Dr. Ovadia offers a necessary paradigm shift by identifying insulin resistance as the systemic root cause of heart disease, moving beyond the conventional obsession with cholesterol. It is a sharp challenge to traditional cardiology that prioritizes metabolic health as the ultimate key to cardiovascular longevity.
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Heart Surgeon: The Real Cause of Arterial Plaque — and How to Reverse It | Dr. Philip Ovadia
Added:Early on in my career as a heart surgeon, I learned there was a link between oral health and heart health.
People that have periodontal disease, those people are at higher risk of having heart disease. It turns out that insulin resistance is the primary driver of heart disease. Dr. Joseph Craft, he looked at all the patients with heart disease. [music] And what he found was 90 to 95% of them were insulin resistant. There's a couple of different pathways that connect the insulin resistance [music] to the plaque and the damage in the blood vessels. The first one is the sugar problem. Insulin resistance lowers production of nitric oxide, a essential chemical that our body uses to help protect our blood vessels. I typically recommend starting with coronary artery calcium scan. All men by the time you're 40, [music] women by the time you're 50, get your first scan. I have 30 year olds ending up on my operating table. That means that that disease started in their 20s. And so screening earlier can be helpful in certain situations. How often you scanning somebody middle-aged and finding no plaque?
>> The statistics are >> when it comes to hard plaque, soft plaque, is there any chance there for a reversal?
>> I think for both, the answer is yes. The million-dollar question. Somebody that gets a reversal, what are you having them do?
Dr. Ovedia, when somebody goes low carb, keto, carnivore, somewhere on that continuum, and they don't get the health results they're expecting, what do you find is at the root of that? Yeah, you know, um we need to understand that um the human system is quite complex and I never like to uh over simplify things, right? So when we say go keto, carnivore, low carb, um there's a lot of nuance that goes into that. And one of the things I think that has become most apparent to me now uh doing this with patients uh in my practice for the past six years is um it's not just enough to focus on the food you put in your mouth.
We have to really get into how your body reacts to that. Um how our body is processing that food. And this gets into issues like gut health um and bioavailability and nutrient density of those foods uh to help us understand why some people react in certain ways and others don't you know react in a different way [snorts] and um that's what I've really come to learn uh over this time is the approach you know we have sort of the general rules uh eat real food for instance right that can be applied to everyone, but there's nuance within, you know, how your body is going to react and maybe some other aspects that we need to look at uh so that we ultimately can get the results that we're trying to achieve with that patient.
>> Okay? So, say a hypothetical patient comes to you, we know we've got the check on the proper quote unquote diet.
And again, there's variability. There's different diets that can work for different people.
but say they're still not getting those results. You named a few different variables there. How do you begin to uncover for that person? What's at the root of that?
>> More and more, like I said, one of our focuses becomes your gut health and simple questions like, you know, how do you feel after you eat? Do you feel bloated? You know, are you getting heartburn? uh uh you know do you feel energized or do you feel you know tired after you eat. These are some indicators that we can use uh to uh determine if they have a problem uh with their gut health broadly. And what [snorts] I really mean by gut health is you've put the food in your mouth, right? You got the input, the information that's in that food, the nutrients, right? That's what our bodies are looking for from food. Uh and now we have to figure out is your body able to properly utilize that. Is your digestive system um working in a manner that we can extract those nutrients? And we can then use them for you know all the things that we need to use them for within our bodies.
So starting with simple questions of you know how do you feel after you eat? um you know uh looking at the quality of your bowel movements is another good indicator of what's going on with your gut. Um there is some testing that we can get into. Uh but honestly um when it comes to gut health, the um clinical scenario, right, the how the patient feels uh and the signs and symptoms that they're experiencing uh actually go a lot uh further in informing us what's going on there than the testing does.
>> Well, let's talk about an ideal situation to understand how digestion works.
>> Yeah.
>> So, somebody is sitting down to a ribeye steak. they take that first bite. Let's walk through ideally what happens in the body.
>> Yeah. So the first thing to understand about that ribeye steak is it is the most nutrientdense uh food that humans can eat. uh and what I mean by that is you know if you want to look at this on a per calorie basis or uh per gram basis right the nutrients that are in that meat uh are really optimized for humans and the other thing to understand about that meat is it's also the most bioavailable food to us as human beings over millions of years of evolution uh for the vast majority of which we were primarily carnivores meaning that meat was the majority of our diet and our um digestive systems uh evolved uh to be able to extract those nutrients from the meat. Uh and we do not have the same uh reaction to plant products. The bioavailability of the nutrients that are in plant products are very poor. We're not optimized for that.
So that's an under, you know, that's the uh reason that I advocate meat as the primary part of our diet. That's the reason I now tell people that meat is medicine. But so when things are working well, the meat goes in your mouth. Um it uh starts to get broken down, right? And this actually most people don't realize this starts in the mouth. We have enzymes and we have microbes right within our mouth uh that start to break down that food and then it continues you know it goes down through the uh what we call the esophagus the food pipe and then it gets into your stomach where things really accelerate you know very highly acidic environment and it's supposed to be a highly acidic environment. One of the most common reasons that we see people today having gut problems is because they've been put on, you know, uh, medications to reduce the acidity of their stomach. They might have had something like reflux, gastroosophageal reflux disease. Uh, and they were told that the the solution to that problem is reduce the acid in the stomach. That's not how it's supposed to work. We were designed to have very acidic stomachs because that's going to help break down that meat uh and help uh break it down into its components, you know, the nutrients, the amino acids, right? And the proteins, all of that that are now going to make it easier for us to extract those nutrients. And then as it goes through the digestive system, without getting, you know, too deep in the weeds here, right, we start to extract the nutrients uh that we need.
we start to uh we get those proteins, those amino acids, we get the fats, right? Another thing that's very unique about animal fats is that it carries a lot of the important nutrients. Um we have what are called fat soluble nutrients uh fat soluble vitamins that need to be in fat for our body to be able to access them. And that's why meat uh and really meat alone is what we are optimized to eat.
>> Okay, let's take this a little bit further. Once these nutrients get absorbed, they're in the bloodstream.
Any other potential hangups on the way to the cell or within the cell?
>> Yeah. So one other thing I think would be good for us to uh bring into the conversation at this point is uh even before that on the absorption part of it uh there are what are called anti-nutrients um and anti-nutrients are things that are in plants primarily that might block the absorption of those nutrients. So, you know, when you eat your meat alone, you're not going to get any anti-nutrients. when people are eating meats with vegetables, right, which people think that's a healthy way to do, you know, have your meat, have your vegetables, and I'm not necessarily saying it isn't, but understand that some of those plants, some of those vegetables have what are called anti-nutrients.
So that when they're in your digestive system together, that might actually reduce how much you're able to get out of the meat. And this is one of the problems that we see with eating things from the plant uh kingdom. Now those same uh chemicals, you know, uh these anti-nutrients as they're absorbed into our system, uh they might be causing problems, you know, elsewhere peripherally, we can say outside of the digestive system, but their primary uh issue is going to be within the digestive system. Now, uh, once the nutrients are in your bloodstream and they're going around, um, yes, there can be, uh, issues with how we're able to, um, use those. Uh, I think one of the, um, common ones that we end up seeing, people may have heard about this, is what are called, uh, methylation issues, right? So methylation is a way that our body uh uh some of these vitamins for instance the B vitamins in particular right they come into the system and they are in a form that is inactive uh we can't use them in the cells and they need to be activated and one of the ways we do this is what's called methylation which is a chemical process that modifies those vitamins so now our cells can use them uh And some people, many people actually for uh have genetic varants that they're not good methylators. They don't do that process well. Um when people become insulin resistance, when people develop inflammation, that might even worsen.
They methylate even worse. And therefore, they might be getting those B vitamins, but they're not getting the end effects that they need from them.
And we might need to do something to help their methylation processes. Uh that's one example of getting the nutrients in might not be enough. We then need to be able to utilize them and leverage them properly >> for that person that is having difficulty with methylation.
What would that look like other than reversing the insulin resistance you talked about?
>> Yeah. So the first thing you want to do is things like reverse the insulin resistance, reverse the inflammation.
But if that patient has a truly genetic block, right, that might not be enough.
And uh a workaround in this case is uh you might need to supplement with the B vitamins in an already methylated form.
And therefore, you're kind of bypassing the need for your body to do that methylation step. For somebody that is unsure whether or not they're in that camp regarding methylation, is the methylated B vitamin safe for everybody?
>> Yeah, I think it generally is safe for everybody. Now, you can test your methylation, right? You can do um genetic testing and uh get a sense of how well you're going to be able to methylate. um more so what we do is we look at one of the sort of byproducts of methylation. So there is a blood test called homocyine.
