Transcription
The Health Care System wants broad guidelines that are easily applied. And the reality of the situation is that for most people with elevated LDL cholesterol, that's going to be combined with metabolic disease. As I said earlier, 90% of adults essentially are metabolically unhealthy. So for most of the people with high LDL, they have that very dangerous combination of metabolic disease and high LDL.
But I think it's incumbent on us as practitioners to also figure out who doesn't fit in that situation. You know, who are these people that have a high LDL but they are metabolically healthy? They're not insulin resistant, their particles look good. And so for those people, there's really no reason. There's no data that we have that shows that lowering their LDL is of any benefit, and there may actually be some harm associated with that in some of the studies we look at.
I love that. I'm glad you hit on the fact that there are a large subset of the population that have high LDL in addition to high triglycerides, low HDL, insulin resistance. In those situations, do you recommend statins or do you focus more on the insulin resistance and weight loss? What is the best clinical track because that's, as you mentioned, very common.
Yeah, so and that's exactly the conversation I have with patients in that situation. Um, yes, you can take medications to lower your LDL. There is going to be a small benefit, and understand that that benefit is a lot smaller than it's purported to be. Um, and you're exposing yourself to the risk of, you know, taking these medications or doing the dietary interventions. You know, you can say, "Okay, low-fat diet. It's going to lower my LDL, but at what cost?" Right?
You know, uh, taking—interrupt there. The cost meaning hormone issues, brain issues, memory decline, diabetes? What's the, the consequence of lowering your LDL with say statins?
Um, so with statins, again, the medications, yes, exactly. You know, we know over the long term, for instance, that statin use more than 10 years increases your risk of developing insulin resistance and type 2 diabetes, which are two primary drivers of heart disease. So this is why I think the statin data is so disappointing when you really look at it objectively. You know, again, the absolute risk reductions in heart disease, um, for people taking statins over long periods of time are minuscule. They're like 1%, 2%, 4% in the best studies, secondary prevention, people already had a heart attack.
Um, but of course, as you know, you're well familiar with, and a lot of your audience is well familiar with, um, you know, we manipulate the way that this data is conveyed to the public and to practitioners. We use relative risk reduction instead of absolute risk reduction, and it makes it look like there's a greater effect than there actually is. So that's the conversation I have with patients. I said, I say, "Yes, you can take these medications. You can expose yourself to the risk of the medications, or you can change the way you eat. You can deal with the true underlying problem, insulin resistance." And that does cause a much greater magnitude reduction. Um, and, you know, if you fix your insulin resistance and again, you shift those lipid particles to the large, fluffy, healthy LDL particles, now again, you're in that situation where the medications aren't going to be any benefit. So you don't have to worry about them. And most people, when they're given the option in that way, they're like, "Sign me up. Tell me what to eat. You know, I don't want to take a medication for the rest of my life."
Yeah, especially as you mentioned, the absolute risk reduction is single-digit percentage. So we're talking about very, very small. Do you think some of the benefits of statins are the indirect, so-called pleiotropic effects of anti-inflammatory and this and there's a million other ways to reduce inflammation? Is that part of it?
Yeah, definitely. So, you know, inflammation is a very important part of the development of heart disease. Um, and, and, uh, so statins do have an anti-inflammatory effect. But as you said, there are much better ways to lower inflammation without taking on the risk of statins.
Sure. Uh, along the lines of statins, and not to pivot too much away, I want to continue this trajectory a little bit. Um, but I was really surprised when I started work with a medical doctor in Colorado, work, uh, seeing patients on a nutritional perspective in his office, Jar Gillery, and many of these patients had high lipids and high blood pressure, and they were given beta blockers and thiazide diuretics, which, as you know, also have the same consequence as the statins do in in exacerbating insulin resistance. And I, I thought that was just so perplexing to me that the very conditions that are being used probably for to to mask the symptoms that are manifesting from their insulin resistance, IE high blood pressure, were causing more insulin resistance. So can you speak to the people right now because there's many people still prescribed thiazide diuretics and beta blockers? Um, maybe having a conversation about looking at something like an ARB or calcium channel blocker or ACE inhibitor?
Yeah, and really two parts of that conversation. Cuz again, high blood pressure is a huge missed opportunity. You know, the vast majority of hypertension, high blood pressure, the root cause is insulin resistance, metabolic disease. Again, so instead of just, you know, using the medication, putting a Band-Aid on the symptom, let's look at that root cause. Um, and, you know, so again, patients that come to me with high blood pressure, um, often times we're able to get them off their medication when we get them, when we fix their insulin resistance, when we get them metabolically healthy, their blood pressure improves, and you can usually reduce or eliminate the medication.
Um, but I would agree that, you know, there may be better medication options, other alternatives like, um, ACE inhibitors or ARBs, um, ACE receptor blockade, um, that, uh, might have advantages over beta blockers, over diuretics. Um, and again, most doctors, they're not trained to think this deeply about it. You know, they have the guidelines and, uh, they're kind of checking boxes off on the guidelines, and they're really, uh, quite frankly, not knowledgeable enough, and they don't have the time to think about all these things. And that's that's where the systemic issues come into play again.
Yeah, I'm glad you mentioned that because many of these doctors are really well-intended, but to get paid or reimbursed, especially if they take Medicare, you know, they're spending hours and hours documenting, and they're just so backed up, and it's just incredible the documentation and things like that, which is really, really challenging. So, um, the oxidation of LDL cholesterol, do you like to look at the ox LDL panels? I know Cleveland Heart and some others are coming up with this. Let's just say someone's a little scared. You know, they're low carb, their HDL is low, or sorry, their HDL is high, triglycerides are low, but LDL is a little high. They're concerned about this. Do you look at LDL oxidation? Is that something that's clinically useful?
Or do you? Yeah, so I don't, um, I'm not a big fan of the ox LDL test. Um, and the reason is that it, it tracks with your LDL. The more LDL you have, the, you know, the more oxidized LDL you're going to have. So we run into the same situation where, you know, a patient will get tested for that, their LDL is very high, their ox LDL by the, you know, lab normals is high, but as a percentage, you know, it's actually low when they have, you know, when they're not insulin resistant.
Um, so I don't find ox LDL ends up adding much, uh, above and beyond if you're looking at their particle sizes. Um, now, uh, there is one lab company that has a sort of indexed oxidized phospholipid test where they, it's oxidized phospholipids, um, divided by ApoB. So it's sort of controls for that a little bit. That may be a better, uh, indicator. But ultimately, you know, when you, um, if you combine, um, an advanced lipid panel and NMR panel, that's going to show you your particle sizes, you do an insulin level and some assessment of insulin resistance, and that can be something like a HOMA-IR calculation, that can be the lipoprotein insulin resistance score, LPI-R, which I am a very big fan of. Um, you know, and you check some inflammation markers, something like CRP. Uh, that probably, that gives me enough information, um, that I really don't necessarily have to go to the ox, uh, LDL test.