Dr. Elizabeth Boham (00:00):
And the reason we’re really looking at cholesterol is because it’s one factor that influences somebody’s risk of cardiovascular disease, right?
Dr. Mark Hyman (00:12):
Welcome to The Doctor’s Farmacy. I’m Dr. Mark Hyman, and this is a special episode of The Doctor’s Farmacy called House Call. And this episode is with my friend and colleague Dr. Elizabeth Boham, and we’re talking about cholesterol and heart disease, and what is the truth and what is fiction, and what should we do when our doctor tells us to take a statin which every doctor pretty much does regardless of our [h-dex 00:00:36] or whatever is going on. It’s the number one drug sold on the planet, and we need to think about why and if it’s actually good for us or what we actually should be doing about our cholesterol.
Dr. Mark Hyman (00:47):
So Dr. Boham is an incredible physician. She’s one of my good friends and has been working with me for 20 plus years now, I guess. It’s a long, long time. And she’s one of the leaders in functional medicine in the world, teaches all over the place, mostly from her house on Zoom, but really is a part of the faculty at the Institute for Functional Medicine. She’s a huge contributor to the field and is what every doctor should be, which is not only an M.D. but she’s a registered dietician and an exercise physiologist. And I’m super jealous of all that. We both went to Cornell, so we have that in common. And it’s great to have you back on The Doctor’s Farmacy, Liz.
Dr. Elizabeth Boham (01:25):
Thank you, Mark. It’s great to be here.
Dr. Mark Hyman (01:27):
All right. Let’s get right into it, so cholesterol … If you are a person in America, and you’ve been to your doctor, you’ve likely had your cholesterol checked, and you probably have been told you need to get your cholesterol down, and you might even have been told that you should be taking a drug called a statin. So tell us what is this whole hullabaloo about cholesterol and statins. And why should we even care about cholesterol? And is it really the thing we should be worried about with heart disease?
Dr. Elizabeth Boham (01:55):
Oh, such great questions. I mean, it’s estimated that 50 percent of people in this country and in Europe, and 40 percent worldwide, have what’s considered elevated cholesterol. And obviously, for those 50 percent of people, not all of them have to be really concerned about that cholesterol number. It doesn’t mean that all 50 percent of us have to be taking a medication to lower that cholesterol. And so people come in all the time with those questions of, “Is this cholesterol too high? And how do I get it down? Do I need to get it down?” And the reason we’re really looking at cholesterol is because it’s one factor that influences somebody’s risk of cardiovascular disease, right?
Dr. Mark Hyman (02:37):
I like how you said, “One factor,” not, “The factor.”
Dr. Elizabeth Boham (02:38):
One factor. Exactly. One piece of the puzzle, and for a lot of people, it’s not even an important piece of the puzzle, right? But it is one piece of the puzzle, especially for people who have a really high cholesterol, like familiar hypercholesterolemia.
Dr. Mark Hyman (02:55):
Dr. Elizabeth Boham (02:56):
Genetic. Absolutely. We’re taking about LDLs like in the 190s, and we’ll talk more about those numbers, total cholesterol in the 300s. There is an association with vascular disease. It can cause plaque buildup, and if the plaque is building up around the arteries around the heart, that can cause a heart attack, or in the arteries leading to the brain, it can cause a stroke. So, for some people, it’s something that’s very important. For other people, it’s something that’s giving us a lot of information, potentially, about their health and where do we need to focus. And so I think it’s an important thing for us to talk about. What are all these numbers mean? People are so confused. What does this number mean? Do I really need to be worried?
Dr. Mark Hyman (03:38):
Yeah. So we’re going to get deep into all the things you should be thinking about if you want to prevent heart disease, cholesterol being one of them.
Dr. Elizabeth Boham (03:45):
One of them.
Dr. Mark Hyman (03:46):
And maybe not the most important one, by the way, because two-thirds of people who have heart attacks actually have pre-diabetes or diabetes, and it’s mostly undiagnosed. Seventy percent of people who come in have pretty good cholesterol who have heart attacks. About 50 percent have normal cholesterol. It’s really striking that we’re wondering about this condition which is actually not so cut and dried.
Dr. Elizabeth Boham (04:20):
Dr. Mark Hyman (04:20):
I think I want to get into the numbers. Let’s talk about cholesterol, because, in my opinion, and I’ve written a lot about this, the test that you get when you go to your doctor is antiquated.
Dr. Elizabeth Boham (04:32):
Dr. Mark Hyman (04:32):
It’s outdated, it’s not the cholesterol test you should be getting, and it doesn’t give you the right information to make a decision about what to do. So you typically get your total cholesterol, your triglycerides, your HDL, your LDL. Those are fine. But tell us about what these numbers mean and what cholesterol test we should be doing that your doctor may not be ordering and that is available through Quest or LabCorp through your insurance.
Dr. Elizabeth Boham (04:57):
Absolutely. So when you get your traditional cholesterol done, your traditional lipid panel done, they’re giving you the LDL cholesterol, the HDL cholesterol, the total cholesterol, and that’s one piece of information, like you said. But we’re missing a lot of information there.
Dr. Elizabeth Boham (05:18):
So it’s really important … I love this analogy of the dirt and dump trucks. Think of all the dump trucks going around that are carrying dirt, and we can make this analogy with cholesterol. So think of your cholesterol like the dirt. And the dump trucks are the particles carrying around your cholesterol. So what we’re learning is it’s not just the amount of dirt somebody has that’s important, it’s the amount of dump trucks that they have carrying around that dirt. And that the size of the dump trucks are actually really important. And so when you get a typical lipid panel done, you’re just finding out the amount of dirt that you have and how much of it is LDL and HDL and triglycerides. And that’s important, and we’ll talk about that. But what’s even more important, or at least as important, is the amount of dump trucks you have carrying around that dirt.
