Doctor Reveals the HIDDEN CAUSE of Arterial Plaque and How to FIX IT | Dr. Ford Brewer

I started as an "ER" doc. I love doing emergency work. But most of these things coming into the "ER" should have never happened.

High levels of glucose or even high levels of insulin irritate that lining of the artery wall. What we're looking for is soft plaque. And here's why we really can't predict a heart attack or a stroke because it's not slowly closing it off. It's when you have that inflamed plaque, and it bursts through and touches the flowing blood, it forms a clot. And if the clot is big enough and it goes to the heart, that's a heart attack. If it goes to the brain, that's a stroke.

If you look at a couple of trials, some people, they went through the full prep, took them into the cath lab, but never did a stent. Other people did the stent. There was no difference in terms of a future heart attack. We got this now, stents don't work, you got to have a "CABG," coronary artery bypass graft. So then they looked at that in a trial called the Ischemia Trial, and guess what they found, bypass didn't help either.

I think it's a good time to quit blaming each other and just realize the real truth, the real way out of this is not easy, but it's what we gotta do. Tell me about the insulin spiral of death and how that connects to heart disease. That's a great question. And it's something that we talk about. We've been talking about it for a year, because it helps people begin to understand just how cruel some of these metabolic spirals can be.

Most people, most doctors included, don't really know that high levels of insulin actually stops your body from burning fat. Well, now, why is that important? Why does that matter? What does that have to do with the insulin spiral of death? So think about what actually happens as we start to age, or sometimes as we start getting a little bit too much body fat, or especially belly or visceral fat, we start to get a little bit insulin resistant. So it takes more insulin to lower your blood sugar, where it's back in a safe level. Well, when it takes more insulin to do that, that's okay at first, but then it takes more and more. And we have people, for example, that come into us all the time with basal or fasting insulin levels. Not a nice level of 5 or less, but 10, 15, even 20. And these people start telling us it doesn't matter. I starve, I... fast, I eat tiny bits of food. And I'm still not losing weight. That's part of the problem. It's that insulin spiral of death where you try to do more to help, and it just doesn't seem to work. More insulin - maybe helping with your glucose at first, but now that more insulin is starting to make it worse in burning fat, there's another spiral of death that's involved with this.

Most people don't understand that having prediabetes or diabetes, insulin resistance tends to cause us to lose our capillaries, our capillaries in our muscles, especially our larger muscles, to our legs. Most people haven't connected dots on that either. But guess what, ---- - you think about insulin receptors. Guess where they live in those capillaries that place between the bloodstream and the cells. So you're losing the real estate for your insulin receptors. And... what does that mean? More insulin resistance. More insulin resistance causes what? You to lose, more capillaries, more real estate. Lose more or have less real estate for those insulin receptors. Again, a vicious spiral into more and more diabetes.

So -- it also brings up one of the points that we talk about. People think that... at first, when you talk to somebody about lifestyle and health coaching being more important than medications, they think, well, this is like mom and apple pie. It's what people would assume would help. But I really want to focus on maybe medications or supplements, because that's going to get me where I need to be. No, nothing is going to improve those insulin receptors, those capillaries that you're losing, like... oxygen deficit. And what does that mean? That means "HIIT" and "re-HIIT." High intensity interval work and reducing exertion. High intensity interval work...

So there's several things that you begin to see as you look deeper microscopically or even metabolically at this disease process, and you begin to realize... this is something that's just spiraling me downwards. It gets worse and worse and worse. So I hope that helps. I want to take some time now and zoom in on the artery you mentioned, the capillaries, but I want to talk about plaque and the whole cascade that leads to plaque and connecting that to this metabolic dysfunction. Thanks. That's one of the things that I didn't realize until I started talking with a lot more people in the low carb community. There's just not a lot of people that have focused that much on plaque. That's one of those places where common knowledge just doesn't work. And metabolic disease can be a complicated place where quite often common knowledge is not so common and maybe it doesn't work.

So here's what I'm talking about with this specific issue with plaque. Most of us have an idea. Number one, that plaque lines the inside of the artery wall and it just keeps lining it until it closes it off. Sounds reasonable. But that's not what happens. Plaque actually forms between the inner lining, what we call the enema intima, and the media layer, the muscle layer, the middle lining of the artery wall. Oh, why is that important? Well, just hang in with me just a second more. It's not that that squeezes - the artery off slowly. And think about it. If --- that's the way it worked, we should be able to predict when somebody's going to have a heart attack, because you can watch that artery slowly squeeze off. That's not what happens. And the reason that we can't predict it is because it's not what happens. What we're looking for is soft plaque. Our body knows that that "LDL," that plaque should not be in -- that lining area of the artery wall. Our body will say, look, let's attack this. Let's send the immune cells in, let's start releasing enzymes, and let's just digest it. So far, so good, because it is digesting it, it makes it soft.

It's sort of like mucus. -- Sort of a soft, mucusy type of consistency. Here's where the problem starts, and here's why we really can't predict a heart attack or a stroke. Because it's not slowly closing it off. It's when you have that inflamed plaque and it bursts through... When that mucus bursts through and touches the flowing blood, it forms a clot. And if the clot is big enough and it goes to the heart, that's a heart attack. If it's big enough and it goes to the brain, that's a stroke. If it's multiple microscopic levels, you can get a heart tissue that looks microscopically like Swiss cheese and one of the forms of heart failure. Same thing with the brain and some dementia problems. So, again, understanding the -- organic or metabolic microscopic details of what plaque is gives you a whole different perspective on what to do next, how to evaluate risk for heart disease and stroke and what to do about it.

So when it comes to this soft plaque, the rupture, the formation of a blood clot that can then lead to a heart attack or stroke, what is it that sets off that cascade? What I'm getting at here is what's the difference between somebody that has soft plaque that's sitting there, say, for years, and they're okay, versus that person that has whatever it is, which is what we're getting at here, that puts them over the edge and dislodges that, sending the plaque into the blood flow to start that whole cascade? That's a really good question. But there's a piece of it that I want us. That I want to touch on. You're not going to have soft plaque sitting there for years. What makes it soft is a process called inflammation. Your own immune system attacking that plaque. That's a process that goes on weeks, maybe months, but it's not going to go on for years. What's going to happen is body's going to say, hey, we have cleaned this up and then it forms scar tissue. Scar tissue, very stable. And you'll actually notice it from imaging results that show calcification. So once we begin to see calcification in that plaque, we know that it's stabilizing.

There is a researcher that did this once. His name is "Honda." I think he's in Washington State, but I'm not sure. And what he did was he took hundreds of images of people and their arterial plaque. One thing that he showed was calcification is not a subjective thing. It's very objective. He actually used optical character recognition to see how much calcification was in plaques. He split these groups into two groups. One group did not have any calcification. The other group did... The other group the study group, the calcification group, had a couple of events right in the very beginning as they were adjusting, and then they never had any more events. On the other hand, the group that did not have calcification of that arterial plaque just kept having events after event after event after event... And by event, I'm meaning heart attack and stroke.

So I guess the better question then, what's the difference between a plaque that calcifies versus one that ruptures? What are the factors at play there? Really good point. I think what you're getting at is I get into this geeky stuff with patients, and they'll sit and listen very politely, and then they'll say, great, but what does that mean for me? What do I do? So, again, if you begin to realize that what we're talking about is active inflammation, the real question I think you're getting at is what causes inflammation and -- I'm assuming that's correct.

Well, that could be underlying it, but I'm trying to decipher what it is between the quote unquote lucky people that calcify... versus the person that has the rupture? And then the event that follows. Well, the big three things that do cause risk for this, and some of it is luck. One of them is genetics. And yes, genetics tends to be luck, but the other two, not so much. Well, one of them's not. It's lifestyle. And then the third is age. Now, we would love to think that there is no reason to age. That's not entirely true. Aging is going to have an impact on us even if we manage our metabolic health... But let's go to that third group. The one of these three things that you can control is your lifestyle... And here's what we know. For example, a blood sugar that's going up over 140 or I think 7.8 if you're outside of the US. -- If it goes up over 140 and it stays there hour after hour after hour, that irritates, inflames the lining of your artery walls. We also know that people that have high levels of insulin, but not quite so much high levels of glucose, and that's what you see with early prediabetes and early diabetes. We can talk about that later if you want. But high levels of glucose or even high levels of insulin and clearly high levels of both irritate that lining of the artery wall.

