Heart Disease: Signs and Symptoms

SUBJECT: My talk is going to be focused
on how cholesterol impacts your stroke and heart attack risk.
So, our learning objectives is to give you
a little overview when you get your cholesterol lipid
profile, what are the different components that go into them,
and then introduce to you a risk calculator that
can calculate your risk score for strokes and heart attack.
But more, the majority of the time,
what I want to spend on this talk
is to discuss evidence-based, proven interventions
that you can use now to lower your stroke and heart attack
risk over your lifetime.
And I want to give credit to the American Heart Association.
The link is down below.
That provided the visuals for me to explain the cholesterol
component that you will see shortly.
On that note, let's just dive right in.
So, what is cholesterol?
Cholesterol is a component of a product that
is made in your liver that assembles it,
and then it is then passed through
and put into your bloodstream.
Colossos also a component in food,
specifically animal products that
contains cholesterol products-- do not have cholesterol in it.
So, that's one reason why focusing on plant-based food
is one intervention which we'll go into.
Now, cholesterol is an essential ingredient in our body.
Part of its function is to help maintain the cell
wall of our cells, and also in is component
that goes into the manufacturing of certain hormones
that we need in your body.
So, I just want to highlight that cholesterol
is an essential component.
We need some, but we certainly don't need a lot of that.
All right, so in cholesterol, when you get the cholesterol
results, typically, it comes in a lipid profile,
and I'll show you an example of that later on.
And it's broken down to different components.
And you may have heard of before.
I want to start with the one that
is linked with all the bad things that cholesterol can do,
and that is the LDL cholesterol, or the bad cholesterol.
The way I'd explain to my patients, L stands for lousy.
Well, it actually doesn't, you know?
It's actually, LDL stands for low density lipoprotein,
so the first is low.
But I just use the word is lousy, so you want less of it.
The lower the better, for bad cholesterol, in general.
So, this is the cholesterol component
that deposits the cholesterol into the walls of the arteries,
and then over time, narrows the arteries.
So, this is one of the factors among many
why LDL cholesterol, the bad cholesterol,
is something that we want to tackle.
That's one of the main interventions
that we do in cholesterol management.
Now, as opposed to LDL, lousy cholesterol,
there's HDL cholesterol, which is the good cholesterol.
Now, H stands for high density lipoprotein,
or I call the H highly desirable.
HD stands for highly desirable.
So, what this component of the cholesterol is,
this is a marker that your body has synthesized and packaged
the cholesterol components to be removed from your body
to be excreted, to be eliminated from your system.
So, that's why when you look at your cholesterol,
some people are blessed with an extremely high HDL
count, highly desirable, a good cholesterol count.
It simply means that that person's body
is very efficient in packaging and moving
cholesterol from the LDL part that gets deposited
into the cell walls and then metabolizes it
into a component where it's packaged to be eliminated
from your body.
HDL cholesterols don't clog up the arteries.
HDL cholesterols are those that are
in the process of being eliminated from your body.
So, HDL is good.
LDL is bad.
All right, another component is triglycerides.
Triglycerides, you can think of it as the oily fatty components
that we kind of sometimes see as you thin down the blood that
gets into it.
Triglycerides is also the ingredient
of which when you eat and you metabolize the food,
it goes into triglycerides to be packaged
into various components in the body.
And if you eat in excess of certain calories,
and in particular, if you eat in excess of sugar
than your body wants, typically, your triglyceride levels
will go up.
So, sometimes you hear people say that triglycerides can also
be a marker of your diabetes risk,
because typically, high triglycerides and high blood
sugar sometimes go hand in hand.
Not always, but you can sometimes
see when people that have a high sugar intake,
their triglycerides tend to be high.
And some people will say, oh, it's a cholesterol problem,
but in fact, many of which the contributor is
excess consumption of sugar calories,
because when the sugar calories get absorbed in the body,
some of it is packaged into triglycerides as a way of being
stored into your system.

This kind of blurb here mentions about that.
So, a little bit about the anatomy now.
So, now you know HDL is the highly desirable,
LDL is the lousy one.
The main thing why we pay attention
to the LDL cholesterol is that the lousy, or the low density
LDL deposits cholesterol between the layers
of the arterial wall.
And this is a healthy arterial wall,
this is kind of the LDL particle,
and it starts depositing in there.
And then over time, you hear about this,
the artery wall gets thickened, and then
it can form into plaque, and then
it can narrow the arteries, causing
the downstream effects that can lead to heart attacks
and strokes.

So, this is just an illustrative example of how physiologically
some of the cells that package these together,
become foam cells that enlarge.
And some of it, then, when you hear plaque,
it's basically the cholesterol components
in the arterial wall.
And the unstable plaque, this is what this is trying to depict,
can erupt, and then the lining of the arterial wall
becomes disrupted.
And when there's a break in it that's not smooth,
the blood components can form a clot around here.
And then if you have a clot, as you can imagine,
it can sometimes block your artery,
then leading to strokes and heart attacks.
So, physiologically, that's what happens
when you have a certain type of strokes and heart attack
is that you have plaque rupture causing a clot formation.
It then occludes the blood vessel,
so that anything beyond the clot no longer has blood supply
and leads to cell death, which translates
to-- if it's in the heart, it becomes a heart attack.
If it's in the brain, it becomes a stroke.
So, that is what--
so, that is the physiological basis of this.
The other reason that we pay attention to this
is that heart attacks, heart disease
still remains one of the leading causes of bad health outcomes
that we have in the country.
Heart disease is the leading cause
of death, still, for men, women, and people
of color, in general.
And even with COVID in the past year and a half
causing over 600,000 deaths, it's
still not even in the top two of leading causes of death.
It's still strokes and heart attacks in that.
And this is a visual that across the nation, the higher the red
you have, the higher rates of these incidents.
And you can see, there are some geographic variation
of how this happens.
Some of it is due to genetic factors, some of it
due to environmental factors, and a lot of it due to,
if you look at us here in California,
we generally have lower rates of that.
And some of it may have to do with our values
and our lifestyle, which I'll go into, that factors in,
why that living healthy lifestyle can
be protective against strokes and heart attack, OK?
But remember, despite the news of COVID,
beside all causes of cancer, heart disease
still and remains the number one leading cause of death.
I mean, it's not the flavor of the month, so to speak,
but that's why we continue to focus on that,
and I'm very glad that all of you have come to this talk
to learn more about how you can impact this and lower
your own personal risk of heart disease and strokes.
So, a little bit about your cholesterol number.
Remember, the total cholesterol is a combination
of various factors.
The three main ones are the HDL good cholesterol,
the LDL bad cholesterol, and triglycerides.
Now, this is not exact, calculating
the total cholesterol score, but it comes pretty close.
So, that's why there have been people saying,
oh, what should my total cholesterol be is less than 200
where I should be.
Well, the truth is that we are looking
at-- what you need to look for is actually
the different components of that.
And you will see this in action when
we do the risk score calculation is
that while the total cholesterol is a number we factor into it,
we do need to know the breakdown, specifically
the ratio of your good cholesterol
compared to your total cholesterol as a way
to interpret your risk score from a cholesterol standpoint.
So, there are cases where people have extremely high HDL
cholesterol, rendering their total cholesterol above 200.
However, in that situation, their bad cholesterol
may be less than their HDL cholesterol,
and that profile becomes less concerning.
So, mistakenly narrow down just to your total cholesterol
score.
When you have your total cholesterol score,
make sure you know what the breakdown is, specifically
what parts are the HDL and the LDL, primarily.

What is here is an example of a patient of mine
and the views of their cholesterol
value on MyHealth online.
So, some of you who are our patients at Sutter
and you sign up for online access
and you do blood tests, specific cholesterol, this
is actually a screenshot of what it will look like.
Now, here is this patient whose total cholesterol is 189.
So, there is a standard range.
Yes, in general, we use less than 200 as a guideline.
In this situation, what matters more
is looking at the breakdown components.
So, for this patient, the LDL, in general,
we want it below 130, optimally below 100
for people that don't have heart disease or strokes and heart
attacks.
This person is OK at 92.
But one thing you can see for this particular patient,
their HDL profile is on the low side.
For HDL, more is better.
The standard is they have 30 or more.
Well, this patient happens to be less than that.
So, that can be a marker-- even though the total cholesterol is
OK, this is a marker of some concern,
because you look at that, one of the things
that I would like you to take a look at
is your cholesterol to HDL ratio.
This is actually-- if you want to look at one number,
this would be a good number for you to look at,
because this puts the cholesterol components
into context and giving you a sense about, oh, how much
do I need to worry?
In general, while the reference range is 4.5,
I use a standard less than 4.5 as the indication
of a good profile.
You can see, this patient, despite a total cholesterol
less than 200, because the HDL is on the low side
and triglycerides are a little bit high,
their ratio is on a higher side.
So, this person, actually, in my mind,
is either higher risk for strokes and heart attack
because of these compounds, and I'll
get into more about that in a minute.
And also, just want to let you know, in MyHealth online,
you have the ability to graph the numbers over time
to see what the trends are.
So, this patient's total cholesterol kind of wanders
up and down.
This to see the trend going down over time,
and this is an indication of the LDL cholesterol, which
the bad cholesterol.
So, for this person, the LDL cholesterol
remains pretty steady.
And for this, I'm pretty sure the decline
in their total cholesterol is due to the fact this person
probably did a good--
did some work to improve their triglycerides.
And I'm pretty sure this person will have--
is tied into having higher diabetes risk,
because again, higher blood sugar and higher triglycerides
sometimes go hand in hand.
That's why you may hear your doctor even saying, hey,
your triglycerides are high.

