Vascular Surgeon: 25 Common Foods That Trigger Heart Attacks

If somebody eats butter every day, that's going to kill the heart. Not all saturated fats behave the same way. Whole fat dairy do not seem to be particularly harmful.

Do you think that oatmeal is always heart healthy? Not always. Dried fruit is candy.

What do you think of sourdough, white bread, and whole grain bread? It's just a hard no.

Dr. Lily Johnston is a vascular surgeon. Today, she'll reveal the three tests that catch heart attacks early and the 25 foods quietly wrecking your health. Wait, hang on. So, if you don't floss, you can get plaque buildup leading to a heart attack. I became a flosser when I learned this. The answer is never just here's your stat and please come back and see me in a year. Let's test the broad spectrum of what's going on with you because for most people, it is not just one thing. If you have a CAC of greater than 300, you might as well have already had a heart attack or stroke for your risk.

Cholesterol, is that a problem for the heart? It's a problem for some people. And I know nobody wants to hear that. If you get less than 6 hours of sleep a night or more than 9 hours of sleep a night, you have an increased risk of heart attack and stroke. Heart disease kills more men and women annually than every single cancer combined. Now, that isn't opinion, it's the data. As a health researcher, I've spent my time digging through all of these stats. But my guest today, Dr. Lily Johnston, sees the patients behind these numbers every single day, and they're suffering. And fair warning, the food that you're eating right now is directly linked to your risk of a heart attack. Dr. Johnson is a board-certified vascular surgeon with decades of clinical experience. And today, she'll explain the absolute worst foods that can trigger a heart attack, the controversial truth about LDL cholesterol, and the 10 specific labs that you must demand right now to know your true risk. And if you want to take control of your health when your doctor can't, a very easy step is to hit the subscribe button because next week I'm sitting down with Professor Tim Nos to prove where our bodies are not designed to run on carbohydrates.

So Dr. Johnston, my first question, you are a board-certified vascular surgeon. Do you think that heart attacks are preventable? Thanks for that question, Reena. You know, as a vascular surgeon, heart attacks are not actually directly in my line of practice. I deal with every other blood vessel in the body. However, we know it's a systemic disease. So, the plaque or the junk that builds up in the arteries, in the legs, and in the neck that I treat as a surgeon also builds up around the heart. And I have now devoted most of my practice to trying to prevent all of these things. So, whether that's a heart attack, a stroke, or cramping or pain in the legs, or potentially wounds, or even amputation, all of this is the same disease. And we do believe that it's preventable, but it kind of depends on when we start because this is a disease that evolves over many many years, probably decades. And our risk factors begin in childhood, right? We get exposed to things for our whole life. And part of the struggle that I have with my patients is many of them don't come to a place where they're really able to focus on their own health until midlife. And even though they've done everything right now at 50 or 60, you know, they're they're still struggling with all of the exposures that they had earlier in life. And sometimes we need a bunch of different tools to be able to kind of counteract that risk that has built up over a lifetime.

Doctors say that saturated fat is going to cause heart attacks and strokes. Do you think as a vascular surgeon that somebody eats butter every day that that's going to kill the heart? This is a loaded question because I've seen both sides of the of the argument, right? I have read the big fat surprise and I have taken a good look at the the Sydney heart experiment and the Minnesota coronary experiment and I have read the primary prevention literature on the cardiology side and gone to the meetings where they say that, you know, if you're not a vegan, you're just not paying attention. And here's the thing, fats, carbohydrates, like these are big terms. Saturated fat is a whole bucket of different molecules. They are different lengths. And what we know is a couple of things. Not all saturated fats behave the same way. So certain ones, for example, from whole fat dairy do not seem when we look at the population level to be particularly harmful. uh we know that in older experiments in the 60s and 70s there was a lot of confounding with trans fats. So you know we just didn't understand at that time what the trans fat problem was and so some people were getting trans fats in these experiments and that's on both sides of of intervention and controls. But we've learned a lot about this and it really matters. The other thing we know is it really matters what you're replacing it with. Are you replacing it saturated fat with refined carbohydrates? Are you replacing it with highly uh processed other things? Are you replacing it with some high polyphenol monounsaturated fatty acids? These are complicated questions, right? So, if you are coming to a way of eating that has relatively high saturated fat, but it has solved all kinds of problems for you, right? It has reduced your inflammation. You've controlled your autoimmune disease. You've controlled your mental illness. Whatever brings you to a way of eating where you may have a higher saturated fat content in your diet. Let's talk about the risks and benefits because every intervention has risks and tradeoffs. Okay? I will never take away a ketogenic diet from somebody who says, "I am off my diabetes medicines. I am off my anti-depressants. I am sleeping like I haven't slept in years. I feel amazing. Okay, fine. That's great. I'm so happy for you. We have fixed like four things that might have led you to have a heart attack and a stroke. And we don't know that it has made your risk any higher, right? But we can look and we can see and then we can talk about whether there is one trade-off of this way of eating that might be worth addressing, right? And the the unspoken thing here would be lipids, right? Has it changed your lipid profile in a way that's a problem? We don't know until we look. It does not for everybody. But if it did, let's evaluate it. Let's get data for you as an individual and talk about what would it take because low carbohydrate, ketogenic diets, this is about again this macronutrient. There are vegetarian keto people, right? It just means that you are reducing your total carbohydrate volume, but it doesn't say what you're replacing it with. There are as many ways to do a ketogenic diet as there are to have a regular diet. So, every person will come to their own approach to this. You can have a very whole food nature focused approach to a ketogenic or a low carbohydrate diet and you can have a trash version of a whole food plant-based diet. I have seen it all. So, this really just depends on the bigger context and the overall nutritional pattern much more so than the macronutrients in my opinion.

Very complete answer. I think it's important to understand that, you know, butter is not bad in isolation, but if you're eating donuts and butter, it's probably not going to be a good thing, but if you're having red meat and butter and limiting the carbohydrates, it's probably going to be a great thing for your heart. So, the context is very important for that person. And that goes to the worst foods that people eat. I have 25 here which I'll get to in a second. But what do you think as a vascular surgeon is the single worst food that you see your patients eating every day that's going to cause them to have a heart attack? It would be anything that comes fried basically, right? Because whatever is come and again, right, if you are pan frying your salmon at home, we're not really talking about that. But if you're telling me that you're, you know, pretty good for 4 days out of the week and then Friday, Saturday, Sunday, you are out at a restaurant eating like the blooming onion that's been deep fried. Uh, we know those oils have been recirculated. like whatever you want to say about oils, if they have been heated and over and over and over again, like those are oxidized. Those are not great. Um, and like somebody told me the other day, well, it's an onion ring, it's a vegetable. I'm like, yeah, not really what we're talking about. If you tolerate vegetables and if we're talking about improving your uh intake of vegetables, that's not really where we're going with this. So, you know, if you want to eat out at a restaurant, okay, I get it. This is a huge part of some people's lives, but please try to stay away from anything that's been in a deep fryer.