I just happened to see - your interview with. I'm blanking on. Is it "Fettke?" Oh, "Gary Fettke." "Gary Fettke." He started talking about the glycocalyx. - So I mentioned the lining of the artery wall in the intima. That intima is a one cell layer thick lining. What "Gary's" talking about in his interview with you recently is... some little hair like structures that come out of that intima lining. Those hair like structures just get mowed over by high levels of glucose or high levels of insulin. When that happens, those hair like structures protect the intima and they're no longer there to protect the enema. What has been demonstrated by some researchers at, I think it's "UC Southwest" in Texas. A thing called transcytosis, and pardon the geek words. All it means is trans means going through and cytosis means going through the cell. So what we know now is if you injure that glycocalyx that "Gary" was talking about, and he was right, it really is the largest organ of the body, not the skin. And it's one of the most important because as you'll see as we go through this conversation, that's what leads to, as you know already, the vast majority of heart attack, stroke, dementia, blindness, kidney disease, heart failure, even for men, erectile dysfunction. This organ, the glycocalyx is so important. And it gets back to the question that you've been asking me, trying to get me to focus on - what causes that... continued inflammation. -- Does that help -- or did I still leave it confused?

So the way I'm understanding what you just explained there, elevated blood glucose, elevated insulin, those causing damage to the glycocalyx and then eventually leading to inflammation, is part of this, too. And I want you to clarify exactly how that fits in... And then eventually this leads to the plaque formation like we were talking about. I'll have you jump in and... clarify if I have any holes in that. Okay, a couple of points.

We've mentioned a couple of names already. "Ben Bikman." I'll also mention I'm a big fan of "Ben's" as well, and he does a good job of dealing with hypertension, high blood pressure. - There are a couple of reasons that having high levels of glucose, high levels of insulin, and even what we call "AGEs," advanced glycation end products. - - And again, a whole bunch of technical terms. But "AGEs," the advanced glycation end products is really. We've all heard of the most common one - hemoglobin "A1C." It's where glucose binds to a protein, in this case, hemoglobin. All those things tend to impact the kidney, and the kidney makes our blood pressure go up. The reason I brought that up is -- a lot of people would say high blood pressure causes this. I think if you talk to some of us, we would say, yeah, high blood pressure is a big deal, but it's actually more of a result of this process than anything else. This irritation of the lining of the artery walls because of - glucose intolerance, insulin resistance, prediabetes, metabolic disease, whatever you want to call it.

Back to your point about what causes that the on button or the off button? What causes it to increase? Again, if you have damage to that glycocalyx that's going to increase this inflammatory process, because you're going to continue to get that transcytosis. --- The "LDL" fading through that intima lining, fading through the glycocalyx, fading through the intima lining, and getting stuck between the intima and the media... As long as that process is continuing to happen, your immune system is going to be continuing to attack this process, to try to pull that back out by liquefying that "LDL" or that plaque, liquefied plaque, is what gets us. So in a way, at the end of the day, when you think through all this, we're really taking friendly fire, the goal is to start slowing that process down. How do you slow it down? Slow down the injury rate from the very beginning. And that gets you back to the low carb community. A lot of folks would just say, forget all that science. Just don't eat carbs. And I get it.

One thing I want to make sure we clarify is the chronic nature of this versus acute. Because even somebody like you or me, I'm sure even being aware of the importance of keeping things generally low carb, we might go to a birthday party or have a celebratory meal... and have that quote unquote spike in blood glucose. How does that differ in the case of somebody like me or you doing that just periodically versus somebody doing it day in, day out? Because I'm assuming you're going to have the damage to the glycocalyx, the inflammation, like we've been talking about. But because it's so infrequent, does it just allow the body to calcify that and repair that?

Well, first of all, I'm glad you brought it up that way. And I get banged on that a lot. I'm a Southern boy, born in South Carolina, the land of once a year, we'd go out and pick blackberries, and we'd make it in a cobbler, which basically just pours the sugar, the glucose into it, or sucrose in addition to the fructose from the blackberries. And then you put a grain crust on top of that, and then you put ice cream on top of that. And then you have that with maybe two glasses of really sweet iced tea. Now, I don't do that anymore, but that's the culture I grew up with. You're Canadian, right? Yeah, from Ontario. So I'm sure you have some of that kind of stuff in your culture too. For sure. And I'm also happy to hear that -- you sound a little bit more like me, I think like an engineer. So a lot of the people that come to see me as patients think like engineers, and some engineers can be a little bit rigid and get very surprised that I'll go ahead and have dessert sometime. My family has a -- dinner event every Monday night. -- And my sister is a great southern cook. And -- sometimes when she fixes something like. And down here, we fix food, we don't make it. - Sometimes when she fixes something like a coconut pie. I'll just have to get a bite. I've gone home. I've had episodes where I've had my "CGM" on my continuous glucose monitor. And pardon the story, by the way, I am getting to a point. I remember episodes where my blood sugar has actually gone up over 200. That, by the way, is one of the criteria for full diabetes. So, yes, I'm full diabetic... But... let me finish with the story. I'm getting somewhere that that responds to your question.

--- I've got -- what some people might call an assault bike. - The bikes that have their wind driven back in my day. And I've got one that's 30 years old, and back in that day they called them "Schwinn Airdyne." It's an old rusty "Schwinn Airdyne" at home. So I'll have a blood sugar of 200, go sit on the "Schwinn Airdyne" and within five minutes I'll have that blood sugar back down to 105. This has happened more than once. Now, the reason I'm bringing that up is to get to the punchline. And the punchline here is this from looking at my own "CIMT," from other imaging studies, from looking at my own metabolic information, it's really clear that I continue to stabilize plaque, I continue to stabilize and improve... my metabolism. So, no, you don't have to be rigid. You don't have to say, I'm never going to eat any carbs at all whatsoever. Now, I do tend to stay. I use a breath ketone meter, and I do tend to stay mildly ketotic about four to five days a week. -- But that doesn't mean that I don't take a carb vacation every now and then... We have patients, part of what we do when we see patients is we get them started on a "CGM" continuous glucose meter fairly quickly and we'll typically learn two or three things. One of them is, oh my gosh, I had no idea so many things spiked my blood sugar. Another thing that patients will learn on the other side is, oh my gosh, my son had a birthday, I went out for pizza and beer with him because that's what he wanted. I just took an easy walk about 20 minutes later and it took the top right off of the spike, that blood sugar spike that I expected to have and that I knew that I'd have. It's not that difficult.

When you're on one of these carb vacation days. One of say, three days during the week. Is that strictly for social and for taste of these foods, or do you feel like there's a health benefit going in and out of ketosis? That's a really good question. I've looked at it a couple of times and I've decided I'm not so sure. I don't know one way or another, but I don't think it hurts you. I'll also say that, ---- -- I don't take carb vacations three days a week. Usually it's one, sometimes two. And it may take me a day or two to get back into ketosis. Quite often it doesn't because my big workout is on Saturday and Sunday.

Coming back to the vasculature and the damage there, the inflammation. Somebody having a carb holiday once a week like yourself, do you feel like you're causing damage to vessels, doing that periodically, or does it take a constant insult over a period of time, chronically, before damage is done? Well, a couple of caveats we need to think about. One is that we're all very unique. And for example, I don't know what your numbers are. --- I do know this... I have some people come in to me that have little or no response on a glucose challenge. On the other hand, if I take a glucose challenge, my sugar will go over 200. So each of us is different. But as I mentioned before, we're watching my plaque on a regular basis and we're putting the results right there on our channel... And it's improving... It's not getting worse.

I guess what I really want to make sure we clarify, though. Do you feel like you're causing damage and then calcifying and then moving on? Or do you feel like, because you're metabolically healthy, having the insult so infrequently, that it never gets to that point... of damage? That's a really good point. So to put this in a different way. -- - I think it takes more than half an hour or an hour once a week... of high blood sugars to do this damage on a regular basis. -- And let's go back and look at it. -- I've got a mild level. I do hit full diabetes when we challenge, but it's still a very mild level. I'll hit to 210 to 220. - We've got people that will hit up to 350 with a normal glucose challenge. And... think about this. -- - And I get that challenge, that hit when I just do, like again, -- a half a piece of my sister's coconut pie. Think about this. I don't eat bread. ---- Sometimes I have eaten at "McDonald's," I will continue to do so. I'll get meat, no bread, no "Coke," none of the carbs in a routine meal there. ----- But let's say that even at my level, very mild diabetes, I had a 64 inch... "Coke." -- A regular "Coke," not diet. - French fries or milkshake, all of these carb sources. And let's say I did something similar like... maybe spaghetti for dinner. And then let's go back and assume, maybe my blood sugar actually hits 350. This kind of person with this kind of diet. And let's say they started with oatmeal in the morning thinking they were healthy or "Honey Nut Cheerios." Their blood sugar is going to be 250, 300, -- maxing out 8, 10, 20 hours per day, every day. That's just so different from an occasional once a week, 15 to 20 minute increase up to 160, 180, 200 and then back down... Totally different universe.

