Preventing Coronary Artery Disease with Dr. Shilpa Saxena: Rational Wellness Podcast 224
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Dr. Shilpa Saxena speaks about Preventing Coronary Artery Disease with Dr. Ben Weitz.
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3:23 The reason why cholesterol plaques form in our arteries is because many of us live poor lifestyles. We consume more calories than we burn off and not the right kind of calories. We are overly stressed and we don’t the amount and type of restful sleep that we need. This results in too many cholesterol molecules travelling through inflamed blood vessels. This results in the cholesterol becoming oxidized. The body doesn’t want this oxidized, inflamed cholesterol floating around, so it stores it under the endothelial layer of the arteries. If you continue with poor lifestyle choices, this oxidized cholesterol plaque will continue to build up.
5:32 The relationship between diet and heart disease. Any foods that inflame your body, including processed foods, foods that spike your blood sugar and insulin, foods that you are allergic or sensitive to can all irritate your immune system and create inflammation, increasing heart disease risk.
6:31 Diet needs to be individualized for each person. This is also the case for eating fats. Some people do great eating a higher saturated fat diet, while others do not. Whether or not saturated fat contributes to heart disease is controversial and individual. Some people can eat a lot of coconut oil and they feel good and their lipoprotein levels look good, but others do not. And certain types of saturated fats, such as the types of saturated fat that comes from coconut or avocado, is higher quality than saturated fat coming from animals. We need to see for each person if eating certain foods, say like bacon and eggs, 1. do they feel good?, and 2. how do their labs look? And if both of these are positive, then that is a good way for that person to be eating.
10:41 In terms of general recommendations for diet, the Mediterranean diet is the most studied diet for the prevention of coronary artery disease. The Mediterranean diet is more plant-based with less animal protein, though with an emphasis on fish, and less sugar, with occasional wine, and healthier fats like olive oil. Dr. Saxena recommends that the carbohydrates that you include be whole grains and lower glycemic impact carbs so that you control blood sugar and insulin levels. Insulin resistance that develops from eating high glycemic carbs and sugar will result in your cholesterol being oxidized and turning your cholesterol into small, dense LDL particles, which increases plaque risk.
19:35 Advanced lipid testing. Dr. Saxena prefers to do advanced lipid testing that includes small, dense LDL, oxidized LDL, Lp(a), HsCRP, myloperoxidase, and Lp-PLA2. Lp-PLA2 is a measure of the ooze ability of arterial plaque. ApoB is another test that you can order, esp. if you can’t do a full lipoprotein panel because either the patient can’t afford it or the insurance won’t cover it. And we need to look at metabolic factors like glucose, insulin and hemoglobin A1C.
Dr. Shilpa Saxena is a board-certified family practice physician whose passion and purpose come to life through sharing her innovative patient education and practice management solutions in her classic “keep it simple” style. She serves as faculty with the Institute for Functional Medicine and the Andrew Weil Center for Integrative Medicine. She also serves as the Clinical Expert for the CM Vitals Program at Lifestyle Matrix Resource Center. Dr. Saxena is currently practicing in Tampa Florida at Forum Health at 3820 Northdale Boulevard Suite 107-A, Tampa, FL 33624 and the phone is 813-269-2700. Her website is DrShilpaSaxena.com.
Dr. Ben Weitz is available for nutrition consultations 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 and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talked 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. Today, we will be talking about coronary artery disease, what causes it, the latest in advanced lipid testing, what is the role of diet and lifestyle, what we should think about statin therapy, the most commonly prescribed medications for managing coronary artery disease, and the role of nutraceuticals in modulating the risk of cardiovascular disease. Coronary artery disease is the most common form of heart disease in the United States, and it refers to the buildup of cholesterol plaques in the artery walls that supply blood to the heart called the coronary arteries. As these arteries become narrowed, they can partially or completely block the blood flow to the heart, which is referred to as a myocardial infarction or a heart attack. This process of plaque buildup is often referred to as atherosclerosis.
I’m very happy that this episode of the Rational Wellness Podcast is being sponsored by Lifestyle Matrix Resource Center, which provides clinical resources, patient education materials, and marketing tools to help healthcare practitioners successfully implement functional medicine into their practice. With these resources plus access to their knowledgeable implementation support team, you can quickly become the go-to expert in your community on a variety of health topics like GI health, immunity, and stress. Learn more at lifestylematrix.com. Exclusively for Rational Wellness listeners, Lifestyle Matrix Resource Center is offering a cardiometabolic case study download, so visit lifestylematrix.com/rational-wellness-download.
Dr. Weitz: I’m very happy that our special guest today is Dr. Shilpa Saxena, who is a board-certified family practice physician. Dr. Saxena’s passion and purpose come to life through sharing her innovative patient education and practice management solutions in her classic keep it simple style. She serves as faculty with the Institute of Functional Medicine and the Andrew Weil Center for Integrative Medicine. She also serves as the clinical expert for the CM Vitals Program at Lifestyle Matrix Resource Center. Dr. Saxena is an expert in the Group Visit medical model, creator of Group Visit Toolkits, and co-author of The Ingredients Matter: India. Dr. Saxena, thank you so much for joining us.
Dr. Saxena: Thank you for having me.
Dr. Weitz: Great. So let’s start with what do we know about what causes coronary artery disease, or to put it another way, why would our bodies lay down layers of cholesterol plaque in our arteries that can narrow the blood flow and kill us?