Dr. Elizabeth Boham (06:21):
And what we’ve learned is that if you have small dump trucks … So if you have a certain amount of dirt, you could either have a few big dump trucks carrying it around or a lot of small dump trucks carrying it around. And what we’re learning is that those small dump trucks, if you have too many small dump trucks, that that’s actually more concerning, that they can get into the artery lining more, they can cause more plaque buildup, it can help that cholesterol get oxidized through oxidative stress-
Dr. Mark Hyman (06:52):
Yeah. More dangerous.
Dr. Elizabeth Boham (06:52):
It’s much more dangerous. So the size of those dump trucks you have carrying around your cholesterol is critically important and something we look at all the time.
Dr. Mark Hyman (07:00):
I mean, the way I think about it is … and another way I kind of look at it is the number you get on your test is the weight of your cholesterol. So it’s milligrams per deciliter. It’s just basically the weight. But it doesn’t tell you if that cholesterol is made up of 1,000 particles or 100 particles. So you could have a cholesterol of 150, and it could be 5,000 particles or it could be 500 particles of cholesterol. And that makes a huge difference in your risk of heart disease.
Dr. Elizabeth Boham (07:31):
Dr. Mark Hyman (07:31):
And you can’t tell from a regular cholesterol test whether you have a lot of particles or whether they’re big particles or small particles. So I think about it sort of like golf balls and beach balls. Beach balls are these big, light, fluffy balls that you can bounce and don’t hurt anything, and a golf ball is small, but it hits you in the had, it’ll knock you out. And the golf balls are the things that are the small particles that are dangerous, that bang up against the arteries and cause the plaque to develop and cause heart attacks. So you can’t tell that from a regular test. And you can have small or large LDL, small or large HDL, small or large triglycerides. And the triglycerides are a little different. It’s the big triglycerides that are a problem, not the small ones. But you can really get a sense from these newer tests what’s really going on.
Dr. Mark Hyman (08:16):
Because I’ve seen people with a cholesterol of 300, their HDL’s … which it sounds terrible, because you’re supposed to be under 200. Their LDL might be 150, which sounds terrible because it should be under 70. Their HDL’s like 110. So they have really high cholesterol. They’re skinny. They’re healthy. They don’t have diabetes, high blood pressure. They don’t smoke. They’re older. Often little old ladies have this kind of cholesterol. There’s no evidence that these people are at risk of heart disease, because they have large, light, fluffy particles. They might have no small particles. They might have the perfect size and shape of all their cholesterol markers. And their risk is really low.
Dr. Mark Hyman (08:50):
I remember talking to a colleague, well, more of a mentor, Dr. Peter Libby, who’s the Chief of Cardiovascular Medicine at Harvard, has written the textbook on heart disease that all cardiologists study. And I said, “Peter, I have these patients, these little old ladies. Their cholesterol’s 300 and they have this and that.” This was like 20 years ago. And I’m like, “Would you treat these people with a statin or a drug?” He’s like, “Absolutely not. There’s no evidence that these people are at risk, even though their cholesterol’s so abnormal.” So you can’t just go by the cholesterol test that your doctor does. So you need something called what?
Dr. Elizabeth Boham (09:22):
Like particle size testing. It’s telling us about those things that are carrying around your cholesterol.
Dr. Mark Hyman (09:28):
Yes. So LabCorp does NMR.
Dr. Elizabeth Boham (09:28):
Dr. Mark Hyman (09:29):
And Quest does something called Cardio IQ, which is similar. And you can ask your doctor for these. And you shouldn’t stand for any other test but these tests.
Dr. Elizabeth Boham (09:39):
Dr. Mark Hyman (09:39):
And they tell you so much. They tell us how do you get a profile that is with these small, dense, dangerous HDL and LDL.
Dr. Elizabeth Boham (09:50):
Well, it’s interesting. There’s a lot of lifestyle that impacts the size of your LDL particles, right? The size of those. Are they small and dense and dangerous, or are they big and fluffy and not so dangerous? I mean, there’s always a genetic component. There’s a genetic component, but then there’s our lifestyle. And we know that that metabolic syndrome where people are insulin resistant, gaining weight around the belly, they typically have lower HDL, they typically have higher triglycerides, but they also typically have more of these small, dense LDLs which are more concerning. And so lifestyle makes a huge impact on the size of those LDL particles.
Dr. Mark Hyman (10:33):
And which part of your lifestyle? What’s the biggest thing?
Dr. Elizabeth Boham (10:36):
Dr. Mark Hyman (10:37):
Your diet. What diet causes you to have the dangerous kind of cholesterol?
Dr. Elizabeth Boham (10:40):
That SAD diet. The standard American diet, right?
Dr. Mark Hyman (10:44):
Dr. Elizabeth Boham (10:44):
That’s the one that full of carbohydrates and sugar and refined and processed foods and lots of alcohol and simple sugars-
Dr. Mark Hyman (10:52):
It’s the starch and sugar that drives it. And what does that do to the body that causes these particles and actually leads to the high triglycerides, the low HDL, the small particles?
Dr. Elizabeth Boham (11:04):
Right. It’s that whole process of insulin resistance, and it results in this really unhealthy pattern. And so we sometimes get clues of that with a standard lipid panel, right? We sometimes get clues when somebody has a low HDL. The HDL’s the one you want higher. And for men, you want it at least over 40, and for women, at least over 50. And then, if that triglyceride’s over-
Dr. Mark Hyman (11:30):
I’m like 50 and 60. I’m more aggressive than you.
