Heart Health Simplified: Expert Tips That Work | Dr Christie Ballantyne

welcome to the Dr Gabriel lion show where evidence-based information meets Innovation and practical application for everyone today I sit down with Christy Valentine MD he's an internationally renowned expert on lipids Athos sclerosis and heart disease prevention he's the chief of cardiovascular research and the director of cardi metabolic disease prevention at Baylor College of Medicine he's in the top 1% of the most cited investigators he has over 800 plus Journal Publications in the areas of athlos sclerosis lipids and inflammation his research has led to the approval of get this to biomarkers for cardiovascular risk prediction and

he has played a prominent role in the development and approval of new lipid lowering therapies Dr christe Balentine is the current president of the national lipid Association he is an absolute unicorn and what you're about to listen to is someone who is an expert with Decades of experience in clinical practice and basic science genetic research this is a highly scientific episode so if you are a provider or if you are someone who is interested in lipids this show is for you please sit down with me with Dr Christy Valentine [Music] Dr Christy Balentine thank you

so much for coming on the show uh current president of the national lipid Association uh just an incredible researcher and academic welcome to the show my pleasure now we are going to talk about all things cardiovascular related and cardi metabolic Health which seems to be the buzzword now but before we do tell me why Cardiology so you know a lot of things that we end up doing in our lives some of the and a Seasons to begin before we were born actually cuz genetics plays a big part in all of our lives uh I never

knew my grandfather because he died of a stroke and I never knew my grandmother because she died of a stroke and when I was a junior in high school my father had a heart attack so he had atypical symptoms went to the hospital was not in the ICU but had a cardiac arrest and he was very lucky that my mother was in the room ran out grabbed somebody and resuscitated him so I had an interest in cardiology beginning uh you know I'm sure because of my father's event with it but there is a so the

family histories are really important so everyone needs to know their family history because there's likely things you may have inherited with that and another the important thing is if you look at the the families it's actually the people who died at the youngest Ages were women not with men my aunt my father survived but his sister did not the first day she had symptoms was the last day she was alive the first day she had symptoms was the last day that she was alive right she lived in a on a ranch in Arizona and was

always taking care of her husband and then she had symptoms and you know did not get into care soon enough and unfortunately my older brother who was incredibly bright but really kind of focused more on alternative approaches to Medicine uh the first day he had symptoms was the last day he was alive Ah that's really significant and I I also really like that you said um alternative practices because oftentimes listen there are certain things that can be treated with alternative means and then there are very particular metabolic challenges that cannot and should not correct so

this is where genetics plays a big role we we can talk more about that but it is something also where knowing what the symptoms are and then you know if you have a bad family history uh if you have symptoms it's better to get it checked out immediately so if you're chest pressure T chest in a shortness of breath just don't feel right and you know you have a family history uh it's easy to go into some of the local ERS they get a quick EKG blood test and they'll rapidly send you home if there's

nothing wrong uh if there's something wrong then sometimes sometimes you go straight to the cath lab but I do think that knowledge is power that's why you're doing this podcast that's right uh uh for it and it's important that people understand it's it's women and men both uh my mother's she her mother died when she was young how old she was probably about eight or nine years old and so and her mother had a stroke hypertension treatment wasn't people didn't treat it well back then uh they were Greek immigrants and uh she probably hadn't seen

a doctor or something I don't know quite why she had the stroke at such a young age but it is you're just because sometimes women think they're protected but actually more women die from cardiovascular disease and from cancer more women die from cardiovascular disease what do we know some of those numbers how many women are dying from cardiovascular disease versus cancer the number one cause of death uh for for women now what happens is women tend to be older so people say well I don't have to worry about when I'm young but unfortunately there's and

this is when we bring up this cardom metabolic concept there's been a change and some of the risk factors for cardiovascular disease so you know when when I when I first started you typically saw someone who they maybe were a heavy smoker very high cholesterol and frequently thin uh and now what we're seeing is unfortunately younger people with the epidemic of obesity they get insulin resistance at a young age many get diabetes at a young age teenagers 20 years old so by the time they're 40 they've had diabetes for 20 years and now you're seeing

young men and women coming in the hospital in their 40s having heart attacks who were not smokers uh didn't necessarily have a terribly high cholesterol so it's so this is one of the reason we talked about cardi metabolic because it turns out that obesity diabetes triggers inflammation other different processes that can also lead to the same events heart attacks and strokes as very high cholesterol or cigarette smoke you know it's really fascinating it's also you know you mentioned um and I have a question that no one I think has been able to answer except I

think you're going to be able to answer this question and it's a very simple question the numbers for cardiovascular disease deaths when someone goes into the hospital and let say they die of natural causes and their heart stops what goes on the death certificate does that get counted towards um does that get counted as a cardiovascular event not necessarily so I think this is one of the things that uh and this is a more nuanced question but when we look at clinical trials so there's lots of studies that are done looking at how can you

reduce heart attacks and strokes and cardiovascular death it's important to look at cardiovascular death but also total mortality because a lot of times we don't know exactly how someone dies I used to work in emergency rooms and when somebody brought somebody in and they were dead and I had to sign the birth certificate I didn't spend a lot of time thinking about that I mean they were already dead so you know what did they have cancer okay I put cancer so maybe they had a heart attack but once someone's dead there's not a lot of

medical investigation that goes on so we don't frequently know unless they died in the hospital and even then sometimes in the hospital we don't know so do think it's your you know your question as to do we know exactly why people die on these when we see these statistics we know more or less but there's going to be some gray areas and the reason I ask is because I I always you know I'm trying to think is cardiovascular we know that there's cardiovascular disease and then there'll be you know the CDC will publish um a

ranking of causes of death and I always think to myself okay well people seem to live with cardiovascular disease for long periods of time and are those numbers accurate is it truly the leading cause of death or is it how it's being reported and it's just out of curiosity yeah so I think it's it's it's in between cardiovascular and cancer what happens is now that we've gotten better with cancer now there people are in living longer they're dying cardiovascular disease so those two are your major two threats one thing about cardiovascular disease is that in

addition to death there's a whole quality of life issue isue and there is with cancer too but you know if someone has heart failure uh if someone's had a stroke if you've had uh have angena you can't do your activities quality of life is very impaired and so that's an important issue we want to live longer but we want to have robust lives and the other one that comes up is you know one of the hats I wear is we're the cor of oratory for the aosc crosis risk and Community study so this was a

study of middle-aged people when it started but it started in 1987 so how long have you been in practice how long have you been practice I've been in practice uh I I joined uh The Faculty I took over the Eric lab in 1997 and I joined the faculty uh at 1988 1988 and to be fair um you're a cardiologist but you also have a lab in um is it translational genetics so we we have a this study the the Eric study was a 16,000 people and they've been follow but now of course they're quite old

and it's turned into a study that's looking at neurocognitive changes and one of the things that there's a and appropriately so people are very concerned about Alzheimer's disease because Alzheimer's hits earlier in life in your 50s and 60s but as you're getting into the 70s and 80s what we're seeing is a lot of the dementia cognitive decline looks to be more of a vascular it maybe sometimes mixed with Alzheimer's but there is a very important aspect is that the biggest predictor of Dementia in middle age diabetes second hypertension third high cholesterol so and those are

all cardiovascular risk factors so I think this is one of the things that comes up is a cardiovascular health is important in terms of both the quantity of life and the quality of life including mental function and including you know other I mean if you just imagine your sexual function that's also vascular Health uh people talk about impotence you know for men and we're talking about really dealing with blood flow in the theal function and the drugs that work there have that effect so it it's it's a big aspect of really you know both quality

and quantity of life if you were to think about what your legacy is to be and what information you want to really impart upon people what is so important and critical for cardiovascular and or I don't know should we say cardi metabolic health because that seems to be with 70% of adults are either overweight or obese what would you tell them what would be the top three things that they should know about cardiovascular well so I I think the thing is most people will die of either cardiovascular disease or cancer we have the knowledge to

prevent 75 80% of the cardiovascular deaths and to reduce pain and suffering and quality of life there you know with cancer it's a little more challenging yes we know smoking sensation but a lot of the cancers now we're seeing for example why are younger people having more colon cancer I mean there's it's something in it the food or the diet we don't understand a lot of what causes cancer is what's some of it's harder to prevent uh with it now certainly Factor would be obesity so obesity is important you know and I'll tell you so

