep got better and my HRV got better, right? So, and that's something that most people don't connect is how our food affects it. You know, certainly if you're not sleeping or you're drinking, most people are aware of that. But HRV is a great metric. Now, as a cardiologist, I do have to put some caveats in here is that number one, if you have a pacemaker, right, where you have electrical stimulation from this device, HRV is probably not helpful because you literally have a metronome in your chest, right? Like, so if you don't fire at a certain millisecond length, it will fire for you. So HRV becomes a little bit difficult. Also, if you're on medications that can affect your heartbeat, like beta blockers, metoprolol, carvedilol, bisoprolol, for instance, calcium channel blockers like diltiazem or verapamil or others that, you know, you're taking medicines that will affect your heart rate. So there are those caveats with HRV. But that being said, I think it is so useful as a tool, so insightful. And what I love is when clients, patients come back to me and say, oh my gosh, Dr. B, I saw my HRV dropped. I didn't realize what a big deal XYZ was, right? Like, oh my gosh, I had, you know, whatever, Brussels sprouts or something, and all of a sudden my HRV dropped, and I realized that my body doesn't like Brussels sprouts, right? Like, and that's just— I don't think I've ever had anybody to say that of Brussels sprouts. But you know, there are these things that unexpectedly affect us, right? Oh my gosh, I I, you know, watch the news at nighttime, or I watched an episode of Housewives of Orange County or whatever. Or my favorite one was, every time I speak to my mom— this was a woman who, uh, was kind of not having good health, and so she realized every time she spoke to her mom, her HRV dropped because stressing— she was stressing out talking to her mom about, you know, whatever mom thinks. So, so it's, it's connecting people with an easily available metric so they can start to make these correlations for themselves and get these realizations. Oh my gosh, this explains it. Now I understand why. Right? I absolutely love those moments for folks. So do I like HRV? No, I love HRV. Right? That's how I feel about it.

Yeah, we found that it's very, very difficult to improve HRV after a person's really— and Kelly and I talk a lot about the foundational principles. Keep the foundation the foundation. What you eat, what you drink, how how you sleep, how you move, and how you think. Those are the foundations. So you begin to make those changes. Once you make those changes, it can become very, very difficult to move the needle in a favorable direction with HRV. Is there anything outside of those foundational principles that you have found really move the needle for HRV?

Yeah, so let's talk a little bit about that too, because I'll get like HRV-resistant people, right? So someone's like, oh my gosh, my HRV is 20 no matter what I do. I go on vacation and that's often the litmus test for me is what is your HRV like on the 4th day of your vacation because that's when you're actually eased into your vacation. The first few days you're like, "Oh my gosh, the hotel and this, that, and the other." But when you're at a steady state in vacation, if you're not seeing your HRV go up, there are some people that it just doesn't track very well or they're carrying a lot of deeper things like traumas and whatnot that don't really melt away. And that's where I think VNS, vagal nerve stimulation, comes into play a lot. So, there's these devices that you can do either ultrasound-based or energy-based on the carotid artery. There's a collar that you can wear. There's devices on your ears that become helpful in really refractory cases. I don't just jump into those. Oftentimes I'll start with breathwork or meditation, really, and very intentional breathwork and meditation to help relax. So one of the things that you can do is 4-8 breathing. So breathe in for a count of 4, breathe out for a count of 8. I'm a breathwork coach, and that really engages that parasympathetic parasympathetic nervous system. Doing things like humming or gargling can improve that. I've seen some stuff on Instagram, you have to be careful with this, but putting your face in cold water. I don't know if you've seen that as a trend, like they'll get like a bowl full of ice water and, you know, as part of the get ready with me for nighttime routine type videos, people are icing their faces. You know, that all does increase your parasympathetic tone, not for everybody. But, you know, I think that this emerging area of vagal nerve stimulation becomes very interesting because not only does it modulate parasympathetics, but it can actually improve cardiac issues like heart failure and arrhythmia and all sorts of things. So, it's working on us at a very primitive level and it's very powerful. So, breathwork, humming, laughing is another thing that you can do to improve HRV. So, yeah, those are— when eating and sleeping isn't enough, Those are some of the tricks I pull out of the toolbox. How about you? What do you like to counsel people on?