Dr. Elizabeth Boham (11:31):
Yeah. Well, that’s really true.
Dr. Mark Hyman (11:33):
Like what’s optimal, right?
Dr. Elizabeth Boham (11:34):
What’s optimal? Right.
Dr. Mark Hyman (11:35):
If you’re a guy, if your cholesterol’s 40, probably not optimal. Should be over 50.
Dr. Elizabeth Boham (11:38):
It really should. It really should. You’re right. It’s not optimal.
Dr. Mark Hyman (11:41):
I’m a tough customer, here.
Dr. Elizabeth Boham (11:44):
And then the triglycerides you want, at least, under 150. Or what would you say? What’s optimal?
Dr. Mark Hyman (11:48):
Dr. Elizabeth Boham (11:49):
There you go, for triglycerides.
Dr. Mark Hyman (11:51):
If your triglycerides are over 100, you’re definitely flirting with danger. And there’s some genetics involved. I want to talk about the genetics in a minute, but it is usually a sign of increased carbohydrate load. And I don’t mean broccoli. I mean like flour and sugar.
Dr. Elizabeth Boham (12:05):
Yeah. Absolutely. So you can get some sense of if somebody is prone to metabolic syndrome, insulin resistance, with that. But then the particle size testing also gives us a lot of information. The NMR, for example, gives you something called your insulin resistance score, so you can get a sense based on the even analysis of the particles of cholesterol that you have how at risk you are of insulin resistance. So it’s just one more piece of the puzzle.
Dr. Mark Hyman (12:34):
If I have somebody with a cholesterol of 150 who have like 2,000 particles of LDL, which should be under 1,000, who have like 900 particles of small LDL, which should be under 300 ideally, probably less than 90 is perfect, and you see that often, and yet, their doctor, “Well, your cholesterol’s 150. It’s fine.” And so you really can get duped by just looking at the total numbers. If it’s 300, it might be fine. If it’s 150, it might be highly dangerous to you. And it’s not so easy without looking at the specific tests. So it’s super important. And so what you mentioned is that insulin resistance is the driver of this, which is pre-diabetes, metabolic syndrome. And to some degree or another, 88 percent of Americans are metabolically unhealthy and have some degree of this.
Dr. Elizabeth Boham (13:21):
Crazy. It’s crazy.
Dr. Mark Hyman (13:22):
Fifty percent have pre-diabetes or type 2 diabetes. Every other American has diabetes or pre-diabetes. That’s crazy. Seventy-five percent overweight, and every one of those people has some degree of poor metabolic health. So if this is true, what else does this diet do that accelerates heart disease, because we know now that it’s not just the cholesterol. Like I said, you could have cholesterol of 300 and be fine. There’s a special ingredient you need in order to cause the heart disease. What is that special ingredient?
Dr. Elizabeth Boham (13:48):
So it’s inflammation-
Dr. Mark Hyman (13:49):
Dr. Elizabeth Boham (13:49):
… and oxidative stress, right?
Dr. Mark Hyman (13:51):
Yes. Okay. So inflammation seems to cause everything these days, from depression to cancer to heart disease to diabetes to everything else. So what is the cause of the inflammation in these patients with insulin resistance.
Dr. Elizabeth Boham (14:04):
So a lot of times, I mean there’s many things, but it’s our belly fat, because we know that that fat around our belly, when we get insulin resistant, we gain more weight around our belly. And we know that visceral fat or weight around the belly, the apple shape, is more inflammatory. It secretes all these inflammatory markers and increases inflammation in the body. And so when people … when they help their weight around their belly goes down, when we get that waist/hip ratio better, that inflammation goes down.
Dr. Mark Hyman (14:35):
So, basically, what you’re saying is that fat around belly is not just holding up your pants, that it’s an immunologically active organ. It produces these molecules we call adipose cytokines. You’ve heard about the cytokine storm with COVID. Well, it’s that same chronic cytokine storm that’s being released from these fat cells in your belly. They’re not just average … I mean, if you have fat in your legs or your butt, it’s not going to do that. These fat cells in your belly are super inflammatory. So then you get the inflammation, which leads to oxidate stress, which then causes what problem with the cholesterol?
Dr. Elizabeth Boham (15:12):
Right. So when your LDL cholesterol gets oxidized-
Dr. Mark Hyman (15:15):
And what is that?
Dr. Elizabeth Boham (15:17):
I think of oxidative stress like excessive free radicals or rusting in the body. We’re always making free radicals in many different cellular processes in the body, but when there’s too many of them, or when you don’t have enough antioxidants to squelch those free radicals, so if your diet’s not rich enough in the polyphenols or those phytonutrients or your vegetables, then what happens is you get more oxidative stress. And that oxidative stress can shift that LDL cholesterol. And it’s that oxidized LDL that’s more damaging and more likely to cause plaque buildup and that will lead to heart disease.
Dr. Mark Hyman (15:57):
So it’s basically rancid cholesterol in your bloodstream that’s the problem … that gets oxidized, which is, like you said, rusting or apple turning brown or your skin wrinkling from too much sun. These are all signs of oxidation. But this happens inside of you, and it leads to this inflammatory process, this oxidative stress, and that’s what causes the heart disease. And some of the interesting studies that I’ve seen, like the Jupiter Study, very big trial from Harvard on heart disease, fascinating to me … The people who had high LDL but no inflammation had very low risk. The people who had high inflammation but kind of okay cholesterol, they were at risk. And those with high cholesterol and high inflammation had the most risk. So I think we have to be focused on inflammation and what’s causing that. And it may be that the statin drugs, it turns out, that the benefits may not have a lot to do with cholesterol lowering.
Dr. Elizabeth Boham (16:49):
But they’re anti-inflammatory.
