Addressing The Root Cause Of Heart Disease
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Insulin resistance is a main driver of cardiovascular disease that we don’t hear enough about.
Paying attention to our sugar and starch intake, eating plenty of healthy fats and vegetables, and getting enough exercise can all dramatically improve our insulin sensitivity and reduce our risk of heart disease and other metabolic issues.
For the next few weeks, I’ll be featuring in-depth episodes from my Longevity Roadmap docu-series on the podcast.
This week, we’re talking all about heart health. I’m joined by a few of my amazing colleagues from The Ultrawellness Center, Dr. Todd LePine, Dr. Elizabeth Boham, and Dr. George Papanicolaou.
Throughout this episode, you’ll learn everything you need to know about preventing and treating cardiovascular disease from a functional perspective, from innovative testing to at-home lifestyle changes.
Heart health is so much more than cholesterol. We’ll explain what markers are the most meaningful for understanding your level of cardiovascular health, when it’s time to dig deeper, and what kinds of options exist for medications and supplements.
There’s a lot of confusion about heart health and cholesterol. In this episode, we hope to give you a clear path towards taking charge of your own cardiovascular health one step at a time.
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I hope you enjoyed this conversation as much as I did. Wishing you health and happiness,
Mark Hyman, MD
In this episode, you will learn:
Why cardiovascular disease is not just about heart health
The true role of cholesterol in cardiovascular disease
Are statin drugs effective for prevention of heart disease?
Habits to prevent heart disease
The dangers of insulin resistance
The importance of LDL cholesterol particle size
What is insulin resistance or metabolic syndrome?
Four behaviors that reduce your risk of disease
Mark Hyman, MD
Mark Hyman, MD is the Founder and Director of The UltraWellness Center, the Head of Strategy and Innovation of Cleveland Clinic's Center for Functional Medicine, and a 13-time New York Times Bestselling author.
If you are looking for personalized medical support, we highly recommend contacting Dr. Hyman’s UltraWellness Center in Lenox, Massachusetts today.
Dr. Todd LePine
Dr. Todd LePine graduated from Dartmouth Medical School, is Board Certified in Internal Medicine, and is an Institute for Functional Medicine Certified Practitioner His areas of interest include optimal aging, bio-detoxification, functional gastrointestinal health, systemic inflammation, autoimmune disorders, and the neurobiology of mood and cognitive disorders.
Dr. Elizabeth Boham
Dr. Elizabeth Boham is Board Certified in Family Medicine from Albany Medical School and an Institute for Functional Medicine Certified Practitioner. In addition, she has her undergraduate degree in nutritional biochemistry from Cornell University and her graduate degree and Registered Dietitian from Columbia University. Dr. Boham focuses on a variety of topics, including women’s health and breast cancer prevention, nutrition assessment, Functional Medicine, Functional Nutrition, insulin resistance, heart health, weight control, and allergies.
Dr. George Papanicolaou
Dr. George Papanicolaou is a graduate of the Philadelphia College of Osteopathic Medicine, is Board Certified in Family Medicine from Abington Memorial Hospital, and is an Institute for Functional Medicine Certified Practitioner. His philosophy centers on cultivating personal relationships and treating the whole person, not just the disease.
Dr. Mark Hyman (00:10):
The biggest killer in the world is heart disease. But our traditional approach is pretty misguided and addresses the symptoms, not the causes. High blood, pressure, high blood sugar, high cholesterol, don’t just happen out of the blue they’re signs of imbalance of underlying dysfunction. That can be fixed.
Todd Lepine, MD (00:31):
We’ve all been told, “Why are we seeing more cardiovasculars?” The number one killer worldwide is cardiovascular disease. And cardiovascular disease is not just about the heart. It’s about the whole vascular system, the whole endothelial symptoms. The heart is the pump that pumps out to the arteries, goes to the smaller arterials, then goes to the veins and it goes through the capillaries and then back through the lymphatic system. And that whole system is intimately tied in with our health. It delivers oxygen, it removes waste. And when we get inflammation in that system or a gumming up of the pipes, that’s when we get cardiovascular disease.
Elizabeth Boham, MD,MS,RD (01:10):
So our endothelium is one cell layer that lines the inside of our arteries and this endothelial layer is critical for our health. We want that endothelium working really well, and it needs to be able to relax, to allow blood, to get to all the different tissues in the body. And we know we can impact the endothelium. If the endothelium is not able to relax, that causes our blood pressure to go up. What we know is we start to see endothelial dysfunction and an inability for that endothelium to relax even before… Years before somebody actually goes on to have the diagnosis of hypertension. So it’s important for that endothelium to be able to relax. And there’s many things we can do that can help with that. We know, for example, that blueberries are amazing because they’re rich and these anthocyanins, these phytonutrients that can contribute to improvement in the endothelium.