Cut out on your sugary intake as a recommendation,
rather than cholesterol.
That's where it comes from.
Again, today, we're not on a diabetes talk.
I just want to bring that in, where this interacts here.
So, again, take home message here,
when you have your total cholesterol numbers,
and also sometimes they use lipid profiles
synonymous with cholesterol profile.
They kind of mean the same thing.
So, when you look at that, make sure you put it into context,
look at the cholesterol field ratio as a guide,
and look at what the standard recommendations are.
I personally use 4.5 or less as a marker of good health.
The lower the ratio the better, typically, in these cases.
All right, so now I want to broaden this a little bit.
And those of you who follow about risk factors,
of markers for heart disease will
know that there are things beyond just cholesterol
that factors into this.
So, what you have on the screen here
are the core common ones that are well
researched and validated as inputs to increase your risk.
We know in general the male sex is at higher risk than female.
Older you are, higher risk.
There are certain ethnicities brings you to higher risk.
We talked about cholesterol already.
Higher cholesterol is bad.
Higher HDL is protective.
Blood pressure, blood sugar, smoking status
all factor into that.
Now, I fully acknowledge there are additional risk factors
that people have follows, such as homocysteine,
LPa, intimal thickness in the carotid artery,
among other things, and other--
high sensitivity CRP.
So, what we have found is that while all those are
can be markers of increased risk, the impact of it
independently is still not as validated as the ones
over here.
So, what I want people to know is
that please start here first.
Understand the components of these
in factoring your heart attack and stroke risk,
and get these under good handle, because primarily, these
are the ones that we have good interventions for,
it's where you focus on, and don't get too distracted
with the other secondary markers.
I mean, they are always in the news.
However, these secondary markers do not supersede the ones that
we know here, and that's the reason why you cannot go wrong
by focusing on your heart health by looking at cholesterol,
your blood sugar, and your blood pressure as the primary
component of where you are.
Now, what can you do?
There is a risk calculator that you can use,
and I have the link below.
And after the talk, my team will find out the link to you
so you can use.
This is widely available on the internet,
widely used and validated.
Now, there are some limitations to these,
which I will mention to you.
But what I like about this is that it
puts the established primary risk
factors into one calculator to give you a global score.
So, it's a situation here where you put these factors--
those are asterisks that are components
you need to put in there to calculate your risk score.
So, let me give you an example of that.
So, over here, we put in someone that's
42 years of age that's female, white race, with a blood
pressure that is borderline, 135 over 85.
Again, ideal blood pressure should be below 120 over 80,
so this person is above that.
We call these patients pre-hypertension.
And in fact, according to some stricter guidelines,
they call this patients with hypertension already.
But in general, let's just use the standard 140 over 90
as a marker of hypertension.
The patient is kind of in the at risk range.
And then the cholesterol, it's above 200.
HDL is low at 30, and for the LDL, I have what, 38 over here.
And it spits out a global risk score here, 2.4%.
Now, what this number me is the risk
of this person having a stroke and a heart
attack in the next 10 years.
2.4%, quite low, kind of 1 out of 25 people
or so, and primarily because this person
is relatively on the younger side.
That's one thing that you don't really
hear about strokes and heart attack
in people generally less than 50 years of age,
because again, younger age is a protective factor over here.
But what I want to call your attention here is this number
here, optimal CV risk factor.
In this example, I put in someone
that has borderline blood pressures
and a borderline cholesterol component,
and you can see if these were all normal,
their risk score would be 0.4%, so basically
1 out of 200 risk of stroke versus 1 out of 25.
So, while this person is low risk,
elevated blood pressures and abnormal lipids
do increase the risk 6 times compared
to someone that has an optimal profile there, OK?
So, yes, while this patient is still considered low risk,
this person has an-- compared to optimal standards,
this person already has a six-fold increase of risk.
And I think that is, as long as these are modifiable,
that's where the intervention can come in to lower
your risk over a lifetime.
OK.
I want to highlight to you-- this is all the same numbers
over here, but to illustrate the risk of diabetes and high blood
sugar in factoring into this.
So, everything else in this slide
is the same as the previous one.
And remember, this rate was 2.4%.
All I did was to say this patient has diabetes,
the blood sugar is high, OK?
And you can see that risk went from 2.4% to 6.5%,
causing its risk up by 2 to three-fold.
So, that's why when you look at stroke and heart attack risk,
you can't ignore the impact of blood sugar and diabetes
into this.
And as you hear now, we're more and more
looking at diabetes as a stroke and heart attack disease
more so than the complications of high blood sugar causing
amputations or kidney disease.
That still happens, but more and more over here,
particularly people with high blood sugars
and higher diabetes, we worry more
about their cardiovascular risk factors
as much or sometimes more so than the damage
that high blood sugar can cause to your eyes, to your kidneys,
and all that.
There are different mechanisms to it
that as you more and more hear, we're
looking to recognize diabetes as a main driver of strokes
and heart attack, therefore so many interventions.
And that's why you hear the recommendations
for people with diabetes that even if they
had a pretty good cholesterol, the standard recommendations
now is to consider adding a cholesterol-lowering medicine
for patients with diabetes.
And the reason is the fact that diabetes almost triples
your risk for strokes and heart attack,
everything else being equal.
So, the take home message here is
that don't get singular focus on just cholesterol or your blood
pressure or your smoking status.
It's really looking at all these factors
all together in combination that is going to be the key,
and you can use this risk calculator to do so.
I want to mention before I move on,
there are limitations for this.
Now, the research that goes behind this risk calculator
has been done on a skewed population,
meaning it has been mainly for--
this was done kind of almost 40, 40 to 50 years ago
that accumulated the data into this.
And it's recognized that it may not properly
capture risk profiles of people from Southeast Asians,
for instance.
So, if you belong in that population over there,
this risk score calculator sometimes
undercaptures your risk factors.
The medical community kind of knows about that.
So, don't be falsely reassured by a low number over here,
particularly the Southeast Asian heritage
in your family or yourself.
Just to put this in context, low risk is generally 5% or lower.
High risk has a different threshold,
but in general, 10% or higher is considered
high risk, so for those of you between 5% and 10%,
I consider intermediate risk.
Again, next time you go in and see your doctor,
you can have a discussion about hey,
I want to assess my risk factors for strokes and heart attack
using a risk calculator, and have the doctor ordered
the components.
They can put them in, OK?
All right, now you understand the factors
that go into stroke and heart attack risk,
and you know how to put those numbers into context
and calculate your risk score.
What can you do?
Well, we start with kind of the more clinical pharmacologic
aspects of that.
Indeed, if you are moderate to high risk,
there they are treatments and medications that can help.
An acronym we use commonly is called ABCS.
Aspirin thins out the blood, reduces
risk of clotting of that unstable plaque,
getting a blood pressure in a tight control,
getting cholesterol under tight control,
and if you're a smoker, stop smoking.
Those are the bread and butter interventions
that I think most of us do know or are familiar with it.
If not, this is a great conversation to have.
If you happen to be at high risk,
these are inevitably components that your doctor
or your clinical team will talk to you about.
Most of us have a sedentary job, that we
sit at a desk, work long hours, high stress, and struggle
of getting enough exercise, among other things.
So, the way you live your life, I feel,
has a huge or even the most important component
about your risk of your strokes and heart attack downstream.
Yes, while you can wait until things get bad
and take a pill for it, I feel very strongly that--
and I think this is one of the things
that I think that in medicine that we
need to do a better job of--
is not to wait to you to be a high risk,
or you to have formal diabetes, formal high cholesterol,
or formal high blood pressure to start intervention,
because having good healthy habits
now inevitably provides long term
beneficial health outcomes by reducing
your risk of metabolic factors that contribute to stroke
and heart attack risk.
The metabolic factors are the impacts
of higher cholesterol, higher blood pressure,
and higher blood sugar on that.
So, what I want to tell you to do
are those various lifestyle components
that you can do right now to understand.
And if you have any habits that are outside of these ranges,
you can start knowing what they are start picking
a few leads to make some improvements,
and the first one is weight.
A healthy weight, if you don't know your cholesterol numbers,
you don't know your blood pressure,
you don't know your blood sugar, you actually
can use your weight as a rough estimate of what your risk are.
As many of you know, being overweight or obese
is a risk factor for diabetes, among other things.
So, if your weight is above target,
getting a weight target is one immediate thing
you can do to lower your stroke and heart attack
risk over our lifetime.
The thing I want to point out to you
is that we use a body mass index.
That's what BMI stands for.
You Google and internet how to do the calculation.
The cutoffs do vary by ethnicity.
So, while in general 25 or lower is considered a normal body
mass index-- again, there are limitations with this.
But in general, we use that as a guide.
But you have to adjust it for Asians and Southeast Asians,
because genetically speaking, their risk
for metabolic disease runs at--
starts earlier at a lower weight.
So, if you are of that ethnicity,
your BMI target should be below 23.
Now, I know, when you start talking about this, you
say, oh my gosh, how am I ever going to get there?
My BMI is 30.
Don't worry.
The risk of these is incremental.
So that if you are, say, above 30,
put initial goal to get you below 30 at the initial point,
because we move from the red bracket
down to the yellow brackets.
In and of itself, it will lower the risk
as you move your way down to the green brackets over here.
So again, we don't necessarily need everyone
to achieve ideal weight right off the bat.
It says just move your weight down.
If you're at a higher risk range,
move down to a lower risk range as the initial goal
for you to have as you work your way down, OK?
So all you need, when it's easy for you
to know what your weight are, so we can get
your weight and your height.
You can easily calculate a BMI.
Actually, there's a lot of apps that can do that for you,
and you can use your body mass index
as a proxy of your overall stroke and heart attack risk
with the goal of getting your body mass index close to normal
as possible.
Now, how do you do that?
Well, it starts with healthy nutrition.
The food that you put in your body
is critical in determining your health risks,
and as I mentioned before, animal protein
is the one that has cholesterol in its source.
So if you look at foods made from plants, and even
with fried fruits and plants, they
won't have any cholesterol in it.
Because plants don't.
So, in general, if you move to a plant based diet and more
of a whole food, meaning less processed food,
less processed food, more plant based,
inevitably is more healthy.
So I'm not saying that you need to be vegetarian.
It's that, if you eat more processed foods,
and your percentage of food tend to more to fats, proteins,
and carbs, move towards a diet that's more plant based
and less processed.
That in and of itself will help you.
In general, if you follow general guidelines,
we do recommend in your meal, at least,
1/3 of your food by volume comes from a plant.
Those are fruits and vegetables combined in general.
If you don't, that'll be a good goal to have.
Typically, people need more carbs or processed foods.
It's not unusual that people load up a plate of pasta
and then put some meat sauce or some veggies on the side,
where the pasta component comprises 50% of your meal
by volume.
What you can do is then shift that ratio, where the carb
parts is no more than a quarter or a third
and having the rest of it taken over by a plant based food.
So whole-food, plant-based diet is one way to go, OK?
And then red meat is one area that you can now
look at as well.
Not that you have to eliminate all of that, but again,
red meat tends to be more inflammatory.
And meat has more cholesterol components in it.
So by shifting away from that, that is another thing
you can do right now.
Again, for those who do have it, you
don't have to eliminate it completely, but just
take less of that.
So that's whole food.
Now, exercise.
There are standard guidelines on these as well.
The more that you move, the healthier you are,
and now, these are guidelines for exercise.
They have changed, that we're not looking for you
to break out in a big sweat.
Anything that makes you move is sufficient to count.
So there are guidelines.
And here's a link that you will get
after the talk that gives you a little guidelines based on age
and your health status about how much you should do.
And in general, anything that gets you moving
is going to be good.
The type that helps you most from a stroke and heart attack
area is cardiovascular.
Those that get your heart rate up,
running, swimming, biking, long hikes, all those things
can do that.
I just simply put down that there
are other forms of exercise that you want to also focus on
over your lifetime.
Doing strengthening, which typically involves
some type of weightlifting, is a good exercise to have,
particularly if you want to lose weight.
Lifting weights burns a lot of calories.
So sometimes, when people have an exercise program,
they sometimes overemphasize the cardiovascular parts
and don't maximize benefit of using strengthening exercises
as a way to help with losing weight.
Lifting weights or using weights do help burn a lot of calories.
So don't neglect that.
And it helps with bone health, particularly if you're a woman.
And then finally, about flexibility training.
This is more applicable for people
that have poor ergonomics, have stiff neck and back issues.
So having some exercise that focus on flexibility
is helpful because a more flexible body prevents kind
of skeletal aches and pains that can
interfere with your cardiovascular
and strengthening exercises.
So that's exercise.
Drinking.
You can drink, but don't drink for the sake of drinking.
And one thing I want to emphasize,
and this one I'm going to go to my visual,
is about portion sizes.
And oftentimes, people get confused on the portion sizes.
So here I am over here.
So this is a small wine glass.
So a standard drink is five fluid ounces.
So I got this.
This is basically colored soda water.
So this is a small wine glass.
So this is five fluid ounces.
So we have a standard wine glass.
The level of it should be lower.
But a lot of people said, oh one drink is one glass.
But there are standard definitions
of that depending on the size of your glass.
I have a small one.
So this is five fluid ounces.
But if we have a bigger glass, that drink line
is going to be much lower.
And that's something you have to keep in mind because portion
sizes often is a challenge for us in America
because we tend to drink larger portion sizes over here.
So a drink is two--
less than two standard drinks for men and one drink or less
for women.
And these are the sizes of it.
So don't go by the size--
just one drink as a one glass or one mug of something.
It is specifically specified in ounces
how much you should have.
And I would encourage you to take whatever
glasses you use at home to drink and then pour it
into a measuring cup to see how much you're actually
drinking to make sure that you adhere to these standards.
And we sometimes neglect the self-care health that we need.
Paying attention to adequate sleep.
Paying attention, we talk about eating well, exercising.
But then, looking at ways to help
fueling connection to people.
Social connections, joining a club,
doing things that you like.
And then spending time in nature, going to hikes,
going to the beach, going to the forest.
They may seem like simple things,
but having these components as a core part
of your day-to-day living that connects you back to purpose
actually has shown to reduce your stress level
and then in turn reduces inflammatory signals
in your body and stress signals in your body.
That helps to help with your cardiac health over time.
So this is one area that they think
does not get as much attention that we do.
And yet, I think this is one of the easiest and most kind
of work-life balance way of addressing
physiologic risk down the line.
So again, I encourage you to look
at these components over here in your day-to-day life
to address that because the healthy way
you live your life reduces inflammatory stress
signals that then lower your strokes and heart attack
risk down the line.
LAUREL: All right, Dr. Yu, thank you so much.
Such good information in there.
And we have many, many questions for you today.
We're going to do our best to get to as many of them
as we can.
And I am going to group some of them together
that are very similar for you.
So our first question is about genetics.
So if your parents have high cholesterol or heart disease,
are you destined to get it?
SUBJECT: Genetics is a factor into your risk factors
over there, but it's not the only basis of that.
So yes, if there is a family history of high cholesterol,
diabetes, or high blood pressure,
it does make you at a high-risk area.
However, that doesn't negate the benefits of the lifestyle
components I have into it.
Because when we look at it, in my mind,
the genetic factors can contribution to stroke or heart
attack risk.
And your lifestyle components of it may have equal if not more
factor in the way how you live your life in it.
So yes, genetics is a factor.
But sometimes it's-- and those you may not modify,
but the lifestyle components you can.
So don't neglect those.
Thank you.
LAUREL: Thank you for that information.
So our next question is, are there any supplements
proven to prevent high cholesterol or help lower it?
SUBJECT: There are plenty of supplements on the market.
In fact, the common cholesterol medicine comes from a plant.