Dr. Mark Hyman (16:50):
They’re very powerful anti-inflammatory drugs, which is quote “a side effect.” But it actually works. Now, there’s a lot of better ways to get rid of inflammation besides taking statin drugs. And so when you’re talking about people’s cholesterol, how do you decide what to do for each patient? How do you decide from a functional medicine perspective how to work these patients up to decide whether they should go on a drug or whether you just do lifestyle? How do you figure that out?
Dr. Elizabeth Boham (17:15):
It is a complex process. We’re taking a really detailed history, and we’re looking at more than just those numbers. We’re looking at what are their markers of oxidative stress. We can measure those. We can measure oxidized LDL. We can measure 8-hydroxydeoxyguanosine and lipid peroxides. All of these biomarkers that give us a sense of is there oxidative stress.
Dr. Mark Hyman (17:35):
And, by the way, these kinds of tests are not things you’ll typically get at your regular doctor. At the Ultra Wellness Center here in Lenox, Massachusetts, we do functional medicine, which takes a deeper dive into the root causes, into these diagnostic tests which are not available usually through your traditional doctor. They may not be interested in, or know what to do, or how to interpret even fasting insulin, which they don’t even do. So we really are excited to help people figure out how to look at their risk and design a strategy that’s personalized for them using functional medicine. And we see people from all over the world at the Ultra Wellness Center. We’re doing Zoom consults now. So it’s really easy to get access.
Dr. Elizabeth Boham (18:09):
It’s fascinating, because there’s so many pieces to the puzzle. And so when you find somebody with high oxidative stress, you ask that question, “Why? Why is there high oxidative stress?” Is it their poor diet? Is it inflammation?
Dr. Mark Hyman (18:20):
Is it their microbiome?
Dr. Elizabeth Boham (18:22):
Is it their microbiome? Is it a toxin?
Dr. Mark Hyman (18:25):
Dr. Elizabeth Boham (18:25):
Heavy metals, like a toxin or some other-
Dr. Mark Hyman (18:28):
Dr. Elizabeth Boham (18:28):
Dr. Mark Hyman (18:29):
All this smoke that the wildfires in California … That increases risk of cardiovascular disease.
Dr. Elizabeth Boham (18:34):
Absolutely. Absolutely. So it’s really important to think about all the different things that can lead to oxidative stress and inflammation, and then try to tease out what is it for that individual person that we need to focus on. So I think that’s important. For some people, and a lot of Americans, there’s so much that’s lifestyle-related, right? But for some people, their lifestyle’s great, and it’s more toxin-related, that we really need to work on that. Or, like you mentioned, the microbiome is an area that’s fascinating, and we’re learning so much about how it influences inflammation in the body. Microbiome in your gut as well as microbiome in your mouth, and gingivitis and how much that … We’ve known for years that that impacts risk of heart disease because of its inflammatory properties. So those are important things that we need to really investigate and look at.
Dr. Mark Hyman (19:25):
Yeah. So true. I’m just thinking about how we work with these patients. So we look at all of these diagnostic tests that may not be looked at. We look at their overall cardiovascular risk, their family history. We may look at diagnostic tests. We may send them for a heart scan to look at calcium, or an ultrasound. Look at particle size. Look at inflammation markers, oxidative stress markers, the microbiome, heavy metals. We might look at other factors like homocysteine, which looks at B vitamin. We look at lipoprotein A and a bunch of other factors that give us a more rounded picture of what’s going on. And so we’re not just focused like a laser on cholesterol. And the reason, it seems to me, that we are so hyper-focused on cholesterol is we have a good drug to treat it. Right? So it’s all pharmaceutical-driven, whereas when you look at the data, two-thirds of all people entering into an emergency room with a heart attack have either pre-diabetes or diabetes, and most of them are undiagnosed.
Dr. Elizabeth Boham (20:18):
Right. So when you say-
Dr. Mark Hyman (20:19):
So if two-thirds of heart attacks are from sugar, not cholesterol issues, and we’re just focusing on cholesterol, it seems like we’re missing the mark here.
Dr. Elizabeth Boham (20:28):
We often are. And we’re saying, “Okay. This is high.” I mean, so many people come back with high on their lab work, and it doesn’t necessarily, like you said, mean it’s anything to be concerned about. And then there’s so many people who come back without that H, that high level, and they do need to be concerned.
Dr. Mark Hyman (20:45):
Hey, everybody. It’s Dr. Hyman. Thanks for tuning into The Doctor’s Farmacy. I hope you’re loving this podcast. It’s one of my favorite things to do and introduce you to all of the experts that I know and I love and that I’ve learned so much from. And I want to tell you about something else that I’m doing, which is called Mark’s Picks. It’s my weekly newsletter, and in it, I share my favorite stuff, from foods to supplements to gadgets to tools to enhance your health. It’s all the cool stuff that I use and that my team uses to optimize and enhance our health. And I’d love you to sign up for the weekly newsletter. I’ll only send it to you once a week on Fridays, nothing else. I promise. And all you have to do is go to drhyman.com/picks to sign up. That’s drhyman.com/picks, P-I-C-K-S. And sign up for the newsletter and I’ll share with you my favorite stuff that I use to enhance my health and get healthier and better and live younger longer. Now, back to this week’s episode.
Dr. Mark Hyman (21:40):
Statins have a role, but let’s talk about the statins for a minute, because it’s very controversial. Like any drug, there are benefits, there are risks, there are side effects, and there’s the right patient for the job. So how do you come to decide what you should do with a patient?
