The Truth Behind Statins: Helpful or Harmful?

Introduction:

Coming up on this episode of The Doctor’s Farmacy.

Dr. Aseem Malhotra:

It’s estimated potentially about one billion people around the world are prescribed statins. It’s also one of the most lucrative drugs in the history of medicine. It’s estimated I think last year, total revenues from sales of statins reached a trillion US dollars.

Dr. Mark Hyman:

Welcome to Doctor’s Farmacy. I’m Dr. Mark Hyman, and that’s Farmacy with an F, a place for conversations that matter. And if you are confused about cholesterol, well, listen up because you will not be by the end of this and you might have your thinking completely overturned from what the traditional concepts are about cholesterol, statins, what we should be managing and what the real causes of heart disease and how to prevent them. And we have none other than my good friend, my colleague, a co-revolutionary in transforming the food system and calling out the injustices that exist within our food system that cause obesity and chronic disease, Dr. Aseem Malhotra from the United Kingdom. He is a national health service trained consultant in cardiology, so he’s a cardiologist. He’s a visiting professor of evidence-based medicine in the, I don’t know if I’m saying it right, Bahiana School of Medicine and Public Health in Salvador, Brazil.

Dr. Mark Hyman:

He’s a founding member of Action on Sugar, and he also became in 2015, the youngest member to be appointed to the board of trustees for the UK health charity, The King’s Fund, which I think is a very important fund. He’s always in the media. He’s always talking up, he’s always telling the truth and he’s called out in many ways for his radical views, but he’s testified in front of parliament and is really doing so much to change thinking about health and wellness in the UK and across the world. He’s written many articles and scientific literature, many of which have influenced me. He’s become a good friend and colleague and I am so glad to welcome you, Aseem, to The Doctor’s Farmacy.

Dr. Aseem Malhotra:

Thank you, Mark. It’s an absolute pleasure always to speak to you.

Dr. Mark Hyman:

Now, you’ve written many books, The Pioppi Diet, The 21-Day Immunity Plan. Your latest book is one I’m most excited about. It’s called A Statin-Free Life. A Statin-Free Life, a revolutionary life plan for tackling heart disease without the use of statins. And I have always had a love, hate relationship with statins because they are a drug which has some benefits, but what seemed to have happened is that there’s been a wholesale embracing of this class of medication as the panacea for preventing and treating heart disease. And your book challenges that thesis, one, that LDL cholesterol is the problem, which is primarily what the statins do is lower LDL, and two, that statins are not a free ride and they come with a lot of inherent risks and side effects, and three, they’re actually not that effective and that the data we have has been highly manipulated.

Dr. Mark Hyman:

And it reminds me of a quote from, I think Mark Twain, or maybe Roger Williams. He said, “There’s liars, there’s damn liars and there’s statisticians.” And I think the way that the data gets squeezed and manipulated often give the impression of a profound benefit, but you challenge that hypothesis and you challenge us to think differently about statins. So I think it’s going to be a very controversial conversation. I’m really excited about it and I hope to learn a lot because even though I’ve studied this for the last 30 years, I’m still freaking confused because there’s so much data. And you’ve just gone into it and I’m so happy to have you, Aseem. Welcome. Welcome. Welcome.

Dr. Aseem Malhotra:

Thank you, Mark. No, absolutely. I think before we continue down this track and more detailed discussion, I think what people need to realize is that we are, I am, we are coming from position about ethical evidence based medical practice and about giving the right patient the right treatment at the right time with informed consent. So really the premise of the book is really about informed consent. It’s about helping and empowering members of the public, patients, even doctors to really have a better understanding of cholesterol and its role in heart disease, but also have an equal, if not more important understanding of the role of statins in preventing and managing heart disease. And I really lay it all out for the reader based upon the totality of evidence. We all have our own biases and I’ve done my very best to ensure that I’ve looked at all the evidence and tried to break it down independently.

Dr. Aseem Malhotra:

And at the same time, Mark, also give people an alternative plan, whether or not they choose to take a statin. And again, I would always argue that’s the patient’s choice ultimately, but also to not be ignoring something that you’ve pioneered magnificently over many, many years the impact of lifestyle, which as you know, is more impactful in many ways than medications and come with side effects and mostly-

Dr. Mark Hyman:

Lifestyle has a lot of side effects; wellbeing, happiness, joy, good health-

Dr. Aseem Malhotra:

I’m sorry. Yeah. You’re right. Absolutely.

Dr. Mark Hyman:

All the side effects are good ones.

Dr. Aseem Malhotra:

Positive side effects.

Dr. Mark Hyman:

Better sleep, better sex, weight loss.

Dr. Aseem Malhotra:

Yeah. A hundred percent. That’s what it’s about, right? Because we are all going to die eventually, but we want to have the best chance of having authentic happiness for as long as possible, and of course, our happiness is very much linked to our physical health as well. So this is really the heart of the book. And I’ve researched this as you know, in detail probably over a decade, looking at cholesterol, trying to understand the root cause of heart disease and trying to shift the conversation and shift the balance towards overall improving individual patients’ health, but also population health as well. And I think where we’ve gone wrong is we’ve, first and foremost, grossly exaggerated the fear of cholesterol and its role of heart disease. We’ve then now, because of that fear, the focus has been that the primary way of preventing heart disease is to reduce cholesterol and the most effective drugs of doing that have been statins.

Dr. Aseem Malhotra:

So widely prescribed, Mark, it’s estimated potentially about one billion people around the world are prescribed statins. It’s also one of the most lucrative in the history of medicine. It estimates, I think last year, total revenues from sales of statins reached a trillion US dollars. So there’s a lot of money involved as well. And I think that is important for people to be aware because that, I think, introduces a huge bias into the conversation. A lot of vested interest depend on fear of cholesterol lowering and statins and other cholesterol lowering drugs. So it’s like, well, actually let’s just break it down so that people are better informed. And then one of the things I’ve also advocated for is something called shared decision making, which is an approach where you have a more equal partnership and when it comes to conversations with patients about any kind of treatment or investigation that they’re going to go through.

Dr. Aseem Malhotra:

But except that it’s really important that we take into consideration patients’ individual preferences and values. So if you look at the evidence based medicine triad, which is geared towards improving patient outcomes, there are three big components. So you’ll use your best available evidence, your individual clinical expertise and last but not least, patient preferences and values. And what I teach my medical students is if you are adhering to those principles, then you are going to increase your chances of improving your patient’s health and wellbeing and that’s really what it’s about. So that’s really the background to the book.

Dr. Mark Hyman:

That’s great. I think that’s a very important framework and what I would like to do is zoom out for a minute and have you answer are a couple of key questions because I hear conflicting versions of the data from cardiologists. And it seems, yes, number one killer in the world is still heart disease. However, I’ve heard cardiologists say we’re winning the war because death rates are going down. We’re better at actually treating the disease, we’re better preventing the disease. Statins have played a big role in that and we shouldn’t ignore that fact, but you suggest that maybe that’s not true and in fact, maybe that the death rates aren’t going down, maybe heart attack rates aren’t going down. So can you kind of unpack the data for us. What is the truth about, one, this massive, this massive drive to put everybody on a statin if your cholesterol’s a little high.

Dr. Aseem Malhotra:

Yeah. Yeah. Absolutely. So-

Dr. Mark Hyman:

And the fact that maybe it isn’t doing all that it’s cracked up to do. So talk about that.

Dr. Aseem Malhotra:

Absolutely, Mark. So yeah, that’s a very good point, right? So let’s try and break all of that down. So death rates from heart disease started to increase in the 1920s. Look at data in the US. Let’s just look at US data, which pretty much parallels most of Western Europe as well, and it peaked around 1970. And then since 1970, the death rates have started to drop. But something I’ve published on the BMJ before is if you break that down to try and see what are the different factors that reduced heart disease, the biggest impact actually was reduction in smoking prevalence. Probably response were about 50% of reduction in death rates. Other factors, emergency care, emergency treatment of heart attacks. So we had thrombolysis, these drugs called thrombolytics that help people. We had emergency stenting, which in the acute phase in a heart attack certainly is lifesaving. Not in the stable phase, that’s a different discussion, but certainly in the acute phase.