Rice yeast extract.
And there are a lot of supplements
that sell those things as well.
So what I would say about supplements
is that I don't have any objection to people
using supplements, but I would not
rely on supplements as your way out of this.
Having-- it goes back to the core basics of how you eat,
how you live your life as the core factor.
Because supplements are not as studied or not as regulated,
if you indeed have bad enough, say, cholesterol or blood
pressure which your doctor recommends medications,
you're then better off taking a standard FDA-vetted and
regulated prescription medicine over a supplement.
So while supplements are popular,
and I don't have any objections to people using them,
is that please don't over rely on supplements
in place of healthy lifestyle.
Thank you.
LAUREL: All right, thank you, Doctor Yu.
So if you have high cholesterol and you
make these lifestyle changes, you reduce
that wine at the end of the day and you
start eating a more plant-based diet, long
does it take before your cholesterol starts to go down?
SUBJECT: So the impact on cholesterol
generally starts to set in about four to six weeks' time.
Now remember, if you are using lifestyle eyes,
it's not like one and done, just like, all right,
I'm going to eat well.
In six weeks, get my cholesterol checked,
and after it gets to goal, then I'm
going to go back to where I am.
So don't make that mistake because cholesterol and the way
your lifestyle and your food impacts
that is a continual process that does not change over time.
So sometimes when I tell my patients,
when you improve your eating, it's
more important that we check it continually
to confirm that you're consistently
doing it and keeping it at a good level.
But in general, if you wait for about four to six weeks
to check that, that's good enough time
for your body to reflect the changes due to dietary changes.
Thank you.
LAUREL: All right, thank you, Doctor Yu.
So our next question is, can you have clogged arteries
without having high cholesterol?
SUBJECT: Clogged arteries can occur
with people with quote unquote normal cholesterol
because there are some genetic basis of people where
cholesterol particles may be just are stickier or more
prone to plaque formation.
So people with normal cholesterol, though rare,
can also have clogged arteries.
So a good question.
Thank you.
LAUREL: All right, thank you, Doctor Yu.
So Doctor Yu, is there any harm on being on any
medications to lower your cholesterol or high blood
pressure for a long period of time, or is that safe to do?
SUBJECT: So the standard medications
that we use for blood pressure for cholesterol
and for diabetes, for that matter,
are one of the most well-studied medications with the best
long-term outcomes that we have.
And in general, these medicines by and large
are easily accessible.
They are very affordable.
And have very good evidence for it to work.
So if you end up being someone that needs medications
to control it, there is no problem for you
to continue on it on a long-term basis
because what matters is the impact of these medications
in your risk factors.
Because if you have someone that has, say,
a cholesterol near 300, most likely you're going to need
medications to lower that because lifestyle alone
typically doesn't--
lifestyle factors on cholesterol impact,
typically we can see up to, in the best cases,
up to a 30% improvement.
Typically for cholesterol is more modest.
We're expecting between 10% and 20%.
So when people have super high cholesterol,
oftentimes lifestyle alone may not be enough.
And you add medications to that.
And if you do, the medicines have-- again,
these medicines have been around for many, many decades
and are among the most well-studied ones
in terms of its safety and its effectiveness.
So I have no problems for people thinking long term
because we've seen time and time again
that people stop and the cholesterol goes back up.
Their risk scores go back up.
And they end of suffering the consequences of it.
So if end up take--
being prescribed on it, I have no problems
with you taking it long term.
Now that being said, is that for instance,
let's just say you happen to be an obese patient with diabetes
that have to be on cholesterol medicines because of that.
And let's just say you go on aggressive lifestyle changes.
Now your weight is normal.
You're no longer a diabetic.
It is possible that then you may be
able to go off of these medications
because now your risk circumstances have dramatically
improved.
So keep that in mind as well.
Thank you.
LAUREL: All right, thank you for that information.
We've had a number of people asking about a cardiac calcium
score.
Can you explain what that is and what those results tell us?
SUBJECT: So a coronary calcium score
is actually a test that we are using more and more.
What that test is, it's basically
taking a scan of your arteries to your heart
and looking for presence of calcium, which is
a marker for plaque formation.
It's called the coronary calcium score.
Now, the way we use that, and based on guidelines actually,
is that we use it in context of your risk score.
So for instance, going back to that risk calculator
that I showed you, let's just say you end up
being intermediate risk.
So for this purpose, say you're at between 5% and 7.5%,
which is typically the standard definition
of intermediate risk.
Should you be on medication to lower it
or can you just focus on lifestyle first?
Sometimes then we use the risk the coronary calcium
score as an additional factor to drive the decision
whether to take medications or not.
If you're intermediate risk, your calcium score
is minimal or zero, that means there's
no plaque in your arteries yet.
And if so, then I think this will be a safer case
to say, hey, focus on the healthy lifestyle as a way
to intervene because there's no plaque yet.
However, if on the calcium score it shows that you already
have plaque or high--
already had formed plaque already,
that means the physiologic is-- the bad physiologic changes
that cholesterol can do.
It has already started and shown up already.
And technically, if you have a high calcium
score in those tests, it is synonymous in having
early coronary artery disease.
Now if that is the case, then those patients,
then we favor enough to start on medications early
because there's already plaque.
Then we want to be more aggressive
lowering your cholesterol to reduce the chance of it further
progressing.
And in some cases, if you take the medicine early on,
it sometimes can minimize the amount of plaque that you have.
So that's how we use a coronary calcium score.
If you're already low risk, there is not much value in it.
And if you're already at high risk,
you should be on aggressive treatment,
including medications for that already.
So the best use of that test typically
are people in the intermediate risk
to assess their likelihood to benefit from medications.
Thank you.
LAUREL: All right, thank you so much, Doctor Yu.
So our next question is, are there
were any at-home devices that can be used
to measure your cholesterol?
SUBJECT: So at-home cholesterol tests have not
been popular or big yet.
And the reason is just you actually
need the sub-components of the cholesterol to properly assess
your risk factors.
So I would not bother.
Unlike blood sugar or blood pressure,
for which there is home devices that you can take,
cholesterol is something that I would
recommend you go to a standard lab to get that assessed.
Thank you.
LAUREL: All right, thank you, Doctor Yu.
So we have a number of questions, really specific
questions, about diet.
So the first one is about caffeine.
Is caffeine dangerous?
Is it OK to have some coffee every day or sodas?
Can you talk a little bit about caffeine specifically?
SUBJECT: Sure.
Like all things, you've got to live life.
So everything, in general, in moderation, is OK.
So caffeine's impact is more on the blood pressure side
because caffeine is a stimulant.
It revs things up.
And, I mean, obviously, that's some of the reasons why
people drink it.
In excess of that, the main impact that we see
is raising the blood pressure and then
interfering with sleep and other things as well.
It's much less so in the cholesterol part.
So if you drink caffeine from a standard--
from a typical standpoint, as long as you moderate that,
I don't have any problems with that.
The standard recommendation is to have two--
less than two standard cups a day on average.
But if you are-- again, if you are looking into it,
what you may want to do--
caffeine is something you monitor the health--
the impact on your body typically
will be in your pulse and your heart rate.
And if you are noticing that your blood
pressure and your pulse goes up when
you drink a lot of caffeine, then just moderate that back.
I don't think that you need to eliminate caffeine,
so to speak.
Perhaps only if you have a really high blood pressure,
then you may want to do so.
But for standard people, having some caffeine in general
is not going to be a problem.
Everything in moderation.
Thank you.
And soda, OK?
Well, soda is sugar.
Again, going back to what I mentioned about healthy eating,
you want to minimize sugar or kind of free sugar
or refined sugar or processed food intake.
So I would not--
and I-- soda is one easy intervention
to get rid of in your diet if you can.
Even with diet soda itself, which has no calories,
but it is now believed that the substitute sugar that they use
may stimulate appetite.
So that while it does not have impact on sugar,
it makes you eat more, which has a weight component that
is negative.
So again, you can occasionally.
I don't think we need to worry too much about it.
But I would certainly not recommend regular soda use
because, in general, it is not a healthy food.
Thank you.
LAUREL: All right.
So Doctor Yu, there has, I think,
been a debate for a long time about eggs.
Are eggs OK to eat?
Should you just eat egg whites?
If you eat a whole egg, can you talk a little bit about that?
SUBJECT: Yes.
Eggs are OK.
Now, you really want to be careful.
The egg component that has the most cholesterol
indeed is in the egg yolk.
The egg white is basically a pretty heavy protein component
and in general has much less issues with cholesterol.
But that being said, unless you eat excessive amounts of whole
eggs over there, I don't-- again,
it's hard for people to overeat eggs.
It's easy for people to overeat carbohydrate calories
or kind of processed snacks and all that.
So I think in context, unless you're
someone that eats six eggs, whole eggs, a day
on an ongoing basis, then we might
want to monitor what your cholesterol impact is.
But on occasion, having some is not going to be a problem.
Again, everything in a proper context.
So if you're worried about that, what
some people do is just say, all right, could you have any eggs?
But if you have eight eggs, making
an omelet for your family, then you just
take two or four to eight yolks out.
So you don't need to go overboard avoiding egg yolk.
Egg in general is a pretty healthy food
because there's no sugar.
No sugar in it.
It's a pretty healthy source of protein
and it's pretty satiating as well.
It makes you feel full.
Just don't over salt it, OK?
And unless you eat a lot of it every day,
I don't think you need to worry too much about eggs or egg
yolks.
Thank you.
LAUREL: All right, thank you, Doctor Yu.
So Doctor Yu, we've had a few questions regarding statins.
Can you talk about what they are, their effect?
There's been a number of people wondering if they can cause
early onset dementia or Alzheimer's.
Can you talk a little bit about that, please?
SUBJECT: Yes.
So statins have been in the news a lot.
And I think there's some people that
were leery about taking them when
they're clinically indicated.
And these type of factors come up.
So let me share with you about statins over there.
The main-- for statins, like any medications, there are side--
potential side effects from them.
But again, statins being one of the most studied medications
that we have seen.
We know quite well about that.
So first off the bat, dementia and memory loss.
No.
Statins actually may help reduce that risk because dementia--
a certain-- most of the dementia and memory issues
that people have that is age-related
are actually related to vascular issues.
Meaning that with time and age, your arteries to your brain
gets clogged up or less blood flows through efficiently.
Now statin has a role to help with that.
Because as we mentioned, statin can reduce the plaque build up
over time, and that can maintain good blood flow to the brain.
And that may have a protective effect
in decreasing people's risk of strokes and heart.
So statin certainly does not cause that at all.
Now, what statin can do is that there
are some people that have an inflammatory reaction
to the statin that causes you to have muscle inflammation
or muscle aches.
It will not be subtle because the effects of statin
will be generally all over your body.
It won't be isolated to just your arm or your leg.
That can happen, but the rates of that are less than one
in 10,000 in general.
But if people have that, then indeed they
should not be taking--
they cannot take statin.
They have to take alternatives.
So again, those are pretty noticeable,
easily identified things.
So statins-- and also, some people ask, well,
statin damages your liver.
Well, statins, while it does metabolize through your liver,
as most of the medicines and of the foods
we eat go through the liver as well, and usually--
even right now, there's no need to continue
to monitor your liver when you're taking a statin.
That was an old recommendation that
has since been eliminated because it's
shown that it really--
statin effects on liver are no worse
than you drinking two glasses of wine a day.
So yes, if you're taking other medicines
that are hard on a liver or if you happen
to be a heavy drinker and you're taking statins over there,
that may be the case we want to do an occasional check.
But otherwise, if you're--
if you eat healthy and all that, the liver effects
are no worse than having-- drinking
two alcoholic drinks a day.
So hopefully that answers your questions about statins.
Statins are one of the safest medicines that we know.
That's what proven benefits for stroke and heart attack
reduction.
Thank you.
LAUREL: Oh great, thank you so much for explaining
that, Doctor Yu.
And unfortunately, we are out of time for our question
and answer period today.
I'll turn it back over to you, Doctor Yu.
SUBJECT: Well again, I appreciate
all the great questions that you have.
Let me share my screen again.
And I really appreciate your great questions.
It is the focus on your lifestyle that you can do now.
And again, it's over the lifetime.
If anything else, remember you can just use your weight
as a good proxy for things.
And then make sure you pay attention
to the stress reduction part to help with your--
to improve your overall health.
The next slide has my contact information over here.
And then there are additional resources that we have for you.
I'll turn it back to Laurel to go through more of that for you
and close out the program.
Thank you.
LAUREL: All right, thank you, Doctor Yu.
All right, everyone, well, thank you for joining us today.
If you are watching our webinars for your wellness program,
the wellness code is cholesterol.
All right, and if you have any questions about our services
or doctors at Sutter, our team is here to help you.
You can connect with us at sutteremployer.org.
On our website you can also learn more
about our new metabolic wellness program, which
has you use a continuous glucose monitor to teach you
about your body so that you can make some healthy lifestyle
changes.
All right, everyone, thank you again for joining us.
And stay healthy.
SUBJECT: Thank you, everyone.
Be safe.
Bye bye.

RONESH SINHA: Hi, great, wonderful to be here.
Let's go ahead and get started.
So, heart disease is a topic that's
very relevant for this month.
It is Heart Disease Awareness Month.
And today's talk will be about avoiding heart disease,
especially in our modern world.

