Lipoprotein (a) with Dr. Joel Kahn: Rational Wellness Podcast 166
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Dr. Joel Kahn speaks about Lipoprotein (a) with Dr. Ben Weitz.
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4:18 Lipoprotein (a) is a particular type of cholesterol particle that can be measured on a blood test. We know that only 50% of those people who have a heart attack have elevated conventional cholesterol levels, so there must be some other risk factors and elevated levels of Lipoprotein (a) is one reason in some of those cases. Lipoprotein (a) has at least three dangerous properties: 1. It is called the sticky cholesterol because it promotes blood clotting. 2. Lipoprotein (a) causes atherosclerosis and it may be found in the plaque that closes your carotid artery, your heart arteries, your sexual organs or your kidney arteries. 3. Lipoprotein (a) causes inflammation. All three of these properties promote heart disease and Lipoprotein (a) is found in one out of every four Americans. A celebrity case is Bob Harper, the trainer from The Biggest Loser television show, who was in tremendous shape and yet suffered a major heart attack. It turns out that Lipoprotein (a) was his main risk factor. In fact, elevated levels of lipoprotein (a) increases the risk for coronary artery disease, heart attack, stroke, thickening of the aortic valve, and even heart failure. If you have elevated lipoprotein (a), you are 2 to 4 times more likely to have a stroke, heart attack, or scarring of the aortic valve. It causes inflammation and foam cells and plaque.
12:04 Since we are in the midst of the COVID-19 pandemic, having elevated levels of Lipoprotein (a) is liable to increase the likelihood of a more severe case if you get infected. It would be interesting to know if actor Nick Cordero, who had severe blood clotting and who died from COVID-19, had elevated Lipoprotein (a).
13:31 The clotting associated with Lipoprotein (a) seems to be an evolutionary disadvantage, so why would it be there? There must be some evolutionary advantage for it to be present in so many people, which was hypothesized by the late, great Dr. Linus Pauling. It turns out that 40 million years ago we developed the ability to produce Lipoprotein (a) at about the same time we lost the ability to make vitamin C. Most animals can make vitamin C, except humans. Perhaps we were eating so many leafy greens and fruits that we just didn’t need that enzyme to make vitamin C. If you are deficient of vitamin C, you can develop scurvy. And you’re going to bleed in your skin and your gums because your collagen and your tissues are super weak, including your arteries. Well, it turns out that lipoprotein (a) tries to prevent breaking down clots. So if you had weak arteries 40 million years ago from scurvy or something close to scurvy, it might be an advantage to have lipoprotein (a) when you have a baby or when you got cut chasing a saber tooth tiger because this would keep you from bleeding to death. Lipoprotein (a) is considered elevated when it is over 30 mg/dL, though some labs measure it in nm/L where the normal range is less than 75.
18:57 If a patient has elevated Lipoprotein (a), you should listen to their heart with a stethoscope to hear if there is a murmur from the aortic valve. You might want to get a heart calcium CT scan (Coronary Calcium Scan) to see if there is any calcified plaque in their cardiac arteries.
22:55 What can you do if you have an elevated Lp(a)? For one thing, statin medications do not lower Lp(a) and they may even raise it. CoQ10 and ground flaxseed can both help to lower Lp(a) 5-10%. L-carnitine might drop Lipoprotein (a) 20-25%. (Impact of L-carnitine on plasma lipoprotein (a): A systemic review and meta-analysis of randomized controlled trials.) If a woman goes on hormone replacement therapy after menopause, that can lower Lipoprotein (a). The most significant supplement is Niacin, vitamin B3, which can lower Lipoprotein (a) by 20-80%. Niacin will lower overall LDL cholesterol, raise HDL, and also lower triglycerides. The downsides are the patient may get flushing. It could elevate blood sugar. It could raise liver enzymes. It could increase risk of gout. The recommended dosage is to start with 500 mg twice per day and you can slowly up the levels if needed, up to 3,000 mg per day. But these patients should be monitored carefully. If you take the niacin with applesauce, it will lower the flushing due to the quercetin in the apples.
26:27 The average Primary Care Physician or Cardiologist is often skeptical of using niacin because of two questionable studies that showed no benefit with niacin. The AIM-HIGH Study tried to raise HDL in patients with almost normal lipids and another study that used an odd combination of niacin and a drug that blocked the flushing, so it did not test niacin alone. Unfortunately, since niacin is an over the counter, inexpensive vitamin, nobody is going to come up with $80 million to do a three year study looking at its effect on the carotid arteries. So the large, long term studies with it have not been done.
29:17 There’s a study that showed that a whole food, plant based diet can modestly lower Lipoprotein (a) (Consumption of a defined, plant‐based diet reduces lipoprotein(a), inflammation, and other atherogenic lipoproteins and particles within 4 weeks) Drinking coffee can also slightly lower Lipoprotein (a) levels. A small company called Akcea Therapeutics has developed something called antisense oligonucleotide, which can drop Lipoprotein (a) by about 80% with a once per week injection. One study in patients with existing heart disease was published in the beginning of 2020 and a five year study will be started soon. (Lipoprotein (a) reduction in persons with cardiovascular disease.) The injectible cholesterol drug Rapatha does help to lower Lipoprotein (a) but at a cost of $6000 per year. There is also a treatment called lipopheresis, where your blood is removed and filtered and then placed back after about 3 hours and this must be repeated every few weeks. It definitely removes Lipoprotein (a) and it decreases your risk of heart attack, stroke, and all the important measures.