Dr. Saxena: Isn’t that just the ringer that like, “Why would our bodies do this to us?” The first myth I’d love to bust is your body’s not out to get you. Your body is doing the best it can with what you are creating for it. So for example, the reason why plaque starts to form is because many of us live poor lifestyles. We give our bodies way too many calories, not the right kind. We don’t burn it off with great physical activity. We generally are more stressed than we were intended to be. We may not be resting, so what you have is the makeup for too many cholesterol molecules that are traveling around an inflamed blood vessel. When these molecules or particles, as we call them, become inflamed, they become oxidized. Just think of it as like burnt oil on your stove. You pour in some olive oil on the pan, and then it gets burnt. You’re not going to use it anymore. The body feels the same way. If you’re on fire and you’ve got some extra oil going around in your blood vessels, and it gets burnt, what it does is it looks in the blood vessel for places to hide it or store it. It doesn’t have a garbage can, so your blood vessels can be leaky.
Just like maybe you’ve heard of leaky gut, you can have leaky blood vessels, so those leaks are perfect places to hide the oxidized LDL, and so it just goes under that skin, if you will, of the blood vessel and it stores it there because it knows traveling through the bloodstream, it’s no good for you. It’s not useful to you to burn for energy. And so after a while, it’s just assuming you’ll stop this behavior, and unfortunately, we don’t, and it’s cued to keep cleaning up, so it’s not an unintentional thing that it’s creating plaque. It’s just resultant from what we’re giving it to manage.
Dr. Weitz: Yeah, poor diet and lifestyle. Let’s talk about the relationship with diet and which types of foods may contribute to making this process worse or better.
Dr. Saxena: As we mentioned, anything that turns your body on fire or inflames it, right, so things that are, number one, inflammatory in nature, processed foods, packaged foods, things that have a high glycemic impact, meaning that they cause your blood sugar and blood insulin to spike and many times crash after that, that’s going to turn on inflammation. Foods that you’re allergic or sensitive or intolerant to can inflame your body, so those foods you might want to identify and eliminate. Those are the things that really just are, if you will, irritating foods. And anything that irritates the immune system or just plain doesn’t belong in the body, your body will say, “I don’t want it,” and then it’ll figure out a place to put it.
Dr. Weitz: Let’s talk about one of the controversial areas, which is that saturated fat has often been called the major contributor to increases in LDL cholesterol. Is this really the case? And if it is, do we know what the mechanism by which saturated fat contributes to increasing LDL?
Dr. Saxena: Thanks for pointing out it’s controversial. The first thing that I’m going to say, which is probably quite obvious, and yet we sometimes overlook it, and that is we don’t have one answer that fits all bodies. We’re all biochemically different. So for one person who has some real genetic vulnerabilities to saturated fat, saturated fat can be problematic if in a high quantity or a poor quality. Then you have people whose bodies really do well with more fat, and that’s just the basis of genetics and biochemical aspects, so I don’t want you to think there’s this one-size-fits-all answer about saturated fat. That’s number one. Number two, the rule that you can say is that good saturated fat is better than bad saturated fat. So for example, an avocado would be a better source of fat than trans fats, which are man-made fats.
Dr. Weitz: Now, let me just stop you there. Most of us don’t think of avocados as saturated fat.
Dr. Saxena: Well, plants can create saturated fat. I know most people just flip to animal protein thinking that it’s like a big hunk of beef, that saturated fat, but no, plant foods are great sources of healthy saturated fats. But as you might remember, there was this coconut oil craze where everybody was slathering in it, adding tablespoons to it.
Dr. Weitz: I don’t think it’s over.
Dr. Saxena: Well, I think a certain population does well with it in a certain population, when I was checking their lipoprotein panels, their plaque and inflammation risks skyrocketed. Again, there’s nothing wrong with coconut oil. It’s your body’s relationship to it. I mean, here’s my funny joke if it makes sense. Water, you think that water would be good for you, but it’s your relationship to it that matters. So if you’re drowning, water is not good for you. So in and of itself, anything is not necessarily good or bad with few exceptions. It’s your relationship to it or your body’s relationship to it that really matters.
Dr. Weitz: Essentially, I think what you’re saying is rather than saying, “What’s the best diet for everybody,” there’s a different diet for each person. I’m assuming that you’re thinking along the lines that I think, which is in order to determine what’s the best diet for you, we’re going to measure, for example, your advanced lipids, and see how you’re doing. And if the way you’re eating is contributing to a unhealthy profile, then that’s not the right way for you to eat.
Dr. Saxena: I have this thing that I say. You said in my bio I like to keep it simple. I don’t treat paper. I treat people. So if you start a diet and you feel great, that’s wonderful. That’s step one. You should feel better, and number two… You should have more energy. You should probably be less inflamed looking, less swollen, less itises bothering you. And then number two, your labs should show that your inflammation number has gone down. Your particle numbers or these advanced lipid numbers are improving over time that they’re not causing plaque. So if those two criteria are met, that you feel good and your labs look better, you’re on the right track with picking the diet for you, or if we may say, the food plan for you. Conversely, if you feel awesome on bacon and eggs, but your labs are like, “Nope,” well then, we just might need to reassess, because clinically, there may be some benefit to some saturated fats, but the relationship to them is not working for your coronary arteries.
Dr. Weitz: Now, I totally agree with everything you’re saying, but what about if you’re asked to make general recommendations for groups or society, then what do we say about saturated fat?