So, as a background, I do run corporate wellness programs.
And really, heart disease has become a big focus
of my lifestyle practice.
And in medical school and medical training,
I was taught that heart disease was actually
a condition that affected mainly individuals of an older age.
And although that's clearly true,
what I was shocked about after coming to Silicon Valley
to practice is that I am seeing individuals of all ages,
including much younger ages, that are coming in
with early heart disease.
So, I remember when I started in my clinic,
even I was seeing heart attack patients in their 30s
and young 40s, which was actually quite shocking to me.
So, really, during today's presentation,
I'm going to talk to you about the origins of heart disease.
We're going to also talk about what
are some risk markers that you can focus on, lifestyle
changes to help prevent and reverse heart disease,
and also the role of technology that I use in my lifestyle
practice, called "continuous glucose monitors," which
have really been a game changer in terms of really sensing
the impact of nutrition and lifestyle on your body.
And I'll present a couple of case studies
to show you how we've been using these CGMs in addition
to an exciting wellness program that we're running right now
using these innovative sensors.
So let's go out and jump right in.
So, I like to teach using case studies.
So, let's use Sam, which is basically a fictitious name
that I am using here for a case study.
And Sam is a 38-year-old software engineer who eats
a vegetarian diet-- mostly grains,
very little vegetables though, so not doing optimal vegetarian
diet--
has a body mass index or a BMI of 24, which technically would
fall into the normal range, being less than 25,
although you would adjust that cut off
for those of Asian ancestry.
He has a normal blood pressure and blood sugar level,
has a total cholesterol level of 190.
And we'll talk in detail about cholesterol
and what the numbers mean.
He visits the gym two or three times a week,
but is otherwise sedentary, and work stress is high.
So this is probably a case scenario that a lot of us
can connect with.
OK, so Sam's wake-up call, at 3:00 in the morning on Sunday,
Sam was woken up with progressive chest discomfort.
He took an antacid, didn't get any relief from that,
and essentially what happened was his wife called 911.
And he was rushed to the emergency room
where he was diagnosed with a massive heart
attack due to a blockage in a major coronary artery.
So, when you look at this diagram of the heart muscle,
the coronary arteries are the blood vessels that actually
feed and nourish the heart.
So, you can see the blow up image of that coronary artery
on the right, in that inset B. And you
can see that a plaque buildup in the artery
and cause that blockage.
So this is really the case of Sam having his heart attack.
Now, I also want to highlight-- because, again,
in medical training, often we talk about men and heart
disease--
but I want women especially to be aware of the fact
that heart disease continues to be the number one
killer in women and men.
OK, so a typical prototype in this case
that I'm using to explain the concept is
we have a techie mother of two young kids on a very
low-carb diet and practices fasting,
exercises vigorously doing bootcamps three to four times
a week, work and family stress are very high,
and gets six or seven hours of sleep a night or less.
OK, so, I've seen women in this category
come in with new onset diabetes, high heart disease risk
factors.
Or in some cases, we end up seeing
women of a fairly young age coming in
with their first heart attack or heart disease events.
Now, the gender differences in symptoms I've gotten
lined up in this image here on the left.
I want to highlight a couple these.
So you can see with men, men more often
tend to get that classic chest fullness or squeezing pressure,
often that can happen with exertion.
The pain can spread to the shoulders and neck or the arms,
sometimes up to the jaw as well, too.
And then that chest discomfort can
come along with lightheadedness, fainting, sweating, et cetera.
I want to contrast that with women, on the right,
where, yes, they can get chest discomfort.
But more often than not, they might actually
get shortness of breath or difficulty breathing.
They might get some stomach symptoms,
like nausea, maybe vomiting or some dizziness.
They can get some back or jaw pain.
They can get unexplained anxiety.
Sometimes they feel like they're having a panic attack.
They can get the palpitations.
And something they feel like they're
having a mild flu-like illness.
Now, at the very bottom of this image right here, this graphic,
you can see that, for men, the trigger most often reported
is physical exertion prior to heart attacks.
So maybe you were on the treadmill or the exercise bike,
or during the winter, you're shoveling
snow, and all of a sudden that stressor triggers this heart
attack symptom.
Keep in mind that for women, they most often
report emotional stress.
And that's really what I'm highlighting.
More typically, they might have an emotionally stressful
situation and then they start getting those symptoms.
So again, there is a lot of overlap between this.
Clearly, women can get chest pain, chest discomfort.
Clearly, men can sometimes have emotional stress
before a heart attack.
But these are some basic categories
of differences between genders I want you to be aware of.
And for women, in particular, it's
important to know about the fact that chest pain may not
be as common, because women typically
present much later to the emergency room with heart
disease risk factors or with heart disease symptoms.
And that could be a problem, because when
it comes to surviving a heart attack
and having the best outcomes, the quicker you
can get to the emergency room, the better.
And because women's symptom are a little bit more vague,
often they present later than men would.
So I'm spend some time on the slide,
but I just want you to be aware of that nuance and difference.
OK, now the evolution of atherosclerosis.
Atherosclerosis is just a fancy word for the development
of plaques inside the arteries.
And all I'm showing you in this is that process actually
starts in childhood.
So from the first decade of life,
we've already started depositing the foundation
of that plaque, which will then evolve throughout life.
And why am I bringing this up?
Because I do give talks to schools and to young teens
and families, and I am actually seeing some teens
in my practice.
And we are already seeing early heart disease risk
markers in kids and teens.
Because the more they are inactive,
if they're already eating an unhealthy diet, if there's
family risk factors and genetics, that process
can start early on.
So, if you really want to prevent plaque formation,
you've got kids, you've got to start the process
as early as possible.
Because, otherwise, when it comes on later,
that plaque formation, it's tougher
to stabilize and reverse.
So, you want this to be a proactive, family-based
approach to lowering the risk of heart disease.
Now, there are different ways to think about heart disease.
And this is one analogy that I love.
I can't recall the name of the cardiologist.
But he literally talks about heart disease plaques
like being like a pimple.
Now, in the early days, we'd think
about heart attacks being like plumbing,
like a clogged artery or a pipe.
But that's actually not accurate.
What you want to think about with heart disease is
that plaque that forms, it's literally
like a pimple that develops inside
of the inner lining of your blood vessel.
And just like a pimple, it fills up with fat, with lipids,
and pus, with inflammatory cells inside it.
So like I said, that process starts very early in childhood,
depending on genetics and lifestyle.
And then what ends up happening is
when a heart attack happens, literally
that pimple actually pops.
It ruptures.
So, with a pimple, you get pus coming out of it.
With a plaque, you also get inflammatory cells
that pop out.
And then you get, basically, the migration of red blood cells
and other clotting factors.
And those will instantly block off the blood.
So this is not necessarily a process
where you're getting all this deposition of the material
and it blocks up the artery plumbing.
You can start with a very small line
of a vulnerable plague that's on the lining of the blood vessel.
And if that instantly pops, the fluid's
going to block off the blood vessel.
And that's how a heart attack happens.
So, I know this is a little bit--
not the most attractive analogy.
But these sorts of analogies can really stay in your head.
But important to know that it really
is more of a process that involves really
a small plaque that can rupture and then occlude that artery
and cause a heart attack.
Now, some of the root causes that we're going to get into--
I'm putting two big categories here.
One is the process of inflammation.
And inflammation is if you sprained your ankle,
you would see a visible inflammation
where your ankle swells up and turns red.
But here, we're talking about were
low grade inflammation where your immune system becomes
activated.
And that immune system, when it's active,
those of white blood cells in parts of the immune system
can migrate into the plaque and, again,
fill up that pimple just like it's filling up with pus.
And you can see chronic inflammation is just not linked
to heart disease alone.
It's also linked to diabetes, to Alzheimer's disease,
all types of the processes.
The other process I want you to be aware of
is insulin resistance.
And I want to talk about that in the next slide.
But that is also an epicenter for a lot of the risk
factors for heart disease.
Now, just to make the concept clear,
I have insulin resistance and inflammation
in separate diagrams here, but in actuality,
both of these things really overlap.
Having chronic inflammation can make
you more susceptible to insulin resistance.
Having insulin resistance makes your body more
susceptible to inflammation.
And usually, with heart disease, both of these
are playing together and really leading
to the development of that plaque in addition
to the other chronic health conditions that
are listed on this slide.
So insulin resistance, the way I like
to describe this is really I call it a carbohydrate parking
problem.
And so you can think about carbs in the form of glucose.
In the center of this diagram, that's the car
that you see in the middle.
And then there's three parking lots.
You've got the muscle, liver, and the fat.
So ideally, when you consume carbohydrates
in food, fats in general, you want
the carbohydrates predominantly to go to the muscle parking
lot at the top left.
And it basically gets inside by using the hormone insulin.
That's like a parking pass that gets a carbs through the door.
But when we see individuals who are becoming insulin
resistant, what that means is the body is producing insulin,
but the muscles are not properly responding to the signal.
So if the carbs can't adequately get inside the muscle,
where do they end up going?
They can go towards fat formation,
especially with the more dangerous stomach or belly fat.
They can go to the liver.
And the liver can actually fill up with fat.
It actually literally turns those glucose molecules
into fat.
And then, the liver also, when it becomes overwhelmed,
it will inject those extra carbohydrate molecules
as triglycerides in the form of fat
or as blood sugar where you become
pre-diabetic or diabetic.
So that's where the constellation of insulin
resistance.
And a high level, we want to teach your body
to get those carbs moving back towards muscle so we can
deflate those fat cells and offload the liver
so it's not releasing all the extra triglycerides,
cholesterol, and sugar into the blood.
Now, what are triglycerides?
Triglycerides are actually the storage form
of fat inside your fat cells.
And they are really an early marker of insulin resistance.
LDL cholesterol gets a lot of press.
And definitely LDL cholesterol is very important.
We'll talk about that in a second.
But really, in my clinic and practice,
I see a lot of individuals with borderline to high
triglycerides.
And often, they don't realize the linkage
between triglycerides and heart disease.
High triglycerides can be and early
trigger to atherosclerosis, and it
can lead to the formation of a more dangerous form of LDL
called Type B. Think of B as standing for bad cholesterol.
So within LDL cholesterol, the Type B
is the more dangerous one.
We'll talk about that in the coming slides.
But just know that high triglycerides
trigger the formation of more of that Type B LDL.
High triglycerides also drive down the HDL cholesterol.
And this diagram right here shows you triglycerides, again,
they fill up the fat cells, kind of like a big beach ball.
When they inflate with triglycerides,
that's when we increase body fat.
Really, through adequate lifestyle changes,
what we want to do is we want to take that ball of fat,
we want to squeeze it, deflate it,
get the fats to get inside your blood.
And ideally, those free fatty acids
that you can see in that blood vessel,
we want it to travel to your muscle
so you can burn that for energy.
So that's the process lipolysis, the breakdown of fat.
That's how we lose body fat and lower heart disease risk.
But many of us might be having the reaction go the other way.
We're actually forming more triglycerides.
So we really want to reverse that reaction.
So LDL, again to highlight, basically,
you've got the Type A, which is the larger LDL particle.
And larger might sound like it's more dangerous,
but actually it's less dangerous than the Type
B, which are the boats.
And you can see this diagram, this is the image from my book.
You've got the larger boat that's floating along.
So lipoprotein particles are basically
boats that carry cholesterol.
And they float through your bloodstream.
So the larger one is a little bit more innocent
as it floats through that bloodstream.
But the Type B tends to dock on the blood vessel wall,
and then, again, it can cause damage and plaque formation.
OK, so that's how we break down Type A and Type B.
I've kind of broken these details down here, too.
But, again, the big meta picture I want to talk to you about
is the fact that when triglycerides get up higher,
especially above 150, our body does
generate more of those dangerous Type B LDL boats.
A standard cholesterol is not going
to break down Type A and Type B. I'm not
saying everybody has to get advanced cholesterol test,
but in my individuals who have high triglycerides and other
risk factors, I might do a more advanced lipid profile to see
what the breakdown of the Type A and Type B
is and also look at the particle numbers, which is also
known as LDL P.
Now, healthy cholesterol, what we call the HDL cholesterol,
what that does is it actually removes cholesterol
from the artery wall and transports it to the liver.
We call that reverse cholesterol transport.
HDL also can have an anti-inflammatory effect.
And again, we want to reduce inflammation of the artery wall
so we're not generating plaque formation.
It can keep the blood thinner, so it doesn't quite as readily.
It can also help relax those blood vessels.
And then, I'll keep saying this over and over,
but often you will see the high triglycerides and low HDL
come together.
They tend to be inversely proportional.
So the higher the triglycerides, it tends to push that HDL down.
OK, so now let's put this into practical application.
We're coming back to Sam's cholesterol profile.
This is our young general and that ended up
having the heart attack.
So you can see the cholesterol tests.
And I put his sample result and the target levels.
So let's look at the first row together, OK?
I'm actually going to use my pen here
so we can highlight some of these things.
All right, so we're going to start right here
with the total cholesterol.
So we see the total cholesterol here of 190.
Now, typically laypeople will say
that if the total cholesterol is less than 200, its normal.
If it's about 200, it's abnormal.
That's not true.
Some people with really good cholesterol profiles
can have a total cholesterol above 200,
because they have more of the healthy cholesterol.
On the other hand, like Sam, individuals who don't have
much healthy cholesterol and they're insulin resistant,
they're total cholesterol might be less than 200.
So really, the big picture point here
is, really, total cholesterol is not very useful.
Obviously, if you're getting up into the 250,
260, 300 category, that's going to flag
that some of the other cholesterol particles are high.
But in general, in this particular case,
not very important.
The LDL cholesterol is right here.
You can see that the result is 108.
Now, most labs will see it at less than 100
is normal and greater than 100 or even 130 is abnormal.
But I would tell you that that's not really--
it's a limited way of looking at the cholesterol panel.
You've got to look at the big picture here.
So we want to focus in more on the additional numbers
that we're going to talk about and the ratios.
Now the HDL, which we refer to as the healthy cholesterol,
you can see that that is 32, OK?
And in males, the target levels, we want that to be above 40.
In women, we want that to be above 50.
So, clearly, the healthy cholesterol here is low.
Now, the triglycerides, which we talked about earlier,
we would like that to be less than 100.
I call that ideal.
Most lab reports will say than less than 150.
And we can see that Sam's triglycerides
is at the 250 level.
Now, here are the numbers that can really
give us a broader snapshot picture of the cholesterol
profile rather than looking at the absolute numbers we
discussed earlier.
And these are ratios.
So the first is a total cholesterol to HDL ratio.
So, you take the total, you divide by the HDL.
And here, the ratio is 5.9.
Ideally, we'd like to see that be less than 4.0.
The other ratio that I really want you to pay attention to--
because this is not typically on a cholesterol profile.
It's listed as part of the results--
is the triglyceride to HDL ratio.
And typically, we want that to be less than 3.
And we can see, in Sam's case if we divide the triglycerides
of 250 by a 32, it's 7.8.
And that's very significantly elevated.
And this is a ratio that often gets missed.
If you are your doctors are knocking attention to ratios
and just focusing on total cholesterol and LDL here,
you might think that Sam's cholesterol profile doesn't
look that terrible.
But these ratios tell us that he was at high risk.
And this ended up being a signal for plaque formation and heart
attack.
So, we really want to get that triglyceride to HDL
ratio less than 3, the lower, the better.
When my patients are really in great metabolic shakes
with low risk of heart disease, they're
can be below 2, sometimes 1 to 1 or less than 1,
because of really elevated HDL and brought the triglycerides
down.
So, a lot of these additional points
I've kind of summarized here at the bottom.
I'm spending time on the cholesterol profile,
because I think it's really important to understand how
we should be viewing cholesterol profiles
when we're assessing for heart disease risk.
And, again, the advanced diagnostic tests,
I don't recommend doing this in everyone.
I can tell from a really good looking cholesterol profile
done with the standard lab that, OK, the ratios look good,
nothing to worry about.
I don't need to get an advanced lipid product done.
But in some cases, if it's borderline,
there's family history, there's other elements,
I might get a additional marker for inflammation called the HS
C-Reactive Protein.
I might do the advance lipid profile
to look at the particle size and numbers.
If there is a early family history
of heart disease in a first-degree relative,
meaning like a parent or a sibling,
I make get an additional test called the Lp little a.
Now, that's usually included in the advanced lipid profile.
But that is a cholesterol marker that
can often signal an earlier risk for heart disease.
And then, in some cases, I might also
get a coronary calcium scan, which
I would explain right now.
So, what is a coronary calcium scan?
So, basically, calcium is a surrogate marker
for plaque formation in the arteries.
So, you can again see here, on the right diagram,
I'm showing the coronary artery blown up.
And then, if you look to the right of that,
this is actually a CAT scan, a CT scan or an X-ray image.
And those white, bright spots there
are actual calcium deposits.
And that calcium is basically an indicator
of the existence of plaque.
And the higher the score, the more that
is indicative of a more significant plaque
which might actually signal a future risk of heart disease.