33:27 Dr. Linus Pauling hypothesized that since Lipoprotein (a) helps your body when your collagen is deficient, then by supplementing with vitamin C and Lysine, the two essential components to make strong collagen, then Lipoprotein (a) would be neutralized. This was shown in a mouse study conducted by his protege, Dr. Matthias Rath published in the American Journal of Cardiovascular Disease in 2015: Hypoascorbemia induces atherosclerosis and vascular deposition of lipoprotein(a) in transgenic mice. Supplementing with 2-5000 mg of vitamin C per day along with 1500 mg per day of lysine will keep the Lipoprotein (a) from causing harm to your arteries, though the level of Lipoprotein (a) will not go down and there is really no way presently to know if this strategy is working.
35:07 Low dose aspirin or natural anti-clotting agents like Nattokinase or Lumbrokinase might be beneficial due to the increased tendency for clotting that is associated with elevated levels of Lipoprotein (a).
Dr. Joel Kahn is an Integrative Cardiologist, internationally known speaker, and best selling author. He has a weekly podcast, Heart Doc VIP and he’s written 7 books, including Your Whole Heart Solution, Dead Execs Don’t Get Bonuses, The No BS Diet, The Plant Based Solution, and Lipoprotein (a): The Heart’s Quiet Killer. Dr. Kahn’s goal is to prevent heart disease by promoting a plant based diet, exercise, and a healthy lifestyle. His website is DrJoelKahn.com
Dr. Ben Weitz is available for nutrition consultations, including remote consults via video or phone, specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com. Phone or video consulting with Dr. Weitz is available.
Dr. Weitz: Hey, This is Dr. Ben Weitz host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates, and to learn more, check out my website, drweitz.com. Thanks for joining me. And let’s jump into the podcast. Hello Rational Wellness Podcasters, Dr. Ben Weitz here. Thank you so much for joining me again today. For those of you who enjoy listening to the podcast, please go to Apple Podcasts, give us the ratings and review. If you’d like to see a video version, go to my YouTube page. And if you go to my website, drweitz.com, you can find detailed show notes and a complete transcript. So today our topic is lipoprotein(a) with Dr. Joel Kahn. So we are going to talk with integrative cardiologist Dr. Joel Khan, about a very specialized factor that increases your risk of heart disease. This is a specialized lipid particle that is not often measured but, can be seen on a specific blood test.
We’ve all heard about cholesterol as a major risk factor for heart disease. Most of us have also heard about LDL, the so called bad cholesterol, and HDL the so called good cholesterol. And you may have even heard about triglycerides, but you likely have not heard about this specific particle. And it’s unlikely that your primary medical doctor or cardiologist has even measured it. The conventional medical way to think about lipoprotein (a) is that it’s determined by genetics and there’s no prescription drug that can lower it. So what’s the point of measuring it. At least that’s what I’ve been told by some primary care doctors and conventional cardiologists but, from a functional medicine perspective, from an integrative perspective, there are some natural strategies that can lower lipoprotein(a). And it’s very important to know if you have this respect, we’ve known for years that a sizable percentage of patients who have heart attacks actually have normal cholesterol. So there must be some other factors that account for why they have this heart attack. And lipoprotein (a) is one such factor. There’s a famous example that’s been in the news a few years ago. One of the trainers from The Biggest Loser, Bob Harper, who was in incredible shape, and yet he had a massive heart attack and almost died. And he had essentially normal risk factors, normal cholesterol but, he had very high LP little a lipoprotein levels. And so elevated levels of lipoprotein (a) increases the risk for coronary artery disease, heart attack, stroke, thickening of the aortic valve and even heart failure.
Dr. Joel Kahn is an integrative holistic cardiologist, internationally known speaker and best selling author. He has a very popular weekly podcast Heart Doc VIP, that I listen to regularly. And he’s written six books. At least six including; Your Whole Heart Solution, Dead Execs Don’t Get Bonuses, The No B.S, The Plant-Based Solution, Young at Heart by Design. And his newest book, an Amazon best seller, Lipoprotein(a) The Heart’s Quiet Killer. Dr. Kahn, thank you so much for joining me today.
Dr. Kahn: You need an ice cold water for all that incredible, kind both very appropriate introduction. And then the kind words. I was at a podcast recently as a guest and I did write a book called Dead Execs Don’t Get Bonuses, how to survive your career without the arc. I was introduced as the author of Dead Exes Don’t Get Bonuses which, if I write a divorce book would also be a… So, you nailed it buddy.
Dr. Weitz: I remember the golfer, John Daley wrote a song called All My Exes Have Rolexes.
Dr. Kahn: That’s very funny, a little play on Willie Nelson there.
Dr. Weitz: So what is lipoprotein (a)?
Dr. Kahn: And this is authentically. I’m so happy to share this with your audience. Nothing about me, it’s about their health, your health, our ability to make a dent in the number one killer of men and women in the United States. That rolls off your tongue; number one killer of men and women. That means 39 year olds die of heart attacks. And 44 year olds have bypassed and 51 year olds have stroke. And we’re also going to talk about a valve in the heart called the aortic valve, which doesn’t get as much press but, creates a couple 100,000 procedures that some people make it through ad some people have complications. So it’s just what you said. We learned way back in the 1960s. Why would I go there? If you smoke, do you have diabetes? Do you have high blood pressure? Do you have a high cholesterol? Do you have a mother, father, sister, brother with an early heart attack, early death from heart disease? These so-called Framingham risk factors. Your doctor sits down with you and might pull out a little app on the phone, on their laptop. “Hey, you’re in really good shape. Your numbers, your history, you’re at low risk.” That does help us define a one-to-one patient. Are you a really high risk patient or low risk patient? Do you need medications? Do you need lifestyle? If you do your best job at that, it’s still missing about 40% of the people that go on to have heart attack, strokes, drop dead or in this case also aortic valve surgery. That is called residual risk. Just as you said, we should care about identifying 50% to 60% of the explanation. You’re a root cause guy, I’m a root cause guy.