Um this is one of those blood tests that kind of flies under the radar. Most doctors don't really know about it. They don't include it in the standard testing. What's interesting about homocyine is when it is elevated, we know that that um associates with increased risk of many things but primarily of interest to me is your risk of heart disease, your risk of high blood pressure, your risk of stroke go up when your homocyine is elevated. Um homocyine becomes elevated when we don't methylate well. Uh and again we'll try to not get too deep in the weeds but homocyine is an amino acid. It's in our bloodstream. It's not supposed to accumulate in our bloodstream. Homocyine is supposed to get converted to other things uh including uh another amino acid called methionine. Uh it also gets converted to some of the neurotransmitters that we use in our brain. uh it's a very interesting molecule uh amino acid. Um in order to do that conversion of homocyine to these other things the methylated B vitamins are what we call a co-actor. It's necessary to have enough methylated B vitamins around so that we can be converting to homocyine. And so when you don't have enough uh methylated B vitamins, the homocyine starts to accumulate. So, this is an easy blood test that people can do. Um, and it gives us an idea about how well they're methylating. Uh, you can also directly test genetically, you know, test the genes that code for a lot of the um enzymes that help with methylation. Uh, there's one uh called uh the one that we talk about most is uh what's called the MTFHR mutation. There's uh a couple of others. One is called comt coomt. Uh these things can all be tested genetically. Uh but usually the first step for me uh for my patients is we look at that homocyine level. And if the homoyine level is high, you know, besides looking at things like inflammation and insulin resistance, we're going to start the patient on methylated B vitamins and uh the vast majority of the time that resolves the problem. You brought up plant toxins.
We'll get back to those shortly.
>> Yep.
>> But coming back to our ribeye steak example, I'm just trying to make sure I understand the different areas within that digestion absorption where issues can arise. The one that jumped out to me, you mentioned the stomach acid. I assume if people aren't producing enough, taking enzymes, taking HCL can help with that.
>> Yeah. But let's talk more to that piece and then others along the chain before we get to plants that can disrupt our body getting the nutrients.
>> Yeah. So besides uh the low acid problem, right, which is going to make uh if the stomach is less acidic, we're not going to break down, you know, the meat or whatever we're eating as well.
And that's going to then make it harder, right? Because the next step after it starts to get broken down is it now needs to get absorbed uh by our body.
Right? So keep in mind our gastrointestinal tract, right? Our digestive system uh it is sort of it is technically outside of our bodies, right? Um it is um there is a lining there is a barrier there, right? that guards against things that we don't want getting into our bloodstream uh and uh regulates what can get into our bloodstream. And this is an active process, right? People uh sometimes get the misconception, right, that as long as the food is sort of sitting there, right, it's going to get into our bloodstream. But it turns out it's a it is a very tightly regulated very active process of what gets across that barrier and ultimately into our bloodstream and what passes through right and gets disposed of as waste ultimately in our stool. [snorts] Um when that lining starts to get disrupted that absorption um the regulation of that absorption becomes a problem. Uh and this is what we call leaky gut. Um we start to get um so the makeup of the wall of the intestines uh has these things. It's called tight junctions.
The cells essentially are very uh tight against each other and that is what blocks things from just passively moving through. Uh when we get leaky gut essentially those cells start to spread out. So now they're they're not as tightly opposed and now we have a problem of some things that aren't supposed to get through start to get through and the things that we are supposed to bring through actively aren't you know properly bought through because there's uh disregulation of this whole system. And so leaky gut along with low acid becomes another big problem that people get that is going to alter their ability to absorb the nutrients that we ultimately are looking for from our food.
>> I mentioned the enzymes HCL. I know there's digestive bidters. Anything else in that realm for people that need help?
Yeah. So, there are there are a lot of supplements ultimately that can help target this. Um, there are all sorts of digestive enzymes outside of just uh the hydrochloric acid. Uh, and um there are things like bile salts for instance that may be helpful for people that are having trouble absorbing fat in particular. Maybe you had your gallbladder taken out, right? And um you know, your bile system isn't uh quite optimized. Um, but again before we get to that stuff, right, we always want to go back to the root cause. Uh, and we want to say why is your gut inflamed?
Why do you have this leaky gut? And what can we do about that? Right? And the primary cause of leaky gut is going to be um again the highly processed foods, the sugars, the highly refined carbohydrates, the vegetable and the seed oils, right? that are um you know lead to uh inflammation within the intestines itself and um dysfunction of those cells right that are designed to be actively bringing the nutrients across. Uh these things are all um impeded by processed foods uh is really the the the big category I put in. And then in some people things like plants right and those anti-nutrients part of why they are uh part of how they work um is by damaging again the intestinal lining and causing things like leaky gut. So that's why we have to have caution about some of those things. Um and um ultimately uh when you really start to talk to people who are just eating kind of a standard western diet, almost all of them have some level of gut dysfunction, uh they may not recognize it as such, but you know, when you start to really uh think about how common it is for people to say, well, you know, after I eat I get bloated, I get gassy, right? you know, I get, you know, my stomach gets distended. Uh, that is all, you know, evidence of indicators of gut dysfunction and it's just kind of accepted as normal within our society anymore, but it's not. It shouldn't be and uh it's an alert that your body isn't working as it should be.
When it comes to leaky gut specifically, you just named a bunch of symptoms. Is that the best way to get insight whether or not we have that? And then you named a bunch of different insults including processed foods. Is removing those enough to let that heal or do you recommend certain supplements or certain protocols?
>> Yeah. So, um I do believe that the symptoms are really the best way to get about this. There are some different tests that can be done.
um none of them really have uh I think proven themselves to do better than just asking about the symptoms uh in my practice ultimately. There are some situations where we might do the testing uh but in general it really starts with the symptoms uh for me. um the uh what to do about it, you know, uh removing processed food uh is always the first step in my mind. Uh again, I always try and look at things like what can we do from a root cause approach before we start relying on things like supplements and and pharmaceutical agents. Um those may play a role. You know there are certainly situations where people have very severe gut dysfunction and things like that might be necessary. You might need to go through a protocol for instance that is rebalancing the microb microbiome right which is another aspect of this that we haven't gotten to yet but I'm sure we'll touch on and um you know that might involve some supplements it might even involve some pharmaceutical agents. So those uh those things can become part of the protocols. But the first step is always you know if it's the food that primarily caused this damage in the first place let's remove as much of the damaging food as possible uh and give the body a chance to heal. Our bodies are miraculous in their capability to heal from lots of different things. But the first thing you need to do if you want your body to heal is you need to stop injuring it, right? And if on a daily basis you're keep putting in these damaging substances, the processed foods, um your body isn't going to have that ability to heal. And so that really is the first step for me always. Coming back to the beginning of digestion, you mentioned it starts in the mouth, which before reading your new book, I always knew about amalayise and the digestion starting there with starches, but there's also fat digestion that begins in the mouth, too.
>> Yeah. You know, again, our our mouths are amazing. uh and everything that's going on there between the um like I mentioned the the oral microbiome the bacteria that are in our mouth uh that start some of this breakdown process uh that start to produce chemicals like nitric oxide uh you know which does so many amazing things within our body uh and having the right balance of the right bacteria is important. So, um, you know, one of the things that has become pervasive in our society that I don't think is beneficial are these mouthwashes, especially the ones that are, you know, uh, heavily uh, alcohol-based and other chemicals, right? And they're designed uh, the concept is well, we don't want bacteria in our mouth, right? Let's try and kill as much of it as possible. Uh, but that's the wrong approach. Uh there are um bacteria that when they become, you know, uh overgrown within our mouth, they're certainly harmful and they might contribute to things like cavity formation. Uh but you don't want to go, you know, wiping out the whole area, right? You don't want to like start uh you know uh bringing out the napal essentially right to your mouth. uh you want to eat the right foods that are going to uh feed the right bacteria so that you can have that good balance of bacteria in your mouth and they are going to start the digestive system properly. Um we then have uh glands right within our mouth the salivary glands and others right that are going to be secretreting some of the things like amalayise that you mentioned uh lipase right which is one that helps to start to break down the fat uh and this is very important as well and [snorts] uh again it is a finely tuned system right if you're not damaging it it works great but the problem is we start damaging it right we start damaging it with things like sugar, we start damaging it with the processed foods. We might unintentionally be damaging it when we use things like mouthwash, um even certain types of toothpaste, right?
That are going to, you know, disrupt things there. Uh those can all be contributors. And then if you have uh something like periodontal disease that has now formed, right? That's going to magnify and uh amplify those problems.
So oral health becomes a very important component of metabolic health. Now what is especially interesting to me about this is you know early on in my career as a heart surgeon right and during my training I learned uh that there was a link between oral health and heart health right we know for instance that people that have periodontal disease uh they have breakdown you know of the gums uh then you know oftentimes that's associated with having cavities and things like that um those people are at higher risk of having heart disease. We also know that when you look at the plaque that forms in the arteries of our heart, you can see bacteria in there that live in our mouth, right? And you know, so conceptually what's happening there is the bacteria from the mouth are getting into the bloodstream. They're causing the inflammation in the blood vessels or they're contributing to it.
uh and then they get trapped within the plaque that is a response basically to try and heal that inflammation. So I've always known that there's this you know mouth gut connection. Um but I didn't realize quite how strong it was right until I started learning about things like metabolic health and learning about the oral microbiome and how it uh really influences things on many levels. Okay, so we've gone over the mouth now, how to take care of it, how to support the microbiome. Let's move down to the gut microbiome. Now, things we're doing that are having a negative impact and how to support that in a healthy way. Yeah. So, uh probably one of the biggest ones I see here is uh using antibiotics. Now I want to be clear antibiotics can be uh and oftentimes are you know lifesaving things right uh clearly one of the um when you look back over the history of medical advancements you know what has had uh major impacts on our uh improved health span and our improved lifespan antibiotics are clearly in that category so I'm not telling people never use antibiotics but the overuse of antibiotics. Um the you know and this starts in childhood right every time uh children have a ear infection they get put on antibiotics uh when a lot of these things are viral and don't need them uh and they just get overused uh and they end up disrupting our microbiome.
um the push for uh shall we say a cleaner society right um again is something that got overdone now clearly again we had benefits from improving our sanitary systems and all of that but the fact now that every time you know uh it seems you walk 5t in any public building anymore right and there's the dispenser of the uh antimicrobial hand gel right and so we're constantly doing this. Uh the fact that we don't let our children play outside as much as we did, right?