This is not something I get in every patients.
Just like the advanced lipid profiles,
I might get this in select individuals
for an intermediate to high risk for heart disease.
So, somebody who, based maybe on age, diabetes, blood pressure,
family history, we might get this coronary calcium
scan to give us more information.
Now, the calcium itself doesn't necessarily
mean that you're at a very high risk for heart disease.
Because often what happens is when you develop a plaque,
it's kind of like developing some scar
tissue over that plaque, it's kind of like a scarred pimple.
But it is an indicator that there was some injury
of that blood vessel wall.
So we have to really intensify lifestyle modifications.
So, this can really help for the risk stratify individuals.
Some of my patients that are resistant to going
on cholesterol or blood pressure medications,
if this test comes back and we see plaque
formations that scores even low to medium to high,
then we are going to basically be
more aggressive about lifestyle plus medications.
So, I actually did a very detailed blog post
on coronary calcium scans.
So, you can refer to that.
But if this is something you're thinking about,
talk to your doctor and see if this
might be a test that would be useful in your individual case.
Now, I talked earlier insulin resistance
and how it can cause more fat storage in the belly, the belly
fat.
So, really, when we think about body composition,
rather than just focusing exclusively on weight and body
mass index, it is important to know where
that weight is distributed.
So, using a waist-based measurement,
like waist-to-hip ratios or waist circumference
is a good way for you to assess whether you might
be at risk for insulin resistance
or you might already have insulin resistance.
And that's a metric we want to really improve over time.
So, the weight-to-height ratio is a good way
to adjust for the fact that individuals that are tall,
they're going to be expected to have a wider waist point.
So, weight-to-height ratio, you can see
is literally your waist circumference over your height.
And that ratio should be less than 0.5.
So, for example, if you're 70 inches tall,
your waist circumference should be less than 35 inches,
half of that 70 inches.
So a nice, simple rule of thumb to use.
And when my patients are making progress
through their lifestyle changes, I'll often ask them,
are your pants getting looser, how's that waistline feeling,
rather than fixating on how many pounds did you lose.
Because this is really the more inflammatory type
fat around the belly that can really
trigger inflammation and insulin resistance.
OK, so, some signs and risk factors for insulin resistance.
We talked about the waist circumference.
We've talked about the triglycerides, a combination
of high triglycerides and HDL.
I've stratified by gender, as well, too.
Elevated blood glucose, either based on a fasting glucose test
and/or an A1C test.
The A1C is your composite score.
That composite percentage shows your average
of just the last two or three months.
High blood pressure.
There are specific conditions that
will raise our risk of insulin resistance, like gout,
fatty liver, Polycystic Ovarian Syndrome or PCOS,
a skin condition called acanthosis nigricans,
or gestational diabetes, which is diabetes during pregnancy.
And then there are some ethnic groups
that comparatively have a higher risk of insulin resistance
and early heart disease.
And I've listed those here in the box, as well.
OK, now here is an example of an individual where I actually
used a Continuous Glucose Monitor.
So these are abbreviated CGM.
So any time I say CGM throughout this presentation,
I'm referring to these sensors.
And this is an incredible tool in really
helping this individual reverse their metabolic dysfunction.
So, you can see the way the sensor works.
On the arm, basically, you would--
so, these sensors have to be prescribed.
And then, you would basically apply the sensor to your arm
typically.
And then, as you can see, in this case,
it's individuals using a reader.
But you can actually use your smartphones.
Every time I want to see my glucose,
I'd wave the phone of my arm.
And I can see my glucose response to diet,
exercise, stress, and sleep.
So, I know this is a bit of a busy table,
but I just wanted to show that before the CGM--
and again, I'm going to use my handy pen since there's
lot of numbers here.
So, again, before CGM, the total cholesterol-- again,
don't get misled by that.
You might look at this and go, wow, 180 is good.
But in this case, you'll see this person did not
have a good cholesterol.
So, this is very misleading right here.
The LDL you might say is good because it's less than 100.
But when you have more small, dense, Type B LDL,
it tends to falsely lower--
it drives down the LDL.
So, it looks mysteriously normal,
but this is actually not a good LDL.
This is mostly Type B.
The HDL, my goodness, is 18, one eight, right?
That's a very low level of healthy cholesterol.
And then, look at this whopping high triglyceride.
If you look at the ratios, 10.4 on the cholesterol to HDL.
Remember, we want that to be less than 4.
And look at this triglyceride to HDL ratio.
23, goodness gracious, less than 3 is what we.
So, 23 is huge.
And this A1C of 8.3 makes this individual a type 2 diabetic.
Weight here 188, OK.
After just three months of wearing the continuous glucose
monitor sensor, look at the change of the numbers.
One thing I want to highlight is you
might think that, oh, my goodness, his LDL right here
went up.
But actually, it's a good increase in LDL,
because now this individual is forming more of the Type A LDL
particles.
Look at the HDL, in three months, from 18 to 40.
Triglycerides have dropped below 100, which is
where I love the numbers to be.
The ratio of 4.2 looks good.
This was the greatest thing.
I love this.
A tenfold decrease in the triglycerides to HDL ratio,
from 23 to 2.3 right here.
A1C is completely out of diabetes range, less than 5.6,
and a nice drop in weight about 165 pounds.
So, in some of my individuals, I can do this without a sensor.
But again, getting real-time feedback,
this individual was able to make unbelievable changes.
This is surely somebody who would have gone out
to develop diabetic complications,
potentially a heart attack, potentially a stroke,
all these things.
And in three months, we were able to fix that.
I'll tell you more about the program,
but we are doing limited pilots using these glucose sensors.
So, I would encourage you to join our wait list.
And the link is right here at the bottom
at sutteremployer.org/mwp, if you're interested in joining
our next program.
Now, when we talk about nutrition, a healthy plate
typically just to simplify things,
I like the bowl or plate-type approach to this.
And really, just to simplify things,
rather than doing all this obsessive counting,
whenever I have my lunch, dinner, or whatever meals,
I'm looking to fill that bowl or plate up
with colorful, mostly non-starchy plants.
So you can see a selection of those right here.
One corner of that's going to be some fibrous grains, just
a corner of that.
A sliver of healthy fats, and we'll
talk about healthy fats, and then some healthy proteins
in the other corner.
And now, vegetarian proteins I put in on the right
because I do see a growing number
of vegetarians in my practice.
And often, they're struggling with protein sources.
So I put a list of really good quality vegetarian protein
sources.
This is also something I've got a dedicated blog post on,
but it's absolutely possible for a vegetarian
to get really good plant-based sources of protein
to really help with metabolism, muscle growth, all
that good stuff.
Now, the way I sort of work this diet here,
too, is on days where I've done a lot of endurance workouts
and my muscles need more carbs, but my dial up
the amount of grains, healthy grains or healthy carbohydrates
and starchy vegetables.
On days where I'm stuck in back to back Zoom meetings,
I didn't get to exercise, my muscles don't
have much of a demand for energy,
I'll be much more restrictive with my carbohydrate intake
since my muscles are mostly sedentary.
And then if I do some weightlifting and things
like that, I might consciously be increasing my protein intake
just a bit based on this.
So this is a rough construct but intuitive
where you can actually tailor some of these things
depending on your physical activity levels
and just your overall body's needs.
Now, I know you probably know this already,
but I do find when I talk to patients
about the types of plants that they're consuming,
many are just eating two or three different colors,
and that's it.
They'll have a banana in the morning.
They have bagged greens.
They're getting plenty of greens because if you
go to any grocery store, they are filled with bagged greens.
But they're really not getting these other colors
conscientiously.
So I want you to really think about how you eat the rainbow.
Eat more vegetables and fruit.
If you have insulin resistance--
I'm a big fruit fan.
I'm not anti-fruit all, but some of my patients
who have insulin resistance, they
can be very reactive to things like overripe bananas.
Or if they're making a smoothie with berries and bananas
and all types of fruits, like a tropical smoothie,
their sugar goes through the roof.
They're better off eating and chewing their fruit
than drinking it through smoothies and other blendables.
But this is really key to keep in mind.
Choose more crunchy and leafy vegetables.
Get at least six to eight servings.
And again, those color wheels are
so important because each of these different colors
has different antioxidant anti-inflammatory actions
on the body.
So next time you go to the grocery store
or if you're doing online grocery delivery,
be a little bit adventurous and add different types of colors
to your plate.
It could be something as simple as maybe I'll
do purple carrots this time.
Maybe try eggplant.
Purple is one color that has incredible benefit.
A lot of us are maybe getting blueberries,
but I would encourage you to really get some more
purple foods into the diet.
I tend to find that's a real color that's
lacking in most of our diets.
Now, I talk about carb copycats.
So a lot of us are struggling with insulin resistance
and weight issues.
So getting creative around how you can introduce carbs
to be disguised as grains is a really powerful way
to lower sugar and really improve metabolism.
But I remember back when I wrote the book and I was doing this,
I would have to teach people in the clinic
how to make cauliflower rice.
But the good news is now you can go to any grocery
store in the frozen and often in the fresh section,
you'll find pre-riced cauliflower, which
is a great rice substitute.
You can do zoodles, spaghetti squash,
lots of different options out there
where you can really lower the amount of carbs in your diet
through these sorts of innovative approaches.
Now, the big question about saturated fat,
I'm sure every time you look at headlines,
you see something different.
Is saturated fat good for you?
Is it bad for you?
Is it going to affect my cholesterol?
I wish I had a simple answer that would
address the entire audience.
But really, the answer is it depends.
It depends on your genes.
There are certain genes that make us much more, what I call,
saturated fat sensitive.
So some of my patients that consume red meat,
they're LDL cholesterol goes through the roof.
They are not very--
their genes basically are not allowing them to metabolize
those fats properly.
So if they go on a high-fat, keto-style, carnivore diet
and they are having a lot of butter, eggs, and red meat,
we see their cholesterol go through the roof.
And I would say that's a concern.
We want to definitely tapering down the amounts of those fats
and really focus on more healthy fats, which
we'll talk about in a second.
So I know this question might come up,
but really, I don't have a straight answer for you.
I wouldn't say that, hey, everybody
is going to avoid saturated fat, or the other extreme about it
is, well, you might have to do some personal dietary
experimentation followed by some lab testing
to see how your body responds to saturated fat.
A general message for you, though,
is I'd like you to diversify your fat intake.
Key message is that the evidence-based heart
healthy fats are ones like monounsaturated fats
like olive oil, avocados, nuts, and seeds,
the omega-3s that come from marine fish
sources, plant-based products, flax seeds, leafy greens.
Whatever your approach is, I think
it's important to get those sorts of fats into the diet.
You absolutely want to eliminate the hydrogenated trans fats,
limit the seed-based Omega-6 inflammatory oils
like safflower, corn, sunflower, canola, et cetera.
And then use well-sourced saturated fat
in moderation, virgin coconut oil,
a little bit of grass-fed ghee, a little bit of butter
if you want.
The one thing I will tell you about saturated fat
is based on the studies, if you're
using high-quality saturated fat,
in most cases when it comes to heart disease,
it looks like saturated fat is fairly neutral
unless you're somebody that's very sensitive like we talked
about.
But I have not seen any studies that
show that saturated fat is heart protective.
That's a really key point.
The ones that I mentioned at the like the olive oil,
especially, the marine-based Omega-3s, those
have been shown in studies to have
some heart-protective effect.
But we haven't seen that.
So that's why regardless of what approach you're following,
I want you to get those heart-healthy fats
in your diet.
Otherwise, there are types of carnivore and keto-style diets
that really go hard on saturated fat,
but they're not doing a good job in
encouraging these other healthy anti-inflammatory
heart-healthy fats.
Now, another thing for you to be aware of
is the role of gut health when it comes to cholesterol.
So LPS or lipopolysaccharide is an actual endotoxin
that is on the cell wall of gram-negative bacteria.
And these are bacteria that actually colonize our gut.
And the interesting thing is that increased toxin,
that LPS from your gut tissues, they can actually
raise our LDL levels.
Now, the reason I'm telling you this
is because some people that have digestive gut issues,
their body is producing a lot of this toxin because
of that bacteria, and that can actually increase LDL levels.
So some of my patients that were struggling with their LDL
levels, and they're doing diet, they're doing exercises,
they're eating more fiber, it wasn't until they fixed
their gut issues-- and I'm not a gut expert--
but until they fixed their gut health issues,
then we saw the LDL actually drop down.
So that's why I'm kind of highlighting this slide here.
So gut bacteria, also, when you've
got the right type of bacteria in your gut,
it can really help with the metabolism and removal
of cholesterol from your body.
And I put a couple of mechanisms about how this happens.
But basically, those little guts, those tiny bacteria
inside your stomach, they can actually
consume, digest, and remove some of that extra cholesterol
from your body.
Many of us that are not eating diverse diets,
like I said the one-dimensional sort of plant-based diet,
really eating one or two different types of colors,
when you start diversifying the foods in your diet,
you'll grow the right type of bacteria,
and they will help your body remove cholesterol
from the body.
So I put a list here of prebiotic foods.
You want to eat a variety of these.
And prebiotics are basically foods
that will feed and populate a higher diversity of bacteria.
So I put a whole list of those here.
The probiotic foods are actually the bacteria themselves.
So these are foods that contain the bacteria that you
want to populate your gut.
So I put different categories.
So for example, fermented dairy, yogurt, kefir,
the Indian lassi--
not that sweetened mango lassi that you get in restaurants,
although that's delicious-- hopefully, more homemade
lassis, yogurt-based drink.
Even cheeses are fermented dairy sauces.
Under East Asian foods, I put a list of typical things
that you can use.
Under Indian foods as well, too.
But the disclaimer is you want to get
these really through natural foods if you can.
Now that probiotics have become very trendy,
there are a lot of foods out there, a lot of types of drinks
and shakes you can buy at the grocery store that
say probiotic rich, but they're also rich in sugar,
and that sugar is going to make insulin resistance worse.
So really be careful about what your sources are
probiotics are coming from.
Really try to get it through natural sources.
And hopefully, if you're eating a very diverse diet--
it's very common for me, by the way, when I make salads,
I will actually add sauerkraut or kimchi to my salad.
And it actually adds a tremendous amount of flavor
to my salad.
I like it better than the usual salad dressing that people use.
But these are great ways to really populate
that gut bacteria.
Now, we get a lot of questions about cholesterol supplements.
People love to supplement the heck out
of all their medical issues.
And I'm not anti-supplements, but they play a minuscule
to no role at all in terms of lowering
the risk of most conditions.
I really want you to pay attention to that.
But let me go through a few of the supplements
here that we have the most research behind them.
So fiber, you want to get fiber through foods first.
Maybe you can try psyllium husk fiber
if you want to add on more fiber to the diet.
But really try to get it through a rich, diverse array
of fiber-rich foods.
The second is plant sterols and stanols.
These are plant-based oils that can
help reduce LDL cholesterol.
This can be a way to maybe take the edge off that elevated LDL
cholesterol, but there's really no vigorous rigorous studies
that show that plant-based sterols actually lower
the risk of heart disease.
But again, it can take the edge off LDL
modestly in terms of lowering that number.
Now, Omega-3s, they don't really lower heart disease risk
much in most individuals.
And I'm talking about the Omega-3 supplements, right?
Again, if they come through marine resources and fish
in particular, it does look like it
has some heart-protective effect from that.
I always get questions about garlic supplementation.
Large studies show that there is pretty much no benefit.
But garlic is a good anti-inflammatory food
that might have other benefits.
Again, get it from food, not from supplements.
Now, red yeast rice is one that comes up a lot.
And what red yeast rice basically is is
it actually has a chemical inside it called monacolin K,
and it basically acts like a statin called lovastatin.
So it's literally like taking a small dose of statin.
But the problem with red yeast rice
is there is a lot of variability in the quality
and the amount of that active ingredient, and in some cases,
it can cause toxicity.
So I find it paradoxical that somebody's
trying to take a supplement that's got statins in it.
Why wouldn't you just take a low dose
of statin, which is regulated and we know
exactly how much statin you're getting in the body?
Just because it sounds nice and natural like red yeast rice,
it doesn't mean it's good for your body.
In this case, it can cause liver toxicity.
And then tea extracts and supplements, be very careful
with these.
A lot of people try to supplement these,
and they can cause potential liver toxicity.
OK, now cholesterol medications, they
are indicated in appropriate risk individuals
if your lifestyle doesn't get you to goal.
So heart disease is, again, usually due to high cholesterol
plus other factors like glucose, high blood pressure,
inactivity, sleep issues, stress issues, excess body weight.
So medications are just one part of this.
I put a couple of categories of drugs, LDL drugs that
are more targeted towards lowering LDL,
triglyceride drugs, but I want to get down
to the bottom bullet point where drugs without lifestyle changes
had a minor impact on lowering overall heart disease risk.
And I'm saying that message to you
very clearly because I see lots of patients
that see me for consultations.
They had one or two heart attacks,
and they were taking statins the whole time.
And because their numbers magically look so good,
they felt like they don't have exercise as much,
and they don't have to do the lifestyle stuff.
But these drugs do not come close to what
lifestyle can do when it comes to lowering heart disease risk.
Exercise, a couple of quick points.
Interrupting prolonged sitting is really, really important.
When we're sitting for more than 30 to 45 minutes at a time,
that can actually trigger inflammation in the body.
So you can get increased cytokine-based inflammation.
It also elevates body fat, raises sugar,