Yeah, definitely that vagal nerve thing. So going back to the vagus nerve, that is a nerve that runs from your brain to your gut and from your gut to your brain. It's bidirectional. It sets your tone for that balance between sympathetic and parasympathetic nervous system. It's very, very important. And oftentimes when we've been chronically stressed, that nerve gets blunted. It doesn't stimulate as well. And so he just described a lot of ways to help yourself stimulate the vagus nerve. And some of them we were taught to do as kids. Hummed, we laughed, we sang, we, you know, we did all the things— hop and skip and spent times with our friends— that help vagal tone. And sometimes as adults, we forget to do those things. So I say gargle in the shower, sing on your way to work.

Yeah, I can't remember the last time I gargled on purpose, but, you know, just, you know, while you're on that, just joy. Yeah, bringing joy back into your life, right? Like so many of us are just forgetting to do fun things, right? Because life is serious and adulting is hard and we're pulled in a million different directions. But, you know, you have to defend that time for you to do something you enjoy, you know? And I think Lori, you were there. One of the things that I've done is I started playing ukulele of all things, right? It's 4 strings. It's easy. There's 4 chords that you can play and you can never ever have a bad time or be angry playing ukulele. It's just not something that can happen. And so I tell myself 5 minutes a day. Now, 5 minutes invariably turns into a half hour, but it's just such a simple thing that has actually brought so much happiness to me. I think of that as a weapon of longevity. You know, like when I bust it out, this is really, you know, it's retraining my brain and neuroplasticity and singing while doing chords and strumming. It's like, you know, patting your head and rubbing your tummy. Like it's a lot of mechanical things that retrains your brain to do things in a different way. But, you know, that's just what I find joyful. But whatever it may be, ballroom dancing or plants or playing, you know, cards with your friends or whatever it might be. But you need to defend that joy time. Otherwise, you know, anger and deadlines and all those things will take over your entire life. Right? So you have to defend that time.

So speaking of longevity, can we talk about aging just for a minute? That darn clock just keeps ticking. And we get older and older. And so as we know, nitric oxide goes down with age. Why does that happen?

So yeah, and I always say that if you think about longevity as a science, cardiologists, we're like the OGs of longevity, right? Because most people die of cardiovascular. So when people say, boy, you're a longevity doctor and a cardiologist, how does that make sense? And like, it's like it makes the most most sense to me, right? It's like, it, it's just, it just goes hand in hand. So nitric oxide is one of these quote-unquote molecules of youth, um, at a molecular bio level. Nitric oxide, which is different than nitrous oxide, which is what people use to get high laughing gas, but nitric oxide is a hormone, and it's what's called the paracrine factor, created by ourselves to vasodilate. So it helps our blood vessels open. It is created by an enzyme called eNOS, endothelial nitric oxide synthetase, in our blood vessels, and it keeps our blood vessels spongy. That's kind of how I think about it. The normal one is eNOS, right? Endothelial. Then we've got the brain one, neural eNOS, and then there's something called iNOS, inducible nitric oxide synthetase. And so iNOS is like the bad player here. That's the one that gets ramped up in inflammation, and it creates this peroxynitrate ion that just creates all sorts in terms of havoc. So as we get older with time, eNOS, that good nitric oxide synthetase, the activity of that starts to diminish over time. That really starts at the age of about 35 or so. We start to see less and less activity there. And, you know, when people think of aging and blood pressure and things, they think of hardening of arteries. So it's not like actual, like, your arteries feel like lead pipes, but— and though they can if you have a lot of calcium sitting around— but rather they become less reactive because we have less nitric oxide. So things that you can do to stimulate that, there are a number of supplements available that in one way or the other give you precursors like arginine and citrulline. Those have kind of fallen out of favor a little bit right now because of that. The reason I mentioned that, and the INOS pathway, is that that can feed that INOS, that more inflammatory pathway. But there are other agents that can be used to give— to kind of boost the endothelial nitric oxide. The good stuff. And so it is just a normal consequence of aging. Other things that you can do are weightlifting and exercise to improve your nitric oxide levels and nutritional support, eating, you know, nitrate-rich foods. And part of that, the surprising thing people don't realize is a lot of the nitrogen fixing that happens in your body, meaning the activation of nitrogen, happens in your mouth. So oral health becomes very important. So there are these elegant studies that were done of college kids. I mean, God, you can pay a college kid $50 to do anything, right? And I did those experiments, as I don't know if you guys did in college too, but just this really amazing study that mouthwash, mm-hmm, so using mouthwash can cause blood pressure to jump up, you know, on average about 6, 7 points, but there are super responders, they're called, that went up like 18 to 20 points in their blood pressure just from knocking out their oral flora, right? So maintaining good oral microbiome, good dental health, is a way to optimize your nitric oxide creation because you're, you're able to take the nitrates from your food, activate them in a proper fashion in a way that your body can use. So yes, and then there's this whole thing with sulfates and, and how that is involved in nitric oxide and glutathione is a storage form for nitric oxide in so many different ways. So yes, nitric oxide, a lot of different things. And we're seeing this now as a hallmark of aging and one of those therapies of aging where you can really slow down that process of aging. Because I don't want to say reverse aging. I don't think that's a good idea. I don't know about you, but I wouldn't want to be as stupid at 8, you know, now as I was when I was 18 years old, right? So we want to be mature but youthful. So reinvigorating these nitric oxide pathways as a way to make our blood vessels spongy, to improve what's called the glycocalyx, which is a layer of, of sugar on top of our endothelial cells, to, to maintain that so that we're not getting elevations in blood pressure and not getting plaque. Um, you know, very important. So there's a lot of different ways to do that.