Dr. Aseem Malhotra:

The development of coronary care units. So a lot of people used to die from heart disease, Mark, because once they were in hospital, they would have a cardiac arrest, which is more likely to happen within 24, 48 hours of having a heart attack. And we then develop [inaudible 00:09:42] where we could monitor patients and then defibrillate them-

Dr. Mark Hyman:

We’re better rescuing them from what happens once you get a heart attack.

Dr. Aseem Malhotra:

Absolutely. And in fact, they’re a life saver. If you have a cardiac arrest and it’s witnessed or you’re in hospital and it’s because of a heart attack, nine times out of 10, you’ll be saved from a defibrillator and you’re fine and your prognosis is same as somebody that didn’t have a cardiac arrest. So all these things are there, maybe to some degree the reduction of trans fats in the food supply as well. That also had a role. But when you look at statins, and this is something that’s actually recently been analyzed, they looked at Western European countries over 12 years since 2000, 2012, right? To see had an increase in statin prescription for different risk groups, low risk and high risk, did that correlate with any reduction in cardiovascular death, death rate from heart disease. And the answer was no. The question is, well, how can that be explained? So again, let’s break the data down.

Dr. Aseem Malhotra:

If you look at the average increase in life expectancy from taking statins from industry sponsored data, so we take that with a pinch of salt because industry sponsored studies, which are most of the statin studies in general are designed and the results are geared to kind of exaggerate the benefits and minimize the harms. But if we take that at face value, okay? Even-

Dr. Mark Hyman:

I want you to stop there for a minute, because it’s such an important point. Most of the data we have on statins is from drug company funded studies in which they actually often are contracting with research organizations to do the research. They’re hiring essentially hitmen names to put their name on the study. They design the study, they write up the study and then they get a bunch of cardiologists to sign off on it. Is that fair to say?

Dr. Aseem Malhotra:

Yeah, Mark. Absolutely. You’re spot on. In fact, just to take a step back for a second, if you look at the issues around health misinformation, we have something called the health misinformation mess, a quote I take from John Ioannidis, professor of medicine at Stanford. And there’s something called the seven sins that contribute to misinformed doctors and misinformed unwittingly harmed patients. They’re rooted in bias funding of research, right? So research that’s funded because it’s likely to be profitable, not beneficial for patients. Biased reporting in medical journals, biased reporting in the media, biased patient pamphlets, commercial conflicts of interest, defensive medicine and an inability of doctors to correctly communicate health to patients and also doctors to not understand health statistics properly. That’s something that isn’t taught very well at medical school and it’s certainly not something we are encouraged to do.

Dr. Aseem Malhotra:

So I’ve been involved with the BMJ and the medical colleges in the UK in 2015 to try and help revolutionize medical practice through medical education and post-graduate teaching, but it takes time. I mean, I was reading somewhere that when you try and revolutionize or change an approach to something that’s been embedded for a very long time within medical practice, apparently it takes 17 years, Mark, before that change happens. So we’ve got to keep fighting and campaigning for it. But you’re right. This is the issue with statins is it’s not dissimilar to many other drugs. And given that information, given those biases, even if you take all those biases into consideration, best case scenario, there was an analysis done to look at randomized control trials of statins in people with heart disease. Forget about prevention for a second. Statins benefits to be there, much stronger in people who’ve already had a heart attack or people who’ve been diagnosed with severe blockages in their arteries, okay?

Dr. Aseem Malhotra:

From those people from the trials who took statins religiously every day for about five years, because the trials only tend to last about five years before they’re approved and before it changes practice, the average or median increase in life expectancy is, over a five year period, 4.2 days, okay? So if we accept that slight increase in life expectancy over a five year period and then you add in the real world, Mark, within a few years of statin prescription, even people at high risk who’ve got heart disease, at least 50% of those patients stop taking statins within two to three years. You can understand from a scientific perspective, from a data perspective, forget about any fraud or any conspiracy theories, just from the data that’s already there, you can explain why statins may have not had any impact on reducing death rates from heart disease in the population.

Dr. Aseem Malhotra:

Now, when you look at individuals, and this is what doesn’t often take place in the conversation between doctors and cardiologists and patients, and to be fair and honest on this, I mean, I think most doctors actually don’t even know this information. That’s another reason I wrote the book is to educate doctors so they can have better discussions with their patients. If you’ve had a heart attack, and this is by the way, what I do all the time in my practice, so all my patient letters that go back to general practitioners, all the patients I see, I always put this in there in the discussion, if you’ve had a heart attack over five year period from an individual, the benefit of a statin taken religiously over five years is it prevents one in 39 of those patients from having a further heart attack and one in 83 in terms of delaying their death or saving their life, right? Now, given that-

Dr. Mark Hyman:

These are people who already have had a heart attack or are at very high risk.

Dr. Aseem Malhotra:

Absolutely.

Dr. Mark Hyman:

And by the way, for everybody listening, 75% of the prescriptions for statins are not for people who have had heart disease or who are very high risk. It’s for what we call primary prevention, and the data on that is even worse and I want you to explain that after you kind of unpack the fact that, gee, only one in 83 people have a death prevented. It means 83 people have to take this drug for five years with all the risks and side effects for one death to be prevented.

Dr. Aseem Malhotra:

Yeah. And Matt, so I caveat in that. What’s interesting is these are also most likely the patients that tolerated the statin and didn’t get side effects because those people are somehow weeded out of the trials. Often we have something called the pre-randomization running period before a randomized control trial starts where patients who don’t tolerate the drug or are non-compliant, they use this word, non-compliant, okay? Which doesn’t make sense to me to because if you’re enrolling in a trial and you volunteered, you are likely to be somebody who’s enthusiastic about taking a drug, right? So that doesn’t make sense to me, but very likely the people with side effects are weeded out within the first few weeks of a trial and then you then report on the results on the people who tolerate the drug, okay? So this is still a bias. So I talk to [inaudible 00:16:11], well, it’s more like those one and 83, one in 39 figures are people that tolerated the drug and were able to take it for five years.

Dr. Aseem Malhotra:

If you add in people who get genuine side effects, and sometimes we don’t know whether the side effects they experience are of statin or not, and I’ll explain what I do with my patients to kind of weed that out, it’s highly likely that that benefit is much smaller, if not even potentially nonexistent. We don’t really know, but there’s a chance that it’s nonexistent and that’s uncertainties. And we have to have those discussions with patients. I think doctors aren’t necessarily very good at saying, listen, there’s a lot of things we don’t know, but let’s just tell you what we do know and of course the potential biases and uncertainties. And Mark, in my experience with all the patients I’ve had these discussions with, even talking about industry bias and all that kind of stuff, patients appreciate that. They want honesty from their doctors. Anyway, so that’s on the secondary prevention, the high risk.

Dr. Aseem Malhotra:

If you look at primary prevention and you’re absolutely right, Mark, most of the people prescribed statins around the world are not high risk, okay? These are people who have got maybe a slightly high cholesterol or even have a risk profile more importantly that suggests they may have, say a 10 to 20% risk of having a heart attack or stroke in the next 10 years and there are risk calculators, people can go online and look at those risk calculators. If you have a less than 20% risk, if you’re not high risk from having heart attack stroke in the next 10 years, then the statin data suggests approximately convicting data, a 1% benefit. So one in a hundred in preventing a non-fatal heart attack or stroke over five years, but this is crucial, no mortality benefit. You’re not going to live one day longer. And when you look at data and studies looking at when we presented this sort of information to patients in this way, and this is without talking about potential side effects, not even gone there yet, most of those patients, Mark, would choose not to take with pill.

Dr. Aseem Malhotra:

It’s just extraordinary. So if we are actually adhering to the principles of ethical evidence based medical practice and informed consent, in my view, most people who are prescribed statins around the world would choose probably not to take the pill.

Dr. Mark Hyman:

Now, now that’s not to say that cholesterol isn’t a problem. The question is, how is it a problem and why is it a problem? And it’s quite different than what we think. And the overarching narrative has been that LDL cholesterol is the cause of heart disease. And it’s convenient because that is what statins do. But it reminds me of that joke of this guy who lost his keys on the street and he is looking under this lamppost and his friend comes by and says, “Hey, what do you do?” And he says, “I’m just looking for my keys.” He says, “Where did you drop them?” “Well, I dropped them down the street.” He says, “Why are you looking over here?” He says, “Well, the light’s better here.” So we have a drug that can treat LDL, but it actually doesn’t deal with the real root causes. And I just want to take a second for people to unpack why we’re looking at the wrong thing when we measure cholesterol today for the most part.

