Cardiology Dietitian: The 5 Heart-Healthy Rules That Actually Lower LDL | Michelle Routhenstein

I must admit I have listened to the National Lipid Association podcast. Probably one of the few out there that that kind of has, I guess it's more, it's more for doctors and medical students, probably that sort of audience rather than a kind of general public audience who is just looking for information on how to eat in a heart-healthy way and make sense of confusing information online.

How would you say that at these conferences? How would you say your views would differ, I guess, to the average cardiologist?

I don't think that it differs. I think that the big problem is that cardiologists don't have the time to talk about nutrition and they frankly don't know about nutrition. People came to me finding that I was a dietitian, or when I spoke, like when I asked the question on the mic and introduced myself, people come up to me and be like, "So what should I eat?" They don't even know what to eat. So there's this disconnect of, okay, follow the DASH diet, follow the Mediterranean diet, and then the applicability of it and how do you translate that when you have five minutes in front of a patient?

Right? And how do you inspire sustained changes?

Yeah. Right. The behavior side of things. Is there, is there as much belief in the power of nutrition for cardiovascular health among cardiologists and dietitians, or do you think there's more belief from dietitians?

There's more belief from dietitians 'cause we have, we're, we're applying it more. I mean, it depends. I work with some cardiologists who are like, "Everyone needs to see a dietitian because there's nuances that you can't really get into with just saying Mediterranean diet." I have other cardiologists who became my clients during my 14 years and it's like, "Michelle, I took a statin for 15, 20 years and let me tell you, I didn't think nutrition mattered. I thought my statin would protect me from getting a stent, but here I am with, uh, a heart attack even though I was on these medications." So, you know, I think it's that disconnect. I actually got into preventative, I was going to be a doctor. I got into being a cardiac dietitian because of the disconnect between prevention and treatment. It doesn't have to be only medicine. There's doctors who will say, "Take medications and don't worry about anything else." Why can't it be, "Take medications, but also pay attention to your diet and merge it together?" But I specialize in cardiology because it's number one killer globally. 80 to 90% is preventable, right? So where's that gap? So I kind of, after becoming a general dietitian, I went on this search and I started looking and see and asking cardiologists, you know, "Why are we having so much heart attacks and strokes when it's preventable?" And they said to me, "Michelle, patients are non-compliant." I look at him funny. I'm like, "Patients are non-compliant? Patients want to live a long healthy life." That's not an answer.

Right. On one hand, I kind of understand the doctor's perspective there, but I think they need to appreciate that their ability to inspire change is made very difficult in a five-minute consultation. So, of course, you're seeing a lot of patients that are not necessarily sustaining the changes because how much time have you spent with them to explain the changes that they can make and then hold their hand and talk about the barriers that are like standing in their way that are making that difficult. A lot of people come to me and they're just outright confused. You know, a lot of times I hear the story and I'm listening to what they've experienced in the cardiology office. They come to me and they say, "Michelle, the doctor told me if I don't take a statin, I will die." They're like, "I don't want to take a statin. I Googled it, all these side effects. I'm scared to take a statin." And I go, "Wait, do you understand why?" And we go through, you know, I review their medical record. I was like, "You have a high calcium score." And I explained to them, "What does that even mean?" People have no idea. People think, "Oh, I shouldn't need calcium anymore." Which is so, so they're Googling it. They're trying to find answers that their cardiologist didn't give it to them just 'cause the medical system is rushed and couldn't provide that.

Right? That cardiologist that's saying, "If you don't take a statin, you'll die." That's a very absolute message that lacks a lot of context and nuance. But again, comes back to the fact that they have five minutes to kind of try and be effective with this person.

Right? If I told you how many people I've actually convinced to take a statin because in their situation, it would benefit them because I explained what does the statin do? Why is it helpful? What are the side effects that could come? How do we assess tolerability? You know, I think that those nuances are important to recognize as one part of the picture. But if a doctor just says, "Go do this," and it doesn't sit right with the person in front of them, they're not going to do it. So, how effective is that communication? And that's a big problem with our healthcare system, unfortunately.

Are you finding that people are also coming to you very confused about the food side of things and what to eat and what not to eat, especially with now having more access to nutrition and food information than ever before?

Ever before. I spend more time in my sessions and in between my sessions having to debunk videos and fear-mongering videos than I've ever had 'cause people are confused and some people speak in absolutes and they scare the individual to not eat this and not eat that, and that brings more health anxiety. Right? If I tell you how many people come into my office with health anxiety, it is every single person because of the misinformation. And the only way to really address it is to understand the why.

Right? What does that feel like for you? I guess as a cardiac dietitian, a lot of people may think your metrics of success are, did you, were you able to get that person's ApoB down and was, did their blood pressure improve? But I'm sure you're seeing, and I'm not sure whether you're objectively quantifying this, but you're feeling it. A patient that comes in riddled with anxiety and fear, and then sometime down the track with you, you can feel that they have renewed confidence, clarity, less anxiety.

Oh, that's my favorite part when people start with fear and anxiety. And I can sense that the second they walk in, and then they leave with confidence, they leave with quality of life.

Yeah. It's huge. Right. That's it. It's not the number that you're trading.

It's not. But you know what? Those numbers help people realize, "I put a lot of effort into this and I'm seeing that my effort yields in me these results that are cardiometabolic risk factors." And so that does motivate someone to say, "What I'm doing works in my body." And that helps fight misinformation, right? Because I've retaught you that carbs are not evil, right? And you can add them in your diet and when you've seen the results, you're going to do it.

Forcing. Exactly. That's like a trust piece, I guess, with the advice that you're giving and then seeing the needle shift in that right direction.

Yeah. Is empowering. You mentioned that a lot of people are coming to you confused. What would you say are the main, kind of top two or three things regarding food that people are coming to you with where they're very confused?

I would say carbs. Like, "Low carb is what we need to do. Carbs cause diabetes and insulin resistance. So get rid of all carbs." Um, that's a big trend right now. And then coming kind of almost joint with that is, "Well, I need a lot of protein." So now all they're focusing in on is eating more protein. That's a big one. There's a lot of also talk about the ketogenic diet right now and is that the right way? Seed oils is always a big conversation too. Um, there's a lot of just misinformation even of like, "How are plants toxic?" People are telling me like, "Oh, I heard that these plants are actually not allowing the nutrients to be absorbed in my body," and they're all confused on that as well.

There's a lot there for us to unpack. Hopefully, hopefully today we get time to do that. If someone is thinking, "Cardiac dietitian," I haven't heard of that before. Like, what, what's involved to, I guess, to kind of become a cardiac dietitian or what's the distinction between a regular dietitian and someone like you that is specializing in cardiovascular health?

So when I became a registered dietitian, I felt like I was a generalist, right? We do our clinical rotation throughout multiple different fields. We go into the ICU, we go into the weight loss clinic, the kidney clinic, the liver clinic, we go through every rotation. And so you learn about everything. You end up being a generalist. Um, and you know, after I got that, I felt like there was a missing piece. You know, 80 to 90% of heart disease is preventable through lifestyle, through nutrition, through medication is necessary. Why is it still the number one cause of death globally? So, you know, there's no cardiology fellowship as a dietitian, but I had the opportunity to work alongside different subspecialties within cardiology. So I worked alongside a lipidologist. I worked alongside a heart failure specialist. I worked alongside an electrophysiologist and a general cardiologist. So, early in my career, I was really working alongside different types of doctors within the cardiology space to understand the physiology, the biology. How is heart disease created? How is an aortic dilation happening? How does heart failure happen? How do we prevent this? Through they're looking at it through a medical lens and I'm looking at it through a nutrition lens, right? But all of these pathways have nutrition in it.

It all comes back to biology.

Exactly. And so I had the great opportunity to work alongside these doctors. They were doing their medical route, I was doing the nutrition counseling, and we saw amazing results when we combined it. We reduced the medications. Not I didn't reduce it, the doctor did. But we were able to see crazy results that we don't see in the research because it's hard to do that kind of research at a global scale.

What kind of medications would you typically see that someone may be able to reduce?

A lot of blood pressure medications was one of the things that was reduced the most. And that's because we don't want low blood pressure, right? Right. And so when we add in foods that help to open up the arteries and allow for good blood flow, it helps to reduce blood pressure pretty easily and we can track it, right? It's not like a blood test we do every three to six months. We can track blood pressure on the daily to assess where is it and how are we getting the right trends over a period of time to then reduce it. But it also helped to not have to increase certain medications too, right? So it worked alongside of it. I think a lot of times when I tell people they need to add carbs, particularly whole grains, into their diet, they're like, "I'm going to gain weight. I can't do that. I have to be on a low carb diet." And they add it in and they go to me, "Michelle, I've lost weight. My waist circumference has shrunk. I trusted you and you explained the science and I did it." And that shocked me the most.

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When you say 80 to 90% of cardiovascular disease is preventable, that's a big number, right? What do you have a sense for kind of how much of that comes down to nutrition versus say exercise and stress and other things?

It's all connected, right? If we just look at nutrition in a bubble, but your sleep is poor, you're not physically active, you have high stress levels, that's going to impact your nutrition. So we like to look at it as lifestyle and all aspects of lifestyle management.

And when your clients come to you, I mean, perhaps you can help us understand the type of clients you're seeing. Who are they? What's a typical client that you would be helping?

So I kind of put them in two buckets. We can call them primary prevention and secondary prevention. So I have a lot of people who find out they have high LP(a), they have a strong family history of heart disease, they find out that, okay, you know, I have an increased risk and I have high blood pressure, or I have high cholesterol, or I have insulin resistance, or I have underlying inflammation, or maybe it's all of them, maybe it's one of them. That's my primary care. They want to prevent a first event. And then I also have individuals who come to me after a cardiovascular event, after a doctor may have told them, "Hey, you have a very, you have an aortic dilation that requires surgery if we don't do something about it." Um, they have a diagnosis and they're trying to prevent further complications or prevent a future event.

If they were to ask you, you know, what's the best evidence that we have that either for primary or secondary prevention that nutrition will actually reduce my risk of having a cardiovascular event? How would you kind of answer that with a client? I guess.

I mean, when we look at risk reduction of events, we have to look at the nuance of what that means, right? I don't tell anyone, "Hey, I'm going to promise you nothing's going to happen." What I'm going to say is, "Hey, listen, this is how the body works. And if we can add these nutrients in, help with your cardiometabolic health, help with your blood flow, help with all of these factors, we're going to reduce the risk of complications and the risk of events." And that's our goal. We're also looking to make sure you have more energy and that you're able to live life to the fullest and be able to take these principles and apply it to the rest of your life. You know, when I was working in New York City, no one cooked. You know, there was a joke, "You put your shoes in the oven, there's no room in your New York City apartment, right?" And so I had to teach people how to figure this out eating at restaurants, traveling, and that's just part of their lifestyle. So I say, you know, we have to look at this from a perspective of applying it in every situation, but making it enjoyable, making something that's sustainable, and making it something that you don't feel restrictive or it doesn't cause more anxiety because you're over complicating it as well.

Do you, do you talk to your clients much about health span? That concept of health span.

Yeah, I mean, when I talk about health span in the sense of longevity, it's, you know, we first talk, a lot of times the intake form on certain of my programs is, "What, why is this important to you? What's your why?" Right? And so that most people say, "It's for my grandchildren, it's for my children, it's so that I can live the best in my retirement years." And so when we apply that, it makes the person want to apply it more, to take the effort. It's effort to change your nutrition habits.

Yeah, I kind of asked that because I've, I've seen health span, I guess it's all over the internet, right? It's used pretty pervasively these days and so much so that I wonder if that word, I mean, it's come up on this show so many times. I wonder if it's losing its meaning and if people really stop just to think like on an individual level, what are we talking about here? And the way that, the way that I kind of internalize that, and I'll throw it to you and you can tell me if this is how you think of it, is when I get to 70 years old, or if I think about my parents at 70, are they going to be in and out of hospitals? How independent are they going to be? How able are they going to be to do whatever activities it is that they enjoy? How much anxiety or lack of confidence do they have in their body and their health? And that's one scenario where you could really, you could be in and out of hospitals, you'll be having a lot of surgery, low in confidence in your health, or it could be a scenario where you're in your 70s and you're relatively independent, able to do these activities, whatever it is that you enjoy, and you're confident in your body. And that's kind of the way whenever I think of health span and kind of come back to why am I making all these daily choices now at my age. That's kind of what's on the line. It's these two different scenarios later in life. And maybe you live a few extra years, but it's more about the quality.