for example in addition to the cardiovas disase in my family uh I had lymphoma when I was in my 40s and so one of the things that came up after that was when talking and no one knows why you get lymphoma uh uh you know could be pesticides there environmental things but talking to my oncologist he said uh ask him what can I do for you know uh stopping a recurrence he said well it looks like the people who do the best are the people who exercise that's probably something that you like to hear about

but no we don't we don't we're not interested in exercise on this podcast but but after you know after okay let's see it's and I forgot on my mother's side it's all diabetes my father ended up getting diabetes later so I've got diabetes I already had coronary Cal when I was 39 years old and then I have cancer said you know and I'd always exercised some but I'm like okay if it's going to make a difference I need to get really serious about this uh and so I do think it's the lifestyle is a huge

part of cardiovascular disease and it's an even bigger part of healthy aging so I do think you know I know you're focused on nutrition and exercise that is our fundamental behavioral changes that we all need to work on it we fortunately we've got fantastic medications and this is where the genetics is really important because if you've got bad jeans and many many many of us do have bad jeans there's something you can do about it now and people understand like in sports and I always use the I think you're new to Houston but Jose Altuve

have you heard of him no am I should I so yeah so Jose Altuve is a baseball player okay and when he he when he he plays for the Astros and when he was first tried out for the major leagues in Venezuela they sent him home they said look you're too short you'll never play baseball and just forget about it height is genetic and when people understand at like a height they say okay he came back the next day they because the Scout said you got to watch him play so if you have bad jeans

it's like height or something in sports what do you do try harder play smarter so it's the same thing in life if you've got bad jeans you got to play smarter so diet and exercise are important for everybody but not for every I mean for everybody but it might not move the needle for those that have but it's still if you don't do it it's even worse so if you have a gene for familial hypol emia even with a great diet you won't normalize it but if you have a terrible diet and then you get

obese and get diabetes you're in a really bad so the issue is if but the play smarter is do the lifestyle and then find out more do you need a medication do you need your what about your blood pressure uh so these are the things you know you if you get so I think the most important message is is it's a preventable and treatable disorder and if you've had a heart attack you can there are things you can do to not have another one and when we think about lifestyle let's talk about exercise what are

some of the key components to exercise so this is one thing uh I think you if you look at the residents who rotating or working with me they always have a little note they say we'd like you to exercise and they always put in it I want you to walk 30 minutes five times a week when that's wonderful that's a great start but I mean that's not exercise I mean that's that's that's moving a little bit because the funny thing is they then they say and you should get 10,000 steps and so they always ask

me said do you know how long it takes to get 10,000 steps can you get 10,000 steps in 30 minutes and of course you can't I unless you're running at a you know you have to really be running fast to get 10,000 steps in 30 minutes so you know exercise to me ends up being is it you know I I try to get an hour day of exercise you a and 10,000 steps cuz sometimes if I'm doing resistance work it may not be as many steps but then I I'll walk more uh steps are great

for vascular health I mean you know getting your heart rate up sustaining it that's very good but I think you you also need in particular as you get older uh you know it's uh like if your car gets old it takes more you know get a lot of more maintenance you know so I and I think so the data on healthy aging and cognition I think exercise is doing even more than just the vascular I think it's doing some other things in terms of brain function that are really important for maintaining optimal uh you know

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is enough how do we begin to think about taking care of skeletal muscle health so I think this is really a critical issue particularly so it's a funny thing you know when uh seeing younger patients versus older patients some of the older patients are like well I walk and I and that's great younger people tend to go to the gym more but it's even more important as you're getting older so when you hit menopause when people are getting into their 60s and 70s 80s the issue that comes up is now we're worried about basically quality

of life healthy aging and things like insulin resistance diabetes you know we get into things why why do we have these issues what we know muscles critical in terms of glucose update but also mitochondrial function and you know one of the things that comes up is and you know balance people fall well walking is good but you know you can do core exercise there's balance exercises you can do a lot of things where you're actually using coordination strength there's an issue of free weights versus machines there's using bands there's I working on a little trampoline

thing where you're having to balance at the same time you're doing weight so using think about all the things your brain is having to do when you're exercising uh but I do think is that walking is it's great it's a strange thing sometimes where a lot of Physicians are like well we can't expect patients to do more than that uh that's a I think that's a the wrong message it's it's completely the wrong message and I think we need to lead by example but the other thing is if you really want Optimal Health we put

people on five or six drugs that's a lot of medications to take uh with it and if if they were really exercising and eating a better diet we can reduce the amount of drugs so I think we want to give people guidance as what is optimal and encourage them to do whatever they can but there's no sense acting like optimalist walking 30 minutes five times a week it is not optimal we don't use you know 5 Mig of Lo lost Statin which was the first step anymore I mean people used to but we' say well

that's not that's not that effective so why are we recommending something that we know is it's beneficial but it's not really optimal it's not the most effective way to to to prevent things or treat things and what role do you think resistance training has whether it's machines or free weights essential I think you I mean there's what you you know the issue that comes up is as you age you lose muscle mass uh so you either going to are going to lose your strength you know this really is just a use it or lose it

uh uh thing so this is why it takes it may may take a little more time as you get older because you may have to warm up more and then build up and do a lot more reps instead of doing real heavy weights depend depending upon if you want to avoid injuries but it's still highly beneficial in fact the benefits are probably even greater as you get older they're they're there all along but I think it's even more necessary you know um you also mentioned diet and I think that especially in the lipid space This

is highly I don't I don't know if it's highly controversial or contentious but in the nutrition space people will say um well don't eat saturated fat because saturated fat is going to somehow translate to blood saturated fat or um don't eat cholesterol because that's going to increase uh your blood level cholesterol but the conversation really in my opinion should be around total caloric intake in carbohydrates so agree with you completely that to Total poric intake is the real issue and where is most of that coming from it's coming from carbohydrates I mean people tend to

uh uh eat I mean if you take a look at now you some of it's fat but it's like potato chips that what people do is there was a nice reading I was at they were talking about highly processed foods where you can in nature you're not going to find lots of carbs with lots of fat and salt all one thing like a potato chip but you know food scientists studied what foods people like to eat and in fact which ones would they keep selecting over and over again so it's almost like uh you know

drug addiction that developing highly processed foods which have very high caloric density uh and which stimulate the brain and and you know and you feel good so temporarily you don't feel you feel bad afterwards but it's there is this issue of uh people eating because they're most of the eating we see you know I in clinic I we always get you know weight lipids blood pressure somebody comes in their numbers are off their weight is up what's going on well there's you know stress there's job there's family someone's ill and people turn to food and

they turn to the wrong foods and then they usually quit exercising and if you do just the opposite if you increase exercising you'll handle stress far better uh and maybe make better selections on your food but I think you know Foundation therapy is is nutrition lifestyle and things like smoking drinking your calories particularly alcohol sweetened beverages your brain doesn't even sense you know stomach doesn't get full so you don't you people can taking a huge number of calories with sweetened Beverages and have you um and yes absolutely and I think that that's one of the

reasons why we're seeing such an increase in obesity people are drinking their calories have you thought much about the recommendation um or any of the dietary guidelines from a cardiovascular standpoint so they chose this number of 10% or less your calories could should come from saturated fat not exactly sure the evidence behind that because it doesn't seem to be solid and then of course cholesterol always in the guidelines which they ended up taking out I believe in 2000 or or 2010 or 2015 do you get asked a lot about um the dietary impact on so

so I see a number of patients now it's interesting so responses to for example someone goes a keto diet uh some people have a beautiful response everything gets better they they lose weight their glucose goes down blood pressure goes down some people have what I call almost a paradoxical response where their cholesterol goes way up and their LDL goes way up now and so this is this you know lean hyper responder uh uh issue so that concerns me uh when I see that and but it's it's it's challenging because some of the people are very

young and very fit and and I don't know exactly how much and it's not easy to assess that because when people are young the Imaging modalities are not as good they're not as useful in terms of that would that be C would that be uh clearly scan or hard and soft plaque scan yeah so you can end up doing CT Ang geography and then there's some approaches towards looking at soft plaque and things like that there's a couple of different companies focusing in this area and more people are getting that and it's reassuring and I

the other one I like for women is still we do credit ultrasounds and there's a lot of criticism but if you have a good this is not one for vascular surgery this is a screening test to look at thickening and specifically for plaque so they got to scan the bulb and if you do that test there's no radiation so in terms of women comparing doing a chest CT where there's some radiation a lot of my younger patients I'll get a baseline see where we stand uh in terms of making decisions say do we need a