Dr. Mark Hyman:

Most people get a total cholesterol HDL, LDL, triglycerides, but it turns out that LDL isn’t even that good of a predictor of heart disease.

Dr. Aseem Malhotra:

Absolutely. Yeah. Really good point, Mark. So yeah, absolutely.

Dr. Mark Hyman:

Let me just finish this thought. And the JUPITER trial, which is one of the largest trials looking statins and heart disease found that if the statin lowered the LDL cholesterol, but not the CRP, in other words, if the C-reactive protein or the inflammation marker was high and you lowered LDL, it didn’t really have an impact. Only if the inflammation was lowered. And so we now know that the underlying risk for heart disease are inflammation and in some resistance which drives something that we call atherogenic dyslipidemia or a kind of cholesterol profile that makes you prone to heart disease. So tell us about a new way we need to be thinking about cholesterol rather than just a simplified, oversimplified dogma of LDL, statin, LDL, statin, LDL, statin, [inaudible 00:20:12] all day long. What is the things we should be looking at and what are those things and what are the causes of abnormalities in the real biomarkers of cardiovascular disease?

Dr. Aseem Malhotra:

Sure. Great, great points you make there, Mark. So taking a step back for a second, just so people kind of understand where we’ve gone wrong with the science on cholesterol or why certainly it’s outdated. And it’s important for people to realize, I think a lot of people have this misconception that medicine is an exact science and if something is truthful at one time, it must be absolute truth and it can’t be challenged. But the reality is-

Dr. Mark Hyman:

What?

Dr. Aseem Malhotra:

Well. Yeah, exactly. But you and I know, I mean the founder, if you like, one of the founding fathers of the evidence based medicine movement, David Sackett, said 50% of what you learn in medical school will turn out to be either outdated or dead wrong within five years of your graduation. The trouble is nobody can tell you which half, so you have to learn to learn on your own. So I bring that concept into how I start questioning that dogma. And I don’t think this was a conspiracy theory or malicious. I think vested interests have taken advantage of what is now outdated science. But traditionally, when people are trying to investigate the cause of heart disease up until the fifties, sixties, seventies, we knew that we found, and this is still true, is that people with genetically very high levels of LDL cholesterol, okay? So this would be, not everybody, but usually at least have an LDL of more than 4.9 mmol, which I think in US units is translated to 139 mg/dL, Mark, right?

Dr. Aseem Malhotra:

So those people who had at least an LDL of that level, most of those people had the genetic commission which affects one in 250 people. They had a very strong association with the development of heart disease. At the same time, people who had genetically low cholesterol and total cholesterol, certainly we’re talking about less 3.8 mmol/l, which I think would be, I can’t remember the cutoff, but I think it’s probably less than 150, if I’m not wrong, total cholesterol. Those people, 1 mg/dL, would have less heart disease, although they won’t live any longer. But most of the people in the middle, when you looked at that data from Framingham, which is one of the original big studies that followed up 5,000 people in Framingham, Massachusetts, starting in the late forties over several decades to try and find links and associations with various markers or risk factors in heart disease, in that they found that there wasn’t really a strong association if you didn’t have cholesterol that the extreme ends.

Dr. Aseem Malhotra:

So the next question then is, does lowering cholesterol, if we fast forward, does lowering LDL cholesterol, Mark, make any significant impact on reducing heart disease? Is there a correlation? And I published a systematic review in 2020 in BMJ Evidence-Based Medicine, we investigated this. I was co-author with two other cardiologists and we found that this mantra which comes out from cardiology societies that [inaudible 00:23:13] with every one mmol lowering of LDL, you have a 20% risk reduction in heart attack, stroke, whatever cardiovascular events, it was simply not true. It was not true. We falsified it. We said there was no correlation. If I’m being skeptical of my own research, I can say there was no consistent evidence to show reducing LDL reduces your risk of heart attack or stroke or cause mortality. Then you add in the other issue is other research I was involved in is if you’re over 60, we did systematic [inaudible 00:23:44] publishing BMJ Open several years ago, I was co-author. If you’re over 60, there is no association at all between LDL cholesterol development heart disease and an inverse association with LDLs-

Dr. Mark Hyman:

It means that when you’re older, if your cholesterol’s higher, you live longer.

Dr. Aseem Malhotra:

Absolutely. Statistically live longer. How do you explain that?

Dr. Mark Hyman:

[crosstalk 00:24:02] become founded by other factors, so go ahead.

Dr. Aseem Malhotra:

Of course, but one of the explanations is cholesterol has a crucial role in the immune system. So that may be why they’re protected, okay? People who are older with higher cholesterol. And actually, if you look at the 19th century, you go back when our average life expectancy, for example is about 40 or 50 years, people with FH, genetically high cholesterol, Mark, live longer than average. And the reason for that is likely because, well, infectious diseases was the biggest cause of death then. So this is really interesting. It’s just something to think about. On the other side of it, the most recent data published in BMJ, and this was last year, a Danish study looking a hundred thousand people following them up over 10 years, different age groups, they found when you look at all causes of death, the optimal LDL cholesterol was 3.6 millimoles, right?

Dr. Mark Hyman:

Which in American [crosstalk 00:24:54] like, how would you translate that to American units [crosstalk 00:24:57].

Dr. Aseem Malhotra:

Yeah. It would probably be between 200, 250, something like that. It was much higher than what people are recommended to [crosstalk 00:25:08].

Dr. Mark Hyman:

Of LDL?

Dr. Aseem Malhotra:

Sorry. No. Of LDL, it was something like, I think a 100, 120, something like that.

Dr. Mark Hyman:

Okay.

Dr. Aseem Malhotra:

Okay. Well, people should clarify that. I can’t remember the conversion at the moment, but that paper’s there and it’s translated. So Danish study, maybe we can pull it up later. And it looked at the [inaudible 00:25:25] for all cause mortality. What they found is if your LDL was very low, okay? Then there was an increased risk of death from cancer. So there is this association with very low levels of cholesterol and cancer, and it could be again, an immune system mechanism. So it just encourages to think a little bit differently. We shouldn’t be obsessing as our primary focus in managing heart disease, at the very least, about lowering [inaudible 00:25:47] better. Now, how do you reconcile this information, Mark, with statins benefits, and you’ve alluded to this already, most people are not aware of this, is statins have an independent effect. So they may lower LDL, but they also have a slight anti-inflammatory and anti-clotting mechanism. And heart disease is a chronic inflammatory disease exacerbated by something called insulin resistance, which we’ll talk about, but also linked to abnormal clotting.

Dr. Aseem Malhotra:

And the reason I bring up the clotting issue is, and we’ve published on this as well and it’s in the book, if you look at FH patients, so about 70% of FH patients who are female-

Dr. Mark Hyman:

That’s familial hyperlipidemia-

Dr. Aseem Malhotra:

Familial hyperlipidemia. Genetically very high cholesterol.

Dr. Mark Hyman:

[crosstalk 00:26:30]. Your cholesterol is like 300, 400. It’s really high.

Dr. Aseem Malhotra:

They will not, 70% of those will not develop premature heart disease without treatment and about 50% of men, right? Will not. So the question is, are we able to differentiate in the FH patients, the ones that will develop heart disease and the ones that don’t. Now, the first thing that’s really interesting is we found there’s no difference in their LDL, between the ones that develop heart disease and the ones that don’t, which makes you think, well, hold on. Then LDL probably isn’t even the issue with them. What is an issue, and there is some research on this, is that the people that tend to develop heart disease have some normal clotting factors, not your routinely measured ones. There’s all sorts of different things that people can check. But that seems to be from lab studies and from other studies, it suggests that FH people with heart disease have clotting abnormalities.