Interesting. I didn't have that on my list, but so um a bloom and onion. So, an onion that is fried and deep fried probably with some crumbs and some carbohydrates. So, anything fried we should stay away from. Um so, let's try to understand the types of plaque that's in our arteries. Now, this is arteries throughout our whole body that can lead to a heart attack or a stroke. Do we have plaque? Does everybody have plaque in their arteries? Like right now, we don't totally know the answer to this, but uh there was a great study called the Peso study, and they took a look at people in their 40s who were otherwise quote unquote healthy. They had not terribly many risk factors. They were not diabetic. And they took ultrasounds to the arteries in the neck called the corateed arteries, the femoral arteries in the groin area. And they looked for what we're going to call subclinical, meaning does not have symptoms, does not have a diagnosis or a disease yet, atherosclerosis or the formation of plaque. And yeah, um almost half had some undetectable plaque. Now, we are probably all, if we live long enough, going to get some plaque. This is not by itself a crisis of epic proportions, but it depends on how much and what happens to it, whether it is really vulnerable plaque or whether we can generally kind of stabilize it. For example, we know that endurance athletes tend to have a little bit more plaque in their arteries than you would expect from somebody who's typically quite fit. Now, there are a couple of possible explanations for that, but they also have a lower chance of getting a heart attack relative to a sedentary person with the same plaque burden. So, let me make that as an example. If you take a mast's athlete who has been doing triathlons for 30 years and he has a calcium score of 300 and you take an age matched person who you know uh rides their bike once a week but is not super active and he has a calcium score of 300. The person who sits on the couch has a pretty high risk of having a heart attack in the next 10 years based on that calcium score. The athlete also has some risk. It's not zero, but it's much lower. And again, plaque is is kind of the result of a lot of different things. We talk about heart disease like it's one disease, but it's really not. It is the end stage of many different kinds of disease processes. For example, the people who form a lot of plaque related to diabetes seem to look different in my practice than the people who form a lot of plaque from smoking. Both of those are bad things. We absolutely understand this. But it's not quite the same disease. It ends up the same way in terms of junk that builds up in the arteries, but they came to it through different pathways. Inflammation is its own pathway to disease. Now, we never really have it so clean where people only just have the very one risk factor. Usually, we have multiple risk factors. But if you look at people who've had a heart attack, over 90% of them have an identifiable risk factor beforehand. Whether that is high blood pressure, a history of smoking, a history of blood sugar problems, right? We can go back and look, but most people who have a heart attack have at least one risk factor coming into that event. So, this is to say that the plaque buildup comes from lots of different pathways, but it turns out that the impact is the same. So, when do you develop plaque? If you're starting to develop plaque in your 80s, I'm not that worried about it, right? It's probably not going to result in a huge problem for you. And that's probably the natural aging process. Uh if you are starting to develop a fair amount of plaque in your 30s and 40s, the odds of that becoming a real problem for you are much much higher in your lifetime.

So the different types of plaque. So there's soft plaque and hard plaque. Which one leads to a heart attack? So plaque has a timeline with it. It's all kind of the same thing. It's about when you have the plaque and when is it a problem. So heart attacks we believe most of the time come from the soft plaque. Now that is typically earlier stage plaque. So if you think about kind of the timeline of what happens right we start getting thickening in what we call the subendothelial space. It's not a great name but it is the uh lining of the artery wall. So that begins to get inflamed. the lipid lipoproteins get stuck there and when they get stuck there they oxidize. Uh they rust and then the smooth muscle cells start trying to kind of fix that and pave it over and over time we sudden we suddenly develop what people think of like this volcano, right? And early on it may not be very stable as it's as it's developing. And that a little bit depends on how much oxidation and inflammation is there, how rapidly is it growing. These are all things that we are evolving our understanding of as our techniques and tools get better. But it's that soft, vulnerable, very lipid rich plaque. And it you can think of it like again this um unstable volcano or people talk about it like a pimple which is gross but sure it's gross. It's full of this unstable lipid rich stuff. And there's a little cap over top of it that is separating it from the blood going through the blood vessel. that little cap if it erodes or pops now all of a sudden that junk ruptures into the artery the body's like oh no this is a problem and it tries to contain it so it gets a bunch of platelets which are sticky things that help blood clot right on top of that to try to seal it down but that can actually suddenly block off the whole vessel so this is the plaque rupture event that accounts we believe for most of heart attacks strokes uh and maybe even acute limb problems And this is from the soft vulnerable plaque and a very thin cap. Now if we are managing our risk factors, we can actually transform that soft vulnerable plaque into one of two things. We can regress the plaque. Sometimes it actually gets smaller and the body will absorb some of that material from the inside out and it will just shrink back down. The other option is that we actually solidify it. We make that fibrous cap nice and thick and strong and we eventually may even deposit calcium in that plaque and that calcified plaque is we believe now having imaged many many patients and looking at this we believe the calcified plaque is much more stable. It is unlikely to rupture because it's really just solid hard and rocky. It's that dormant volcano that's not going to do anything at this point. So this is why things like calcium scores are a little bit nuanced, right? Because it's detecting the calcified plaque. Well, that plaque is actually pretty stable. But we know that again plaque is on this spectrum. And if you have some calcified plaque, you probably also have some other newer plaque that's ongoing that is not stable yet. And that is really what the calcium score represents. So you think of it like an iceberg. The calcium is like the little piece that you see. And that's what a calcium score detects is just a little bit above the water. But what's underneath, and it's not really underneath the calcified plaque that you're seeing, but it's elsewhere in the body, is all of the earlier lipid rich plaque with that thin little cap that's just about to rupture. So if there's a lot of calcified, we believe there's also a lot of that plaque that is vulnerable and soft and gross and sticky. Um, but if you are working on your metabolic health, if you are working on reducing your cardiovascular risk factors, you can convert that soft vulnerable plaque to stable plaque. And then it's a little hard to interpret, right? Calcium scores go up. Is that bad? Is that good? It really depends. And at the individual patient level it we just don't understand. So this is why other imaging techniques like CT and geography where we actually inject die and we see the whole arterial system with the soft plaque and the calcified plaque or a corateed ultrasound even a femoral ultrasound where we look at the soft plaque and the hard plaque we can see both. That's why these tools are evolving into the prevention space because they give us a much better perspective on overall risk.