There's a book called "Blood Sugar 101" by "Jenny Ruhl." Have you heard of it or have you seen her website? No, I haven't. It's a good one. I haven't seen it in a couple of years. But when I was looking at this specific question, what level of blood sugar for what amount of time causes this irritation to where you start forming plaque or cardiovascular risk? She's not a medical scientist, but she does pretty good. And she had looked at that data a few years ago, the evidence, and she made a good case that you --- need to be over 140 and you need to be there hour after hour after hour. And obviously the higher over 140, like 350 for 20 hours a day, day after day. That's dangerous.

I want to come back to the plaque and talk about anatomy of the plaque. You've brought up "LDL" but we haven't gone deep into this piece. Okay. Conventional wisdom would say that's definitely the biggest piece of all this. How do you look at "LDL?" And then we'll get into other parts of the plaque. It's a good point. I mentioned "LDL" on purpose there because I think "LDL" has been a red herring. If you remember that term, you're familiar with it. It's way back in, a couple hundred years ago -- they did autopsies of people dying with heart attack and stroke. And they saw, quote, fat in their arteries. And for hundreds of years, we thought fat was killing us. You eat fat, it deposits in your arteries, it kills you. The science is so different now. And in fact, I get sort of beat up sometimes in the low carb community as a physician, because I still do use statins, but I use them entirely differently from what your typical doc does on the street. I don't recommend statin to lower "LDL." In fact, I personally don't think that in most cases "LDL" is the driver at all.

Given what I do, I see enough cases of people that have what we call familial hypercholesterolemia. It's a genetic. Are you familiar with it? I am, yes. Okay, -- there's 2,000 different genetic variations which makes your liver struggle in terms of metabolizing ""LDL"... I've got tons of those cases. And over the past couple of years, my number of cases of lean mass hyper-responders has just skyrocketed. I'm seeing, nodding your head, you're familiar with that term as well? Yes. People that are thin and low carb or ketogenic, and they have "LDL" that skyrocketed. Usually if somebody has an "LDL" that's 180 or above, they've got an 80 to 90% probability of having one of these two conditions. And "Dave Feldman's" a friend of mine. I just went to --- the premiere of his movie the "Cholesterol Code." It's a fantastic movie. They're looking at getting distribution rights through "Netflix," I think. And it actually has some of the... update, the follow up to the Miami Heart Study Control Group, this group where their "LDL" wasn't 180, it was on average, 272. How does that compare? That's one in a thousand... levels, -- that's one in a thousand people have "LDL" levels that high. And so you would assume they'd have a lot of plaque. No, they've already published the Miami Heart Control Group where they looked at people from Miami Heart that really didn't have much risk, and these people had the same amount of plaque. In other words, high "LDL" was not causing their problem. Well, some of these people actually went up to 700 and above. So we're talking some... astronomically high "LDL" levels. And these people -- come to me as patients and they say their doctor is just wearing them out, refusing to see them, forcing them to take "PCSK9s," multiple drugs. And again, that's why they came to see us, because... they've heard us. They know that we know the space. They know that we're not so focused on "LDL"... being a risk. We're more focused on metabolic disease. And I know you know what that means and I know your audience does too. So we're more focused on -- your metabolic health than we are on "LDL"...

Back to the original point, we do use statins, but we use them for inflammation. There were a couple of smart guys at Harvard, "Gavin Blake" and... I can't remember the other guy's name but they noticed about 25 years ago that in comparison groups, people on statins still tended to have lower heart attack rates no matter where their "LDL" level was. --- That's where they started to think about maybe it's something else and maybe it's inflammation. And sure enough, over the ensuing 20, 25 years, "Paul Ridker," who is the other guy, and "Gavin Blake." "Paul Ridker" mostly has done tons of follow up studies where he looked at different types of anti inflammatory products and... found that some of them had a huge impact on decreasing... heart attack and stroke risk. So when we use --- statins, we use a very, very small amount because you get that anti inflammatory effect from a low dose. You don't need a high dose. -- And we're looking at "LDL" levels, we're not looking at "LDL" levels, we're looking at potential for inflammation. So at the end of the day, if you formed plaque, we know that you've gone through that inflammatory stage, you didn't feel. So we recommend something like a baby aspirin to slow down that clotting process. And a lot of statin and only one of two, Rosuvastatin, the generic for the old "Crestor" or Pitavastatin. And that has to do with things like "Lipitor." "Lipitor" is -- one of the originals. They were great marketers. "Lipitor" doesn't really improve - inflammation. It does, but not nearly as much, especially... if you're diabetic, which most of these folks are. Most of the cases are pre diabetic or diabetic or if you're a female. So we don't use "Lipitor," we don't recommend it. The other thing that happens is our typical patient will come in and say, well, I've heard you, I know you have a different perspective on it. If you really want me to take it, I can, but I'm nervous. I still have a different perspective. And that is why do it if you're nervous? Even these low dose statins are not important compared to lifestyle. If you get those carbs out of your high levels of blood sugar, high levels of insulin out of your daily life, then stuff like statins, any medications have been proven time and again to be way back there in terms of priorities.

All right, there's some nuance here I want to make sure I understand before we move forward... So it's either the baby aspirin or the statin and this is somebody that currently has plaque or what if they had plaque in the past and now they're metabolically healthy and that's calcified? Is that still recommended? Couple of really good nuanced points. Thank you so much for calling me on those. Number one, no, both aspirin and a lot of statin because the low dose statin is working on is decreasing the inflammation, cardiovascular inflammation, specifically the baby aspirin is stopping that, giving you a safety net for that next step of forming the clot. So that's what I'd recommend. And again now to get back to your next point, which is a very good point. Do you know how much data there is out there, how much evidence there is out there about people who are completely cleaned up on their metabolic health... and then a clinical trial for something like a statin or even baby aspirin or anything else? No idea. It's just not there. It's just not there. Things that we do know. For example, there was a good head to head comparison on metformin versus - very minimal lifestyle changes for prediabetes. And as you might imagine, even minimal lifestyle changes. Like we're talking five pound weight loss, we're talking talking, going on a gentle walk a couple of weeks, it was three times more effective than metformin. And I think that given my experience, what I see, I think that's probably a pretty good analogy for statins, for... baby aspirin, for all these things, you lose 30 pounds, you're in a whole different risk category than you were before. So that's the focus. It's again, lifestyle, lifestyle, lifestyle. And yes, the other things like medications. -- It's like suspenders in a belt. They're helpful, but they're not -- the priority.

Right, I see where you're going with all this, but I'm curious, somebody who is taking these two medications. Well, one, is there more natural form supplements that can do the same thing? And then secondarily are they just taking those because they're not willing to make the lifestyle changes? Well, that gets into our medical culture. I'm a "doc." I've spent a career hiring and managing the performance on docs. --- I understand. I know. I get it. You come out of training before you see your first patients and you think, oh, this is going to work. I know what I'm going to do. I'm going to save the world. I'll just tell people to lose weight and they're going to lose weight. No, they're not... That's not what happens. So the docs just get to a point, then they start dealing with - the hospital administration or the insurance companies, the folks that are watching over them to make sure that they're, quote, productive... Well, what really changes health is somebody's lifestyle, not a medication. So what's really productive is to spend time with a patient, listen to find out what their perceptions are, what the challenges are in terms of lifestyle changes, things like that. But insurance doesn't pay for that. Clinic ownership doesn't pay for that. What do they pay for? Things like prescriptions. So docs just get hammered on both sides of the patient and the payer and the management --- scenario and just start saying, okay, I give up. I'm just gonna push pills. And that's what happens. - Patients, on the other hand, often that most people are not going to want to take blame for something, and then they're going to turn around and say, well, my doctor never told me this. All he or she did, they just wrote a script and walked out the door. I think it's a good time to quit blaming each other and just realize the real truth. The real way out of this is not easy, but it's what we got to do.