Dr. Aseem Malhotra:

But this is the good news. When you look at the risk, so what do I do with my FH patients? Well, of course, statins may have a role from antiinflammatory processes so we could still prescribe it to them, but we don’t have this data about one in 39, one in 83. There’s never been a randomized control trial to break down the absolute benefits in those. So we’re presuming there’s some benefit, but the people who had low insulin levels and low waist circumference had the lowest risk of developing heart disease, almost only slightly higher than the average person, which is really interesting. So the focus on FH patients should be lifestyle that targets in insulin resistance, okay? Which is basically your body’s getting resistant to the hormone insulin. You’ve spoken about this, Mark, because of lifestyle factors, high glycemic index carbohydrates, ultra-processed foods, not getting enough sleep, being over stressed, being inactive, all these things contribute to insulin resistance.

Dr. Aseem Malhotra:

So that should be the lifestyle approach. And actually heart disease, most of heart disease is rooted the biggest risk factor if you like is insulin resistance. And you asked me the question about what you look on the cholesterol profile, which is a marker of insulin resistance and that’s having high triglycerides and low HDR cholesterol. And the rule of thumb is you want triglycerides to be lower than your HDL in general, to have your cholesterol levels optimized. And the way you do that, lifestyle.

Dr. Mark Hyman:

Yeah. I think it’s so important what you bring up because when you look at the data from what I’ve looked at, and I wrote an article, which was, Fat: What I Got Right, What I Got Wrong, where I sort of unpacked this a little bit and I wrote about this in my book, Eat Fat, Get Thin, where essentially the biomarkers that are most relevant for predicting heart disease is not just LDL cholesterol. In fact, it’s not a very good predictor when you look at it. The best predictors is the triglyceride to HDL ratio, which you just talked about, and that should be one or less, right? And that goes up when you eat sugar and starch., so triglycerides go up, HDL goes down. Also, you get small dense particles. You get small HDL, dysfunctional HDL. So even if your HDL looks okay, it might be dysfunctional and then you also get dysfunctional LDL, which is the small dense LDL particles. So it’s just not the total number. When you get a regular cholesterol test, you’re just measuring the weight, literally milligrams per deciliter.

Dr. Mark Hyman:

Per 10th of a liter, how many milligrams of cholesterol. It’s just the weight. When you don’t know anything about the quality of that cholesterol, so when you look at particle size and particle number through innovative testing called NMR or cardio IQ, which is [inaudible 00:29:43] America from Quest or LabCorp, those actually help you figure out whether you’ve got this phenomenon we call atherogenic dyslipidemia, which is far more predictive. And what causes that is not fat, it starch and sugar. In fact, fat can often be the cure for that and actually raises the HDL. It can actually lower the triglycerides. In fact, triglycerides are fat made from sugar in your liver, right? So those are the real predictions. So insulin resistance then drives inflammation, inflammation drives heart disease. So when you look at the data on this in America, and I’m sure you’re catching up in the UK, but 88% of Americans are metabolically unhealthy, meaning they have high blood pressure, high cholesterol or blood sugar.

Dr. Mark Hyman:

And all of those are caused by insulin resistance or pre-diabetes, this whole spectrum of metabolic poor health. And that’s really what’s driving heart disease. And so statins have become the go-to therapy, but it misses all these other factors. And it’s just surprising to me how many cardiologists and how many doctors just don’t even look at this data, which I could not treat a patient if I don’t know what their numbers are because I could see someone with a cholesterol of 300, an HDL of 100, triglycerides of 40, and they might have very few particles and no small particles and they’re fine. Otherwise, I’ll see someone with a cholesterol of like 150, but their triglycerides are 300 and their HDL is 30 and I’m terrified for that person, right? Even when their cholesterol is 150, which sounds amazing, perfect, but it’s not. So I think the thing about statins, to sort of jump back to the statins is that they have what we call pleiotropic effects.

Dr. Mark Hyman:

In other words, they have multiple actions. One is lowering cholesterol or LDL, two is lowering inflammation through its effect on nitric oxide synthase, which is, nitric oxide is what Viagra does. It makes nitric oxide, but it actually also is a great vasodilator, antiinflammatory, antioxidant. So there’s a lot of secondary benefits and may affect clotting, but it also has some negative effects, which I think don’t get talked about enough. And I sort of want to unpack that with you a little bit. The major one is muscle damage. And I’d love to hear your perspective on this because I read a study once that was a biopsy study where they looked at muscle biopsies. There were two that kind of really terrified me about taking statins and I want to hear your perspective because I do think statins have a role, but I just think they’re overprescribed. The first study was looking at muscle biopsies and actually found that anybody taking a statin had mitochondrial injury.

Dr. Mark Hyman:

In other words, the energy factories that produce the fuel that your body runs on actually get damaged and you get a damaged mitochondrial, which you’re going to measure on a muscle biopsy. And mitochondria are the key to longevity and healthy aging and metabolic health. So on one end, you’re doing something to help, but you’re also maybe harming. Two, it seems to cause insulin resistance, which is kind of counterintuitive because insulin resistance is the thing that causes heart disease. So you got that. And the third thing is that this is, I think, related to the muscle biopsy study was it was also a terrifying study where they took two overweight groups of people and they put them on an intensive exercise workout regimen. One group got statin, like 20 milligrams of Zocor, I think. Another group, nothing. And they actually measured all their fitness markers, their VO2 max, their metabolism, their muscle, all of it.

Dr. Mark Hyman:

And at the end of 12 weeks, the group that took the statins, despite the exercise program, was worse off than before the exercise program because they took the statin and the other group actually got much more physically fit. So can you unpack that for us and take us down the road of the pros and cons, and then take us down the road of who should take this, because I don’t think it’s a drug that we should ban or get rid of, but I do think it’s overused and we need to sort of focus in on, one, who should take it and who should benefit, how we measure the benefits and risk, and then the next part of the conversation will be, how do we unpack? What are the real root causes of heart disease? What should we really be looking at and how do we really prevent it and treat it?

Dr. Aseem Malhotra:

No. Absolutely, Mark. So all really good questions and the kind of questions that patients ask as well that’s most important. So in terms of the side effects issue, I mean, that’s been very controversial over many years. Statins, they can cause many side effects, but the most common that we see in clinical practice is one of muscle aches and fatigue. Other side effects include people with stomach upset, brain fog, erectile dysfunction. They can affect pretty much every organ system. So the way I approach it is if a patient comes in with an unexplained symptom, the first thing, I mean, that’s been my default now anyway with all patients. So you have to think, my mindset is this is a side effect until proven otherwise, okay? So you look at the medication because we have an over medicated society. And what you often find, what I do is as a trial and error from a trial and error perspective, I will give patients the information about the potential benefit of the statin and say, listen, I think most of these side effects generally are reversible very quickly.

Dr. Aseem Malhotra:

So you stop the statin, you have an informed discussion to say, listen, why don’t we just stop. You know how you feel. And I ask the patient if they’re complaining of a side effect and often they already have this in the background anyways, is it interfering with the quality of your life? And that’s a crucial thing. If it’s like an occasional niggle here or there, nothing much of an issue, then you still have the informed discussion, but there isn’t necessarily an urgent requirement stop in statin, unless of course the patient’s now fully informed and they’re like, doc, you know what? Given that information, I don’t really want to take this drug. Fine. Okay. We’ve had an informed discussion. But if they’ve got say, fatigue or memory disturbance or something else, and [inaudible 00:35:14] I’ve been doing this for a very long time with many, many patients now so I’ve got certainly a lot of anecdotal evidence in my practice of this, that usually the patient side effects, if it’s a statin disappears within a few days to a couple of weeks.

Dr. Aseem Malhotra:

And people are amazed about how they feel. Their energy’s back, all that kind of stuff. And then the question is, well, do they want to go back on the statin or a different statin and then you can try a lower dose? Say they’re high risk and they’re kind of like, well, you’re actually less like to get side effects at lower dose. So say for example, you’ve got 80 milligrams of atorvastatin, which is the highest dose you give people who have heart disease, you can then say, listen, let’s try you on a lower dose. And I explained that there’s a slight anti-inflammatory mechanism, for example, let’s try you on a lower dose, see how you tolerate that, be reassured [inaudible 00:35:57] side effects are reversible. If this comes back again, we just stop it, for example. So that’s my approach to it.

Dr. Aseem Malhotra:

In terms of the prevalence markets, very interesting. I mean, data varies from say, anything from if you trust the industry sponsor trials, they say like 1% of people may get muscle aches or fatigue. And then in my practice, I don’t know. I mean, it goes from 20%, 30%, whatever. So there’s-

Dr. Mark Hyman:

One in five people taking the drug have pain muscles and they stop it, right? 75% don’t take it after a year.