I think, like you said, health span is kind of that, that weird terminology. And a lot of times when you think of health span, longevity, it's going through the whole, "Take this supplement, take this." So it's anti-aging, it's anti-aging, but the foundations are lost in that, right? You want to be able to go to the grocery store and pick up your groceries by yourself. You want to be able to get down on the floor with your grandkids and play blocks. You want to do those things that are so important to the quality of life, to the meaning of life, to the purpose of life. And maybe it's also just traveling, right? Getting on an airplane. If you're sick or you have higher risk factors, those things cannot be as easily obtained. And so the health span is really a simple way of, "How do you want your life to be in your 70s, 80s, 90s?" It's not, "Oh, I want to live the longest." The longness, if it's not with good quality, is meaningless.

So let's, let's go high level here. As of 2025, as we sit here right now, how would you describe a heart-healthy cardiovascular healthy dietary pattern?

So, I would look at it from a high level as something that is nutrient adequate. Why do I say nutrient adequate? Because I find that when we term, if we look at and tell someone, "Follow a vegan diet," "Follow a Mediterranean diet," "Follow a DASH diet," things get lost in translation. But it doesn't personalize it. And so many people will say to me, "My cardiologist said I'm really at high risk. I should go vegan. I tried it. I just can't do it." So they kind of put up their arms and be like, "You know what? What, what, what am I going to do?" So it's kind of looking at, well, where are you in the scheme of what's sustainable to you? And within that dietary pattern, how do we make sure you're getting enough protein and you're getting enough complex carbs and you're getting enough healthy fat? So that way it's easy to understand, to grasp, and then to sustain whether you're traveling, you're home, you're at a restaurant, wherever it may be.

So that's nutrient adequate. And then where would you go from there, I guess, in terms of what the dietary pattern looks like in terms of foods?

So, we, it doesn't, I think a lot of times people get turned off by the extremes of, "Okay, I got to go this way or that way." So we do need to have plants in our diet. You need to have a plant-forward diet with whole grains, with nuts, with seeds, with antioxidant-rich fruits and vegetables, with lean protein, both if you want animal protein in there, lean animal protein primarily from fish, chicken, or, you know, if you're going to be fully vegan, just getting the amount of protein you need from plants, your beans, your legumes, your soy, any of those items can fit. But it needs to go into your culture and your food preferences and ensuring that you enjoy it. If you don't like the way it tastes, if you don't enjoy what you're eating, you won't do this long term. And heart disease is progressive. It's not what you eat in one month. It's what you're eating on a regular, consistent basis that's truly going to protect your heart health.

Do any of your patients ask you when you explain that and they say, "Great, that gives me options. That's cool. I can find a way of doing this that I'm going to enjoy and I can sustain. Thank you for like giving me options. That's cool. Is this going to reverse the damage in my arteries?" So, if we're talking about like a client that is in front of you who has had some scans done, has some plaque buildup, they're hearing what you're saying. Is this about halting progression or will these dietary changes, eating more fatty fish, you know, olive oil, salads, legumes, nuts, seeds, all these things, can these foods actually lead to a shrinking of the plaque and damage, regression, I guess, of the damage, reversal of damage that's there?

It really depends on which type of plaque we're talking about, right? So, if you have a calcium score that's elevated, that's hardened plaque. That's the last stage of plaque formation. Our goal is not to remove that, reverse that, but that is going to still be there. We can stabilize it. That's our goal. We want to stabilize it, put on the outer edges of the arterial wall so it doesn't cause a cardiovascular event. But a lot of times when someone has a high calcium score, or even if their calcium score is zero, they can have soft plaque, which is the earlier stages of plaque formation. And that can be more dangerous in terms of potential plaque rupture and blood clots. And we can shrink that and that's our goal too. We can stabilize that, but we have to recognize and I think a lot of times when we look at a calcium score, I think people look at that as, "Oh, that's the only risk factor."

So when you say stabilized, that's some of the soft plaque kind of shrinking, or is it being modified into hard plaque? Is that what's happening?

Exactly.

Yeah. Okay. What, what kind of dietary recommendations within that theme that you're putting forward there do you think most surprises people?

I think a lot of times when I tell people they need to add carbs, particularly whole grains, into their diet, they're like, "I'm going to gain weight. I can't do that. I have to be on a low carb diet." And they add it in and they go to me, "Michelle, I've lost weight. My waist circumference has shrunk. I trusted you and you explained this science and I did it." And that shocked me the most.

What would you say to someone who is not convinced yet that carbohydrate-rich foods like whole grains are actually good for their body weight, body fat levels, metabolic health, etc.?

I think I, well, I take a snapshot, I take a seat back and I say, you know, "Why do, why are you afraid of them?" That's one. I think there's a lot of misinformation. I'm not telling anyone to go eat, you know, five cups of oatmeal for breakfast. I'm telling someone, "Okay, you should have oats if you like oats, or if you don't like oats, barley. If you're gluten-free, hey, we can have quinoa or buckwheat, etc. But you're having half a cup for you. And then you're adding protein, you're adding complex carbs, you're adding healthy fat, so you're helping to halt blood sugar rise." And I explain to them why our body needs carbohydrates for our brain function, for our heart function, and how research shows when we go on a low carb diet, it could potentially increase atrial fibrillation. There are a lot of nutrients in whole grains that a lot of times are not discussed. And to really kind of put into perspective of what magnesium and potassium and soluble fiber and potentially resistant starch, prebiotics can do in your body. People go, "Ah, okay. I think I need those things in order for me to protect my heart."

Yeah. Are you, are you surprised by how, how strong the low carb messaging is out there?

Yeah. And you know, I question why. I question why the low carb diet is so pushed. And I don't know if it's an alter, like I think it becomes hard when people don't understand when you, when you reduce carbs from your diet, you go on a very low carb diet, what does your body do? It takes what you're eating and it turns it into carbs. And when you understand that you don't want to stress out your body because then it compensates over time and it leads to insulin resistance. People realize that carbs are not the enemy and we're not having a high carb diet. We're having a balanced diet. Yeah, I have Kevin Hall on on Friday this week and he's, he's done a lot of research obviously in the kind of low carb versus high carb space and helped, helped clarify a lot of things and really, I guess shine a light on the fact that low carb diets are not superior to high carb for metabolic health and weight loss. Some of these hypotheses that were out there. I, I think low carb kind of caught fire and is trendy because if you, when you take someone who is consuming a high carb diet and let's say a lot of those carbohydrates are refined carbohydrates. When you put a framework in front of them that says, "Okay, you're not going to eat carbohydrates or you're going to eat really a low amount of them," it removes a lot of hyperpalatable, I guess energy-dense, what we may define as ultra-processed foods from the diet and does shift them to a more whole food diet. And because of that, at least in the short term, they experience some short-term benefits.

And I think that's also the conversation that needs to be had. No one's telling people to go eat a lot of sweetened beverages and eat a lot of candy and soda. You know, the carbohydrate terminology, there's different types of carbohydrates and they provide a lot of different nutrition profiles and how our cardiometabolic health and labs will respond depending on the type of carb. And I think that gets lost a lot in that translation too. Back to that dietary pattern. I know on your website you talk about kind of root cause nutrition. Can you, can you just run us through the, we were talking before about like the biological pathways or the risk factors, whatever we want to call them. How would you summarize the effect that that dietary pattern is having on someone's physiology?

I like to always really take people a step back. What does your heart do? Right? I think a lot of times right now we're really focused on the plumbing, right? The atherosclerotic, the buildup of plaque in the arteries. And a lot of times we focus on the coronary arteries versus recognizing we have arteries everywhere, right? Your carotid arteries, your peripheral arteries, your renal arteries, they can all get clogged. So.

Yeah, the carotid arteries don't get a lot of air time, do they? Unfortunately.

No. And especially in women, that's a lot of time where I see it build up. But so we have that plumbing system, right? We have that component of the heart. But a lot of people don't ever think about their heart pump until they get a diagnosis of end-stage heart failure or they have a diagnosis of an ejection fraction which is very low and they have symptoms of shortness of breath, fatigue. You know, no one really thinks about that component of it. And so we need to understand that what we put in our body also has effect on the ability of our heart to pump effectively. And then we also have the electrical component and that's the heartbeat regularity. And most people don't think about it until something happens where they feel that extra heartbeat, they feel, you know, those chaotic heartbeats and it really goes down to this is happening in your vascular space.

Are you seeing a lot of atrial fib?

Yeah. Yeah. I see a lot of atrial fibrillation and they, a lot of times it's not, they don't come to me with atrial fibrillation because they're like, "No one told me nutrition has a role in AFib." It comes to me because they had a high calcium score or they have a high blood pressure. And then when I connect the dots saying, you know, "Hey, high blood pressure is the leading cause of AFib and this is all connected," they go, "Ah, my electrophysiologist just told me to get an ablation."

Right. Are the, are the dietary recommendations that you make for AFib the same as you would make for kind of treating atherosclerosis?

Very similar. So your heart needs certain foods to help, or certain components of foods to help beat regularly. You need magnesium, calcium, and potassium to allow your heart to beat regularly. And hence that is also components in plaque regression with a DASH specific diet. Right? We see that also help with blood pressure. And blood pressure, when it's high, your heart compensates. Right? So if your heart pump is compensating, it's trying to do its best it could do, but high blood pressure is continuous, you're going to make the heart enlarge. It can cause your heart to not work as effectively, causing bulges to lead to aortic dilation. It's all connected. But until someone gets a diagnosis, it's not on their radar. And so, I bring it to people's radars because prevention is about knowing about it before it leads to something.

Are there particular biomarkers? Because I know that personalization is like a big part of what you do, right?

Yeah. Yeah. What would you say the main biomarkers are that you're keeping an eye on that kind of speak to all of those things that you just kind of mentioned there, the important functions of the entire cardiovascular system?

So it's really a lot of different biomarkers. And so this is where the personalization gets to lend in because I can explain things. So, for instance, I had a client come to me the other day who had resistant high blood pressure. So he was on three classes of medication and nothing was bringing down his blood pressure. He got extensive work from his cardiologist and his SDMA and ADMA were both elevated, meaning that nitric oxide bioavailability was severely decreased. And so I had, that was my first kind of prioritization with him of, "Listen, it doesn't seem like your body is making enough nitric oxide, and that can cause constriction in the arteries leading to high blood pressure." So that's the first category of what we're going to be working on. We can't work on everything at once. Dietary changes take time and it takes a habit formation process, which means prioritization. What are the top things we're going to prioritize in? And that's how we personalize nutrition. So the first step is kind of assessing what's the high ticket items of what we need to be doing and what are three or four habits that will support that.

So, what, what other biomarkers are there outside of, of, is it SDMA?

Yeah. So we also look at inflammation, right? So if you have low LDL, we see in research, but you have high hs-CRP, your risk of a cardiovascular event is increased, right? If there's inflammation in your blood vessels systemically, it's going to make plaque more unstable.

Are you seeing that often, like a low LDL with a high hs-CRP?

I see that a lot. But I also see, with extensive blood work that we have now available, I also see Lp-PLA2 activity high and I see, you know, different GGGT being elevated, inflammation around the liver. Um, so if there's inflammation in your body, which can come from multiple different causes, per se, we need to address that 'cause that means the environment in which the artery is in is stressed. And then of course, other, you're measuring ApoB, I'm presuming?

ApoB, I'm looking at ApoB, I'm looking at your LpIR, so your lipoprotein insulin resistance factors. We're looking at your blood pressure. We're looking at, really, all these factors. I'd also add another one in there that I don't think is really looked at as much and that's BNP, right? So we're looking to assess, is your heart under stress? And if it is, why? What do we need to be looking after? And I see this a lot in my athletes. I have a lot of athletes who come, they've done a whole Boston Hearts diagnostic or they've done function, they've done all these things and their BNP is very high and they're like, "Oh, no one brought that up." But that's a sign to me because athletes are at increased risk of aortic dilations and high blood pressure when they don't pair nutrition along with their exercise. And so that's another one that I like to really hone into as well. It's not saying don't eat any fat. That's not what we're saying. We're saying the type of fat really matters.

