It's Not Cholesterol. Inflammation Is What's Actually Causing Heart Disease

Key Takeaway

Nearly 90% of Americans are metabolically unhealthy, yet fewer than 3% meet four basic health criteria: not smoking, 150 minutes of weekly exercise, eating whole foods, and maintaining healthy body fat. Even more striking: two-thirds of normal-weight people are metabolically unhealthy. The key isn't just weight—it's addressing insulin resistance, inflammation, and metabolic dysfunction through diet and lifestyle changes that can prevent 80% of heart disease cases.

Episode Overview

This compilation episode features Dr. Cindy Geyer, Dr. Eric Topol, and Dr. Aseem Malhotra discussing a paradigm shift in understanding heart disease. Rather than focusing solely on cholesterol, they explore the root causes including inflammation, insulin resistance, metabolic dysfunction, and lifestyle factors. The experts reveal why standard cholesterol tests miss critical information, how insulin resistance drives heart disease years before symptoms appear, and the emerging diagnostic tools and treatments that could transform cardiovascular care.

Full Transcript

Transcript of It's Not Cholesterol. Inflammation Is What's Actually Causing Heart Disease from The Dr. Hyman Show. Auto-generated from episode audio; may contain minor errors.

Why are we still so see seeing so many people with heart disease? Yeah, it's still the number one killer around the world, not just here. And it's still the number one killer in women who, you know, they think that it's breast cancer. No, no, it's this is it. I concluded that one of the root causes, Mark, was this was this flawed hypothesis that we should have low-fat diets to prevent heart disease. Cardiovascular disease is an inflammatory process that it's not just about cholesterol, but there's ongoing inflammation, ongoing inflammation, ongoing inflammation, chronic stress, loneliness, isolation, bad sleep, those things are huge in heart disease.

But we know that 80% of cases of heart disease and diabetes may actually be preventable with diet and lifestyle. and lifestyle. and lifestyle. As part of our summer series, we're revisiting some of the most important conversations we've had on the topics that matter most to our health. And few are more important than heart disease. Heart disease remains the number one cause of death worldwide. And yet, despite decades of research, millions of prescriptions, and billions of dollars spent on treatment, many people still are confused about what actually causes it and what we can do to prevent it.

For years, the conversation around heart disease has focused almost entirely on cholesterol. But what if that's only part of the story? In this compilation episode, you'll hear from Dr. Cindy Guyire of the Ultra Wellness Center, Dr. Eric Toppel, and Dr. for Simhotra as they explore a different perspective on heart disease. One that goes beyond cholesterol and looks at the deeper drivers of cardiovascular risk, including inflammation, insulin resistance, metabolic dysfunction, metabolic dysfunction, metabolic dysfunction, lifestyle, and early detection. You'll hear why many experts now believe that heart disease often begins decades before symptoms appear, why traditional testing can miss important signs and that are warning signs, and how emerging science is giving us new tools to identify risk earlier than ever before.

And more importantly, you'll hear a message that is both practical and hopeful and that many of the factors driving heart disease are within our control and that prevention remains one of the most powerful tools we have. So, let's dive in. So, let's talk about heart disease cuz we think we know all about heart disease. Oh, it's cholesterol and statins are the cure and if that doesn't work, you get a bypass and angoplasty and you know, if that doesn't work, you get a transplant. That's sort of and then you know of course there's all the normal causes we know like diabetes and high blood pressure and high cholesterol but diabetes is a symptom.

High cholesterol is a symptom. Smoking is a habit and yet we're kind of missing the boat I think on a lot of the reasons we have heart disease and what we can do about it from a a more systems perspective. So, let's talk about um just what a big deal this is and and how few people actually are meeting the simple behaviors that will prevent heart disease. disease. disease. Yeah. Again, this is another one of those conditions that the debate is, well, it's in my family, so I'm doomed to get it.

But we know that 80% of cases of heart disease and diabetes may actually be pre preventable with diet and lifestyle. And despite that really powerful message, fewer than 3% of the US population is meeting the core four basic characteristics that predict low risk. And it's a pretty low bar, Mark. What are those? What are those four things? things? things? It's not smoking. Okay. Okay. Okay. Getting the minimum recommended 150 minutes of exercise a week, eating in the top two quintiles of what's considered a whole foods diet, and having a healthy body fat percentage.

Fewer than 3%. I still find that shocking. So, not too much body fat, eating pretty healthy, little exercise, and don't smoke. Simple things to do, but like we're not even there yet. 3%. 3%. 3%. Yeah. Yeah. Yeah. And and and what's really staggering is that, you know, not only do people not meet those habits, but that there there are some really other big factors that we we are just so bad at in America. Our whole society is set up to actually cause heart disease. heart disease.

heart disease. Absolutely. Absolutely. Absolutely. What are those things that that really are these risk factors that besides cholesterol? besides cholesterol? besides cholesterol? Well, of course, it's inflammation. I mean, you and I were working together back at Canyon Ranch when that pivotal study came out. I think it's been 21 years ago. I remember that New England Journal of Medicine review paper, Peter Libby and Paul Ricker showing that cardiovascular disease is an inflammatory process that it's not just about cholesterol, but there's ongoing inflammation. And as you've talked about many times on this podcast, inflammation is not it's also a symptom that it can come from a lot of different places.

Because in our paper, our local paper, when that article came back out, I don't know if you remember this, it said President Bush's doctors measured his CRP, which is the common marker of inflammation, inflammation, inflammation, and they don't know what to do about it. Right. Right. Right. So, it's one thing to say, well, we know inflammation matters. It's another one entirely. entirely. entirely. Take aspirin. Take aspirin. Take aspirin. Take aspirin and a statin. Right. But it's another to say, well, what are the root causes of inflammation?