So the big pillar we keep hammering home throughout the conversation is metabolic health. That's something we can control and prevent a lot of this heart disease. You mentioned genetics. What other factors outside of those are working independently of this metabolic health piece, causing damage to arteries? Things like sedentary lifestyle, smoking, other factors people need to consider to get the full picture. Well, I'm going to start with a very arc. My brain tends to go backwards and it tends to confuse people. So please, let me give you some forewarning. I'm going to start with one of the more unusual things, and then we'll get to what you're talking about. I thought you were going here. There are causes of inflammation. That are not cardiovascular but can cause, can cross over to cardiovascular inflammation. And let me give you a couple of examples. Rheumatoid arthritis and a thing called psoriatic arthritis. You've heard of psoriasis? Yep. These are autoimmune problems. And both of those, once you get psoriasis to a point where it's psoriatic arthritis, both of those things cross over and both of those things create as much increased risk for heart attack and stroke, diabetes... We just don't hear about those that often because they're just not that common. Not nearly as common as metabolic disease, where 90% of us have some of that. So we tend to think of lifestyle related issues. When I see a patient with psoriatic arthritis or rheumatoid arthritis, especially psoriatic arthritis, I'm following their C-reactive protein, which you may have heard of. - I'm following their C-reactive protein and so is their rheumatologist in terms of major determinants of their health. So that's something else that can cause major problems with arterial health, but not as many people have them.

To go back to your point. Yeah, a lot of people smoke, a lot of people vape. A lot of people have sedentary lifestyles. And those things can be -- radioactive for arterial health. For my crowd, the folks that tend to come see me, I rarely get a smoker. I get people that have watched my channel on "YouTube" and so they tend to be - folks that have... totally turned their life lifestyle around already... or folks that already had a good lifestyle and they're focused on it... But I still have a large group of people that are in their 60s and older. And here's one of the things that you tend to see with older groups. They don't focus as much on muscle... And you're talking about exercise and muscle. Again, it gets to that thing about lifestyle is not just mom and apple pie. It is critical... to your longevity. As we get beyond our mid-60s, a lot of people would say. And I think they've got a good case... that loss of muscle, metabolically active muscle, is maybe becoming even more important on a population basis than having too much fat. Because metabolically active muscle is our best internal safety valve against blood sugar going up. You see these cute little old men or cute little old ladies that have thin legs. - That is a big, big problem. It's not cute little. These folks have a big problem and a lot of risk. I've noticed -- because of our channel, we continue to watch and see who's publishing what. I noticed recently something that was really exciting to me. Somebody did a video on three leg exercises that you must focus on if you're old, if you're elderly. And that thing took off. I never, ever would have thought people would have gotten interested in it. But they've demonstrated things like soleus push ups. Have you heard about -- those? No. So the soleus is the muscle in the calf, one of the two big muscles, the soleus and gastrocnemius. And let's say, okay, we went to a meeting, everybody was seated, they had a lunch. - I ate some stuff I'm a little bit nervous about, maybe had some bread or something. And I'm sitting here, I have to remain seated. Maybe I could go, you can't go up and stand. I'll usually go and stand in the back of the room. But what they did was they said, look, we think people can help their blood sugar even with what we call a soleus push up. And that is just simply... having your foot on the ground and pushing it up like that, or even bouncing a little bit. And so you've got that one muscle, but it's a large muscle, it's a leg muscle. -- And it's bouncing and it's active. It pulls that glucose in... without having to worry about -- failing insulin receptors. And they did, they've demonstrated that. And a lot of folks in my community talk about you can even just do soleus push ups while seated and still improve your blood sugar. You don't have to get on an assault bike, you don't have to go walking down the block. Just some soleus push ups.

Before we move away from the muscle, I want to make sure we acknowledge the two different pieces of this. And the latter part of what you're discussing there is using muscles to bring the glucose down, which in turn is going to help keep insulin down. Before you're talking about muscle being a safety release valve. Yeah. And I assume in that case you were talking about building muscle and being preventative that way. So let's talk about the physiology of that piece where taking time, going to the gym, putting on muscle, especially in the legs, is gonna help with your metabolic health down the line.

Well, actually, let me, if I could take it in a similar direction. But talk about a couple of things that I think are very helpful to think about. And it's two different components of muscles. First of all, if we realize that these muscles that support us, the thighs, hips, calves. They are our largest muscle mass. Back in the "Pumping Iron" days, the bodybuilders used to talk about - new bodybuilders. And they'd say, yeah, he came in, he just worked his arms like crazy and he's getting nowhere. And the other advanced bodybuilders knew why... he wasn't working his legs. If you don't work your legs, you don't really change your metabolism... And we always talk about that with our patients and we say, look, we're not trying to make you a bodybuilder. What we're trying to do is change your metabolism. Now, there's two major components to... these large muscles of the legs that are important. One is the capillaries that we talked about a few minutes ago. The major area of real estate for the insulin receptors and the major area of interface between the blood supply and the muscle. But there's another key component. Anybody that's read anything about longevity for the past 50 years has probably heard about it. And it's called the mitochondria. So the mitochondria is very much related to strength. And that's where we start talking about getting some, -what you're talking about going in preventively, making sure that you have good strength, hitting your mid-60s, and making sure that you don't start to lose that muscle. Because... mitochondria have been a part of the anti-aging formula or destroying mitochondria. Losing mitochondria have been a big part of every aging, or not every aging, but the vast majority of aging mechanisms discussed for the past 60 years. So first of all, you want to have strength. And then I'd get back to those capillaries and say you also want to have good capillary... penetration of those muscles. And that's where you come in with the oxygen deprivation or the "HIIT," the "re-HIIT." So not only strength, but the capillaries as well.

All right, now that we've gone into the physiology, a lot of people are probably wondering what camp do I fall in... Am I in that 90%... of people right now who are metabolically unhealthy? You've touched on a couple of different tests that I know you're a fan of oral glucose tolerance test and "CIMT." But let's start by going conventional, somebody coming in to have their cardiovascular health assessed... What are the testing methods done traditionally there and then the problems with those? And then we'll go into your system. Okay, so I wrote a book about, and it was titled "Prevention Myths: Why Stress Tests Don't Predict Heart Attacks." You want to start there? Sure. I looked through it... preparing for this. You know. Oh, my gosh. -- You thought so? Did it put you to sleep? It's a great book. I thought so. No, I'm into this stuff. I liked it. Well, great. I appreciate that. And I appreciate you taking the time to do it. -- - It's the typical conversation. It's like "Tim Russert" had with his doc - a few months before he died from his heart attack. Hey, doc, I'm starting to gain a little bit of weight. -- I'm a runner. I think I'm in good shape, but maybe we could just do a stress test to make sure I'm okay. Now, a stress test. You got to understand what a stress test is... It's what we call a flow study. It measures the flow in arteries. And specifically, a stress test is going to show positive if you have decreased flow in the arteries of your heart. It's not got anything to do with inflammation. It's not got anything to do with things like inflammation that make those. Those plaques soft or friable or at risk for forming clots. It's just flow. Does it flow well? And again, "Tim Russert," he wasn't an Olympic athlete by any means. His waist size was pushing significantly above 35, headed towards 40. But it was a runner. And he ran three miles a couple of times a week. And those kind of people will finish these stress tests usually just fine. A stress test is more of a test of cardiovascular conditioning, not a test... of heart attack risk, not a test of whether or not you've got inflamed plaque. And clearly not a test of the number one driver of this problem, and that is undiagnosed diabetes or prediabetes. So... "Tim Russert's" like the poster child... for somebody who had a normal stress test... and then had a heart attack and died. And if you looked at his. They did a big -- one of these. Like emergency news videos, and I took some clips out of it. His doc was a smart guy. He said, you know what? We could have done that stress test 10 hours, two hours, one hour before this heart attack, and it could have been fine. Stress tests don't prevent heart attacks. - You would think. So what do you think the -- incidence, the use of stress tests have done? Do you think it's tempered any since then? Do I think people are using them less? Doctors? I would say no. Mmhmm. Not at all. The American boards of preventive internal medicine, the cardiology boards, the standards committees for all these groups say this time and time again, this is not some crazy guy saying this is the standards committees for these doctors. They're saying you're doing to many of these. You don't have good indications for doing them. And yet more and more are being done. There are many, many times... stress tests being done on a population basis compared to when "Tim Russert" died. So stress test is clearly not one of the tests that you need to look at. But it's common sense. People say, hey, my uncle "Fred" died from a heart attack. I look like him... Can we just get a stress test? And the doc's going to make money off of a stress test. I used to shy away from making that comment, but I do think stress tests have financed a lot of... mortgages and clinics. So docs are still doing them. -- They're not a good test. More of them. No More of them. Is that the total standard of care or what else will they do along with that? Oh, well, they start off with a thing called "Framingham." Have you ever heard of that? Yeah. Reading your book. And I'd heard of it before. Oh, okay. - It's in our world. So yes. Yeah. So "Framingham" is a community about an hour outside of Boston, Massachusetts and the US Congress, in its infinite wisdom, what, a hundred years ago, decided to set up a research center for cardiovascular disease research. It picked this place just outside of "Harvard" and started watching these people. And you've got more databases there and more publications about cardiovascular risk coming out of there than anywhere else in the world. Now there's a questionnaire. Why this came up was your question about, well, are there other ways of evaluating cardiovascular disease than stress