So a few things I heard, and I just want to reiterate, is mouthwash is not a good idea, right? So I just want to say that very clearly because, um, I do— we spoke to a dentist last year and, and we constantly talk about that because for whatever reason, that is something that people feel the necessity to do. And we're like, it is really not a good thing on a daily basis. Beyond just, I think, oral care. You said that too, how important the mouth is to the heart. Good cleanings, um, flossing, just taking care of your mouth.

Well, and, and your gums are like a direct path into your vessels, right? Like, if you have yucky gums, what happens? Well, your gums bleed a lot, right? And so that's a two-way arrow, so that oral flora can get taken into your blood vessels. And, you know, in the conventional cardiology world, I would probably see a few cases a month of something called endocarditis, which is infection of the heart, just as bad as it sounds. And the most common cause of that is poor dentition, right? So poor, poor oral health. So you really want to take care of your mouth. And this is where, borrowing from the Ayurvedic tradition, of oil pulling becomes really interesting because swishing coconut oil around your mouth, um, for, you know, 5-10 minutes and spitting it out really does promote the prop— you know, it gets rid of that dysbiosis. You maintain the, the proper oral health. It's great for your gums, great for, for your teeth. Um, and, you know, something so simple, right? Like, you know, halitosis— I don't know if you know this, you might know the story, but they were trying to find ways to market Listerine, you know, the mouthwash. And so the ad agency was like, what's the grossest sounding word that we could come up with to make people afraid of having bad breath? So they created the word halitosis and made it like an epidemic and almost like a— because, you know, when someone's got bad breath, so, you know, it was almost like a shaming, like, like being smokers, right? Like, oh, you have bad breath, you must suffer from halitosis, you need this therapy when it's a construct. It's not anything. And, you know, garlic makes your mouth mouth, you know, smell different. And onions make your mouth— it's not a bad thing, it's just a sign of health. But, uh, but there are ways to improve your oral health, like oil pulling, that don't induce that same, um, you know, dysbiosis, uh, and have that same effect of your nitrogen-fixing bacteria. So yeah, if your listeners are listening, you know, Google that and check it out. It's, it's what I recommend to my clients.