Elizabeth Boham, MD,MS,RD (02:10):
And we know that when people have what’s equivalent to one cup of blueberries, twice a day, within four weeks, studies have shown that you can drop systolic blood pressure, that top number on your blood pressure, by as much as a blood pressure medication. There’s many things that can be damaging to the endothelium. Oxidative stress, for example, we know can cause damage to that endothelial layer. We definitely know that inflammation is a trigger for damage to that endothelium.
Elizabeth Boham, MD,MS,RD (02:40):
We know that, that may be coming from the visceral adiposity. When people hold on to too much weight around their belly, that weight around the belly is not just sitting there. It is an active endocrine organ. That means it’s creating inflammatory markers like Interleukin 6 and tumor necrosis factor, which goes on and causes inflammation throughout the whole body. We know this because when men gain too much weight around their belly, they have a higher risk for erectile dysfunction. And erectile dysfunction is definitely caused by endothelial dysfunction. So we need that endothelial those blood vessels to be able to relax. And that’s really important for everything from prevention of erectile dysfunction, to keeping your blood pressure nice and low. And what we see with research is when men are able to lose the belly fat, they have improvements in erectile dysfunction. We see that all the time.
Todd Lepine, MD (03:37):
The one thing that I need to tell everyone out there is that cardiovascular disease is not about cholesterol. Let me repeat that, cardiovascular disease is not about cholesterol. Cardiovascular disease is about inflammation in the setting of cholesterol. And the standard cholesterol test that a lot of doctors do is in my opinion, pretty much worthless. You really need to look at a whole host of different things to look at a person’s cardiovascular risk as well. How are they going to potentially develop heart disease or cardiovascular disease down the road? You don’t want to wait until you have blocked arteries in all your veins, and you can’t walk up a flight of stairs to say, “Oh, you’ve got heart disease now.”
George Papanicolaou,DO (04:17):
What is cholesterol? What’s it doing on our body? And how is it involved in heart disease? Well, cholesterol is not water-soluble so it can’t move around our body freely. It needs to be carried around. So it’s carried around by proteins. They’re called lipoproteins. So when you go to the doctor, everybody by now gets their lipid profile done at least once a year. And they hear the terms, total cholesterol, LDL, which is your bad cholesterol. HDL is your good cholesterol. Those are lipoproteins. So there’s the low density lipoprotein, which is LDL, which is considered a bad lipoprotein.
George Papanicolaou,DO (04:58):
And then there’s HDL, which is a high density lipoprotein, which is considered good. LDL carries cholesterol from your liver to parts of your body, where the cholesterol is needed to do its work. HDL, the good cholesterol carries cholesterol from the periphery of your body and cells that have used it back to the liver for disposal. That’s that’s HDLs job. That’s why it’s a good cholesterol. It carries cholesterol away once it’s been used and gets rid of it. So where’s the problem arise and why is LDL the bad guy? And honestly, it’s not the bad guy. And we’re going to talk about that in a second.
George Papanicolaou,DO (05:46):
The problem with cholesterol is that it has an affinity for inflammation. And if the endothelial lining of the blood vessel wall in any part of your body is inflamed, that creates an opening in that protective lining. The endothelial lining is the inner lining of a blood vessel. The blood vessel’s like a pipe that’s carrying water in your house. Well, your blood vessel carries blood throughout your body. The critical places these blood vessels have to be the healthiest are in your heart and in your brain. If you have inflammation in the inner lining, it’s almost like rust in a pipe.
George Papanicolaou,DO (06:31):
If you have rust on the endothelial lining that’s inflammation. And cholesterol, particularly LDL has an infinity for the inflammation and it will attach to the inflamed blood vessel wall. And it will actually enter in underneath that lining and begin to collect. And that’s when it becomes a problem. When that happens, the immune system recognizes the cholesterol as a foreigner and creates an inflammatory response. And it sends these immune cells called macrophages to the site, and they begin to gobble up the cholesterol. And when they get big enough, they die and they form these things called foam cells. And then these foam cells initiate an even more potent immune response. And that goes on day after day, month after month, year after year. First it’s on a microscopic level. But then as that what we call plaque begins to grow underneath the endothelial lining it pushes into the blood vessel wall, and that begins to occlude the blood flow.
George Papanicolaou,DO (07:44):
And when that happens to the blood vessels that feed the heart, then you start to experience what we call ischemic heart disease. Your first symptoms may be chest pain with exercise, chest pain when you’re under stress. What we experience is the most devastating outcome of having that plaque forming is when it gets big enough that it cracks. And when it cracks, it causes a blood clot and that blood clot will fill up the remaining space in the blood vessel. And that is a heart attack, and those can be lethal. And if they’re not, they can create a great deal of disability for patients. That’s why cholesterol has gotten a bad rap because it’s the last bank robber running from the bank. And that’s the one that got seen. But that’s not the problem. The problem is what happened first and that’s the inflammation. So what causes inflammation, lots of things.