Right? So unsaturated fat helps in a couple different ways. One, it allows LDL receptor activity to work more effectively and it can also help with HDL functionality and that helps to recycle that LDL better from our bloodstream to the liver. And so when we're looking at swaps, it's important when we have the mindset, "Oh, I got to get rid of red meat." No, no, no. What are you switching it with? That is going to change a lot more. So if you're having red meat and you're now having it to fish, that's going to help maybe lower your ApoB LDL by 30%. And we make that swap versus just elimination. My nutrition philosophy has always been pretty simple. Start with a healthy plant-rich dietary pattern built around whole foods. That is the single most important nutrition move that you can make when it comes to optimizing your health. But even with a great diet, even with the best diet out there, many of us are still susceptible to falling short on our intake of key essential nutrients. That's where IM8 Daily Ultimate Essentials comes in. Daily Ultimate Essentials was formulated by yours truly alongside previous guests of the proof, Dr. Dawn Musulum, Dr. Suzanne Decoder, and Dr. David Catz. With the right dosage and forms of essential nutrients like vitamin D3, B12, iodine, selenium, zinc, and choline, IM8 was formulated to help you optimize your essential nutrient intake to support your energy levels, cognition, mood, metabolism, and overall well-being. It's also NSF Certified for Sport, which means that every ingredient is third-party tested before blending and every single batch is tested after blending to confirm that the active ingredients on the label are in the product in the right quantities and nothing more. In a world where supplements are underregulated and many supplement companies are cutting corners to keep their costs down and boost their profits, it makes sense to me to buy supplements that are NSF Certified for Sport where possible. For listeners of the proof, IM8 is offering 10% off your first order. Head to im8alth.com and use the code SIMON at checkout. That's im8alth.com code SIMON for foundational nutrition that's clinically backed, tested for purity, and built for performance.

Okay. So maybe we can step through a few of these avatars using that kind of that framework that you just mentioned there where you'll often prioritize. So you, you basically assess someone, you get their results back and then you prioritize the dietary changes in a way that allows them to kind of implement them and form a new habit. That's what I'm hearing rather than kind of overloading them, which makes a lot of sense. So for that person that came in and you were able to determine that they weren't producing enough nitric oxide, where do you start with that person?

Gut health.

So you. So you. So you make nitric oxide by your gut and your oral bacteria communicating. So if you have gingivitis, periodontitis, if you have negative oral bacteria in your mouth, your body will not make nitric oxide. And so we see this a lot with people who've been on high doses of antibiotics and never really paid attention to their gut.

Yeah. What about dental hygiene? Is that part of that?

Yes. Dental hygiene, right? So you think of heart health in isolation.

Who would have thought coming to see their cardiac dietitian and then leaving with a prescription to floss?

Yeah. But you, you would be surprised how, how periodontitis is so prevalent and it's one of the gateways we can go into your system. Um, so if it's inflamed, that can be a source of inflammation, decrease in nitric bio, nitric oxide bioavailability. And as we age, our bodies store and make less nitric oxide also. So gut health is where I start.

And, and when you say gut health is important for nitric oxide production, nitric oxide production being important for blood vessel dilation and function. What does gut health being important? What does that actually mean? And how do we, how do we look after our gut from a nutrition perspective?

There's several different ways. A lot of times we think of stress. Again, we think of it as isolation. "Oh, there's a lot on my mind." But there's a lot of times where the stress goes straight to your gut too. And so nowadays, people are eating really quickly. They don't have time for lunch or, you know, they're skipping a meal and they're rushed, rushed, rushed. They're standing up to eat, right?

Scrolling on their phone.

Right. And, you know, we need to slow down. Chew our food. Release salivary amylase to start the digestion process. So the first thing is, as simple as it sounds, chew your food. Take time to eat. I promise 10, 15 minutes of eating is not going to take more out of your day. It will add to your day. So that's one. And then also looking at it from a standpoint of, what are you eating to fuel your gut microbiome? And are you also adding some good bacteria in your gut too, right? So fermented foods are really important, but then on top of that, the plant-based foods that nourish those good bacteria is really going to be helpful too. There's a lot of people who are like, you know what, Michelle, "I can eat the same thing every single day." And I go, "Okay, but we're going to have to vary it up. Your gut bacteria needs that variety." And not complicated, right? In the beginning, when we're trying to make habit change, I'm all about basics. And then when we get to that level of support where we're like, "Okay, we can now add that variety," that's where we go. So, I like to do things in slow and steady increments, but understanding the knowledge that we do these things slowly to support your gut health and make it sustainable.

So, if this client of yours says, "Okay, got you. I'll change two or three foods this week or food groups to increase nitric oxide." And they're going to add in a fermented food. What, what might two other foods look like that would be good for their gut health and increase nitric oxide production?

Yeah, so there's two pathways in which nitric oxide is made. There's a direct nitric oxide pathway where we want to have more nitrate-rich vegetables. So things like your kale, arugula, your beets, your garlic, your cacao, those are going to help to support that. So we do want to see where those can fit into your diet. And then we also need to recognize the secondary pathway, which is a little bit more convoluted in how we get all those nutrients. We need vitamin C, we need folate, we need L-arginine, we need all of these other factors. We have to assess, okay, can we add in another vitamin C-rich food? Because if we have oxidative stress that doesn't allow for nitric oxide to be available either. So can we add in more citrus? Can we add in perhaps some strawberries or kiwi? Or can we add in some cauliflower or bell peppers, but in the raw? So, I think it's also important to say there's so many different foods that have such great benefit for your heart health. And this is where individuality helps. Someone tells me, "Ew, I hate beets. I'm never going to eat beets." I'm like, "Okay, we don't have to go there."

We maybe we can try something else to start.

Some dark leafy greens.

Yeah. Okay. So that's an example of kind of how you would look at, assess someone, prioritize the biomarkers that are placing them at increased risk of cardiovascular disease, and then give them a roadmap that is sustainable.

Exactly.

Inflammation was another risk factor that you mentioned. Where do, where does your mind go to when you see certain inflammatory markers as elevated? How are you thinking about helping kind of shift those into a favorable direction, reducing inflammation in that person's body?

I assess what they're missing in their diet. So, if you look at the dietary inflammatory index, it really looks at, are you getting the amount of nutrients you need in adequate volumes to support your body's functions? And if you are depleted in them, that can cause inflammation. And this goes to say, even with B12, if we don't get enough B12, it can be inflammatory, right? Same with vitamin C, polyphenols, there's so many different aspects. Omega-3 fatty acids. But what are you missing? Often times, people come defining their diet by what they do not eat. "I don't eat this. I don't eat this. My doctor said not to eat this and not to eat that." Okay, but what are you eating? Right? We're also in this mindset of, you know, "I only eat one meal." Can you get all your nutrients in one meal? No. And so my big part is when I say nutrient adequate is, are you getting these nutrients in the right volume for you? It can be also as simple as calcium, right? I have a lot of women who come to me in menopause and they have osteopenia, they have osteoporosis and, you know, they have a high calcium score. Very goes hand in hand a lot of times. And they say to me, "Michelle, I'm scared to eat calcium because I have a high calcium score." And I explained to them, "If you don't eat enough calcium, your body will get it from your bones." And it's not an easy process. It's an inflammatory process to do that. And so nutrient adequacy is that hallmark of, "What are you missing in your diet?" And when you explain how your diet is, "Oh, I avoid dairy, I avoid gluten, I avoid meat, I avoid this." Well, let me see what you're eating. Are you getting those nutrients from foods you do like and the foods you do that you can eat to help support your whole body?

Are there any commonalities that you're seeing among clients, nutrients or foods that they're not eating that you think would be increasing their risk of having higher inflammation?

Fish. Right?

Unpack that.

You know, a lot of people, they get the omega-3 index and it is very low. And we know.

Like four or 5% or something, or even lower.

Three. Three percent. And, you know, they're like, "Oh, I hate fish. I don't like the taste." Or maybe they just don't like it. But they're not supplementing or they're not getting it from other sources, right? I'm not going to come here and say everyone needs to eat fish. If

You're allergic to fish, you don't like fish, the practice is not in your wheelhouse, that's no problem. But let's make sure if you can't get it through your diet that you are supplementing to make sure that you're getting the nutrients that your body needs.

I think people are confused by this because omega-3 supplementation is another one where the headlines have flip-flopped back and forth and back and forth, and so you end up with a lot of people who are just not confident, like, what's the answer here? Should I buy a supplement? Am I wasting my money? Am I not? And as you say, like, how many people are actually having two or three serves of fatty fish a week? Not many. How do you, how do you go about educating, informing someone on how to supplement if they're like, "Okay, well, yeah, I don't eat fish or I don't eat fish regularly and I can't really see myself sustaining that as a habit. I'll supplement. There's lots of different supplements out there, lots of different doses. Like, how, how are we navigating that?"

It's a good question, and I, it really comes down to kind of assessing different aspects of it. You know, we've had headlines also showing does fish oil supplements cause AFib versus when we eat it from food, it lowers the risk. So, I, I always take a food-first approach. If someone likes fish but they just don't know how to cook it or they don't know how to do it, we start there. And then afterwards, if supplement is where we go, we kind of assess, you know, the quality of the supplement. We assess the third-party testing of the supplement to make sure that it, it says what it is, and then also making sure that the dose is appropriate to you. I'm very metric-driven because everyone has different bioindividuality, right? So, we can check omega-3s. Let's assess. Let's start at a lower dose and see where does that bring the omega-3 index. Where do we start on the omega-3 index? Are we a five or are we a three? That's going to also determine the dosage as well.

Yeah. I, I ran that experiment on myself. I was, I did my baseline and it was like 5 point something percent. And a 1.2, I think grams per day was the supplement I was taking. DHA and EPA got me to about 9 to 10%. So I haven't retested it, but I, I, I think one gram a day gets me above 8%.

Right. And, and someone else with a different body size may might be different. And I think that that's why metric-driven care is so meaningful because you know, hey, that's probably a good dose for me.

And so you're going to continue doing that dose because you know it works in your body. Why do you think that the studies looking at supplementation have found an increased risk of atrial fibrillation, but that hasn't necessarily been replicated in studies looking at correlation between fish intake and atrial fib?

There's so many different supplements out there, right? And fish oil, it depends if it's sitting in a hot truck in Amazon, it can become oxidized. It could change. We see supplements sometimes the dose says one thing, but when they test in third labs, it's not the same. So, we don't know the purity. We also don't know what is the difference between EPA and DHA, right? We've seen studies that show EPA helps, but DHA may raise LDL cholesterol. So, is it an oxidized supplement? Is it the wrong dosing? Is it as personalized as we need it? Is there another factor that can be part of it, right? When you're having fish consumption, we have more of a standardization of, okay, how much on average omega-3s is someone having versus the supplement can be so vast in terms of what the quantity is in that person.

Yeah. Which almost seems counterintuitive. If the, if the supplement industry was better regulated, it should be more specific than than fish.

Yeah.

But you're right, it's, it's underregulated. It's nice that certifications like NSF Certified for Sport are starting to become more prevalent, and we're starting to see this trend where almost through pressure from, from the public, and rightly so, brands are kind of publishing their third-party test results on a per-batch basis, which is, you know, obviously really important to have that that level of transparency.

You know.

So that's inflammation, nitric oxide, what about ApoB cholesterol? I'm sure you get a lot of clients that are coming to you having seen their doctor. Their cholesterol is high. They say, you know, "Go and see Michelle." What questions do they have firstly about their cholesterol? And then let's, let's talk about how you navigate that.

So, some people come without knowing what ApoB is, right? So, some people come with a standard lipid profile and their doctor says, you know what, you need to go on a statin. And they're like, "Can I give nutrition three months? Can I just see what nutrition will do for three months?" And so they're like, "Sure." So they come to me with not really that Apo marker tested. So that's one group of people.

They don't, they don't typically get that tested with their cardiologist.

A lot of cardiologists don't know to test ApoB. They go, "Why do we need it? We have LDL." And they just.

That, that it's still like that.

It's very common. The only people who really get ApoB testing are people who have taken under their own control for that own advocacy. But so many people have no idea what ApoB is, have never tested it, and when they go to their cardiologist, they go, "We're not testing that." So, and that's very prevalent. So, if that's the case, I calculate their non-HDL cholesterol and I use that as a surrogate marker in the interim and then say, "Hey, if next time you go, show them the NLA's assoc their paper to physicians about the importance of ApoB testing." And so then a lot of times they will test it after. But when someone comes to me with an elevated ApoB, I explain to them why that's an important metric and we talk about from a dietary perspective what increases its production and what could potentially lower its production and how it works in their body.

Yeah, let's, let's go through that.

Yeah.

I'd love to hear your explanation.