Well, you're all about test don't guess. Um because we can prevent heart attacks and strokes by testing and not guessing to see if we have plaque in the arteries. So, we're we're going to talk about the three tests that you would recommend. Um but let's understand firstly what is causing the plaque buildup in the whole arteries. What is the role of elevated insulin in plaque and clots? Hyperinsulinemia. So too much insulin which usually results from too much energy and for many people that is too much carbohydrate. Although there is some evidence that even too much fat can cause insulin resistance believe it or not. Uh now let's get back to the question. Too much insulin circulating because of excess energy from whatever cause begins to downregulate nitric oxide. And nitric oxide is a molecule that dilates and relaxes our blood vessels. So, just like you would like a person that you meet on the street to be like nice and relaxed and cheerful and happy golucky, you want your blood vessels to be nice and relaxed and able to go with the flow, right? Pun intended. A stiff, rigid, unfriendly blood vessel has no nitric oxide. And just like somebody you meet on the street who is rigid and like not able to be flexible or friendly or fun at all, like that's lame. You don't want that. So, nitric oxide is great. and too much insulin will downregulate it and make your arteries more stiff. We also see that uh the hyperinsulinemia and too much glucose can downregulate something called map kynise and that will create a situation where those smooth muscle cells in the artery wall more likely form plaque. they do something called transform and they they be become a different type of cell that like forms the plaque instead of just being a regular blood vessel muscle cell. So all of these things do absolutely contribute to the formation of plaque.

Do you think that cholesterol, too much cholesterol, if somebody's following low carb ketogenic lifestyles, is that a problem for the heart? It's a problem for some people and I know nobody wants to hear that. Nobody wants me to say that. I make everybody unhappy. I make the preventive cardiologists really unhappy because I don't tell people they absolutely have to stop eating meat or eggs. And I make the keto carnivore people really unhappy because in my patients who already have plaque, cholesterol is relevant. Now, we can decide how relevant it is and whether it is worth it to you to treat it with medicines, with supplements, with changes in your nutrition. That is a very personal decision. It is not my job to make it for you. It is my job to tell you at the population level what we know and in some people especially if you already have a fair amount of plaque. Your lipid levels your atherogenic meaning plaque forming lipoproteins the apo molecules that we have circulating in our bloodstream are fuel for this fire. So you uh may have heard me give this analogy before, but plaque is a is a forest fire. So changing your metabolic health changes the weather. It changes the humidity. It changes the likelihood of that fire, your forest, excuse me, igniting and going up in flames. But the apo particles are the trees. They are the fuel for that fire. So, the fewer trees you have, the less likely you are if lightning strikes or somebody leaves a campfire burning to have this ignition process. Now, does that mean you go cut down forests all the time for everybody? Probably not. Changing the weather is by far the best thing for most people in the prevention space to help reduce the chances of plaque, heart attack, stroke. Now, if you already see smoke, the fire is already burning, right? This is plaque and a high level of it that's potentially going to rupture, potentially going to keep growing. This is a what we call a feed forward process. There are already oxidized particles in that artery wall that are going to oxidize more particles, and the more particles you have circulating, the more likely that is to keep growing. So, we have to put out the flames. And that might mean cutting a fire line in that forest, reducing the amount of fuel for that fire, reducing the apo particles if you already have a lot of plaque. If you do not have plaque and you want to talk about is cholesterol reduction important in prevention, it's a possibility and it is there is evidence that would support it. But the question is at what cost? Again, our every intervention whether it's nutrition, whether it's exercise, whether it is changing your lifestyle, whether it is medications, whether it is supplements, they all have benefits and trade-offs. So, the question becomes, what are you willing to trade off? How much risk are you willing to take? Now, as we've discussed, while changing what you eat is the first step in fixing chronic inflammation, we also have to look at the light environment that we live in. Because we evolved to be in the sun, receiving a full spectrum of frequencies. And when we don't get that, especially red light, it can actually impact your metabolic health, even if you're strictly low carb, carnivore, or keto. And that's why I'm so proud to have Boncharge as a sponsor of today's episode. Now, I've been using their red light therapy devices, which delivers bioactive frequencies of red and near infrared light at 660 nm to 850 nm. And since making this part of my daily routine, my sleep has significantly improved and my skin feels noticeably clearer. And it's backed by science because red light therapy actually boosts cellular energy within the mitochondria. And because I travel so often, I use their mini red light therapy device from Boncharge. It's incredibly portable and makes it really easy to get my daily 10-minute session in no matter where I am. And if you want to fully optimize your environment, you also have to address a blue light from screens. So, to do this, I personally use the Brooklyn blue blocking glasses from Boncharge in the evenings to protect my sleep quality. Now, what I love about Boncharge is that it's high quality and it's backed by over 5,000 five-star reviews. So, if you want to try their red light therapy devices or their blue blocking glasses for yourself, just head to bondcharge.com/theprimal or use code the primal to get 15% off because light therapy is just as important as what you eat.

What about LDL cholesterol? If somebody has higher LDL cholesterol, they're on a low carb lifestyle, is that a problem? Again, how bad was your health before you came to a ketogenic way of eating? When did you go on a ketogenic diet? If you are starting in your 60s and you had, you know, 55 years of standard American diet and your arteries are on fire, I'm going to tell you that it's not the best if your ketogenic diet raises your LDL cholesterol a lot. Right? You may have an LMHR phenotype. Uh the data on that are evolving, right? I know that the paper is out. it's been retracted. We are working on figuring out what the right answer is, but so far the people who already had plaque seem to have some progression and again the question is not does it matter. I think the the answer from a wide range of scientific papers is that the lipoproteins do matter but they don't study the people that we are talking to most of the time. they're not studied in the people who have triglycerides of 60 and an HDL of 80. Uh now, is that protective? We don't know yet. So, the question again becomes, do you want to incur the risk of more lipoprotein circulating? Do you want to incur the risks of trying to reduce them? It is possible to stay on a ketogenic diet and reduce your lipoproteins. Uh you may not think that that's worthwhile for you. That is your choice to make. But as somebody who treats people with a lot of plaque, I will say I do think that it is part of how I counsel patients. I do prescribe lipid lowering medications, I do my level best to make sure that they do not negatively impact people's quality of life, people's muscle mass, people's uh metabolic health and insulin sensitivity. There are ways to do this that are safe and appropriate if people want to do it. And if you don't, that is your choice. That is absolutely your choice.

So what you you're saying is that LDL is not something that we shouldn't say, oh it's all good, it's all bad. It's context um for the person watching. So let's just give you a patient who is following a low carb ketogenic approach. So a low carb approach, their fasting insulin has dropped, their HBOC has dropped, they've lost weight, but and their triglycerides are low, HDL is high, but the LDL is a little bit high. Would you be concerned for that patient? I mean they have made so much progress right we have moved the needle in the right direction for so many things that is amazing I will never take that away my next question is do you have plaque? Let's get some pictures. Let's image and go look right because the risk calculators the prevent equation the pulled cohort equation all these things where you punch in a bunch of numbers in a calculator talk about population risk they do not tell me nor do they particularly effectively predict at the individual level, who's going to have a heart attack? So, let's go look for plaque and see whether it's a problem or not. And if you have zero plaque, even zero soft plaque, we're going to let it ride, right? We are going to keep going. And if you tell me, I don't ever want plaque. Everybody in my family died of a heart attack before the age of 60 and there's a lot of dementia in my family and I want to reduce my chances of that. I want to be as aggressive as possible. I would say some evidence would support lowering your LDLC or your APOB levels even further if you're willing to take those trade-offs. So this again is a very personal thing depending on what your whole picture looks like.