George Papanicolaou,DO (08:47):
We’re going to go back to lifestyle. And one of the most important things that causes inflammation are carbohydrates, particularly refined carbohydrates and sugars. And in the last 50 years when we were living under the dogma of cholesterol is bad or food industry started making low fat foods. And to make low fat foods tasty, you needed that sugar, you needed to add salt, and you also need to add fat. And the fat that was being used, which was thought to be safe were vegetable fats but they were highly processed. And when you highly processed vegetable fats, they become inflammatory. So now you have sugar, you have inflammatory oils that are now coursing through our bloodstream, creating inflammation. That’s the critical piece.
Todd Lepine, MD (09:40):
There are things that you can do to preempt heart disease. One of the big things that we’re finding out is that the gut microbiome and leaky gut, and also the oral microbiome are intimately tied in with cardiovascular disease. So if you have leaky mouth, leaky gut, you’ve got bacteria that are floating around in your system, your immune system then reacts to these organisms and then potentially can cause an inflammation that’s then being expressed itself in the vasculature is in the brain. You’re getting problems with memory problems, with brain fog problems, with shortness of breath, all of those things contribute to heart disease. The use of statins in primary prevention, meaning that if a person does not have any known heart disease. The number needed to treat, you have to treat about 500 people to prevent one heart attack.
Todd Lepine, MD (10:30):
So statins for primary prevention really have no role in my opinion unfortunately because of standard of care and protocols, et cetera, and also how we sort of look at heart disease. A lot of people are unnecessarily being put on statin medications, and these medications do have their role. If you have a person who has had heart disease or has had heart surgery or stents, there is good evidence that taking statins prevent secondary heart attacks and decrease risk for stroke and further heart attacks. But for primary prevention, which is what they’re being used primarily for, they really are dangerous medications. There’s lots of side effects. Patients can develop muscle disease, I think about one in 10 people will develop a muscle injury that’s related to the fact that statins are actually poisonous to mitochondria.
Todd Lepine, MD (11:22):
And then also they increase a person’s risk for insulin resistance and diabetes. So again, statins really in my opinion, should not be used for primary preventative for heart disease. I have had patients who have come to me with a history of heart disease and never have they had their microbiome in the gut looked at. Never had they had any type of testing done for increased intestinal permeability, which leads to metabolic endotoxemia, which is those gram negative bacteria floating around in your blood. And then I also had some patients who’ve had heart disease that never had their oral microbiome looked at. The oral microbiome is really important. Lots of regular doctors don’t even think about it. Even functional medicine doctors may not think about the oral microbiome because they’re not dentists. And a lot of dentists actually don’t think that the mouth is connected to the heart.
Todd Lepine, MD (12:13):
So there are tests that you can do that look at the oral microbiome and interestingly various specific organisms are more tied in with cardiovascular disease also autoimmune conditions like rheumatoid arthritis and potentially even intestinal cancers. And so CoQ10 is the body’s natural antioxidant. Our body produces CoQ10 and statin medications are actually called HMG-CoA reductase inhibitors. That’s stands for hydroxy methyl CoA reductase inhibitors. And when this enzyme is blocked in the synthesis of cholesterol, you also block the production of CoQ10. CoQ10 is vital in the body for its antioxidant functions. And it’s also vital because it also helps with mitochondrial function. So if a patient does need a statin medication, pretty much any patient should also concomitantly be on Coenzyme Q10. You can also make an argument as people get older their production or the natural production of CoQ10 can drop, and you can actually measure CoQ10 levels, but optimizing CoQ10 in patients over 50 is a good idea, but especially if patients are already on statins.
Dr. Mark Hyman (13:25):
High cholesterol is not a statin deficiency. In fact, some studies aggressively treating high blood sugar, high cholesterol, and high blood pressure with medication to prevent disease and pre-diabetics actually made them worse. Don’t get me wrong. Medication is often life-saving and critical when needed, but we’re missing a big piece of the puzzle. Medications cover over the symptoms instead of addressing the underlying biology. And in the case of heart disease that’s inflammation, insulin resistance, oxidative stress, which is rusting in free radicals, hormonal imbalances, and toxins, and lots more.
Dr. Mark Hyman (14:03):
Bad diets, lack of exercise, stress, environmental toxins, nutritional deficiencies. Those are the things that lead to high cholesterol, high blood pressure, high blood sugar, and of course, heart disease. In fact, over 90% of all heart disease can be prevented with a few simple habits. Staying your ideal body weight, exercising, not smoking, sleeping well and eating a whole foods nutrient dense plant rich diet.