Well, it's true. And and we there's a lot of them. Um, and some of the things that we don't typically think of as causing inflammation, we know infections and allergens, things like that, even toxins and bugs in your gut, but uh, stress causes inflammation. Absolutely. Absolutely. Absolutely. Lack of exercise causes inflammation. Yeah. Yeah. Yeah. Bad sleep causes inflammation. Loneliness and isolation cause inflammation. And those are pandemics. pandemics. pandemics. Yes. Yes. Yes. In America, chronic stress, loneliness, isolation, bad sleep. I mean those things are huge in heart disease and we often miss miss the boat on helping our patients really deal with those those those right right right so okay so the typical person comes in he's you know got a high cholesterol he or she is a high risk for heart disease maybe family history um typical doctor does sort of what workup and and what kind of treatments so typical doctor might measure a glucose and an A1C to look at their blood sugar status and they would do a standard cholesterol profile, which interestingly enough calculates your LDL cholesterol, the one we usually think of as being the lousy cholesterol, from a formula, doesn't even really measure it, and base most of the decisions on that.

If they have symptoms, they might send them to a cardiologist for a stress test if they have chest pain. If they have chest pain, right, or shortness of breath on exercise, it's already kind of down the road, right? Um, but most doctors don't measure a C reactive protein because, as I mentioned before, it's like, well, what do we do? What do I do with it? Oh, statin and aspirin. And then they're probably going to treat them with if they are pre-diabetic or diabetic, they're going to give them metformin or medications to lower blood sugar and probably a statin to control the cholesterol.

Um, how often do they actually talk to them about those root causes such as diet and stress and sleep? Maybe not. Yeah, they're talking about this poly pill as a as a treatment, which is this combo com combo pill of an aspirin, a statin, and a blood pressure drug. Yes. Put it in the water. Just like give it to everybody. It'll prevent heart disease. I'm like, yeah. Okay. Well, why do we have high blood pressure? Why do we have an aspirin inflammation? Why is our cholesterol all screwed up?

screwed up? screwed up? Yeah. And you know, it's really interesting. There's, believe it or not, there's a potential behavioral component for patients who go on a statin and their cholesterol is now normal. It's good. good. good. Oh, yeah. I I can eat my cheeseburger. I can eat my cheeseburg chicken. Isn't that interesting that people change their diet in an unhealthy way? Oh, yeah. When their numbers better. One of the worst things I ever read was there was a bunch of cardiologists advocating for selling statins over the counter at McDonald's and fast food restaurants.

restaurants. restaurants. Oh my gosh. And I think I think they do sell even statins over the counter and like you know it's like it's like those commercials for the acid blockers like take some Pepsid cuz don't worry daddy you can eat your peppers and sausage just take and I'm like no don't eat the peppers and sausage. Um so you know you kind of mentioned they do a sort of a cholesterol profile but there was a hint of a a subtext in that sentence where they really weren't measuring the right thing.

Yeah. So, we tend to look at things that we're used to looking at that are easy to test and measure, but you know, one of the things that that I think people forget, and I think doctors honestly forget is we get trained in this panel of tests. Mhm. Mhm. Mhm. And it's your blood count and your metabolic profile and your cholesterol and we measure like a few things. Maybe it's 30, 40 things. Maybe if like it's a super fancy doctor, they'll measure a hundred things like and they think they're kind of checking everything.

Oh, your tests are fine. Everything's great. You look good. And the truth is that they're missing a huge amount. There are literally tens of thousands of different molecules in your body all doing things all the time, every minute, every second. And we ignore most of them. And they we in fact we may ignore some of the most important ones. And when it comes to cholesterol, we've covered this on the podcast with Dr. Bow and we went really deep into this. We just should just do a quick refresher because um the test that most people get, not the one we get here at the Ultra Wellness Center, but the test that most people get is like an antiquated cholesterol test that doesn't really tell you a whole lot.

And I I have a patient yesterday who was a classic example of that, right? Uh so tell us about and I'll tell you about his test in a minute but tell us about about your you know the new kind of testing that we're doing. It's not so new because we've been doing it for 20 years but years but years but and the discovery that allowed for the testing was oh 50 years ago. Yeah. So so the focus has been on amounts of cholesterol but we want to know the quality of the cholesterol.

So we know for example LDL that's typically labeled the lousy cholesterol. There's big fluffy puffy pattern a LDL cholesterol which is less easily made into a plaque in the artery less prone to inflammation and oxidative stress and rupture. So it's a less risky LDL whereas somebody could have small dense pattern B LDL and that's the really risky LDL. So quality matters and if you have two people with a calculated LDL of 130, one of them could all have pattern a low-risisk LDL and they're actually fine.

somebody else could have lots of those dense particles that's not captured by the calculated LDL of 130. So the quality matters. The same is true for HDL. We've historically thought of HDL as being the good healthy cholesterol, but size matters there, too. Small HDL doesn't seem to be as able to cart out the bad LDL and get rid of it. So we want to know the quality and the size of both the HDL and the LDL. And we want to know what other remnant particles are floating around like very low density lipoprotein and intermediate density lipoprotein.

And those don't show up on a typical panel. Yeah. So, so, so practically what you see is people come in with what it looks like a normal cholesterol. Like this guy yesterday has early dementia. His cholesterol I think was 160 something. Sounds good. Sounds good. Sounds good. Yeah. His LDL was I think under 100. His triglycerides weren't bad. his HDL was 39, which is kind of low. Um, but we looked at his particle number. Even though his his LDL like the regular dog, oh, that's a great 160.

That's a great cholesterol. Uh, they missed the boat because his particle number was was like 1,500. It should be under 1,000. under 1,000. under 1,000. Wow. Wow. Wow. And his small particles, which should be like zero or less than 300 is, you know, you can live with, but anything over that is high. His was 900. Wow. Wow. Wow. So he was like and he was a skinny older guy was 84 years old and had you know lost muscle, belly fat, you know, underweight, over fat and he was pre-diabetic and that was driving some of his dementia.

But they go, "Oh, your cholesterol is fine. Not an issue." And and we also look at a lot of other things besides. And by the way, you know, in 2021, no one should get their regular cholesterol panel. I mean, you you got insist from your doctor. You can get it from LabCore Quest. It's called NMR, Cardi IQ. Uh it's it's so important to do and and I guess you know the problem is most doctors won't know what to do with it once they find it. There's no drug for it.