I think people are going to hate you. They absolutely hate me but they hate me on both sides and that's important. I would say that it's depends on the actual person. So what you said is test your soft plug and as we said that is going to lead to heart attacks and strokes. So if your dietary uh uh intervention is leading to less plaque and no soft plaque, then that's a good thing. But if you say that I have heart attacks and strokes in my family and I want to try to fix that one, then maybe you want to try to lower your LDL. Basically, LDL is not all bad and it's not all good. It depends on the person. Um I want to move on to HDL. Is a higher HDL always great to prevent a heart attack? Absolutely not. And we have learned this over many, many years. So what we do know for sure is that low HDL is a sign of the metabolic syndrome of insulin resistance. So low HDL is definitively quite bad. But raising HDL does not necessarily make things better. And the reason for that is that the amount of HDL cholesterol does not tell you very much about how effective HDL lipoproteins are at what we call reverse cholesterol transport. So why was HDL considered the quote unquote good cholesterol? It is because HDL particles can actually suck the lip lipids out of your plaque, out of places they do not belong, recycle it in the body, and take it back to the liver. So instead of depositing lipoproteins in your artery wall, they might remove them and bring them back to the liver, but you don't have a sense for how effective your HDL particles are at doing that just by counting the amount of cargo that they have. So you lipoproteins, these these molecules that traffic our fats around in our body are delivery trucks. So, you cannot open the back of the Amazon Prime truck and see how effective the driver is by counting how many boxes are in the back. If you have a huge number of boxes, well, maybe they've just been sitting eating a steak all day and not delivering any of their packages. Or maybe it means they've made eight runs and they are trafficking a lot and so they're just super effect. You don't know what's happening with that truck just by counting the amount of boxes in the back of it. So this is why advanced lipid testing has evolved over the years and why are we're now counting the particles, right? The number of trucks rather than the amount of cargo or the cholesterol that they have. HDL is the next frontier because we're slowly beginning to understand how to measure the functionality of the HDL particles and and how effective our reverse cholesterol transport might be. We are not ready for prime time on that. I do not test that in my patients yet because I don't know how to act on it. But we have tried raising HDL cholesterol with a number of different molecules and we have not had any success in moving the needle on cardiovascular outcomes when we do that.

Then what is the main thing that's going to help in cardiovascular um outcomes? Heart attacks and strokes. If it's not so much LDL cholesterol, it's not about a high HDL, what do you have to lower? Is it insulin and glucose? It depends on why you have plaque and what's for like why is your forest on fire, right? Was this somebody who left a campfire burning? Was this a lightning strike? Was this really bad weather and bad metabolic health? The question about how we put the fire out, you know, first of all, we have to put the fire out. So, let's work on that and then understand was this an inflammation problem? Is this visceral atapostity and how are we going to address that? Is this autoimmune disease and inflammation from that? How are we going to manage your inflammation? Is this a lipoprotein problem? For some people it absolutely is an APOB LDLC problem and lowering that may help. Um and it really evolves into broader testing and a multiaceted approach. Right? The answer is never just here's your statin, please come back and see me in a year. It is also never just well you know don't eat inflammatory foods and come back and see me in a year. Uh or just go take this vitamin and come back and see me in a year. it is let's test the broad spectrum of what's going on with you because again as I mentioned earlier for most people it is not just one thing right if you have bad dental health and you have periodontal disease that is probably contributing to your inflammation and the plaque in your arteries how many doctors are asking their patients do you floss? Do you have bleeding gums? When was the last time you saw a dentist? Like this is important.

Wait hang on so if you don't floss you can get plaque buildup leading to a heart attack? If you go look at the plaques I scrape out of the arteries in the neck. You can find little bits of the bacteria from our mouth in those plaques. There's some debate whether this is association or actually causation. However, I became a flosser when I learned this. I was not always a flosser and I am now a daily flosser because I think that the at least the association is strong enough that it's worth addressing and uh my dentist has always asked me to do it. And like what's I mean it's annoying but like what's the price really like there's no real risk to me do like flossing every day if it's might be maybe going to help and I had high inflammation so I needed to do everything I could do to reduce all possible sources of inflammation for me and so again yeah you need to you need to be brushing twice a day. You need to be flossing. You need to be getting your dental checkups. If you have bleeding gums you need to see somebody about that. Like we need to get all of these things. And this is what I think frustrates so many people in modern medicine is that they don't have a doctor who gets the big picture. They have a doctor who wants to just do one thing at a time. And this is why we've not been particularly effective at reducing heart attacks and strokes. It's not that some of these interventions don't work at all. It's that we have so much residual risk. So for example, if you've had a heart attack and a stroke, you will be on lipid lowering therapy and an aspirin. It absolutely helps the chance that you will not have another one, but it's probably not enough. Right? If we do that, but we don't manage your insulin resistance and diabetes, we've not succeeded. If we do that and we don't manage your inflammation adequately, we've probably not succeeded. So, we have to take the whole big picture into consideration when we think about preventing heart attack and stroke. I floss, so I'm happy about that. And I hope that people do floss as well because we know that your your oral um microbiome is associated with problems um especially heart attacks and strokes. So we have to floss and clean our teeth um and have a good healthy diet.

So I want to move on to the scan that shows heart disease years before symptoms. So you mentioned three tests. We're going to go through them, how to access them, and how much they cost. CAC score is that the most effective test that people can actually do. It is the best starting place for most people because it is so widely available and it's the cheapest. So while it is not my favorite test, it is the one that if you are watching this and like you are feeling stumped about how to access the higher level tests that will show soft plaque, you are more than encouraged to at least start with a calcium score because it should be about $150 if you're in the United States. It'll be cash probably, but you can go to one of many imaging centers near you. Your primary probably feels comfortable ordering it for you if you have to have an order. Some places you can go on off the street and do it yourself without a doctor. So, uh that's very location dependent, but for most people it is a good place to start. The caveat is if you are young like under 55, um if you have a strong family history, if you are metabolically very unwell, a CAC of zero is not necessarily as reassuring long term as you might want it to be. It is reassuring in the short term. Meaning, if you have a CAC of zero, the chances of you having a heart attack or stroke in the next 10 years are very low. But if you're 40, you probably don't care about just knowing your health until you're 50. You still want to know what about 55? What about age 60, right? Uh what about 70 when it's time to go out and play with grandkids and go be on a cruise or go be hiking, you know, Machu Picchu? Like what else do you want to be doing in life when you're older? And it's hard, really hard to keep that in perspective when you're younger. Anyway, the moral of that story is CAC is broadly accessible. It is pretty inexpensive and it's a really good place to start for most people. even though it doesn't show soft plaque, even though it's not a great test for my younger patients.