Dr. Mark Hyman (14:34):
Not a plant-based diet, a plant rich diet, or what I like to call the pegan diet. But you may say, “Well, high blood pressure, diabetes, heart disease, they run in my family.” Here’s what the science tells us about genetic risk, your genes load the gun, but the environment pulls the trigger. Your genes determine your predisposition, but not your destiny. In fact, 90% of chronic disease and unhealthy aging is caused by something called our exposome not our genome. The exposome is the sum total of all our life inputs into our biology.
Dr. Mark Hyman (15:14):
Our diet first and foremost, that’s most important. Our activity, stress, sleep, our relationships, our connections, meaning, purpose, toxins, microbes from outside, and also in your gut, allergens and lots more. The good news is we have control over almost all of it. Heart disease is a leading cause of death in the United States and also around the world. About 647,000 Americans diefrom heart disease every year. That’s one in four deaths in America. Now what most people and lots of doctors don’t realize is that two thirds of heart disease is caused not by fat or cholesterol, but by sugar and starch in our diet causing a condition that’s known as insulin resistance.
Dr. Mark Hyman (16:12):
In fact, the central feature of almost all age related disease, whether it’s heart disease or cancer or diabetes or dementia, even muscle loss, and what we call sarcopenia and even hormonally imbalances is something called insulin resistance. And that happens when we consume boatloads of starch like flour, bread, pasta, rice, and refined grains and sugar. In fact, we eat an average of about 152 pounds of sugar per person, and 133 pounds of flour per person every year. This makes up about 60% of our calories and it’s killing us and it’s making us age very, very fast. Now, the good news is that everything we discuss in this docu-series is focused on getting to the root causes of aging and none is more powerful than insulin resistance.
Dr. Mark Hyman (17:05):
And it is something we can completely reverse. Now years ago, I remember one of the top cardiologists at Harvard saying that if you found a group of 100 year olds with clean arteries, they would have one thing in common. They would be insulin sensitive, meaning that could perfectly regulate their blood sugar with very little insulin. And this, my friends is the key secret of healthy aging. But the bad news, my friends is that today in America, only 12% of Americans are metabolically healthy, meaning we are not insulin resistant. They’re insulin sensitive, like those 100 year olds with clean arteries. This is shocking. It should be headline news.
Dr. Mark Hyman (17:48):
That means that 88% of people are metabolically unhealthy, including the 75% of Americans that are overweight and get this between 20 and 40% of normal weight people who are over fat, even if they’re not overweight. What I like to call skinny fat, they are equally at risk of heart disease and aging, and all the other complications that we see as people get older. Now, abnormal cholesterol, high blood pressure and high blood sugar are all signs of not being metabolically healthy. This is even more important in the age of COVID-19 because the biggest risk factors for serious disease and death with COVID-19 are being overweight, obese, or suffering from an age-related chronic disease. And these are all signs of being metabolically unhealthy. And this is also why we see such an alarming rate of heart disease.
Elizabeth Boham, MD,MS,RD (18:48):
What’s amazing about these particles is that we can really influence them with our lifestyle. So we can make our small dense LDLs get bigger and fluffier. We can make our LDL cholesterol become less atherogenic. We can make your LDL particles be less concerning in terms of causing plaque production in your body. And one of the best ways that we do that is by decreasing somebody’s insulin resistance in their body. By pulling away the simple sugars, by removing the refined and processed foods, we can see the LDL particles get bigger and fluffier in size. And that’s a wonderful thing we can measure. We measure it all the time with this NMR LipoProfile test. It’s a really interesting test that tells us about the size of your LDL particles. Are they small and dense and therefore more at risk for causing heart disease and plaque, or are they big and fluffy and less of a risk for your health?
Elizabeth Boham, MD,MS,RD (19:51):
So it’s good if your cholesterol, if your LDLC is a little bit high, we want to ask your physician, “Let’s do some more testing. Let’s look at the particle sizes of those LDL cholesterol.” I want to see, do I have the small dense or do I have the big fluffy? If you have the big fluffy particles they’re less concerning. And if you have the small dense ones it’s time to say, “I’ve got to make a change in my lifestyle. I’ve got to make some changes in my diet, my exercise program and my sleep. I’ve got to work to make these LDL particles bigger in size,” because many times we can. Sometimes when somebody’s LDL cholesterol comes back very elevated, then it triggers us to look a little bit deeper. There is a subset of our population. It’s about one in every 250 people who have something that’s called familial hypercholesterolemia.
Elizabeth Boham, MD,MS,RD (20:43):
And they have a genetic variation that prevents their body from getting rid of their LDL cholesterol as easily. So for that subset of patients, we might see their total cholesterol be almost 300 or higher. We’ll see their LDL cholesterol be greater than 190. That’s very high. That’s not very common, but if you have those numbers that are higher like that, you want to ask that question, “Okay. what’s going on? Do I have familial hypercholesterolemia?” Because, we know that people who have this genetic variation have a much higher risk of heart disease. They have a 20 times increased risk of heart disease. And it happens at a much younger age. So they might start to develop heart disease in their 30s or 40s, as opposed to in their 60s or 70s or 80s. So if you have a family history of early heart disease, which means less than 55 for a man, or less than 65 for a woman.