Tests? The first thing that the doctor thinks... he or she is doing when you come into their office or when they come into your patient room and begin to talk to you is they think they're doing a "Framingham," which is a set of questions. Age of the patient is a big deal, gender is a big deal. Whether or not they smoke is a big deal, exercise is a big deal. Every one of the things that you and I just got through talking about. The doctor thinks, okay. --- 49 year old smoker, male. --- High blood pressure, yeah, you've got some significant risk there. Or... 30 year old female, non-smoker, you don't have any risk. But the reality is that's not a "Framingham." Even those standards committees that you and I mentioned a minute ago will say, look, this is not a two-minute conversation. This is not a six-question conversation. It involves a conversation about lifestyle, cardiovascular risk.

And docs are just not doing it. In fact, in most cases, it really gets a little bit worse. And this, I don't have to tell you, and probably most of, I'm sure most of your viewers understand this too. The vast majority of the time it turns into... what's your cholesterol? And it's a single synapse, single connection. Focus on, okay, if your cholesterol is high, I'll give you a script for statin and then send you on your way. And I'm going to go see the next patient. I've written a prescription for you and you're good to go. And the standards committees don't agree that that's good care. They just don't.

So it sounds like "Framingham" type questions are done initially by the doctor in a very rudimentary way. Right. Lipid panel including "LDL." And if "LDL" is high, statin may be prescribed at that point. How does the stress test fit in? How does a doctor determine if that's necessary? Well, first of all, it's really, really clear that differs dramatically by doctor. Dramatically. And doctors will tell you that too. ---- That's not a secret. That's not something that doctors try to hide. Doctors are really clear. -- Some folks are just real quick to the trigger of, hey, you know what, let's just get a stress test. And then when it comes to... cath lab, I know stress tests can lead to somebody going there. Yeah. Is that the next step? If they fail the stress test, typically sent to the cath lab after that? Yeah. So with an interventional cardiologist, that's usually the next place you're going to go if there's any... potential for significant risk. And the patients coming to me will often have or give quotes that, hey, they said that I was 100% blocked. Usually in the "LAD," quote the widowmaker, or I was -- 90% blocked. I only had 5% function there... And the cardiologist said, let's go ahead and take you to the cath lab. -- We will -- use radio-opaque dye and take a picture of your arteries and go ahead and sign for me to do a stent while I'm in there because we don't want to bring you back out and then take you back in. And that's the standard process. And a lot of people come back out with they get their stress tests, then they go to the cath lab and they come back out with not only an angiogram, but a stent. And how do they determine whether or not to use a stent? Is there a certain percentage of blockage they're looking for? Again, it varies dramatically.

And let me clarify something. A lot of people think that I am a cardiologist, an interventional cardiologist. I am not. I'm a prevention doc. I started as an "ER" doc. Oh, gosh, back at about the same time as "Hippocrates." -- About 40 years ago, and got very interested in this issue and thought, you know what? I love doing emergency work. It's exciting. But most of these things coming into the "ER" could have, would have, should have never happened. But they involve education. So I'm going to go someplace I can find to understand how to prevent this in the first place. - That was "Johns Hopkins"... I went there. I trained in preventive medicine, loved it, did well, have a little bit of a brain for. Number one, I'll be polite because I grew up in South Carolina. But number two, I also am very skeptical about and was about what makes sense and what doesn't. And it was really clear when I went through my early med school training that so many things were based on a recipe. - Doctor "Jones" says do this. But where was the evidence for what Doctor "Jones" was saying to do? -- I did well at "Hopkins," ended up running the program, training other doctors in prevention there. -- And again, pardon me for diverting into an origin story, but I want to help clarify why I'm not going to answer what each cardiologist decides is going to be his or her criterion for doing a stent. -- So... at "Hopkins," I had a blast. I loved what I was doing... And more recently, about 10 years ago, 8 to 10 years ago, I was sitting in a weekend seminar. It was really good. It was a couple of thousand bucks, though it was very expensive. It was about heart attack and stroke prevention. It was given by a fellow named "Brad Bale" and his partner, "Amy Doneen." And I was thinking, there's this kind of information needs to be made available to the public. I know there are people out there that would be interested in it. - It shouldn't cost $2,000. - And there's this new technology, this new platform called "YouTube," where they'll find the people that are interested for you. And so I started putting the content on, and that's -- the origin story for my channel. Again, pardon the diversion, but I'm not going to be able to tell you what each cardiologist uses. And I'll also tell you this, as I said before. It's subjective enough and variable enough. Then nobody's going to give you any clarity in terms of what's actually happening out there.

I'll typically hear from patients. They'll come in with a motion saying it was 90% blocked, 95% blocked, even 100% blocked. And you may know where I'm going next with my question with the patient, and that is. Okay. Are you running or exercising? Oh, yeah. I do hill sprints. So when you're doing your hill sprints, are you having chest pain? Oh, no. - Let's see if we can make the connection here. You're doing hill sprints, your heart rate's getting up to 130, 140, 150, and a doctor's telling you that you have so much blockage in the arteries to your heart... that you need a piece of metal in there. - Help me connect the dots here. I know where you're going. Where? Where am I going? The body is smart, and it grows new arteries to make up for that blockage. Collaterals. Exactly. There's another thing, too. The arteries are not plumbing. They're not rigid pipes. You start to exercise, and the tissue notices a need to increase... artery flow. The artery expands. There's so much hocus pocus to decisions made on when to put a stent in. It's very frustrating. And by the way, I mentioned the standards committees saying there were way too many stress tests done. Guess what they say about stents? I'm assuming they like them. No, way too many stents are being done. They say the same thing. Oh, okay, so they don't like the amount of stress tests or stents, but yet those are standard of care. Exactly. They're saying that we're doing. They're saying, well, they are the standard of care for far fewer indications that they're being done for, and they're being done way too often.

Okay, well, let's talk more about the stent story. You've alluded to and touched on the fact that they're not all that they're cracked up to be. Yeah. Talk about that person that fails the stress test goes to the cath lab, they sign the waiver, they get a brand new stent put in. How is that helping prevent future incidents of, say, a heart attack? Well, if you look at a couple of trials, one of them was called the Courage trial. I can't remember the name of the other one. -- If you look at those... trials, they were... clear head-to-head comparisons... One of them was done in the UK. It could never, the story was this never could have been done in the US because of human subjects review. So what they did was this. They took people. - A large group of people that were set up for stents, and they said, okay, we're going to intervene when they go into the anesthesia prep for getting a stent. Some people, they went through the full prep, took them into the cath lab. Did anesthesia, took them back out, but never did a stent. Other people, they did the stent and that was randomized. -- And I have to tell you, I think here's the real reason why it happened in the UK because of their nationalized health system, doctors were not getting paid differently anyhow, as you might. You can tell from where this is going in this conversation, there was no difference in the group that had the stent versus the group that didn't have the stent in terms of a future heart attack... No difference at all. So the Courage trial showed that. The other trial whose name I can't remember right now, showed it... So then you have the - thoracic surgeons, "Philip Ovadia's" crowd... saying, okay, we got this now stents don't work. You got to have a "CABG" coronary artery bypass graft. That's the only thing that's going to work. So then they looked at that in a trial called the ISCHEMIA trial. And guess what they found? Same thing. Bypass didn't help either. These things don't prevent heart attacks.