Just to clarify, if somebody gets a CAC and then they have a like a score of a thousand, should they freak out? Freak out? No. Should you sit up and pay attention? Yeah. If you have a CAC of greater than 300, that is equivalent risk to already have a heart attack or stroke. So, the chances of you having a heart attack or stroke, uh, if you've already had one, are very high. That's called secondary prevention, right? If you've already had an event, if your CAC is over 300, you might as well have already had a heart attack or stroke for your risk. Now, if you're not having chest pain, if you're not having problems when you're exercising, you do not need to like go check yourself into the emergency department, but you do need to go find a doctor who can help you figure out what the situation is, why your score is a thousand, and what you need to do to be safe and prevent that from turning into a heart attack or a stroke.

Holy heck, I should get a CAC score. I don't know my score, but I do know that if it's over 300 that we have to be really alarmed. Um, okay. So that's the first one about $150. So that we have to pay out of pocket. Next one is CIMT. CIM that's your favorite. Why? Gotted intimal medial thickness. And so CINT is a broad category. I say CINT because it's it's easy. What we are measuring is actually several things. And it doesn't have to be limited to just the corateed artery. If we're being really complete, we would also include the femoral arteries in the groin that go to the legs. What we are looking for is this is an ultrasound based test. So ultrasound is a sound wave. It's the little probe. It's the same one pregnant women get to look at the baby and those sound waves bounce off the tissues and we get really nice, very precise pictures. The IMT is the intimal medial thickness. It is the thickness of the inner two layers of our blood vessels and they become thickened before they turn into plaque. Right? I told you that the artery walls get inflamed, stuff deposits, the cells grow, they transform, and then this plaque develops over time. The IMT will show us an inflamed artery that's starting to form plaque. We also image the plaque itself. So, it is not just the IMT, it is also a plaque detection tool. In the corateed arteries, the artery splits in the neck into the internal, which goes up to the brain, and the external, which feeds the face and neck. Where the artery widens and splits, that's called the bulb, and flow is more turbulent there. So, it's like an eddy current in a river. Where flow is turbulent, the stress on the wall of the artery changes, and plaque is more likely to form where there's a branch point because of this turbulent flow. So we look at the corateed bulb and if we see plaque there that is its own measurement separate from the IMT but they're part of the same test protocol and we do the same thing in the femoral arteries. The femoral artery also has a division or a branch point where we can see plaque form and again when we start looking at people in their 40s who otherwise are low to medium risk. If we image plaque, suddenly our risk profile changes and we need to get much more aggressive about understanding the root cause of where that plaque came from and how we can stabilize it or even reverse it.

Okay. So to get the CINT, you like cardiorisk.com. Is that correct? That's correct.

And how much is it? Depends on how you get it done. Anywhere from $250 to $400. And that is again location dependent who's doing it. Um, the reason I like cardiorisk, ultrasound testing is very dependent on the person who has the ultrasound probe in their hand because it's not always the same picture. We're taking a three-dimensional structure and transforming it into two-dimensional pictures. And so, it's very sensitive to which pictures you're taking, what settings you're using on your machine. So, cardiorisk has a very, very strict protocol for how we do the testing. And I know because they've measured it and shown me the data that those tests are accurate down to 200ths of a millimeter for detecting real change. So they're very precise at least for the IMT. The plaque measurements a little less uh sensitive. But for all these reasons, having a really high quality lab who reads the test and measures the IMT is very important for CINT. It's also important to distinguish that kind of a corateed ultrasound versus the regular corateed ultrasound that you'll probably get if you have any neurologic symptoms or if you're just going to your primary and you say I want an ultrasound on my corateed there will be somebody who gets an ultrasound out and and ultrasounds your corateed they'll tell you um there's nothing more than a 50% narrowing it's fine that's about the threshold in regular like mainstream clinical medicine is if it's less than 50% narrowed, they're not really going to talk about it because there's nothing anybody would do about it. So, some labs are quite good and will say there's some plaque here, but you're not going to get an IMT measurement and you're not going to get this plaque no plaque answer. What they're just going to measure is the speed of blood flow and tell you that there's like severe narrowing or not. And so, lifeline screening, if for example, that's what you get from Lifeline, you'll just say like it's not severely narrowed. Yes. Guess you're okay. Now, as we've discussed, our health is much more than just your diet. It's actually what your skin can absorb. And you might be eating the cleanest diet in the world. But are you showering in toxic waste? You see, everyday soaps and shampoos are often hidden with endocrine disruptors that wreck your gut and your hormones. Because most store brands pump products full of parabens, phalates, and even fluoride. And these harsh chemicals seep through your skin and directly affect your body, even if your diet is perfect. And that's exactly why we spent months perfecting the Primal Talo balms, soaps, and our new shampoo bars. You see, everything that we make is 100% bioavailable using grass-fed tallow that is naturally rich in vitamins's A, D, and K2. There is no synthetic junk. There's no cheap fillers, just pure ancestral goodness that your body actually recognizes and craves. And I've been using this unscented shampoo and body wash every single morning. It's a total game changer that hydrates deeply without stripping my skin of its natural oils. And our USA store is now open officially, which means faster shipping and our best prices ever. And for the next 7 days, you can grab 30% off our new shampoo bars and body wash to finally ditch the chemicals for good. Just head to the primal.com/shampoo or use code shampoo at checkout to claim your exclusive discount. I've also linked them in the description.

So it sounds like most places are pretty crap in terms of understanding your actual risk and knowing how much is blocked. Does that make sense? So you need to go to a the right place to get the right scan and make sure they do it properly. Is that kind of correct? That's correct. Yeah. And so the reason that even though I love CINT, I don't recommend it for absolutely everybody is that it can be hard to get access to CINT. Cardiorisk is a pretty small company and they don't have people who scan in all places. uh they will send a synographer out to a physician's office to do them if there is enough interest and there are little pockets where there are people who scan for cardiorisk but um for example like I think there's three of us in California who scan for cardio risk regularly that are don't work for cardiorisk so like people come down from Alaska Northern California uh Hawaii like people come out here for CINTs uh and and do that because it's not that accessible so if you're having trouble getting a CINT I totally appreciate that we are working really hard to raise awareness and get more

People scanned, but it's going to be a slow process. And the main, like, the cardiology community doesn't love this test, and so it's not generally recommended by the cardiologists. And for those reasons, again, it's a bit of a niche test. As much as I really like it, I can't say that it's best for everybody, no matter where you are. Because again, the best test is the one you can get, like the one that you have access to that you will actually go and do. So if you're going to say, "Well, Dr. Jay wants me to get a CINT, but I can't." I'm just going to throw my hands up and forget about it. Well, no. Go get a CAC and let's start there.