Elizabeth Boham, MD,MS,RD (21:42):
So if you have aunts or uncles or parents or brothers, who’ve had a heart attack at a young age, or if you have any signs of really high cholesterol. So your LDL being greater than 190, maybe you’ve got some cholesterol deposits around your eye called xanthelasmas. You can often see those just by looking in the mirror. You’ll see some bumps under the skin around your eye. And if your LDL cholesterol is more toward over 190 or your total cholesterol toward 300, and you have a strong family history of heart disease. Many times in these situations, though lifestyle is critically important and can get and decrease your risk of heart disease. But these are the patients that we take lowering their cholesterol much more seriously. And these are the patients that really may benefit from medication to lower their cholesterol. Plant sterols are the components of our plants that prevent the reabsorption of cholesterol from the gut.
Elizabeth Boham, MD,MS,RD (22:36):
So plant sterols will bind to cholesterol within your intestines and prevent it from getting reabsorbed into your body. Then the plant sterols will take the cholesterol out in your stool. As a result, they can lower cholesterol. We know that two grams of plant sterols a day can lower LDL cholesterol by 10%. You can take plant sterols as a supplement, but you can also get them from lots of your food. So foods such as your beans, legumes and nuts and seeds are naturally rich in these plant sterols. When somebody has a very high LDL cholesterol, and we’re having a hard time getting it down with changes in diet, we really focus on making sure they’re getting a balance of their protein in their body. So not just relying on the animal sources of protein, but pulling in more vegetable sources of protein.
Elizabeth Boham, MD,MS,RD (23:29):
This is where you can really get benefit from your beans and legumes and your nuts and seeds. They can help with providing your body with these plant sterols that help with lowering cholesterol. Vitamin B3 is also known as niacin and niacin can have a positive impact on your cholesterol. It can lower triglycerides and lower LDL cholesterol and raise up the HDL cholesterol. Niacin though, you really want to work with a provider when you’re trying niacin as a supplement, because you want to get a slow release niacin to help with some of the hot flushes it can cause or hot flushes in the body and too much too fast may not make you feel so good. So work with the provider if you’re going to try niacin to help with improving your cholesterol levels. Fish oil can really help with lowering LDL cholesterol and lowering triglycerides and raising up that HDL cholesterol.
Elizabeth Boham, MD,MS,RD (24:20):
Fish oil is phenomenal for so many aspects of our health, but definitely has a good impact terms of risk of heart disease. The vital trial showed that if people are eating less than one and a half servings of fish in a week, then if they take one gram of fish oil per day, they can decrease their risk of having a heart attack. For people eating a lot of fish, fatty fish, especially in a week, they might not need the added fish oil. They may be getting enough from their fish, especially the wild caught salmon, sardines. Those are great sources of your fish oil. You may wonder, “Should I take some extra fish oil?” The people we definitely use fish oil supplements for people with a high triglyceride level and low HDL cholesterol because fish oil can help with lowering those high triglycerides and increasing that good HDL cholesterol.
Elizabeth Boham, MD,MS,RD (25:10):
Two to four grams of fish oil a day has been shown to have a real positive impact on improving your cholesterol levels. Look for a good source of fish oil. One, that’s a good one quality. And I always say, “Keep your fish oil in the fridge.” There’s other sources of omega-3s like ground flax seed that are great to add into your diet as well. Ground flax seed is a great source of fiber and is also really rich in omega-3 fats that can improve your cholesterol profile. One ounce of nuts, five times a week can have a really positive impact on your cholesterol. It also has been shown to decrease risk of heart disease, to lower inflammation in the body. So nuts are a wonderful thing to add into your daily routine. So what is one ounce of nuts? That’s like equal to 24 almonds or 15 Walnut halfs or 15 pecan halfs.
Elizabeth Boham, MD,MS,RD (26:01):
And you want to keep your nuts fresh. So what I always recommend, I get raw nuts and I keep them in my freezer and that keeps them really fresh. Prevents them from oxidizing. That’s the best way to get those nuts into your daily diet. One of the number one causes of heart disease is insulin resistance. So it’s important to understand what insulin resistance is. Every time you eat a meal, your body’s blood sugar increases after that meal. And then the body responds by producing insulin. Insulin is that hormone that takes the food and gets it into the cells, so you can use it for energy. Unfortunately, what can happen as we get older, or if we’re not taking good care of ourselves, or if we’re eating too many and processed foods, and we’ve even shown that some toxins can cause this as well. We can develop what’s called insulin resistance.