Like, oh, your LDL's high, we'll give you a statin. It's like we it's like we treat what we're what we can easily test and find, not necessarily what the right thing is. And and so with with heart disease, uh you know, it really is a metabolic issue. It's it's it's you know you could they shouldn't be called cardiologists they be you should be called cardioendoimmunologists cardioendoimmunologists cardioendoimmunologists right because it's all about the hormones including insulin all about the inflammation immune system and uh and you mentioned earlier that study by Paul Ritker and and Libby in which uh was sort of the beginning of the conversation a lot of the follow-up studies like the Jupiter trial they found that if patients had a high LDL but they didn't have a high CRP their risk of heart disease was negligible.

But if they had a high LDL and a high CRP, that was the problem. So independent of inflammation may not be an issue. Most of us are walking around in a state of chronic stimulation. Your cortisol is elevated, your nervous system is stuck in go mode, and we wonder why we can't sleep or focus. And one thing I've been using that I generally look forward to at the end of the day is the infrared PMF wrap from Bone Charge. PEMF, otherwise known as post electromagnetic field therapy, delivers gentle electromagnetic frequencies into the body that mimic what you naturally absorb spending time on the earth.

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Summer is supposed to be the season where we feel more energized. Travel and heat and schedule changes and longer days can actually throw off sleep, recovery, and stress levels pretty quickly. That's one reason I recommend magnesium to so many patients. Is involved in hundreds of biochemical reactions in the body, including regulating the nervous system, supporting muscle recovery, and helping your body transition into restful sleep. The challenge is that magnesium deficiency is incredibly common and many supplements only contain one or two forms that aren't always well absorbed.

And that's why I recommend magnesium breakthrough by optimizers. It contains seven different forms of magnesium designed to support your brain, your muscles, your stress response, sleep quality, all in one formula. So go to bio optimizers.com/heimman optimizers.com/heimman optimizers.com/heimman and use the codeman to save 15% off your order. Plus get a free travel size bottle of their bestselling massy digestive enzymes while the supplies last. And also you can get falsely confused by cholesterol tests. You've seen these these patients who were and I I don't mean to stereotype people but like it was this kind of cohort of women who were probably in their 70s and 80s who were thin who were fit the ladies we see at Kenya Ranch who like exercise eat well don't smoke normal blood pressure no diabetes and their cholesterol is 300 and their HDL is 100 and their LDL is like I don't know maybe 150 or something and and their they have no small particles and they have all these large fluffy things and they're in really no risk for heart disease and they don't need a statin.

Right. Right. I even asked Peter Libby who's the chair of cardiology at Harvard like do these women need a statin? They're like no they don't. We don't have any data to say that they do. And I'm like oh that's interesting. So we kind of have to be really personalized in our approach and that's the other feature of functional medicine not like one size fits all. Everybody gets the poly pill. Everybody gets a statin aspirin and blood pressure pill like no we have to sort of think about what's the cause and there heart disease is is a symptom.

It's a syndrome. It doesn't there are many many causes. So let let's talk about this whole idea of metabolic health because uh you know we were chit chatting a little earlier and it's staggering to me as a physician just how poor our metabolic health is. [snorts] [snorts] [snorts] Uh so so how how healthy are Americans metabolically? metabolically? metabolically? Yeah. Not very. So, so a recent study was looking at the Nahannes data from 2009 to 2016 government surveys our blood tests and health records and everything right everything right everything right and trying to say well how many people are what we would call metabolically healthy and it if you're not familiar with for people who may not be familiar with that term it's sort of meeting the optimal numbers for a blood pressure less than 120 over 80 um HDL levels being in the high range a good range uh greater than 40 for men 50 for women um having triglycerides that are low um having a glucose that's less than 100.

And they found that 12.12% of Americans of Americans of Americans 12.2% 12.2% 12.2% 12.2%. Thank you. 12.2% of Americans were metabolically healthy, which kind of means that almost 88% of Americans are metabolically unhealthy. And since 75% of people are overweight, there's another 13% there. Yes. It's like what are the what's what's going on with the skinny people? Well, and that's the interesting piece. Fewer than onethird of so-called normal weight people were metabolically healthy. So, that's another really important message. important message. important message. Wait, wait, wait, wait, wait, wait.

Did you just say that twothirds of skinny people are metabolically unhealthy and have pre-diabetes like syndrome? Yes. Yes. Yes. Twothirds. Twothirds. Twothirds. That's mindboggling to me. Okay. So, that that means that what like 95% of Americans are are men among like among like among like No, no, no. still the 88%. All right, but we're looking at how strongly it correlated with weight. That's so terrible. So just having a body mass index that's less than 25 is not a guarantee that you're metabolically healthy. So if you're a skinny sugar and bagel eater, don't think it's fine cuz you're skinny is basically the bottom line.

Exactly. Because foods have other impacts besides just what they do with cholesterol anyway. Foods directly impact the elasticity of the arteries, for example, which is another key play. You mean food is more than calories, Cindy? Cindy? Cindy? Food is information, Mark. You've said that for years. It talks to our genes. It talks to our systems. Yeah. Yeah. Yeah. Wow. So, you're talking about how the food impacts our metabolic health. And and and we're not really good at diagnosing metabolic dysfunction, right? I mean, 90% I mean, okay, one out of two Americans has pre-diabetes or type two diabetes.

And if you look at this new study, I would argue that nine out of 10 Americans have some degree of pre-diabetes or type two diabetes. Like 90% of Americans. So So So when you look at that data and you also look at the parallel data that 90% of Americans with pre-diabetes are not diagnosed by their doctor, right? right? right? That's terrifying, especially because this is a 100% reversible, preventable, treatable condition. And it gets worse and worse over time and people just don't even know they have it.

and doctors miss it because there's no pill to take. Oh, tech metformin. Well, that's not going to help, right? It's like and and so um what are the kinds of ways that we look at these patients differently? What are the tests that we do? What are the things that we really focus on when someone comes in with a risk of heart disease or they're concerned about heart disease? You know, what's our what's our approach? It's not just looking at the typical cholesterol and even CRP. Yeah.

So, we would look at those, of course. We would also want to know what is somebody's insulin. Most doctors measure glucose but not insulin. I personally like to look at somebody's glucose trends over time because if you think about something that's preventable, you don't want to wait till they cross that threshold to pre-diabetes or diabetes. So even in the range of so-called normal glucose mark, um you know this somebody whose fasting glucose runs less than 85 is in a very different metabolic place than somebody whose fasting glucose is 95 to 99.

even though they're both technically normal, that it's a spectrum of risk. And the farther along you mark that spectrum, the higher the risk of heart disease and diabetes. So, if somebody's glucose used to be 85 and then it was 91 and now it's 98, we're going to talk to that person right off the bat about all the things they need to put into place to prevent it from progressing because they're already on that spectrum. We also want to know insulin levels. Not just a fasting insulin, but sometimes the insulin response to food.