can raise blood pressure.
All these factors can actually result from prolonged sitting.
And many of us that are in back to back meetings
throughout the day now, really taking opportunities
to sit, to stand, to do all types of different positions
can be very useful and important.
So your goal in general is to do what's called exercise
snacking where you snack on movement every few minutes
throughout the day, and this can really
shift your metabolism so your body is
burning more fat and cholesterol rather than storing it.
Remember, lipolysis is the breakdown of fat,
and regular movement throughout the day
can trigger more lipolysis so that fat cell empties out
some of the extra fat.
Lipogenesis is storage of that fat.
And when we're in sedentary throughout the day,
that's what ends up happening.
So again, I said for at least 4 to 5 minutes of movement
every 30 to 45 minutes if you can.
Now, the right aerobic exercise dose-- so many of us
are doing aerobic level activity,
but some of my patients are on the other end of that spectrum.
If they measure their heart rate, many of my patients
were wearables like Fitbit and Apple watches,
and I find that their heartbeat is too high.
The optimal dose to protect your heart,
to facilitate weight loss and help with insulin resistance
is really a zone that we call moderate.
And there's different ways you can calculate it.
I like using the Maffetone heart rate or the MAF heart
rate developed by Dr. Phil Maffetone.
And really, it's a very simple equation.
It's 180 minus your age, OK.
So if you're 40 years old, your upper limit is going to be 140.
So 80% to 85% of your workouts should really
be pushing that ceiling of 140, again, if you're 40 years old,
and maybe once a week or so, you can do more anaerobic-based
HIIT-type training.
Now, some of you might argue, no,
I've read HIIT training three, four, or five days a week
is better.
It saves me time.
And for some individuals, maybe that works,
but I find that people that do excessive HIIT training also
have increased hunger-- that's been shown through studies.
And they have increased injuries unless they're athletic
and they've got a strong core and they're really
doing a lot of things to really prevent injury.
But really, this aerobic dosage is super, super
important to make sure you're getting enough
of that type of exercise.
And this shows you that exercise,
there is dose-dependent effect.
So you can see on the left-- let me just use my pen here
so I can highlight.
This is really important because I often
have this discussion in the clinic with my patients.
But here on the y-axis, you see all-cause mortality or death
rates, and here on the x-axis is basically
the amount of exercise.
And when we look at all this together,
when you're sedentary, clearly, you
can see mortality and death rates are higher.
As you get physically active, you
can see it's dropping down, which is good.
We want mortality to go down, mortality to go down.
So the optimal amount of exercise is somewhere in here.
Now, some people that keep doing more and more and more
exercise, they're training for triathlons
and running marathons and just going non-stop,
we see that excessive endurance-based exercise
can increase fibrosis or scarring of that heart muscle.
It can cause arrhythmias, which are abnormal heart rhythms.
It can lead to more coronary artery Calcification
so there is a point in which excessive exercise can actually
have an opposite effect and actually increase
the rate of heart disease.
So really keep that in mind.
OK, fasting we get a lot of questions
so let me cover a couple of quick things here for fasting.
So some tips on Time Restricted Eating or TRE
or intermittent fasting, whatever you want to call it--
so first, you ask yourself when do you start and stop eating.
That's your eating window.
And I tell people try to shave one
to two hours from your baseline.
So you can go straight to a 14/10 or a 16/8.
So that first number is the fasting interval,
and the second number is the--
I'm sorry the first one is yes, the fasting.
The second number is the feeding window.
So a 16/8 basically means that you're fasting for 16 hours,
and you're basically eating during the 8-hour window.
So just trying to end eating earlier, for most individuals,
finishing by 7:00, 7:30 PM, it works well.
Later meals are linked to higher heart disease
risk, increased glucose, and inflammation.
So I have some individuals that I've seen in the clinic,
and they're eating around 9:00, 9:30, or 10:00 PM.
That is not good for inflammation and insulin
resistance.
You want to really pull that back earlier.
More is not always better for fasting, especially for women.
You want to really personalize that interval.
I've done a lot of work, a little bit of research,
and looked at the data on fasting.
And really, people that are excessively fasting
can often lose muscle mass, and there can be other side effects
to that.
So there is a proper dose of fasting that most of us
should pay attention to.
And I did a detailed blog post on that that's
linked here at the bottom here.
It's bit.ly/sinhafasting.
So information in this individual,
I just want to focus on one specific number.
I've already hammered you with a lot of cholesterol information,
but this is an individual that made some really great changes
in diet, and you can see the triglycerides got much better.
But there is one test I want you to pay attention to here
is this C-Reactive Protein.
I mentioned earlier that's a marker for inflammation.
Now, with lifestyle changes, you see
that this C-Reactive Protein dropped from 10.6 to 3.6.
So that's a good improvement.
But there was one change in particular
that completely normalized this individual's level
inflammation.
And what was that intervention?
That was meditation.
And I see this in my patients.
A lot of times, we just obsess over diet and exercise so much.
And we don't realize that when our system,
our emotional system is basically revved up,
when chronic stress is constant in the background,
it can rev up our immune system and cause increased inflation.
That's why chronic high levels of stress
are an independent risk factor for heart disease.
So literally doing mindfulness-based practices
for this individual completely normalized that
C-Reactive Protein.
So I want you to be aware that.
The other direct effect of stress
is stress can absolutely raise blood sugar.
It can raise blood sugar in some cases more than eating sugar.
So this is an individual from our Metabolic Wellness Program,
and I wanted to highlight the fact
that this individual throughout the two-week course of wearing
this sensor had not seen any abnormal blood sugars at all.
And let me use my pen here again so I can make this point here.
So basically, you can see here, the glucose levels
from the sensor were pretty stable throughout
the whole time she wore this.
But then what happened?
She has a single heated discussion with her in-laws,
and all of a sudden, the glucose went up into this zone,
into the 170s.
She had never seen anything go up that high
throughout the course of this program.
And this tells you that that emotional stress,
that cortisol, it can trigger the liver
to produce more glucose.
So this is going to happen episodically for some of us.
But if you're constantly in conflict and stress
with your family, during work, because of life circumstances,
know that the metabolic impact, again, can be very significant.
And as I mentioned earlier, if you're
interested in joining our program, the link is down here.
And you can join the wait list for this.
But this, again, this along with the C-Reactive Protein,
I hope helps quantify the effect of stress
it can have on inflammation and on insulin resistance.
So here, remember that diagram I showed you
in the beginning of the inflammation and insulin
resistance?
These two cases show directly quantitatively how
stress can actually lead to both of those conditions.
So really important to keep that in mind.
Emotional stress and heart disease,
we covered this already.
So stress and sleep tools and resources,
I put some of my links.
I've got some instructional videos
on my blog that tell you how to help manage stress
through breathing.
I've also got an e-book that helps with sleep issues
as well, too.
And through Sutter Health, we also
offer health education classes, courses on mindfulness,
and things that can really help you manage stress and also
improve your sleep.
Now, smoking I want to say a couple of things
about because some of my patients during the pandemic
did resort to increasing, restarting smoking,
or doing social smoking.
The smoking really is the strongest reversible risk
factor for heart disease.
It can have effects on lipids.
It can increase blood clotting.
All these factors can really raise plaque formation
and accelerate that process with increased heart disease risks.
And one final point I want to make about smoking
is even one cigarette daily is deadly.
Many of my patients who are social smokers
since think they're off the hook,
but I want to highlight this last bullet here
where smoking one cigarette daily
has half the risk of someone who smokes 20 cigarettes daily,
not 1/20 of the risk.
So it's not mathematical on that scale.
It's basically one cigarette enough
can cause that to perpetuate an increased risk,
especially if you're already insulin resistant.
So if you're smoking at any degree,
please quit altogether if you can.
And you can reach out to your health care team
around resources and support to help you quit.
OK, so I wanted to leave enough time for questions and answers.
So we are going to move on to that.
And because I know we're going to get questions
about our metabolic program, I'm just
going to keep this slide up here,
which has the link for joining our wait list along
with some fast facts on the program itself.
All right, so let me go ahead and stop sharing here,
and we can jump in to questions.
And I'd like to introduce Laura [INAUDIBLE] who's
going to help be moderator for a long list of chat questions.
I don't envy your job right now, Laura,
but I know you're going to do a great job as always.
LAURA: Oh, thank you so much, Dr. Sinha.
And thank you for all that information.
We do have many, many questions for you today.
So we're going to do our best, everybody, to get to as many
of them as we possibly can.
All right, Dr. Sinha, for our first question,
is it possible for someone to find out
if they have a clogged artery before they
have a heart attack?
RONESH SINHA: OK, really good point.
So like I said, so for the clogged artery, the only way
you can tell if the artery is clogged, and god forbid,
if you have a clogged artery, you're
going to have symptoms of that already, right?
What you're really trying to identify
is those vulnerable plaques.
Remember, you want to identify that pimple before it pops.
And basically, one of the best ways
to do that if you're at intermediate risk
is to basically get a coronary calcium scan.
I don't recommend that in everyone,
but that is one way to visualize if that's happening.
Another indirect way that you can
tell if you might have a blocked artery
is if you're somebody that is developing chest pain
or shortness of breath with exercise,
then talking to your doctor about getting a stress test.
What they'll do is they'll have you basically exercise
on a treadmill, and based on the EKG
or if we're doing an echocardiogram and ultrasound,
we can see changes that take place that would give us
an idea that you have an artery that's
possibly getting squeezed or getting tighter
as you exercise.
So those are two ways we can get a bit more visual dynamic
feedback.
LAURA: Great, thank you so much.
Our next question is, does a woman's risk
for developing heart disease increase during menopause?
If so, can it be minimized with hormone replacement therapy?
RONESH SINHA: Yeah, great question,
a very controversial area.
So the first thing is although there are some studies
to indicate that menopause might increase heart disease risk,
if you really do a deeper analysis,
it's all over the map.
It's conflicting because clearly during menopause, women
are also aging, and there's a lot of age-related risks
that occur with that.
Now, something specific that can happen with menopause
is your lipid profile might change because
of the hormonal changes.
So sometimes the LDL cholesterol might go up a little bit.
The healthy cholesterol might go down.
But I would say based on available studies,
it doesn't look like menopause significantly raises risk
independently, but the age itself
does raise risk on top of that.
Now, with hormone replacement therapy,
again, lots of conflicting studies.
Some studies-- earlier, we used to think that it lowered risk.
Now really what we're finding with hormone
replacement therapy is it's probably more neutral.
There are some studies that showed
there might be a slightly elevated risk of heart attack
or stroke.
But even that's being questioned.
So really, the approach to hormone replacement therapy
is if you're having symptoms that are really affecting
your quality of life, talk to your doctor
about going on a temporary course of hormone replacement
therapy.
But again, the big meta picture here
is hormones and menopause, conflicting data
that out there.
If you want to lower risk, focus on all the things
we've talked about around diet, lifestyle, stress, sleep,
all those things.
Those are far more important.
LAURA: Great, thank you, Dr. Sinha.
Our next question is regarding alcohol consumption.
Can you talk about alcohol consumption
as it relates to heart health?
RONESH SINHA: Yes.
OK, so what I will tell you is when you look and do
a deeper analysis of the studies around alcohol, many of us
have grown up thinking alcohol is protective.
If I drink a glass of red wine, it's
going to protect me against heart disease.
And I'll tell you, most of the studies that were done on this
are absolute garbage because the problem
is in most of the studies, when you're
assessing alcohol intake, these are usually
when you try to basically do a deeper analysis,
you find that a lot of individuals
who have lower heart disease risk,
it's because of that population of people that are drinking
those one to two drinks.
So often, this can be a healthier population that tends
to be more health promoting.
So a lot of people that are drinking a glass of wine
or two in the evenings, they tend
to be individuals also that might be exercising and eating
healthier foods.
They're more health conscious.
So when you actually look at those lifestyle factors
and confounders, in most studies,
you don't see a significant protective effect from alcohol.
So my bottom line advice to you is
if you enjoy alcohol in moderation
and you don't have any contraindications
based on your health, you can continue drinking
in moderation.
If you don't drink alcohol, I would never
recommend that you start drinking alcohol to protect
yourself against heart disease.
That's not going to be a good strategy.
And there is not evidence to back that up.
LAURA: Great, thank you so much, Dr. Sinha.
So our next question is about genetics.
What role does that play with heart disease?
RONESH SINHA: Yes, so with genetics,
anywhere from about 40% to 60%.
So it can play a significant role.
But the good news is when I see patients
at the clinic that have had one or two family
members that have heart disease, often, they get very nervous.
They're like, oh, my God, am I going
to go get a heart attack at age 40 or 50?
But you have to keep in mind that those genes,
they're kind of like apps on your phone.
They don't get turned on unless your adverse lifestyle has
an influence on that.
So often when I ask patients about their parents
or grandparents that might have had early heart disease,
I ask them, were those parents overweight?
Were they consuming an ideal diet?
All these things are really important because most
of the time when they look back, their parents
might have been smokers.
Maybe they weren't exercising.
Maybe they were eating a moderately unhealthy diet--
I'm sorry.
Not modern, but a Western unhealthy diet.
So if we can get our individual to reverse
some of those lifestyle patterns,
often we see that they don't develop heart disease
at a premature age.
So genetics does play a strong role,
but lifestyle can trump a lot of that genetic risk, which
is what you want to focus on.
LAURA: Great, thank you so much, Dr. Sinha.
So Dr. Sinha, what causes your heart to rapidly beat,
and is this something that's dangerous
and that you should talk to your doctor about?
RONESH SINHA: Yeah, so rapid heart beats
can come from various causes.
First, I want to answer the last part of it.
Yes, you should talk to your doctor about that.
Rapid heart rate can come from caffeine intake.
It can come from anxiety, stress, severe dehydration.
It can be medications or supplements.
So if you're having it once in a while, not a concern.
But if it's happening more often or you
have symptoms that are going along with that,
then definitely talk to your doctor about rapid heart beats
just to make sure there's nothing serious.
They can check an EKG, do testing
like for thyroid disease.
When you're thyroid is overactive,
it can cause palpitations.
But they can do a more thorough workup
to see what the cause of that rapid heart rate might be.
LAURA: Great, thank you.
So Dr. Sinha, can your body actually recover,
reverse the signs of heart disease
after decades of overeating, drinking, not exercising?
But if you are doing all of those things
and then turn the corner and start exercising and eating
healthy diet, can you reverse those effects?
RONESH SINHA: That's a really good question.
The good news is our body, thank goodness,
is incredibly forgiving.
So at any stage when you come into this with whatever
stage you're at, we find that the minute
you can incorporate these lifestyle changes,
take a couple inches at the waist line, start exercising,
you can actually-- what you end up
doing is, for example, my patients that have calcium
on their coronary scan, you may not
make that calcium disappear.
But the whole game with this plaque
is whether you make the plaque disappear or not,
you want to scar it and stabilize it.
And that's what lifestyle does.
When you're managing stress, you're eating properly,
you're exercising, often what happens is that plaque,
that pimple gets scarred over.
The pimple may not disappear, but as long
as it becomes inactive and it's not going to blow,
it's not going to explode or pop,
that's really the goal that you're looking for.
So to answer your question, the earlier
we can intervene, the better.
That's why I mentioned that, hey, already
watch your kids' habits.
If they're sitting in front of a computer on a screen all day
and if they're eating garbage foods,
you want to get on top of that now.
But even if you present at 35, 40, 45, 50,
and you've already got existing risk factors or a high calcium
score, at any stage, you can intervene
to really slow down or stop that progress
so it doesn't turn into a catastrophic premature event.
LAURA: Great, thank you, Dr. Sinha.
We've had lots of questions regarding the Metabolic
Wellness Program.
Can you further explain that?
I know you have a slide on that.
RONESH SINHA: Oh, yeah.
Sorry.
Let me jump back into these slides again here.
Yeah, yeah, absolutely.
So this program right here is basically it is a 12-week--
and you can see my slide?
LAURA: Yes.
RONESH SINHA: OK, so it's a 12-week guided program,
and we use a glucose sensor.
And really, what we're doing is it
can often be difficult to get your hands on a glucose sensor.
So our team is the one that prescribes the sensor for you,
and we get the sensor in your hands.
We teach you how to put the sensor on,
and we teach you how to actually interpret the data
and make lifestyle changes based on this.
So it's super cutting edge because most
of the time, these sensors have been used exclusively
in diabetics on insulin.
But we teach how to use it in the context of your daily life.
So really, this program is designed
on the proper use of the sensor, interpreting your data.
And then we have a team, myself included.
I lead some of the health education sessions.
We've got some functional medicine practitioners,
a great dietitian that does sessions on ketogenic diets,
on fasting, on anti-inflammatory things, stress, sleep.
So we've got a nice comprehensive line of resources
that help support people's metabolic health while they
track it using the sensor.
We have limited space with each pilot.
So if this is something you're interested in,
I would go to that link and just enter the wait list.
And there's also a video that tells
you more about the program itself
with some additional information on that web page.
So something to keep in mind.