Elizabeth Boham, MD,MS,RD (26:51):
And that means that after our meal, our body has to produce a lot more insulin to get the food into our cells. So when somebody has insulin resistance, their insulin levels are actually high. They’re much higher than they should be, but the body is not listening to that insulin as well. And so, even though you’re making a lot of insulin, but the food, the nutrients aren’t getting into the cells, as well as they could. As a result of that high level of insulin causes us to gain weight around the belly, which is that really inflammatory, visceral adiposity. High levels of insulin have been associated with heart disease, they’ve been associated with stroke. They have been associated with many types of cancer, including breast, prostate and lung cancer. And they’ve been associated with dementia. So what we want to really focus on keeping our insulin sensitive, keeping our insulin in that normal range. You can ask your doctor to check a fasting insulin level.
Elizabeth Boham, MD,MS,RD (27:48):
And most research has said less than 12 is considered normal for fasting insulin. We are a little stricter and we like to see that fasting insulin closer to five. And when I start to see somebody getting towards seven, nine, 10, definitely over 12, that’s considered insulin resistance, or pre-diabetes. Another word that’s been used is metabolic syndrome. And so a high fasting insulin is one sign that you have metabolic syndrome or insulin resistance. There’s other signs as well. So if you’re gaining too much weight around that belly, if your waist to hip ratio for a woman is greater than 0.8 or for a man greater than 0.9, that’s a sign that you’re gaining too much weight around the middle. And that’s also a sign that you may have some insulin resistance or metabolic syndrome. If your blood pressure is starting to increase, that’s also a clue that there may be a problem.
Elizabeth Boham, MD,MS,RD (28:42):
And if your good cholesterol, that HDL cholesterol is too low, if it’s less than 50 for women or less than 40 for men, that’s a sign that there’s a problem with insulin resistance. If your triglycerides are too high, that’s also a signal. And finally, if your blood sugar is starting to get too high. So we can look at fasting blood sugar. We know if it’s greater than 100, you’re at risk for insulin resistance or metabolic syndrome. If somebody is greater than 125, they have type two diabetes. And that’s what happens when you’re greater than 125. But what we’re learning is that when you’re pre-diabetic in those years before actually getting diabetes, when your blood sugar is starting to go up and you have all those other markers of insulin resistance, that high insulin, the weight gain around the belly, the low good cholesterol, the high triglycerides, the elevated blood pressure.
Elizabeth Boham, MD,MS,RD (29:37):
We know that in those years, even before you get diabetes, your risk for all of the diseases that come along with insulin resistance, like cancer and heart disease and stroke are increased as well. So you don’t want to just wait until your blood sugar starts to get too high. It’s really important. Many times in conventional medicine, doctors don’t have enough time with patients or enough tests are not done. And many times this is missed. I see it missed all the time. Patients, their blood sugar will be slightly high or starting to creep up. And they don’t realize how important it is to act at this time, because this is the time where you can really reverse the pre-diabetes. You can reverse the insulin resistance and prevent all of these diseases from occurring.
George Papanicolaou,DO (30:23):
So there are several markers of inflammation that we look at. One’s called a CRP one’s called, the homocysteine. And I say, I certainly can’t make a decision or help you make a decision about whether you should come off your statin or take a statin, unless I know how much inflammation you have in your body. So that will be two tests that I will get if they’re not part of their profile. Then, I will perform something called a nuclear magnetic resonance lipid profile. That is when we are able to look at the actual molecular structure of the lipoproteins that go through your bloodstream and determine which ones you have. And when we do that, we’re able to find other lipoproteins and they’ve been researched and they’ve been found to actually be more important markers of heart disease, or risk for heart disease than LDL, total cholesterol, and low HDL.
George Papanicolaou,DO (31:26):
One of them is called your low density lipoprotein particle number. And one’s called your low density, lipoprotein size. The low density lipoprotein particle number is really a measurement of how many LDLs you actually have. Not just the total, but how many individual LDL molecules do you have? The LDL size is how big are those LDLs? So it’s not just a total LDL, now we’re getting more granular. How many of them do you have and how big are they? And what we found is that, the really small dense LDLs they’re like missiles. They can penetrate in the endothelial lining where there’s inflammation and build up very quickly. So you want larger LDL molecules because the big fluffy ones puts you at lower risk for heart disease. And if you have big fluffy LDLs, that’s going to be a favorable measurement and is going to be one step towards, “Hmm, your LDL may be high, but they’re big and fluffy and you have few of them.” You want a low LDL particle number, the fewer particles you have and the bigger they are, the lower risk you are.
