Dr. Jason Kaplan - 'A Cardiologist's Low Carb Journey'

so I talk to you a bit about the cardiologists journey to blog Club and this is just a brief summary slide about some of the things I'm gonna be some going to be talking about this is a slide modified from dr. Seema Malhotra was published in the British Journal of Sports Medicine last year along with Rita red Berg was sort of edits from the annals of internal medicine and it talks a bit about some of the two diet and lifestyle factors in terms of coronary artery disease prevention and we coronary artery disease is only one aspect of heart disease the other aspects have been talked before about things like high blood pressure and I'm gonna do a little bit about atrial fibrillation but I think the other really big aspect that maybe it's not being mentioned enough is the effects on the brain as well and we talked about the effects on the heart we're talking you also going to think about the effects on the brain and the long term effects of the brain of you know of diabetes and high blood pressure now I want to focus on the lower part the lower part of the diagram because that's where a lot of where low carb low carbohydrate makes a really big difference in my patients and and a lot of you that it's fantastic at treating interested resistance type 2 diabetes combating this concept but at organic dyslipidemia I'll talk a little bit about it this is where you're you know you have more at Regina Clippard particles or talking about LD old sub fractions and then instant resistance leads to hypertension leads to H or through painful fibrillation at Paul Masson talks about sub optimal omega-3 too much in 86 and we are for measuring in a lot of album so how do we get a journey to low-carb and lifestyle prevention of heart disease so as has been mentioned before by dr. Bronco in medical school we had very little training in nutrition I think we had we actually had three lectures I went to Uranus W and I think I probably skipped two or three of those we didn't think that would that important in order to learn how to treat we wanted to learn how to treat disease then I went to the internal medicine residency where we learned how to treat disease from sick people yet often people come in with heart disease complications from diabetes and these people were fairly fairly unstaged and then I went into did cardiology training just up here at Royal Prince Alfred hospital attached us to the University in an academic cardiology program and I spent three years treating heart attacks acute heart failure you know strokes and spend a lot of time getting to treat the really sick people but didn't get to learn a lot about how to treat them at the other end or how to prevent them so that's how I got started on started on my journey and I've been very lucky to be associated with our Doran and for Mason who sort of brought me along on this brought me along on this journey and in fact relearning what we taught for for many years about cardiovascular risk factors about styles of lady or I learned the only thing we learns about the love that love that was good for heart disease yet we're seeing more heart disease more more obesity more high blood pressure more atrial fibrillation is actually not reducing the burden off of heart disease so for me the journey of moving away from our traditional teaching and learning some new ways of treating of treating disease and the great thing for me was patients were actually getting results and it's very heartening to see a few of my patients here and to you know who came to speak it's actually to get results where for years they were not getting results from traditional methods from getting traditional advice from diet the doctors they were not getting the results and until I started you know working with low carb or evading and dr. Mason patients did not lose a significant amount of weight yeah I'm going to show you some examples of some of my patients have done fantastically in reversed aspects of their of their heart disease and one of the major things is reducing or eliminating the type 2 diabetes now when you think about over the age of 50 type 2 diabetes is one of the most important risk factors for development of coronary artery disease and if you've had a cardiac event or you've had coronary artery bypass surgery uncontrolled diabetes is the major risk factor for the recurrence of heart disease down the track and I'm sure a lot of you who have been involved in this movement know about the amazing effect at reducing diabetic parameters reducing HDL and see reduced in fasting glucose treatment than the metabolic syndrome and I mean you just sort of see some of you learn in a diabetic field know about the plethora of diabetic drugs that have come on the market in the last few years they keep on coming up with new diabetic drugs that keep on coming up with new studies to try and show the reduction in cardiovascular outcomes but how about eliminating diabetes altogether and not putting people on the medication even you know in talks about getting a gastric sleeve operation or people resort in sending half their stomachs cut out to try to lose weight and then even it doesn't sort of have long lasting doesn't have long lasting long lasting effects the other thing in lockup ideology a trend move towards Lopez and wife personalized medicine so for some of you who start on low carb diet plan you'll see that you'll get a lot of parameters measured of the stuff you get your omega-3 index you'll get you a real subfractions you get your HSC RP as you come to see me I'm gonna talked a bit about calcium scoring but we measure where you are we get a very clear idea about what what your risk is and then we want to be able to measure parameters as well to see how you're doing and to see what effect it's having because we are all so different in so many ways in terms of how our bodies have