Dr. Aseem Malhotra:

Well, exactly. Well, that’s [inaudible 00:36:27]. In the real world, when you look at studies and surveys, in one study in the US, statin usage survey, 75% of people stop taking the pill within a year of prescription. And when you ask the patients why, 66% of those said it was because they had side effects. So that makes me think, hold on a minute, there’s something that doesn’t add up here. And I don’t think it’s about… They talk about something called nocebo effect. If the patient is going to be aware of potential side effect, they’ll imagine it. And of course that exists, but a lot of the awareness of side effects of statins, Mark, in the mainstream only came out really in the last several years. I mean, they were prescribed for a very long time under the belief those side effects didn’t really exist. So I don’t think these patients were imagining it, I think it’s more likely they genuinely suffered side effects.

Dr. Aseem Malhotra:

I think that’s really important. But either way, I think doctors should be aware, patients should be aware that these potential side effects, which aren’t serious or life-threatening at all, but interfere with the quality of life and that’s of course, very important for people, are very common and you shouldn’t be afraid of discussing with our doctor and having a trial period potentially after discussing with your doctor of them. The other thing that we didn’t mention is when we talk about all this issue about management of heart disease with statins is that for many people, it gives them the illusion of protection so they think I can eat what I like-

Dr. Mark Hyman:

My cheeseburger and whatever, my soda.

Dr. Aseem Malhotra:

As long as I’m on statin, they continue to gain weight. And there was one study in JAMA Internal Medicine a few years ago that showed if you followed people of similar risk profiles who were on statins and ones that weren’t on statins, over a 10 year period, the ones on statins gained more weight. And the reason for that probably is to some degree the illusion of protection. So again, this is about educating and informing patients-

Dr. Mark Hyman:

Or maybe because insulin goes up and insulin makes you gain weight.

Dr. Aseem Malhotra:

Absolutely, absolutely. And we also know it now has been established about 1% of people who take statins will develop type 2 diabetes because of the statin, right? So there’s a lot of information that people aren’t being told and would change their decision making process and that’s really where we need to change the conversation across the whole of medical practice. And it’s taking time. I think people are becoming more aware. Doctors are becoming more aware. I think one of the concerns and issues I’ve had and I’ve campaigned on in the UK is that when you financially incentivize doctors to meet certain targets of cholesterol lowering or targets of treating certain people at certain risk, then it’s more like to bias a conversation and the patient really is the one that suffers at the downstream because they’re not really getting involved in fully informed consent. And that for me is ethically dubious.

Dr. Mark Hyman:

Yeah. I mean, the challenge is that most doctors are very busy and they are seeing patients and doing good work and they want to do the right thing. And they don’t have time to go into looking at all the data and analyzing and sifting through it and sorting through it. And so they’re hearing the sound bites. They’re hearing the sound bites that generally come from continued medical education. And I was once skiing and I joined a chairlift and sitting on this chairlift with this woman, I’m like, “Hey, what do you do?” She’s like, “Well, I’m in pharmaceutical marketing.” I said, “Oh really?” I said, “What do you do?” She said, “Well, I put on conferences for doctors.” So essentially a lot of the medical conferences are funded by the pharmaceutical industry and they’re putting their speakers on, they’re having their spin on the data. And so the average doctor really is very hard pressed to actually get into the nuances of what all this data shows.

Dr. Mark Hyman:

And it’s really unfortunate because they’re missing the boat. And the other problem is in medicine, we don’t like to feel disempowered as doctors. And when most of us have zero training in nutrition or lifestyle medicine and the biggest cause of heart disease is in some resistance, which is a lifestyle driven disease for which there’s really no good medication. I mean, metformin, maybe a little, but it’s kind of marginal and doesn’t work as well as [inaudible 00:40:17] and that’s been proven many times over in the diabetes prevention trial and other trials. So you want to do something, right? And so as a doctor, you want to help your patient, but this is all they know how to do and they don’t even know how to diagnose in insulin resistance. 90% of people with prediabetes are completely undiagnosed. And the one story I read from, I think it was from the UK about, if I get the numbers right, I think two thirds of everybody coming into the hospital with a heart attack had either diabetes or undiagnosed prediabetes. That was the biggest driver.

Dr. Aseem Malhotra:

Yeah. So two thirds of people admitted, a large US study several years ago that showed that two thirds of people admitted to hospital with heart attacks had metabolic syndrome. So that’s the worst type of poor metabolic health. You’ve got five markers, which we’ll go through and if you have three of those abnormal, which basically is linked to high blood pressure, pre-diabetes or type 2 diabetes, increased waist circumference, high blood triglycerides and low HDL, those are the five. If three of those are abnormal, you have metabolic syndrome. 66% of people admitted with heart attacks in the US have metabolic syndrome, so three of those are abnormal, but 75% of them had normal LDL and normal cholesterol. So clearly-

Dr. Mark Hyman:

What did you just say? Wait, wait, wait, wait, wait. Slow down. You’re talking fast, slow down. You just said that 75% of people admitted to the hospital with a heart attack have normal LDL cholesterol.

Dr. Aseem Malhotra:

This is from 2009.

Dr. Mark Hyman:

Yes. But only 10% had optimal HDL.

Dr. Aseem Malhotra:

Yeah, probably. Yeah. That’s true. Absolutely.

Dr. Mark Hyman:

I think about 70% had abnormal triglycerides, right?

Dr. Aseem Malhotra:

Yeah. Yeah. So the question is at that time, so why have we not changed things? I think one of the things you said, you hit on the nail on the head there about lack of awareness of nutrition and that kind of stuff. One of the things that’s also there’s a huge lack of awareness is about how rapid lifestyle changes with diet at the forefront, but the other things of course are crucial, can improve those risk markers of metabolic syndrome. So one study showed that 50% of people with obesity that had a dietary change, which in this particular trial was low carb, okay? Reversed their metabolic syndrome within 21 to 28 days, Mark, right? That’s massive, right? So those risk markers are triglycerides coming down, HDL coming up, even blood pressure coming down to some degree, getting out of pre-diabetes, getting out of type 2 diabetes. They start to have an effect and that’s why I wrote this. It wasn’t gimmicky.

Dr. Aseem Malhotra:

I mean, 21-Day Immunity Plan was also based upon those principles. And the same thing I talk about in this book as well is that people will see the improvements in those marker very, very quickly if they adhere to the prescription, the lifestyle prescription that doctors prescribe for them that really focus on insulin resistance. That’s it. If you focus on insulin resistance as your end goal to improve that through various lifestyle mechanisms, but dietary change alone is the only intervention, Mark, for any lifestyle study that can rapidly improve those markers.

Dr. Mark Hyman:

Well, what’s really striking to me is even at major, major heart hospitals around the world, the heart disease prevention diet, the cardiology diet they get when they go in the hospital is a low fat, high carb diet.

Dr. Aseem Malhotra:

I know.

Dr. Mark Hyman:

And I’m like, what’s going on here? Is like we’re living in the dark ages and the data that’s now here is not getting incorporate into the practice of medicine, which is really unfortunate. So I love your work because what you’re doing is you’re not just taking things at face value, you’re looking under the hood, you’re looking at the data and you’re creating nuanced conversations that aren’t black and white. It’s like statin is bad.

Dr. Aseem Malhotra:

No, absolutely.

Dr. Mark Hyman:

It’s really about looking at the honest accounting of what we know and what we don’t know and actually where should we be looking. So as a cardiologist, what really is the best predictor of heart disease if it’s not LDL and what can we do lifestyle-wise to both prevent, treat and reverse the risk and even the status of actually having heart disease?

Dr. Aseem Malhotra:

Yeah. So Mark, so I think again, I would come back to keeping the basics, stuff that’s relatively simple to measure, inexpensive, okay? So the things I always go through with my patients like, so let’s go through these five markers, what’s your blood pressure? You want your blood pressure ideally to be less than 120 over 80. Now the diagnosis is if it’s between 120 and 140 systolic or between 80 and 90 diastolic, then you have pre-hypertension and that doubles your risk of stroke and also contributes to heart disease. So you want to look at the blood pressure, HbA1c should be less than 5.7%. I know different countries have different ranges, but essentially between 5.7% and 6.4 is pre-diabetic and 6.5 and above is type 2 diabetic. So you want your HbA1c to be less than 5.7% ideally. You want your weight circumference for a Caucasian man to be less than 102 centimeters measured around the belly button and less than 90 centimeters, if you’re female.