George Papanicolaou,DO (32:50):
So if you have that profile, that’s one reason why you might not need to be on a statin because it doesn’t matter if the LDL is high, you have small ones and you have fewer of them. You have big ones and you have fewer of them. Okay. Then there’s another marker. It’s HDL size. You want your HDLs to be big. So, even if you have a mildly low or low HDL, if we look at the size and they’re big, that’s really good because HDLs are like, we know what they do. They collect cholesterol and they take it to the liver for it to be disposed of. If you have small HDLs, then that’s like having small dump trucks and they can’t really pack on a lot of cholesterol and they’re not very efficient at collecting it and driving it to the liver and getting rid of it.
George Papanicolaou,DO (33:43):
But if you got really big dump trucks, really big HDLs, they can collect more cholesterol, carry to liver and have it removed. So your HDL size is also important. And finally, there’s a really interesting marker that’s gaining a lot of ground as being an important marker for heart disease. And it’s called lipoprotein (a) or Lp little a. So Lp little a is very much genetically programmed. So 90% of the people that have this Lp little a, they have a gene for it. And there’s some thought that this may have conferred for that population of people a lower risk of dying from injury, because it helps blood clot.
George Papanicolaou,DO (34:36):
So evolutionarily, it may have had a value at some point. But now, because the diets that we have and the lifestyle we have. That what used to be evolutionary advantage may now be a disadvantage when it comes to heart disease. So Lp little a, actually expresses itself very quickly. So by the time you’re two years old, it’s fully expressed and you’re making a lot of Lp little a. By the time you’re five, you’re making a lot of this lipoprotein (a). And what it basically is, is an LDL with an additional lipoprotein called apo(a). It’s fully expressed by age five to your adult level. So you’re living with this really high Lp little a if you’re inclined to do that, genetically for most of your lifetime. Knowing that value we understand about that is that it increases your risk for heart disease four-fold, but nobody screens for it.
George Papanicolaou,DO (35:37):
And so I will screen for an Lp little a because if that is really high number, even if everything else being equal, you’re sort of on the borderline with your numbers. A high LP little a is going to really concern me and I’m going to really want to work at changing your lifestyle and using that as leverage to have you do it. So what I’ve just talked about are different ways of looking at cholesterol. And I told you it’s inflammation, but I just got done telling you that they’re important cholesterol markers that we need to look at that increase your risk for heart disease, it’s both. Inflammation is the genesis and cause of heart disease in that it creates an environment for cholesterol to create those plaques that create those blockages, that create the diseases that cause heart attacks and strokes.
George Papanicolaou,DO (36:39):
So when it comes down to it, we need to be aware of those things in our life that will create inflammation. And we also need to be aware that our doctors need to measure it appropriately. So when you come to me as a functional medicine doctor, I’m going to look at not just your total cholesterol and your LDL and your HDL, but the markers that identify risk more sensitively. As I’ve explained, those are LDL particle number, LDL particle size, LpL (a) as your cholesterol markers. On the other side, and more importantly is do you have inflammation going on in your body right now? And two the really important markers that need to be included in your cardiovascular risk assessment when we’re looking at our physiologic markers are CRP and homocysteine. Because both of those are linked to increased risk for heart disease because they’re markers for inflammation.
Dr. Mark Hyman (37:44):
Well, I always start with the basics. If someone has a poor lifestyle, if their diet is not great, if they’re not exercising, they’re under too much stress. If they’re not sleeping, if their nutrient levels are off, I start by focusing on those and I do that aggressively. But there is a subset of patients that don’t respond to that, and that have a genetic problem. Maybe something called familial hyperlipidemia, which means you get really high cholesterol. And I have a patient right now who’s just following all the advice I’m giving him and he’s doing great, but he’s one of those patients that needs a statin. And he’s a very significant cholesterol absorber. So we actually can do tests now to see whether you’re a cholesterol producer or you’re a cholesterol absorber. If you’re a hyper absorber. So you absorb the cholesterol and fat in your diet in a way that’s not good for you, or maybe your liver just produces too much of it.
Dr. Mark Hyman (38:40):
And we can use things to help block the absorption of cholesterol, whether it’s fiber or other factors, or we can use something to help block the synthesis of cholesterol in the liver, whether they’re natural products or medications. So it’s very personalized and individualized. There’s not one size fits all. But the problem today is if anybody comes in with a cholesterol or an LDL of over a 100 or 130, the doctor goes, “You need a statin,” sort of one size fits all. And that’s just not how to practice medicine. And we know this now. I mean, the medical profession understands this. The National Institutes of Health has a whole department of precision medicine and precision health and precision nutrition. So we’re understanding that this one size fits all medicine just doesn’t make any sense anymore, but it takes a while to get it into practice. And functional medicine is the science of personalized medicine.