Dr. Elizabeth Boham (21:58):
Yeah. I mean, you really want to get a good, detailed family history. I think that there are some people who are at very high risk of vascular disease. And for people who have a strong family history, which means that if you have a first-degree relative, which would be a parent or a sibling who has had a early heart attack, so for a man, less than 55, or a woman, less than 65 … that means they’ve had diagnosed heart disease because of plaque at an early age … Those people who have that type of family history need to be more careful.
Dr. Mark Hyman (22:32):
Or were they smokers? Were they very overweight? Did they have diabetes? What are the other factors? I always look at that as well, because-
Dr. Elizabeth Boham (22:38):
You have to.
Dr. Mark Hyman (22:39):
… I remember my grandfather, everybody in his family … I think he had nine siblings … everybody had heart attacks in their 50s. They all had bypasses, heart attacks. And they weren’t significantly overweight, but they were pretty high risk, as a family. And he was deaf, so he couldn’t hear. So he really couldn’t get a job, like a white-collar job. So he had a blue-collar job, which was basically loading big bundles of New York Times onto the trucks from the conveyor belt. So he was constantly working out all day long and was very, very strong and healthy. And every night he would go out in Queens and he would down the street and feed all the alley cats. So he walked every night after dinner, which we now know is a very good way to improve your health. And he didn’t really get heart disease until his 80s. And they all got it in their 50s. And his diet wasn’t the best. But still, even with simple lifestyle things, it can make a big difference.
Dr. Elizabeth Boham (23:37):
Absolutely. So you bring up a great point, that genetics and family history is just one piece of the puzzle. It’s not what makes us make all the decisions in the world, but we take that into account, as well as all their other risk factors like you’ve mentioned, like type 2 diabetes, and are they a smoker, and … So we really have to pay attention to all of those lifestyle factors.
Dr. Mark Hyman (24:00):
And high blood pressure, a lot of high blood pressure is a big factor in heart disease. But, again, high blood pressure is usually caused by the same thing, which is insulin resistance-
Dr. Elizabeth Boham (24:07):
Dr. Mark Hyman (24:07):
… so is sleep apnea. Yeah. It’s very, very common. And I just sort of recall a patient … I’d love to hear any cases you’d like to share. But I just remembered a patient I saw that was about 50 years old, and he came to see me. And he had a little bit of belly fat, maybe 20 pounds overweight. He’d had a heart attack, had a stent, and was freaked out, at 50 years old to have his heart be at risk like that. And he was on a pile of medications when I saw him. He was on a statin, a beta blocker, blood thinner-
Dr. Elizabeth Boham (24:38):
The whole cocktail.
Dr. Mark Hyman (24:38):
… blood pressure pills, pretty much everything. And I said, “Well, listen. Are you willing to make some changes?” And so he totally revamped his diet. We got rid of all the junk out of his diet. Very, very low sugar, starch diet. Lots of good fats. Lots of fiber. Got him on some basic supplements, B vitamins, folate, and also fish oil. Got him on an exercise program. And over the course of a year, he lost I think … I don’t know. Maybe he was more overweight. I think he lost almost 50 pounds. He was able to normalize all of his numbers. And his blood sugar was high. His insulin was high. He wasn’t quote “diabetic” but he was pre-diabetic.
Dr. Mark Hyman (25:21):
And they completely missed it. It’s staggering to me that after 30 years that I’ve been doing this, that the literature has been there, that doctors don’t check for pre-diabetes on a regular basis, which affects, basically, one out of every two Americans or more. And so you check that by measuring insulin, A1C, a glucose tolerance test with insulin. There’s ways to look at it. And look at particle number and particle size. And he lost the weight, and he was able to reverse all of his numbers, and he was able to get off all of his medications, including statins. And his numbers were better off the statins than they were on it by fixing all these lifestyle factors. And he’s been heart attack free for the last 20 years.
Dr. Elizabeth Boham (26:07):
Dr. Mark Hyman (26:08):
So I think we are so stuck in this paradigm of treating the symptom, the cholesterol, instead of the cause.
Dr. Elizabeth Boham (26:16):
Absolutely. That’s critical. That’s a good story.
Dr. Mark Hyman (26:20):
You’ve had some patients too, right? So-
Dr. Elizabeth Boham (26:23):
Yeah. The two cases I wanted to talk about today were people with this in between cholesterol, where they really wanted to know what to do. They weren’t crazy high risk, but they were told they should go on medication, and they came to me to say, “Well, is that the right decision, or what else can I do?”
Dr. Elizabeth Boham (26:42):
So the first one was a 45 year old gentleman who was told his cholesterol was too high. He didn’t have a strong family history of heart disease, but his total cholesterol was 225. His good cholesterol, his HDL, was 37.
Dr. Mark Hyman (26:58):
Which is low. It should be over 50, right?
Dr. Elizabeth Boham (26:58):
It’s too low. His triglycerides were 185 fasting.
Dr. Mark Hyman (27:04):
Which is high, right? Should be ideally under 70.
Dr. Elizabeth Boham (27:07):
Too high. And his LDLs were 145. So his doctor said, “You know what? I think you should start some medication.” And he said, “Well, you know what? I want to see what else I can do.” So he came to see us, which was great, because a lot of times with patterns like this, we can make a huge change.
Dr. Elizabeth Boham (27:24):
So we did an NMR lipoprofile. So we looked at those particle sizes, and we saw that he had a lot of the small, dense LDL particles. His pattern … they sometimes give you a pattern. Are you pattern A or pattern B? Pattern B being the more concerning. You have too many small, dense LDLs. And that’s what he had. He looked like he had a high risk for insulin resistance, which we knew even before we did the tests, because his waist/hip ratio was too high. His HDL was too low. His triglycerides were too high. So it was obvious, but that test confirmed that. It said you have a high risk for insulin resistance based on your cholesterol panel. And we also-
Dr. Mark Hyman (28:05):
Before you go there, I just want to point out, because this is really a very easy, cheap way to check to see if you have insulin resistance. And it’s a far better predictor of your risk of heart attacks than your LDL.