Yeah, really good. So I— we are currently or constantly faced with with a key question from our clients about supplements. So our language around supplements is supplements fill in nutritional gaps. Who creates those gaps individually? We all do. I'm responsible for mine. You're responsible for yours. Kelly's responsible for hers. We won't talk about what those gaps are, right? But at the end of the day, we all have those gaps. So one of the key questions we get a lot, because supplements are not inexpensive and quality supplements are essential. If you had to choose, as a cardiologist, 3 supplements that you would recommend, top supplements, what would they be? Not brands, but—

No, I get it. I get it. So in terms of— it really kind of depends. For a purely healthy individual, meaning no cardiometabolic concerns or anything, Um, you know, I still think that most of us are deficient in fish oil. I think magnesium is important. Um, and let's see, what would be a third in there? Fish oil, magnesium. I mean, there's not— I'm not a huge supplement guy either in my practice, so I think just between the, the two of those— magnesium is great for blood pressure, it's, you know, so important for hormone health and a lot of different things. Make sure you're getting a bioavailable form. Like, I like glycinate a lot, or Mag 3 and to help you sleep. Fish oil, I think you have to really be careful of where you're getting it and are you getting the right stuff? Because as you mentioned, quality becomes an issue. And I tell people, you can tell the difference between a $2 bottle of wine and a $200 bottle of wine, right? Like in the hangover that it gives you. So very similar, you want to make sure that you're getting pure fish oil, a reputable source. You know, the big box retailer fish oils generally are not going to be high high quality. They're going to have a lot of fillers and can have contaminants. You have to worry about mercury and all these things. Now, if you are someone who is on that insulin-resistant, high-cholesterol, kind of a pre-cardiac patient, um, then my go-to is berberine. I absolutely love berberine. It has so many great things. It is a, you know, it really activates AMPK, so that now you're kind of using energy a little bit differently. It works as an endogenous PC-K9 inhibitor, meaning that it affects your cholesterol not by affecting your body's ability to produce cholesterol, but it unclogs drains so that you drain more cholesterol. So I think that's really great. I've seen it have great blood pressure effects. Berberine can help heal the microbiome and, and, and kind of get rid of that dysbiosis. That's why in some people who are really dysbiotic, you have to be careful because you can get diarrhea for the first time— for first few weeks you're on berberine. I had one woman who I had to stop the berberine on because she was just intolerant. She was having to go to the bathroom like 10 times a day and was afraid to go outside of her house. And bless her heart, she didn't want to tell me because she didn't want to disappoint me. And I was like, my goodness, stop the medication for the love of God, right? Stop that supplement, you don't need it. But berberine is great. Again, I'd put fish oil in there. And in my cardiac patients, I would use a high EPA fish oil, um, if they've had cardiovascular vascular events. So the beneficial omega acids— there's EPA and DHA. DHA is more of the brain health one, EPA is more of the cardiovascular health one, so I go with that. Um, and then I've been in love lately with mitochondrial support. Um, and, um, and I'm, um, you know, mitochondrial health is really, I think, the key to longevity, right? When you get rid of your phone is when the battery health goes down, you plug it in and then it lasts for like an hour or two, and then you have to get mobile battery pack and you carry this around, you're like, you know what, I'm just gonna get a new phone, right? Because energy, right? Similarly, when we look at cardiovascular diseases like heart failure, hypertension, atherosclerosis, all of these have mitochondrial dysfunction as their underlying milieu. So optimizing mitochondrial health, which is more than just like carnitine and CoQ10, but, but, um, you know, uh, reconfiguring the lipid membranes of mitochondria becomes really important as well. So so like phosphatidylserine, phosphatidylcholine, I think are essential in this. I'm actually doing a talk in a few weeks at PLMI, one of the conferences. And so I'm looking into the mitochondrial markers of aging. And one of the things that happens is that the mitochondrial membranes start to become more porous. So now the electrolytes aren't sequestered and you get a lower gradient. And so you get less energy. And that makes sense, right? Because as we get lower What do we see oftentimes as we get older? People are taking more naps. They have to sleep a lot more. My father-in-law, bless his heart, I'll be talking to him in a conversation and he just takes a nap, right? And he's in his 80s. My dad kind of the same thing. So that currency of energy becomes so important. And so for someone who's on that spectrum of insulin resistance, glucose is an important fuel for your body. And if you can't get it in cells, your mitochondria will suffer. So we really need to do the things to support mitochondria. And, you know, and then of course, I think for anybody, a good multivitamin is really important because we're just not getting the same nutrients from our soil that we used to. And so the apple from 1980 is very different than an apple from 2026. So I will oftentimes suggest a multivitamin. So those are my, those are my go-tos.