>> Okay. Next one. CCTA. Is that available for most people?

>> It is becoming more available, right? Anywhere you can get a CT scan, you can probably get a CT angio. So, it's the same scanner, but now you're going to get an IV in your arm. They're going to inject some dye. They may also give you some medicine to slow your heart rate down so that they can get really nice, crisp images of the blood vessels in your heart. The old way of reading this was that a radiologist would take a look and see if there were any areas inside the vessel that were narrowed, and they would say, "Yes, they're narrowed, and it's, you know, 0 to 50, it's 50 to 70, it's 70 to 99% or it's blocked or occluded." Now there is this interesting computer overlay, right? We have the, uh, you know, machine learning tools like Clearly, like HeartFlow that have come on the market that are now doing very quantitative analysis of how much plaque does somebody have in the whole coronary tree, and how hard or soft is it, how vulnerable is that plaque? And we can get like super precise measurements about this. Um, let me rephrase that. We get super detailed measurements. What is evolving is this concern that the precision of these algorithms is a little bit iffy. The reproducibility, right? If I send the same scan in three times, do I get the same exact answer three times? So, it's a very good baseline test, I think, to just get a general sense for, do you have soft plaque? Do you have hard plaque? How much? And is it narrowing the artery? So, for example, you mentioned earlier, like, somebody gets a CAC of a thousand, like, should they be worried? Probably the next best thing for that person is to go get a CT angiogram because the angio will tell us, is there narrowing? Is there severe narrowing in any of the vessels? You can have a lot of plaque and actually not have a lot of narrowing. The plaque can grow out or it can grow in. And it starts by growing out and eventually it will start to narrow the lumen or the flow channel where blood goes, but it doesn't have to. How you know is getting that CT angiogram or maybe even an invasive angiogram. But that's the next way to assess how much trouble is this plaque going to cause and and when.

Um, the downsides for CCT Angio is over time, we're not sure about the reliability of these AI tools. And I think that, you know, Dave Feldman, Dr. Adrian Sodtomoda, Dr. Dr. Nick Norwit, they have all shared with us their trials and tribulations with the ketoca trial and the Clearly analysis versus the HeartFlow and the QAngio. And and I really respect them for sharing so transparently everything that has gone on with that study. And it has really made me question how reliable are these AI overlay tools, and especially following people going forward. Right? If I knew for sure that if I sent in the same scan, I would get the same answer back, I'd feel a lot better about it. Right now, I think it's a great baseline tool, but I think the jury is really out on whether we can use this to monitor people's effectiveness of treatment going forward. I'm just not so confident that that all of this, um, machine learning is is stable yet for us to be relying on it at at that level.

>> Well, at least we know three possible tests that we could do to like test and don't guess. But we need to also go into the things that are destroying our arteries and our heart and then how to finally fix it. What are the lifestyle tips? So I want to go back to the worst foods that might be destroying our arteries and our heart. You just tell me, is this good or bad for your arteries and your heart? Do you think that oatmeal is always heart healthy?

>> Not always.

>> Good. Do you think that all sugar is good for the heart?

>> Nope.

>> Donuts, cookies, and cakes, good or bad?

>> Bad.

>> Pizza and processed carbs, good or bad?

>> Bad.

>> This is interesting. Bread. What do you think of sourdough, white bread, and whole grain bread?

>> Uh, I think bread is bread, personally.

>> That's pretty.

>> Yeah. I mean, you know, sourdough might be less for some people. Uh, I've had people tell me that they, their CGM is different for sourdough versus other things. Do you maybe get some gut benefits from sourdough that you don't get from Wonderbread? Maybe. Um, for me, I don't eat bread. I just don't. And I I miss it sometimes and I think about, well, maybe I'll get sourdough from like, you know, unrefined wheat that's been grown in in Europe. And then I sit back and I think about it and I'm like, no, no, I don't eat that anymore. I just don't because I can't control myself if I start eating baked goods. I just can't. So, for me, it's just a hard no.

>> And you'll be surprised that some people think that sourdoughs are are very healthy for you. So, that's why I asked the question. Next one is like juice, fruit juices, smoothies, and dried fruit. Good or bad for the heart?

>> Generally bad. I think that you might be able to get away with some berries in a protein smoothie if you really tolerate that and if you're working out in a way that allows you to process that. So, you know, whole berries maybe. Um, drinking our calories is always a little bit of a fraught thing, right? It is much more processed than if we just ate the whole foods. And some people are living a lifestyle where that is a compromise, a trade-off, right? We talked about trade-offs that might work for them sometimes. So, I won't say that it's always a problem, but dried fruit is candy. Uh, and that's, you know, again, like if you are somebody who does okay with that and you eat candy and that's like part of your lifestyle and you are metabolically well, I'm not going to argue with you about it. But um if you are have excess adiposity or visceral adiposity in particular, if you have trouble with insulin resistance, uh, if your health is not great, then I would say it's bad.

>> Next category is dairy. Do you like flavored yogurts and low-fat dairy?

>> Nope.

>> Do you like margarine and fake coffee creamer?

>> Nope.

>> Do you like condiments like ketchup, mayonnaise made with seed oils and barbecue sauce?

>> Nope.

>> Sports drinks. Is it good?

>> Again, what what's a sports drink? Um, I add electrolytes to my water because a) it helps me drink more water and stay better hydrated and uh, but will I go buy Gatorade? No, I will not. So, um, there is some evidence that electrolytes are more effective with a little bit of glucose and that, uh, creatine may actually be better absorbed with a small amount of glucose. And I'm talking like a couple of grams. If you are an athlete and that is part of your fueling thing and it's very intentional, by all means. Uh, do you need to be very careful about what you're doing and why and assume that just because you are, you know, exercising that your sports drinks are fine? No. Right. And who who told us that best? Profoss, um, was running marathons and developed type two diabetes. So exercise is not a free pass to eat whatever you want or drink whatever you want and hope that it'll be fine. The, um, there are people even on a ketogenic lifestyle most of the time who will selectively add a small amount of carbohydrate for fueling for an athletic endeavor or a race. Again, like this is with you and your coach. You guys figure it out what's going to fuel you to live the life that you want. This is about living our lives and feeling our best, and that does not look the same for everybody.

>> So that's why I was trying to understand the 25 worst foods that people are eating. And it sounds like it's just processed carbs that's not real food. I'm not against carbs. So like I'm going to talk about some things to eat. But I just think that if people can realize that, you know, all these processed keto fake, you know, fake creamers and margarine and all these things, it's not helping your heart. It's not helping your arteries, it's clogging them. So, let's move on to the practical takeaways to fix our arteries and our heart. What do you think are the five foods that people would eat to have a well-formulated lifestyle to prevent heart attacks and strokes?