Dr. Elizabeth Boham (28:17):
Dr. Mark Hyman (28:17):
Which is your triglyceride to HDL ratio. And this guy had a ratio of about 5. If it’s over 1, not great. If it’s over 2, you’re in trouble. He was 5. And that pattern of high triglycerides, low HDL is what you see in these patients with pre-diabetes even though they might have a normal cholesterol. I mean, his was 225, but I’ve seen people with a total of 150, triglycerides of 300, HDL of 29. I’m terrified for these patients.
Dr. Elizabeth Boham (28:44):
Dr. Mark Hyman (28:44):
Even though their total cholesterol is 150, [crosstalk 00:28:47] ideal.
Dr. Elizabeth Boham (28:47):
You’re absolutely right. Right. That’s where we get really nervous, because we know that’s such a pro-inflammatory process. And what we know about heart attacks, especially sudden heart attacks, there’s typically … I always sort of draw this picture for my patients of the inside of the artery. And so often we think when somebody has a heart attack, the plaque just keeps building, building, building, building. They’re 50 percent blocked, and then they’re 90 percent blocked, and then they’re 100 percent blocked and they have a heart attack. But what we know is that sometimes you’re only 30 percent blocked, but if that’s inflamed, if that blockage is inflamed, kind of like that can rupture, and then cause a significant blockage.
Dr. Mark Hyman (29:30):
It’s like a pimple popping that then your body protects by making a blood clot in your artery.
Dr. Elizabeth Boham (29:35):
Right. And that really often what we see when somebody has a sudden heart attack, right? That blockage just ruptures, and so it’s often missed. People aren’t necessarily coming in with years of chest pain and shortness of breath, those things we see as people get older. They just have a sudden rupture of that plaque. So, yeah, those are the situations you get really nervous. And a lot of times, you see a lot of inflammation. So we also did an oxidized LDL with him, which was high and concerning.
Dr. Mark Hyman (30:07):
That’s the rancid cholesterol.
Dr. Elizabeth Boham (30:09):
Yep. That’s that rancid cholesterol. For him, with all those signs of insulin resistance, metabolic syndrome, the diet for him was that really low glycemic diet. We needed to work to lower those carbohydrates, to lower the sugar. We know that triglycerides really decrease when you cut out juices, sugars, alcohol-
Dr. Mark Hyman (30:31):
And they’re basically fats that are made in the liver when you eat sugar and starch, right?
Dr. Elizabeth Boham (30:37):
Dr. Mark Hyman (30:37):
They’re not produced by eating fat.
Dr. Elizabeth Boham (30:39):
Nope. Nope. Sugar. And you can lower your triglycerides pretty quickly when you pull out the alcohol, the juice, the lots … if some people doing too much fruit-
Dr. Mark Hyman (30:50):
Flour and sugar.
Dr. Elizabeth Boham (30:51):
Flour and sugar. Absolutely. Sugar, sugar, sugar. So when you cut that out, you can bring your triglycerides down really pretty substantially, pretty quickly. So we really focused on lowering his carbohydrate load, all the bad carbs. And you also focus on giving him more of the omega-3 fats, because we know those omega-3 fats are really anti-inflammatory. And two to four grams of omega-3s a day can lower your triglycerides and raise up that HDL.
Dr. Mark Hyman (31:21):
And this is FDA approved as a drug, quote “a drug,” which is fish oil, which is prescription that you can buy to lower your triglycerides.
Dr. Elizabeth Boham (31:30):
And you can get it from food, right? Like a can of sardines. Three ounces of sardines has about two grams of the omega-3s in it.
Dr. Mark Hyman (31:36):
That’s what I’m having for lunch.
Dr. Elizabeth Boham (31:38):
That’s my favorite lunch, sardines on a salad with some walnuts, very heart healthy. So we made that switch with his diet. And what was amazing, and what I love to see is in three months we repeated that NMR lipoprofile, and he went from having too many of the small, dense LDLs to having … He was now considered pattern A. He had more of the big, fluffy LDLs. His HDL improved. Now, it wasn’t yet optimal, but I think it got up to like 47 in three months. His triglycerides came down to 120. So maybe not … This was just three months of doing this. We can see really quick changes in people’s bodies with making these changes in lifestyle, which is phenomenal.
Dr. Mark Hyman (32:23):
Yeah. I think one of the other thing I want to talk about … this is a great case. You’re able to change his diet and improve things. But one of the things that we’re really bad at in medicine is personalizing care. And there’s no place that’s more important to personalize your care than dealing with your heart attack risk and cholesterol, because it’s different for different people.
Dr. Elizabeth Boham (32:41):
That’s very true.
Dr. Mark Hyman (32:42):
And what I’ve seen, I’m sure you’ve seen this over the years, is people respond dramatically differently to the same diet. So typically we’re told, by the American Heart Association, that we should have less than 5 percent of our diet as saturated fat. Although, breast milk is 25 percent saturated fat, so maybe we should ban breast milk, according to the American Heart Association. I don’t know about that. But it’s really important to get saturated fat in your diet, because it’s a building block for cholesterol, which is not necessarily a bad thing. I mean, your cholesterol makes your hormones. It makes the nerve coverings for your nerves. That’s part of your brain. I mean, it’s really important. A lot of your hormones are made from cholesterol, your sex hormones. And what I found is depending on the person, their response is very different to diet. And I’ve talked to Dr. Ronald Krauss, who’s one of the world’s experts in cholesterol and this, and he says, “There’s a lot of heterogeneity.” And I’ve seen this. Just two cases come to mind. One was of a woman who was overweight; who was clearly pre-diabetic; whose triglycerides were 300, which is really high, it should be under 70. Her HDL was like 30, which is terrible. Her total was probably 250-260. It was pretty high. She had a lot of small particles, a lot of overall particles, just way off.