Dr. Saxena: Well, I would say that the most studied diet for coronary artery disease is the Mediterranean diet. What we’ve done in functional medicine is take it a step further. The Mediterranean diet is kind of an assortment of diet profiles inherent to the Mediterranean area. So in general, they tend to be more plant-based with less and less animal protein and less and less sugars with occasional wine, but really focusing in, if you will, on the food part with plant-based proteins and the ratio against animal protein, if you will. Saturated fat does play a role, but it’s healthier fats like olive oil or what you might find in a fatty fish. Of course, red meat is allowed, but in much smaller proportions, maybe two times a month.
Dr. Weitz: Isn’t olive oil basically omega-9 rather than saturated fat?
Dr. Saxena: Right. It’s not a saturated fat, but I’m just speaking to fats in general [inaudible 00:11:55] speaking it.
Dr. Weitz: Right. Gotcha.
Dr. Saxena: It’s fat, but when people start thinking fats, I don’t think they really go into saturated and polyunsaturated, monounsaturated. They many times clump it all together. So I always like to say there are good oils, and then there’s saturated fats that for sure we want to optimize the quality and then optimize the quantity. The Mediterranean diet is where I would start, and then I would say, “Hey, take it a step further. When you’re doing your grains, have them be whole grain so that they have a lower glycemic impact, because we do know one of the silent killers of people is not just cardiovascular disease, but cardiometabolic disease.”
What that means is that if you get a standard cholesterol panel, and your numbers look good, you actually haven’t screened for a hidden risk, which is called insulin resistance. So when you take the Mediterranean diet, and you add in the low-glycemic impact version of it, you’re addressing the hidden insulin resistance aspect. And if you’re taking in saturated fat while you’re insulin resistant, I don’t think that’s a great combination, because it’s oxidizing those fats, turning them into what we call small dense LDL, and that increases plaque risk. One thing that I might say is this, “If you want to know how to intake saturated fat, first, be sure that you are not insulin resistant and inflamed.”
Dr. Weitz: And then don’t take it in with a lot of carbohydrates either.
Dr. Saxena: Right. Well, remember, I’m going to say not a lot of refined carbohydrates, because there’s definitely-
Dr. Weitz: Right, or high-glycemic carbohydrates.
Dr. Saxena: Right. Right. We use the word carbohydrate, but broccoli is a carb, so I want to teach people fats aren’t bad. It’s bad fats that are bad. Carbs aren’t bad. It’s bad carbs that are bad. You know what I mean?
Dr. Weitz: Right. Gotcha.
Dr. Saxena: I think people are so… They’re so used to villainizing a macronutrient, and we don’t want to villainize them. There’s good versions of fats, proteins and carbohydrates. We just need to choose those more often.
Dr. Weitz: What about foods that are high in cholesterol like eggs? Is it okay to eat eggs every day?
Dr. Saxena: Well, I guess you’d want to check your profile. I think it’s the same answer, but nice… I think these are funny questions, and I think they’re common questions that people have. It’s like almost people are negotiating. It’s the same answer. It depends. If you are, first of all, sensitive to eggs, no, it’s going to create… Let’s just say it doesn’t even create a cholesterol problem, but it can create inflammation that will create still a secondary risk, so we want to make sure… Eggs, it’s not just the fat that they have. You want to make sure eggs is one of the top eight allergenic foods. Make sure you’re not allergic or sensitive to it as well too. But if you’re… Again, people always say things in moderation. That’s the place to start Mediterranean, and then check your insulin resistance, inflammation markers with these advanced lipid panels that you’ve been mentioning.
Dr. Weitz: I was going to ask you about the best diet. You basically said low-glycemic Mediterranean diet. Recently in the news, it’s been mentioned in several studies, there’s a diet called the portfolio diet, which has been touted for reducing cholesterol and heart attack risk. What do you think about that?
Dr. Saxena: I don’t know about the portfolio diet. If you wouldn’t mind sharing a little bit about it, I’m happy to tell you my opinion.
Dr. Weitz: It’s a diet that, I think, is somewhat plant-based, but includes four food groups, which is nuts, soy, plant sterols, and soluble fiber like oat bran or oatmeal.
Dr. Saxena: This is very much based on some of the nutrition guidance that Dean Ornish and his crew have shown, and also Caldwell Esselstyn that a plant-based diet that’s high in fiber, low in saturated fat, low in oil content in general can be useful for certain populations. So I would say the higher-
Dr. Weitz: Well, this was a… I don’t think the portfolio diet is necessarily low in fat, but…
Dr. Saxena: Oh, it’s not?
Dr. Weitz: No, I don’t think-
Dr. Saxena: Where do the fat come from?
Dr. Weitz: I’m not sure exactly, but I think the main thing was that you make sure you add these four foods that are all been shown to reduce unhealthy LDL.
Dr. Saxena: You know why, it’s the nuts that might be the healthy fats, so-
Dr. Weitz: Nuts have been shown to reduce LDL. I think soy beans have also in some studies, and then there are some studies have shown that the plant sterols… I forgot where the plant sterols come from. Then there’s also been studies showing that the soluble fiber, it was really big at one time, right? All these people were eating oat bran muffins and stuff.
Dr. Saxena: I think that people go… They’re looking for… Many people are looking for the trend that solves the problem, but I would tell you, for instance, intermittent fasting, I think it works tremendously for many people. I tried it, and my lipid profiles went up. Fasting, for me, causes my blood sugar to spike, so I think I’m going to keep… I mean, I’m so going to be boring here and say try it out. See if you feel well, and see if your numbers pre and post look different. But I think the more you try, not you, Ben, but people try to just make one diet better than the other, the more confusing our approach to medicine will be. We believe in personalized medicine. Personalized means that you’ve got to find your answer, and it’s going to be different than mine and different than Ben’s.