Dr. Aseem Malhotra:

And then your triglycerides should be ideally less than one [inaudible 00:45:25], which the equivalent I think in the US is I think 150 milligrams per deciliter. Mark, you would probably correct me on that if I’m wrong, but I think that’s the range, you should be less than 150. And the HDR to be similar. So above 150, right? So greater than one [inaudible 00:45:40]. And if you have those all in range, which as you said earlier on actually having all those markers in normal range for the average American adult is only about 12% of adults. 88% of adults in the US don’t have those in the normal range, which is very troubling, right? And this isn’t just older people. Only one in four adults aged between 20 and 40, Mark, in the US have those in the normal range. And this is what we’re dealing with. But the good news is, again, those are really indirect markers of insulin resistance.

Dr. Aseem Malhotra:

If you want to do slightly more expensive tests and people get this in the US more easier than the UK, is you do a fasting insulin level and there are different units. I won’t get it wrong, but there’ll be a normal range. I think it should be less than six international units, I think, if I’m not wrong in terms of insulin, fasting insulin, right? So that’s another marker that you can use. So once any of those are out of the normal range, then you’ve got some degree of insulin resistance. So the question is, what can you do about it? And then it’s, well, let’s just go back to very basics principles. I keep it simple. So avoid ultra-processed foods. What are ultra-processed foods? Well, the data now, and I know you’ve been a big advocate for this, Mark, in recent years as well and writing about this is that more than 50% of the UK diet, more than 60% of the US diet is now coming in terms of calories from ultra-processed foods.

Dr. Mark Hyman:

I think [inaudible 00:46:56] 67%. 67%. [crosstalk 00:46:56].

Dr. Aseem Malhotra:

This is food that comes out of a packet that usually has five or more ingredients, a combination of sugar, starch, unhealthy oils, okay? Usually with additives and preservatives. And that’s a very simple [inaudible 00:47:13]. So I tell my patients, if it comes out of a packet and has five or more ingredients, it’s [inaudible 00:47:18] ultra-processed, avoid it. And that includes even packaged bread, right? So these are things to cut out and then low quality carbohydrates, so minimized sugar and low quality carbs. So these are refined carbohydrates like fiber; your white breads, your pastas, your rice, your potatoes. Now, it doesn’t mean you have to completely eliminate it. It depends where you’re starting from. So a lot of people have also metabolic health already who are generally doing this stuff right 80% of the time, probably don’t need to be as strict. But if you’re starting from a position where you are type 2 diabetic and all your markers are off, then you have to be more extreme to see the bigger benefits, right? So-

Dr. Mark Hyman:

Listen, my insulin levels are like less than five, pretty much about two. I have a 6% body fat. Yes, I’m bragging, but I’m pretty metabolic healthy, exercise a lot, I eat really healthy. And I went to Sardinia last summer and I’m like here I am for a week, I’m just going to eat whatever and I’m going to eat the pasta, the bread, I’m going to drink the wine. And I was treated well and had a very abundant diet and I gained like five pounds and I got the belly fat. So even if you are extremely healthy, if you start to eat more of that stuff, you’re going to start accumulating that and unless you are just doing a marathon every day, it’s really tough to keep up with that carbohydrate load that we have. And so-

Dr. Aseem Malhotra:

Well, that’s a really important point. Yeah. I think we have to be aware of that. And different people are more sensitive to these carbohydrates as well, right? There’s a quote in the book from Dean Ornish. I quoted him just to give people a concept to understand a bit of nuance with this management, Mark, is that it takes more to reverse disease than it does to prevent it.

Dr. Mark Hyman:

Well, I think he was borrowing from Benjamin Franklin, which says an ounce of prevention is worth a pound of cure.

Dr. Aseem Malhotra:

Absolutely. Right. Yeah. But in the bigger picture, for most adults in Europe, Americans, around the world, the big issue is ultra-processed foods, low quality carbs, as you said. And I think if you get that out of the diet, then it’s about patient preference and the values. I’m an advocate for the traditional Mediterranean diet, but minus the way we’re living now, obviously the starchy stuff, because there is, as you know, we’ve talked about gut microbiome as well. The positive side comes from with the best available evidence we have and things evolve seem to be that there is antioxidants, anti-inflammatory components with whole fruit and vegetables, extraversion olive oil, nuts and seeds. You want to be getting obviously enough protein. You want to get all your nutritional requirements as well so you think about, okay, how am I going to get all my nutritional requirements?

Dr. Aseem Malhotra:

So I minimize the need for supplements. I mean, I know supplements have a role, but minimize the need for supplements, right? And also reduce the chances of me developing insulin resistance from the diet. And if you focus on that, it’s what I do with my patients, then as long as you get the base of the diet right, other things here or there doesn’t matter so much. So get the base right, cut out the crappy stuff, pardon my language, right? And then it’s about [inaudible 00:50:23], it’s different cultures, right? Different types of foods, Indian food, Chinese food, whatever. There’s going to be, obviously, some big differences in a lot of the food that people eat.

Dr. Mark Hyman:

Yeah. I think that’s right. And I think the lifestyle stuff is so huge. And you talked about the Pioppi diet, I talk about the Pegan diet. It’s essentially focusing on quality. So whatever you’re eating, the key concept is it should be high quality, meaning nutrient dense, unprocessed, whole real food. And you can kind of go up the chain, eating a filet steak is better than eating, for example, a bunch of bread, right? But it’s not as good as eating wild elk or eating a grass fed steak. So you can keep going deeper in the quality chain. The second is to really understand that food is medicine and that everything you’re eating is regulating your biology in real time. And three, it’s personal. Everybody’s biologically different and some people may be more carbohydrate tolerant than others. Some people may be more fat intolerant than others, and there are ways to figure that out, which is really important.

Dr. Aseem Malhotra:

Absolutely. Absolutely. So that really covers a lot of the diet outside of stuff. And then obviously, from a heart disease perspective, exercise I think we’ve somehow… The most important message is keep moving, do what you enjoy. Be careful of overdoing it. A lot of people get injuries. They overdo it, especially if you’re stressed out and you’re doing more than say 60 minutes of moderate to vigorous exercise a day, more vigor side, that can actually worsen your stress. So the data really says that 30 minutes of moderate activity a day and you can do different things. You do Pilates, you do yoga, you can do cycling. I used to be a runner. I’ve kind of shifted more to cycling now because running on the road generally is not particularly good for your knees. I mean, I do sprints once a week, I do hits, right? So all these things are there, but do enough, but don’t overdo it, right? With the exercise.

Dr. Aseem Malhotra:

And then the big thing, Mark, something I’ve discovered in the last few years, which certainly has a big impact in my patients is stress, psychological stress, chronic psychological stress, which in its own right, and I wrote about in this book, is the equivalent of another risk factor like high blood pressure or type 2 diabetes in terms of its vascular risk. But a lot of people are managing that not realizing how important it is. And of course, it links to inflammation. There’s a lot of emerging data. There’s stuff related to clotting problems, increase in [inaudible 00:52:40] in the blood, which is involved as a clotting factor. And what I do with all my heart patients is I ask them, I do a very simple questionnaire kind of on them and I ask them in [inaudible 00:52:51] to 10, in the last few years, these are people that come, they’ve already got diagnosed heart disease. Some people who’ve had scans done, they’ve got some flaring of the arteries.

Dr. Aseem Malhotra:

And I say to them, where is your stress levels in the last two or three years? I know it’s obviously been pandemic time so it’s a bit skewed, but in general, most of them say that they are stress levels that are kind of eight, nine out of 10, right? For the last few years and they’ve not done anything about it. And then I write about in the book, we need better quality data, more data, but what’s fascinating, the largest study on heart disease reversal, which was done in India by an interventional cardio school [inaudible 00:53:28] called The Mount Abu Healthy Heart Trial, basically it took patients with significant chronic disease, so well over a hundred patients, moderate to severe. So at least 50 to 70% blockage in their arteries. These are people that didn’t want to have a bypass operation, didn’t want to have stents, and he put them through his healthy lifestyle plan. Now in India, there’s a lot of vegetarians.