Dr. Elizabeth Boham (33:59):
Yes. Metabolic syndrome.
Dr. Mark Hyman (34:00):
Yeah. And she struggled with weight loss and diet. So I put her on a high saturated fat diet. I put her on basically butter and coconut oil, and almost a ketogenic diet. And it was striking. She never could lose weight. She dropped 20 pounds like that. Her cholesterol dropped 100 points. Her triglycerides dropped over 200 points. Her HDL went up 30 points. And you just can’t get that result with a drug.
Dr. Elizabeth Boham (34:29):
Dr. Mark Hyman (34:30):
So I did that with her, and saturated fat was the cure for her cholesterol, not the cause. But another guy was this super fit, mid-50s biker, would bike 50 miles a day, and super healthy. And his cholesterol wasn’t great. And he had a genetic issue with his cholesterol and had more of the small particles. So I said, “Let’s try just do more of a ketogenic diet. See what happens. Or more saturated fat.” His cholesterol turned terrible. So we had to totally change gears and get him off saturated fat. And I think we’ll soon be able to do a test, which is a cheek swab or a drop of blood, measure your genetics, and figure out which one are you. Are you somebody who should be eating more fat and saturated fat, or more carbohydrates, or more of the right foods, different kinds of fat? We’re not quite there yet, but I think in functional medicine, and here at the Ultra Wellness Center, we can on an individual basis really come to learn what is the right thing for this particular person. And I think it’s really important.
Dr. Elizabeth Boham (35:30):
Yeah. That’s so important. That’s so important, because what’s really key diet is personalizing it, right? That’s when we get the most benefit from our nutrition intervention. And I think what you mentioned with the first woman, the reason you saw such an improvement with the ketogenic diet is you lowered her insulin so much. So we know that the carbohydrates that you eat cause your insulin to spike. So when your insulin is high, and you can’t lose weight because your insulin is high because it’s causing you to put on weight around the belly, when you change to a diet that doesn’t cause your insulin to go up, which is like a ketogenic diet … I mean, that’s the extreme, but you can do some things in between, too. But then that insulin doesn’t go up, and that’s when we can see huge benefits for some people in that situation.
Dr. Mark Hyman (36:18):
That’s really true. I mean, insulin, for the most part … And for the one guy it wasn’t, because he was so fit, and there’s genetic variations. But, for most people out there, it is really the most common thing. And, aside from getting the NMR particle test, getting a measure of your fasting insulin, really great. If you can an insulin test after you have a sugar load, that’s even better, because by the time your blood sugar goes up, you’re down the road, way down the road. I mean, it’s a late stage phenomenon, even having your blood sugar going up fasting, and then two hours after a sugar load, you see it a little earlier.
Dr. Mark Hyman (36:50):
But doing these tests for decades, I just see this pattern over and over again. You can have perfectly normal sugar, perfectly … I mean, I had one woman who was really overweight and she had a giant belly, and clearly she was metabolic syndrome. She had high triglycerides, low HDL, same pattern. But when I measured her glucose tolerance test and her A1C, perfectly normal. Like her fasting blood sugar was normal. Her average blood sugar was normal. Her one and two hour blood sugar tests, like normal. Her fasting was in the 80s. After was like 110. But I measured her insulin. Now, normal insulin should be under 5. If it’s over 10, kind of in trouble. Her fasting insulin was like 30. And then we did a sugar load, and her insulin went up to 200, 250, and it should be under 30 after a sugar load. So she was like 10 times normal, and it was keeping her blood sugar normal, but it was driving all this weight gain and inflammation and abnormal cholesterol. So you really have to dig in in a different way than your traditional doctors are digging in.
Dr. Elizabeth Boham (37:52):
Absolutely. Those people can’t … they have such a hard time losing weight, especially if you don’t pull the carbohydrates to low.
Dr. Mark Hyman (37:58):
Yeah. I mean, she lost 50 pounds like that.
Dr. Elizabeth Boham (37:59):
Once you pulled the carbohydrates out.
Dr. Mark Hyman (38:00):
Yeah. It’s so easy. I feel embarrassed about it, because what we’re telling people to do is so simple, but when you understand the biology … which is what functional medicine really is about. It’s understanding each of our unique biology, looking at things that traditional doctors don’t look at, at function, at differences in the responses to different insults, like diet and toxins and various things. So we have a really different scope.
Dr. Mark Hyman (38:26):
At Cleveland Clinic, where I also work, one of the leading doctors there, a cardiologist, Stan Hazen, has done incredible work looking at the microbiome and how the environment and the gut can increase your risk of heart disease and how certain foods increase certain problems. And it’s just fascinating to think here at the number one heart hospital in the world, they’re going, “Wait a minute. Maybe we should be looking at poop.” And so the paradigm’s breaking down. The hyper-laser focus on cholesterol, which we’re talking about today, is only one small part of the story.
Dr. Mark Hyman (38:59):
And getting into the nuances is really important in order to really look at your risk and design the right program for you. And that’s what you do. Here, at the Ultra Wellness Center, it’s what we do. We’ve been doing it for decades. And I think it gives people a chance if they’re concerned about their heart disease risk, to come up with a personalized plan that can help determine their best outcomes and reduce all of these factors.