So, a big part of it is, okay, while I'm a very, let's add in food, we also have to recognize there are foods that will increase these levels too, right? So, we look at, for instance, saturated fat, particularly from certain foods like our red meat, like our coconut products or tropical oils. And explain to them that, okay, saturated fat, why do we need to limit it? Because saturated fat in excess doesn't allow the LDL receptor receptors on the liver to do its job effectively. So, you know, some people like to call the idea of, you know, there's gum or gunk in the LDL receptors. And if they're gummed up, the LDL, the liver can't actually recycle LDL. So, there and a so more Apo, more LDL is in the bloodstream. But it also signals the liver to make more ApoB and to make more LDL. So, we have to limit it in order for us to be a our liver to do its job effectively.

Do you find that this is another area of personalization where the extent to which saturated fat gums up the LDL receptor and drives up ApoB production and LDL is somewhat variable, even though that's like a good general heuristic? Are you seeing different responses clinically between people?

Yes and no. So, there are people who are overproducers of LDL, and in those individuals, we have to limit their saturated fat more, more so than others. But there is, you know, when I'm seeing people lower their saturated fat and then replacing it with unsaturated fat, we're seeing a lot of that ApoB go down and their LDL go down as well. And just to be clear, if someone's kind of entering this conversation without a whole lot of back background context here, what's the problem with a with an elevated ApoB in in circulation?

Well, ApoB is a marker of atherogenic lipoproteins. So, it's going to increase the risk of plaque progression. And plaque, in order for plaque to be made, ApoB needs to be there. It's part of atherosclerosis. And I think there's this misconception and there's a lot of things on the internet of, "Oh, we need cholesterol. We need this for our brain and for that." There's also people saying, "We don't need any of it." And I think it's an important conversation to be had of that there's different types of cholesterol. Your brain makes its own cholesterol. So, this is not when we're testing your blood, it's your blood cholesterol. And if you go back to what I mentioned about your vascular space, if you see if you have ApoB in there and your arteries are conducive to plaque formation, it's going to be part of the plaque formation process. So, we have to lower it to your target, which is also individualized based off of your risk.

What are the most common points of confusion that clients would come to you with regarding cholesterol?

So, it's that whole idea of my brain health, that, "Oh, well, I want to take care of my heart, but I don't want it to be negative on my brain." So, they've heard, "Oh, if if I lower my cholesterol with these dietary changes that you're recommending, is it going to increase my risk of dementia?"

Right? And then explaining to them that you need good blood flow. And I like to simplify, you know, there's so many risk factors of heart disease, which makes it confusing, right? Some one cardiologist says, "Just focus on LDL." We know there's a lot of things going on. I like to say, if there's havoc in your blood vessel, it's something we need to address. Whether that's blood sugar, whether that's excess free fatty acids, ApoB, we don't want it in excess. That is what is conducive to making more plaque and to put more strain on your heart. And that's going to impact your your body's ability to to be healthy and live a long life.

Yeah. It's funny how often it becomes an either-or conversation when in reality it's like, you know, trying to titrate and improve all these different risk factors rather than just zooming in on one. You know, it's not, it's not a single thing in isolation that that explains all of your risk.

Right? But and also, you know, we, we spoke very gently about we really focus on the coronary arteries, but not the carotid arteries. So, you know, if you have plaque in your coronary arteries, there are studies that show you probably have some plaque in your carotid arteries too, and that is giving blood flow to your brain, increasing the risk of stroke. You know, if you go in a hospital system, the stroke unit and the cardiovascular unit are different. You have a stroke, you're seen by a neurologist and you're seen by a cardiologist, and they often don't communicate to each other. So, when you, most people, and I went on a stroke podcast, had no idea it was a cardiovascular disease.

Yeah. And it surprises me. I mean, if I just pause and think about this for a moment, heart attack's scary, but I think I think a stroke's scarier.

Yeah.

Yeah. So, if, if someone is going to make changes to lower their ApoB with diet, and you kind of explained a little bit about what that might look like, but from a food perspective, if you think about the most common foods that the typical person would be eating that is increasing their saturated fat consumption, what, what are those foods that you would be wanting them to eat less of? And importantly, what would you be recommending that they eat more of?

I think there's a lot going around that we need meat in our diet. That we need red meat. "My iron's low. My this is low." Well, you're not eating enough meat. And so, we spoke about saturated fat, but I also wanted to add in the unsaturated fat component here, too, right? It's not saying don't eat any fat. That's not what we're saying. We're saying the type of fat really matters. Right? So, unsaturated fat helps in a couple different ways. One, it allows LDL receptor activity to work more effectively, and it can also help with HDL functionality, and that helps to recycle that LDL better from our bloodstream to the liver. And so, when we're looking at swaps, it's important when we have that mindset, "Oh, I got to get rid of red meat." No, no, no. What are you switching it with? That is going to change a lot more. So, if you're having red meat and you're now having it to fish, that's going to help maybe lower your ApoB/LDL by 30%. And we make that swap versus just elimination, right? Looking at, okay, you're eating maybe healthy fats, maybe you're eating lots of avocados, nuts, and seeds. What's the quantity? It's not a free-for-all. I think that's another big component here, too, right? Someone might be like, "Oh, I love nuts. I love seeds." Great. But they still have some level of saturated fat, and volume matters.

So, you don't think the saturated fat in those foods is necessarily being offset by the, the mono and the polyunsaturated fats?

It is, but in quantity matters, right? So, if someone's eating a whole cup of walnuts, you know, and there and that's about four grams of saturated fat, and then they have a 10 gram limit for the day, and then right, they're having other components, and now they're hitting 30, 40 grams of saturated fat. It's still a a threshold.

Yeah. That was a question I, I, I did have for you was if there are any heart-healthy foods which when consumed in excess are not heart-healthy. So, that kind of answers that. Is there any others?

I mean, it's all in context, right? You can look at anything and say, "Oh, well, I love eating leafy greens, so all I eat is a lot of salads." Leafy greens are great, but if you're not having the other components of your diet, you're going to be nutrient deficient in them. So, I always like to say, we want to include all these heart-healthy foods, but just having a cup of blueberries a day does not only protect your heart.

So, what would you say to someone who says, "Well, I don't know how much, how, how much nuts and seeds and avocado to eat. When, when is it going to be too much saturated fat? How, how does someone on an individual level kind of work that out?"

You have to figure out what's your saturated fat allotment for your day, right? So, we're seeing about, you know, if we want to protect your heart, keep it less than 6% of your total daily caloric intake.

And that's for whether someone is primary prevention, just has some risk factors but hasn't had an event, and also someone who has existing cardiovascular disease. I look at it as we want to help everyone prevent heart health, and I think a lot of times we always say, you know, you know, this person's at a higher risk or this person's at, but to really kind of look at it as we're all at risk of heart disease. We do want to keep that fairly low. And some indiv, some people, they're not overproducers of LDL cholesterol, and they can increase that a little bit depending on their risk factors and their numbers. But generally speaking, we do want to keep it low from a heart health perspective.

And so, is this again where it comes back to to measuring? So, when you make, presumably you're making the changes with your clients, they measure their ApoB again, and is that, is that guiding whether you're going back and kind of making more food changes?

Yeah. So, I mean, the, the liver component of your LDL, your liver makes LDL ApoB. Saturated fat, unsaturated is one component of the picture of reduction in ApoB, right? The second happens in your gut. So, we can't just look at that one component. We have to look at at your gut health, making sure that we're binding bile acids in your gut, helping to get enough fiber, but get the two different types of fiber, right? And so, that's another component. So, I don't like to just look at that. I like to say, are we getting enough soluble fiber? Are we getting enough insoluble fiber to help reduce the the ability of bile acids to be increased in your bloodstream, too? But if you measure ApoB in the in the bloodstream, is that, is that not a kind of net marker that is giving you an indication of how much bile is being reabsorbed and how much, uh, kind of ApoB is being produced by the liver?

Exactly. So, it looks at both action points. And so, this also goes down to bioindividuality. If someone comes to me and says, "I love this is my non-negotiable. I like eating whatever it might be. I like eating red meat and it's my non-negotiable. I can have it once or twice a week and I'm not changing that. I'm not going to change that." Right? I can guide you, but at the end of the day, that person needs to implement it. So, we need to have honest conversations. And so, my perspective, especially in the beginning of our work together, I might say, "Okay, we'll leave the red meat, but can we pair in some more soluble fiber alongside of it? Can we pair in more butyrate foods to help with reducing TMAO production? Can we help with looking at other aspects that you're more willing to do?" And so, that's another part when we are taking the science and applying it into someone's lifestyle. What brings someone joy that they're not willing to change? Let's not change that.

When you look at at soluble fiber, what, what are the best kind of sources of soluble fiber for someone to include in their diet? And, and why is soluble fiber so important in this context?

So, I like to explain soluble fiber as the binder, right? So, it binds the bile acids. It helps to form an actual amount of stool, right? And then you have your insoluble, which is your broom. It pushes it out. We need both. We need an effective bowel movement for optimal heart health, for de for your body's natural detoxification system to work. And so, soluble fiber is an integral component, right? Many people will be like, "Oh, I had more vegetables and I reduced my red meat, but my cholesterol didn't go down. It must be genetic." And I go, "You didn't add any soluble fiber." If you added more soluble fiber, that's how we get rid, one way we get rid of that cholesterol. So, soluble fiber is things that are soluble in water, right? You put chia seeds in water, you put flax seeds in water, they expand, right? They goop up all the water. You put oatmeal, you put oats in water, beans in water, you put barley in water, it expands. When you cook barley, you need three cups of water for one cup of barley. You don't get rid of that water. That's that expansion. And then if you see that gumminess that it makes, that's really kind of the pull of what it's doing in your gut. And so, soluble fiber is a huge component. And this goes back to saying carbs, right? All those foods I just mentioned, most of them, your beans and your whole grains are rich sources of soluble fiber.

Right? So, if you're heavily restricting carbohydrates, you're missing out on some of that.

Yeah.

Is there a role for any type of fiber supplement there for, for any of your clients?

Definitely. I mean, it's all personalized, but I'll give you some kind of way to look at it. A lot of times when you add in fiber in a supplement form, for it to be effective, you have to drink it. And let me tell you, it's not very palatable to drink a glass of psyllium husk for anyone who's tried that. It's gummy. You don't drink it right away. It turns into a glop.

You could blend it into a smoothie.

Yeah. But you have to drink that smoothie very, very quickly in order for you to not let it settle and be something that's hard to get down. So, a lot of people say, "Well, oh, let me just take a capsule. I don't need to take, I don't want to take the powder." And I go, you need 15 capsules to get a serving of soluble fiber. So, it's tricky on that regard. I've baked with soluble fiber. I've baked with psyllium husk before and it turns out great in breads and great in flatbreads, but it's not that very, it's not very palatable when you drink it. And I think a big part that we need to realize is, as much as food can be really helpful and therapeutic, there's an enjoyment factor. It's not so much, it can't be robotic. We have to recognize food comes up from an enjoyment factor. It comes up from a c, we're celebrating, we have food. We tr, everywhere there's food. And so, we need to plant it in when it's also enjoyable. And if you're taking something that you don't like, is it sustainable? Is it enjoyable? Not really.

What are your personal, I guess, favorite foods that are rich in soluble fiber?

I love barley. Barley is a big one. I like mushrooms also.

And how do you eat the barley? What do you normally do with that?

So, usually I'll, I'll cook it on my stovetop with like a low-sodium vegetable broth. I'll mash in some pressed garlic in there. I'll, I'll cook that up and then I'll make a huge stir-fry of vegetables. So, like, I'll put leeks and mushrooms and parsley and oregano and, and then just put them all together and it turns to be like a mushroom risotto. It's delicious.