Dr. Weitz: Is it healthy for some people to eat a carnivore diet?
Dr. Saxena: Yeah. I have found people. I have some people who really do not do well with plant protein. I would say it’s a small group of people that they don’t either metabolize or respond well to the lectins and food. There are people who do much better on a carnivorous diet, but I want to make sure that they also have an anti-inflammatory version of these animal proteins, happy animals, the stress hormones from there. The other thing that I really think is important is to never take a diet out of the context of your entire lifestyle. There’s many people who may come to see me that come from a third world heritage, the so-called third world, so they’re used to eating a diet high in, let’s say, corn or rice or grains, and a big proportion of it might be so. So when they say, “Well, listen, we’ve always eaten this way, and we’ve never had heart disease,” I would generally say, “Yeah, but you likely didn’t have as much stress 200 years ago, and you likely did eight hours of physical toil out in the hotter or sweating and detoxing.” You can’t take a diet from 200 years ago, and transplant it into modern society, so you got to take the diet. If you’re going to eat that way, then you got to work out that way. Burn those carbs off like your great, great grandparents did. So just remember, when we start… Going back to history, if you want to eat paleo, okay, that’s good, but you might want to act like a paleo person and move a lot more too.
Dr. Weitz: Unfortunately, I’ve seen too many people who act like paleo people.
Dr. Saxena: Yes.
Dr. Weitz: Let’s talk about advanced lipid testing. Which markers do you feel are the most significant contributors to heart disease?
Dr. Saxena: Well, I think there are some core ones that generally tell me the news. I will get a standard cholesterol panel just because that’s, it’s almost for me, to show people how unreliable it is, especially in the phase of insulin resistance, so I usually will get what we call an advanced lipoprotein panel. That’s available through insurance-based lab companies as well. That’s wonderful. We can do this inflammation and lipoprotein testing. I’d like to order a lipoprotein panel, where I’m looking for small dense LDL. If you can find oxidized LDL, that’s great.
I love to make sure that we have an hs-CRP. If you can also… That’s a measure of total body inflammation, but specifically cardiac if you have no other confounding variables like an infection or trauma. Then the other thing I like is Lp-PLA2. This is a measure of, if you will, the ooze ability of your plaque, because what is commonly known to cause heart disease is plaque that just builds, builds, builds, and causes a blockage and then the blood can’t flow, but the other mechanism that causes heart attacks and strokes is when your plaque is actually not rigid and slowly clogging up the plumbing. But when it’s gooey like a zit, if you will, and this zit volcano blows because it’s vulnerable to rupture, and then the body in the blood vessel’s like, “Oh no, there is a cut,” and so it sends a clot to patch it up, and it’s the clot that can then obstruct the flow of the blood to the heart or to the brain, and cause the heart attack and stroke. Lp-PLA2 tells us the ooze ability, if you will, of the plaque. I think it’s also good to know myeloperoxidase if you have a high-risk person, because if they have an elevated Lp-PLA2 and an elevated myeloperoxidase, together, those can confer a significant risk for cardiac event in the next three months.
Apo B is another test you can order if you can’t do a full lipoprotein panel. I think those tend to be… Oh, and LP little A, this is the genetic predisposition to clot. So remember, you’re not just looking for cholesterol. You’re looking for everything in that environment of blood vessel that makes problems, and you want to modify each one of those variables to reduce your total risk, and then that’s not even talking about the insulin, hemoglobin A1C, that kind of stuff.
Dr. Weitz: Right. What about HDL? Where are we in terms of the significance of HDL? I know for a while, we were looking at HCL particle sizes well, and it seems like the emphasis now is more on HDL functionality.
Dr. Saxena: HDL, sometimes people call it like your pickup trucks that go into the plaque, and pick up like it’s an efflux mechanism to clean plaque. I definitely think that that can make a big difference. However, just as you were mentioning, people can have high levels of HDL cholesterol, but very dysfunctional HDL particles, so they look good on the… Like great trucks on the outside, but they don’t actually clean up, and so we do want a functional test of HDL. What I’ve found clinically taking care of thousands of people is that there’s definitely a handful of people that have gorgeous HDL particles, and it can make up for a moderate mess they’re making with their LDL particle numbers, but that’s not as common as people making a big mess with their LDL particle issues.
Most people are bigger plaque generators than they are cleaner-uppers. How do I know who’s winning the war between who’s making plaque, the LDLs, versus who’s cleaning up plaque, the HDL? Many times, we’ll look at the Lp-PLA2, and get a sense of who’s winning the game. Because if they look, if you will, ugly on the LDL particles side, and they look really good on HDL, but I see their Lp-PLA2 looks good, and hs-CRP is down, I’m going to say, “Hey, they’re cleaning up quicker than they’re putting the plaque down.”
That tells me if I’m just still optimizing lifestyle and nutraceuticals that they could be, if you will, safe. Nobody’s guaranteed safe, but it looks good, and they could be more comfortable in proceeding with that functional medicine approach.
Dr. Weitz: I think what you’re saying with the Lp-PLA2 is that if that number is high, it refers to plaque that’s less stable. Is that what you’re…
Dr. Saxena: Yeah, it’s more rupture prone, and the easiest way patients get it is it’s oozy like a volcano.