PEI-HSIU HUANG: Thank you for taking the time
to join us today while we talk about cardiovascular disease
in women.

OK.
So we are near the end of February 2021,
and this will mark the close of the 57th annual American Heart
Month.
And this is important to take into account
because heart disease has claimed countless lives
over the years, and even most recently has claimed
over 800,000 lives each year.
Heart disease continues to be the leading
cause of death in the US, prior to COVID, of course.
And more people die of heart disease
than all cancers combined.

Here is a different depiction split
into male and female deaths.
If you look at the bold, blue wedges,
they represent heart disease, which include ischemic heart
disease where the blood supply to the heart muscle
is affected.
Looking at the slide, about 22% of women--
basically, one in five-- deaths are due to heart disease.
And while the proportion of cancer deaths is similar,
breast cancer--
which is also very much in the forefront
with a lot of attention and initiatives--
causes a relatively small percentage of total cancer
deaths, as you can see here.
And this all in all is about four times less
than the deaths caused by heart disease.
So historically, heart disease was
thought to be a man's problem.
Back in the 1950s and a lot of men
were smoking, a lot of people had heart attacks.
And when the mortality started to be tracked a little bit more
carefully, you noticed that in 1984, the blue
and the red lines cross.
And for many years thereafter, note
that more women die from heart disease than men.
And the deaths for women continued
to rise, despite an improvement in the death rate in men.
And this is kind of peculiar because around this time,
this is when a lot of transformative developments
in understanding of ischemic heart disease were made.
Angiography was already being performed to identify blockages
in the coronary arteries.
Medicines that were developed to break up
clots in the coronary arteries were already
being used to treat patients with heart attacks.
Angioplasty, which was first utilized
in patients in the late 1970s was now
being routinely used to treat patients with heart attacks.
And in 1994, the FDA approved the first coronary stent
for use in the United States.
So despite all this, why did the female mortality
remain so high?
I'll come back to this in a little bit.
First, I want to talk about Jane.
Here's Jane.
She is a bit of a heavyset person.
And four years ago-- she has chronic back pain.
So four years ago she was undergoing evaluation
to have back surgery.
And at that time, she told her doctor
that her father had had a heart attack when
he was 54 years old.
So she had an electrocardiogram done,
and it was a little abnormal, but some other tests were fine.
So she underwent back surgery.
She went through it without an issue.
Subsequently, she was diagnosed with high blood pressure.
So following that, she had some really nondescript chest
discomfort, and just made her feel a little bit uneasy.
She said it was kind of difficult to describe
exactly what it feels like.
Sometimes that the discomfort would shoot her back.
Occasionally when she walks around,
she had some shortness of breath.
And she was thinking, well, because her father had a heart
attack when he was 54, she was kind of worried about it.
So Jane went through tests.
She went through tests, and she went through more tests.
She initially, saw a cardiologist
and had an echocardiogram, stress test,
had a heart monitor done, none of which
really showed anything.
She continued to have symptoms.
And so a year later, she had another stress test.
This time it was a little bit abnormal,
but the cardiologist thought, well,
maybe that's just artifact.
Well, a few years after that, she
continued to have chest discomfort
and had another echocardiogram and another stress test.
Nothing was found.
So she had another echo, and finally another cardiologist
said, you know, forget the stress test,
we just can't find anything.
Let's just do a coronary angiogram.
So she went through and had a coronary angiogram
and didn't really find much.
If you look on the sides, the panel on the left--
let's see, where is it?

Here we go.
The panel on the left really shows not too much in terms
of everything's pretty smooth.
There's no obvious blockages.
The panel in the middle, these blood vessels
look pretty smooth.
The panel on the right here, the blood vessels
look a little small, but there is no pinches or no blockages
anywhere.
So what do we do with her?
The treatment, in this case, pretty much
was more of the same, but at least more decisively
so because, at least now, her doctor
knew that, her cardiologist knew that she
didn't have a blockage.
And so she just went through lifestyle changes,
tried to lose some weight.
She ended up going through bariatric surgery.
After, she was diagnosed with diabetes.
And then she went through some other testing
for some other symptoms, but never really completely figured
out exactly what it was.

Now, what we just described, this scenario
is actually pretty commonly encountered and one
that potentially illustrates some of the differences in how
women present with ischemic heart disease compared to men.

So it's important to recognize what increases someone's risk
for developing cardiovascular disease because 90% of heart
attacks and other heart disease events
occur in people with at least one of these risk factors--
I would say the traditional risk factors.
I group them in my head in two separate categories-- number
one, the nonmodifiable ones such as age.
Can't really change that.
Can really change which family you were born in to.
And the rest of them are more modifiable-- things
such as blood pressure, cholesterol, diabetes,
and lifestyle issues with regards to smoking,
what you eat, stress level, physical activity.
And while a lot of these risk factors
are the same ones that we pay attention to and mend,
these risk factors tend to occur more frequently
or even have greater impact than the risk
of cardiovascular disease.
For example, high blood pressure occurs more often
in women over the age of 60.
It has a stronger affect to the risk of developing
heart disease than men.
And as far as cholesterol, after the fifth decade,
women generally tend to have a little bit higher cholesterol
level than men.
And while we often focus on the level of bad cholesterol--
the so-called LDL--
it turns out that for women, having
a low HDL, a low level of good cholesterol,
is more strongly associated with the risk of developing heart
disease.
So as far as obesity, this is an epidemic in the United States
and around the world.
And with obesity, that goes hand in hand
with developing metabolic syndrome.
In fact, it is one of the components
of metabolic syndrome, which is really
a combination of obesity, high blood pressure, diabetes,
and having cholesterol issues.
And metabolic syndrome tends to occur more commonly
after menopause.
So smoking doesn't really have the same effect
in men as in women.
It turns out that women, even smoking as few as one
to two cigarettes a day, have a stronger--
it almost doubles their risk of developing a heart attack
in the future.
So those are how the risk factors are common with men--
or different-- or affect women differently.
Now, women have unique risk factors
that largely are related to hormonal changes that occur
during the woman's lifetime.
For example, a younger age at menarche
is associated with a higher risk of cardiovascular disease.
And while cardiovascular disease is
unusual in premenopausal woman without any risk factors,
the postmenopausal state seems to increase
the risk of heart disease.
But it's hard to know exactly why it does that
and how much it does that.
What we do know is that from the many studies,
such as the Women's Health Initiative and the HRT, two
studies, that hormone replacement therapy does not
seem to be protective against the increased risk.
And, in fact, can itself increase
the risk of heart attack, stroke, and forming clots.
Polycystic ovarian syndrome is really
strongly associated with developing diabetes
and metabolic syndrome.
And that in itself can increase your cardiovascular risk
as well.
And then pregnancy complications--
there are the issues encountered during pregnancy.
If someone has a history of pre-eclampsia,
which is a hypertensive condition that involves
multiple organs during pregnancy,
the risk of developing heart disease in the future
is double.
And if at any time during the pregnancy
a woman has high blood pressure or diabetes,
that increases the risk of having high blood pressure,
diabetes later on in life after pregnancy,
and thus the risk of developing cardiovascular disease
has also increased.

So symptoms-- it is probably the case
that women with ischemic heart disease more often than not
have classic anginal symptoms.
And the classic anginal symptoms are this.
We call it typical angina, and tends to have all three
of these characteristics in terms of being severe, being
brought on by some sort of activity, exertion,
and it resolves with rest or taking
a little bit of nitroglycerin.
And it's usually described as heaviness, pressure, tightness.
You may have heard on TV people saying, oh,
the classic heart attack, the hand over the chest.
There's an elephant sitting on my chest.
And it's usually in the center.
Sometimes it goes to the left.
I would say off in the left neck and the arm.
And it's accompanied a lot of times by shortness of breath.
You may feel a little bit nauseated or have sweaty skin.
And some of these symptoms will often
be found to have some sort of severe blockage in at least
one or more of their coronary arteries.
But studies showed that women, even
though they experience angina--
and sometimes even more frequently than men--
as they age, may describe the symptoms a little bit
differently.
And it's not only in the descriptive words that
are used to communicate with the physicians,
but women are more likely to have symptoms that occur
at rest and with exercise.
So it's not necessarily predictable.
Sometimes women may have these anginal symptoms
that occur during sleep.
The intensity of the pain may vary over time.
And these symptoms, much like the one
that Jane had described, it doesn't always
raise suspicion of someone having heart disease.
And so this may be why studies have
shown that women are significantly less
likely to have diagnostic testing such as stress
testing or coronary angiogram, or even
undergo angioplasty or bypass surgery even
when they're admitted to the hospital for chest
pain or a heart attack.
Another study showed that women only had coronary angiography
about half as often despite the fact
that, when they were admitted to the hospital,
there were symptoms of angina.
They had angina as frequently with more debilitating symptoms
than men.
And as you can imagine, this leads to delays in treatment
and even lack of appropriate treatment in many cases.
So to complicate things more, it's been shown that up to 60%
of women with heart disease symptoms
have no severe flow limiting blockages on the angiogram
when they have one, just like Jane.