And uh you know get play in the dirt, right? Uh which helped uh help helps children to develop the proper microbiome. And so there are a lot of things that we are doing that end up disrupting our microbiome. So our B microbiome starts off early in life less healthy than it should be and then throughout life we're doing things to constantly kind of attack it uh indiscriminately and um that ends up causing a lot of trouble. Uh the microbiome is essential to our health uh having a properly balanced microbiome. Now, um, here's where things start to get a little muddy. Um, because testing and understanding what's going on in your microbiome is difficult. Uh, we have lots of different ways these days, right? We we now have uh these very advanced tests, right, where you can look at your your stool and uh they can find the DNA sort of uh fingerprints of the different bacteria that are living in your colon and we can get very detailed reports about all the distributions of all these different you know types of microbes that are living in your colon. uh but we don't really yet have a good understanding of what healthy is and what unhealthy is. And the re one of the reasons that we don't yet have that understanding is we we have um preconceived biases that have gone into the interpretation of the results of these testings. So, you know, when we started thinking about the microbiome, um, we said, well, we know what a healthy diet is, right? And that version of a healthy diet was, you know, think the old food pyramid, low-fat diets, plantforward diets, right? And we said, okay, the people that eat those diets more, this is what their microbiome looks like. So, we're now going to basically make the assumption that that is the optimal microbiome.
And it turns out that people that are eating uh meattheavy diets, right, carnivore type diets, um their microbiome ends up looking a lot different than someone eating a plantforward diet. Um and we've made a judgment that the plant one is better than the carnivore one, but we really don't have outcome studies yet, right?
Do people with a carnivore microbiome have better results? You know, less heart disease, less chronic disease, all of that stuff. Uh, or maybe the people with the plant-based diet do, right?
What we don't have those studies to that level yet. So, it's still a little bit of a guessing game when you start doing all this microbiome testing what the next step is. And that brings me back again to what we talked about earlier. I still kind of rely on the clinical symptoms there. um you know if you're having uh issues uh you know with your digestion and especially when we start getting into some of the symptoms that point more towards the colon uh and the uh you know the lower intestinal tract as we call it. Um, that starts us getting thinking about things like the microbiome. And, you know, maybe it's as simple as, you know, you need a good yogurt that has a a good balance of microbes that are going to help you reestablish a healthy microbiome. Um, it uh, like I said, the microbiome is still one area where we don't quite have all the answers yet, but we're getting there. And I'm I'm hopeful that studies like, you know, one that I just mentioned, right, where you can start to say, okay, this is microbiome A that tends to occur more in people on plantheavy diets. This is microbiome B on a meat heavy diet. Uh, which one actually leads to better outcomes? Those are the types of studies that I'm hopeful we'll start to see in the future. When it comes to these two different microbiomes based on the diet, are you aware of what those differences are? Is it to do with diversity, types of bacteria?
Yeah, it has to do with both of those, uh, actually. Um, and, uh, so, you know, again, uh, one of understanding the complexity of the microbiome is another issue that we have, right? because we're not just dealing with like five or six types of bacteria that can end up in your uh you know end up in your intestines in different uh proportions. We're talking about uh thousands of types of bacteria, right? And you know uh you start to do the math of how many different combinations you can end up with, right?
And all the different proportions and that's a lot of data, a lot of noise, right? to start to find the signal within. Uh this is one area right where you know AI large language models right those things might start to help us because they can go through large volumes of data uh efficiently and start to figure out the signal within there uh because there is going to be a lot of noise when you're dealing with such a complex system.
>> If you talk to any dietician these days they're going to say you want to eat the rainbow. Y >> get a lot of different plants, a lot of fiber. That's going to cause the diversity of the microbiome.
>> I assume by what you're saying here, that's not your stance.
>> Yeah, correct. That is not my stance at all. Um, as many people know, right? I am uh a proponent of a carnivore diet.
uh and um I have uh me personally uh lots of people that I work with, lots of patients that I work with, right? Uh we uh consume very little to zero fiber on a regular basis and I can say my gut health is better than it's ever been. Uh my overall health is better than it's ever been. So the concept, you know, simple concepts like we need fiber, uh those should be questioned. Um when you really look at the literature around fiber, the scientific literature around fiber, what you see is if fiber is displacing uh processed food, junk food, um you demonstrate a benefit from that, but you can't really demonstrate uh that there is benefit from the fiber itself. Uh I would argue in those cases, it's taking away the processed food that's really leading to the benefits. Um the most interesting thing about fiber uh that most dieticians, most doctors don't realize is um the the best study that I'm aware of that was done uh looking at what we call idiopathic constipation. So constipation that didn't have an obvious cause. Um, and they did a study, a randomized control trial where they gave some of the patients with that fiber supplementation and then they had the group that didn't take the fiber supplementation and the constipation got worse in the group taking fiber. So, fiber does not help with one of the most common problems that we're told that it helps with, constipation.
uh and uh I think the benefits of fiber in the diet are largely overstated. I do not consider it to be essential. Uh and uh of course the whole plantforward, you know, eat the rainbow concept is another one that I take uh issue with. You mentioned there again the difference between a plant-based microbiome versus a more carnivoreish.
I'm curious, obviously carnivores have a microbiome, although it's different.
Yeah.
>> What is it that's feeding that? Do the muscle meats feed that? Some of the other parts of animals, the gristly parts.
Any thoughts on quote unquote animal fibers?
>> Yeah. So, uh, exactly right. It turns out that there are essentially equivalents of fiber that occur within the meat. And a lot of this is like kind of the connective tissue type stuff uh that um you know is in the meat uh and it's in all cuts of meat, right? Ground beef is going to have lots of it, but even within a steak, right? You you think about those connective tissues that are in there. And uh that seems to be uh a primary fuel uh for microbes in the gut. And it is I have kind of started to think about it and uh we mentioned in the book that is basically an animal form of fiber and that's may be why people on carnivore diets don't need fiber uh to maintain their gut health. You mentioned yogurt there. How do you feel about fermented foods in a broader sense? We have kefir, fermented vegetables, probiotics.
>> Yeah. talk more about how you think about receding the microbiome if it's been damaged and for maintenance.
Yeah. So, I think um fermented foods broadly can be a uh good tool uh to use when you're trying to improve your gut health. And whether we're talking about, you know, fermented dairy uh or fermented um plants or even fermented meat, uh you know, there are fermented meats that uh traditionally ancestrally, you know, were were part of the diet and uh remain part of the diet. uh in some cultures. Um you know it's interesting when you look at the plants um uh the new book uh stay off my kitchen table uh the forward to it was written by Bill Schindler. Uh Dr. Dr. Schindler is a anthropologist who has studied uh kind of food history, how we came to eat the things that we eat and specifically looking at um for instance plants right and when you go out in nature broadly um a large proportion I forget the exact number right but it's something like 95% of the plants as they occur in nature would kill us if we ate them right they are poisonous to us. Um, and what humans be what one of the things that human beings were able to do over time is figure out how to detoxify enough of these products, right, that they could eat them, right? And that's a agriculture essentially. And one of the methods uh that is used in traditional cultures is fermentation. Uh and it turns out if you ferment plants uh you can detoxify a lot of the issues that come with plants. And so the fermentation process is very uh fascinating. And um I always tell people if you're going to uh incorporate plants into your diet, fermented plants are probably one of the best ways to do that. Um, but uh, you know, it's it's one of the things I put in the category of if you're having gut problems, you probably, you know, fermented foods can be a great tool to use to heal that. Uh, I'm not totally convinced that fermented foods are necessary. Uh, you know, as a maintenance thing for people. Uh, they don't see they're not harmful. If you like them, if you want to eat them, great. Uh, but you know, I know plenty of people that do carnivore diets, for instance, that don't incorporate any fermented foods and they're still doing great. Uh, so I don't think it's a necessity, but they can be a tool uh to help with all of this.
>> What are your thoughts on probiotics?
>> Um, in terms of the supplements, you know, that get sold, >> capsules, >> yeah, I'm not a big fan of them. Uh again, I don't I think many uh maybe most of the ones that are out there uh the reality is is that the counts the bacteria counts uh are not high enough to really impact our gut uh and our uh gut health and uh they don't get absorbed. They don't survive through the digestive tract like we think they will.
So um probiotics are not something that I recommend broadly to people. Um again I think if you're targeting certain aspects of heart health of gut health um uh fermented foods uh probiotic type uh foods can have some benefit there but I'm generally not a fan of the probiotic supplements.
>> Let's come back to plant toxins and start really broad here.
>> Yeah. What are some of the healthy fruits and vegetables people are eating quote unquote healthy that are actually causing problems?
>> Yeah, I think most of them actually could be put in that category um to be honest and again it's going to depend on the person but um uh you know let's take broccoli, right? Uh broccoli has a host of anti-nutrients in it. Um spinach is another big one. Spinach, kale, right?