stat or not there's always the issue in terms of younger people when do you start uh and some sometimes it's if it's clearly genetic like uh familial hypocholesterolemia with an LDL of 230 or 240 in a family history we don't have to worry we don't need any Imaging tests we can start you would start them on a Statin um as opposed to say a zamite so and that's the other one that comes up is there's not enough utilization of combination therapy so it's interesting in blood pressure I mean this will really show you how did

when I I I was a resident at UT Southwestern and they taught say you start with one drug you dose it up to the top dose and only then do you start the second drug so can you imagine a diuretic like hydrocor thide so we did 25 then 50 then 50 twice a day oh my gosh I mean and so everybody that just kill quality of life too so everybody had you know they had all kinds of you hypokalemia and metabolic alkal discus so it it it was like okay this people real that pretty quickly

and then it's like B blockers to huge doses clonidine I mean terrible drugs at terrible dosages and then they said wait a second why don't we just go to combination therapy we use a low dose of Two drugs you get control faster with fewer side effects so I think there has been this is the case with the zomi you mentioned you can use a zomi with a low dose of Statin and and get the same as the highest dose of the stattin without the muscle problems without the insulin resistance stands are fantastic drugs but when

you go to the top dose the top dose is there for a reason it's because the dose above that led to unacceptable side effects ruist Statin we did the trials there we were studying 80 milligrams but at 80 milligrams we had some cases of rabdom myolysis and then they noticed it that it was nonlinear pharmacokinetic so that some people suddenly shot with very high levels and it turns out east Asians were problematic so they reduced the dose to the top dose is 40 milligrams so and in general you might say well if if the top

dose is there for a reason you're probably safest at the dose below that there's a logic to that which is pretty reasonable so why do we go all the way to the top dose before we add a zom I don't think it makes any sense I you can add in and if someone's afraid of side effects from estaten add it to a low dose and and that Bloss cholesterol absorption also yes and you know I don't want to I don't want to let you off the hook on the nutritional science part the um the saturated

fat and cholesterol because I'm sure people are asking and you know on social media you'll hear people say LDL cholesterol doesn't matter right uh it can be as high as you want it to it it doesn't matter um I'm curious as to what your thoughts are that and I recognize that we're going to cover LDL cholesterol apob LP little a it's not simply just one one marker but so so that and that's one of the things that comes up is LDL cholesterol LDL cholesterol does matter but so do all the other things so if someone

you know ends up having low blood pressure excellent body composition they exercise on a regular basis which is also giving vascular Health they don't smoke uh they don't Vape they don't do cocaine they don't do some things that are adverse vasoactive no family history everyone lives to be 100 years old you know I don't know I mean I'm not I is it ideal no but is it harmful for this person there's sometimes and we see older people who have high cholesterols they're 7 years old they got zero calcium and they're having someone said they you

know they're on a stat and they're having they're having side effects well you know is maybe you don't need a stattin so frequently we end up trying to help people understand do you really have to be aggressive or sometimes you can say look your health is good everything else is perfect you have this one factor and i' like to lower it a little bit but if it's causing problems with your lifestyle it's not worth it's not worth it the risk benefit's not there what would your cutof off number be for something where you're thinking okay

if we were to just take a hypothetical patient um is it fair to take a lean mass hyperr or should we just take uh an individual who comes in with um you know LDL cholesterol of 250 so every patient I try to look at the total picture so we always look at all the traditional things what's the age sex makes a difference in terms of and and for women also you know in women you need to also take a look at things we call them risk enhancing factors if someone was pregnant did you have hypertension

during pregnancy did you get impaired fasting glucose did you get diabetes if you had preac ampsa we know that you're increased cardiovascular risk U if someone has polycystic ovary syndrome increased cardiovascular risk that's interesting is that from is that just related to insulin resistance it related to insulin resistance yeah so yeah there are some things that you can also be getting that and then then things you're measuring lipoprotein a hscrp for inflammation you might look at that if they're at appropriate age I get a coronary calcium score sometimes I can an ultrasound uh and then

if there's a bad family history we're also we started doing genetic testing uh uh for people looking at beyond the traditional change sometimes and would that be uh a GBS Insight something like that we happen to be using them because we're doing projects with them to try to get better understanding of uh their polygenic rist ores and also you laugh is that because there's another no no there there's many many different I'm just laughing because we haveen you know we're doing some research with them uh with it so we've been using GB Insight a lot

uh for it I think it's particularly the area of high triglycerides they they have an interesting panel um and when you are thinking about RIS stratification so there's not an absolute so it's not just one number what you're saying so it's very myopic to say LDL cholesterol at this number is um unacceptable is that fair to say or would you say listen this is 300 this is a risk for pancreatitis if if well if a l deal is 300 I'm worried No Matter What so is there are there numbers I think when we get into

190 we start think genetic okay uh for it uh for some people though 130 could be high so it depends upon the individual you know it's a continuous variable in medicine we like to have make things dichotomous we want to have a cut Point yes we do I would like the algorithm please but the unfortunately life is not like that you know I mean it's basically so it ends up is you need to put that variable in with a bunch of other variables and when I tell like lipoprotein a is important and can you explain

so before we we move on cuz I I we have to talk about LP littlea um I will say we've been measuring that in clinic since we started um and uh I'm glad to hear that that's very valuable the um LDL cholesterol there is a certain number where you so above 190 the I think the next question is at what percentage will that if it's dietary related could you modify that by 20% do we know is there a certain percentage that we can move the needle you know so you can for some people are diet

and lifestyle sensitive and I've had some people have drastic changes and you can go to extreme diets I would say Dean ornish so Dean ornish went to bayor medic bayor College of Medicine and you know he goes in with if you go with a vegetarian diet with extremely low fat basically low cholesterol now he also had meditation exercise weight LW they lost weight in his program so there were a lot of things going on in that program I'm also curious as to the per the quality of the weight loss how they were able to maintain

their skeletal muscle mass so I don't know they didn't do that they didn't lose that much weight but it was they were doing yoga it was part of the program actually will which is beneficial yeah so that was also part of one of the one of the things that was with with the program and he showed some benefits but it's it's it in general those types of diets are hard to maintain I think we have lots of information that the med tranan diet which includes more fat but a lot of it's monounsaturated things like olive

oil but I mean you we talk about healthy fats omega-3 fatty acids so it's not necessarily the fat it has also to do with the quality of the foods that have the fat so I do think that someone's eating a lot of high saturated fat trans fats are clearly bad do they still allow those in the diet they're not supposed to be yeah I think that they're not even yeah they're not supposed to be allowed but you know the issue that comes up is that and it would be something also like if you take something

like uh ghee which is a you know particularly the way it's done where they just keep uh Heating and heating and heating it so you're probably doing a lot of modification and having you know if you have oxy steroids if you you can probably make foods more unhealthy sometimes than if you're eating something that's more in a you know like in a natural state of so so would you say that maybe so some people can have big drops but in general it's hard to modify your level of LDL so usually if someone can you say

that again so in general it's pretty hard to modify your level of LDL cholesterol regardless of by diet by diet by diet so triglycerides is a completely different story okay triglycerides you can modify tremendously but LDL you might some people might get a 20% reduction that would be considered great that would be considered amazing and it doesn't always happen and it's more likely going to be 5 or 10% is what you see and and there are things that we used to use for you know increasing soluble fiber there were things that you can do drugs

like a difference 5 to 10% you can get in that 5 to 10% now there was a there was a Canadian who looked at the combination of diet and adding some of the uh some of these other things we talked about uh uh and he could show that if people really worked at it they got around 25% uh that was using some basically nutritional things that to to to complement your changes in diet and the would you say that the alal cholesterol is typically at a genetic set point and the body if you the body

will make a certain amount of cholesterol so much more so than triglycerides in terms of it's it's much harder to modify by you it doesn't mean it's not worth the effort uh cuz I do think it is worth worth having a healthier diet but triglycerides we can see dramatic changes I mean someone can go from you know 5,000 down to 200 uh uh with changes in lifestyle and that can happen within 10 days it can happen in a week where do you like to see triglycerides ideally so we talk about less than 150 being Desir

nor it's normal but desirable optimal be less than 100 absolutely agree with you and when you are looking at your patients is there when you count do you guys Counsel on diet do you talk about diet so we do uh we my clinic used to be run by a dietitian but she just retired uh unfortunately you know like a a year and a half ago but it was nice cuz we would she would do the the same time U uh for that and it turns out also she was really good at getting more information soon