If you look at more carefully, though, at these women,
at those coronary arteries, there is one study--
several studies, actually-- looked at it very carefully,
some with a special ultrasound catheter.
You can see that the coronary plaque in some of those women
were deposited a little bit more differently
than they are in men.
They tend to be more uniform and more evenly distributed
or diffusely distributed into many of the coronary branches.
So this led to the description of
the potential different patterns of plaque distribution
with men compared with men.
So women tend to have smaller coronary arteries.
And they don't necessarily have a discrete stenoses.
If you remember Jane's angiogram,
one of her blood vessels looked kind of small.
It looked pretty uniformly small all the way down.
And so compare that with men, where it's lumpy,
bumpy and you see this--
right in the middle of the blood vessel right there--
discrete blockage.
And women tend to have more soft plaque, less calcium.
And a lot of this ends up affecting the microscopic blood
vessels and cause dysfunction of flow
through those microscopic blood vessels.
Those are blood vessels that you cannot stent,
you cannot bypass.
And as a result of effecting those blood vessels,
you also can cause a coronary artery to spasm.
And so those are the various ways
that plaque and coronary flow differ.
But the research that's been done in this area,
you have a better understanding.
And now you can imagine that the full extent of disease in women
may not really be recognized.
Let's go back and take a look at Jane's angiogram.

Let's see.

So the inset, right here, if you take
a look at this particular blood vessel,
perhaps Jane had a lot of diffuse plaque buildup.
I mean, this vessel is clearly a lot smaller
than the other ones.
But you don't see any discrete blockage.

So if you can't see what you're treating,
how do you know you have something to treat?
And I think it's been described that this is probably
a large part of what contributed to the big differences
in the rate of death among men and women
between the late '90s and early 2000s, if you go back and look
at that mortality slide in the beginning.
All right, let's switch gears a little bit.
Let's talk about Anne.
She's very healthy.
She's 43.
And pretty much going about her business,
and one day woke up having pretty severe chest discomfort
right in the middle, and it radiated,
it spread over to both arms.
She fell a little bit short of breath, a little sweaty,
went to the hospital.
And then she had an electrocardiogram that really
didn't show all that much.
But when her blood test came back,
she had one specific blood test called the troponin I level.
It is supposed to be pretty low--
0.4 is well above the upper range.
It's definitely abnormal.
So because of this she underwent coronary angiography.
And what was found is the right coronary artery, which
is the panel on the left, didn't really have too much.
But if you look at the left coronary artery,
in the panel on the right, you can see that this particular
blood vessel down the front-- and I'll let you take a look
at it a bit more carefully--
it looks completely diseased all over the place.
It is very different than the blood vessel on the left panel.
And even the other branches over on the right panel--
that's the left anterior descending artery.
And that's specifically where the electrocardiogram
might have shown changes.
So the cardiologist who did this thought that, hey,
we've got to get this taken care of-- she's having chest pain--
and ended up putting a stent in.
And the stent is almost like a pit in a python type of look.
The stent is a little too big compared to the blood vessel,
but given what was there to begin with, not
too bad of a result.
And so what do you do with something like this?

You put some on medicines, and over the next 10 years--
literally 10 years--
Anne continue to have random episodes of chest pain
and had a lot of atypical features,
sort of like the ones we talked about in the past.
They come and go.
The intensity would vary.
Sometimes it would occur at night when she was sleeping.
And it was pretty random, no real pattern to it.
And to the point that her cardiologist had written
in multiple notes that he thought
that the chest pain she was experiencing was,
quote, "noncardiac chest pain."
And through the 10 years, just to check
because she's had a stent already, just
to check to see what else is going on,
she ended up having four different stress tests.
And finally, the last one that she had
showed an abnormal finding.
So she was referred back to get another cardiac
catheterization.
And take a look at the cornea arteries pretty carefully
this time.
The panel on the left, if you take a look
at the right coronary artery right here,
it looks actually bigger and smoother.
And if you look at the panel on the right,
the blood vessel that was really heavily diseased 10 years ago,
this one that has a stent right about here,
looks pretty normal.

Take a look at that.
And if you compare 10 years ago to today--
so here's 10 years ago.
If you look at this blood vessel down the front
here, compared to today it looks like a completely different
person.
And so what exactly happened to Anne?
I think, in this case, she probably
had a bit of plaque buildup.
She probably ended up having just vasospasm.
So what you're seeing right here is blood vessels
are not exactly like lead pipes.
They're like soft rubber hoses, and they
can constrict and shrink and dilate and get bigger
based on how much blood flow is needed.
And in some cases, if there's some sort
of issue with the mechanism that causes
the blood vessels to shrink and dilate,
you can have a vasospasm.
And sometimes it occurs in one blood vessel.
Sometimes it occurs in some other blood vessels.
And this is probably what happened in Anne
because her blood vessels look completely normal.
And this is a procedure that I had done.
And I put an IVUS done there, this Intravascular Ultrasound
catheter.
In fact, she had no plaque at all.
And so her heart attack 10 years ago
was due specifically to vasospasm, and not
necessarily a "true heart attack"
in the classic sense of the [INAUDIBLE] blood vessel.
In any case, so Anne just ended up
continuing on with medical management.
She was treated with medicines that
was promoting blood vessel dilation to try to prevent it
from constricting.
And she has actually done pretty well.
So both the patients that we discussed actually
did quite well after their medicines were increased.
And actually, eventually even Jane's symptoms
improved after she lost weight and had her medicines really
aggressively increased.
And now their doctors, their cardiologists
had a better idea of what disease was actually there
to need treatment, I think that they actually received
more appropriate treatment.
And that's just across the board,
how that people have a little better understanding of what
sort of disease women have, even if they don't
have the classic, just discreet severe blockage
in a coronary artery.
I think more women are being diagnosed and started
on appropriate therapies.
So treatment for these type of cases--
if you have a severe blockage, then you
got to consider opening a blockage up
to restore blood flow to the heart muscle.
And that could involve putting a stent in or going
through a bypass surgery if you have complicated
disease or multiple blockages.
But beyond that, that should be in addition to--
everyone needs to be on what we call a guideline directive
medical therapy.
So you need to be on good medicines
to prevent progression of disease.
And these medicines, even in the absence of severe blockages,
can actually sometimes potentially
even reverse plaque, as some studies potentially suggest.
And along with guideline directed medical therapy,
having a good diet, exercising--
the current recommendation is 30 minutes, 5 days a week.
And if you smoke, that's a huge risk for having continued heart
disease.
And these things are often enough to improve symptoms.

So now that doctors, like I said,
were able to identify people and treat them appropriately,
you're starting to see that as the number of deaths in women
peaked in or about the year 2000,
the general trend followed the general trend of the reduction
in deaths in males, in men such that in 2014,
for the first time in 30 years, the number of women
dying from cardiovascular disease is now less than men.
So now like it or not, men are dying more again.
So unfortunately, we have seen an uptick in the rates of death
due to cardiovascular disease.
And I'm not sure that's fully explained at this point.
So a lot of this is attributed to,
I think, public awareness of a lot of the new research that
has been done, really plays a role
in improving the outcomes for women.
And part of this public awareness
was this very large initiative that I'm
sure everyone's heard about, not only
the February American Heart Month but American Heart
Association in 2004, launched a large initiative called
Go Red for Women.
And the point of this was to increase awareness
about women's heart health.
And it's had significant impacts to the point
where now, I think over 50% of women
are aware that heart disease is actually
the leading cause of death.
And breast cancer had been taking a lot of press,
and it's not really a competition.
But these are issues that everyone--
all of these issues need to be taken seriously.

That's a brief discussion about cardiovascular disease
in women and the things that a cardiologist
should be paying attention to and
the things that the general public need to be aware about.
So I'll stop here, and I'll take any questions.

OK, so here's a question.
The question is, can some chest tightness and/or shortness
of breath indicate COPD as well?
And if so, wouldn't that eventually translate
into heart issues?
And what type of doctor should be seen in this instance?
And what type of tests should be run?
So, absolutely.
I think heart and lungs sometimes,
it's difficult to separate out what's causing what.
And hang on a sec.
That scrolled off the screen.
So absolutely can indicated COPD.
But oftentimes, people with COPD have had some risk factors
to develop that as well.
So if there is concern, then I would certainly
start with your primary care physician,
express the concerns, and what sort of tests can be run.
The first test that can be run to determine whether or not
your have COPD is just a lung function test.
We call it a pulmonary function test.
And it will allow you to measure how well your lungs move air.
And if it looks like there is any obstruction,
then it's potentially hinting at you might
have some issues with that.
So a primary care doctor can definitely start that process.

So it says, the internet says, occasional flutter feeling
lasts a few seconds is normal.
Is that always true?
That's hard to say because everyone
will have some abnormal heart beats at some point.
If you hook all of us up to a heart rhythm monitor,
we're all going get an extra beat or early beat or a skipped
beat every once in a while.
I think if that happens occasionally,
you should mention it to your doctor just
to make sure that there is nothing else
going on because it depends on what else is associated too.
And occasionally, some people may have a heart rhythm issue.
So I think, depending on what it is that you're feeling,
what it is that you're describing to your doctor, that
would determine whether or not more testing is needed.

All right.
Here's another question-- you talked about a pain
in the left arm.
Would a sharp, stabbing pain in the left
shoulder down that arm that lasts few seconds be
a good description?
I think if you're having that, and if you're
having that frequently, it's something
that you might want to check with your doctor about,
and see if more testing is needed.
Certainly, it would be more of an atypical type of description
based on the traditional definition of anginal chest
pain, but certainly something that should not be ignored
if you feel like it's abnormal.

All right.
So here here's another question--
been frequently feeling a pulse heartbeat flutter-type feeling
in my throat.
Should I be concerned?
That's also a difficult one because it
depends on how often you're feeling it
and what the circumstances are.
And that's something I believe that you need to speak
with your doctor about.
Perhaps a heart rhythm monitor may be needed.
Sometimes if you have some extra beats or skipped beats,
that can feel like it's the throat
and feel like it's a bit of a flutter.
And if you have that often, I think it's worth checking out.

All right.
Are there any guidelines for working out?
Absolutely.
The American Heart Association itself puts out--
has a recommendation of exercising 30 minutes a day,
5 days a week at a minimum.
So that's sort of minimum passing grade.
And working out doesn't necessarily
mean running a marathon or biking 50 miles
or something like that.
It just means a brisk walk, something to stay active.
And that's really what the American Heart Association
is trying to get people to dd to stay active.

Can you explain what normal blood pressure is?
Well, so technically speaking, with the recent,
I guess, guideline updates, the normal blood pressure
is 120 over 80.
And the top number is 120.
We call that the systolic number.
And the bottom number is the diastolic number,
and it should be under 80.
Anything above that, you start getting into what
we call stage one hypertension.
And what that means is, stage one
doesn't necessarily always necessitate
you starting to take medicines.
But it does really mean that you just
need to start paying attention to your blood pressure
and tracking it carefully.
So if that's you, it would be helpful to figure out
how to track your blood pressure in some way.

All right.

So usually we are told that if we have high cholesterol,
you have a high risk for cardiovascular disease.
I also heard that the criteria to look at
is the number for the bad cholesterol, not
total cholesterol.
In other words, as long as you have your number
for the good is very good, you shouldn't
worry about that much.
Is that correct?
Sort of.
As we were talking about earlier, a lot of times
we focus on the bad cholesterol number.
But I think, it really is a combination of both
because, particularly in women, the good cholesterol level
seems to be more predictive of the risk of developing
cardiovascular disease than the bad cholesterol number.
But in either case, men or women,
if you have a low good cholesterol number and, on top
of that, a high bad cholesterol number,
that's not necessarily going to be good for you.
So that's something that can be changed with change and diet.
Good cholesterol is generally associated with--
you can change that by exercising more, smoking,
and stuff like that would certainly cut that out
and that can help your cholesterol profile.

What kind of food are recommended
to keep your heart healthy because I think
prevention is better than cure?
Absolutely.
Prevention is always better than cure.
Unfortunately, all the cures that we have-- quote unquote,
"cures" are mostly band aids for stuff.
There's really no absolute cure for heart disease.
And so in terms of foods, the recommendation
is really just a balanced diet.
And there's been more focus recently
on foods that have a lower glycemic index because it's
thought to lead to lower risk of developing diabetes.
And I know there's more of a focus on vegetables
and plant-based stuff as well.
I think, generally speaking, any one of these trends,
having a balanced diet across the board,
not too much of one thing versus another,
cutting out saturated fats and things like that,
and eating more vegetables in general
is just going to be good for you.

Ha!
Is wine really good for your heart?
So the studies are mixed.
And I think the consensus is that moderate drinking
is actually good and lowers your risk of death.
But I think you have to take that with a grain of salt.
You can't just take that as, I should drink moderately.
And because it's thought that if you drink moderately,
people who do that-- have, say, a glass of wine with dinner
every day--
tended to have other healthier lifestyle choices as well.
So I'm not sure that that alone lowers the risk of--
is good for your heart, necessarily.
But it's that along with all the other things that come with it
that's good for your heart.

Is it true that genetics plays a significantly larger role
in diet and lifestyle?
Well, I would say that we're not at the point yet
of understanding just how much of a role genetics play.
I think we are at the point of being able to identify genes
are associated with disease, but just because you have a gene
doesn't always mean-- depending on the disease and stuff--
doesn't always mean that you're going to develop the disease.
And so I usually give advice that if you have a family
history of heart disease, if you have,
say, your parents both had heart attacks before they were 50,
you probably have some genetics that if you
add on top of that, bad habits such as smoking,
eating way too much salt, you don't exercise,
that doesn't help the situation out at all.
So control what you can control.
And the rest, unfortunately, right now we just
have to see what the research and studies show.

OK.
I think we're probably close to wrapping up here.

All right.
Well, thank you.
I want to thank everyone for taking time out their lunch
hour to join us.
And I thank you very much for your patience
through all the technical difficulties that--
these heart health resources, here's some information
that if you're in the Sacramento region
and need some cardiologist, advice, give your primary care
doctor a call, and we're happy to help you out.
All right.
Well, thank you very much.
It's a great way to close out the 57th American Heart Month.
And we'll see you in the future.