Your cholesterol, your blood pressure, your blood sugars up. It’s not just a prescription. It’s diet, fitness, stress environment, chronic infection, toxicity and all the rest. We should be searching why don’t we reach more than 50%, 60% of explaining heart disease. Lo and behold, 57 years ago, 1963, a Scandinavian researcher found a new cholesterol particle in the blood. And now there’s several thousand research papers. And we know which gene and we know what RNA. We’ve characterized it completely. It got the name, It’s not a good name. That’s the biggest problem. It’s like the Pinto. If you go back long enough for a Ford car, it never was a good name; name a car after a bean. This was named Lipoprotein-little-a. Some people call it the sticky cholesterol. Can you imagine if all the research called it the sticky cholesterol? That has Madison Avenue attraction, because we just got to get it unstuck. But, what we’ve learned, I’ll be brief, is you go to your doctor, you have your annual physical. You go to a wellness fair. You go to a corporate wellness fair at your business. You get your finger poked or a full blood draw. And your doctor says cholesterol, HDL, LDL, triglycerides, blood sugar, blood pressure, all those things. They’re great to know but, they did not measure this cholesterol particle that was found 57 years ago. Although it is simply a blood test, you can’t do it as far as I know from a finger prick. Any lab; Quest lab, LabCorp, any hospital in LA, anywhere for about $30. So what have we learned? We have learned that this cholesterol particle does three things that are just awful. It causes atherosclerosis. It actually may be found in the plaque that closes your carotid artery, your heart artery, your sexual organs, your kidney arteries, leg arteries. It may be found in the plaque more than the one we talked about a lot, LDL cholesterol. There’s a reason, I’ll tell you in a minute. So it causes plaque. That’s bad. Plaque causes people to lose quality of life and quantity. Number two, it causes inflammation. It has some really unusual attachments called oxidized phospholipids. You teach your patients about inflammation as a root cause of many chronic diseases. This particle is pro-inflammatory. And the third thing so unique is it actually promotes clotting of the blood, is prothrombotic. Even LDL cholesterol doesn’t do all that. Some people have said, imagine LDL cholesterol, has cholesterol in the middle, has some things called phospholipids on the outside. And then it has, it’s called apolipoprotein B. It’s something you can measure in the blood. I don’t want to get too technical. People say LDL is like a baseball and apolipoprotein B as the stitching holding it all together. So it can float through the blood either back to the liver on its way to tissues on its way to your arteries. Lipoprotein(a) has the LDL, then it has a little, it’s called two sulfurs, a little bridge. And then it’s got this unique tail and people say, imagine a baseball, the pitcher is throwing at you with huge spikes all over the place. God forbid you get hit by that sucker. You’re going to have a lot of damage. That’s just an analogy. But, that’s the difference between LDL, which is already a problem if you have it in excess. Potentially, getting under your arteries, responding, it’s called the retention of the cholesterol in your arteries to drive the plaque. And now we’ve got these spikes all over the place. So lipoprotein (a) is a nasty little beast. And this is the magic. You said the word genetic. Okay. I learned when I was a cardiology fellow in Dallas where a Nobel prize in medicine was awarded to two of my professors. When I was there about LDL cholesterol in the pathways, one in 500 people, maybe one in 250 from their parents inherit a high LDL cholesterol purely on genetic. Eat sprouts, go to the gym. Be thin, still got a cholesterol of 400 that’s genetic. It turns out this lipoprotein (a) is the new kid on the block in terms of what most people know about it. One out of every four people, not one out of every 250, or one out of every 500. That means right now how many people are listening to this very valuable podcast?
One out of every four, you got it. You got it. You got it. You got it. It’s a lot of people. That’s 90 million Americans and those 90 million Americans from the time they’re one years old have this triple threat particle in the blood and slowly, slowly, they might, It’s not inevitable. Like these risk factors, you can have a high cholesterol and not end up with a heart attack but, you’re at risk. You end up about two to four times more likely stroke, heart attack, valve scarring; the aortic valve gets scarred. And need heart valve procedure. And Doctors scratch their head and say, “Bob, Sue, why did you have a heart attack? You’re numbers look so good; your lifestyle, your diet.” You know, “Mr. Jones, you just said your heart valve up. We have no idea why you developed this problem but, we’ve taken care of it.” Well, it turns out very frequently. It’s lipoprotein-little-a that drives all this. That’s the broad picture. Would you want to know that you inherited one out of every four people? It could be one pair. You could get the double jeopardy of both parents on chromosome 6, there is a gene in one out of every four people. And there’s a whole lot of discussion, why do we have it? When did we get it? What can we do about it? But, it will become in the next five years routine. You’re hearing it now early, five years. So now there’ll be an expensive drug that the pharmaceutical industry will be sure every healthcare provider in America knows to check lipoprotein (a). They do it in Europe but, God bless America, great country, or sometimes a little slow to adapt new science, like 57 years a little slow.