as people don't tell The Physician everything U and then when they get out and someone ask questions that that all of a sudden they'll say I didn't really understand what he was saying can you help me um the triglyceride numbers we see I worked on some of this um some of the early studies with uh Dr Donna Layman out of the University of Illinois and when we reduced um total carbohydrates to 130 or less we would see a drop and we it would it would completely so 130 Gams of carbs or less would completely normalize

their Trail list rides yeah so what ends up happening is it's it's a when everybody comes in with high triglycerides I give a like a quick because I ask them okay what are triglycerides so people have heard of cholesterol and they've heard of the bad cholesterol LDL cholesterol the good cholesterol HDL cholesterol which really isn't good cholesterol right it's not well it it ends up being we call it not harmful I would say not harmful choler and unfortunately the better number would have been the non-hdl cholesterol because that's it turns out your LDL cholesterol is

usually calculated what's measured is total cholesterol triglycerides and HDL cholesterol and they use they derive the Rest by calculation called the freed toal equation which has been wasn't that good if you had a high triglyceride or low cholesterol so that's been replaced by other numbers now at least by some of the labs with it but basically you can do something simple if you subtract the HT cholesterol from the total cholesterol everything else is bad and and unfortunately it's non-hdl cholesterol does not sound very threatening I mean what how can a non HDL cholesterol that's really

the number that should be looked at oh really in terms of negative outcomes well in terms of atherogenic cholesterol in terms of arenic it should have been called atherogenic cholesterol or something like that the non HDL the non-hdl cholesterol which has an extremely high correlation with apob 100 okay so let's break this down because we have clinicians and we have people so so when you get your lipid panel it'll show total cholesterol triglycerides LDL cholesterol and HDL cholesterol if the LDL cholesterol is high that's bad but as you point out if the triglycerides are high

that's also bad and many times people get false reassurance they may see their triglyceride is 250 they say oh GE my LDL is only 100 but if their H HDL is 35 and then see what the if you were to look usually that means if you subtract the total HD from the total cholesterol they have a high level of non-hdl cholesterol now what's happening in your blood is that cholesterol and triglycerides are not soluble in Aqua Solution you put fat with water it floats so they're being packaged in these particles and the LDL particles are

particularly bad but those particles carrying triglycerides uh they're called vldl and vld Remnants IDL they also contain cholesterol and they're also harmful so when you see a high triglyceride you should be looking at all of the bad cholesterol the arthrogenic cholesterol uh and that's one reason why yes apob is better than LDL cholesterol but so is non-hdl cholesterol non-hdl cholesterol um when you think about non-hdl cholesterol that what you're saying is that that is atherogenic and what that means is that um causes plaque deposit how what when someone hears atherogenic and why it would be

bad what that so that's think thinking of that that the that's the cholesterol that can be built up in the plaque and the Archer wall and we know that in the if you look in the atheroma so when we talk about atherosclerosis that means there's atheroma aoma has macrofagos and they have cholesterol crystals and where is that the aoma is that it's in the arterial wall in the arterial wall so and that's from data from going back uh from a nitchoff who was looking at foamy macras so we call them foam cells so you now

another approach is to measure aob B 100 because there's an one apob molecule in each LDL particle and in those trious R particles there's no apob in HDL uh so you can me there's no apob in HDL right and then what about non HDL so all the particles in non HDL have an apob so an apob has a very high correlation n HDL cholesterol so if someone's using that non-hdl cholesterol there's less discordance with apop and I know there's a lot of focus on you have to measure apop you're not necessarily in everybody I mean

that turns out a lot of people you don't need to measure apob uh uh with it why is that so let's break down because I will tell you apob is the most popular that's all we hear about so it's been popularized by some people I've done a lot of research in this area and it's if you take a look like in UK biobank this huge study the correlation between apob and non-hdl cholesterol was 0.95 so 0.9 95 coration well 1.0 is perfect that means they're the same and if if I if if our lab runs

assets from two different companies measuring the same thing if we get a 0.95 correlation we're quite happy you're very excited yes yeah we think that's great so how much extra information do you get from an apob versus non HDL a little bit now from LDL you get substantially more and and the problem so apob B you know so why it's because of this triglyceride issue that you bring up why is apob important is that what you're saying apob gives us more information about uh what kind of particles are in those people with high triglycerides because

some people with high triglycerides have lots of small LDL particles so someone might say oh wait isn't there there's another test using NMR that looks at LDL particle concentration and so would this be this would be the Boston heart so Boston Hart does it but so does so does labore and you can get a a ldlp concentr creation T and they'll break it down into small LDL and they'll also give you like an LP insul resistance score sometimes with at least with lab core now that technology is actually newer than apop uh and the confusing

part is unfortunately the labs use different software and different magnets and so if you get it with lab core or Quest or Boston Hart they may not be using the same modalities to get the same numbers so it's hard unless you're if you get the you got to get the same Labs on the same patient uh uh and that's the that that I think that's a really good methodology unfortunately because of these comp competition and it's all proprietary software there's not a single platform that's apob is all standardized so there's an advantage of the standardization

now the thing that's you don't see from the lipid profile is lipoprotein a so and just to wrap up AP so apob apob 100 is a marker is how would you you explain it it's a it's related to your particle concentration of bad particles non-hdl cholesterol is related to the cholesterol concentration of the bad particles and the NMR gives you the actual animals per liter of those particles uh uh uh with it so it's another way of looking at it and it breaks it down into the small particles it gives you the different particles sizes

uh so you know NMR actually gives a lot of information uh for patient if you were to pick one marker let's say um you could pick LDL cholesterol you could pick non HDL cholesterol and I know I'm putting you on the spot apob LP little a uh out of any of the markers that you have access to and you obviously you told me that this is a multifactorial um disease is there one where you would say you know what I need to know what this person's number is so I still start with a lipid panel

and the reason for that is I like to see what the triglycerides are and I like to know the htl cholesterol because there still a risk marker so you it sounds like you care more about triglycerides initially then really well I care about LDL but I I also want to know about triglycerides and HDL every risk equation always uses HDL cholesterol and that's cuz it's a more powerful marker and what HDL cholesterol the reason it is is goes back many years ago some brothers patch Brothers Austrian at Bader they said listen you know it turns

out that it's just like you know hemoglobin A1c is a better predictor of cardiac events than fasting glucose and it's because during the day your glucose goes all over the place and hobin A1C is looking at the area and the curve of your glucose measurements looking at what's what's happened to this person's glucose over a six week period so their hypothesis was that HDL cholesterol is the hemoglobin A1c of lipids that it tells you that's interesting so it tells you what's happening with your post prandial lipia that's really interesting and um so that the HL

cholesterol is actually telling you what is happening post panial so it's telling you it's like it's integrating what's happening in the post period okay and now with all this recent data on triglycerides and tri leopard proteins it makes a lot of sense that it turns out if you measure Tri glycerides they bounce all over the place just like glucose I have a I have a question for you we typically do Labs that are fasting right um is there some Merit to doing for example you'll do a a glucose challenge test or a glucose tolerance test

is there some Merit to doing a a standardized um lipid challenge or carbohydrate challenge test where you're looking at triglycerides so you know we we've done these types of studies and you can see there's a marked variation in terms of the post perinal triglyceride Excursion uh we also looked at this in the Eric study and it looks like there wasn't that much more predictive value than so it wasn't really valuable didn't add that much you know it's it's a little bit like the fact is in terms of predicting cardiovascular risk the hemoglobin A1c is just

you know gives you about the same thing as a doing a glucose tolerance test now that might give you not exactly saying is when do they get diabetes but for cardiovascular risk hemoglobin A1c is easy to get and it gives you a lot of information so that's why if you take a look at it everyone gets a him they won't see now it used to be everyone got a two glucose solance test what a pain well it was because it's also cumbersome you know and and and doing doing the doing a 2hour it's the worst

the the postp lipemia test is 6 hours the post penal lipemia test okay yeah that's when we do the studies we go at least 4 hours out cuz the peak the peak is at 4 to six hours and how much did you dose them what was the so the do done trying to we had we did one with we so this is standardized test meal gross you have to drink that right well you can or else you can give test meals so we like we done it once with McDonald's you know uh uh for people

and we did something else in another trial uh with it to try to and and you can see even four days of that diet so and it turns out we were doing something we're going a high saturated fat but also having Fair number of carbs in there so that's quite different you know if you throw in a highs saturated fat with carbs you get a adverse response when it comes to health what works for someone else may not work for you because we are unique we have unique genetics habits and health goals that's why I'm