Yeah. Nice. Wow. Getting hungry. So, we're, we're on ApoB here and you, you've highlighted the importance of thinking about food swaps that lower saturated fat intake, but importantly, it's not about a low-fat message. It's like ramping up unsaturated fats at the same time. So, you gave the example of reducing red meat, increasing fatty fish, eating, you know, more nuts and seeds and olive oil, but not too copious amounts because they also do contain some saturated fat. And it makes me think like last night actually, I was having dinner with a friend and he's a little bit older than me, maybe 15 or 20 years older, and he said, "Oh gosh, I remember growing up and all the messaging was low fat, low fat, low fat." And I do think even though like the 1980 dietary guidelines, I'm not sure how familiar you are with them, but the, the dietary recommendations from 1980, at least the way that they've landed with many people is that the recommendation was just to go low fat overall. And then what they ended up happening was they reduced fat in their diet, but instead ate a lot of foods that were high in refined carbohydrates, didn't have soluble fiber. And of course, we didn't see the reduction in cardiovascular disease that we would have liked to have seen. We saw increasing rates of diabetes and obesity, etc. The, the 1980 guidelines, they do say to eat more unsaturated fats, but it was almost, I think, lost in some of like the public health messaging. So, it's nice to to now to be in this era where it's not about being scared of fat. It's like you said, it's the quality of fat that determines the healthfulness or not. I think it's also a lot of times these easier guidelines to say, "Cut it out, right?" Same thing now, right, with carbs. "Oh, just cut out the carbs. If you have insulin resistance, the carbs the problem. Cut out the carb." But that, that information is not accurate because that's not how our bodies work in terms of needing carbs and insulin sensitivity that we need to focus on. And so, a lot of times it's, "Get rid of this, get rid of that, focus on this," without the the details of, "Well, what type? What are we talking about here?" And those nuance details matter tremendously from both a nutrient adequate, you know, perspective, but also just an overall, you know, ability to absorb these nutrients and utilize them effectively.

Have you seen RFK Jr.'s views on the upcoming dietary guidelines and saturated fat? I, I saw one thing, but to be honest with you, and I tell this to a lot of my clients, health anxiety is coming from being inundated with so many different perspectives that don't have truths to them. And so, I've, I've seen a couple things and been like, "Oh, man."

Yeah. Why I mean, I ask you because I suspect we were talking about confusion at the top of this episode. I suspect that based on some of the messaging that when these guidelines come out, they are going to soften the language around reducing saturated fat, and that might, that might cause more confusion.

100%. And that's why I hope people understand how, why is saturated fat in excess an issue we need to to, you know, address. And I think a big thing is, you have to sit back and you have to say, "Does this make sense?" And a lot of people don't understand how our bodies work, right? Going back to low carb, if you get rid of carbs, are you solving insulin resistance? No.

It's a bit like a band-aid.

Exactly. You're essentially also teaching your body not to know how to process carbs, right? But if you help your body become more insulin-sensitive, so insulin is released, opens up the the cell, allows glucose to go in, and you have good blood sugar regulation.

Right?

That includes carbs.

I think that's lost on people. If you take out the carbohydrates, then like, yes, your blood sugar could could be low, but often that's framed as as promoting metabolic health. But your metabolic flexibility, your ability to utilize carbs and fat, which sounds like you would argue this as well, that's really what metabolic flexibility is. Give it different fuels and how well can it actually handle those and turn that into energy. But when you restrict carbohydrates, you, you lose that metabolic flexibility.

And some of my clients who have been on low carb for a while and, you know, still have some level of insulin resistance, they're confused. So, they do the CGMs, and when I add carbs back in and I pair them accordingly, like, "Okay, have an apple, but have 10 walnuts with it." They're like, "Wow, Michelle, I didn't realize like my blood sugar was better than when I eliminated them all together." So, some of that also is helpful understanding that why, but then realizing how it works in your system to to then move that forward.

While we're on this topic of saturated fat, you mentioned fermented foods earlier, and that gets me thinking about dairy as a food group. I'm sure your clients are coming to you with all sorts of questions about dairy, having heard everything from "dairy is poison" to "certain types of dairy are a superfood." And I guess here in the context of thinking about a marker like ApoB, some dairy foods can be rich in saturated fat and have more of an effect on ApoB. How are you helping your clients kind of navigate that food group?

So, it's very nuanced in the fact that there's different types of dairy, right? There's some dairy that's removed all the fat in it, right? So, it doesn't have the saturated fat element. There's also fermented versus non-fermented dairy. And when we look at the research, fermented dairy is beneficial for cardiovascular health, primarily because it helps reduce the inflammation in the gut. But then this also goes into a little nuance again. Some people have dairy and they feel bloated, they have, they get cystic acne, they don't do well with dairy. And those people, we definitely don't want to be giving dairy. But for those who tolerate it and enjoy it, there is some benefit. I actually like there's this really cool kind of um study that came out looking at how when we have fermented dairy, it can help prevent the conversion of TMA into TMAO by our liver.

Is that right? I actually, I've been saying that study. Tell me more about that.

I mean, that's just crazy. That's so cool. So, when we eat certain foods, right, if we eat a food, very food groups that are very high in choline and carnitine, our gut microbiome can make TMA. TMA is then converted into TMAO by our liver. Why do we care about TMAO? Well, when we have excess TMAO levels in our blood, that can lead to more arterial stiffness and plaque progression. So, we.

Is that, is that like an association or is it causal work? Like, where are we at with that?

Yeah, I mean, we, it's a lot of association. It's a lot of also a field of nutrabolomics where we see certain things cause the metabolites. But it's also patient-specific. I've seen people who have TMAO levels that are low, and that diet that they were following was very high in carnitine and choline. On the other hand, I see people who don't eat any meat and their diet, they have high TMAO levels. We know that TMAO is something we need to look at, but again, everyone's body is different, and this comes back a lot of times to their gut health. If you have bacteria, gram-negative bacteria in your gut, primarily LPS, lipopolysaccharide, that it causes more potential for TMAO to be produced. But the dairy, when that was was h, when people were eating dairy, they also found when we were having cruciferous vegetables that gave the indoles, those helped to prevent that conversion. So, again, your gut health, we're learning a lot about cardiovascular disease and gut health. It's kind of a newer research. So, is it very strong? No. But it's there, and we do see the improvements in labs when we hone into these specifics.

Do you measure TMAO?

So, I, I'm a dietitian in New York. In New York, we can't really take labs, but I do recommend labs to my patients. And a lot of the services that they're using, whether it's Function Health, has TMAO already built into there. So, we do track it, especially if it's elevated. We want to make sure we're bringing it down. And is there ever a case, I'm thinking of someone who does have elevated ApoB, is making some changes to their diet, is still consuming dairy foods, does downshifting on dairy foods in your experience clinically, are you seeing that when someone reduces dairy foods that are high in saturated fat, is it affecting their ApoB much?

It is, depending on like if they're having whole-fat yogurt or whole-fat milk. Yes. So, I do like to cut down on that saturated fat. I also look at saturated fat as a whole amount for their day, and it does contribute. So, again, if this isn't, if this is something we can, it's a non-negotiable, we don't touch it. But in many times people are like, "Well, you know, I heard that whole-fat dairy is better because I can absorb vitamin D and vitamin K2." And I go, "Yeah, those are fat-soluble vitamins. We do need fat, but you can also do a non-fat version and add chia seeds or flax seeds and get the same benefit."

In terms of other types of fats, you mentioned before nuts and seeds and and olive oil, and I think at the top you mentioned seed oils. What are your views on seed oils generally speaking, and what type of questions are people coming to you with?

You know, it's funny. Seed oils get so much talk, and it, it, I always like putting things in perspective. When I ask people, you know, "What do you eat?" So many people in the last two years have come to me like, "Oh, I don't eat seed oils." And, and I look at them and I go, "Even if you ate seed oils or you had eaten seed oils in the past, were you eating a liter of seed oils for that to be the cause of every chronic condition?" Right? So, take out the research. We'll talk about that in a second. But I think it's being overplayed as to say, "How can seed oils be the number one cause of chronic disease when we're not making it a major component of our diets in totality of things, right?" Okay, you're using a little bit of oil to put in your your cooking, for instance, that, what percentage of your diet is that? If someone was here that argues against seed oils, I think what they would say is, well, supply and consumption of seed oils has gone up overall, but you're right in that that's not from people putting it on their salad. It's like it's from eating ultra-processed foods.

Right. Right. And if we look at the research, seed oils actually could lead to potential cardiovascular benefit.

Which is, I think that's like a bit of a hard pill for people to swallow because of the the stigma. And I, I agree with you. I think the evidence there is like pretty clear on that. But the, the kind of rhetoric about seed oils oxidizing and how unnatural the production is and like the story around that is so strong that anytime someone comes out, myself included, and says, "Look guys, I don't know whether we should be demonizing this food group so much, probably not explaining all the the disease we're seeing." people have a kind of visceral reaction to that.

You know, I, I've noticed also just this big trend of like wanting to pinpoint one cause of the problem. And when we do that, we don't get to look at the whole picture, right? When people say, "Oh, LDL cholesterol is not the cause of heart disease, it's insulin resistance." I go, "Why are we picking one? They both are important." I think that's our infatuation as human beings wanting certainty and simplicity in any problem in our lives. It's like, how can we reduce this down to one thing so we can get our, and myself included here, small brains kind of around around this complex where there's actually so much uncertainty in things that we don't understand and so much complexity. And to to take that position you're taking requires a little bit more humility. I wish there was just one reason for heart disease. We would then take it off of that, you know, number one killer over all cancers combined. We would be able to do that, but it's nuanced. There's so many things going biologically that can cause these things to occur, and we have to look at the whole picture. But to go back to seed oils, I think there's so much nuance even with that, right? When are you using those? Are you using it to deep fry something? Are you using it to even grill something? Right? We know high temperature, dry heat cooking can lead to advanced glycation end products, oxidative stress, and a lot of times we're using some of these oils in the wrong in that capacity. And so, we're missing the nuance of how science works. And it, when you simplify it, it, you want to make it easy to understand, but you have to bring into the picture of what's actually going on. So, if we simpl, simplify that from a very practical kind of perspective here, if someone's trying to work out what oil to buy for for home, how do they make that decision and ideally how are they using that in their cooking that's safe and healthy?

Yeah. So, when you're picking a cooking oil, I think it's important to recognize the smoke point of that oil. If you're using a very low smoke point oil on a high temperature, you're going to change potentially the structure of that oil, right? If you are choosing an oil for its polyphenols, let's take olive oil, right? Those are very susceptible to heat. So, if we're putting it on high heat, are you getting the full benefit? So, again, a little bit of nuance, but really focusing on how are we using it and the quantity in which we're using it, too. And in terms of high heat or smoke point, like, let's, let's take olive oil. So, the listener is thinking, "Okay, I use olive oil and I cook in my pan," which obviously a lot of people do. Is it enough for them just to observe it and see that it's not smoking? They can't see smoke, and therefore that's at a safe temperature.

Yes. I mean, that's one way to look at it. But also knowing that, okay, it, it may have a relatively lower smoke point at 325, 350, depending on the brand. You may want to look at the gauge on your on the stovetop. Are you in a rush? I bring it back to everyone's in a rush these days. Are you trying to cook your food really quickly, so you yank up the heat? You know, that's that's kind of a red flag to say, "I'm going to be cooking this on a higher heat. I should choose a higher smoke point oil." Is there an an oil that you would say kind of ticks all all of the boxes and gives you the most flexibility in terms of cooking temperatures?

Yeah, I mean, personally, I like to use avocado oil because it has a 500° smoke point. It's neutral. I don't really have any taste to it, and so that works for me and my family. But sometimes I don't use the oil if I don't have to, because I'm wanting to. I don't need to, right? You know, I cook a lot with like a low-sodium vegetable broth when I'm making a soup, when I'm trying to do something that I'm already, if I'm making the barley I mentioned before. A lot of times I don't necessarily use the oil if I don't, if I'm trying to use a different modality. But I don't think we need to fear oils. I think we need to recognize how much. Right? If you took a bottle of avocado oil and you just kind of pour it into what you're doing, you don't know how much you're using. And I'll tell you, my husband's very heavy on that when he uses it. I'm like, "Then you just use a quarter of a cup of avocado oil." He's like, "No, I didn't." I'm like, "M, yeah."

So, that's very easy to be liberal with that. And,

you know, it's very calorically dense, 110 calories per tablespoon.

And also, what's the nutrition profile, right? You're not going to get the same aspects of an avocado with avocado oil. Do you find people are so used to cooking with oil that it kind of scares them to not cook with it in terms of a palatability and b just not sticking?

But you don't need to get rid of it. That's one. It's just scaling back, recognizing how much oil you're using. But I think it goes back to a principle of, you know, when someone, a doctor says, "Follow a low-sodium diet." Someone gets rid of all of their sodium. They're like, "This food has no flavor." I'm not, like, they're not used to it. Well, did you replace the salt with anything else? Did you add an acid to bring out the flavors? What did you do in replacement of it? And I think that's a big part, too. It's about recognizing how much do you use in your oil? How do we scale back? But then, how do we cause, how do we allow more flavor to be developed that you were getting from the sauté of the oil with your vegetables and with whatever you're making. So, it's recognizing the shifts of how do we make it enjoyable while we recognize that we're overdoing the oil that you're putting into the pan.