Dr. Weitz: How about adding this to the risk factors. Here we are in the midst of the coronavirus pandemic, which causes clotting. What’s the likelihood that somebody with elevated lipoprotein (a) if they get coronavirus is liable to have a worse prognosis?
Dr. Kahn: You are like a visionary. That is a theory. There’s very few people in the country that are studying lipoprotein-little-a. There’s not a lot. And some of them have brought up this question. Could it be if you’re at UCLA or you’re at USC, and you’re sick in the ICU. Like Broadway actor Nick Codero has been in the news in Los Angeles. So 39 years old, and he’s still 90 days later, clotting has taken one of his legs. And I hope that God doesn’t take his life. Could it be since it’s one out of every four, that ICU bed, that one, that one, no clotting, clotting here. It’s been hypothesized that it could be somebody needs to draw the blood and run the numbers and see if it correlates. And tries to explain this monster problem in COVID-19 of apparently blood vessel damage and clotting which is a real deal. It’s become even more in the focus of the media to some degree, the science community to some degree. We got to get the word out and then we can play with it. Let me talk to you about the clotting for a minute, because it’s a question. Why do we have things in the blood that seem to be all a disadvantage? What is the reason?
Dr. Weitz: Right. It’s got to be an evolutionary advantage if it’s there.
Dr. Kahn: And so it turns out the only species on the planet that have the ability to make lipoprotein (a) in the liver. It’s not made like LDL. That is made in the liver. This is a whole different factory. Now, GM and Ford, totally different. About 40 million years ago, we may have developed the ability, one out of every four people to produce lipoprotein (a). Well, why would we do that? This is a little complex but, it’s really interesting. And it’s going to fit with your emphasis on nutrition for sure. That, also about 40 million years ago, humans lost the ability to make vitamin C and very few people know that your dog and your cat make vitamin C whatever amount they need from glucose. Actually glucose can be converted to vitamin C. Humans lost the enzyme. It’s believed maybe we were in the jungle and eating so many leafy greens and fruits and such that we just didn’t need an enzyme pathway anymore. And maybe there was an advantage that whoever lost that gene had some super power that evolutionary, favored their survival.
Dr. Linus Pauling, who wanted to know about prizes into some people, they immediately would say the vitamin C guy, yes, he’s passed away. But he was the vitamin C guy. He hypothesized when we lost the ability to make vitamin C, if you have the gene for lipoprotein (a), you had an advantage. Let me just run you through this. If you are deficient of vitamin C, you can develop scurvy. And you’re going to bleed in your skin and your gums because your collagen and your tissues are super weak, including your arteries. Well, it turns out lipoprotein (a) tries to prevent breaking down clots. So if you have weak arteries 40 million years ago from scurvy or something close to scurvy, might be an advantage to have lipoprotein (a) when you have a baby. When you got cut, chasing a saber tooth tiger, if that’s the right term. I haven’t said that word in a while. It might’ve been an advantage in terms of excess bleeding by favoring clotting. It is similar to something in our body called plasminogen. Plasminogen breaks down clots. Here’s a competitor that interrupts that process. Very complex idea to think about it but, it’s interesting and when you talk COVID-19 all of a sudden, it might just be the factor that’s a disadvantage by promoting clotting and not allowing breakdown of clots. Interesting theory, more traditionally it’s an issue with just clogging your arteries. And if you have carotid surgery and you take the plaque and look at it under a microscope, you can find a ton of lipoprotein-little-a structures in the plaque. Same with if you have bypass surgery and they take out some of the tissue of the heart arteries and look at a very dense concentration. So it’s in the plaque. It’s not some window dressing. It gets under the endothelium. It gets retained. It causes inflammation and foam cells and plaque. And it does it on the heart valve too, which is really unusual. One out of every seven aortic valve surgeries in the United Sates are believed to be due to the constant from the time your one year old irritation, inflammation and a thickening of the valve from lipoprotein-little-a. So it’s just a monster to deal with clinically that we haven’t even addressed really.
Dr. Weitz: So when you see it on a lab, what level do you consider significant? A couple of the labs that we typically use, usually say anything over 30 milligrams per deciliter. Some people say 50, I’ve heard other people say, “Well, it should be as low as possible.”
Dr. Kahn: So it turns out, and I want to stress as again, this is just a lab test. This is $30. We’re not talking about needing to have a bone marrow biopsy to determine this. Tomorrow at your doctor you can have your blood drawn for this or at any lab. There’s two ways unfortunately like pounds and kilograms. They both describe your weight. There is a unit milligrams per deciliter, less than 30 is normal. And over 50, just an arbitrary cutoff is felt to be the higher risk group. But, that can go 50 milligrams, a hundred milligrams per deciliter, 200, 300, 400, 500. I’ve got patients who I practice that are 400, 500 plus. Not much more than that. You’re not going to see a thousand. And again, one out of four is over 30 but, a substantial number is over 50, 60, 70, 80, I think. But, two or 3% of people are over 100. There is another unit called nanomoles per liter. Quest Lab now reports in nanomoles per liter. Other labs report… It doesn’t really matter. They’re the normal range there is less than 75 is normal. Over 125 is considered high risk. They’re pretty similar. I think pretty soon we’ll stop doing the milligrams per deciliter. But again, there’s no real issue about one more accurate than the other, or ignore one. Pay attention either way it’s measured. Simple, simple lab tests.
Dr. Weitz: So, if a patient has an elevated LP little a, how do you work them up to see if they’re having any negative effects from it?