Dr. Aseem Malhotra:

So it was a very high fiber vegetarian diet. There was some starch in there, but it was very high fiber vegetarian diet. It was moderate exercise, so two 30 minute brisk walks a day, okay? And then it was something called Raja Yoga meditation, which also wasn’t just about meditating. It was like there was a bit of counseling. It was about reconnecting with your family and your friends in the social aspect, trying to reduce stress levels. Long story short, after two years of the trial then followed for five years, they found that in the people that adhered to the lifestyle program, there was a 20% reduction on average in the stenosis of the arteries, which is unheard of, right?

Dr. Mark Hyman:

[crosstalk 00:54:28] the clogged arteries got better.

Dr. Aseem Malhotra:

Yes. Yeah. They got better. They reduced from say, 70%, 50%, 50%, 30%. I mean, extraordinary, right? It’s unheard of.

Dr. Mark Hyman:

And this is no statin.

Dr. Aseem Malhotra:

No statin. This is pre-statins, no statins. And then when they tried to look into what was the most important factor, by far of all the lifestyle factors that contribute to the reversal, it was 40 minutes of meditation a day.

Dr. Mark Hyman:

Wow.

Dr. Aseem Malhotra:

Right? So this is a big missing area, I think. And I think the other thing about the stress reduction, which links to chronic inflammation, the mechanism is that we think now heart disease, these plaques that develop, these blockages, they’re dynamic processes. So you get some inflammation, you get a plaque formation, it then progresses. It seems that you can potentially reverse those blockages or reduce them. But the biggest factor so far, I think, that’s been ignored is stress reduction through meditation. And as you know as well, if people incorporate that, then they’re also more likely to sustain the other lifestyle factors in terms of adhering to the diet. But their mental health is better, Mark. So quality of life is not just about something potentially you’re being helped within the long term. Within a few weeks when people do this and some people need more help. I find it difficult to meditate just from using an app. I have a Pilates teacher that I started seeing a few months ago that comes to see me once a week. I need to probably do more.

Dr. Aseem Malhotra:

It was fascinating. Within an hour, even that session of Pilates one hour, which is also it’s a great exercise, but it’s meditative as well, you feel your stress levels, you just feel like a different person.

Dr. Mark Hyman:

Yeah. Yeah. It’s true. I mean, I think that the mechanisms are interesting. When you look at stress, what it does is a number of things. One, as you mentioned, increase inflammation. Two, it increases cortisol, which is a hormone that your body makes that actually causes your blood sugar to go up, your blood pressure to go up, causes your lipids to get worse. If you look at race car drivers, before and after a race, their cholesterol goes up a hundred points just from the stress. And not only that, but it actually causes your fat cells to store more fat. So if you eat under stress, there’s nerve endings that innovate your fat cells and the stress response communicates through your nerves and your autonomic nervous system to your fat cells and tells them to store the fat. So it’s kind of a big deal. And I agree with you. I think we are under such a barrage of stressors in our lives, whether it’s work, family stresses, financial stresses, COVID stresses, climate change.

Dr. Mark Hyman:

I mean, I don’t watch the news anymore, it’s just too stressful for me. And yet it’s so simple, it’s free, it’s accessible. And I’ve been practicing meditation for years and it’s such a key thing to help regulate your life and your biology in so many ways. It improves its stem cell production, it reduces inflammation, it improves neuroplasticity, brain connectivity. The data is just so powerful on this. And if an anybody’s really interested, you can listen to the podcast I did with Daniel Goldman about his book, Altered Traits, which studied advanced meditators using very advanced imaging technology, looking at their brain function and their brainwaves and seeing what happens when you have somebody who’s been meditating for a long time, but really you don’t have to be a professional meditator where you’re living in a cave for nine years, just 20 minutes a day or 20 minutes twice a day is very powerful.

Dr. Mark Hyman:

And I personally use a technique, it’s called Ziva Meditation, Z-I-V-A Meditation. You can look it up online. You can take an online course to learn how to do it. It’s super easy and you don’t need any special equipment except sit on the floor or chair. And through that technique, you are going to have all kinds of benefits, not just heart disease, but all kinds of benefits. So I encourage you to take hard to what you’re saying because I think it is one of those neglected factors. So diet, exercise, stress reduction, sleep. I think the data you presented on the reversal is quite interesting because most of us don’t think we can unless when you take aggressive high dose statin. [inaudible 00:58:23] work show that there may be possibility to through lifestyle interventions to change the course and actually reverse the trajectory-

Dr. Aseem Malhotra:

Yeah. And Mark, anecdotally, I’m getting [inaudible 00:58:31] and I will be writing about this soon and hopefully I’ll be able to even fund a trial to try and get a bit more definitive in terms of the answers, but I’m seeing patients, many of my patients coming back who have either halted the progression of heart disease, so from imaging, and some have even had some reversal. One patient recently contacted me and I’d forgotten and he said, ” Dr. Malhotra, I saw you in 2019.” She’d suffered a TIA, a mini stroke. She’d had a blockage in one of her blood vessels of 75% and she emailed me back saying, “I’ve followed your lifestyle protocol.” And I was shocked, Mark, to receive this. I had to read it again. She said, “I’ve repeated the imaging and now the reduction is gone to less than 50% within two years.” And I’m just doing what the data… I’m saying, the very least let’s reduce your risk.

Dr. Aseem Malhotra:

I don’t give people false promises and say there is some potential here, but your quality of life is going to be improved. We’re going to improve your risk factors and hopefully there may be some reversal, but at least we can help stop progression at the very least according to what would happen normally. And the feedback is extraordinary once people follow it. So we need to try and get this more data, of course, but we need to get this more inculcated into medical practice as well across the board.

Dr. Mark Hyman:

I mean, the behavior change factor is a huge thing. That’s a separate topic, which we could spend hours on. I’ve had BJ Fogg talking about behavior change and I talked [inaudible 00:59:49] behavior change. So the power of community and the power of group support or medical group appointments or shared medical appointments can be very, very effective. And we’ve seen this at even getting people to change their lifestyle is and the outcomes are almost three times better using groups than actually one on one doctor visits. We’ve done that at Cleveland Clinic. It’s really quite interesting data to see. One last question before we wrap up. I want to talk about, it’s a hypothetical patient because for me, let’s just say my cholesterol would be a little high and I do a coronary calcium score, which is a way of measuring calcium deposits around the heart and the arteries, which by the way, calcium is the body’s bandaid. Where there’s inflammation, calcium goes.

Dr. Mark Hyman:

And so it’s an indirect marker of potential plaque. However, there’s some questioning of the data around the benefits of coronary calcium and there’s new imaging techniques like a coronary angiogram with a CT scan that looks at soft plaque. There’s a company called [inaudible 01:00:57] that looks at the analytics, they use sort of artificial intelligence. And how do you use that technology to help influence your decision about how to treat the patient and which patient would benefit from a statin and which wouldn’t. Because one of the things we’re talking about with these levels, these numbers, I mean, abnormal cholesterol is not a disease, right? But it’s a predictor, potential predictor. But during a one to one correlation where they need one patient is very difficult, right? But when you look at the actual plaque burden and not just the calcified plaque, but soft plaque, which is the more vulnerable plaque to rupture, the more vulnerable plaque to actually cause a heart attack, how do you sort of navigate that decision tree with a patient and who would get what?

Dr. Aseem Malhotra:

Yeah. So great question. It’s all individual based. I think we have to walk before we can run. So you’ve alluded to the issue of calcium scores, which in themselves are still very, very predictive and then very good in terms of their risk stratification. So they supersede all the other risk marker in terms of heart attack risk; high blood pressure, type 2 diabetes, whatever else. If you get a calcium score that’s zero, close to zero, less than a hundred, then your risk is very, very low of having a heart attack in the next 10 years, despite what’s going on. Although I would always tell my patients, listen, you’re lucky where we are right now, it hasn’t caused any significant damage, but if you carry on as you are, probably this calcium score is going to increase. So at least we need to sort your lifestyle out. And often I will repeat calcium scores in a year and give them some reassurance of what they’re doing is making a difference. So that’s some one way it can be used. So sequential calcium scoring. In terms-

Dr. Mark Hyman:

Can you see regression of calcium? Can you see removal?