Cell membrane health. I don't think we talk about it enough. And I do think that is key to getting nutrients intracellular. Especially protecting that mitochondria. And to your point, that electrolyte balance is huge. It is just huge. And so we can have a whole other hour just talking about that.

I mean, I'll just— I'll just touch base on something really quickly from a metabolic program. I did a talk this week on the cell danger response. All right. So when our bodies are upset, our cellular biology changes. And one of the things that happens is that our our cell membranes are at every level become more rigid, right? And so now you're not letting things in and out. It makes sense, kind of like what, you know, what our politicians are doing to our borders right now, right? Is they don't want anything coming in or out, right? And that limits what you can— what— how the cells can function, right? We're getting more rigid. You know, the reason— and I don't think a lot of people know this— but the reason you take fish oils and you want to get this optimal 6:3 ratio is that gets into your cell membranes and makes your cell membranes spongy, right? So, so yeah, while mitochondria is having its moment this year, um, I think I'm going to go ahead and predict in 2027 it's going to be the year of the membranes, right? The cell membranes, the mitochondrial membranes, and how do we optimize membrane health. Because that, as you mentioned, that two-way communication, those ion channels opening and closing regularly to let the good in and let the bad out, all that has to happen correctly and in balance for our imbalance, not imbalance, but imbalance for our bodies to work correctly. And yeah, it's something that I think even in the functional medicine community, which is a very forward-thinking community, we're just now realizing the importance of.

And we've been looking at that for quite some time because of the treatment of many of our clients who have chronic inflammatory response syndrome, mold and Lyme biotoxin. The challenge we're facing is how do you test test for it, right? So that's, that's where I think we— the jury's out. We've got, we've got some work to do, but we can definitely take the data and look at the data we do have with some of these biomarkers, and we can conclude that we have a cell membrane issue and we need to be proactively treating that, particularly I think in this glucose insulin patient, because I— we measure, of course, OmegaCheck. That's what we can do right now. That's what we have available to us right now. And I can tell you that the majority of people that I test for, and we do a lot of testing, I would say that 80% of the people that we check, and maybe even more than that, do not have the proper ratio between their 3s, their 6s, their 9s. Right.

I think 80% is optimistic. I think, like, as I look at those things, I mean, the normal ratio is supposed to be what, like 3 to 1? 4 to 1, 6 to 1, somewhere in there. And in the United States general population, it's often 20 to 1, 30 to 1, right? We're just so omega-6 heavy and so imbalanced. And yeah, it's not something that we talk about. It's probably gotten better because we're getting rid of trans fats and just more awareness. But at the same time, we're nowhere near where nature intended us to be, right? And we're running this amazingly intricate operating— getting back to the phone— amazingly intricate operating system them on ancient hardware, and it just doesn't work, right? We have to get back to those ancestral levels of these ratios, and it becomes really important. So kudos to you for checking that, because a lot of people— I mean, even I remember my, my partners when I was in practice, uh, in a conventional practice, they would make fun of me for doing all these advanced checks. And I would be like, yeah, I think the, the shoe is on the other foot here. I think you're the ones that are kind of outdated and not doing what needs to happen, because this is so important to human health.

And that 80% I'm speaking of are the people that we have been treating, doing the foundational work, right? And they're still having a problem getting there.

And it's food sources, right? It's what your food ate, right? These sorts of things. So if you're eating grain-fed cattle, right, and you're a beef eater, that's going to have a very different 6:3 profile than grass-fed, grass-finished happy cows, right? If you look at eggs, Eggs, kind of same thing. And synthetic is never going to be as good as natural sources, right? So, yeah, it's a thing. I agree.