Dr. Kahn: So for the past 10 years, if you do find lipoprotein-little-a mentioned in the guideline, the American Heart Association might come out with somebody about prevention, the National Lipid Association. A group that really deals with complex pharmacology and pathophysiology. They might tell you if your family history is strong for early heart attack, early stroke, early valve problems, calcified aortic valve, ask your doctor if it’s reasonable to measure the lipoprotein-little-a. Again, blood tests has been available for over a couple of decades but, not a routine test has been recommended. That’s starting to change in November 2019 pretty recently. In Europe, it’s called the European Society of Cardiology. They’re equivalent. They came out with a new guideline that said, “We not believe it’s prime time.” Everybody once, should have the level measure. If you’re normal, you don’t need it again. You don’t have the genes that are actively reducing lipoprotein-little-a. And if you’re elevated, well, it fits in the risk factor profile.
It may explain some of the risks that your standard approach hasn’t identified. So the workup is take out a stethoscope if you have one as a healthcare provider, make sure there’s no murmur from the aortic valve. Make sure there’s no noise. And then that [inaudible 00:20:27]. And make sure they’re not describing anything that suggests blockage like shortness of breath or chest tightness or chest pressure. Look at the other numbers; blood pressure, blood sugar, weight, waist circumference, inflammation, maybe homocysteine and the other cholesterol panel. My approach, I think it’s consistent with the general approaches. If you’re 40, 45 and you’re really a health seeking individual, and now you’ve checked your lipoprotein-little-a and it’s abnormal, you might want to get a heart calcium CT scan. You have no symptoms.
That’s a quick five seconds CT scan. It costs about a hundred dollars at UCLA, at Cedar Sinai, at Good Sam. Some of the best places in America where they’re done. No injection, no IV. And it takes a quick look at your heart arteries. And if it comes back really good and your blood pressure’s good and your other numbers are good, okay, you’ve got no risk factor. Eat a little better exercise a little more and do the whole program of heart disease prevention with maybe a little more incentive to really do it well because you identified it. If you knew you were prone to kidney cancer, if you knew you’re prone to breast cancer. There’s some measures, you might not be going to Arby’s and McDonald’s every day.
So lipoprotein (a) to me is a good platform just to get people on a good place. But, if there is known disease, “Doc, I had a stent last year and nobody checked my lipoprotein-little-a. And now you’re telling me it’s 300 milligrams per deciliter.” Or if they’re silent but, by calcium scoring or a murmur, you identify there’s a disease process that isn’t yet overt. There’s room to consider what do you do about it? And before we dive into that, you always treat all the other stuff. You want your blood pressure to be at its best, use all the approaches, standard and natural from yoga to acupuncture, to breathing, to sleep. And the whole thing that your audience knows so well from your good work. Now you want your cholesterol to be in range and do it with diet, you watch your blood sugar. But, do you specifically address the lipoprotein (a)? And in 2020, there’s a divergence of opinion. And to tell you the standard opinion is, use it as a risk factor but, there’s no way to deal with it just as you said at the beginning of the podcast, I disagree with that but, that’s the standard approach.
Dr. Weitz: So, why don’t we start with the nutritional supplement approach?
Dr. Kahn: Sure. And thank you. Let me just say what doesn’t work right off the table; Lipitor Zocor, Crestor, the statins. What’s your doctor’s going to ask you to consider taking if your cholesterol is very high and certainly if you’ve had an event like a stent, they do not lower… Again, the production of lipoprotein (a) in the liver is totally different than LDL cholesterol. Your LDL cholesterol will fall with a statin almost always. But, it actually doesn’t address lipoprotein (a) and it’s sometimes raises it. That’s the disconcerting part. “Doc, my lipoprotein (a) was 180 milligrams per deciliter. We went on Crestor and you just told me it’s up to 207.” I’ve seen that dozens of times. Now, some would say don’t reject it. The reason you started Crestor was to lower the LDL, lower the C-reactive protein, be consistent with a lot of studies in somebody with known heart disease. But, don’t expect your lipoprotein (a) to go down. That’s the main prescription drug. Back to natural. There’s been an adequate number of studies to look at some issues, Coenzyme Q10, a great heart supplement, it goes down a little; ground flaxseed, might go down a little [inaudible 00:24:17], 5%, 10%, nothing substantial and nothing in the range that’s really felt to really move the needle a lot in terms of better outcome. There are no large long term studies. There is the supplement your well aware of, L-Carnitine. That isn’t a lot of energy drinks. Even it’s in Red Bull or Monster but, that’s not where I’d prefer a patient to be getting their L-Carnitine. It’s obviously comes from red meat. So the carni of carnitine but, you can take a capsule or a powder with L-Carnitine. You might drop your lipoprotein(a) 20, 25%. A little more substantial. If a woman’s perimenopausal and chooses to go on hormone replacement therapy, lipoprotein(a) tends to go up a little at menopause and it’ll come back down maybe substantially with hormone replacement therapy if they find a practitioner that does that.
The big one though is niacin. Niacin, plain old $10 a month. Get a big red hot flush face from taking vitamin B3 will lower LDL cholesterol. Nice. We’ll raise HDL cholesterol often. We think that’s good. We don’t know. Will lower triglycerides. Nice. Will lower overall cholesterol but, it actually can lower lipoprotein (a) pretty predictably and variably 20% to 80%. So you can sometimes, if you choose to use niacin, you got to tell a patient about the flushing, about rash, about watching your blood sugar, your blood enzymes, gout. But, it’s been around for 50, 60 years. You can buy a big bottle of good natural niacin for $30 to last three, four, five months. So it’s not been studied though. I mean the big drawback from the academics, like if you go 90 miles south where you live, and UCSD has the leading academic physician. And he won’t publicly blast out use niacin, because where’s the thousand patient 10 year study that identifies you just drop that person’s risk of heart attack or stroke. Privately, and in certain publications he uses niacin too, because we know it’s on a limited range of therapeutics. It works. And now there’s new stuff. We’ll talk about that, one second.