Because the other thing that's emerged is insulin is a player. And way before somebody's blood glucose goes up, they might be pumping out tons of insulin to try to keep it in a good place. And insulin by itself contributes to inflammation and more weight gain around the middle the the middle that visceral atypose tissue. So we want to know their insulin both fasting and in response to a challenge. a challenge. a challenge. So wait wait wait. Are you saying it's sugar not fat that's causing heart disease disease disease and sugar the the thing that's driving the insulin because fat doesn't cause insulin spikes?

insulin spikes? insulin spikes? Well there is some I mean fat is a player. player. player. Fat by itself. You eat fat with other food it will but Yeah. Yeah. Yeah. Yeah. And I would say that Yeah. And I would say that quality of fat does matter and we can talk some more about that but I think fat plays a role with artery elasticity which is another component of vascular risk. risk. risk. Yeah. So fried foods, trans fats, refined oils, those are nasty and health. health. health.

Absolutely. Absolutely. Absolutely. But but fat itself if it's made from whole food sources and nuts and seeds and avocados and might actually be beneficial. beneficial. beneficial. Actually beneficial. Yeah. So what you're talking about is is a set of diagnostic tests that are are so important but mostly ignored. So the the the particle size and number which nobody's doing and the second is not just measuring your blood sugar A1C which may be perfect and you may be in really bad trouble but measuring also insulin in response to drinking like a couple of Cokes, right?

right? right? I I have a patient Cindy that I remember who was at super high risk for heart disease and she had uh I mean she looked like the Tasmanian devil. And she was just like a round apple ball like this and her belly was just like this big thing and I'm like this woman is in big trouble and she's inflamed. She's high heart disease, high blood pressure, diabetes and I'm like let's check her glucose tolerance test with insulin and this is you know this is like 20 plus years ago and no no one was like looking at this.

Even today no one's looking at this. It's like so hard. I mean, it took 50 years from the time the guy said, "Hey, we should wash our hands before surgery for us to wash our hands." You know, McKinley died, President McKinley, because he got shot in the belly. And the doctor, Mc Bernie, stuck his finger in the wound to check it out without washing his hands, you know. So, that's like crazy. It took 50 years from the time the guy said, "Let's do a sk the stethoscope so we don't get lice jumping into the doctor's hair to start using the stethoscope because the doctor used to put their head on the patient.

So, it takes forever." And we've been doing it. So anyway, this woman, I did this test. I gave her this drink and it was the most shocking thing I'd ever seen. Uh, and it taught me so much about what we miss in medicine. Her blood sugar was perfect. Like 80 like and and she took the sugar drink and it was like perfect. Like like it never went over 110 after taking like the equivalent of two Coca-Cas. Oh, she's fine. Her A1C was perfect. Her insulin normally should be under five fasting and under like 25 or 30 after a drink.

Her insulin was like 50 fasting. Wow. Wow. Wow. And like 250 after a drink. So her body was just pumping out insulin which was making her hungry, slowing her tablets, putting fat in her belly cells, which were basically inflammation factories inflammation factories inflammation factories and leading this perpetual cycle. And she was able to lose 50 lbs like that when we cut out starch and sugar. Uh, and I just feel like, you know, that that showed me so much because you can even do a normal glucose tolerance test and if you were super hyperinsulinemic, you're going to miss you're going to miss that patient's real problem.

And you know it's interesting Mark because that scenario is also associated with that cholesterol profile we talked about with the small dense LDL and and and low HDL and the squelli that we usually link to diabetes fatty liver peripheral neuropathy all these other organs that are affected and it can happen with the high insulins alone before the sugars go up. up. up. Yeah. Yeah. Yeah. It's a metabolic imbalance. Yeah. So that's really the take-home here is that that heart disease is really a hormonal issue around insulin and insulin resistance and an inflammation issue.

So let's talk about the the heart reduction because people say, "Well, that story's been told, you know, we've got statins, we've got this PC SK9 inhibitors, we're all good. Like what's the big deal? What should we worry about? It's just all about LDL cholesterol. What's new? I mean, what what should we be looking at? What should we be thinking about? And and and why why are we still seeing so many people with heart disease?" Yeah, it's still the number one killer around the world, not just here.

And it's still the number one killer in women who, you know, they think that it's breast cancer. No, no, it's this is it. This is exciting because, exciting because, exciting because, uh, we do know the things that we've been reviewing for risk factors, but we have a way to now, uh, establish the risk. Are they really high risk without before they ever have heart disease, 20 years plus? Um and way we do that is we can get a simple lipid panel add uh the LP little Apo B so a little more than what is the standard lipid panel the L LP little A will be part of a lipid panel in the next year or two but anyway when we get that lipid panel which is again very inexpensive and we can also get a polygenetic risk score very inexpensive we can also get a heart clock right and we can get inflammation markers anyway Now you have the full stack with your records and you know and and you have somebody who is well before they've ever manifest heart disease and you say, "Oh wow, this person is really high risk for heart disease.

What do we do?" Well, do?" Well, do?" Well, you get their LDL down, you know, not just to below 70, we go down to 20 or, you know, less than 30, right? We have so many ways to do that now. Uh we have these injectables that are against this PCSK9. We've got new drugs, five new LP little A drugs that are going to be out within the next year or so that are really potent. really potent. really potent. And we've had none of them. None until now.

now. now. Yeah, we never had one. We always tell, well, too bad your LP little A is over 100. You know, nothing we can do. We're going to be able to change that and that's going to have a big impact. We can get o all the inflammation get all over it right in terms of bringing the inflammation down. Uh we've already seen how GLP1 drug do that before any weight loss. So that should work well in people who aren't even obese. And we've seen how that can prevent heart preserve ejection fraction heart failure which is half of all heart failure right GLP1s prevent that.