So good. Well, listen, we could have you on here forever. I'm thinking about topics. We could just have a conversation on AFib. We could just have a conversation on high cholesterol. We could just have a— so to be continued.

To be continued. Absolutely. Yeah.

Happy to be back and talk about whatever. I mean, I think that that, you know, one of the things about being an integrative cardiologist is that I don't even realize how many questions people have. Like, I take these things for granted because heart health is scary, right? When, when, you know, when you, when you tell someone, oh, I've had diarrhea, they're like, oh, it sucks for you, you know. But if you say I'm having chest pain, that hits us a little bit differently, right? Or if you're feeling your heart beating in your chest, that's very foundational. So, you know, a lot of the work that I do, and I'm opening up a membership community where we I have like group meetings and stuff is really to number one, I think demystify a little bit of this because, you know, I tell people, if you know how a toilet flushes, you're overqualified to be a cardiologist. That's so much more complex than anything that I do, right? But also just giving people information and knowledge in a way that hits home, that they understand without the fancy jargon. And, you know, for me, what's so important is that at the end of the, visit or encounter that I have with the patient, that they go home truly understanding what it is that we talked about. But I think more importantly, tactically, what are the 1, 2, 3 steps that they need to do or that they can enact, you know, once they get home to optimize their heart health? And I'm not saying it's just 3 things, but, you know, if you make these 1% changes, they compound over time, right? So, um, so it is my pleasure to be here. I'm happy to be back. We can have an hour long about AFib and hypertension and cholesterol. And shoot, I can talk about a brick wall for an hour and a half, and I'll be happy to. So thank you guys for having me. I love it.

Well, and thank you for your dedication too, and your willingness to take a leap. And I know it wasn't easy because this was part of the story, was what your wife did when you took the leap out of the traditional world into integrative. And that's for another time. But thanks for taking that leap because we need more We need more specialists in this line, in this field, talking about proactive care instead of that interventional care afterwards.

Exactly. Well, thank you. That— you gave me goosebumps. So thank you.

Yes.

Yes.

Well, tell us how to get in touch with you.

Our—

I'm sure that you were just talking about what you have going on the horizon for 2026. So, yeah. A little bit about what— how to connect with you.

Yeah, some exciting things. So a couple of ways that people can work with me. So I work— I am licensed in California. So if you're based in California, I'm opening up a telehealth practice. I am starting an online membership community. So even if you're not in the state of California, but you want to get my wisdom, you know, in the membership, we'll have weekly lectures that drip out and then office hours with me, which is really cool and exciting to really spread the word because not everybody has has an integrative cardiologist anywhere near them, right? So I think that's awesome. I run a couple of programs. My signature program is called Well12. It's a cardiometabolic optimization program, helps people get off of meds and onto life. So we have a great history of getting people off of blood pressure medicines, off of medicines for insulin resistance, reducing cholesterol medications, improving hormone balance, just a lot of very foundational things. And I am now starting a program called GLP-1 rescue. Um, so for the longest time— and that's a whole other podcast that we could have— but I, you know, was trying to fight against GLP-1s. I think they are helpful for people, they're helpful in— but what we're seeing a lot in the medical community, and you guys are probably seeing this too, are micronutrient deficiencies, protein deficiencies, loss of the wrong type of weight. So people are losing bone mass, losing muscle mass above and beyond just whatever fat loss they have, up to 40% in, in some instances. So we really need to have that nutritional, that lifestyle support so that number one, you can lose weight correctly, but number two, that you don't just bounce back and gain all the weight when you come off of medication. So those programs, links to all those programs can be found on my practice website, which is lagunamedicine.com. So lagunamedicine.com. And, you know, I'll be happy to provide show note links and all that stuff for you. But yeah, if I can be of help to you guys in any way, please, please let me know. And probably my biggest social media presence is on Instagram. So I am @DrSanjayMD, D-O-C-T-O-R-S-A-N-J-A-Y-M-D, because nobody can pronounce my last name, on Instagram.

Awesome. Well, thanks. Have a wonderful rest of your day and your weekend.

Thank you guys so much for being here, and, you know, I look forward to helping you guys however I can.

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