a food and power genetics and food genetics I live a handles food and we're gonna get very good at and get idea about how bodies respond to a certain type of eating the other great thing is we've worked together with you know other committed health care providers so as a teenager in terms of your health and I'm looking forward to further outcome studies which were being done and I'm going to show you one that's been published and also you know being able to follow patients on this and since in how they do so this is just a very brief story about atherosclerosis atherosclerosis is the precursor to coronary artery disease so this is what causes most of the problems in Western society and it starts off you see on the phenotype to lesion so this is where you've got no Clark and gradually plaque starts to form in the arteries initially you start to get soft soft plaque forming in your in your arteries and the coronary arteries the arteries that supply the heart and then you start to get what's called nylon calcified part all of this time the calcium score is 2:0 and this happens as a gradual process over over many years and it's a dynamic it's a dynamic process you know plaque is going into I recently been taken away and over the course of time this plot starts to harden when it hardens it starts to calcify and that's when he picked up on so non-invasive imaging which is my other other area of interest and when you start to get sort of very unhealthy plaque that is plaque that has a lipid rich core plaque that is unstable that's what causes the heart attacks on the type 6 complications that's basically what causes heart attack and for about a quarter of men they have coronary artery disease their first presentation of heart diseases that is their heart attack and it would not have caused symptoms because that particular plaque is not causing and narrowing so in what I do it's very important to pick up early signs of disease and for people on the T appropriate management since briefly across chlorosis is a gradual process it takes many many years to build buildup in the arteries and often than many people starts in they're in their 20s so calcium scoring is a way I need to detect atherosclerosis and it's a great it's a great test it is a very it's a low radiation CT scan of your heart it takes about 10 seconds to do in most modern CT scanners what costs unfortunate them Medicare not rebating this test year that cost anywhere between 100 to 200 dollars you you know you don't need you don't need a specialist referral together you can ask your GP for an extra factor you're probably just the request one yourself and you know to get one any large radiology provider and it basically looks for the presence of the disease and disease is that for cirrhosis so what the calcium score does is it integrates your genetics your risk factors your additional risk factors all into something you can actually see you actually see it in in the arteries instead of looking at surrogate surrogate markers were actually looking for the presence of the presence of disease and takes everything into account so there's some examples of some coronary artery scan so this is no calcification so the radiation dose is - chest x-ray so it's really very minimal this person has some calcification arm in and then this particular person has a lot of plaque so this is per says is high risk and high your calcium score the greater risk you are for vesicular events and this particular person is an example of a patient so the calcium score and that's called the a g'sten score a Gerson's author of one of her that for the diet served in the ninth season versus South Beach diet but he came up with his score as well the scores mm so this is a very high caste in sports man's this person's got a lot of disease in his in his arteries what effects calcium scores and these are some of the factors when you look at very large studies and populations what can effects it and I'm gonna focus on a couple of things increase body mass index in in middle-aged high blood pressure diabetes metabolic syndrome microalbuminuria is a consequence of the majority populations of diabetes and high blood pressure an abnormal lipoprotein profile so more type B pattern more at four genic morphogenetic LDL high triglycerides lower HDL increased inflammatory markers so for those who had urge you to think about getting a high sensitivity CRP and this is looking at in CRP was sort of in vogue around ten years ago that's because they that one of the companies published a study that showed that statins reduce CoA we're getting it we're seeing it in a lot more interest now because we know that if we reduce inflammation than juice the chance of someone having a cardiovascular event and actually there's some very expensive way so a CRP but I think there less expensive ways with lifestyle renal dysfunction so there's common causes of renal dysfunction kidney problems in our society is hypertension and diabetes and then males I have a little bit more calcium than females and the percussive score is a great predictor of vascular events and measured in you know if you zero you're in you're in great shape your risk is very low I 1 to 100 you've got very mild plaque anything above 300 you have a tenfold increase of having a cardiovascular event of the next of the next ten years and this is just a very brief interpretation of what your calcium like might mean but your FRS equivalents is basically your way of your risk profile equivalents but if you have a calcium score zero the 10 year event rate is actually I think is actually lower than then probably you know 1.1 percent and as you saw to get your calcium score above 100 never above sort of 400 you have a one in five chance of having a having a heart attack over the next start of the next 10 years without without intervention so that's a little bit of complicated slide and I