What are those kind of common recommendations that you would give someone who is wanting to reduce oil but wants to maintain palatability?

Yeah. So, I love vinegars. I think vinegars are very underused but they add a lot more depth and flavor. So, depends the dish, right? So, I don't know. Give me an example of a food. Let's say we'll go to soups, just because you use oil to sauté the onions and the celery and the carrots to give it that caramelization. If you used water, maybe you wouldn't get so much oomph out of them. But if you used either a little bit of oil or you used your vegetable broth that you're using anyway, and then you added in a little bit more of different spices in there, you'll let it sweat the same way, but now you've added an agent, right? So, that could be anything from garlic to oregano to basil to rosemary, where you're letting it still sweat, but you're doing it in a different modality to increase the flavor.

How do you think about the the nutritional profile of some of those ingredients like garlic or herbs and spices? Are they, are they purely for flavor or are they also bringing important nutrition?

Important nutrition too. I mean, if you look at the dietary inflammatory index of like the most helpful spices to lower inflammation, cloves is really high. Most people are like, "Hm, cloves. What am I going to do with cloves?" So, when I read that study, what did I do? I went to Whole Foods and I bought cloves in two different formats, whole cloves and in ground cloves. And I said, "Okay, how am I going to do if I'm going to advise other people to have this? How am I going to make it palatable?" If you have cloves by itself, it's a little bit pungent. It's a very strong spice.

Especially if you leave them in the meal and then you bite into one. A whole clove, which my mom kind of scarred me of when I was a kid.

Yeah. But, but you feel that, right? So, you feel the power of those antioxidants in that bite almost. It's that potent. So, I've played around with it and I found, well, if you mix it with cinnamon, and if you mix it with coriander, and you mix it with powdered ginger, ooh, okay, I got kind of like a pumpkin spice going on here. And cloves are part of pumpkin spice. They're also part of allspice. So, a lot of ketchups that if you're making that or you're buying that has that in there, too. So, adding them adds in a lot of antioxidant, anti-inflammatory benefit, plus the flavor as well. And a lot. You don't need a lot for it to be beneficial, right? I'm not saying go empty out, like have half a, you know, cup of cloves. A half a teaspoon, a quarter of a teaspoon has a lot of benefit, and we don't, they're underutilized in my opinion.

And back to the broth, you mentioned low sodium. Is that, is that a blood pressure related decision?

Yes and no. So, I find that I personally, I don't love very salty foods. It's maybe it's partly salt sensitivity, but it's just too much for my palate. So, I can always add more of that in. But, I like to go low sodium to kind of start. And then on top of that, since we're back to the broth, another thing that I love to do is I'll put tomato paste into the broth. And that adds in a lot of lycopene. So, a lot of great anti-inflammatory benefit, but flavor is tremendously increased when you're sweating out your vegetables with that, too.

Is that low sodium, too?

Tomato paste generally doesn't have salt in it.

Okay. When you're when you're working with a client who has high blood pressure and perhaps has been told by their cardiologist that certain dietary changes, things like sodium restriction could help with their blood pressure, what are the the major kind of dietary levers or components of their diet that you would draw their attention to?

So, sodium's a thing that's important for us to discuss because I would say that's probably like the number one thing that people come to me saying, "Oh, my doctor said low sodium." So, I look for zero milligrams sodium on all of my labels. I'm like, "He didn't say no salt. Let's, let's clarify that." A low-sodium diet does not mean no sodium. It just means not a very high volume of sodium. But I think a thing that's often not discussed is that sodium doesn't work alone in the body. And we need to make sure that we are looking at your sodium to potassium ratio. And this goes into a lot of my clients go out to eat. It's part of their social connection, something that they enjoy, and they should enjoy doing. And when you flip the switch of, "Okay, I have to lower sodium," and you say, "Well, no, I have to add potassium." You're going to help control your blood pressure that much more because sodium constricts the arteries. Potassium reduces that tension, signals the kidneys to get rid of the sodium. So, we need to be thinking more. Do we have enough potassium relative to sodium?

And to do that, what's the, what, what's the best way to increase potassium?

So, potassium is abundant in our food supply. It's really found in our beans, our soy products, our salmon. It's found in our leafy green vegetables. It's found in our colorful vegetables, our carrots, our sweet potatoes, our broccoli, our spinach, our dates, our yogurt. It's found.

abundantly in our food supply. But volume matters. So in a whole day, you should be getting around 4700 mg of potassium. And a lot of my clients will come and say, "Michelle, I follow a healthy diet. I eat fruits and vegetables, but my blood pressure is still high." But the volume of which potassium's in their diet is not enough to give these benefits.

Do you work with clients on getting to an ideal body weight? Some clients, I guess, that are willing and and and kind of have that as a goal.

Oh, definitely. The way that I measure that though from a card metabolic standpoint is their waist circumference. So, I have every single one of my clients before, you know, we even speak essentially to check their waist circumference before you, you know, right when you wake up, get one of those soft measuring tapes and align it to your belly button and I assess where that is cuz that tells me your visceral fat. And visceral fat is more pro-inflammatory and increases the risk of cardiovascular disease. But it's also very connected to to epicardial fat because the epi the fat surrounding your heart muscle is also kind of made up of that same tissue. So if we target that, we're also helping with reducing epicardial fat and potentially reducing the fatty liver as well. So that's what I target. Your laser.

Talk to us a little bit more about epicardial fat. I think a lot of listeners will be familiar with the idea of fatty liver, fat going in the liver, but maybe for the first time are hearing that there can be fat building up around the heart and what's what's the what's the problem with that? What are the consequences?

Yeah. So there the the fat that's around our abdominal organs, so visceral fat and the fat that can come around our heart muscle can be very active. And what I mean by that is pro-inflammatory cytoins are being released. If you have fat around the heart muscle that's active, it's strain. It can strain the cardiovascular muscle, not allow it to do its job, which puts pressure also on our blood vessels and our heart, leading to an increased risk of heart failure.

And so treating that, reducing pericardial fat is part of that is weight loss.

Part of that is weight loss. But where is it centered? So because we can measure waist circumference easier than we can measure at home our epicardial fat, if we can lower your waist circumference to be an optimal range, then we know we're also potentially reducing that risk of that epicardial fat as well. And so when you're working with a a client who does have a goal of of losing weight, what what ways does the nutrition plan look differently to I guess what we've discussed or what things may you be focusing more on?

Yeah. So a big principle that I teach a lot of my clients is what I call the hunger scale. Okay. So it's a hunger scale so that you can start eating to your cardiomatabolic health. There's a scale 1 to 10. One is you're starving. You'll eat anything in sight. And 10 is you overeat. Even if you ate the healthiest food, but you overeat, it's still a metabolic strain, right? Your body has to digest that and it's struggling to do so. But if you eat within a four to six window, four, you're slightly hungry, you eat. Six, you're slightly satisfied, you stop. You're eating to ability of your body to digest the food, put into the cell where it belongs without having to overcompensate. And so that's how I like to teach all my clients to look at eating for cardioabolic health, which will facilitate weight loss. I don't like calorie counting or calorie restriction cuz most people who've come to me have done that yo-yo dieting and it doesn't work because they're so focused on calories, they don't actually look at nutrient density. They don't look at what they're actually eating to help their heart, to help lower inflammation. they're fixating on a number versus their metabolic needs and to help support that.

Are there any specific nutrients or foods that you find are helpful for improving hunger, reducing hunger, I should say.

It really goes back to the balance of your meal, right? You can eat just a bowl of oatmeal for breakfast and then be hungry an hour later. That didn't satisfy you. you should really be eating that breakfast and not being hungry for 3 to four hours because that tells me your body digested in the right quantity for you.

So what's missing from the the bowl of oatmeal?

Right? So your protein, where is that coming from? Right? So whether you eat yogurt, you can add that in. If you don't eat yogurt and you like egg whites, you can add that in. If you don't eat that and you have tofu, you can eat that in. So that could be individualized. You can make it savory. add in some lentils. You know, you can make it however you want, but you need to add the protein there that's going to help with satiety, right? Same with I look at oatmeal kind of as more of that starchier carb, right? So, you still need to add in some more non-starchy fiber, which will slow down the release of that blood sugar spike from the oatmeal. Okay?

And what might that look like from a a food perspective? It could be a cup of berries if you like it savory, a cup of vegetables, whether it's leftover that you make right there, right? Non-starchy vegetables, and then a little bit of fat. And that when it's balanced holds you for 3 to four hours.

So that could look like overnight oats, Greek yogurt, nuts and seeds, and berries.

Exactly. Are you noticing that more and more of your clients are on a GLP1 agonist?

It's a mix.

And are you are you finding that that's a helpful kind of addition to to the changes that you're making?

Yeah. So, my whole practice is not GLP1. It's a small practice of people who have been on GLP1s are currently on them. And those who are on a GOP ones, it works when it kind of takes off that food noise and they're able to eat three meals, maybe a snack or two. In some individuals, it really is hard on their digestive tract and it can make them nauseous, GI issues, but a lot of them that can be attain actually fixed, so to speak, or adjusted with adjustments in their diet. But I've also seen people beyond GLP1s who eat one meal. That's hard. that's hard to get all your nutrients in on one meal. So, I think it's helpful for many people who tolerate it well and then there's some people who don't tolerate it well. And so, again, individuality. There's some people who don't tolerate it and they're like, well, my doctor says I have to be on there, but they're having diarrhea or vomiting. That's not the right fit. And we have to understand that some medications work really well in some people and some don't. And we have to make sure we take that into account. Are there any risk factors that you closely or keep an eye on or really like to to measure and then guide your personalization of nutrition plans that we haven't spoken about?

You know, one thing I don't think I mean, we spoke briefly about blood pressure, but if I had to tell you, you're like, Michelle, pick one thing. I know all of it matters, but pick one thing that matters most. I will tell you it's your blood pressure.

And we don't talk about it enough.

Yeah. Why? When your blood pressure is high, it's a hint something's going on. If I told someone, hey, you have plaque formation in your arteries. The first thing they're going to say is the doctor will be like, oh, it's cuz your LDL cholesterol is high. And I'll be like, yeah, we need LDL and APOV to go in. But if you have high blood pressure, your risk of aththeroscerosis is so much more higher. And we've seen that in the data. High blood pressure can cause that pressure on the arterial wall to cause that micro tear. High blood pressure increases cognitive decline, kidney disease, aortic root dilations, heart failure, atrial fibrillation, and most people just ignore it. They go to the doctor. Oh, I'm nervous. Of course, it's going to be high. A whole year they say, "Oh, go monitor it. We'll we'll keep track." White coat syndrome gets blown off. Oh, yeah. Of course, you're anxious. Yeah. No, but you never checked it at home after you you actually went decades with a high blood pressure. I had a client who had migraines for 20 years of her life. She went to this doctor, that doctor for her migraines. Didn't know what happened. Do you know how she found out what her cause of migraines was? She ended up in the ER because she had an aortic root dissection. She could have died and it was her high blood pressure. And no one, not one doctor said to her, "Your blood pressure is the reason for your migraines." It pains me because so many people are like, "Yeah, I'm anxious. Oh, it's my blood pressure is high because I'm nervous. No, we need to really address that more timely.

Yeah, it's I think that's the most underrated non-invasive biomarker that we can test at home. And for like $50, $60 US or something, you can get a pretty decent at home cough.

30 bucks.

Right? Even less. I just had Raymond Townson on the show. I'm not sure if you're familiar with him, but he's he's a nefologist that specializes in hypertension. And we were talking about exactly this that so many people are are basically just often going years without knowing what their blood pressure is. It's wild.

That and also they don't know their baseline, right? So, if we're going really by personalization, if your blood pressure is always 90 over 60, and then you find that your blood pressure is now 120 over 80, still normal, but whoa, for 20 years of your life, it was 90 over 60. What's going on? Something is your artery, your heart's working harder than it did before. Why? Let's talk. Let's make sure we address that.

What kind of changes to blood pressure are you seeing?

People are floored. I have clients who call me, they're like, "Michelle, I went to my house, tested my blood pressure. I've never seen this low number. I went to my neighbor's house, tested it. It was still low. I went to another neighbor. I couldn't believe my blood pressure reading." People tell me, I thought white coat syndrome like was something I always would have. I went to the dentist and it was 110 over 70. Huge. I mean, think about it, right? If your blood vessels are constricted, blood pressure will go up. If we're feeding your arteries what we need to open them up, it's going to go down. It's one of the one of the best methods through diet that we can help reduce.