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my promo code Dr Lion at checkout that's pu ri.com lion you guys will love this brand what do you think would happen if you had isocaloric so you were within your calorie target range for weight maintenance of say saturated fat and protein do you think you would see so calories are controlled um carbohydrates are uh null we're removing them or keeping them within a particular range do you think that you would see abnormal an abnormal lipid profile if someone is calorie controlled with highs saturated fat diet and protein so I think there's going to be

variable responses and some people might have a a bump up many people most people will not so I think there is and I don't know what the genetics are CU some of these uh people because most people when they go keto they do not have a big spike in their cholesterol when when they they so I don't know why some people do and and the genetics of that you know I talking to Ernie schaer head up Boston Heart labs and trying to understand why does some people have such a dramatic response uh there's all there's

some mystery in this but most people do not and let's say they had a dramatic response wouldn't the body somehow regulate um four to six weeks later in terms of I have one patient it's just complete mystery like it doesn't regulate it just stays way up there and he's very healthy so I don't understand uh why that is so but I do think that for you know that's always there's going to always be a few people who are outside the norm but for the majority would you say 90% of the for most people you can

end up doing these things it the bigger culprit in our diet tends to be carbohydrates now and I think it's you know the food advertisers is when they said no cholesterol low cholesterol diet what they do on the PO potato chips no cholesterol well there was never cholesterol in a potato chip so then they said uh low fat and they sold snack Wells right full of sugar uh simple sugars too so people have used you know the low cholesterol lowfat advertising to sell unhealthy foods which were very high in carbs and that spikes your glucose

and in fact what we've seen as you point out is if you have this now if someone's trious rides are 2,000 you got to cut the fat out yeah but you if you see someone running into 250300 it's usually they're carbohydrates 250 300 yeah I mean that's and that's pretty bad but you know that's not a normal triglyceride but that's usually going to be the carbohydrates driving that they're overproducing and they have insulin resistance how fast would you see a course correction within two weeks I mean we we saw it within two weeks I don't

know if you you see in two weeks you can see big changes very rapidly and for someone who's really high triglyceride in the thousands you can see it two days two through through a few days if they just you know change what they're eating and start exercising so um going back to your hierarchy of what is most important for how you start to R stratify PTI so we get the lipid profile and then all the other risk factors and then the first extra test I like to get is a lipoprotein a over apob over apob

lipoprotein a I can have I have a pretty good idea of looking at those numbers what's going on now some cases I'll get either I can get an NMR profile or an A because I'm worried about discordance uh with it particularly when the triglycerides are up a little bit so if the if the triglycerides are 50 you don't really not worried about it I'm not worried about it uh if they're higher then I worry about it more but I worry more about A lipoprotein a because if the lipoprotein a is normal great if they've got

a li protein a of 3150 nimals per liter and a family is string oh boy you you know you inherited this so you know we we I got a whole different perspective on that patient if there's an apob it's a few points higher uh where do you like to see apob well I mean you know your optimal apob it's like where's the optimal LDL we used to say under 100 and then we said under 70 now we're saying under 55 depends upon the individual could it ever go too low would you have issues with I

think there's probably some genetic disorders where they they don't make enough cholesterol and then they're not absorbing these these uh fat soluble V so so there are there are you can have a mutation in apop or MTP and you don't uh you have super low levels now some of the people get fat malabsorption and they get fatty liver uh but it's I don't think the low level of L is the problem the problem is the fatty liver uh in that case because you're basically you're not secreting the particles uh they get you just builds up

in your liver at least in the trials when we use pcsk9 the the ldls were going down to on average 30 milligrams Peres really low and they didn't they didn't see any side effects from that and there was also a big cognitive study and one of them no no no problems with cognition so you would say that the guidelines you would follow um what typically they're recommending apob less than I don't know 89 something like that oh 89 high so that that so that that so we there's another one that came up from the national

limit Association so we which by the way you're the president of yeah so things like 60 is a you know the number they had in there I mean I think they had something ridiculous in the uh ACC guid lines it was like I was a was like 120 or something they say was a risk enhancing Factor 120 is out the roof uh so for a risk- enhancing Factor you'd have to go lower than that uh what where is your in an Ideal World of a healthy person where do you want to see their apob well

I mean I think you'd like to be you know ideally ideal with anything you like to have your LDL probably in the 60s egg be I think my LDL are in the 60s what's that I don't think my LDL but you're yeah you don't you probably don't need it you probably everything else is you know where it's supposed to be and that's the whole thing is it's all depending upon it's complicated if you don't you don't need to use a bunch of drugs in someone who has no atherosclerosis if you have more problems you've got

to figure out where's it coming from and then try to treat that so if there is a lipid problem we know it can benefit that person but but a non- lipid problem an apob of 70 you'd love that that'd be fine 80 probably fine also I mean it just depends upon the individual okay um tell me about LP L A what is it why are we testing it um most people don't tell tell me all about it and this is actually where you've done a lot of your work um both basic science translational science and

um clinical so so lipoprotein a you know we're talking about these particles and we have carrying cholesterol it is another one and it's distinct from LDL and vldl it's it does have an apob molecule but hooked to the APO B molecule is something called APO a I don't know how they call these numbers because it's AP could done like a better job me APO little a because if if somebody orders APO capital A that's something different that's APO A1 that's an HDL so there's this specific particle so it's an it's an interesting because it it

has this shape of a a cringle which it's like a Danish the Danish de I don't know what those are we don't need those in our house so it's so and they and it's this molecule that's attached it's mostly genetic much more so than the other factors that we talked about so many people have an extremely low level and that level will always be very low when you say low so yeah that that'll be seven milligrams or you know 25 nanomoles or something like that so it's really low they they measured two different units other

people have extremely high levels and can you can you give us some numbers so so so we have a recent statement uh uh update to the National limp Association scientific statement but basically if you're looking at milligrams less than 30 milligrams is desirable over 50 is high okay okay now that's a there's notice there's something in between there and that's what we're talking about there's not a single cut point so your lab slip would say elevated if someone has a 40 milligram per Deiter so it's important that Physicians and patients know when they everyone's on

the same page the lab company is telling you that's elevated it is elevated it's not desirable but it's not in what we'd call the really high risk Zone okay uh the numbers for nanomoles are 75 less than that is desirable over 125 is high so that's for nanomoles and then you have this kind of Gray Zone in there intermediate risk now intermediate risk we say it should be measured at least once in a lifetime so if you're low like if you're at Prett low level you're going to stay low even if you go through menopause

and some of these other so now that's where we have this intermediate risk group because it turns out that uh you can change and if someone goes through menopause and they were running let's say they were 100 animals they may end up being 150 I mean some people have big changes that's a really large change if someone is normal let's say they're desirable LP little a of 35 in general in general if they have an LPA that's very low you know 35 uh uh 30 now 30 is milligrams you have 35 nimals which one you

talking about you pick okay if it's 35 nanal 35 nanal you're going to probably stay low I have a question when you are looking at these Labs it's not have to go back and think about it are they reporting it in various so it it's depends on the lab sometimes it's so this gets confusing the patient so if you may say oh my look I used to be so you know I say oh I I was you know 40 milligrams and now all of a sudden I'm 100 animals and you're like okay those are two

different unit so it's that's the same number and you recommend going and utilizing the same lab with the same person yeah so it's easier to understand and we prefer to get nanal now okay nanal so what is the lp little a ideal range for animals so that that would be less than 75 okay less than 75 and over 125 is high now it turns out in trouble it is no longer the silent killer we are so you're worried about it so so it turns out if you were a woman you might jump up from 100

to 150 so we looked at this in the in the the Eric study and we saw that first of all women tend to have higher levels of LPA than men so it's it's I don't know women are different than men smarter better I don't know I'm I'm kidding but so it it there's but it ends up is that they tended to increase more the other one that comes up is if you're black you have higher levels substantially higher levels and then are RIS the same so is so for the for depending on the level so

the risk does go up if you have a higher level and then the other no matter what even if genetically a subset of people have higher levels of alp okay and then the other one that comes up renal disease particularly if you're spill in protein and we know that's very important with diabetes but then that the RIS the levels of LPA go up H um and then so L what is the function of LP littlea in the body that's a good question we don't know what's do the healthy function we don't know but we know

it's it ends up increasing the risk for coronary arosc crosis aortic valve stenosis calcific or bosis is increased and there's also some increase in Peripheral arterial disease and even some increasing heart failure so it's it's adverse for cardiovascular do you think you know it's interesting when I when I hear stuff like that I always think okay well do you think that it plays a role in the body doing something else outside of cardiovascular disease is there do you you know is so so this is one of the things is it's got to have some kind