talked to you a little bit about the rationale for showing it to you you know I'm the cardiologist that takes people off statins for many years there was a knee-jerk reaction whenever you had a high cholesterol you went to see your doctor you're a high cholesterol you better go on a statin so the disease so the disease not necessarily high cholesterol the disease is what the calcium score shows you is after all or Rosas well it's if you don't have adverse chlorosis you do not need and if your calcium score is very low you do not need to go on statin therapy and so on you know if you think about that so all these people went in my opinion really put on statins inappropriately and going on a chronic long-term medication for many years if not life for one for no particular reason so we can better personalize the prescription of statins by using imaging such as calcium scoring and they're currently guidelines that that published by the large cardiac society such as the American Heart Association American College of Cardiology we have our own guidelines Australia that way that recommends statins if your 10 year risk for vascular events is over seven and a half percent so I'm going to show you that the this way it says recommend statin in in the red where your ten year risk is seven point five to twenty percent so when you use calcium scoring to help reclassify these patients you know about almost half of these people that would have been recommended statins and traditional guidelines have a calcium score of zero and they do not need statin therapy these people then fall into a low-risk category so if you are on statins are you know just for high cholesterol I'd speak to your doctor about getting a if appropriate of the coronary artery calcium score even in the very high-risk people where your risk is above 20% you know when you receive about 20% you do have to pay very close attention to your risk factors but even some of them you know even a quarter of them at a zero had a zero calcium score as well so using imaging like we do allows us to really reclassify the magnetical on statins and avoid the inappropriate prescription line so this slide says about elderly people but in elderliness with the study looked at people of the age of sixty years and unnormalized 16 elderly but they we looked at subclinical so we use people who may be stats ineligible and unfortunately the guidelines the older you are the older you are the more likely you are the guidelines will say you should get a statin and we used and this was used for subclinical arterial sclerosis look at coronary artery calcium scoring and use a disease glide guided reclassification and so this allowed a much better redistribution of statins less of those stats and usage and reclassifying people insert into appropriate risk or risk or groups so is it reasonable to do a coronary artery calcium score for men I think over the age of 45 it's very reasonable to do or if you're over 40 and you have quite a few risk factors for heart disease especially if you have a strong family history where you've got any of the traditional additional risk factors for heart disease for women around the time of menopause or potentially earlier fit very strong strong family history or risk factors and also if your risk score and I'm going to show you a calculator I can calculate your own risk or lies around five to 20 percent and very helpful as I showed in last life it can reclassify you into very low risk your calcium score zero or if your cousin happens to be higher your fall into a high risk category so this is a this website up for two things the first is it's called CHD best science medicine and it's a wonderful website for calculating your personal cardiovascular risk you can put in your numbers and there's four ways of classifying your risk on this website the one I'd uses there's museum guidelines of accha guidelines and it also allows you to look at the intern interventions so I want you to see you know what you can do is you can show your doctor look yourselves about there were the absolute benefit of statins in lowest people and you will see the number needed to treat in lowest people is very high often more than 100 150 to make any difference that means you have to treat a hundred and fifty people with statins make any difference in cardiovascular in cardiovascular outcomes and you also see the effects of lifestyle and diet on reducing a risk in in that lower area and then if you've got a calcium score try getting to the risk score calculator below and that allows you to plug that calcium score into your risk factors and allows you to calculate your risk or exactly and if your 10-year risk is not above 10 percent or your calcium score is not greater than 75th percentile on that calculate allows you to see where you fall into age or as much cohorts then there's limited benefits of statin to reduce cardiovascular risk compared to you know diet and lifestyle change and so zero calcium support was pretty priceless in terms of reducing your risk all right so I can get asked a lot about you know diet diets to prevent heart disease and this has been a journey that I've had to learn as a consultant because as I said we're not taught very much about it Isis one of the things that I guess the low-carbon movement has been great about and is about and actually examining some of the diet studies very carefully it's called for a grade of rigor in how we look at diet studies and greater analysis we're so dive studies focus on matric macronutrients for people who don't eat macronutrient macronutrients in isolation they consume food as part of overall dietary pattern and for example a carbohydrate contents of large bowl of fruits and vegetables is similar maybe similar to corn flakes but its effect on health is very different and in your body randomized studies of diet interventions are very difficult to do you need