So for heart disease we're seeing some really breakthroughs for the treatment particularly the new target of LDL that we have five different drug classes. Statins you've mentioned but the the PCSK9 we have three different ways to do that now. We got other new drugs that are coming. Uh just recently the CETP inhibitor worked really well on top of so we got we can stamp out inflammation. The other thing is we have a metric we never had before which is AI and by the way that also goes with Alzheimer's.

You can do a retina AI exam. So I have a picture of the retina and you do AI on it and it tells you when you're going to have Alzheimer's if you're going to have Alzheimer's 5 to seven years in advance. The retina also tells if you're going to have heart disease or a stroke in advance. It will even tell if you're gonna um you know your calcium score of your heart arteries through your retina. It's remarkable and we should that should be widely available. It isn't yet, but it will be.

We'll be doing smartphone retina checks someday, right? But um here's where we get um a real uh kick on a jump on this because if you are concerned about high risk and somebody you say 40 50 they have significant risk factors you can do a CT angio which is now becoming very inexpensive inexpensive inexpensive uh and you can look at inflammation in the artery I go through this in the book inflammations in the artery without a narrow okay so the the it basically It does AI of the fat around the artery and it and this is something that was developed in the UK and it's now getting ready for FDA approval.

This is a big jump because we always were so this isn't the Clearly scan. This is something else. something else. something else. No, no, the clearly and the other ones in the US don't do this, but this is a a a Oxford University of Oxford spinout. I think it's called Carista. They're going to have that available soon. And I went through the data in the book. I mean, they've had multiple papers, but it's striking. If you have inflammation without a narrow, it's, you know, you you could have 15fold risk of a heart attack.

So, that's when you use that as a metric, just like we were talking about the PTA 217 for Alzheimer's. We've got all these new things for cardiovascular. We are going to get a a grip on this and we got to, you know, ideally start early, but you know, the lifestyle factors work really well. This is the most preventable known of the three big age related diseases through lifestyle lifestyle lifestyle because even without a lot of the drugs like lifestyle plays a big role like you know I've seen data up to 90% by healthy diet, exercise, stress mitigation, sleep, right?

sleep, right? sleep, right? Yeah. I mean that is that in the book I found all these studies that I was really struck by that are recent that show that if we practice the lifestyle factors that we've been reviewing with the details um that we we discussed that gets us 7 to 10 years of healthy aging without one of these age related diseases. I mean, who wouldn't want seven to 10 years of healthy aging just from the stuff we've been discussing without any, you know, magic potion or pill?

Uh, so that's I think people don't know about that. I didn't know about that. It's really impressive. That's powerful. So, so, but you're saying that some of the advances in cardiology are more pharmacological that you're thinking are coming like the drugs that lower this genetically determined lipoprotein called LP little A, which I've been checking for 30 years. Apo B, which I've been checking for 30 years. I read some article the other day that was like, there's this great new test that can be more predictive of your risk of heart attack than any other test.

It's just discovered. I'm like, what is that? I'm like, look like they're the article. It's like Apo B. I'm like, oh god. I mean, you only you only need to get it once and then you can tell that if you need to check it out further, but you're getting at a a key point here is it isn't just that we have better, you know, more aramentarium of drugs, but we didn't know how to get the risk down. You know, we didn't know how to say this person's really high risk for aththeroscerosis aththeroscerosis aththeroscerosis because we didn't really have we didn't use the polygenic risk score.

We didn't have as we do now, we're going to have a heart clock. We we are so there's a big debate out there as you probably know how low should we go on LDL should we pull out all the stops well if you look at all the data the lower you go the more protection but you don't want to necessarily give people you know zettoide and a statin and a injectable and all these things unless they really are high risk then you go for broke and you also get the LPA and you get the inflammation down we have ways that we can do that and we're going to keep having better ways.

So, this is a striking uh it's a combination of who's at risk, the partitioning the risk, and having a better ways to work on that risk. Just to play devil's advocate because this conversation comes up all the time. You're a cardiologist, so your favorite organ is the heart. And so, your idea is get the LDL as low as you can, but your brain is made up of a lot of of of only in people who are at high risk. In people at high risk. Okay. So if you're really high, but like what what about the effects for example on the brain and cognitive function cuz the you know cholesterol is a big part of your brain and sex hormones which is what your testosterone is made from is cholesterol.

So how do you kind of navigate that and what's the truth and what do we know? Yeah. I mean the statins are probably the most studied drug class uh of in history really. Some of the data that comes out of these big metaanalyses which say, "Oh, people don't get any leg cramps." That's not true. You and I know that's not true. People do get severe leg cramps where they can't even sleep at night, you know, uh and and all sorts of other, you know, leg uh and muscle related symptoms.

Now with respect to cognitive and u uh sexual dysfunction the data really don't show a hit there at all and in fact um you know I think that uh we have some data to suggest the chances of having dementia uh in people and Alzheimer's as you know accounts for 70% of dementia that if you if you don't have the LDL lowered to let's say less than 100 less than 70 you're going to be at higher risk for dementia. So if anything the data support uh statins um and you know the data for what sexual dysfunction it's again some of that's vascular and it mo if it's vascular we're talking about athoscerata uh and that again is going to be uh ailarated with with with and it of course we don't have to just rely on statins a lot of people do have side effects from statins no matter what the group at Oxford keeps saying that everyone can take a statin and it's just, you know, it's mental if they can't that when I wrote a when I wrote an op-ed in the New York Times like a decade ago and I called out the diabetes from statins.

Okay. Because if you take a very potent statin, you have a higher risk of developing type 2 diabetes, right? right? right? Yeah. Yeah. Yeah. Oh, did I get slammed by my cardiology colleagues for that? I think, well, wait a data, folks. I'm sorry. And over the years, we've seen many more reports about, you know, the potent statins, high doses where you get a higher risk. Yeah. And you know what? Most physicians are not keeping up with this. They're not watching their patients to see if they're glucose glycohemoglobin, you know, A1C or fasting glucose.

And this is bothersome to me because that is a side effect of statins, particularly potent statins. So again, this is important because if we're going to lower LDL and pull out all the stops and you know high doses of rovite and crusttor or a torist lipur that could also raise the risk of that person developing type 2 diabetes we don't want to do that and we have cardiologists my colleagues they are you know really sold on statins and they basically ignore this this diabetes issue and did I ever take grief?