These are loaded with something called oxalates uh that again are are damaging to us can contribute to that leaky gut forming. Um oxalates uh form uh crystals right that can be thought of as as basically daggers right that start to damage the gut and they can get into our joints and start to contribute to things like uh you know gout and other inflammatory sort of gout uh joint disorders. Uh so um most of the plants right uh understand the the the reasons that the anti-nutrients are there is it is the plant's defense mechanism. Plants don't want to get eaten, right? Um, you know, broadly thinking about life on this planet, right? Every species, uh, the goal of that species is to continue to propagate, right? You want to be able to reproduce and make sure you persist.
Um, animals, right, our defense is animals can run away, animals can fight, right? You know, uh, so that is how animals defend themselves. plants can't plants can't move. Uh you know plants can't really defend themselves in that physical manner. So the plant defense system that um evolved is if uh when an animal tries to eat the plant, that animal gets sick, right? They're um the rest of that animal pack, animal tribe is going to learn, don't eat that plant.
And um these uh defense chemicals right these anti-nutrients these toxins like oxalates and other things uh are how the plant defends themselves and um we have to realize as human beings um our intestinal tract our intestinal system uh can't deal with that. Now what's unique about some animals especially the ruminant animals right they can deal with those defense chemicals they can actually start to detoxify them um and um therefore they uh are more uh adept at uh and more uh designed you can say or have evolved to uh be able to eat the plants. The ruminant animals extract the nutrients from the plants well uh and those nutrients then end up in the meat in the fat of that animal and we as human beings are designed to then eat the animal and that's how we get the nutrients from the plants. We were not designed we are not optimized to get the nutrients uh directly from the plants.
When you were talking about fermentation, you mentioned the fact that it can help with the toxicity of some of these plants.
>> Yeah.
>> Any other methods of preparation people can use to have that same impact?
>> Yeah. All of the really uh you know uh uh cooking methods that we came up with, right, for um for plant products. Uh and it can start with things like soaking and sprouting um and then just cooking in general, right? Uh these are all ways uh to help detoxify and also help to start that breakdown process, right?
When we w when we went back to the you know basics of digestion, right? Uh again um the the types of enzymes that we have within our uh uh digestive system are not optimized to break down plants. Uh they're optimized to break down animals. Uh so we have trouble in a lot of cases breaking down the plants.
And you know when you start to soak something and sprout something and cook something uh that starts that breakdown system. So now we can uh you know eat these plants and and start to extract nutrients. So again uh Dr. Schindler is probably the best resource in the world.
Uh I would point people to his book called um Eat Like a Human. uh where he really goes into um it took a lot of work for our ancestors to figure out how to make enough of these plants uh not you know not uh at least overly toxic to us. But there are still some persistent lowgrade toxicities that again we don't fully recognize all the time uh that um uh end up contributing to this.
>> For somebody that wants to include plants in their diet, at least right now, what would you say are the safest of the ones people are eating?
>> Honestly, I think that's going to depend on the individual. And this is where I utilize the carnivore diet as a uh great elimination diet, right? Because when we reset the system, when we take all of the plants out and uh you know, you give it 30 60 maybe 90 days of doing that and uh you get to what is for most people sort of an optimal state and then you can start to selectively add things back in. This can be a good way to figure out uh you know what you react well to and what you don't react well to. Um and um this I find to be particularly applicable for people that are dealing with things like autoimmune conditions, uh dealing with the gut dysfunction, the leaky gut. Um one of the powers of the carnivore diet is it is the best elimination diet that human beings can do. Again, meat is the simplest food that we can exist on. Uh, and so, you know, you kind of do a reset with it and then you can start to figure out what plant products you react to and what ones you don't. Um, and for a lot of people, the reality is is that, you know, probably most uh fruits and vegetables are okay to eat in some level. Um however uh they are not essential to human health. Um the one of the big you know kind of messages that I aim to get out to people is uh the carnivore diet is a perfectly valid dietary approach for human beings. Um meat is medicine I tell people and meat is actually essential to health. Uh the plants are optional. Some people tolerate them just fine and if you enjoy them and you want to have them and you're tolerating them well then I tell people go ahead you know they are a whole real food and so they fit in my kind of uh you know highlevel schematic of what we should be eating whole real food um but they are not essential this messaging that we have gotten uh you know that you need your veggies that you know certain nutrients are only available in plants is just not true. Uh human beings can get every essential nutrient that they need from meat and meat alone. Uh and there is nothing unique that are in plants that we cannot get from meat. Uh the opposite is not true by the way. Uh you know plants do not have all of the essential nutrients that we need. And that's why people that are doing vegan diets, they need to supplement to remain healthy. um you know carnivores do not. Uh so ultimately you know like I said I put the plants in the category of uh if you want them for a lot of people they're not going to be harmful and you can feel free to eat them. Uh there are a fair number of people though that they are harmful and they can be subtly harmful. Uh and you need to acknowledge that and um you know you need to be pretty selective about what you're putting in and you need to ask why you know why are you putting it in because if we start with the basic thesis right that um the reason we eat is to get the nutrients that our body needs and to get the building blocks that our bodies need. And we can get that all from meat which we can and we can optimally extract it from meat which we can then why are you putting the plants in right and it becomes a very different conversation about how we're constructing our diet?
>> Are you currently consuming any plants on a regular basis and if so why? No, I'm I'm not. Uh like I said, I maintain and have maintained now for a long time a uh you know, carnivore diet. Uh the vast majority of what I eat is from the animal kingdom only. Now, uh the reality is is that I don't react negatively to plants generally. Um I can eat them. I just don't choose to because I'd rather have the the most nutrient-dense uh you know product and and uh a carnivore diet has just worked great for me. So, I continue to do it. Uh you know, but yeah, there might be a situation where I have an occasional plant product uh but is not something I do on any sort of regular basis.
>> You talked about people using this carnivore diet potentially as a reset for somebody wanting to do that.
what are the initial carnivore foods that they would want to allow and then how long till they start introducing other things.
>> Yeah. So again, uh the simplicity of carnivore is one of the things that I like most about it. Um it's real kind of black and white. If it comes from an animal, it's part of the carnivore diet, right? So these are going to be your meats of all kinds. Uh these are going to be seafood I include in there. And these are going to be eggs and dairy products, right, that uh come from the animals. And that's, you know, that's what you include on a carnivore diet.
And if you're doing a very strict version of a carnivore diet, you're not going to have anything else beyond that, right? You may not even use things like spices that comes from plants. Now, again, do most people need to go that extreme? Probably not. But some people do. Uh, and uh, I always encourage people, uh, you know, to start with a 60-day trial. Uh, I think that's a good amount of time to start to really um, and again, a lot of this is about what you're not eating, right? The processed food and getting that stuff, the effects from that all sort of flushed out of your system, uh, is a way to think about that. So, 60 days, I think, is a good thing. Some people, you know, they say, "Well, I can only do 30." So, I'm like, "Okay, start with 30." Uh, and at the end of 30, they're usually like, you know what, I'm feeling pretty good on this and I can do this, so I'm going to go 60, 90 days, right? Whatever it might be. Uh, and then, like I said, you really get a baseline of how good we're supposed to feel. One of the very kind of insiduous things that has happened in our society is um most people don't actually understand what good feels like. You know, I mentioned earlier we start we've become accepting of things like it's just normal to be bloated after you eat. It's normal not to have full energy. You know, the the little aches and pains that starts to sneak into life for many people, right? And everyone says, "Oh, well, that just happens when you get older." Um, it's not the way it's supposed to be. Uh, we are supposed to be able to op, you know, uh, function optimally, you know, well into our lifespan and, um, we've lost the appreciation of that because quite frankly, we look all around us and everyone else around us has these things and so we say, "Oh, well, it's normal."
Uh, but it turns out you don't need to have those things. And uh you know, eating a carnivore diet can be a great approach to show you how good you're supposed to feel. And then you say, "Okay, you know, I want to I miss whatever it might be. I'm going to try reintroducing it." And um I encourage people to do that kind of systematically. You know, pick one or two things at a time and, you know, reintroduce it for a week or two. And if at the end of that time you still feel that same optimal level that you felt without it, great. Your body tolerates it, you can incorporate it. But if you don't, if you start to notice, oh, you know, that ache and pain that had gone away, all of a sudden it's back. That's the signal that your body is not reacting well to that food. And uh you don't want to uh incorporate it. Um, now within the carnivore framework, are there things that some people do not react well to? Uh, the answer is yes.
And dairy is probably the big one here.
Some people, um, dairy is problematic to them. And, uh, I'll oftenimes tell them, you might want to start your carnivore diet without the dairy. Um, now dairy is interesting in that a lot of the people who uh have negative reactions, right?
They they'll say the lac lactose intolerant, they're dairy intolerant.