Any chance either of them cause more issues because... obviously when you go in and you're putting a foreign object in the vessel, it's going to change the way blood flows? Maybe different molecules, including red blood cells "LDL," "HDL" could get caught up on that. And when you're putting in, bypassing, you're going to change the way blood's flowing and... how blood flows. So if it's not doing anything, I could see how maybe it's even causing worse outcomes. Well, you might think that. And again, you might think, given... my position on a lot of this, I would look hard for that. And I have looked hard for that. The bottom line is there's very little significant evidence that stents or even stress tests actually do a lot of harm. You might think exactly what you were saying. That would actually be maybe common sense. But it's another area where common sense really doesn't pan out in the data.

So one of the things I'll tell my patients this is an emotional event when somebody gets told, I got to have a stent or I'm going to die. And they will, patients will come to me all upset, and -- I'll say, look, if you're looking for me to tell you not to do this. - Number one, you're coming to the wrong place. You're "Luke Skywalker." This is your battle, your life. - But I am "Yoda," and I've been in a lot of those same battles with your peers, and I'm also one of your peers. I've been the same battle myself. -- But I'm not going to tell you what to do. I can't. That's your job as the patient, to decide what you're going to do. And if you're gonna. If you're thinking, I'm gonna tell you that a stent or a stress test is gonna ruin your life. No, the decisions that come out of that might and often do, with the most common decision being, hey, you know what? I had a heart problem. I had a stent. I got it fixed. That kills a lot of people. That makes sense. And bypass same thing? Bypass, not quite the same thing. I had a patient named "Lois" that came on my show one time and told her story. Bypass overall doesn't really kill a whole lot of people, but it's not like a stent. It's brutal. You take a saw, you cut all the way up through here, you pull the chest open aside so you can access the heart, you do a lot of damage. - And the whole point is to try to put new vessels in there that aren't going to have this problem... At the end of the day, it is the same message. - - Bypass graft doesn't fix the situation... metabolic health does. - And going through all the pain of getting your chest opened up and then wired back together I haven't done this. I doubt you've had one of these either. But the folks that have these by get their sternum wired back together tell me that it hurts a lot to get back to routine, appropriate exercise. -- -- I do discourage people about doing that. "Lois," for example, said, look. - "Lois" shared her story. She's. She has "FH." She had high levels of "LDL." She was used to arguing with her doctors when they panicked over it. She was used to arguing with doctors who wanted to do stents or bypass grafts. But she shared on the channel or on the show that you know what the doctor was panicked, very emotional, and she looked over and her daughter was at the door listening to all this. And she said. I know, I don't want this, I don't need this. It's going to put me through a lot, but I'm just worried that it's going to put my family through a lot more if I don't do it. Well, "Lois" also had a genetic variation in her blood and her hemoglobin. When they gave her blood... immediately --- after the bypass, it almost killed her. And she was in a whole different place spiritually because when she and I met after that event, because the bypass, again, is not nearly as harmless or as safe as just a stent. Folks should remember that.

Say somebody is lucky enough to come across this video or one of your videos and say they're metabolically unhealthy, they're overweight, middle-aged, but they haven't gone the conventional route yet, and they want to get assessed properly to see the health of their vessels. What do you recommend? Thank you so much for asking it. I'm very excited, as in just right now about, about that specific issue. When we did the channel. Yes. The free content on "YouTube" was received very well. And as you might imagine, a lot of people started saying, hey, I'd like to come see you. - We've actually got a clinic now. We've performed this by telemedicine all over the world, were licensed in all 50 states. Won't go into the bunny hole and why that happened, but we see a lot of patients for that. But one of the things that's been a recurring problem from day one is... insurance is not going to pay for this... Again, a long bunny hole about multiple trials to make that work, including "Medicare Advantage." At the end of the day, 1 out of 10 people would call us --- up, would actually say, yeah, I can afford that. Let's go, let's do that. And most of them would say, gosh, that's just too expensive. It's always been a couple of thousand bucks to get the proper labs, to get started with us, to get stabilized. - Sometimes a little bit less, sometimes a little bit more. But I've always wanted something for people that didn't feel they could afford that. And now we have it... We've got a little kit. - It's a metabolic evaluation and you can do it right in your own home... It costs 160 bucks. Now, as you know, I know you know a whole lot about this community. You know that some labs "Function Health," different groups are starting to say here, you can get all of your labs drawn. We will give you a report on them and you'll know your metabolic situation, your metabolic health. - Number one. Most of those labs give you a bunch of things like "A1C." "A1C" is important, but I get people all the time. For example, you met "Jesus," my partner. And in the channel, his "A1C" has always been less than 4, but he's -- been metabolically unhealthy. He had significant pre-diabetes. He's one of those people that had a genetic variation in his hemoglobin. If he had not done this testing, he would never have known. Two of the most important tests on the labs are oral glucose tolerance test with insulin response. Other people, especially your viewers, may have heard of it. And as the insulin survey, the "Kraft" insulin survey, very similar to that. - We do in this box, a home oral glucose tolerance test. We also look at grip strength, which nobody knows why it's such a good predictor, but it is. We actually get -- over 30 different bio-indicators of your health. And here's the other thing. As you know, you've got a whole channel on this, over a thousand videos. Metabolic health is not a simple thing. It can be complicated. You picked up on a couple of nuances very quickly on the discussions you and I were having. - People get confused. They need a coach, they need a guide. And even with this $160 box that we've set up with the "OGTT" and the other stuff we give the patient and the person, you get an hour of time with that coach... to go over the results of your metabolic evaluation, understand your pros, your cons, your strengths, your unique weaknesses or needs, and then to talk about the next steps. So it's such a --- confusing area. - You and I sometimes may, you may not, but I forget sometimes how confusing this can be. People need help, they need a guide, and that's what you can get. The response to this has been really more than we expected. We've had to back off a little bit on... advertising and just keep it mostly to our community. - But we're gearing up, we're getting it to where we're able to offer it to more folks.

All right, so testing as part of that kit you mentioned, oral glucose tolerance test with insulin. What other lab work are you doing? Or is that it? So on the routine on the lab evaluation, one of the things that we add now, this is not in the box because the box is done totally at home. For folks that want to go deeper and say, yeah, let's go to the lab, we'll also get what we call fractionation. You're familiar with that? From your work, yes. Okay. So for your viewers' perspective, fractionation is actually looking at the bell curves, the distribution of "HDL" and "LDL"... Now you might be reacting at first and saying, yeah, but that's cholesterol. Again, I know "HDL" and "LDL" particles carry mostly cholesterol, but when you begin to look at the actual frequencies, the bell curves of each of those two, you get to find out something far more important, and that is triglyceride. And what's important about triglyceride? We go back to that very first thing that you and I were talking about. Too much insulin... stops your body's ability to use fats for fuel. And triglyceride, too high a triglyceride level is one of the outcomes. So some doctors, very few, but some doctors know to look at what we call fractionation. And then you have to use sometimes inside-out logics and things like that, but then begin to understand what role is insulin playing... in that individual's ability to burn triglycerides, to burn fats. So when you look overall, you step up to 30,000ft. We have some leading and we approach this like I did as when I was management at "Toyota." -- I was management there for about a decade and they said at my level, all of us had to get management coaching. And my coach said to me, I know you're a doctor, we know, we see all that. But I tell you, you think like an engineer and yes, I do think like an engineer. - When you get up to the level of saying, what are the best ways to evaluate. We look at leading indicators in an engineering sense, that would be your lifestyle. Then we look at current indicators that would be things like your fractionation and your "OGTT" with insulin response. Then we look at result indicators... That would be the "CIMT" that you brought up, we discussed. And "CT angiogram" with functional flow reserve, "CT angiogram" with "AI" analysis. So that's what we do on a regular basis. Our patients then, as we've discussed a couple of times, it can be very geeky, very detailed, very scientific and nuanced to go through all this, but our patients really develop a comfort level after just a few visits. Hey, I got this. I know what these things are. I know what my unique profile is. I know the buttons I need to push, the dials I need to turn.