of function right right so I I don't know I you know it's one of the things that most animals don't have LPA and the people with extremely low levels seem to do just fine animals don't have LP little a No it's it's just it's just it's all evolutionarily no it's it's only in primates and humans and then the Hedgehog has a different uh genetic architecture Matt my producer I knew you related I knew it um that's fascinating so we don't just to be clear we don't know of any positive influence LPA would have or any

relevance except for something that's damaging um do we know how it works in the body so it affects the so it's thought to be basically something that it carries oxidized phospholipids it's felt to be pro-inflammatory progenic and to have an effect in regards to increasing calcium deposition and uh fibrosis in the ortic valve would you expect someone for example a woman who is has an LP little a of um nanomoles so let's say it's 200 which is to be high okay so 200 would you expect her in her postmenopausal uh phase of life to have

a higher calcium score I would be worried and I want to check it so what we so this is the same thing you know we mentioned one risk factor like an LDL not everybody with LDL gets in trouble uh some people smoke they never get problems so it's it's but it increases your risk so we would like to then do risk ratification what's your blood pressure what have calculators you guys have calculators that you use yeah you can there's a calculator online the uh European arthrosis Society published uh their update and if you look online

in that manuscript there's a calculator you can find where you can basically plug in the LPA value with the other variables and it it change shows the change in Risk you can also if you want to do it in a simple way think of it as a risk enhancer so if someone's LPA was 200 then you might say okay if I used a risk calculator by the AHA and it was 12 at 50% so it's 18 you know how uh You' mentioned I mean I think it's very fascinating that an individual should get their LP

little a tested uh one time right but I think at least at least okay at least once uh number one is there an age in which we should start so for example I have a three and 5-year-old I they have not had their LP little uh taken we um I on my side have no cardiovascular history we don't know my husband's side would you say by the time they're 15 we should see what yeah I think you can get that so in general the the levels don't hit steady state until like after puberty but you

mentioned once again I don't know we know there sex hormones make some difference in terms of the levels with it and we know that same thing with cholesterol and other lip and Li proteins they they they vary somewhat you can look at the trajectory so an LPA level but you know you don't know what the final level is going to be but you can see by age adjusted Norms if they're different but we don't usually recommend it until uh unless there's a very strong family history we'll check that but that's a reasonable age to check

yeah um you mentioned sex hormones change it and women so actually if we did see that HRT replacement lowered LPA HRT meaning just testosterone or HR for women yeah for women getting estrogen so that was done in some older studies where they were testing you know back in the day and where they were testing estrogen and progestin to see if it would reduce heart disease but it did reduce LPA that would make me think that um potentially it would reduce heart disease so you know unfortunately Women's Health Initiative uh study failed but and so everyone

says well I mean you're being very kind about it it's failed miserably so it well it it failed but you know then I I was at a remember that conference and an endocrinolog saying he says now let's take a look at the endocrine system you know think of the way how thyroid how complicated it is and think of the estr cycle and can you imagine any medical treatment where that has to do with the ingrin system first of all look at the choice of hormone so where would where did the estrogen come from you mean

like the they use oh from urine horse urine yeah so think about so you get you get everybody the same dose of estrogen from horse urine what a bad choice and and then you add the same dose of progestin irregardless of their metabolism uh and remember that the ovaries don't secrete into the portal circul I mean they go the systemic circulation not the portal circul so you take this medicine it go straight to your liver right and because that increased you know thrombosis and maybe you gave it the wrong medicine the wrong way I mean

I mean you only tested one thing and and and so and I thought wait a second yeah you know most things that we give we don't give you know NE protect like hormones you don't give everybody the same you no sense makes no sense right it's not very physiological it just it makes no it it makes absolutely no sense so so I don't know that for sure we can say that if you did hormone replacement in a a different manner at the present time could you see different results particularly if you started earlier uh because

even in women's health ini looks like the women who were younger didn't seem to have as much you know harm from it as as when you gave that to older women who had been menopausa for a number of years so I don't know I think there's a lot of questions out uh and it's it's the same thing you know we look at you know sex hormones are very complicated uh with it it's the same the testing even for men's you know recently showed that giving testosterone if someone had a low testosterone was not harmful uh

you mean in the Traverse trial yeah were you involved in that no a that would have been amazing um from a cardiov you know it's interesting I I now since uh prepping uh for this podcast and my team prepping for this podcast I always thought thought about cardiovascular disease um but it it's almost like cardi metabolic diseases first and then everything else filters down to that then that is probably one component that drives cardiovascular disease it's really that metabolic component and we see a lot of changes as individuals age through their body composition with uh

per menopause menopause uh andropause I know it's not a real thing BRS um but you see changes in lipid profiles right with these decreasing sex hormones do we have an understanding as to why and then my follow-up question is it's not there's nowhere in the guidelines that I've seen that part of the treatment of treating lipids or abnormal lipids or um cardiovascular disease includes hormone replacement is that is that true yeah I think that's because of the we used to in the past you can basically androgenic progestin lower triglycerides uh androgenic progestin progestin so we

used to do things sometimes with hormones and then you know the there was a thought that HRT was protective so we would sometimes you know but with a failed study uh so difficult that went that went out the window so you know I don't I don't know uh of any there there's so there right now there's that's not done U I think there has been the issue of looking at for example cutaneous preparations have led adverse effects and we know that you look at if you look at the doses in oral contraceptives they have different

effects on raising cholesterol so can you talk to me about that well I I think it's important to take a look at you know what's what what is someone taking he said oral or cutaneous so if some people have a big increase they can't have an increase in cholesterol on they can have an increase in cholesterol so so then we might say and is there a different preparation uh and the other one ends up being is you know like if they're triglyceride went up could you put an androgenic component in there sometimes there so there

can be some back and forth between I think someone who doing the lipids or internal medicine or family practice and then their uhuh Obin in terms of selection of optimal uh uh yeah remember I had one patient and she was going through menopause and her LPA was normal and this was you know this was many years ago and this is really before um it was favorable people would say okay well you don't want to use estrogen in someone who's menstruating right so she was still menting was this whole thing and her LP little a Skyrocket

and I kept thinking well if we had put her on or if we put her on an estrogen patch like let's say we don't use oral estrad or oral anything and we put her on um an estrogen patch would that have lowered cuz it it's not in the guidelines to treat LP littlea with um hormones but that's when we see see the changes so a lot of things are you know the guidelines move take a lot of Trials large numbers and so the center of the earth is going to cool faster yeah so I it

turns out sometimes the uh expert pathways are at least a little faster but then you have areas where we just don't have enough data so someone needs to do trials like you said have you thought about that you know CU you are an expert in LPA arguably one of the world leading experts in LPA how are we have you thought about the horn hormone influence on LPA and if it you know if that's a tool in the toolbx I have you know we do have some therapies at lower LPA 95% that we're tting so laughing

is that I I think if those work they'll get a precedent and so and they're tested in randomized control trials but I think if you were to think about like you're saying could you design a trial which might in a more selective and thoughtful way take women and then treat them with it other forms of HRT like you know giving something cutaneously have you seen it have you seen I have not seen a study like that but I think have you seen in clinical practice no because you use other agents right so no but I

think the issue of you know the whole thing of cutaneous Administration makes a lot of sense uh with it and and I I don't know unfortunately you know it's interesting like for example we used to have no trials with diabetes and cardiovascular outcomes because they had done a very big negative study University drug project and it failed and looked like all the careers went downhill wa wait what happened it was it it increased events s FAS and it increased events and so that there were no studies on outcomes for years and years because they were

afraid of doing harm to people well not just because everyone was afraid to do the trunk it failed so now we have positive trials and the next thing you know there's so many studies going on about obesity agents and everything else like gp1s which we're definitely move so so I think it's the issue is unfortunately you said Women's Health Initiative failed well it was a spectacular failure a lot of money probably the biggest failure in lot lot of lot of money spent and so as a result it it it really has been a barrier towards

doing good powered studies with with you know things like you're talking about it's challenging and I would say as Physicians it's challenging because we gosh you know I can speculate and I'm not a cardiologist I'm not a lipid expert and I always would refer to you or um you know we have cardiologists that we refer out to it's it's challenging because as family practice and as a geriatrician um I would love to be able to say okay well could this be used off label and someone would say to me well you can't there are other

way I mean you could but there are other ways that we would impact LP little a yeah and we just we we don't know are there um LP little a is genetic you said that there is one case in which we see it change and that's through it's about 90% but there are there are things that can the other things like protein nephrotic syndrome uh there are some medications that might alter it uh that people take sometimes but any lifestyle factors a lifestyle is and and this is one it turns out in terms of lifestyle