Um, it turns out it's because of that underlying gut inflammation. And if you give a carnivore diet a chance and you heal up the gut inflammation, I have had many patients who said, "I can't tolerate dairy." They go on the dairyfree version of the carnivore for 30, 60, 90 days and um they then reintroduce dairy and they tolerate it just fine because it wasn't really the dairy itself that was the product the problem. it was this leaky gut that was altering you know the proteins and stuff that got across that barrier uh that was causing the problem and the gut healed and now they can tolerate things like dairy uh which has been a very interesting phenomena like I said that I've observed multiple times now in my patients for somebody with gut issues can you think of a better way to heal the gut than going carnivore minus the dairy for that 30 60 days >> no I really can't at this point uh clinic clinically I haven't seen it you know and like I said there are lots of protocols and stuff that they're out there and people go through and they do these you know the the cleanses right we hear about uh and I have not come across anything that performs as well as a carnivore elimination diet >> somebody who is now excited about this they're on a standard type diet right now >> yep >> they make the switch they do it pretty extreme dream and go right in.
>> Y >> what are some of the things you want to give them a heads up on that they might experience changes in their body?
>> So the first thing to understand is uh if you're coming from a high carbohydrate diet uh and you're going to a low carbohydrate diet uh there are important um hormonal and biochemical changes that are going to occur. Uh so for instance your insulin level starts dropping and one of the things that happens is that alters within the kidney how you're handling electrolytes things like sodium uh and uh initially as your body is making that adjustment you're going to lose more sodium in the urine and you need to replace that. So this is why we usually advise um you know salt on your food uh good high quality sea salt and a lot of people need to supplement with electrolytes uh you know and sodium and magnesium are probably the two biggest ones. So salt uh maybe m using a magnesium supplement uh you know there are lots of kind of those electrolyte uh supplements out there and those are oftentimes necessary when you're first transitioning uh from a high carb diet to a low carb diet and of course a carnivore is going to be a very low carbohydrate diet essentially a zerocarbohydrate diet. Um so that would be the big one. The other thing that people need to understand is that your uh primary energy source that your body is going to use is going to be shifting from uh sugar right to fat. Um and you need to account for that. So having enough fat in the diet becomes very important. And again, most people, right, our whole lives, we've been programmed against consuming fat. So people go on the carnivore diet and there's like they're like, well, you know, I'm going to eat my lean chicken breast, right? I'm going to eat my lean cuts of meat only. And they don't recognize the importance of no, we actually need that fat. That's our energy source now. And uh that's another common area where I see people kind of get tripped up initially.
How does that change as a person is on this diet longer? And the reason I ask that somebody coming to it often times it's going to have a lot extra fat on their body.
>> Y >> is it early on the body is not good at pulling that fat and using it as energy.
So we have to bring it in through the diet.
>> Correct. Uh and this specifically has to do with the effects of insulin. So we think most people when they think insulin they think okay insulin is there to um get the sugar out of the bloodstream lower the blood sugar level and yes that's something that it does. Uh but one of the things that they don't recognize is uh when your insulin level is high it blocks your body from accessing the body fat from pulling the fat out to use for energy. So again, people that are coming from a high carb diet, uh, that have high insulin levels, uh, they're probably insulin resistant, they may be diabetic, right? Type 2 diabetes, that's the that's the basic biochemical thing in type 2 diabetes is your insulin level is high. And therefore, your body is blocked from accessing your body fat.
And that's why you're going to need to eat high fat um uh to give your body that energy. Now, after an adaptation time, right, your insulin level has now come down because you're not eating the carbohydrates. Uh now, you might not need quite as much fat in your diet. And now we can let our body start to burn that body fat, right? Which is what most of us uh want and need to do. And so, uh, often times as people are, you know, getting settled in on their carnivore diet, we might have them, you know, lower the fat some. You never want to go very low fat. Uh, because again, like I said, the nutrients in many cases are stored within that animal fat. It's essential, right, to get the nutrients from that standpoint and to have some fat to use for energy. But, you know, many people can kind of back off a little bit uh so that we can start burning more of our body fat.
>> How do you think about ketosis for yourself, other people eating this way?
Is that something you're naturally going to fall into? And then is that important?
>> Yeah. So, uh yes, you're going to naturally fall into it. uh you know, when you eat uh when you're not eating carbohydrates any longer, your body is going to get to burning fat and you're going to start to make some ketones.
Now, um you may not make a lot of ketones. Uh and everyone always asks, you know, is that important? Should I be testing my ketone level? Should I be looking at your ketone levels? Uh and again, the answer ultimately becomes, well, it depends. It depends on what your goals are, what you're dealing with. There are certain conditions where being in higher level uh of ketosis, having more ketones in your bloodstream is clearly beneficial. Uh the three big ones that I always point people to for this are um uh neuroscsychiatric conditions, right? So again, think back the the the first use of a ketogenic diet clinically was to treat uh seizures, treat epilepsy in children. Uh so obviously it must be having some sort of effect on the brain. We now over the past couple of years have realized what a major impact ketones have on the brain. We have a uh new uh field called metabolic psychiatry where there are amazing people out there like Christopher Palmer, like Georgia Eid, uh and so many others that they are treating advanced psychiatric illnesses like schizophrenia, depression, bipolar disorder, uh with ketogenic diets, and um they are having amazing results.
They're getting people off of medication uh you know off of these powerful uh antiscychotic and you know other uh psychiatric medications uh with just changing diet. So brain conditions neuroscychiatric conditions is number one. Uh heart failure is another area where having higher levels of ketones have been demonstrated to be beneficial.
It turns out that the heart loves ketones. Uh many people don't realize that there is a direct connection anatomic connection between our intestines and our heart. There's a structure it's called the thoracic duct.
And what that does is part of the fats that we eat, right? The first place they go is right to the heart. Uh they bypass the liver and they do this because the heart loves fat as fuel. It loves ketones as fuel. So patients that are dealing with impaired heart function, heart failure, uh they can benefit from ketones and having higher levels of ketones. And the third condition that higher levels of ketosis may be beneficial in is as a adjunctive cancer therapy. Uh, and so those are a couple of the situations where I tell people, yeah, you probably need to test your ketone levels and you may need to adjust your diet in such a way that you can get those real high levels of ketones.
People that are just kind of going for general health, you know, weight loss and those types of things, probably not as important. Um, it can be beneficial.
Some people find it useful to do that as a kind of guide to help them determine, you know, Well, ultimately, right, if you're on a carnivore diet, uh the only macro, uh variability, uh you know, and I'm talking about the food macros, right? The macro variability is going to be how much protein versus how much fat.
And um you know, and that's going to determine how much ketosis you ultimately get into, how many how much uh you know, what level of ketones you ultimately generate. And uh so in some situations paying attention to that and testing it is useful. In a lot of situations it's not.
>> So it sounds like it when it comes to carnivore and people that aren't producing the ketones like they would like to. That's because of the up protein and this protein bolus that's going to cause gluconneogenesis.
Is that right?
>> Correct. So uh you know our bodies can convert protein to glucose uh to make energy. It's again it's it's not a preferred way for our body to make energy. It turns out that it's a fairly inefficient way to make energy. But if our body doesn't have a choice it's going to do that. So again, if we're in a situation for instance where there's um you know, someone is insulin resistant and they're not accessing their body fat well and they're not consuming enough fat, uh the body's going to take the protein that they are consuming and it's going to do gluconioenesis, convert it to glucose, and use that for energy. Um and in a situation like that, I I may be advising people, okay, you want to back off the protein some.
Again, we're not going low protein. And you want to start adding some more fat to your diet so that we can get you into uh you know, uh uh a more ketoic state.
Uh more ketones, less glucose uh as our fuel source. So, it's obvious you're not fearing fat.
>> Yeah. But for the average carnivore who isn't seeking ketones, how do you feel about adding fats to things like a ribeye, putting butter on top, adding heavy cream to coffees? Is that something you ever advocate for patients or something you do?
>> Well, I I basically tell people to kind of titrate your fat intake to your energy levels, right? the the way that I kind of start to construct carnivore diets with people is, okay, let's set your protein goal. Uh let's figure out how much protein you need. Uh and again, my starting point is usually around one gram of protein for each pound of uh lean body mass or ideal body mass that you're kind of targeting. Uh so um you know and again for most people that's going to fall somewhere between 100 to 150 grams of protein a day as a rough starting point. Um and then I tell people eat the fat that comes with it, right? And you know again I tell people don't fear the fatty cuts of meat. Uh you don't have to have ribe eyes all the time. Uh you can but you know you don't have to for most people. do a kind of mix and you know you'll end up at a certain fat level and then see how you feel and if you feel like your energy levels aren't adequate. Um if you are someone who is targeting higher levels of ketones for maybe one of those reasons we discussed earlier then yeah start adding more fat. Uh now some people from just a enjoyment perspective right they they want to add a lot of fat at the beginning and I usually don't discourage them from doing that but if they then reach a point you know and this comes up most commonly in the context of people are trying to lose weight and they're like I I you know went on my low carb carnivore diet. I lost a bunch of weight at first uh and then it kind of stopped and now I'm kind of stuck or maybe I'm even gaining back a little bit of weight. And that's usually where we'll start looking at, well, you know, how much of the extra fat are you consuming? You know, are you putting more butter on? Are you putting a lot of cream or even butter in your coffee? You know, which is uh popular.
Uh and maybe, you know, that's an area we want to start to back off of uh a little bit. Like I said, I don't tell anyone you need to be on a low-fat diet.
I really, you know, uh, rare. I can't think of a situation where I've recommended a lean carnivore diet, right? You do need the fat. You do want some fat. But, yeah, like everything in our society, sometimes that gets taken to the extreme. And, you know, uh, everyone thinks they need uh, you know, every meal needs to be a ribeye uh, with a lot of butter on it and they need to be drinking all sorts of heavy cream in their coffee. Uh, and most people don't need that. Most of us have the body fat, right, that we can, you know, when we're able to utilize it, we should be utilizing it.