Dr. Elizabeth Boham (39:21):
Yeah. So the second case I had, she was not at risk for insulin resistance significantly. Her insulin, I don’t really remember what it was, but it wasn’t that concerning to me. But she was also concerned about her cholesterol. She was 55. Her doctor had just checked her cholesterol. Her LDL cholesterol was 160. So he was recommending some medication. She didn’t have a strong family history. But when we looked deeper, or when we … with her cholesterol … so showed her triglycerides were okay, at 90. Her HDL was 55, again, maybe not perfect, but it was really that LDL cholesterol I was a little more concerned about. We did particle size testing on her, and she didn’t have too many of those small, dense LDLs. She was more pattern A, more of the big, fluffy LDLs, which made me happy to see. But she’s like, “I want to bring down this LDL cholesterol.”
Dr. Elizabeth Boham (40:20):
So with her, the focus in the diet was a little bit different. She was about 10 pounds overweight, so she wanted to lose some weight. So we focused on that. And then we also really focused on her protein, because protein’s really important as well when we’re talking about cholesterol, because there’s some vegetable proteins that can help with lowering that LDL cholesterol. So beans and legumes, nuts and seeds, these are vegetable sources of protein that have plant sterols in them. And they can help bind to the cholesterol in the gut and lower your LDL cholesterol. So when I have a situation like this, I really talk to them about balancing where they’re getting their protein from. More of that pegan diet, where they’re getting some of their protein from a vegetable source, like beans and legumes, healthy forms of soy, nuts and seeds, and some of their protein from an animals source, but maybe not … more of as that condimeat, as you speak about. So I think that’s a really important area to focus on. So she, with three months or so, the weight came down, and when we re-checked her, we saw that LDL cholesterol come down to like 130 and her HDL even went up higher, which was great to see. So she had a nice improvement with shifting her diet, but we just focused a little bit differently than we did with the first gentleman.
Dr. Mark Hyman (41:42):
And you’re right. I think you bring up a lot of very important points. It’s not just what you take out of your diet, like sugar and starch. It’s what you put in your diet. And using compounds that are naturally found in plants, like plant sterols that come in beans and nuts and seeds and high fiber, you can really have a big impact. And I think one of the things I like to use as extra fiber is something called PGX, which is basically from a root of a Japanese vegetable called konjac. It’s not like the alcohol. It’s K-O-N-J-A-C. And it’s a fibrous root. You can actually make noodles out of it. There’s these shirataki noodle, so you can have pasta, in a sense. But it actually is zero calories. It’s all fiber. And it blocks the absorption of cholesterol from your gut. So adding more fiber plays a huge role, changing the quality of your diet, increasing the good fats like olive oil or the avocado, and also improving the overall content of phytochemicals in your diet, all helps to reduce your risk dramatically.
Dr. Mark Hyman (42:45):
And I think we’re really not focused on that in medicine. We’re just like, “Here, take this drug. I’ll see you later.” And people will often get a false sense of security, say, “Oh, I’m taking my statin. I can have the fried food, or I can go to McDonald’s.” They were talking about selling Lipitor at McDonald’s, which I thought was insane.
Dr. Elizabeth Boham (43:02):
Dr. Mark Hyman (43:02):
But I think we really have to understand that heart disease is a complex disorder. It’s not just about cholesterol. That from a functional medicine perspective, we do much more detailed workups looking at inflammation, oxidative stress, looking at particle size and number, looking at even your gut, heavy metal toxins, other factors of nutrition like homocysteine. And we get a really good sense of what’s going on, and we then personalize the treatment. And it’s a very, very different approach to reducing your risk. And it’s been so satisfying for me. I’ve had patients who’ve had heart attacks and then we follow them for 20 years and they’re just great, and they’re healthy, and they have no risk, because they really have changed the cause of their heart attack. So taking a statin doesn’t change the cause of why your cholesterol’s messed up.
Dr. Elizabeth Boham (43:47):
That’s very true.
Dr. Mark Hyman (43:48):
And I think it’s … I want to say heart disease is not a statin deficiency, right?
Dr. Elizabeth Boham (43:51):
Mm-hmm (affirmative). Right.
Dr. Mark Hyman (43:52):
So thank you so much Dr. Boham, Liz, for being on The Doctor’s Farmacy podcast. If you’ve suffered from heart disease, if you are having issues with cholesterol, if you’re concerned about it, someone in your family’s struggling with issues, I really encourage you to dig deeper. Don’t just accept at face value that you should take a statin, cholesterol is the problem. It’s often more complex. And find a doctor or practitioner who can help you. We’re, at the Ultra Wellness Center here in Lenox, Massachusetts, happy to help anybody. We’re doing mostly Zoom and virtual consults now, so we can take care of anybody from anywhere. And it’s just really satisfying to see how quickly people respond and fix these things and get off the medications and fix their numbers, and more importantly, they get better. They feel better.
Dr. Elizabeth Boham (44:32):
They feel better.
Dr. Mark Hyman (44:32):
Because I don’t really care about the numbers as much as how do you feel, what’s your vitality, energy? And I think the side effects of these medications are not benign. And so I’m just so excited we got a chance to talk about this on The Doctor’s Farmacy. You’re just a wealth of information and knowledge, and I’m so excited that we get to do these House Call podcasts and give people information about things that, often, they’re struggling with and have questions about that are kind of obtuse but that in functional medicine we really do a powerful job in fixing.
Dr. Elizabeth Boham (44:59):
Thank you, Mark.
Dr. Mark Hyman (45:00):
So if you’ve been listening to this podcast and you loved it, please share it with your friends and family on social media. Leave a comment. We’d love to hear from you and how you’ve fixed your cholesterol. And subscribe wherever you get your podcasts. And we’ll see you next time on The Doctor’s Farmacy.