is that actually it seems to be that here one where the highs saturated fat diet has the more favorable effects than the uh uh High carbohydrate do people ask you these kind of things all the time about diet because you know lipidology I I don't know how um involved in nutritional Sciences you guys get so unfortunately there used to be much more support in terms of the ability to afford nutritional counseling and then also we had a lot more nutritionists and they could specialize in certain areas is uh and it's you know it's one of

the problems with medicine right now is that the focus on prevention there's way more money that goes into interventions and end of life care than it does for prevention and particularly things like lifestyle so nutrition exercise physiology uh you know it's unfortunate you see you know we were working with our Hospital towards taking over CTIC R and they say oh we decided just to close this one and just have it one location someplace else and you're like okay I can't get my patients there right yeah LP little a tell me about diet impact so you

said that there's really kind of two Divergent Pathways so there's not much impact at all but it if this is one where you don't change Alp much might with diet however this is one where it looks like this I'm not trying to be biased here this one this is one where it does look like that the diet that is typically not recommended would be a you know a higher fat diet has a more favorable effect on LPA than the typical lowfat higher car carbohydrate diet can you can you expand on that study and maybe we

can link you know I I I I I I I wouldn't know that I don't know that we have really good studies on that but that's just if you look at the reviews of it that's where it stands nothing makes a big impact but if anything it's kind of favoring you know not not tradition not not the traditional approach it's it's fascinating because it's probably uh it from what I would think in nutritional science that it's actually just the lowering of the carbohydrate potentially I mean it might be I don't know you're the lipid expert

uh what can someone do to treat LP littlea and we should also and I I think we should start on the actual treatments for LP little a what is available who is a candidate um and then kind of circle back to what you think about treatment of uh the other so you want to think about LPA the same way way we think about other risk factors you have to see it in the perspective of the entire patient and and and and people will say well why would I I don't have a drug to read LPA

why do I need to know it calcium scores are very popular uh uh and you have patients getting calcium scores all the time right mhm hard and we usually use something called the clearly scan so clearly scan is CTA also but if you just get a calcium score and even the same thing clearly they say they have got lots of calcified plaque do you ever send them to kation no you don't treat the calcium you treat the risk for having an event so if someone has an LPA I may not be able to treat the

LPA but I do know that first of all we talked a lot about nutrition and exercise blood pressures in more you know I I can make sure they're not their blood pressure is treated I can I can use a Statin if they have a high cholesterol uh you know cigarette sensation vaping I mean there's a lot of things that are increasing cardiovascular risk we know how to do that so yeah it's if you know if someone knows that they're having a greater risk let's just use the things that we know that work uh for it

so I do I disagree with people saying well I I'm not going to do anything with about is why should I measure it you measure it just the same way you measure a calcium score I don't get rid of the calcium but I treat the risk factors when you are thinking about um physical exam are you looking at obviously blood pressure and how would you stratify uh most important to least important that's probably irrelevant question because they're all important blood pressure waist circumference what are what are targets that you can say Okay I want your

blood pressure to be um I don't know 120 over 80 so so ideal blood pressure is 120 80 or under it's not 140 so that's what about in an older population for cerebral profusion so in older individual you can still be getting down I don't know if you're going to jump from 160 to 120 you'd have to be moderating going down but what we can certainly see is at middle aged middle the optimal blood pressure is going to be probably like 115 uh with it and I think in general even older individuals you want to

keep yourselves under 130 uh if people get you have to give some warnings people get orthostatic even without any hypertensive medications as they get older changes in postural position your autonomic nervous system is a little slower uh so they have to be warranted okay you know you if you get those symptoms sit down but in general I think it's lower is better you can't get too low you'll get symptomatic so you just but it's it's manageable uh for it so I mean and so you know now we'll see the kids something that we forget about

is uh I think like you know it it's like you were saying if you had a if you're let's say when they're 15 or 16 or maybe they're a little older 17 18 they get an lpus out the roof sometimes I'll have them come in and we'll talk about lifestyle diet exercise and also some things like cigarettes vaping cigarettes are vioc constrictors vaping is the same as injection so The Vaping is that nicotine or what so when people are vaping they're and they have all these chemicals and the you know all these flavors and stuff

so when you breathe these in it's just like you know we used to do Cardiac Arrest if you couldn't give epinephrine uh uh injection put it down ET tube cu the lungs is immediate absorption so it's it's like snorting cocaine it goes straight into your system so and that's another one that comes up is you know young people go to parties someone is doing cocaine they may do cocaine cocaine was used by surgeons to it's a baso constrictors they wouldn't bleed on you know ear Nos and throat guys so you might be the young person

who has the heart attack because you had some plaque in there soft plaque and so I think that knowledge is something that's get someone think may you know I got this genetic disorder might not be very smart for me to smoke or to vape or you know when my friends were doing cocaine it's not a good idea friends well it's not a good idea anyway but it's just you know young people do they go to parties and they you know they do things and so what about alcohol people always ask about alcohol so alcohol is

not going to be that same kind of Basil constrict something it has lots of other health you know harms to it for it but so I think just the lifestyle part then the issue of you know you mentioned in terms of the exam yeah waste is important uh weight waste combined with weight BMI alone not so great but if you put the waste in there and also be looking at if someone's South Asian and you know maybe their voice isn't that impressive but you get the bmis 26 27 skinny arms skinny legs the abdomen is

clearly you waste is increased for that body habitus uh and then you see insulin resistance that person actually has lots of visceral fat so those the exam low skeletal muscle yeah and you can look at things like acanthosis nigricans and other things which are showing you know insulin resistance uh for it and and usually they are you know the skinny arms and legs not enough skeleton muscle body distribution fat distribution it it's going to be wonderful when it becomes routine to test skeletal muscle mass we we don't have access no one really does to be

able to do that in a meaningful way yet but that's going to be tremendous you know there's a lot of discussion you mentioned so are you doing impotence how are you measuring it in your clinic um so we do um well there's a few ways we do an inbody which is not amazing but it's what we have SC yeah impedance said that um we would you know you can do MRI most people aren't doing right expens spring and doing MRI but we would love to do that but then the question is how often for example

if someone is doing an MRI then how are we following those Trends we're not doing an MRI every yeah it's expensive um yeah and it's timec consuming but an inbody is adequate and then also um yeah there's not a great uh truly there's not a great way I mean you know ultra sound is dependent on the the technician you once you've done that simple things every time you see them wait blood pressure see the lipids usually all three go out of whack at the same time yeah and we want people to be getting stronger yes

I I I think that strength is is really important you know there's a lot of discussion around gp1s and um various generations of those on cardiovascular health what are your thoughts and are you guys using that well I got to say you know obesity in terms of pharmacal therapy has been very very difficult until recently uh most of drugs like fin fin adverse cardiovascular effects and uh gp1s and then gp1 Gip and there's a whole host of things in the pipeline I mean they're really exciting I mean they have traumatic effects uh in terms of

weight loss we see the selectron cardiovascular event reduction they're very expensive so in terms of a societal answer you know there's no way the society can be putting everybody on these drugs and the other one that comes up is uh people do need to understand that when you're losing weight you're also losing muscle so I think that one of my concerns is is older individuals uh wanting to do this for cosmetic reasons who might be trying to get themselves down into lower bmis that are really it's BMI is a funny thing but if if if

we take a look at shape is a U-shaped so and that's because of Frailty yeah so if people are in their 70s and they had a BMI of 20 and they're not exercising a lot uh that's a setup for osteop osteoporosis uh Falls fractures uh and actually increase mortality even hepf for some reason increase would you how can someone who's thin get heit but it's happening uh so I don't know there there this whole issue of sarcopenia and then you know even some people overweight but I think we have to be a little cautious is

that uh the injections be still accompanied by he trying to get healthy eating habits and it very important to get some exercise uh for this and particular if there's any hope of reducing the drugs we do know that the one thing that seems to really make a big impact for sustaining weight loss is exercise and there one study from Copenhagen that look like they could at least reduce the dose which is the home of NOA nordis oh yeah at least they were able and a number of people to reduce a dose and some of them

stopped when they got in some pretty successful Lifestyle Changes uh but I I I am a little concerned about potential the drugs look great but this is four or five years that you know the in the study with it but some some people may be trying to go a little bit too much for the Cosmetic rather than the medical then that could actually hurt their health are there U benefits to various supplementations on cardiovascular health I mean there's you know there's been a host SL of okay use nin to lower HDL okay that's kind of