Dr. Weitz: Yeah. The average primary care doctor who doesn’t really study this stuff a lot, who’s not really up on supplements. The few things they’ve seen about niacin is, “Oh, niacin doesn’t work. It might even be harmful, forget it.” They basically have a negative view of niacin but, that’s because of a couple of studies that weren’t really valid, right?
Dr. Kahn: Yeah. The idea of people that had an almost normal lipids trying to raise the HDL, called the AIM-HIGH Study and another study with a very odd form of niacin that had a combination drug. So, for many years we used just plain old niacin or prescription niacin and saw good results in the blood work and had reason to believe we saw some benefits in the arteries but, never has there been a substantial study; a hundred people, 500 people. So it’s untested. Problem is that niacin’s cheap and niacin’s generic. Who’s going to come up with $80 million to do a three years study looking at carotid arteries. It’s a hot potato. The exciting news but, it’s not…
Dr. Weitz: By the way, what dosage do you find you need with niacin? Do you get results with 500, how much do you have to take?
Dr. Kahn: I will start a person and I’ll say the name of a brand. It’s not my company. I use a over the gutter brand called Endur-Acin, E-N-D-U-R-A-C-I-N. It’s been used for decades. It’s inexpensive and I will start 500 twice a day, warning the patient about flushes, rash, take niacin with applesauce so you don’t get as much rash, or with a nonfat yogurt. Typically, they don’t complain that much but, I will try and work them up based on labs to 1500, maybe 500 or more than a thousand a night, off into a thousand out of a thousand. You can go higher: 3000, 4,000 but, you really got to watch that patient. The flush isn’t bad. I take niacin a lot just for the fun of it.
Dr. Weitz: Yeah the apple contains quercetin and that’s what we need to help counter the flush. So you might be taking quercetin now as part of your immunity programs, So you can probably…
Dr. Kahn: Exactly. That’s a study Merck should have done. They did niacin with a noble prostaglandin inhibitor. And the study gave niacin a bad name. You should have done the niacin with applesauce study. And we could have probably been much more optimistic. Now, just recently, I don’t know, five years, there’s been a growing emphasis. We need a pharmacologic approach. I will say exercise, please. If your lipoprotein (a) is found to be high, exercise. It’ll improve all your other risk factors. It doesn’t do much to move lipoprotein (a) though. You can drop your cholesterol substantially with exercise and weight loss. There’s one distressing study, if you lose weight, your lipoprotein (a) goes up. Oh my God but, exercise anyways. There’s a 2018 study that a whole food plant diet healthy, bright colored may lower lipoprotein (a) but, it was a modest amount. It’s not the kind we expect with…
Dr. Weitz: In your book you mentioned coffee.
Dr. Kahn: Yeah, coffee a little bit. It could lower it. So there’s a lot of reasons to drink coffee rather than Coca Cola or Mountain Dew.
Dr. Weitz: That can be the new marketing campaign for Starbucks.
Dr. Kahn: That’s right. Coffee for your lipoprotein(a). We may even put niacin in coffee beans and we could corner the market. But, a little company called Akcea came up with something called antisense oligonucleotide, ASO. This is not a word we say too often but, as the gene for lipoprotein(a) produces RNA, this thing binds and mimics what should happen normally to stop. So you don’t make lipoprotein (a) it’s an antisense oligonucleotide. It’s actually an injectable once a week product. And about 280 people with high lipoprotein (a) and some sort of vascular disease, completed a study published late 2019, very little side effect injecting this once a week. And about an 80% drop in lipoprotein (a). The company, I’m not sure if it was bought or merged with Novartis. One of the giant pharmaceutical houses. And so this spring there was supposed to be a 7,600 patient study moving forward now; placebo, the same drug, high lipoprotein(a), vascular disease. Because you can’t get FDA approval nowadays. Dropping lipoprotein(a) doesn’t get you FDA approval. You got to show heart attack, stroke, safety measures and all the rest. With COVID-19, I’m sure recruitment and follow up has been very, very difficult. So we can only hope they can get that study really quickly going and enrolled. So by 2024, that was the original estimate, we’ll get some data. I’ll say two others actually to be thorough because your audience is sophisticated. There is a very bizarre therapy. You inherited the other kind of genetic cholesterol. Your cholesterol was 700 and at 32 years old, you had a stent. There are people out there, one in 250, one in 500. And it may be very difficult to get your cholesterol down with lipitor and other drugs in the market. There’s a procedure that’s like dialysis. It’s called lipopheresis. They stick a needle in your vein. They take blood out for two, three hours. It filters but, the filter doesn’t get rid of kidney products. The filter gets rid of cholesterol. Your plasma goes back in your body. Three hours later, you got a bandaid, you can go home and two weeks later you come back and do it again. So your LDL cholesterol, if you have that problem can fall 95% in three hours and it’ll slowly go back up and do it again. That has been shown in the United States, in Europe and it’s insurance covered for the right person to decrease your risk of heart attack, stroke, and all the important measures. It’s also approved for lipoprotein(a), very few places doing, Germany’s a hot hotbed. They got thousands of people with cholesterol disorders that use that approach. And you might find that Cleveland Clinic and perhaps UCLA or Cedar Sinai, you’ll find one or two programs in the state if they’re a densely populated state. Lastly, there’s an injectable cholesterol drug that is FDA approved called Repatha. And probably it turns out they’re very powerful lowering LDL cholesterol but, they modestly lower lipoprotein-little-a. They’re just not approved for that. So if I submit to insurance, my patient Charlie needs to get his Lp(a) down and I want to use… That’s the other name for lipoprotein(a), Lp(a). I want to use Repatha at $6,000 a year. They’ll tell me that’s not appropriate. We can only use it to treat LDL cholesterol. So, you work around that and help to get a patient on that if they meet the criteria.