You're on the board of the National Menopause Foundation. Is that right?

Are many of your clients coming to you like as they're going through permenopause or postmenopause?

Yeah.

Are there any specific risk factors or things that change through that period that we should bring the listeners attention to? So one is nitric oxide bioavailability goes down. So blood pressure actually goes up during pmenopause and menopause. And if you're not actually tracking it, you have no idea. There's also 30% of the population that we're seeing that during pmenopause and menopause their LP little a goes up, right? So now you're having an increased risk on top of menopause risk too.

That's interesting. I I had thought that LP little A was just genetic, but you're you're saying it now is genetic plus life stage potentially.

We're seeing that in menopause, we're seeing this switch that goes on. We also know LDL receptor activity goes down in menopause, right? So, you could be eating the same exact diet before and after and you're like, why did my LDL go up? We need to shift some of the dietary changes to support that.

Right? Back to what we were talking about earlier. Maybe now you're you're more sensitive to saturated fat, so you can get away with less of it or you can't get away with as much in the diet or maybe you need more soluble fiber. Okay, what else is changing at this this period?

Yeah, we also see shifts in the gut microbiome. So, we also need to pay attention to gut health. We see insulin resistance happen more. We see more shifts in that abdominal distribution too that that's that actual abdominal region, right? we see those shifts happening. It doesn't mean it's inevitable. I think there's this thought that oh no, I'm going through menopause. All these things are going to happen. It's more that we need to have it on our radar.

And be measuring these things.

Yeah.

So you can be proactive in a sense. Okay, this has changed. Let's make some dietary changes, some lifestyle changes before living, you know, 5, 10, 15 years with that risk factor.

I think it's hard for cardiovascular disease when you look at it from like, okay, we can prevent this. So why aren't we? It's silent, right? You don't feel borderline high blood pressure. You don't feel high cholesterol. You don't feel any of these things until it's the end. It's the later stages of it.

What dietary changes would you say your clients that are going through per menopause or are postmenopause have made that have been most helpful?

You might be surprised by this answer, but a lot of them come with me like, "Oh, wow. I've gained this weight or I've gained this abdominal more abdominal weight. They go on a low car low calorie diet. And my big shift is you're not eating enough. You're not actually fueling your body. And so that's a big shift that happens because you know in your mind the first thing is oo I'm gaining weight. All these things are happening. High cholesterol, high blood pressure. Maybe if I lose some weight these will become normal. and you know it's actually not necessarily true if you're not eating enough that's not and you're not eating the things in appropriate quantities that can also be a negative component to get these numbers to be optimal.

So I can understand from that client's perspective it must be frustrating to see the scale going up but to be to be looking at your diet and thinking well I haven't been eating more calories. So what what is explaining the increase in body weight that they are observing on the scales?

A lot of it is, you know, we we look at calories definitely from a weight loss perspective, but we also have to recognize that our bodies are our body's purpose is to give the fuel it needs to do its job. So you don't realize all of the things it does in the in the scene behind it. And if you're not feeding enough calories, our metabolic rate goes down. So, we're not expending as much calories. Our body is doing whatever it can to supply the glucose your brain needs for what you're giving it. And so, we have to recognize, well, if I feed it and I fuel my metabolism and I rev my metabolism, weight loss will actually be more effective and sustainable. It's not just about losing weight. It's about losing it and maintaining it. That's so important. So what you're observing is that people are heavily restricting their calories and their their body's kind of fighting back against that by lowering the the metabolic rate.

So that's one part. Another part is, you know, you wake up and they're like, "Okay, I'm not going to eat. I'm going to be really good." Right? So you have this plan and then your body at the end of the day is like, "You didn't feed me enough." So what does it do? It eats a lot more than you realize. And that also causes your an elevation of glucose and triglycer and all these things because you're more insulin resistant at night. And so we have to recognize fueling our body is important and it has to happen in the beginning of the day to really help with getting that right calorie amount. I'm not saying overeat. That's not what I'm saying. It's saying eat what your body needs so it could do its job most effectively. You've no doubt seen hundreds if not thousands of of clients at this point. Are there any dramatic kind of health transformations that that come to mind that you could share?

Yeah, so I love what I do because I still get floored and I fall off my chair when I hear my clients results. Two of them come into particular things that shine. I had a client 42 years old. It was his third heart attack. After his first after his second heart attack, the doctor's like, "You need to lose 20 lbs. I don't care what diet you go on, just lose 20 lbs." He lost 20 lbs on the paleo diet. And he had another heart attack. And he was just confused. And at his third heart attack, they were going to place another stent, but the doctor's like, "I can't do it. You're too inflamed. come back to me in 3 months and then I'll put the stent in. He worked with me in those three months. He went back and his doctor says you don't need the stent anymore. You don't see that in research because we're not going invasively and seeing who needs a stent and who doesn't. But there was too much inflammation before and when we added in all the nutrients in the right quantities, that helped. and he lost the weight, but his waist circumference after his second heart attack was 42 in. It was still elevated. And so by addressing those factors, we helped with his vascular health. And so that story is always, it always kind of shocks me when I hear that because we don't see that. We're not going in invasively.

And he he avoided surgery in the end.

Yeah, PE needs surgery.

Wow. Still healthy today.

Still still healthy. He still follows up with me. He still gets his blood work every 3 months. He meets his panels have not changed, but he's on top of it and he's looking at all risk factors. First, he only looked at LDL, then he looked at his weight, but he didn't look at the full picture. And now he's on a very anti-inflammatory diet, adding in all these things, and he's making sure he checks everything because if it goes up, he knows, oo, what am I doing differently? So, that's one. I've seen people whose ejection fractions go up astonishly from 18% to 48% in 4 months. And you know, I never whenever I have an initial consultation with any of my clients, I don't guarantee anything. Everyone's body is different. But a lot of them come to me and say, "Michelle, I have a lot of side effects with medication." And I asked my doctor if I can just not go on all these heart failure medications, just try nutrition. And they the doctor's like, "You can do what you want, but I'm going to call on these prescriptions. You need them." So, they decide, you know what? I'm just going to do follow this and we're not doing it risky. I'm not saying, "Hey, don't take your medications. We're just adding in nutrition." And they go back and this is one of my clients and her ejection fraction went up and the doctor's like, "You don't need the meds. Do what you're doing."

How long did that take?

That was 3 months cuz they wanted to be more aggressive. Usually, if it's like, "Okay, they'll wait 6 months." But he was like, "You really need to be on these meds. I'll give you three months, but like 3 months is it." And like some people it takes longer. It depends their body. But if your body is if your blood for this particular person, her blood pressure was high. She had inflammation that was obvious. She had high homocyine, high AOB, there was a lot of things that were very conducive to, hey, nutrition is going to help lower these values and it's going to help take that strain off your heart so it can recover well, right? So it depends. But even if someone has for instance genetic cardiomyopathy I think a lot of times you know when a doctor says there's nothing you can do it's genetic it doesn't allow the person to be empowered to say well my decisions matter because even if it's genetic what you feed your body is going to make your heart work harder and it's going to make more complications. So hey you may not reverse it that's not our goal. Our goal is to prevent complications and that requires to look into your nutrition and lifestyle, you know, and I think that needs to be said. I mean, I have so many times where people have aortic root dilations, needing surgery, 5 cm, and they're like, you know, give me 3 months, give me 3 months, and we work together. We control blood pressure, top priority with an aortic root dilation. And we look at adding in all of these foods. They go back for another cardiac MRI, another echo cardiogram, depending on what they're looking at the doctor and they're like it's stable, you don't need it. There's a guy who came to me in 2019. His doctor wanted to do surgery. To this day, he does not had not done surgery on his aortic dilation cuz it's stable at 4.2 cm. People have shrinkage in the order dilation and the doctor's like, "Oh, our first test was an error. There's no way this could have shrunk." The guy's like, "But I put so much effort in here. You sure?" like there was and the doctor doesn't want to believe that nutrition can have that impact because the research doesn't look at that. We don't look at that nutrition with aortic root dilations and for some people maybe it won't necessarily decrease. We can't promise that, but it may it could stabilize. It could potentially get better. And for a doctor to say there's nothing you can do, surgery is inevitable, gives people a lack of hope. And also, they don't prioritize it, right? So, they continue doing what they're doing when they could tweak and make improvements and monitor their blood pressure at home. Have I told you how many people have aortic root dilations and are not measuring their blood pressure at home? Astonishing.

Someone hasn't heard of an aortic root dilation before.

What is that?

Yeah. So, it's a bulge. You when you think of your heart, you think of your heart as an isolated organ, but as I mentioned, there's all these blood vessels throughout your entire body. It needs to supply oxygenated blood throughout. If your heart has trouble doing that, it there's bulges in the aortic root that brings our blood to our other organs. And so if that bulge is there, right, and you have high blood pressure, what do you think's going to happen? It's going to get bigger and bigger. If we reduce that that aortic root dilation by controlling blood pressure, your heart's not working so hard to pump that blood. Hey, it may not get smaller, but it won't get bigger. And that's something that we have to recognize. But without you can measure blood pressure at home. That's why I love blood pressure so much because we can see what it is. And for anyone who's anxious about a blood pressure monitor, I think it comes from a fear of what if. What if it's high, right?

Sometimes we don't ask the question we don't want the answer to.

Right? But if you're proactive and say, "Okay, it's high. Well, why is it high? And what can I do to lower it?" you take control and that's a huge part of reducing risk of cardiovascular disease.

Yeah. Yeah. It's amazing how much we can fool ourselves, you know, myself included there where, you know, ignorance is bliss until we end up with whatever diagnosis. We spoke about omega-3 supplements earlier and that gets me thinking, I'm sure you're almost every day you're getting clients come to you and say, "Hey, I've I've I've heard about supplement X or supplement Y like nascin or red yeast extract or CoQ10, things of that nature. Do these supplements reverse atherosclerosis? Do they shrink plaque? Do they reduce my risk of having a heart attack? What's your view, I guess, overall on these supplements and whether any of them are worthwhile?

The research just doesn't show plaque regression with these supplements. And I think it's important to understand why are supplements included in someone's regimen, right? Is it to give your body the nutrient that it may not need? So take CoQ10. If someone's on a highdose statin, it may inhibit the production of CoQ10 and then take on the the understanding that CoQ10 naturally declines when we age. Maybe they need CoQ10 because they're deficient in CoQ10. And in that patient population, sure, maybe CoQ10 will be helpful. But then there's nuance. There's different types of CoQ10. There's CoQ10 and there's ubiquinol. Your body as you age doesn't know how to make bioactive CoQ10 which is ubiquininal, right? Dosage matters, but that isn't necessarily to reverse plaque because we don't see that in the research. It's to make sure that your heart is getting CoQ10 because it's an important component of the energy in our heart cells. So, the purpose is not always very linear to say plaque like plaque regression. It's to say you need these nutrients. Are you does is your body making less? Is it not getting enough from food? Do we need a supplement? And that can help in certain patient populations.

What do you think about red yeast extract specifically? And have you ever had anyone come to you and say they're thinking about taking red yeast extract instead of a statin?

All the time. So red yeast rice used to be the what we used to make lovatin which was on the pharmaceutical market. It was taken off or not really being used because it was causing liver damage and liver failure from high levels of monocine K. That's the bioactive ingredient in red yeast rice. It then got shifted to the supplement market which is not as regulated. Some of the supplements take it out completely. So the active ingredient that helps to lower LDL and APOB is no longer in the red yeast rice, meaning it's not effective. Some supplement companies have higher levels of that and it can increase your liver enzymes. And if those are not monitored, that can cause liver damage and liver failure. But for someone to come and tell me that they're not going to go on a statin, but they'll go on red yeast rice is silly to me cuz the pharmaceutical a mark, you know, we test the statin to make sure the appropriate dose and that it's pure and it doesn't have contaminants and it's giving what it says it's giving on the bottle in the pharmaceutical market. But when we bring it to the supplement market, it's not as well regulated. So, one bottle may have that active ingredient, the next bottle doesn't LDL and APOB is higher and you have no idea.

Yeah. It's a trap that our our minds fall into where we think pharmaceutical industry out to get us in profit. Supplement industry natural and has our back.