Okay, just so I'm clear, so in the kit itself, you can do the "OGTT" with insulin at home with like a finger prick? One correction, there is no good home insulin test. -- I'm blanking on on his name. He calls himself the carb addiction doctor. You know who I'm talking about? Yeah, "Rob." He's been on the show. I don't know how to pronounce his last name properly. "Cywes," yeah, yeah. "Cywes." Ah yes. So "Cywes" and I are friends. He loves to argue with me about statins. I love to argue with him about stuff, too. Well, bottom line, he likes to argue. He does. He does. -- So "Rob" says he knows that somebody has done it now and it's coming out... That was a year ago, and this has been going on for over five years where somebody says, yeah, we got -- that home insulin test. Bottom line is they don't have it yet. So the test that we have for you at home does include the "OGTT." It does not include you have to go to a lab to get insulin or fractionation. It includes some things that you might not want to do especially, more female types look at body fat. It's got calipers to start doing some pinching and measurements on different places where -- you're looking for body fat. Some very simple tape measures to start looking at that. Then we start looking at heart rate, heart rate recovery, -- - genetics, family history... Again, we get over 35... in the mid-30s in terms of bio-indicators to help people begin to understand... what means what for them.

All right, I want to move into the "CIMT," which we've touched on a couple times. And then you mentioned the "CT angiogram." So who are these tests for then? Talk about a general overview of each. Okay, so let me go back maybe and get a little bit broader. - The original, we talked a few minutes about -- getting a stress test and then go into the cath lab and getting an angiogram. Let's back up and acknowledge that, gosh, what, 30, 40 years ago, a new test came out. It was called a calcium score. It is a type of I think, "CT" where they were able to adjust for the movement of the heart and they were looking at calcium in the arteries of the heart. -- That was another one of those tests where the cardiology community really had a hard time accepting it. -- - That didn't make a lot of income. - - It was a new test. You had to be willing to think outside the box to do that, but it still told you good information. Here's the problem with calcium score. -- It's one of the more common reasons for coming to see us. Somebody will have heard about a calcium score score. They'll go get it, and they'll have a positive one. They'll have over a thousand, two thousand, three thousand, four thousand even, and they decide, oh my gosh, I'm dead man walking. They come in and see us. We use other things too, because we know that calcium is actually stabilization. The assumption that a 1000 calcium score means you're going to die is also based on the assumption that you haven't cleaned up all of your plaque, so therefore you have a whole bunch of -- soft plaque there. That's not always the case. In fact, these people with these really high calcium scores do tend to be people that have gotten religion, lost 30, 40, 60 pounds, and have stabilized and calcified all of this soft plaque that they had before. Now there's been another test which said that to set up this item, this understanding. So really what we want to know is not so much calcium. We want to know soft plaque. Does that make sense? Yep. Well, I do want to come back to the hard plaque, but yes, for now. Okay, so... is there a test that will show us soft plaque? And in fact, there has been -- one for a long time... It's called "CIMT." Carotid, this is the carotid artery. Intima, remember that lining of the artery wall where... "Fettke" was talking about the -- glycocalyx, which comes off of the intima and I was talking about the intima. So carotid intima media. Remember the media is that muscle layer. So you're looking in between those two. Remember I said the plaque is not really inside the artery wall, it's in between those two layers. A "CIMT" is a harmless... ultrasound technology. There's no radiation... Costs 2 to 400 bucks compared to most of the other technologies that cost thousands now. -- And it tells you something that you don't get from a calcium score or a stress test or most other technologies. It tells you soft plaque. And that's what we really want to know. Now, if you're sitting there listening, thinking, yeah, but this is up here I'm worried about here. Well, two counterpoints to that... up here also gives you risk for a stroke. And the other counterpoint, which is even more important is this is a metabolic issue. It's not an anatomic issue. If you have it here, you're going to have it here and everywhere else in your body. Because glucose problems, inflammation is a metabolic problem. It's not a localized issue. So that's the "CIMT" carotid intima media thickness program. And you look to see how thick that space between those two layers is. There was a big study with over 10,000... people in Italy at a place called "Cafe di Caves." It looked at it and here was the question. They knew that if they had enough plaque to interrupt flow, that that created risk. The question was, what about people that had plaque but it wasn't enough to interrupt flow? And they did that. They looked at it and found out, sure enough, major increased risk. If you had plaque, even that was not enough to interrupt flow. Well, since then, in more recent studies, the Oh, my gosh, it was one of the Ivy League prevention programs. I'll probably think of it later. - But they have said the same thing. Look, two thirds to three quarters of heart attacks occur in people that have plaque. But it's not enough plaque to cause a problem with flow. Hence the reason why a stress test doesn't predict a heart attack. So you start looking at that and yes, you would think it would be valuable. You'd think a ton of people would do it. But here's what happened... It was a problem of garbage in, garbage out. - I won't go down the bunny hole of the technology, but a lot of people did these studies with "CIMT" and basically did not know what they were doing and put a lot of garbage into the literature. Academic centers, other centers that had good quality control, had great evidence coming out of it. -- There has been back and forth, up and down. My friend "Todd," who runs a program doing this, has actually testified to the standards committees on this. They get closer to accepting it and using it. And they have done that. They do accept it now. But then out of the blue comes a whole new technology, "CT angiogram" with "AI" now, "CT angiogram." It's a "CT" you remember, like the "CT" calcium score, but it's a whole angiogram where you inject dye. -- It actually shows the anatomy. I personally have been afraid of it because when you see the anatomy that good, you're likely to say, hey, wait a minute. If I just put a stent right there, I'm going to fix the problem. And it turns out that at least among my patients, I'm not really getting that kind of reaction. What's happening is people are looking at the right thing. They're saying, hey, what should I look at? And here's what they should look at. Once you get "AI" analysis involved with this process, number one, the quality of the program, of the result improves greatly. In fact, I would advise people, anybody that's getting a "CT angiogram" now, if you don't get it with "AI" analysis, then you're really doing yourself a disservice. Once you get that what you want to look for is what you and I have already been talking about. You want to look for soft plaque and the amount of soft plaque that you have. So what's going on with my patients now is basically on an imaging perspective. - If somebody's got relatively little risk, my advice is you don't really need... to do a "CT angiogram." It's a couple of thousand bucks. On the other hand, if you're -- so inclined, it's not. It doesn't hurt people. -- And when you get one, if you have major risk, most of us would agree, yeah, you probably ought to repeat that annually... What we do in our clinic is most people in our clinic don't have major risk, and most end up doing one of these every three to five years. That's what the cadence is going to be. And on off years, they're going to get a "CIMT."

When you were talking about "CIMT" there, you mentioned the fact that carotid artery is good to look at because it gives us an idea of the whole arterial system. Which for me, brings up the veins. Yeah. And given everything we've talked about today, why are they not affected by all this? There's a couple of things to think about with the vascular tree. We had a patient or no, a viewer on our live today's Friday just yesterday asked the same question. He said, why not veins or why not pulmonary arteries? Well, think about it. Veins and pulmonary arteries have very, very low pressure. - Even the pulmonary artery is going to have 20... veins are going to have even less. And you and I are probably, your blood pressure is probably a little bit lower than. Well, actually, mine's corrected to 120 over 80. So those are the kind of levels when my heart's pushing in and the arteries are pushing down. It's up to 120 millimeters of mercury. When it's relaxed, it's still up at 80 millimeters of mercury... in the... arteries of the lungs, 20, 25. And in the veins... too. You know just enough to get back up to the bloodstream. So when you think about plaque and how it forms, you remember we talked in the beginning that you get some injury to that lining and cholesterol starts to transit those or to go through that damaged glycocalyx, through that lining cell, but it can't go through that muscle layer, the media, so it gets stuck there. You remember that? Yep. So that's really only going to happen mostly you're only going to get significant plaque formation, mostly in these... arteries that have significant media or muscle covering in which it's 120 over 80 kind of pressure. All right, makes sense.