Dr. Aseem Malhotra:

Yes. Yeah.

Dr. Mark Hyman:

The lowering the score.

Dr. Aseem Malhotra:

And the calcium score. Absolutely. But I think the other thing is, Mark, you’re right about soft plaque. So the calcium score can sometimes miss soft plaque, but it’s still very reliable. So we come back to the basics of the history, right? What is their risk from the risk factors and an individual patient based. And if they’re also getting like, for example, I’ve seen some patients that have got quite typical symptoms of angina, but think that they should just have a calcium score and often the calcium score could come back and be relatively low, but you do a CT coronary angiogram. I think that’s what you’re kind of referring to, which actually looks more detailed and we’ll see soft plaque and you can see a significant soft plaque. They’re relatively less common so I think it’s something to be aware of. I think calcium scores still have a very important role, but if there is doubt, then of course you can just go for the full CT coronary angiogram and then you can see both calcified plaque and non-calcified plaque.

Dr. Aseem Malhotra:

So I think they have a role, but I think still calcium score still should be used much more frequently than CT coronary angiogram based upon all the different risk profiles of that individual patient.

Dr. Mark Hyman:

Yeah. Very important. And I think some patients, for example, with a high calcium score or soft plaque, they might be candidates for statins, right?

Dr. Aseem Malhotra:

Yes. And again, the data that I’ve read most recently suggests the ones with a calcium score more than 400, but then you are already automatically into the high risk group anyway which we just talked about, which is the one in 39 benefit from non-fatal heart attack over five years, one in 83. So it’s pretty consistent still with what we know, but people with calcium scores less than 400, there doesn’t seem to be any big benefit from statins. So I think one of the other slightly confounding factors is statins also increase coronary calcium. So they can potentially stabilize plaques, but increase coronary calcium. So you’ve got to also think about that in the context. If patients come back two years later, they’ve been on a statin, oh my God, why’s my calcium gone up? Well, actually it may well be the statin, but then it could be this progression of disease. So in that situation, Mark, you could then say, well, maybe we should have a CT coronary angiogram and actually look in more detail to make sure there’s not been any significant stenosis or soft plaque or whatever else developing.

Dr. Aseem Malhotra:

That’s the way I would approach it. But I think overall in terms of where we’re going with this and trying to make sense of what’s going on in the world with ill health and everything else, I look at things that also philosophically and rationally. And I always think about my purpose and our purpose as doctors ultimately is to improve patient outcomes. But what do we do for that? We use knowledge and the ultimate purpose of knowledge is to reduce human suffering, but that knowledge needs to be based on the complete totality of evidence on the truth. And one person I’ve recently, I’m just going to throw this in there that I’ve been very fascinated with and I follow his work and I know he’s a bit of a controversial figure, but I like what he says is Jordan Peterson, the clinical psychologist. And ultimately we need to speak the truth, we need to know the truth.

Dr. Aseem Malhotra:

And if we move away from the truth, then we are really going to increase suffering and in his words, we are going towards hell. We need to redeem the world from hell. And by not speaking the truth, and that also requires courage at times, people speaking up, doctors when there’s misinformation being propagated from vested interest, we have a role to actually speak the truth from a rational perspective because if we don’t, the situation’s only going to get worse. And even if we’re avoiding conflict in the short term, we’re going to increase further damage down the line, if not for us, then for our kids and the kind of environment and their futures. So I also have to look at this from a philosophical point of view as well when you come into the whole issue around trying to help people understand what’s going on. And I think everybody knows, Mark, you just look around you, in the last 10 to 20 years, ill health is getting worse, mental health is worsening.

Dr. Aseem Malhotra:

There’s a whole issue on a separate discussion about, and I’m not going to go into any detail on this, but even our management of the pandemic about COVID, about vaccines, about informed consent, all of that’s there and if we don’t speak the truth and we don’t get access to the truth, then the whole of the world and society’s going to suffer. And you combine that with hostility and division, people [inaudible 01:06:52] very tribal about statins or whatever else and exacerbated by social media, my concern is losing our capacity for empathy, as well as access to the truth. And that’s sending us down to a very, very dark place. So our job now is to reverse that.

Dr. Mark Hyman:

Yeah. Well, thank you, Aseem, for your work and thank you for being one of the really leading voices in showing us what the data actually say, for taking the time, which is precious to do the hard work of looking at these studies, going back to the original data, dissecting them, making sense of them and actually sharing with people what we know and what we don’t know, and being honest and transparent about it. You’re not anti-statin, you’re just pro-truth.

Dr. Aseem Malhotra:

Yes.

Dr. Mark Hyman:

I think just to kind of summarize because we unpacked a lot and then we’ll close up, the most important thing people need to realize is that heart disease is not a statin deficiency. Number two, that it’s primarily driven by lifestyle and primarily by the amounts of carbohydrates that we’re eating; sugar and starch, flour and sugar. And three, that the over focus on LDL is misguided and that in fact it may be other biomarkers such as triglycerides in HDL or the total cholesterol to HDL ratio or the inflammation biomarkers or oxidative markers around cholesterol or the particle number, particle size, things that we’re not typically looking at, insulin. I mean, if I had one test to look at heart disease actually risk, I would do a glucose tolerance test measuring, insulin fasting in one and two hours later because that, [inaudible 01:08:39] almost more than any of the other tests and it’s something that most people don’t do.

Dr. Mark Hyman:

And then the other thing we kind of covered was that we need to do the right cholesterol profile, which is the NMR or cardio IQ test from LabCorp or Quest, which you can get from your doctor. It’s a much better way of looking at the total picture, along with the other bio markers of blood sugar, insulin, A1C, inflammation markers, and so forth. And that the good news is that according to the epic trial and many other studies, 90% of heart disease could be prevented by simple lifestyle changes; eating a whole foods real food diet, exercising a little bit, not smoking, keeping to your ideal body weight. I mean, that’s pretty simple. And yet on meditation, you might even get a better benefit. That’s a 90% reduction, right? It’s actually really relevant. And yet statins, although they are good for certain patients with high risk conditions or with lots of plaque or who’ve had heart attacks, they do form part of the tool kit.

Dr. Mark Hyman:

But I would just sort of emphasize, I saw this one sort of medical journal that said lifestyle doubles the benefits of statins and I’m like, oh God, that is such a poor framing. In fact, lifestyle may be all you need if you are aggressive enough. And I have patient after patient, I’m sure do, who are on all the medications. They’re on high blood pressure medication, they’re on statins, they’re on aspirin. They’re on all kinds of cardiology medications, and they’ve had a heart attack and their numbers are better off the statin once we fix the underlying lifestyle issues. Actually, their whole profile looks better. So that’s to say that you need to have a more nuanced view around statins, a nuanced view around heart disease to deal with the root causes of it and I really encourage everybody listening to get a copy of Aseem’s new book, it’s called A Statin-Free Life. And it’s such a good summary of the data and the research.

Dr. Mark Hyman:

He’s done the hard work. He’s told us actually what we need to be thinking about in a way that is really refreshing. It’s coming from a cardiologist. And of course, you’re an honest broker. You don’t have any vested interest, you’re not getting big funding from pharma. You’re often vilified in the press. You’re taking a lot of arrows in your back, but you’re telling the truth and I think for people listening who are on a statin, who have high cholesterol, whose doctors told them to take a statin, this book is really important. A Statin-Free Life: A Revolutionary Life Plan for Tackling Heart Disease – Without the Use of Statins, available anywhere you get your books. I want you to get it and read it. And if you know somebody who’s got some issue, send it to them too. It’s a good present.

Dr. Mark Hyman:

And if you love this podcast, share with everybody on social media. Subscribe wherever you get your podcast. Leave a comment. How have you managed your risks? How statin’s helped you or not, or what side effects have you had. Tell us about your story. We want to hear. And we’ll see you next week on The Doctor’s Farmacy.

Closing:

Hi, everyone. I hope you enjoyed this week’s episode. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you’re looking for help in your journey, seek out a qualified medical practitioner. If you’re looking for a functional medicine practitioner, you can visit ifm.org and search their find a practitioner database. It’s important that you have someone in your corner who’s trained, who’s a licensed healthcare practitioner and can help you make changes, especially when it comes to your health.