And you know what? What's crazy that I don't understand how this works is there are some cardiologists, physicians who will say, "Don't take a statin. Don't take a statin." But then they'll sell all the supplements. Right? So, a big part for me is that supplements need to be individualized. So, if you go to someone's web page and they're selling a lot of supplements and telling you not to take your medicine and take my supplements instead, huge red flag. That in and of itself, buy my supplement and stop taking your medications. That should be a warning sign.

Yeah. But so many people do it and it gets dangerous, especially when people go to functional medicine doctors and they say, "Get off your blood pressure medication and take my supplement regimen instead and their blood pressure is still high and they're walking around now with a dangerous level because the functional medicine doctor says, "Trust me."

That's got to annoy their cardiologist if they go back and see their cardiologist. Yeah, I have many doctor, many patients who go to a cardiologist and go to function medicine doctor and they go, "Michelle, I'm so confused. My cardiologist wants my cholesterol one number. My functional medicine doctor wants it really high. He wants it low. What do I do?" And it goes back to understanding, well, why do we not want high levels in our body? What is the purpose? We don't want plaque in our arteries, right? We have to understand that if there is high levels of LDL cholesterol, it can increase risk of plaque. And once you understand that your brain makes its own cholesterol, right, and that the blood what we're testing is blood cholesterol, you're going to understand why they have differing views. The interesting thing about that is that functional medicine, one thing that they've they've done well from a branding, marketing, positioning point of view is that they claim to to treat the root causes, right? But I mean, this entire conversation that we've had today has been about treating root causes through nutrition. It's no different in terms of how it's being positioned. But I feel like functional medicine has kind of convinced the public that they, you know, different to cardiologists and perhaps different to dieticians, they they know what the root causes are.

I think a lot of it also goes to, you know, I hear a lot of, "Oh, your liver needs detoxification. That's why your cholesterol is high." Well, no, you need to help your liver do its job. It doesn't need a detox. You feed it what it needs. Your liver will do the detox for you. Your kidney, you have three amazing organs. If you feed it what it needs to be fed, you're going to help it do it its job, right? Your gut, your liver, and your kidneys. If they start working the way they should, your body is a detoxification method. There's no, oh, take all these supplements. You're hurt. You're making your liver overwork. That's not going to help it do its job better. Going back to some of your success stories that you've seen clinically, are there any particular common threads that you see among the people who adopt your recommendations and are able to sustain them long term that separate them from people who perhaps are motivated for a little bit but then drop off.

A lot of the people who come to see me want to know the why. So, I spent a lot of time explaining the why, right? They had this massive heart attack. They're like, "How did I have a heart attack? You know, I go I go to the gym regularly. I eat clean. How did this happen?" And so, they're looking for those answers and a lot of it is explaining that to them. So, they're somewhat curious to know why this is happening. And when you understand the why, but then you understand why the food is going to help, you're more apt to apply it when you're traveling, when you're at a restaurant, when you're at home. And so and that becomes habitual, right? So a lot of it is recognizing that habits form not overnight but over time. But when you understand the why and then you can apply it everywhere. So a lot of times people be like, "Oh, I don't want to know the why." And I'm like, "But you have to know the why." And so I think the most successful and the people that I do attract are curious to know the why because it makes their choices easier. It makes their decisions easier. I'm teaching you how to eat, not telling you what to eat. And that way, you can apply these principles everywhere. It makes it more practical, but also sustainable because without sustainability, I haven't done my job. I need this to be lifelong. It is not a diet. Most people say to me after they're like, "I've always dieted. You've taught me this is a lifestyle and it's helped." But it also helps with mindset because if you start thinking this is a diet and that means that there are days where oh m like if someone asks me in the beginning or you know can I have a cheat day I'm like hm we're not dieting here this is a lifestyle there's no such thing as a perfect diet right and if you strive for a perfect diet I'm concerned of anxiety around food I'm I'm concerned about other components of of the long-term aspects of here what I want is this to look as a lifestyle and you start being mindful. When I eat this way, I have more energy. I perform better when I exercise. My labs are are optimizing. This is what works for me.

Comes back to what are we trying to do here?

Yes.

Right. The the goal is not to avoid having a heart attack and stroke, but live with anxiety for 40 years. Right.

That would be a significant trade-off that I, you know, I don't think most of us would would would make. So coming back to how is this going to be sustainable and how is this going to feel good for me I think is really really important and I too I often see people approaching their diet as or the way they eat as a diet and something that they're going to do for the next couple of months rather than for a lifetime. I mean, back to what you were talking about earlier, like these this disease is something that it's slowly silently progressing over a very very long time. You know, it's not something that you just wake up at 50 and all of a sudden you have it. It's and it's it's not a disease that comes down to how perfectly did you eat for a couple months of your life. It's what was that what did your diet look like consistently, right? Albeit imperfectly. What would you say to I think it's someone like the guy that you mentioned before who was told he needed surgery or someone who's had a heart attack or a stroke. I think for pretty obvious reasons they have a strong why and motivation to make some change. I think where it can be harder for someone to grasp is primary prevention or even the 20 or 30year-old who maybe has one risk factor kind of you know not not in the optimal range but has not had that that acute experience or has not been told like hey you need to make some serious changes now or you're going to end up on the on the surgery table here. How would you speak to that person to inspire them to to take this seriously from the age of 20?

You know, that's a really good question and I wish that I could reach as many of those as possible. I think it really goes to understand what's going on and why do we have to care about it now and realize that it doesn't just happen, right? We know the risk factors. So, we have to be doing it at an earlier age. But that comes from understanding, you know, hey, this is a risk. Everyone's at risk. I think a lot of people and at least what I'm seeing now is that in the 20s and 30s, people are getting their LP little A tested, right? Like that's a big trend right now. And when people in their 20s and 30s are like, "Oh my god, I have high LP little A." Some people are like, "Oh my god, heart disease is inevitable. I'm going to die of heart disease. I can't do anything. It overconumes them." And I say, "Wait, why don't you change that perspective? I have high LP little A. And what do I do? Well, I know I'm at increased risk. I have that information. Use it to your benefit to say, okay, heart disease can't just happen. I have a very high susceptibility at lower cardioabolic thresholds. I have to care about it more in order for me to halt that progression in my life. Right? So, something has to pull. Right? like someone who has normal people, no strong family history of heart disease, it's hard to get that person to start thinking about blood pressure and cholesterol. But you know what I would encourage that person to do? Check your blood work. Go to the doctor on a routine basis once a year or do outside testing. See where your parameters are. If they're elevated, let's make sure we don't ignore that because if we do, then it can start brewing. And I think that data drives people because they're like in my blood it's elevated. What does that mean? But then turn that knowledge into empowerment versus fear because it can trap you, right? It can trap you. Oh my god, I have high risk of heart disease. What does that mean? It means that you know.

Yeah. Do you do you remember when you got your LP little A result?

Yeah, it was a couple years ago. And when I first started, I was like, who? Because in my mind, I wouldn't tell you that I have a strong family history of heart disease. I wouldn't. And then I got, you know, my siblings tested, my parents tested, and when I told my dad that, hey, I have high LPLA, and I'm pretty sure you probably do, too. He goes, no, I don't have it. And he got it tested and his was elevated. Um but I I've been a cardiovascular dietician for 14 plus years. So I had understanding of LP little A and for me initially I was like oh okay it's high but it's been on my radar of my cardium metabolic health. What changed though was my targets. You know I used to be like okay LDL less than 100 I got that. Now it's less than 70 for my LDL.

So and you get there with diet alone. What what changes did you have to make to get from 100 to below 70?

I went from 92 to like 69 to be exact, but.

That's a good that's a good reduction.

Yeah. So, I really honed into how much soluble fiber was I consuming in a day. You know, it's not just one bowl of oatmeal. That's not going to do that's not how how much is that going to reduce apob? It's going to reduce it some, not significantly enough. I think this is where a lot of cardiologists are like, "Yeah, diet will just reduce it by 10 to 15%." Well, it depends how much change, how much soluble fiber, how much unsaturated fat the volumes are going to give that bigger risk reduction. I also kind of looked at, you know, my animal protein, my plant-based protein, kind of swapping the quantities of which, pairing them a little bit different, really focusing in on all aspects and just as much as I do it for my clients, kind of calculating it more for me, too. And so, that's what helped me get where I am. And you know, I I think a lot of people expect as a dietician that I'm anti- medication and I'm not. It deserves a purpose in certain people at certain times. Maybe someone else with a high LP little A can't get the RAPO be down with dietary measures alone. It doesn't mean one is better than the other. They both can coexist.

You had have made those dietary changes and your LDL was stubborn genetically. That's where that's where it is. Even doing you know quite let's call it extreme dietary changes to reduce saturated fat. Would you have added a statin?

I may have.

Yeah. Speaking of of cardiologists, so a lot of cardiologists listen to this show. How would you how would you describe what effective collaboration looks like between a dietician, a cardiac dietician and a cardiologist? I have had many different relationships with cardiologists, but the best cardiologist relationships I've had is when we co-c collaborate. So, I'm a dietitian. I'm not touching medications. I may if you tell me, hey, this person needs to be on the statin and I know that was your recommendation, I'm going to help that person convince why that's helpful. But if the person opens up to me and says, I went on the statin, I had really bad brain fog and muscle aches and they don't want to take it. I may communicate that with you to say, let's do a different modality of cholesterol lowering. There's so many, right? So, I'm on your team. And I think that that's something that we need to recognize. At the same time, your words are powerful. And so, when a person comes to me with a on a discovery call and tells me, I have a high calcium score, but my doctor says, take a statin and don't worry about your diet and lifestyle. I I'm hurt by that. Because I hurt for that person. You could have said take your statin and nutrition and lifestyle matter and that's going to be helpful. And I think a lot of people expect to go to a cardiologist and get all the nutrition advice. You can say, "Hey, you would benefit from a dietitian. I want to refer you to this person." Instead of just saying, "Oh, follow the Mediterranean diet." That's really vague and people don't know what to do with that information. So collaboration is key and communication around that too. I mean I have cardiologists who be like I went on this person had high triglycerides. I gave them everything. I gave him phenop fibroids. I gave him you know a statin. I gave them vipa. I gave him all these things. It didn't budge. He met with you in 3 months. I've never seen this guy's triglycerides be enorm in like 300s versus 800. And this cardiologist said to me Michelle this is the problem though. There's some dietitians who understand cardiovascular disease and nutrition and some that don't. And so they might say oh this guy's triglycerides are high. cut out all the carbs, but they don't ever talk about saturated fat. This guy has familiar hyper triglyceria and they don't know how to treat it.

Do you think that at the very least if a dietitian was just helping the average person eat according to the dietary guidelines? That would be a good starting point.

You know, I think that dietary guidelines get a lot of negative rep, but how many people are following them? Not many. Finishing here with that idea of health span that we spoke about. Why is this important for you personally? Why make these changes to your diet? Like what's what is your why behind everything? I have four sweet little boys and I have a husband and we want to live a long and healthy life, you know, and we want to be able to take care of our grandkids and, you know, have our kids go away on a weekend and us bring our kids to the zoo and travel and make memories. That's really the big part of it. And so, you know, I really firmly believe in prevention at every level. My kids cook with me in the kitchen. My kids know what's healthy and what's not healthy. My kids, but not in a bad term. It's like, oo, this is going to make me strong. This is going to make my brain work better. Oh, I can see better with my eyes. I mean, I have young kids. My kids range from 2 to nine. But I teach them because my goal is for all of us to live a long healthy life in my family. And that requires my kids at a young age to understand the importance of nutrition, understand the importance of physical activity and importance of mental health and stress and all the aspects. I want to teach them when they're young. And I think a lot of people, you know, when you have kids in your life, whether it's grandchildren, kids that are watching, we need to give our knowledge to them, too. So when my kids are in college and they have a huge buffet of all sorts of things to choose from, they're choosing what's going to protect their heart health because if I have high LP little A, at least one out of four of my children do also.

Beautiful. Thank you so much for coming out here to LA and I'm glad that Carol put us in in touch and this was a master class. So yeah, really appreciate you hanging out with me today. And if we want to send people your way to to learn more about you, to work with you, where can we send them?

Yeah, check out my website, entirelynourished.com.

Beautiful. Thank you so much.

Thank you so much for having me.

There you have it, friends. I hope you enjoyed this episode. If you did and want to stay up to date with future episodes, be sure to hit that subscribe button on YouTube and follow on Apple or Spotify. Finally, thank you for showing up and the effort that you're making to take control of your health. I look forward to hanging out with you again in the next episode.