>> You're going to be so unhappy with me. This is not a question that has an easy answer. We eat in a certain way for so many different reasons. If you want the diet that has the most evidence for heart health, it's a Mediterranean approach to diet. Now, that means a lot of different things and everybody gets all like flustered when we talk about the Mediterranean diet because it's not one way of eating. But the PREDIMED study, yes, it was retracted. We can talk about it. It's not amazing. However, right, we can talk about it is low glycemic index. It is, uh, whole foods and it is a diverse array of different foods. But that's just the heart. If we are talking about the interventions that are going to help you with your bipolar disorder, well, that's probably not the same thing. If we are talking about what you figured out on your own after three years is what fixes your gut or fixes your autoimmune issues, that may not be the same thing that's the best for your heart, and that is okay. We will work with you. But you are a whole person, and we all come to a way of eating that manages all the things that are going on with us, right? As much as I am bullish about heart attack and stroke because that's what I see in the hospital every day in my practice, I recognize there are people who are eating in a certain way because it's managing their cancer. It's managing their mental illness. It's managing a whole host of other things. They're eating this way because their family has to eat this way because whatever the case may be. So, the foods that work for you are the foods that work for you in your whole life. And we may make some trade-offs about what that means for a specific organ system. That is okay. Let's just be very clear about that.

>> Next one, sleep. Do you think that's really important if somebody wants to unclog their arteries?

>> I I can't tell you how important it is and we're going to we can talk about stress in the same in the same breath because they're they're related. But the underappreciation of sleep health in cardiovascular disease and in overall disease is enormous. And probably the biggest one that people miss is sleep apnea. But we can even just talk about sleep habits. But if you get less than six hours of sleep a night or more than nine hours of sleep a night, you have an increased risk of heart attack and stroke. It's just that simple.

>> Wait, if you get less than six hours or more than nine hours?

>> Yep. So too little and too much are a problem.

>> So how much should you be getting per night?

>> The challenge is that we all actually have our own independent clocks. So some people are longer sleepers than others naturally. Uh, and to what extent that is com, you know, a part of this, we don't know. Again, this is where population data do not necessarily always apply to the individual sitting in front of us. But, um, seven to eight hours would be optimal.

>> Interesting. Why I get the seven to or eight hours, but I didn't know that if you're sleeping too long, that's not a good thing because it's probably a sign that there's inflammation in the body and that's why you need to sleep more. Um, I wanted to ask about symptoms because apart from tightness in the chest, if somebody's experiencing that, but do you think if you see a black toe that's a sign of a clogged artery?

>> Yep. But even before you get So, a black toe is pretty severe disease. I mean, sometimes that's a little plaque that has flicked off and gone down just into the toe artery. But often when I see patients who have what I mean, that's gangrene. That's typically dry gangrene. That's very severe peripheral arterial disease or plaque building up in the leg arteries. That has a mortality that is equivalent to stage four cancer by the time we get to a black toe. What most people get earlier than that is cramping pain in the legs with walking or they don't really totally process that the legs are not working as well and their walking just gets shorter and shorter and shorter. They used to go for two-mile walks and now it's just a mile and now it's just around the block and now we don't even walk at all anymore. And they don't totally appreciate that that's because the legs are a problem. But in reality, that's what has happened. And there are many reasons for it. Blocked arteries are not the only one. Spine issues can also be part of this. But if you are getting cramping, especially in your calf muscles or in your thigh muscles or in your buttocks when you are walking, that is an enormous sign that you need to go get those arteries checked out and at least get an ankle-brachial index, a blood pressure measurement that compares the blood pressure in your legs to the blood pressure in your arms. That is a very easy, fast test. Even your primary doctor can potentially do that for you. If you have a blood pressure cuff, you might be able to do it at home even. There are some good videos on this. It's not perfect, but it's a pretty good start and you can check on that yourself. Perhaps most impactful and surprising symptom that I think most people ignore: erectile dysfunction. If you are having problems with your erections, you should go get your blood vessels checked out. That is a big one that people miss all the time.

>> Holy hell. Well, I don't have a I'm female, so I'm not going to have that problem.

>> Um, our ladies, our ladies are a little less likely to notice any of that. But um, certainly if you are having libido or other issues as a woman, you can get that addressed and, um, for all kinds of reasons, you should talk about that with your OB/GYN or your family doctor. Uh, women also have circulation problems that manifest. It's just not nearly as obvious.

>> There was a question where I asked about the black toe and then the leg pain. Um, because do you think that exercise is important to open up the arteries and to encourage the blood flow?

>> Exercise is perhaps the biggest lever we have to improve our vascular health. I mean, nutrition, of course, right? I'm not going to pick a winner like it's like picking a favorite kid, but, um, it's, you know, and exercise by itself will never be enough. However, if I could say there was like one thing that would by itself improve your cardiovascular health the most, it is going to be exercise. Now, does it have to be only aerobic exercise? Probably not. I actually think there's a huge benefit to interval training, to the low-intensity steady-state training, and those are both in that aerobic or cardiorespiratory fitness. But I love lifting weights and I tell all my patients, I think that that is enormously important for their metabolic health, right? Muscle is a metabolic organ, but also for their blood vessels.

>> What do you think about calf push-ups?

>> Uh, calf raises. Um, if you want to build your calf muscles, that's great. But, uh, it's great to help prevent a blood clot on an airplane or in a car, long car ride. Uh, if you are trying to improve your circulation overall and it's all that you can do right now, that's fine. But I'd love to have you walking. I'd love to have you doing some interval training. I'd love to have you doing some band work or weights. Um, the calf raises by themselves help move the vein blood up. Uh, especially if we're seated or standing for long periods of time, but in terms of improving arterial circulation, they will not be quite as effective as we need them to be.

>> Got it. So maybe like more of the HIIT training, weight training, just walking around is going to be good for your legs and for your arteries to get the blood pumping. Last question for you. The 10 labs every single person needs to know to know to unclog their arteries and fix their heart. So, I'm going to go through these 10. You just tell me, what do you think the the optimal level should be? Because there's always a question, optimal levels versus what the doctor says, which is very different. Fasting insulin, what's optimal?

>> Optimal is three to four. I will take anything under six as pretty good.

>> Okay. Platelet count. Why is that important? And what's optimal?