No, I agree. I I agree with you. And I think I think there's there's um a concern I have around its effect on mitochondrial function and some of the data I've seen that even in people without muscle pain, even without elevated muscle enzymes, that there's mitochondrial damage on muscle biopsies. And for me, mitochondria are so key to healthy aging in the brain, in everything from Parkinson's to al to heart disease, diabetes. Diabetics have poor poorly functioning mitochondria. that maybe part of why it causes it. And so I I'm wondering, you know, some of these other drugs that are coming down the pike, even though some of them are expensive, maybe a better solution.

Well, people that have the clearcut uh adverse effects, um you know, the the PCSK9 injectable drugs are a winner because they're potent and they have not been associated with diabetes, which is really interesting. really interesting. really interesting. They have not been associated with cognitive cognitive cognitive uh or other side effects. So most insurers cover that. Now we, you know, went through years where it was a because they were so expensive, the cost has come down. So as long as people uh have the right indication where they have significant side effects or they need to have their LDL substantially lowered, it's usually not a financial um stress for most people.

So heart disease still lifestyle, but then there's a cocktail of other drugs in very high-risisk patients that you can detect early to figure out. And what about lipoprotein fractionation which is a lab test that we include as part of function health as well as apo and LPA something I've been testing for 30 years but you do you think that's as important because to me the particle number and particle size story is important and it's a sort of a clue that there's insulin resistance which is one of the biggest drivers of heart disease and all the other age related disease.

Yeah. I mean I think it's um these mild potentially mild incremental information. I just don't see that it has nearly the impact of just zeroing in on LDL and LP little A and I do recommend everybody get an APO at least once uh and then you can figure out whether that needs to be further assessed. These other things you know that it's an additional expense. I just haven't seen the the value. But, you know, I have colleagues that are lipidologists that test every known particle to mankind, right?

I just haven't I haven't really seen the benefit because it doesn't change usually to me. I got to know the person's risk person's risk person's risk and then I'm going to go after inflammation. I'm going to work on their lifestyle and if necessary, you know, get their LDL down as low as possible. So the the other things just don't have a for me a added uh value. U but I do know there are people that are you know wild and crazy on every particle small large dense you know you name it out there.

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I think diabetes is sort of all in there related, but you're talking about how there's kind of a newer with the advances in our diagnostics, whether it's imaging or retinal scans or new new ways we can measure dementia biomarkers we never had before, cancer, we'll get into in a sec, that these diseases can become more optional, like they're not inevitable. We have more agency than we ever had before given what we know now. And when you layer up what we're learning with a AI and using multimodal treatments, we're able to actually make a big dent if people really understood how to navigate this.

And the sad part is that, you know, you spend your time thinking about what's coming. Most physicians are just trying to deal with the onslaught of what is and don't have the the bandwidth to actually apply this stuff until it kind of is way often decades later. And so I I I really appreciate you're sort of paying attention to, you know, what's happening and keeping your nose to the scent of where things are emerging because otherwise people just don't know and doctors like you said don't know and and the average person doesn't know.

But this is such a hopeful message and and I'd love you to sort of unpack how you came to go from being a trained cardiologist cardiologist cardiologist who basically swallowed the gospel Yeah. to one who understands and has looked at the literature and has come to a different conclusion because it's not just that you're anti-drug or you're anti-medical care, anti the system. You're for the truth and for science and for an objective look at the facts. So the question I have is how did you go from being a trained cardiologist who believed in statins to one who started to question statins to one who's come to understand that our approach to cardiovascular might be a little bit misguided and we'll talk about what the right approach should be later but I I kind of want to start with unpack unpack the science for us because everybody listening has no heard if their cholesterol is high to take a statin.

Sure. And if statins cause side effects, which they do for a lot of people, probably 20% get some muscle damage or some symptoms or increased risk of diabetes, you know, we'll talk about that data. There's still there's still a huge drive in our society for prescribing these and globally. globally. globally. Yeah, absolutely. So my interest in this came from really looking at the initially the obesity epidemic. So 2004 WHO announced it as an epidemic. You know, by 2010 I was in nine years qualified as a doctor.

I was specialist registra in my cardiology training. Um I was seeing more people this viscerally. I'm very sensitive to how do I put it suffering around me if you like but also seeing my colleagues under more stress in the system and I was like hold on a minute this if we carry on down this trajectory the whole healthare system is going to collapse. We want to even manage people acutely if they are ill, right? I never thought that would happen and and ultimately that one of my own two of my own p two of my parents basically died because of failures in the system because the system's under so much stress, right?

Never predicted that would happen. But that's where I started from. And when I looked into the issue of obesity, you know, I I I concluded that one of the root causes, Mark, if not the main root cause, was this was this flawed hypothesis that we should have low-fat diets to prevent heart disease, food industry exploited that increasing sugar intake, increasing refined carbohydrate intake. It became quite clear, there was a clear correlation between that change in guidance in the late 70s in the US and early 80s in the UK.

Yeah. when the obesity epidemic started to then you know take its uh trajectory down the wrong way. wrong way. wrong way. Yeah. And I covered a lot of this in my book Eat Fat Be Thin which I sort of unpacked the whole history of how we got this lowfat craze led to this high sugar starch craze that then led to this dramatic rise in obesity which now of course we're treating with another drug the GLP1 agonist and you knowide and some glutenic and it's kind of crazy right just kind of flipped it upside down.

down. down. Oh absolutely. So, so when I looked at that, started looking at the data and spending years and and and months and years looking at it and looking at different bits of data, I I was able to put it all together and I wrote a piece in the BMJ in 2013 called saturated fat is not the major issue, right? I read it. That's how I first came across it. across it. across it. Yeah. And that got a lot of attention, right? It was international news and British news and CNN international and whatever, you know, cuz obviously suddenly you've got a cardiologist busting this myth that we think butter has been bad for our cholesterol.

But when I did that, okay, so what I looked at the data and it was very clear there was no clear association with saturated fat consumption and heart disease. So if that's true then and we know saturated fat raises LDL cholesterol, that means LDL cholesterol can't be that important. So and if LDL cholesterol or total cholesterol isn't that important as a risk factor, how does statins work? But I knew statins had a separate effect to lower cholesterol which is their anti-inflammatory and their anti- clotting. And I knew this even it's well known within cardiology circles.