>> Insulin resistance is something that's come up a few times. Let's go into greater detail on what that is and why somebody might have it and not even know.
>> Yeah. So, first of all, what it is, right? So um uh when we eat uh carbohydrates primarily uh our insulin levels are going to go up and the reason we mentioned it earlier is you eat the carbohydrate gets converted to glucose to sugar. Uh that sugar goes in our bloodstream and our body knows that too much sugar in the bloodstream is toxic. So, we don't want to let it hang around. And insulin is the primary hormone that gets the sugar out of our bloodstream. And um the way that it gets the sugar out of our bloodstream is either we're burning the sugar immediat immediately for energy or we're putting the sugar into storage and we have what's uh a short-term storage system. It's called glycogen. uh that can go in the liver and that can go in our muscle and then we have the long-term storage which is fat body fat and uh you know so that goes into our fat cells. Now, if you're eating too much carbohydrate and you're eating carbohydrate too often, um your insulin level is going to remain elevated and the cells, right, the fat cells, the liver cells, uh the muscle cells, right, that are taking in all of this sugar, they're going to get full. They're going to say, "Can't take in any more sugar."
And um they're going to stop listening to the insulin essentially. And that's what insulin resistance is. And the body's initial reaction to that is, okay, well, we're just going to make more insulin and, you know, kind of force these cells to listen. And that might work for a while, but then it's going to stop working. And finally, what's going to happen is your blood sugar level is going to remain elevated, right? And that's where most doctors pick up on the problem. All of a sudden, you're diagnosed with diabetes. And the problem is they've missed the long period of time, often decades, that the insulin was high. The body was becoming more and more insulin resistant. And during all that time, there's damage being done. There's damage being done to your blood vessels. There's damage being done to your other organs. And it's a huge missed opportunity because if we just do a very simple test, look at the insulin level. uh look at what's called a fasting insulin level. You haven't eaten for 8 to 12 hours. How much insulin is in your bloodstream? And if it's a lot, uh and I consider anything in double digits to be a lot when you're looking at the test results, uh it tells you you're on your way to in you're insulin resistant or you're on your way to insulin resistance and we got to do something to reverse that. as a heart surgeon, talk more to that piece about high insulin and damaging blood vessels.
>> Yeah. So, it turns out that insulin resistance is the primary driver of heart disease. Uh we can go back to some studies done uh primarily by uh Dr. Joseph Craft 1970s 1980s and uh he was one of the you know leading uh uh clinicians and scientists looking at insulin resistance and one of the things he did was he looked at all the patients that came into his hospital with heart disease with heart attacks and he screened them rigorously for insulin resistance and what he found was 90 to 95% of them were insulin resistant. So, heart disease is insulin resistance primarily. Now, you contrast that against what we've been told more recently is the cause of heart disease, cholesterol, right? And you look at those statistics, the patients that come into the hospital with a heart attack, how many of them have high cholesterol?
And it turns out that's like a 50/50 shot, right? maybe half of them have high cholesterol uh versus like I said 90 to 95% that have insulin resistance.
So which one should we be focusing more on? Insulin resistance. Uh insulin resistance is the root cause of heart disease and I believe our path forward if we're going to have meaningful impact on heart disease is let's attack the insulin resistance. And uh that's really been the um primary thing that I have been doing with patients uh now to try and manage and prevent their heart disease and we are seeing great results from it.
>> Let's get into the mechanism there.
>> Somebody with circulating high blood glucose, high insulin, how does that cause plaque in the vessels?
>> Yeah. So there's a couple of different pathways, right, that connect the insulin resistance to the plaque and the damage uh in the blood vessels. So the first one is the sugar problem, right?
Sugar is directly toxic, directly damaging to the lining of our blood vessels. And so, uh, as you're becoming insulin resistant and, um, you're not controlling your blood sugar level as well and you're starting to get these spikes in your blood sugar, you know, every time you eat, uh, that's going to directly damage the blood vessel wall and that's the first step in the plaque formation process. Now, insulin resistance does a couple of other things that magnify that problem. Um, insulin resistance lowers the production of nitric oxide.
Nitric oxide is a uh essential chemical that our body uses to help protect our blood vessels. Um, nitric oxide helps lower our blood pressure, does lots of things, but it it protects the lining of our blood vessels from damage. And when you get lower levels of nitric oxide, um, you're now, you know, more prone to damage to the blood vessels. And it turns out that insulin, uh, blocks one of the enzymes that helps it that our body uses to produce nitric oxide. And therefore, insulin lowers nitric oxide levels. Um the third important way that we start to connect insulin resistance and plaque is that insulin resistance actually um alters the types of cholesterol that we have in our body. Right? And this gets into the discussion around um cholesterol LDL cholesterol, right? And we've all been told uh and you know you've heard it from your family doctor, you've heard it from your cardiologist that LDL cholesterol is bad cholesterol. It is harmful. Uh it turns out that that is only partially true. Uh because LDL cholesterol isn't one thing. LDL cholesterol is actually a family of uh what we call lipoproteins uh particles that transport cholesterol around in our bloodstream. And broadly speaking, there are two types of LDL cholesterol particles. There are what we call small dense particles and there are what we call large buoyant or large fluffy particles you'll hear them called. And those actually are very different things because the small dense particles these do get involved in plaque formation.
They are what we call atherogenic particles meaning that they promote the formation of atheroscerosis the plaque in the arteries. Uh but the large particles the large buoyant particles are non atherogenic. They don't get involved in plaque. So um insulin resistance one of the effects of it is that it causes more of those small damaging atherogenic particles and less of the large healthy um nonathogenic particles. And uh that is a third way that insulin resistance ends up contributing to plaque formation. Um so those are probably the three big ones.
There actually might be even a few more that we can point to. Uh insulin itself, the high level of insulin itself, some studies have suggested is also toxic to the the endothelium, the blood vessel uh wall. Uh and um uh that is why we see such a strong connection between insulin resistance and heart disease.
>> You hear this term to oxidized LDL. Is that tied to the small dense? it is tied to it. It's not quite the same thing. Um but there is sort of a a linkage there.
Uh and um oxidized LDL is another form essentially of dysfunctional LDL. So um small dense particles are more likely to become oxidized is really the connection there. Uh but it's a different type of damage that's being done uh to those LDL particles. And again the problem becomes now so we're going to take another step back and we're going to say well why you know uh why is cholesterol why does cholesterol exist in our bodies right what is its purpose and one of the purposes of cholesterol in our bodies is it is a repair mechanism so when we get damage to the blood vessel wall cholesterol is sent there to repair the damage and what's supposed to happen when you have the large buoyant cholesterol particles, right? They go, they repair the damage to the wall, they get sort of reabsorbed and they disappear and there's no nothing left behind. You have a nice new, you know, wall. um the small dense particles and the oxidized particles when they go to the blood vessel wall and they're trying to repair the damage but because they themselves are dysfunctional and damaged um the body reacts negatively and now this small dense LDL particle that was there to try and fix the damage it ends up magnifying the damage. It sets off its own inflammatory uh uh reaction and you get things like macrofagages that come in which are cells that you know are now trying to get rid of the small dense particles and everything becomes kind of inflamed and it becomes this vicious cycle and that's what is ultimately causing the plaque to build up.
>> Let's walk through life cycle of plaque from the beginning. I know there's soft plaque, hard plaque. Yeah, >> I believe the soft plaque is the initial and then eventually it becomes calcified and hard. But take it right from the beginning and then we'll talk about best case scenario. What you just said is a very commonly held belief, right? That we kind of start with soft plaque and over time it becomes calcified plaque.
Um the reality is is that we haven't quite proven that yet. Uh and the reason this is brings up another important concept around heart disease. uh understand that up until very recently, and I'm talking like the past five to 10 years, um the only way that we would see plaque in the blood vessel, right, was either an autopsy was being done, right, someone died, we opened up their blood vessels, we see what's going on in there, or someone like myself, a surgeon, is going in there to operate on a blood vessel, right? And we open up the blood vessel and we see plaque. Now, neither of those things um get repeated, you know, over and over again throughout someone's life, right? The autopsy is obviously only a one-time thing. Uh and even surgery like I do, right? It's rare that we're doing it, you know, repeatedly on patients. Um, we didn't up until very recently have a good way of looking at plaque in people's arteries in living people and being able to do that, you know, year after year after year, right, on a serial basis. We now do have very highfidelity uh scans of the heart that we can do that we can actually start to see the plaque. So a lot of our understanding around you know soft plaque calcified plaque uh has to come from animal models and we really don't have a perfect animal model of um of plaque. Uh other observations come from okay we sometimes end up doing autopsies on young people and this is what we see in their blood vessels and then we do autopsies on older people and this is what we see in their blood vessels. And so, you know, the thinking is, well, it's an evolution, but it might not be as clear as that. So, um, yes, you are correct. There are two types of plaque. Again, broadly speaking, there's what's called non-calcified or soft plaque, and there's what's called calcified plaque or hard plaque. Um, and it does seem that the older that people get, the more likely they are to get calcified plaque.