Dr. Weitz: Right, as opposed to maybe plaque that’s calcified.
Dr. Saxena: Right. Well, you want your plaque to be stable, but what can happen is that as it starts calcifying… I mean, that could be good in one sense if your plaque is relatively low. But as you get more and more plaque if you calcify it, then that’s a little bit harder to reverse out, and that’s why people will get stents and the Roto-Rooter version of opening up the lumen or the blood flow.
Dr. Weitz: Right. What about homocysteine? Is at another marker you look at?
Dr. Saxena: Yes. I mean, I could list a bunch of markers. Homocysteine is definitely an elevated homocysteine, and that would be above nine for me on most of our American-based metrics and insurance-based labs. Above a nine tells me that I need to look at methylation, and start looking at other aspects, nutritional aspects. I also look at an omega index to see, “Hey, what’s going on with their fat intake? What’s the omega-3 to omega-6 ratio?”
Dr. Weitz: What is your target for optimal omega-3 index?
Dr. Saxena: So interestingly, I aim for like… If you want to get an A+ in my classroom, I go for an 8.0, where normally, 5.5 is the cutoff that is provided in the labs. The way that I say it is like, “If you want to be 100-year-old with a rocking brain and a rocking body, you want to be so uninflamed, so you want to get your number to 8.0. 5.5, you got a solid maybe B- with me.
Dr. Weitz: No, definitely, at least eight. I sometimes aim for 10. What do you think about the role of coronary calcium scans?
Dr. Saxena: I think that’s actually a wonderful new way for us to get a better indicator, because when we’re doing these labs, they’re short-term indications of what’s going on. And if you want a longer story, you don’t just want one chapter view of what’s going on in the timeline of your artery, a coronary artery calcium score could really be useful, because then I can see what’s happened to the artery the decades prior. Whereas sometimes when I’m looking at labs, I might get some clues, but if they look, if you will, ugly on their labs like, “Whoo, these don’t look good.”
Dr. Saxena: Then I say… Then they seem to have the risk profile like a stressed-out male who’s obese and does the wrong things, if you will, I might order that coronary artery calcium score to see, “Do I need to get you over to a cardiologist to get stress testing sooner rather than later?”
Dr. Weitz: Right. So let’s get to what can we do about some of these problems, and why don’t we first mention pharmaceuticals? Statin medications are often the most commonly prescribed medications to reduce heart attack risk. What do you think about statins?
Dr. Saxena: I think there’s a time and a place for most everything. It’s the relationship with it. I definitely don’t think you’d take a statin, and then have your ice cream and trans fats. I think that if you are at a high-risk situation, where you need some immediate reductions with some anti-inflammatory signaling from the statin, and you might be able to reduce some significant LDL, it might make sense, and you really do have to think about medical legal considerations when you’re in this market. You at least offer the statin, and document it’s the standard of care, and then if the patient refuses, if they don’t want to, because there’s definitely a growing group of people who are statin refusers or statin intolerant.
I think that there’s a group that are definitely at high risk, especially some that have genetic familial hyperlipidemia. They have LDLs in the 400s, and they’ve been having it. They’re due for a heart attack in their 30s and 40s, so that would be a little bit of legal suicide not to offer a statin to that person or not refer them to a cardiologist. But otherwise, I think most of the people who are coming to see me who will say our primary prevention, they’re trying to prevent their first heart attack or stroke. Not that they’ve had one, but they’re preventing their first one. Most of the time, we’re not dealing with people who would not qualify for a trial of therapeutic lifestyle change and nutraceutical with early repeat lab testing as well as BMI and waist circumference checks and all these types of things. I would never go, “No statin. Here’s some lifestyle stuff. See you in six months. Hope it works well,” if they showed some moderate risks.
Dr. Weitz: Right. I think the data on primary prevention is much thinner than the data on secondary prevention, right?
Dr. Saxena: Correct.
Dr. Weitz: Now, there’s a number of studies it seemed to show that statins have no negative effect on brain health or testosterone levels or muscle dysfunction, but I think most of us in the functional medicine world think quite a bit differently based on our experience with patients. What do you think?
Dr. Saxena: I would say that there is definitely a group of people. And if you just look at the physiology of statins, they’re HMG-CoA reductase inhibitors, so they’re just going to downstream reduce your CoQ10 production. I mean, you just can’t argue that CoQ10 is necessary for certain tissues to function well, including the muscle, the liver. Then the other thing that you mentioned about low T or hormones, low T I’ll just say because many times, it shows up as low T, low testosterone, excuse me, in men. Some of the targets that people are just pushing for LDL cholesterol are lower than necessary.
It’s almost like, “Hey, just in case, let’s drop it to 70 LDL cholesterol,” meaning drop it below 70. There’s definitely a group of people that may need that for secondary prevention or higher-risk conditions. But if you just take the average male with average risk for primary prevention drop his LDL down to 70 or below, you’re likely reducing the precursor that he needs to make his testosterone, so he can make muscle mass to keep himself lean. I do think it’s a vicious cycle that we have tunnel vision about the cholesterol that we forget that cholesterol is necessary in the body.
Dr. Weitz: They’re lauding a target of 40 for LDL cholesterol with some of these newer drugs.