Before we move away from testing, we went deep into conventional versus the way you do it. Even within the way you do it. And talking about a lot of the great tests that are out there today. We did get into a lot of detail. And I want to make sure people who are... leaving this feel like they understand the basics. So we'll say somebody who is middle-aged, they feel metabolically healthy, but they want to look at their vasculature... and determine whether or not there are problems there and plaque buildup. What are the basic, basic tests they could have done? So it depends on whether you go to you do lab tests or not. -- Let me just say this one thing, and I'm not sure whether you meant to use the term or not, but it gives me an opportunity to bring it out. Nobody has ever felt plaque forming in their arteries. No, I didn't mean it that way. And I know that. -- I just mean somebody that feels metabolically healthy. I know you know that. Somebody kind of like me. I feel metabolically healthy. I'm middle-aged. Yeah. What do I need to do... as somebody that wants to be preventative? And again, given the fact that we don't feel it without going overboard and overwhelming people, what are the great tests that we can do and still keep it simple to figure out whether or not we have any issues cardiovascular wise. So I'll go back to the box that we talked about a few minutes ago, and that's focused on somebody that says, you know what, I don't want to go to a lab. I don't want to spend 500 bucks. I want a good, practical answer. And you'll get that for less than 200 bucks right there at home. Now, let's say you want to go to a lab. Then I'd add a couple of things to it. - The insulin response. Remember, you can't get insulin at home. I'd also get the fractionation in terms of labs... So those together are going to add maybe a couple of hundred bucks more. And -- let's say you got a couple of hundred bucks more. And you really want to know. I would get a good "CIMT" at that point. You know, so you said you're what, in your 40s? Early 40s, 42. So I think that hopefully that helps you in terms of. --- Do you know, how about your audience? What age groups are your audience? When I look at the "YouTube" stats. The biggest group is actually 65 plus. Yeah, mine too. So older group. Yeah, mine too. - So again, for 65 plus, you've clearly got the risk. We talk about 90% of the adult population having at least one sign of poor metabolic health. --- That speaks to another component of do you really feel like -- you're metabolically healthy? -- It reminds me that you may. You've seen the "Dirty Harry" movies or any of them? I haven't, I know of them. I should see them. The most famous quote out of it is I've got six chambers in this gun I fired four. Are you feeling lucky? I've heard that one, yeah. - And this is again, you got to ask yourself, if 90% of us have some problem with this, are you really feeling that lucky? Do you not want to test? So I'm glad you brought the question up. Okay, so your kit fractionated on top of that, fasting insulin on top of that. That goes along with the, well, not fasting insulin. Insulin on top of the "OGTT." And then the "CIMT." Yes. That would be the complete baseline kit we'll call it. "TT," correct. Very detailed pickup, especially on that difference on insulin, because we will pick up another 15% of people with problems who have a perfectly normal "OGTT." And these are people who their pancreas is working harder and they're putting out too much insulin to get the response that they need. So, yes, you're exactly right. Start with the kit. If you've got a couple of hundred bucks more, go ahead and add insulin response to that "OGTT" and fractionation. And then if you got a couple of hundred bucks more than that, usually 3 to 400 bucks more, get a good "CIMT." And you may want to call our office before you get a "CIMT" because there's a couple of things about imaging groups. A lot of people will come to us and they'll say, oh, I've got my "CIMT." They called X-rays are us across town. -- They said, yeah, we do those, we do ultrasound, we do ultrasounds of the neck all the time. And what they actually got was an ultrasound of the neck. "CIMT" actually involves some more technical "IT" evaluation... of the specific imaging. And don't waste your money, make sure that you get the right kind. You don't want garbage, you want a good test. -- Those are some of the things to think about. And I appreciate your focus on the details and your ability to pick up nuance.

What I want to do here, before we part ways, is come back to the 30,000-foot view of what we've talked about, which is to maintain cardiovascular health, we want to control our metabolic health. And to do that we want to regulate our carbs, which is going to control blood glucose and insulin. But let's get into more detail what that would include somebody again, relatively healthy now. They've listened to this point and taken a lot of information in, but they want to do the 80/20 when it comes to prevention and taking care of their cardiovascular health. Other than the lower carb, controlling blood glucose, controlling insulin, and again, the thesis of metabolic health within all of this. What other pillars should they look at? - The way you phrase this question, "Jesse," reminds me of something that I probably should have brought up a minute ago. Get a "CGM" continuous glucose monitor and eat to the glucometer. And then once you find out what foods may tweak you. - And also don't say, okay, that peak only went to 120, so I'm fine. A lot of people, that's why we get insulin response. A lot of people get really high insulin responses, but they're still keeping their blood sugars low. So get a "CGM." Even in early 40s, I would clearly get one of those. There's no question. And if you want to use one of the prescription-level ones, I'll be happy to write the script for you. I feel very strongly about people doing that. You have to pay for it. Insurance is not going to pay for you because they want to wait until you get really, really sick and diabetic before they will. -- But get --- a continuous glucose monitor.

Okay, diet aside. Now we have the pillar of again, maintaining blood glucose. "CGM" is a good way to look at what's happening there. Mmhmm. Mmhmm. What about fasting? We've talked about exercise, but let's bring fasting into it and then other big pillars that contribute to metabolic health. So really good point. The big three are diet, exercise and sleep. Then you get into things like environment. Now I saw your interview with "Robert Lustig" about a year ago, right after you did it. He came on with me a few months later and he had just published a great article where he was talking about the four types of obesity. The bank account, calories in, calories out, what you and I tend to focus on more on carbohydrate, insulin model, the... oxidative model, which gets more into my space, more high-tech, deeper medical evaluation of inflammation. But then the fourth one was obesogens. -- The environment really is. - There are some obesogens out there and they're right there in a lot of people's homes, like black plastics and... phthalates and things that people use to make it easier to wash their frying pans. So there's a lot of that. So be aware of the ways that you can get into this problem. Go back to the basics. You asked about... fasting. Let me give you a vignette about that. A lot of people come to me and as I mentioned before, have already lost 30, 35 pounds. And I always ask them how they did it. Almost all of them will say the same thing. Well, the first thing I did was I cut carbs. The second thing I did was intermittent fasting. And technically intermittent fasting just means closing your eating window almost... And it's preferable to do it for dinner, for supper, the last meal of the day. Almost everybody does it breakfast, just because we're humans. -- They'll ask, well, what do you think is the next step? And I always ask, well, have you ever done prolonged fasting, 24 hours or more? Oh no, I'm not going to go there. We have a lot of people that do it, but for every person that does prolonged fasting, there's probably a hundred, maybe 200 that'll do intermittent. But prolonged fasting is a great way to reset your metabolism. - As we mentioned before pillar number one is diet, pillar number two is exercise. As we mentioned before, it's not just going out and jogging like my generation learned 50 years ago. There's been crossover study designs, head-to-head comparison. Every age group, 30-something, 50-something and 80-something people. - And for every group, high-intensity interval work was far better at dealing with metabolic disease than anything else... A relatively close second was resistance training. A distance third was aerobics. So consider that as you're building your exercise program. Also consider what the weightlifters know. Your legs are going to change your metabolism. Not your arms. So then you get into sleep. If you haven't read the book by I'm blanking on his name "Why We Sleep." Have you heard of that book? "Matthew Walker." "Matthew Walker." Yeah, you're right. -- If you haven't read that, you should. And the greatest quote in there is in the intro where, hey, if you can go to sleep listening to this book or reading it, more power to you. I've accomplished my work. Sleep is critical, especially for boomers, guys my age, and especially for folks with prediabetes. It starts with basic sleep hygiene and then it goes beyond... I've got a long, long story about my own sleep, it's a battle. ---- Once you get beyond sleep. Then again, we talked about environment and we're talking about "Robert Lustig" and obesogens. Then stress and... relationships. Relationships are, I think it was,. I can't remember his name. One of the recent - surgeon generals wrote a book about how this is becoming the lonely generation. -- We do need to have an acknowledgment for mental health. Stress is very much related to cortisol, and as you know, cortisol drives metabolic disease. So those are some of the things that we need to be thinking about. You noticed medications have not made it into the list yet. They're this far down. Eight and nine supplements, the same thing. They're -- clearly evidence. They can work. They can help in certain situations, especially when you get my age and you're fighting that uphill battle. But -- it's the other stuff first. And the other thing you'll notice is that stents and bypass grafts didn't make it in the end of the cut.

All right, "Ford," we're going to leave it there for today. We're going to link up your "YouTube" channel, your book, your social media, everything in the show notes, great conversation. I appreciate you. The work you're doing, it's ever so important. And thanks again. Thank you a lot. I appreciate you having me. Now that you're done, you're going to want to stick around here and catch this other incredible episode. You don't want to miss it. I'll see you over there. And people are getting more comfortable in saying that a high "LDL" cholesterol in the setting of metabolic health is not something that needs to create