Dr. Mark Hyman (39:33):
It’s the science of personalized nutrition and personalized health. So everybody’s different. I treat everybody differently and I look at what their issues are, what their genetics are. And I push as hard as I can on the things that are the least toxic, the least harmful with the least side effects. Nobody’s going to die from improving the quality of their diet. The opposite is true, but some people may have adverse effects from drugs. So I use them, but I use them as a last resort, not as the first step. There’s interesting technology available today that allows us to look at the quality and function of your blood vessels. And that’s really cool. So we can see in real time, are they stiff? Are they pliable and soft or are they hardening?
Dr. Mark Hyman (40:20):
And if you’re arteries are hardening and stiff, it’s not terminal. You can influence that by the quality of your diet, by lifestyle, all the things we’ve been talking can change your blood vessels from stiff and hard and at risk for damage to soft and pliable and fluid, which keeps you healthy and free of heart disease. So we look at these tests like for example, EndoPAT, which is a machine that’s non-invasive that looks at the vascular health. How has your blood vessels, are they good? Are they bad? And this EndoPAT test can be done at your doctor’s office. Again, many don’t use this preventive technology, but it’s a great way to see and then you can alter your lifestyle and you can come back a month later and do it again and you’ll see the change. And we see that very often.
Dr. Mark Hyman (41:08):
Well, if someone has poor blood vessel health, we know so much about how to get your blood vessels working better, which is to eat an antiinflammatory diet. Low starch and sugar, lots of plant rich foods, lots of good quality fats, lots of nuts and seeds. What I call the Pegan diet. It’s something I’ve been talking about forever. It’s the quality of our food matters more than the quantity. What you eat matters more than how much you eat. And so focusing on the quality and upgrading the quality of your diet is so critical. And getting rid of all the junk, getting rid of all the flour and the sugar. Doesn’t mean you can’t ever have it, but it’s just not a staple in your diet anymore. Exercise also has enormous benefits on your vascular health, on function. Saunas, who knew? But saunas actually increase your vascular health and can produce better vascular resilience and response increase something called your heart rate variability, which is a sign of the quality of your heartbeat.
Dr. Mark Hyman (42:09):
Is it good or is it bad? Is it more risky for heart disease or less risky for heart disease? There’s meditation, which also can affect your blood pressure and inflammation and oxidative stress and all the things that cause your blood vessels to not be happy. And then there’s lots of nutrients out there. Fish oil is a great one. Curcumin is another one, vitamin D antioxidants, a whole list of plant derived compounds we call phytochemicals and also just nutrients play a huge role in your vascular health. So we design a comprehensive program to upgrade the quality of your vascular system and your blood vessels so you don’t get heart disease.
Dr. Mark Hyman (42:50):
With the increasing interest in ketogenic diets and low carb diets, we’re seeing a phenomenon that’s pretty fascinating, which is the variability in individual’s response to different diets. Some people do really well on a lower fat diet and other people do really well on a higher fat diet. Some people do better with lower starch and sugar. Some people have more ability to manage starch and sugar. So I have a good ability to manage starch and sugar but I’ve noticed, for example, when I have a high intake of certain types of fat, like saturated fat, my cholesterol goes really high.
Dr. Mark Hyman (43:32):
So there’s this phenomenon called lean mass hyper responder, which we’re still studying and still learning about. Which is people who are fit and healthy, when they jack up certain types of fat in their diet it doesn’t work so well for them. And we can actually do analysis that we do in our clinic here at The UltraWellness Center, called DNA diet, where we can see how you respond to fat, how you spot a carbs and how you respond to different factors that regulate your eating behavior. How you respond to salt tastes and various kinds of bitter tastes and what actually you should be eating to maximize your genetic potential.
Dr. Mark Hyman (44:09):
When it comes to heart disease, your diet and your lifestyle is the single most important thing. Acting now not only saves you later, but the things you need to do to prevent heart disease make you feel great and younger right now. A very big European study called EPIC found that incorporating four simple behaviors can dramatically reduce your risk developing heart disease by 90%. So not smoking, exercising three and a half hours a week, eating a healthy diet and maintaining a healthy weight. In fact, researchers in the EPIC study found that adhering to the four behaviors alone seem to prevent 93% of cases of diabetes, 81% of cases of heart attacks and 50% of cases of strokes. And also 36% of cases of all cancers. Now there is no medication on earth that can do that.
Dr. Mark Hyman (45:06):
Of course, there is a role for medication in some patients for some patients with significant genetic risk, or if they’ve already had heart disease or a heart attack. But over time by addressing the root causes, many people can come off these medications. Through lifestyle changes and addressing root causes, I have seen patients lose weight, get off all their medication, normalize their blood sugar, normalize their blood pressure and cholesterol, and even reverse congestive heart failure using functional medicine. Incorporating positive dietary and lifestyle changes can lead to miraculous results. You just have to implement the right strategies. So we’ll see you next time for episode three. And thanks for tuning in.
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If you are looking for personalized medical support, we highly recommend contacting Dr. Hyman’s UltraWellness Center in Lenox, Massachusetts today.