Dr. Saxena: Right. I just think it’s not a balanced view. It’s not definitely an integrative full functional view, a systemic view of the body, and then we know, just as you mentioned, that the brain needs good fats, and LDL is not bad. It’s just the relationship to it. So when it’s oxidized, when it’s too much or too little, that’s going to affect the health of our total system. I’ve seen data that talks about the association between statins and dementia, statins and diabetes. I do think it solves one problem, but in a laser way sometimes, but it doesn’t take into account the impact in other departments, and so we have to look at the total benefit risk package before we just slap somebody on with a statin, and drop them to a 70 or 40.
Dr. Weitz: Right. By the way, for those who don’t know, what does LDL even mean? What is LDL?
Dr. Saxena: It stands for low density lipoprotein. What that basically means is when you eat fat as a macronutrient, there’s different kinds of fat, and they can compartmentalize as high density lipoprotein, HDL, which I call healthy happy HDL. Then it can turn in sugars and carbs, many times turn into terrible triglycerides, and then they can also turn into lousy LDL, the low density lipoprotein. And terrible triglycerides and lousy LDL cholesterol, they don’t actually travel separately in the bloodstream. They actually join forces, and the ratio between the trigs and the LDL determines the size of the particle they make. We call that still an LDL particle, but it can be small, medium, or large based on that ratio, and the smaller it is or the more dense it is, the more prone it is to oxidation. What you eat and how you move determines the size of that particle and its vulnerability to be oxidized and then turn into plaque.
Dr. Weitz: Right. Let’s say you have a patient, and you think they’re at some risk, and they don’t want to take a statin. When do you consider using alternative pharmaceuticals as opposed to diet and nutraceuticals since now we have a number of alternative pharmaceuticals for affecting heart disease risk like, say, Zetia, and then we have bempedoic acid?
Dr. Saxena: I would just tell you that the most commonplace I go to if someone does not want to use a statin is not an alternative pharmaceutical. I go straight to lifestyle and nutraceutical, because I do think that they hit at the core root cause better than the Zetias and some of these targeted therapies. In the functional medicine approach, when you address inflammation, which one of the common sources is the gut microbiome, when you reduce inflammation through improving lifestyle, whether it’s stress, movement, diet, sleep, and when you address insulin resistance and some of the immune dysfunction through lifestyle and targeted nutraceuticals, but these targeted nutraceuticals are not targeted like pharmaceuticals are. They’re targeted towards a big systemic biology issue like inflammation or insulin resistance, right? So if you replace vitamin D, it helps all branches of your tree of life. It’s not just this one branch, whereas Zetia is only working, if you will, in one branch in terms of absorption, so I always like to go-
Dr. Weitz: One narrow pathway as opposed to affecting multiple pathways.
Dr. Saxena: Right. Exactly. Functional medicine is all about modulating many pathways softly versus one very strongly.
Dr. Weitz: So what are some of the best things we can do nutraceutical wise to move the needle on, say, somebody who has an elevated LDL particle number?
Dr. Saxena: Great question. So the first thing I’m just going to say out loud to make sure it’s crystal clear is you don’t get to have… I’m going to use a little French here. I think you’re from up north just listening to your accent. I’m from Queens, New York originally, too.
Dr. Weitz: I was actually born in The Bronx.
Dr. Saxena: I was born in Flushing. What I’d say is you can’t nutraceutical your way out of a crap lifestyle, okay? Number one, you don’t get to eat junky, sit, stress out, not sleep, and then think that nutraceuticals are going to make up the difference, so lifestyle is number one. Then to compliment and to make up for what it takes lifestyle sometimes a little time to clean up is when we bring in these nutraceuticals, so I’ll put them into a couple of different camps. Number one is the camp that will reduce inflammation. Many times, we’re doing omegas. You might take, for instance, a berberine to be able to help reduce inflammation at the level of the gut microbiome. You might take a bergamot, which is going to help with LDL particle number, and the LDL particle size is what I’ve seen in my lab profiles as well too. It’s not just the number, even though the original study was looking at a cholesterol panel against rosuvastatin.
Dr. Weitz: So it will increase LDL particle size?
Dr. Saxena: Yeah. Well, what I see… Right, exactly. I see my small dense LDL number reduce, so it fluffs them as well as reduces the quantity.
Dr. Weitz: What dosage of Bergamot do you find effective?
Dr. Saxena: We usually use a 500 milligram and use two of them at bedtime, and that honors the Eastern philosophy of the circadian rhythm of organs. Your liver is most active in the evening, so feed it the bergamot because it’s really acting to support the liver as it regulates LDL sizes.
Dr. Weitz: Okay.
Dr. Saxena: So bergamot, berberine, vitamin D3 plus K2, so D3 alone definitely signals the body to use up calcium. But if you use D3 alone, calcium can be told to get out of the bloodstream, and you’re assuming it’s going to the bone, but it’s actually been shown that it can go into plaque. We don’t want that. We don’t want to calcify plaque. So what we do is we give D3 a bodyguard called K2, and we say, “Hey, make sure when you’re telling calcium to get out, to make sure it goes to the bone and not the plaque,” so D3, K2 is a huge… I used to at least get it above 50. I like 60 to 80 as a level for vitamin D 25-Hydroxy OH.
Dr. Weitz: What dosage of K2 do you like?
Dr. Saxena: What I do is a lot of these companies will have paired D3 and K2. Do you believe that I am blanking right now because you’re asking me on the dose? I want to say 45 twice a day or 90. Somewhere around 90 to 180 micrograms is what I’m thinking off the top of my head if I remember correctly.
Dr. Weitz: I think the average vitamin D product maybe has 50 and some may have 90, but some of the integrative cardiologists have recommended 180 to 360 K2 a day.