And when you look at young people, they generally don't have calcified plaque, but they may have some of this soft plaque. So, there may be a time component to this. It may be that soft plaque does turn into calcified plaque over time. Um but again um we're only now starting to get very good data around this because now we do have these highfidelity scans that I can scan someone today and I can scan them a year later and I can see with great detail, you know, this is where plaque was and it was soft plaque and now maybe it became calcified plaque, but that doesn't seem to be always consistent. Um there may be other factors that cause calcified plaque to form sort of primarily uh and uh non-calcified plaque to occur in other situations. And it may not be quite that one always turns into the other. Uh we're starting to see patients in my practice for instance uh that they have calcified plaque and then we scan them a year later and the calcified plaque starts to disappear.
uh which is a you know concept that wasn't really understood previously and uh so we're starting to understand all of this plaque dynamics. Uh but ultimately you know there are two types of plaque we can say that for sure. Um these plaques tend to behave a little bit differently right so the danger coming from this plaque uh are probably different when we're dealing with soft plaque. There is a concern that soft plaque might be unstable. It might start to peel off the blood vessel wall and this can set off a blood clotting response and lead to a heart attack, what we call plaque rupture. Um calcified plaque, it starts to make that blood vessel more stiff, right? and it can't um expand like it's supposed to and it can cause start to sort of gradually choke off the blood vessel as that calcified plaque builds up. And um the reality is is that most of the time when you're looking at plaque in people's arteries um these two coexist uh you know when you look at an area of plaque with these highfidelity scans you're often times seeing combinations of soft plaque with calcified plaque. So imaging has become a very uh important uh tool that we can now use as we're trying to figure out heart disease for people as we're trying to prevent and reverse heart disease for people. And this is really I think uh one of the things that over the next 10 years is going to vastly change how we approach heart disease. Uh the fact that we can now dynamically see in living people what is happening with their arteries is really going to change our understanding of you know how things work when it comes to heart disease.
>> Somebody that wants to use one of these new tests, see where they're at, what do you recommend?
>> I typically recommend starting with what's called a coronary artery calcium scan. This is a simpler version of the imaging. It's only looking at the calcified plaque in the heart, which is a limitation of it. Um, but it is a uh easy to perform scan. Uh, literally takes like two to three minutes. You don't have to put an IV in. You just lay down on the CAT scan uh machine and you go in and you come out and we get to see um is there calcified plaque in the arteries of your heart? And this turns out to be a great screening test. Right.
I I oftentimes uh you know uh draw the analogy of the mammogram, right? And we're trying to see the disease heart disease versus breast cancer on the mammogram at its early stages. And that's what if we see calcified plaque, we know that you have already started this progress towards heart disease. And if we see a lot of calcified plaque, it tells us you might be far along in this process and we might need to be worried about you. So, that's where I usually start. Coronary artery calcium scan.
Like I said, very easy to do, inexpensive. Most areas $100 to $200 um to get a coronary calcium scan. And I now advise all men, by the time you're 40, get your first one. Women, by the time you're 50, get your first scan. Uh if you have reason to be concerned, if you are metabolically unhealthy, if you are insulin resistant, if you are diabetic, if you have a strong family history of heart disease, uh get the scan even earlier. Uh because the reality is is that I have 30 year olds ending up on my operating table these days. And that means that that disease started in their 20s, maybe in their teens. And so, you know, screening earlier can be helpful in certain situations. And then those highfidelity scans that I was talking about, they're called CT angiograms.
Now, these are a little bit more complicated. Um, we need to put an IV in you. We need to give you die through that IV. uh the radiation exposure is higher and the expense they cost uh more money to do especially um the the kind of latest version of these that use um AI technologies to analyze the pictures and analyze the plaque um you know these things are still somewhat expensive and they involve more radiation and they're more complex so I reserve that as the second level you If your CAC score is concerning, um, we might want to get a CT and if you're, um, having symptoms of heart disease, we might want to get a CT and uh, but it's generally not the first test that I recommend to people.
>> How often you scanning somebody, man or woman, middle-aged, and finding no plaque?
The statistics are for a uh 40year-old male um you're going to have about a 60 to 70% zero, you know, 60 to 70% are going to have a zero score. Uh when you're a 60 year old male, you're going to have 30 to 40% with a zero score. So it kind of inverts there. Um women tend to lag about a decade behind men when it comes to heart disease. So, you know, 50 year old women are going to tend to be more in that, you know, 60 to 70% are still going to have a zero score. And by the time you get to about 70 years old as a woman, you're probably down into the 30ish% uh zero score.
>> When it comes to hard plaque versus soft plaque, let's branch off and do each separately.
>> Yeah.
>> Is there any chance there for a reversal?
>> I think for both the answer is yes. uh I think probably soft plaque there's more chance uh than the calcified plaque but I have patients in my practice now that we are seeing their amount of calcified plaque decrease their coronary artery calcium scores are going down uh now I'm always realistic with people let's say you have a CAC score of 500 or a thousand it's not going back to zero uh it might go down 10 20% um uh the natural history. Okay, so coronary calcium scans these have been somewhat prevalent for you know 20 25 years now.
So we do have good uh studies looking at the sort of natural progression over time and on average um coronary calcium scores tend to go up by 10 to 20% per year. Um, when patients don't progress that much, if they only go up 5% or they go up 0% year-over-year, we know that that puts them into a lowrisk category.
That patient is unlikely to have a heart attack uh in the intervening couple of years. Uh, so the progression over time becomes an important predictor of the disease. Uh and like I said, we are now starting to demonstrate plaque regression, lowering of both calcified plaque and the non-calcified plaque because now we have patients that have gotten CT and the higher fidelity study uh on a uh you know serial basis a year or maybe two years apart and we can see both types of plaque can reverse but I always tell people as long as we have stopped it from getting worse as long as it's continuing to progress. That's sort of uh what victory looks like to me.
>> The million-dollar question, somebody that gets a reversal, >> what are you having them do?
>> Yeah. So all of the things that we've talked about and maybe a little bit more uh the primary things we need to do are reverse your insulin resistance if it's present uh lower your inflammation if it's present and we need to uh optimize the quality of your cholesterol. Right?
That's not the same thing as saying low cholesterol levels. That's getting mostly large, you know, fluffy LDL particles, little of the small dense particles. That's making sure your HDL cholesterol is high and your triglycerides are low. Um, and uh, we do the advanced measurements. We look at those particle sizes routinely in our patients so that we know what we're dealing with. Um, so lower insulin resistance, lower inflammation, optimize your cholesterol quality. Those are probably the three big pillars. There might be some other things that help.
There are some supplements that people talk about like nattokinise, vitamin K2, uh nitric oxide we talked about earlier, right? And if people are low in nitric oxide to start with, uh then you might want to do something to boost their nitric oxide. Uh that can be something by the way like going out in the sun, exercising, right? Those are ways to raise nitric oxide. Or it might be something like taking a supplement that might help you raise your nitric oxide level. Uh so all of these things can start to come into the picture. But again, it all starts with get rid of insulin resistance, get rid of inflammation, and optimize the quality of your cholesterol. And that sets the stage for stabilization at first, stop it from getting worse, and then give the body a chance to heal. and let's see some improvement.
>> When it comes to a carnivore diet and nitric oxide, how does that, if it does, help with production? Because you often hear eat beets, certain plants can boost it.
>> Yep.
>> But talk about it from the carnivore perspective.
>> I think the way that carnivore really promotes higher levels of nitric oxide is by removing a lot of the things that are damaging, you know, nitric oxide, right? uh the insulin resistance, the uh processed foods, uh the pro-inflammatory foods. So, uh that is uh one of the things that we uh that that is probably the primary reason. Um um are there specific components of meat that help make nitric oxide? Um yes, there probably are. Right. the component the uh precursors right that our body uses to make nitric oxide. A lot of these things end up being available in meat. Um you know are there some plants that have these things as well? Yes, there are. Uh but again you know we can probably get all that we need from the meat and if we're eliminating the things that are uh hindering our production of nitric oxide uh that becomes a big advantage as well. You quickly mentioned nattokinise. Yes. Explain the mechanism and how that fits in.
>> Yeah. So nattokinise brings in a whole different aspect of plaque formation that actually we didn't get to uh talking about today. Um and that is um blood clotting.
So, it turns out that one of the other things that contributes to plaque formation is we start to get these they're kind of microscopic blood clots that form and um those can start to uh contribute to the formation of plaque.
Uh and so nattokinise uh primarily works on the blood clotting system. it uh increases what it actually does. Uh it's interesting. It doesn't necessarily stop the formation of blood clots, but once a blood clot starts to form, nattokinise uh uh increases the body's ability to get rid of that blood clot. Um so uh that's why nattokinise has been shown to potentially be helpful uh in uh reducing plaque formation or even potentially helping with um existing plaque to lessen. Uh there are some studies that have pointed to this.
Um you know there might be some limitations to these studies like they always are but um ultimately uh you know nattokinas has been shown in some trials to help reduce the amount of plaque.
Those trials were primarily looking at plaque in the arteries of the neck, not necessarily plaque in the arteries of the heart. But you know again uh mechanistically one of the ways that nattokinise is working is by uh helping the body to break down blood clots so they don't persist and turn into plaque.
>> When it comes to blood clots, I just want to make the connection there with the plaques.