>> Platelets are the little sticky fragments in our blood that start clotting. And when platelet count is elevated, it can actually be a sign of inflammation. So, you know, I love to see a platelet count of like 250,000 or less. They shouldn't be lower than 150,000 or so. If we are platelets are too low, that's a sign that maybe the liver is damaged or not working properly. Over 250, over 300 really might still be in the normal range. But if I see it 400, 500, then I'm concerned that there's active inflammation. It typically is like a true illness. It is not a sign generally of chronic inflammation and I would never treat somebody whose platelet count was 300,000. That's still very normal. Uh, and it may just be where your bone marrow wants you to live. But 250 is a great number.

>> Got it. Kidneys, BUN, creatinine, and albumin.

>> So BUN and creatinine are measures of your kidney's ability to filter out bad things. Albumin is a measure of protein. And so you have to be a little precise when you're talking about are we looking at microalbumin spilling into the urine or are we talking about a serum albumin level which tends to reflect our like native protein stores. Um, microalbumin in the urine is a very useful test and it has to do with the kidneys really have two jobs. They filter out toxins and they keep good stuff in the body where it belongs. So protein is a good thing and should stay in our body. We should not be peeing out protein. If we are peeing out protein, that means that the chain link fence that's supposed to keep all the good stuff is ripped open somewhere. And why would that happen? That tends to be from poor blood sugar problems or high blood pressure problems. So patients with diabetes or insulin resistance can start spilling urine into the start spilling protein into the urine and patients with long-standing high blood pressure will also potentially start spilling protein in the urine. So we should have a, uh, and women and men are a little bit different, but microalbumin to creatinine ratio is how we like to measure this. Um, in women I'd love to see it less than seven and a half. In men I'd love to see it less than three. The lab will tell you anything less than 30 is normal. But if I'm starting to see anybody in the tens, 15s, there's something going on there. Sometimes it's just a one-off lab problem. Get it checked again before you start freaking out. Um, but if you are repeatedly seeing it in the 15, 20 range, like we're starting to have an issue here, and that's a sign that we need to be be paying closer attention.

>> Got it. Okay. Next one is HDL and triglycerides. I'm not mentioning the LDL, but what do you think are optimal markers for HDL and triglycerides?

>> So, your HDL needs to be above that threshold. Uh, whether you're a man or a woman, it's a little bit different, right? But I'd love to see women 55 or higher. I'd like to see men 45 or higher. And I'd love to see your triglycerides under 100. Um, to me, again, this is a sign that you do not have metabolic syndrome. You do not have insulin resistance. Whether and I will say an ApoB or an LDL-C does need to be part of your lab testing, right? It's it's not appropriate to ignore that. Um, but while we're talking about triglycerides and HDL, the key is to make sure that they are not showing us signs of metabolic syndrome.

>> Got a LP little A. Everybody should have lipoprotein little A checked once in their lifetime at least. This is now part of new guidelines. Lipoprotein little A is an independent type of atherogenic particle. It's an apo-related molecule, but it's got this very sticky, long velcro tail on it, and it makes it much more likely to stick in your artery walls. It has oxidized phospholipids on it and it also makes us, um, a little less likely to break down blood clots. So, LP little A has an association with plaque. It also has an association with calcific stenosis. So this is a narrowing and a stiffening of the aortic valve in our heart that allows blood to get out of the heart and go to the rest of the body. If that valve gets stiff and it doesn't open, then blood has to work really hard to get out of the valve, and that's a real problem for people. It's why people get aortic valves replaced. So, LP little A does have an interesting signal that if you are very metabolically healthy, your waist-to-hip ratio is normal. Perhaps LP little A is not as bad for you. But everybody should at least check it and know whether this is something that is predisposing them to early plaque in the arteries.

>> Okay, HS-CRP. Is that a good marker for inflammation?

>> High sensitivity C-reactive protein is a very good marker for inflammation and optimal level would be less than one. One to three is average. If you are routinely three or higher, we need to go find what is causing your inflammation.

>> Homocysteine. Is that good too?

>> I measure homocysteine in all my patients. Homocysteine is a marker of B vitamin metabolism and your ability to convert inactivated forms of B vitamins, which is typically what we get in our diet, into the activated forms of B vitamins that our body uses. If your homocysteine is elevated, and I would consider optimal certainly less than 10, maybe even less than eight, then homo, so homocysteine 14, 15, 18, then you are not converting your inactive B vitamins into your activated forms. Giving you methylated B vitamins will lower your homocysteine, and we actually have good evidence that that will help you prevent stroke. The evidence for heart attack has been very limited, but it's also actually confounded because most people were using not methylated B vitamins, but cyanocobalamin. And in the studies, patients with kidney disease, that cyanocobalamin actually became a cyanide byproduct and hurt the kidneys. And so even though the trials have not shown benefit for heart attack with homocysteine, most of us in the prevention space still believe, again, very low risk to giving somebody methylated B vitamins, generally very high benefit, uh, particularly for stroke prevention that is quite solid and probably also for heart attack.

>> Okay, last one. Vitamin D. What should be the optimal levels?

>> I tell people I'd love to see them 60 to 100. Um, and that is a little soft. Our our evidence is that, you know, naturally, vitamin D levels that are higher seem to associate with fewer things, right? Vitamin D is, it's called a vitamin, but it's a hormone. It's very important in our immune system regulation. There is some evidence actually for it now in cardiovascular disease when it's done in a targeted way and dose specified to the patients. Um, supplementation is a little, you know, so here's the problem with all of our vitamin literature, right? We measure people's levels natively, and then people who have high levels of vitamin K or vitamin D always do better than patients who have natively lower levels. But and does not necessarily immediately follow that if you supplement people to those levels that they'll do better. This is a, this is a different question. Supplementation to get people to that level is a challenge, and it doesn't always mean that we're going to get the same benefit as we would have if your natural levels were that high. But again, I think that vitamin D supplementation is, uh, has a big upside and very little downside as long as we are measuring people's levels and making sure that they're not getting toxic, which is quite uncommon in my clinical experience.

>> So, if somebody follows all the advice in this episode, do you think that they can stay out of your operating table and clear their arteries?

>> Mostly. Depends on when you started. The earlier in life you start, the better the chances. If you are starting late in life, you should absolutely still follow everything that we've talked about in this channel. And I do think that your chances of needing me as a surgeon are dramatically lower if we do all of that. It may not be by itself enough. You may need some additional help from supplements, medications, procedures to, you know, keep you in optimal working shape for the rest of your life. But, um, the earlier you start, the better chance we have of preventing that heart attack and stroke. And I absolutely believe no matter when you start, there is always hope.

>> Dr. Jay, that has been absolutely amazing. All the links for you is going to be in the description. I hope that people try to follow you and maybe go see you because you seem to know how to unclog the arteries where other doctors just test their cholesterol and that's it. Um, thank you so much for your time.

>> Thank you, Reena. It's been a real pleasure.

>> I hope you love this episode. Check out this one with Tom Cowan. It is all about the true cause of heart attacks and strokes, and it's not LDL cholesterol. I'll see you next week.