Dr. Saxena: I don’t… Definitely, more is good in most… I’ll say… No, I’m going to say in most situations. K2 and vitamin D3, being liberal with it, I think, is generally safe. Toxicity is not common. Again, I like to track and then always double check that we’re not treating everybody. We’re treating you, so let’s see how you look when you take these doses.
Dr. Weitz: Right. What about red yeast rice?
Dr. Saxena: Ooh, then that’s a little bit controversial. I think red yeast rice can… What I’ll tell you is that red yeast rice definitely acts similar to a statin, right? Similar. It has a similar mechanism, so it’s going to affect the same pathway, but it won’t press as hard if you will. The debate has been, “Well, if you’re going to use red yeast rice, should you not just use an FDA-regulated statin because you don’t know what you’re getting?” There are some arguments that would say that if you don’t know the supplier of your red yeast rice, you might be getting actually the statin anyway, so you might as well use a regulated form. So what I think-
Dr. Weitz: Right. Yeah, but certain manufacturers will make sure that there’s no lovastatin in the red yeast rice, and yeah.
Dr. Saxena: So yes, and then I just want to make sure our people know to do their due diligence on the good companies that are doing their homework on their sourcing of their red yeast rice. I have a group of people who definitely are pro red yeast rice, but just be careful. You want to make sure that you replace the CoQ10. I generally get a lot of traction from bergamot and berberine, and then I don’t have to worry about them actually spending on CoQ10, because sometimes CoQ10 can get expensive.
Dr. Saxena: We do have to admit that these things cost money, and people have an X amount of discretionary income.
Dr. Weitz: Oh, for sure.
Dr. Saxena: Then, you know what, but if they have a mitochondrial defect, I want to make sure I get that CoQ10 in to cover my bases for something else that could be beneficial.
Dr. Weitz: I just want to get out there. For some reason, I’ve talked to quite a number of people who are taking red yeast rice, and very few of them are taking the recommended dosage. Sometimes these are even the integrative physicians who are recommending it, and they’re taking one or two capsules a day, and the therapeutic dosage for red yeast rice is 2,400 to 4,800 milligrams a day. Typically, that means four to eight capsules a day, not one or two.
Dr. Saxena: They could be doing some therapeutic doses. I’ll just tell you what I tend to do. I tend to… The other thing that I will do for patients, especially when I’m looking for cost savings, the half life of rosuvastatin is actually quite long, so I might do twice weekly, five milligram rosuvastatin. Sometimes that little touch of statin helps me with some of my moderate-risk patients. Now, I’m not telling you not to do red yeast rice. I’m just telling you if that’s covered, and they can’t afford the CoQ10 and then this and that, because just as an aside, I take insurance. You may not have that population, but if you do, money does matter at times. I also want to talk about niacin. Niacin, for sure, is something that we use to be able to help, especially with the insulin resistance, triglyceride, HDL metabolic dyslipidemia. Just be careful with your patients with liver dysfunction. Many times, I like to do blends so that they’re not getting any one thing, any one signal too strong. So, if you could do blends of a low dose of a fish oil and bergamot and berberine, niacin, you can create these blends that make a bigger difference for people.
Dr. Weitz: Niacin is one of the most effective things to move the needle on LP little A, also increases LDL particle size.
Dr. Saxena: That’s right.
Dr. Weitz: What form of niacin do you like?
Dr. Saxena: I like the form that does cause a little bit of flush, I will tell you, and what-
Dr. Weitz: [inaudible 00:42:41] flushing form is totally ineffective.
Dr. Saxena: Well, right, and so one of the things that I like to do is actually go a little slow, and I like to use things synergistically, because I do find that my patients with niacin, if they get the flush, and they get it in their head that they’re allergic or sensitive, then it’s hard for me to capture the niacin for long term. You can mix it with quercetin, which really helps. I try to use it at bedtime. I’m not really pushing aspirin these days with some of the new data, so I think when I blend the niacin in and I keep it at a lower dose, I like that better for my patients I’ll say.
Dr. Weitz: What dosage is that?
Dr. Saxena: 500 to 1,000 is plenty for many of my patients as long as I don’t use it as monotherapy. If I use it with a good fish oil, and I’m using it… I’m telling you berberine and bergamot are some of my favorites, because they’re just such a low side effect profile.
Dr. Weitz: Right. Of course, berberine works on a similar mechanism as metformin, so super beneficial for blood sugar and diabetics, and may also have longevity anti-aging benefits.
Dr. Saxena: Without the B12 depletion, right?
Dr. Weitz: Right. Talk about-
Dr. Saxena: There was a recent study that came out just interestingly, and I’m sure it applies to statins, because I want to say there was a study about it. But within three months of somebody being prescribed metformin, compliance drops down quite a bit, so I do think that sometimes, we give people pharmaceuticals, and we’re not paying attention to the nutrient depletions, and then they get secondary symptoms and or they’re just not feeling well, whether it’s GI or energy or muscle pains or something with metformin, so using these other tools and then tracking their labs and showing them, “Look, they made a difference with little side effects,” and if anything, beneficial to other parts of their body, right? Berberine’s helping inflammation everywhere.
Dr. Weitz: What are some of the nutrient deficiencies that occur from statins? You mentioned-
Dr. Saxena: CoQ10.
Dr. Weitz: … CoQ10, but there’s actually a bunch of others, right?
Dr. Saxena: Oh yeah. Selenium is another big one. If you deplete the selenium, then you can start to see thyroid dysfunction. Have you seen that quite a bit?