>> Yeah. The way I understood it coming into this is that soft plaques when they rupture that's when you get a blood clot. Do I have that right?
>> So that is one of the situations where you're going to get a blood clot. And those are kind of the bigger blood clots that are actually going to block up the blood vessel and cause a heart attack.
But at a microscopic level again when we have that damage to the blood vessel wall, right? blood clots become part of again that healing mechanism uh you know uh and starting to fix the blood vessel wall and um those are the the kind of microscopic blood clots that the nattokinase really helps to uh target so that those blood clots don't become persistent and ultimately contribute to the plaque formation. It's interesting when we look at plaque under the microscope, right? Um, and we see the cholesterol that's there and one of the hypotheses that has been put forward, right? Understand that our blood cells, all of our cells, but our blood cells uh being relevant in this uh aspect, the lining of the blood cell, right, the wall of the blood cell is made up of cholesterol. So, um, one of the ways that the cholesterol might end up in the plaque is not that it's that cholesterol that's circulating in our bloodstream.
It's that we started with a blood clot, right? We had the red blood cells, the platelets, you know, uh, in that blood clot. Those broke down and what was left behind was the cholesterol from their walls. Uh and so um uh that is one of the um lines of evidence you know that starts to connect blood clotting to plaque formation and that is one of the reasons that we think things like nattokinise or aspirin is another example right of a of a anti- blood clotting agent that has been demonstrated to help uh reduce the incidence of heart disease. One thing that comes up for me as you share blood clots and getting rid of those, reversing plaque, whether it be through nattokynise or something else is poking the sleeping bear and if things are stable, starting to tinker with that and potential problems that could arise.
Any thoughts on that?
>> Well, yeah, there's always uh balances, right, in everything that we do. uh there's always risk and benefits of any intervention that we're thinking of. So um you know uh something like blood clotting uh you know you want to find that right balance right you don't want to overly impair the body's ability to blood clot because that's to uh clot because that's going to lead to other issues and uh you certainly don't want to be overly promoting blood clotting right that's going to lead to certain issues and it really you know uh the concept in uh physiology in general right is about homeostasis uh finding that right ba uh that right balance uh between too much and too little of a lot of these processes.
>> So you went over a couple of different tests we can have done to look at plaque. Let's talk about blood work.
Somebody going to get a lab panel.
>> Yep.
>> And they say to you, "Dr. Odia, cost isn't an issue here. I want to get a full workup." what would you have them do and what would you really look at?
>> Uh mentioned it earlier, insulin resistance and inflammation. Uh these are the two big ones. And then the quality of your cholesterol. So what's involved with that? Uh insulin resistance. There are a couple of different ways that we can test it, but the easiest and the one that I usually start with is let's look at your fasting insulin level. How much insulin is in your bloodstream when you have been eating for 8 to 12 hours? uh we want that to be under 10 in the single digits ideally under eight I tell people uh we can also use that if we've tested your fasting insulin and we've tested your fasting glucose sugar level uh we can plug those two numbers into a calculator it's called the homir score h a hyphen IIR um and uh we can that is one way that we can measure how insulin resistance people are um inflammation. The main measure we're going to look at there is called HSCP uh C reactive protein, high sensitivity C reactive protein. And uh this is going to give us an indicator of kind of total body inflammation levels. Uh and um you know that's another uh one for us to look at. Um uh there are some other relevant inflammatory markers that I usually bring into my blood panels. Things like uric acid, things like uh feritin. Um and then there is a blood vessel specific inflammation marker that we can check called myoperoxidase.
And this gives us an indication of are the blood vessels actively inflamed which is going to correlate with plaque formation. Um cholesterol quality right so this is pillar number three. Um on your basic lipid panel you get your HDL cholesterol you get your triglyceride you get your LDL cholesterol level. Does not tell you about the quality of the cholesterol. It only tells you about the amount of cholesterol. uh you want to get what's called an advanced lipid panel. Uh it might be called an NMR panel or a lipid fractionation uh panel. And this is going to break down what type of cholesterol do you have, the LDL specifically, is it large or is it small? Uh and so that is a test that I recommend to everyone. Uh we mentioned homocyine earlier uh as an indicator of uh methylation problems.
Get that test done. Uh um and uh probably the last kind of uh piece that oftenimes gets missed is something called lipoprotein A. This is a special form of LDL cholesterol. Uh and it has this an extra protein attached to it.
That's where the name comes from.
Lipoprotein A is the extra protein that's stuck onto that LDL molecule and it makes um LDL sticky. It makes it interact with that blood clotting system that we were just discussing. And so patients that have elevated lipoprotein A levels are at increased risk of heart disease having nothing to do with the cholesterol but having to do with that blood clotting system again. So, those are um I think the high points of the blood panel that I get from my patients and um it it turns out it's not super expensive to do that. It's going to cost you a couple hundred bucks. Uh but I think it's a good investment in your health to do that a few times a year. Your insurance oftentimes will cover a lot of that. Uh the trick, the challenge for most people is getting a doctor who understands these tests and will therefore order them for them and that's where it becomes a little bit more difficult for most people.
>> I'm glad you brought in LP little A. I wanted to get into that.
>> Yeah.
>> The way I understand it, that one is heavily genetic based and having one test done is often sufficient to see where you're at. Do you agree with that?
>> Sometimes. Uh, so yes, it is heavily genetically influenced. If you get an LP little A test and your LP little A level is normal, you probably don't need to keep retesting it. Maybe you do it again, you know, five years later just to make sure that it wasn't an anomaly.
um if your LPA is high um yes it's going to probably stay high for the rest of your life but we do see some influence of diet and lifestyle. So um I've seen LP little A levels come down when people resolve insulin resistance um by you know uh 10 20 maybe even 30%. And that's where I I do tend to actually retest it.
Uh you know, in those situations, I want to see what's happening with it. Um but yes, largely genetically determined. Um if it's high, you want to maybe take some extra protection against blood clotting. So this might be a situation that would push someone more towards using something like nattokinise, using something like aspirin. And you also want to be alerted to the fact that you're at higher risk of heart disease.
So um you might want to be more aggressive about getting those imaging tests for instance uh to see uh you know what's the impact of the lipoprotein A.
>> Okay. So nattokinise reverse insulin resistance.
If you yourself were in that category anything else you'd add in there? I guess the other things I would talk about, you know, the general pillars of health, making sure you're getting a good amount of activity, uh, making sure you're sleeping, right? Making sure you're getting out in the sun, uh, you know, those dealing with your stress, right? Those are the other things that I would throw in there that we know can contribute to this as well.
>> How do you think about April B? Is that a test you like to even look at?
So, um, APOB [clears throat] suffers from the same problem that LDL cholesterol levels do. You're looking at the amount of cholesterol, but you're not getting insight into the type of cholesterol. APOB measures both the large LDL particles and the small LDL particles. It also measures something called VLDDL particles, which are also atherogenic. And that's why APOB ends up being a better test than LDL alone, but you still have the same problem. You if your APOB level is high, um you don't know do you have a lot of the large particles that are not harmful and therefore that high apo is not going to be problematic or do you have more of the small particles which are harmful and it's going to be problematic. Now you also see the opposite problem or I see the opposite problem. APOB levels, LDL levels can be what are considered low. You know, uh maybe you're on medication to do that, maybe you're not, but you could have primarily small particles and you are still at risk. So, this is the reason that again I don't like relying on the apo alone or the LPL or the LDL alone. Uh I want to know what type of particles we're dealing with.
>> Last question for today. I want to talk about hope.
>> Yeah.
>> Somebody who is middle-aged, they haven't been applying what we've been talking about today.
Maybe they know they have plaque. Maybe they assume, but they're feeling like, "Okay, half my life's gone by. Do I have a chance here with being preventative?"
What would you say to them?
>> I would say definitely. So, I what I always tell people is um it's never too early to start this, but it's also never too late to start this. Um, we now have in my medical practice 80 and 90 year olds uh that are doing this and they're doing great with it. Um, even if let's take this a step further. Let's say you've already had the heart attack.
Let's say you've already had a stent placed, you've already had bypass surgery. Um, we still can do the same thing. we can stop it from getting worse and we can give the body a chance to heal and start to see some improvement.
So, um, never too late to start this. I am all about patient empowerment and giving patients hope and that's what I think this is all about. Heart disease is not inevitable. We do not have to accept the fact that heart disease remains the number one killer year after year after year. We do not have to accept the fact that 750,000 Americans die of heart disease every year. I am on a mission to change that. I am on a mission to give patients back the hope and say this is a preventable disease.
And if you get aggressive about it, if you are proactive about monitoring your level of disease and let's stop it from getting worse and let's try and get it better, we are going to change, you know, what is thought to be destiny. Uh you can do something about this. you, the patient, you are in control and let's give you back the hope and let's give you the tools that you need to keep you ultimately from having heart disease. Love that. Perfect place to end it. Dr. Ovedia, we're going to link up the new book, your YouTube channel, social media, website, everything in the show notes. Loved round two. Farreaching conversation. We covered a lot. I appreciate you. Thank you.
>> Great seeing you as always, Jesse.
Thanks for watching the episode. I got another great one lined up for you right here. Don't miss it. I'll see you over there.
>> Visceral fat is pathological always. It should never happen, but we have an epidemic of it going on right now.
Estimates are anywhere between 40 and 50% of the population may actually have fatty liver.
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