gone away we used to use a lot of high do nasin right and then um you know I think there there's been red yeast rice there's just various supplements red yeast rice in the United States lacks the active agent so in Canada it basically turns out that the lesten these were the stattin were discovered as fungal metabolites so basically red yeast rice so red yeast rice actually has a fungal metabolite that's like a Statin and what happened in that the FDA made them take it out because they said well if people are taking statins they're

taking this they make it into you know Higher Side Effects but it also doesn't work without it so in Canada it works here it doesn't work much what about omega-3 fatty acids and I know that you've done um some various trials on on Omega-3s so omega-3 fatty acid so so if you look at the typical you see fish oil first thing is what's in it because it usually says that 1,000 milligram capsule but it usually look in the back at how much EPA DHA it's usually 300 milligrams now they lower triglycerides how at what dose

so if you're using for example four grams a day of EPA DH omega-3 fatty acids now that's a lot if you're getting supplements because if they're only having 300 milligrams you can just you do some math there you're taking what is that 14 of those capsules and they're they're big capsules uh the prescription generic uh is a gram two basically you take two grams twice a day and that can be EPA EPA okay EP or DHA or the combination they work fine for lowering triglycerides in terms of cardiovascular event reduction the only one that's shown

benefit is EPA and it looks like the benefit in that study was probably not there may have been a little bit from trius but it's probably other aspects of EPA EPA is involved with resolution of inflammation resolvents uh there's a lot of biochemical derivatives that have biological functions so I don't know the exact mechanism and it looks like it's not explained mostly by the lipid changes it's explained by other vascular protective effects so um we' if you're wanting to for cardiovascular risk reduction if you're going to use omega-3 FY acids it was EPA and it

was 4 grams a day if it's lowering triglycerides you can use the combination there fine H are there any other supplements that you guys talk about are you interested in uh nitric oxide or any of those kind of compounds you know nitric oxide is very important biologically uh with it uh John Cook's a friend of on and he started a company up about trying to give a nitric oxide supplement it didn't seem to work all that well uh but anyway so I I don't I'm just dubious as it you know that they work we there

was a recent study that was done and they compared uh you know garlic and a bunch of other things the statins and they really were all pretty ineffective uh other than the the Statin low dose of Statin and um do statins affect men and women differently I know that there's fat soluble and water soluble Statin is there so yeah there is this issue that women have more Statin and TS than men uh and is that defined by the outcomes of uh myalgia inability to tolerate even even any dose so but it's also interesting you know

if we look at encin which was an injection yeah what's that is that still used no incin is an injection of it's an srna it's a new therapy pcsk9 it but it turns out women had more injection sight reactions than men so you know so so there's two ways of looking at this some people say and which I which I wonder what is it are women simply more perceptive so people say Well they're you know you might see I think so this would be one said you know like maybe do they notice it more or

something well yeah I mean you know women may be more you people say women are more in touch with their feelings well that actually may be true maybe women actually even in terms of what's happening with their body Sensations or something like that I don't quite feel right or something like that I don't know I think you were saying it you know think you said your husband's a Navy SEAL he didn't get to be a Navy SEAL by you know oh my toe hurts you know I mean mean so men get we get taught in

the early AG maybe they're dead maybe they're giving out Navy SEAL cards but no but I you get taught in an early age to push push things aside don't worry about it uh so I you know I don't know if there could that be I mean it's a little bit it's just maybe there's something that uh the a perception of the medications but but we don't know any other outcomes that Statin seem to work equally well in women but it was you know when I saw this thing with in clist I thought well that's really

strange because it's that's an injection and yet there's the same thing in terms of the side effect profile women were more had more complaints about it than the men uh and and you see this and I wonder if there's actually a biological basis to it uh or neur neological basis I don't I don't know you know women clearly have more autoimmune disease yeah uh so I don't know what it is but when I saw it happening with something else it made me think that uh there is this issue of perception of side effects and maybe

you know who knows but it's it's it is a fact so what what does that mean that yeah you try the multiple stats but it means you don't give up okay we have other we have things like boric acid we have zet is if they can't take a Statin the last thing you can do is tell someone it was just in your head everything's in our head right all of our feelings and perceptions are in our head so I do think that if you say that you'll be on a uh if you if you were

to say to your wife you'd probably be on a a milk cart side you know so milk so you got to be thinking is that this person came to see me they need help they tried it it didn't work uh I need to listen to them can you can try a lower dose you can try every other day there's lots of things you can try but you can also so consider other treatments uh for it it's you know I see that you know my job is uh I function as a guide someone comes to see

me it's their heart it's their cardiovascular system I try to help them avoid a major problem uh but you know they're driving the car yeah so but there's other choices uh that you can make so that if we do everything we can to get them on some dose of EST Statin but we have other agents and it and you you certainly cannot challenge because there are clearly some people that do have serious problems with statins it happens uh and you know is there a choice whether it's a fat soluble do you prefer a fat soluble

versus a a water soluble one having something that's you know water soluble it might be useful I mean lot of times we use I use sometimes I'll use half of a rubis in so 2.5 milligrams Monday Wednesday Friday very low dose very very low dose can they tolerate that if they can let's add it at them and surprisingly that combination can give you some very big reductions in LDL would you ever just use a zide alone first and I sometimes us that if some if someone's tried all the statens with all the complaints they they'll

say look I don't want to take a stattin fine let's try a Zam we can even try zet half a pill Monday Wednesday Friday there's this issue of just getting someone to tolerate something you slowly build up but I do think it's important is that since you know it was interesting there said boric acid and for the first time in a trial you actually had equal numbers of men and women because it was a trial of stattin intolerant highrisk patients because there are more women who complain of stattin intolerance and so rather than telling you

know I think we just okay that's a fact we just deal with it and then we do the best we can to make sure that they get treated adequately women tend to be undertreated for risk factors for for cholesterol for a lot of things why do you think that is you know I think there's the deception they don't get heart disease but I do think for whatever reason what we see is there's a lot of undertreatment of women and then also written off for chest pain sometimes yeah we were reading um uh that women take

seven minutes longer to diagnose heart a heart attack when they go to the ER then sometimes symptoms are slightly atypical and then people say well look you know it's a woman she looks youngish and younger women are having events and getting blown off so I do think it's it's a just important that we treat cholesterol aggressively uh and if you end up having to take a little different approach you can you can make progress and and it may end up being well maybe I can't get the LDL lower but maybe we can work on the

blood pressure working on just try to improve the entire risk profile and how important would uh say a V2 Max or stress test be for your say a young healthy person so I still like stress testing because it gives me a baseline of the you know performance and I can see what happens with blood pressure some people blood pressure really goes high and then I say okay you've got a hypertensive response to exercise that's good for me to know because I might I'm going to really watch your blood pressure do we need to monitor at

home some are you going to be someone of these blood pressure medications and what's their Fitness level I mean poor Fitness level is poor prognosis I think it would be nice to get V2 Max's uh just you know yeah that's difficult you know for patient I mean it's just not I know I mean we were doing that uh when I was at wasu and it's just patients don't want to do it's a lot to ask we don't rely we don't routinely get it would it be nice yeah itd be nice yeah it be nice but

we know that the more fit you are the longer you're going to live the more muscle mass you have the longer your and better your trajectory uh and survivability what are you most excited about that's coming out in cardiology or lipidology coming up I mean there there's we've got all kinds of new therapy is coming up uh in terms of I think the the thing that to me is the most exciting is so how much we can do uh we it's still the biggest challenge is adherence to get a good lifesty exercise program but the

blood pressure medications are so much better the lipid medications with many more in the pipeline uh diabetes medications my gosh how much better they are and now we have obesity therapies so I mean it's it's really pretty remarkable uh what we can do so to me it's and then you know the things in genetics and imaging I mean it's a phenomenal how the science has evolved uh unfortunately the lifestyle of style has gotten worse it's it I you know you're listing off all of these things these medications and I can't help but think here we

are spending all this time and all this money looking for external solutions to things that are right in front of our face so yeah so I I and this is where it's all very exciting but and this is the the issue as a society and in general children starting at Young ages you know uh teenagers young adults you we've got to do a better job with nutrition and exercise we have to because you know we're not trying to raise children we're trying to build stronger humans you know um Dr Christy Valentine thank you so much

for spending time with me and really the listeners are going to love this episode and just cleared up so many myths and and brought up things that I think people would benefit so greatly for from so thank you so much thank you [Music]