Dr. Weitz: Yes, and vitamin D, vitamin K. There’s a bunch of nutrients that are really depleted by statins.
Dr. Saxena: That’s something that I think has been quite compelling. I’m actually the chief medical officer for Forum Health, and we work in my office. We have an alliance with a college of osteopathic medicine and the pharmacy team. What they routinely do is nutrient depletion checks on all pharmaceuticals that the patient is taking, and they submit that to us as the clinical team. Patients are just astounded with how their routine medications are depleting nutrients. I think it’s a great exercise to just do a nutrient depletion check on some of your patients, and not only would that be useful for them to know, but it would give them more buy-in for taking their nutrient therapy if they have to take a pharmaceutical.
Dr. Weitz: What’s your favorite testing for nutrient depletion?
Dr. Saxena: My favorite testing, you mean like what, my favorite company?
Dr. Weitz: Well, I mean, we know that serum testing for a lot of nutrients is not particularly accurate, right? I mean, it is providing a D, but not for a lot of others.
Dr. Saxena: For everything. I mean, I’m really… Are we allowed to say company names here?
Dr. Weitz: Oh, sure.
Dr. Saxena: Got it. I like Genova’s NutrEval quite a bit, but that’s… I am not… Because I started as an insurance-based physician, I learned many times using history and physical exam to be able to get a sense, “Do you have a functional nutrient depletion?” Dr. Michael Stone at the Institute for Functional Medicine is just an absolute wiz in the nutrition-oriented physical exam. If we just get back to some physical exam skills, and take a good history and just research some of the depletions from a pharmaceutical, you can do a lot. I save a lot of money for my patients doing it that way. Now, of course, it’s nice to have testing, but if it’s not possible, I’m just making sure that all of our practitioners with different populations have an answer.
Dr. Weitz: Right. What if a patient, they have a coronary calcium scan, and they have plaque, and they said, “Put me on the best program to reverse my plaque,” what would you put them on? Let’s say that money is no object. [crosstalk 00:47:20].
Dr. Saxena: I’d have to… Well, first, I would do a timeline analysis, and get a sense of what are the things that I think that led to their plaque. Is it… If heavy metal’s a part of it, would I then include some plaque X, some chelation with it? Do I have to really work on heavy metals? Is it really just horrible lifestyle? Is it just gut inflammation? Is it genetics? I would… I don’t know. I don’t have a program as much as I just identify and address their underlying causes, if that makes sense.
Dr. Weitz: Okay.
Dr. Saxena: Yeah? I don’t know. What’s your answer? I’d like to know what your answer is.
Dr. Weitz: Well, Dr. Mark Houston has this plaque reduction program, and it’s 10 different products with some of the things you mention and aged garlic and tocotrienols and Arteriosil, the product that improves the endothelium. It’s a whole series of different nutraceuticals.
Dr. Saxena: I do think that all of those have merit, but for me, I would… I tend to be the person who doesn’t do all of it at once, because I find that compliance. It’s a special person who can take 20 supplements. I have this thing that I say like, “You, knowing these things, meaning one person knowing these things is very different than them doing it.” You can give them the handout that says, “Do all these supplements, and do, do, do, do, do, do, do.” And if they go like, “I understand that,” and they don’t do it, it’s useless. Who cares about the program?
Dr. Weitz: Of course.
Dr. Saxena: There’s so much engagement that has to occur so that they can… What I do is I whittle away at the thing that I think will take the biggest chunk of risk out, and then I negotiate, and then we reassess. It’s so important, in my opinion, that we recheck with the patient data that is compelling to them, whether it’s the number on the scale, or it’s their LDL particle number, but I got to figure out like, “What makes you tick, and what makes you want to do the next thing?”
Dr. Weitz: Right. I think once you’ve ruled out toxins and heavy metals and some of these other issues that are creating inflammation in their body, and ruled out food sensitivities, getting on a good, healthy diet, making sure they’re exercising every day or almost every day, getting good sleep, and then things like vitamin D, fish oil, and then niacin, citrus, bergamot, a few things like that, you’re probably a good way there.
Dr. Saxena: Berberine.
Dr. Weitz: Berberine [crosstalk 00:49:51].
Dr. Saxena: Magnesium. There’s just some real simple things that can make a big impact in my opinion.
Dr. Weitz: Sounds good. All right. So any final thoughts for our listeners and viewers?
Dr. Saxena: You know what? I’m going to tell you that action is the most important thing to get a result. You having listened to this podcast is amazing. If you do nothing after it, you’ve done nothing for yourself. So take something that was said here today, and do it, because it’s the only way you’re going to get a different result, right? Don’t just intellectually have fun. Get in action about anything or more about what you learned here today.
Dr. Weitz: Sounds good. Just do it.
Dr. Saxena: Just do it.
Dr. Weitz: Thank you, Dr. Saxena.
Dr. Saxena: Thank you. Take care.
Dr. Weitz: Thank you, listeners, for making it all the way through this episode of the Rational Wellness Podcast. Please take a few minutes and go to Apple Podcasts, and give us a five-star ratings and review. That would really help us, so more people can find us in their listing of health podcasts. I’d also like to let everybody know that I now have a few openings for new clients for nutritional consultations. If you’re interested, please call my office in Santa Monica at 310-395-3111. That’s 310-395-3111. Take one of the few openings we have now for a individual consultation for nutrition with Dr. Ben Weitz. Thank you and see you next week.
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