Dr. Weitz: And then there’s the Linus Pauling thing with vitamin C.
Dr. Kahn: Oh, so good you mentioned that, which goes back to what we said 40 million years ago. We’re dependent on vitamin C exogenously. That’s called food usually because our collagen production is dependent on intake of vitamin C. So he hypothesized, he wrote an article in 1990 and then he died in 1994. He was like 95 years old. So he’s 91 years old writing original research. I think there’s lipoprotein(a), vitamin C thing is real. And if people would just take in more vitamin C and lysine. The two essential components to make strong collagen, and then this lipoprotein(a) thing would be neutralized. It would circulate in the blood but, it wouldn’t be able to actually harm arteries. That was a theory till 2015, when his protege a guy named Matthias Rath, did a mouse study. And the mouse study confirmed the theory. There’s still no human data. What’s the bottom line. I have a lot of patients with high lipoprotein(a). What’s the harm to take in two, three, four or five grams of vitamin C powder or capsules. Certainly to eat the foods rich in vitamin C. And what’s the harm to add 1500 milligrams a day of lysine as a powder or capsule. But, you won’t see the blood level necessarily go down. There really isn’t a way of objectively to monitor it. So I have to tell my patients it’s faith based therapy until the definitive study is done that shows we blocked lipoprotein(a) from being the sticky cholesterol. That’s the idea and makes it not so sticky to your arteries. Cool stuff.
Dr. Weitz: Yeah. I think you mentioned a low dose aspirin as well.
Dr. Kahn: Well, because of the vascular risk you might argue. You could talk about Nattokinase, Lambrokinase.
Dr. Weitz: I was just going to ask about that.
Dr. Kahn: There has been a study suggesting in a high lipoprotein(a) patient. And certainly if you have abnormal calcium score, or if you find a center that does carotid ultrasound medial thickness. If you have plaque, you’re probably going to want to be on a 81 milligram aspirin anyways.
Dr. Weitz: I saw an article that showed EPA from fish oil had some benefit as well.
Dr. Kahn: These are all… That’s the problem. Other than niacin, carnitine, modest, HRT, hormone replacement, modest. CoQ10, flaxseed and Omega 3, really modest. There’s been an estimate that you really need to drop lipoprotein(a) something like 50 to 60%. It was a modeling thing to expect that you’re going to see a significant drop in event. So it’s important to get to that point. The future is some sort of gene editing and I’m not a world expert on gene editing. There’s a new company I would call Verve Therapeutics, bright people and a lot of money right now. And they just announced in an animal model that they were able to cut out and turn off an LDL cholesterol gene and a triglyceride gene and successfully dropped blood levels of those markers, provocateurs of vascular disease significantly. Nobody’s yet got to that point to do it for the lipoprotein(a) but, with 90 million people in this country alone, somebody is going to get hot on the trail of finding out how to do that. That may be the next five to 10 years. It’s very hopeful. It raises all out of other questions. You’re a 54 year old man or woman at your doctor, and they tell you your a lipoprotein(a) is high. What do you say to your 25 year old kids? Because there’s a chance your spouse may or may not have lipoprotein(a) as a genetic inheritance. But, your kids may or may not. Should they know at age 20,25 that their smoking habit is double jeopardy and their cheeseburger habit is double jeopardy. I would argue why wouldn’t you want to be fair with the data and not scare but, educate. American Heart has something called the simple seven on, or it should be the simple eight. Do a little bit more if you’ve inherited Lipoprotein(a). It doesn’t have to be the scariest conversation in the world.
Dr. Weitz: Yeah. Everybody thinks about heart disease for people in their fifties and sixties. But, they’ve done autopsies on 17 and 18 year olds like I think in Vietnam. And a lot of them had atherosclerosis that had already started then. So this is long term process…
Dr. Kahn: Very slow progressive deterioration on blood vessels, that is detectable in your teens, twenties and thirties but, we just don’t have a system that encourages that. So, yeah. I would want my kids to know. I happened to have had… You really only need the blood test once and if you’re normal, you’re done. And I’m normal and my wife’s normal, so our kids not going to have a high level, assuming they’re my kids. You never can really be sure. But, if it was a different situation I would want them to know. Just the BRCA gene, a lot of conversation about that. And we’re getting a little better at measuring pancreatic cancer genes and other disease states. You can tailor your life a little bit in favor of avoiding the disease.
Dr. Weitz: Right. Great. So I think that pretty much wraps it.
Dr. Kahn: Yeah. I’m trying to think of there’s any wow factor.
Dr. Weitz: We talked about diet a little bit. Anything else about diet?