You know I trained as an interventional cardiologist and that means key heart surgery stances for example patient comes in we didn't even check their cholesterol maybe some of the thinking was a lower the better which we'll come on to as well so it doesn't matter what their cholesterol starting from um the lower your cholesterol the better in fact 2011 2011 a cardiologist one of the editors I think of the American journal of cardiology wrote an article which I I mentioned in my book a statree life which was entitled it's the cholesterol stupid right and what did he say in that He said, "You can be an obese diabetic smoker that doesn't exercise." Sounds crazy, but as long as your cholesterol is low enough, you're not gonna get a heart disease.

You're not going to get heart disease. That's like That's like That's like like really. So, okay, I had to unpick that and and and what I what I also then did moving forward from 2013. That's how I got down this track realizing that our obsession with LDL lowering has has been a You looked at the saturated fat literature and you weren't impressed and data showed that it didn't seem both observational data and randomized control trials no benefit like in lowering it no association nothing right right right right and when you look at all the data so that was the first sort of bit that I was okay was okay was okay some might even been protective like some of the dairy fat well we know now yes there is there is some suggestion that dairy fat could be protective absolutely so there's all that and then coming back to the LDL hypers hypers hypers by the way you're not alone on this I mean there was a major paper published by Darish Mazafarian from tus and others looking at butter and and actually showing that there really wasn't evidence that it was so Mark this is what's interesting that article I wrote because creates such a you know um a lot of headlines and and then backlash or whatever else that's when people like Darius started looking at this again so it was all really from the back of that BMJ piece it all came together so then everybody's like you know I know and at the time I was I was writing just a a commentary which was peer reviewed but I could have got it wrong I could have but I was like you know what there's enough here that for me at least to provoke the thoughts right right right and then it all get got proven that you know what I'd written had validity right which is good but the other aspect to this if we go back and you mentioned cholesterol so the so is chole so for is high cholesterol a risk factor for heart disease and is LDL cholesterol risk factor so you have to go back to square one right so these are the framingham of studies that uh you know started in Massachusetts in 1948 and went over decades looking at thousands of people where a lot of risk factors emerge for heart disease whether it's diabetes high blood pressure smoking for example now high cholesterol high cholesterol high cholesterol and high cholesterol right so you go and look back at the Framingham studies and what and the just to summarize it without complicating the situation too much William Castelli is a cardiologist and he published uh he was a co-director of Framingham and in 1996 he published in one of the cardiology major cardiology journeyings a summary of Framingham specifically looking at LDL cholesterol let's just let's just look at LDL because that is the so-called bad cholesterol and he said from Framingham Unless your LDL was above 7.8 8 mill moles which by the way I think in your units is probably 250 or 300 250 probably I think maybe we can look it up and calculate but let's just say for argument sake around 250 which is very very high by the way it absolutely had no it was useless as a predictor for coronary artis coronary artis coronary artis LDL LDL now why is that when you correct for triglycerides and HDL okay which by the way is a more important predictor of heart disease LDL loses its significance completely So then if that's true and I'm saying that means LDL isn't really a risk factor of heart disease and I believe with everything I know now that to be the case.

Okay, let's let's unpick every part of it. Does lowering LDL cholesterol from diet or drugs, but more specifically drugs cuz they're the most potent ways of lowering LDL cholesterol, whether it's PCK9 inhibitors, whether it's statins, whatever. Is there is there a clear correlation? Is this dogma true that the lower the better? So myself and two cardiologists did a systematic review of the totality of drug industry sponsored trials by the way and some diet trials but many drug industry sponsored trials all of the randomized control trials on cholesterol-lowering drugs statins PCK9 blah blah was there a clear relationship as you lowered LDL in low-risk and high-risisk patients Mark okay over 30 studies studies studies was a relationship with lowering LDL and preventing cardiovascular events no even in high-risisk patients even in high risk it's nonsense it's nonsense.

So the question then is why do we all so firmly believe so does that mean stat but then I said well of course statins have a role they do have a benefit from the from the RCT data which is small because I knew already they're anti-inflammatory and anti- clotting so it's nothing in my view listen I could be proven wrong here but the evidence at the moment looks very clear that there is no consistent relationship right it's definitely not a clear relationship so if even if it's a weak relationship mark let's just argument sake let's say there's a weak benefit lowering LDL.

What else is going on? And what else are you ignoring? Right. Yeah. Yeah. Yeah. What else do statins do? They cause insulin resistance. Say one in 100 people get type two diabetes because of statins. statins. statins. One in two. One in 100. Yeah. One in 100. So about 1 to 2% but one in 100. Some some studies say one in 50, right? Will get type two diabetes because of the statin. Probably reversible still, but not ideal, right? If you're on a stand drug. The second thing is look at the whole patient coming in.

We have the illusion of protection. We have patients I used to see coming in and they thought my cholesterol is low. I can go and eat a McDonald's. It's fine. And they they're and they're getting more and more overweight, more insulin resistant. They're increasing their cardiovascular risk. They're not told the statin is going to give them a 1% benefit. I.e. more likely than not they're not going to benefit. So you could imagine that concept that the overall net effect of the way that statins are prescribed and the dogma around them in my view has been negative and has actually been one of the main reasons why we have got this pandemic of chronic disease.

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Exactly. And it's it's stunning to me that you I was talking to the lab director at Quest Laboratories. He said, "What percent of your tests you get to come in are measuring insulin, which is, I think, one of the most important things you need to know about your biomarkers." your biomarkers." your biomarkers." Uh, and he was like less than 1%. And it's part of why I co-ounded this company, Function Health, to really look at a deep biomarker set around cardioabolic risk factors, including insulin, including LP little A, including something called Apo B, which I want to talk to you about.

not just your total LDL, HDL, and triglyceride levels, but also particle number, particle size, inflammation markers, all the things that are often missed, but that are much better at giving you a holistic picture of your cardiovascular risk. And then you know where to intervene. And it and in what one of the studies that it was so interesting to me was actually from I think Scotland or Ireland was where they looked basically at a series of patients who came into an emergency room with a heart attack and they did glucose tolerance tests on everybody who came in with a heart attack and they found that twothirds either had diabetes or pre-diabetes.

Yeah. Yeah. Yeah. Who had a heart attack. Yeah. Yeah. Yeah. That that was really the big driver. Now there's a subset of people have familial lipid disorders. you know, inherited genetic lipid disorders and not those people probably need to be treated more directly. But but for the majority of people out there who are obese or have pre-diabetes or metabolic dysfunction, which is basically in America, 93% of Americans, that's what's driving probably most of the heart disease, not 100% 100% 100% butter or saturated fat or no LDL elevations.

Well, something else to throw into the picture, right? So, you can make the argument, okay, Dr. Motra, you're saying there's no consistent relationship. It may be a benefit. Why not just lower your LDL? Okay, so 2016 and the reason we did this me and a number of international scientists looked at we decided to do a systematic review of observational data looking at people over 60 was there a relationship with LDL cholesterol and heart disease and the reason we did this by the way is another thing that was interesting from framing which wasn't well publicized is that when after people hit 50 years old as their cholesterol dropped their mortality increased.

So we thought okay is there something you know because for it to be a risk factor for heart disease it should be consistent really across all age groups and both sexes right mortality mortality mortality for mortality yeah but even for heart disease as well right you that's a good point so we looked at was there first of all any association if you're over 60 with LDL cholesterol and heart disease right we found none okay interesting but what was surprising was there was an inverse association with LDL cholesterol and all cause mortality In other words, statistically, if you're over 60, the higher LDL, the less likely you are to die.

So, what's the reasoning for that? Well, something that's been forgotten or missed or not discussed, cholesterol is has a very vital role in many functions in the body, including, you know, the brain, hormone production, but also the immune system. immune system. immune system. Mhm. Mhm. Mhm. And it's likely that that's where the protective benefit comes because older people are more vulnerable to dying from infections. And we also know there is an association. I'll use this word, an association, right? is definitely causal between low cholesterol and cancer.

Again, it's probably related to the immune system. immune system. immune system. Yeah. I mean, I think I think the problem with this data though is I'll just push back a little bit is it's it's observational data and the data like from the Hawaii study show that you know you were older and you had higher cholesterol, you know, you're more likely to live longer than if your cholesterol is lower. But it may be because the people have low cholesterol or malnourished, have cancer, and other reasons. reasons.

reasons. So, let me push back on that. So, we we accounted for that and we found actually no when you you count like time lag, you go back five or 10 years. No, it's not. It's not. That does happen, but it No, it's independently it does seem to be an issue. issue. issue. Okay. So, you sort of looked at all the data and you came up with this very kind of contrary opinion, which is that LDL isn't all it's cracked up to me. That statins work a little but not for the reasons we think.

Meaning they lower inflammation and they may have other properties that may beneficial. We don't even know are called this pleotropic effects. So they for example they induce nitric oxide synthes which dilates your blood vessels and reduces inflammation and helps your lining of your blood vessels. All that's protective and so it maybe it stabilizes plaque and may help in those ways but it may not be the LDL lowering effect. In fact Paul Ritker from Harvard I remember he published trial I think it was the Jupiter trial where they show that if you if you had a high LDL but didn't have any inflammation you didn't have that significant a risk of having heart disease.

But if you had interesting interesting interesting a high level of inflammation, high LDL, you had a much higher risk. So it was the inflammation that was really driving the heart disease. And that was really the seminal paper was in the New England Journal of Medicine over 20 years ago. I remember reading it by Paul Richtor and and his crew that really laid out how heart disease is not a plumbing problem. It's an immune problem 100%. It's a chronic inflammatory process exacerbated by metabolic risk factors or insulin resistance.

And I wrote wrote wrote metabolic risk factors. By that you mean problems with your blood sugar and insulin insulin insulin resistance and pre-diabetes. 100%. Uh and actually we published an editorial with two cardiologists I did in British own sports medicine in 2017 which was a very long title but it got a lot of publicity and more than a million downloads which was um uh saturated fat does not clog the arteries. Coronary artery disease is a chronic inflammatory condition which can be effectively managed with lifestyle changes.

That was the title of this thing but it's all there people. It's free access. People can look it up and read it. But we talked that we've overdone the thing and wasn't just Dr. Mahhatra his opinion being controversial. The two my two co-authors were both editors of medical journals and cardiologists. Luis Redberg, editor of John Medicine and Pascal Meer, editor of BMJ Open. Why why is this not getting more play? Why why is still the dogma and the orthodoxy that if you have a high LDL, you take a statin?

Do do you want my honest answer, Mark? Yeah. I mean, not all I mean I know doctors are usually very good-hearted. Sure. Sure. Sure. Very smart, well-intentioned. Don't want to hurt their patients. try to do what's in the best interest of their patients and follow the science. So why why are they not hearing about this? Okay, so let's go to the root cause of the problem even in society today. What's what's the big issue in health? We have commercial distortions of the scientific evidence. Who is behind that and who has more power and control over medical education, medical training, the media ever before?

Big corporations in this case big farmer. And the level of this control and power mark has got to a level where it can be very easily and rationally not in an inflammatory way or overplaying it as as being tyrannical. What what what also happens with these big corporations in the way they exert their power is that they want to avoid conflict, right? They want to avoid the truth coming out. So there's a debate and discussion because ultimately people like myself, like you who are obsessed with the truth, who want to get it out to help patients when we speak and act from a place of of integrity and truth.

It has a very powerful resonance with people and it can very quickly destroy all these other dogmas that people have created because of that power that that that the truth has. They want that conflict to remain latent, to remain hidden. So that, you know, Num Chomsky says the general public doesn't know what's happening and they don't even know that they don't know. That's right. That's right. That's right. Right. So a lot of these doctors and I agree are well intentioned, but they don't they're living, you know, in many ways they're living they're climbing up the wrong wall to success when it comes to helping patients because it's a drug companies that are are really calling the shots.

So we are under a situation of tyranny. And the reason I call it tyrannical is because there are doctors that know this uh mark. There are a few doctors that kind of know this, but then they're less they're afraid to speak out. And only a minority of the doctors that know what's going on will then speak out. If you love that last video, you're going to love the next one. Check it out here.