Dr. Kahn: Now, there was originally a paper 20 years ago that a high… I don’t want to get into diet wars. There’s a bunch of ways to eat poorly. And there’s a bunch of ways to eat in a healthier pattern. There was a study some 20 years ago that a higher saturated fat diet may lower lipoprotein(a). It was also modest. Subsequent studies haven’t confirmed it. In fact, there’s an acute feeding study, take humans, measure their lipoprotein(a) for six hours. When you feed them a diet high specifically it’s called palmitic acid and stearic acid, the long chain saturated fatty acids find the meat in animal products. You really get a spike in lipoprotein(a). It actually has a little bit of cool studies have been done that… And this gets into why we have in our blood, if I take you to the cath lab and do an angioplasty and stenting, which is part of my history and training. And you measure lipoprotein(a) for a few hours, it spikes up for a while and then it falls back to baseline. It has called an acute phase reactor. And the idea there is perhaps we don’t want plaque to form. That it’s fighting with plasminogen, it’s kind of reacting to this activated balance of clotting and unclotting. There are some little neat factors in some of the studies that have come up. But, I just want to emphasize again, the biggest challenge will be your listener has a annual physical scheduled next week after July 4th or after [inaudible 00:40:40] whatever it is, goes to the doctor and says, “I heard this really interesting podcast, and I want you to check my blood.” And the doctor’s going to say, “I don’t think our lab does it. I’ve never really heard about it.” Because doctors who’ve been in practice for a while are smart and wonderful and good meaning people by in large for sure.
But, no pharmaceutical reps coming by right now. No grand rounds lectures coming by right now. It’s in the medical literature. Anybody can just go look it up. There is a nice site, lipoproteinafoundation.org. A woman who had a heart event in her thirties. I love people that take their personal problems and turn them into a passion to help others. And the woman that’s behind Lipoprotein(a) Foundation is one of those women. It could be a man but, everyone I know who’s done it is a woman. And it’s a very informative website. It’s a little conservative. They don’t encourage niacin. They’re waiting for definitive trials. Their board of academic advisors are good academic doctors that like to see big outcomes studies. I honor that but, real people right now are challenged by their levels. And so one-on-one, you can be a little bit creative with people.
Dr. Weitz: Right? And then we talked about exercise, right? Exercise obviously is beneficial for anything related to lipids.
Dr. Kahn: You better believe it. And changed particle size and particle number and insulin resistance goes away. And you can’t depend on some pharmacology that might come down the road in four to five years. So you’ve got to do the hard work but, consistently we see over and over the lifestyle, the avoidance of smoking, the regular fitness, the real food diet, the emphasis on sleep, stress management, optimal weight is the pathway that has been shown recently to help prevent Alzheimer’s disease type 2 diabetes, inflammatory diseases. And it’s the heart program. I mean, body reacts, you know it; oxidative stress and inflammation. I know it can damage all the organs or if you play your cards right and do the hard work, it can avoid damaging all our organs.
Dr. Weitz: Excellent. So how can our listeners get a hold you, find out about your book?
Dr. Kahn: Yeah. I mean the books and all the online sellers of course it did spend March as the number one heart book on Amazon, which is always a treat because I didn’t have a whole big press team behind me. I tried to blab about it. Some, because I really want people to know about it. I’m at drjoelkahn.com, D-R-J-O-E-L-K-A-H-N.com. And I see patients and I do a lot of interviews and I have a podcast. And like you said, it was very kind of give me a shout out. I just like to educate and like you, if I’m going to educate, you got to read, you got to study, you got to learn. So it’s the best of medical practice when you’re fired up about bringing people new stuff. So you do a great job of that. And I appreciate you letting me share this time with you.
Dr. Weitz: Absolutely. And I thank you for joining me today.
Dr. Kahn: So what’s the other thing we learned today? Don’t wear a denim checked shirt on a [crosstalk 00:43:58]. I started with that before we went live and it looked like some kind of electric Kool-Aid, 1960s experimentation. So I feel down to a simple green shirt.
Dr. Weitz: I was listening to one of your recent podcasts and you were talking about fish oil and some people have kind of been maligning fish oil because there was a couple of studies that maybe fish oil might lead to prostate cancer risk.
Dr. Kahn: Right. But, nutrition science is tough. [crosstalk 00:44:36].
Dr. Weitz: It turns out that both of those studies that were authored by [Borowski 00:44:40], both of them were based on levels of DHA and EPA in the blood. Neither study were patients given fish oil.
Dr. Kahn: Right. That is an issue you can see on meta analysis that included people that got a hundred milligrams of EPA DHA in the same database that got 2000 milligrams, which is probably a much far reasonable and therapeutic level but, you lump them all together and you dilute out the good studies with studies that may have been dramatically under-dosed. And who’s the group you’re studying, it goes on and on. That’s the challenge. That’s why once in a while the Cochrane database will come out with a statement that most people feel is of higher quality on a nutrition topic. And no one study changes everything forever with very rare exception. You just got to put it all together and say where does this fit in the big picture?
Dr. Weitz: Exactly. Awesome, Joel.
Dr. Kahn: Thank you.
Dr. Weitz: Thank you. Talk to you soon.
Dr. Kahn: I hope you have a wonderful summer.
I’m not hearing a clear course of action. I read Dr Kahn’s LPa cook book that suggests diet change, but this discussion minimizes the effectiveness. Lots of possible vitamin suggestions, but again, with minimal results. What’s the protocol? BTW – Aetna does not cover the test. It was about $150. They said it was experimental.
Niacin and L-carnitine along with flax seeds. If you go in paying cash, the test should be $30-40.
You can get a test through Life Extension (lef.org)… very inexpensive.