very many patients to do it often greater than five or 10,000 and each arm this is very difficult be funded because most of these largest studies are funded by pharmaceutical companies if you're just doing observational studies they're limited with uncertainty many studies rely on food surveys and food surveys and a touristy unreliable and also you'd be surprised at the very low frequency the food servers largely filled into some of these diet studies and people include a very diverse in very many ways as I sort of spoke about and you know ideally if we're looking at diets with you look at systemic reviews or meta-analyses and this is just a brief the table summarizing some of the important studies that come out in last sort of five years the woman's Health Initiative which is a very nice study 48 over 48,000 woman looked at the low-fat dietary intervention did not significantly decrease the risk of heart disease pretty much which was the Mediterranean style high-fat diet showed reduction in cardiovascular events just for diet by a 30% that was reanalyzed this year they've got the same results the pure study by Yousef published last year show that a higher dietary and some of carbohydrates was associated with the increased risk of all-cause mortality and a high consumption of dietary fat was associated with reduced mortality the CH Imani studied was this amazing study of this of his tribe of hunter-gatherers in the in the Amazon who had the lowest rates of coronary artery disease of anywhere in the world and population had died unprocessed natural foods plants fish and wild game and then fruit fruit and vegetables is also shown to reduced cardiovascular event this is just a very brief study that we the pure stallion with adorns and talk about some that's a bit in the next in his talk but what joy a focus upon is on the very right hand side the energy from carbohydrates the greater energy from carbohydrates the greater you know total mortality both in cardiovascular disease and total mortality and when you start to add more fats died the greatly lower risk of lower cardiovascular event rates just was a you know the sort of landmarks you know dark dietary study I want to give you some examples of some patients in my practice of what which worth um dr. poore Mason about how we've made some made some changes and we've actually measured beyond a measured Hydra vascular outcomes objectively so firstly in blood pressure so the patient a 62 year old female she's in the history of high blood pressure initial evaluation of blood pressure was elevated 155 on 95 I'm still on on some tablets so what I do my room is that do something called on pulse wave analysis so this is where we look at arterial stiffness and stiffer arteries the gradient risk of cardiovascular events once you've got a pulse pressure above 50 years of stroke is very high and so we look at we also look at essentially all red blood pressure as it's coming out of the heart this is all very non-invasive method that's just a small picture of the device when she first came she an arterial age of greater than 70 she had a pulse pressure of 60 or arterial stiffness was much higher than for age in 18 months on low carbohydrate nutrition she's lost 20 kilograms in weight she came to see me faithful follow-up her blood pressure has dropped to 100 three pulse pressure of 34 she now is low on arterial stiffness her arterial ages down to the woman of 46 she's a calcium score of zero a non HDL which is two point zero which is low and she's going to come off all of them her blood pressure medications this sort of finding was recently published published last year in journal I was a small study initially showed that weight loss using her the dietary carbohydrate restriction can reduce pulse pulse wave velocity which is a marker of arterial stiffness as little as four weeks interesting it was great affecting woman woman than men and we needed to larger studies to confirm this but made it made a big difference to their blood pressure what about in cholesterol so gentleman come to see me 66 years old she was his initial cholesterol reading some when you look at it on the surface it's probably not too bad but hit a high CRP he was newly diagnosed diabetic so hba1c is my ID I could make diagnosis of diabetics get a positive glucose tolerance test but also some of you might have had LDL subfractions earlier subfractions is a way of how we look at how atherogenic or how likely your cholesterol is gonna cause clot and this man had a type B pattern he had lots of peaks in more a frenetic cholesterol morphogenic LDL six months on a low-carb ketogenic diet he dropped his tried dropped his triglycerides from four point nine to two LDL was similar but in six months he changed his profile to a type-a profile he lost his peak in small LDL see he is now not diabetic as a normal good cost of this statins do not change statins do not change we've got more atherogenic LDL or not this was life lifestyle changer over by being in the diet and you'll just recently published in cardiovascular diabetic this year some of the expected biochemical changes you might see on a on a ketogenic on nutritional ketosis so where does the majority of the blue on the left-hand side of the screen these are the things that they found four people on one year on a ketotic diet they reduced hba1c they reduced their blood pressure they managed to increase their up very they reduced their up OB which is more original you know atherogenic cholesterol they all reduce the triglycerides the HDL ratio they reduced their inflammatory markers significantly that managed all reduce the cardiovascular risk reduced stats and usage came off antihypertensive medication especially diuretics which are from useful fluid retention or as part of the usual lung blood pressure medications we use this is great you know early study to look at the change in biochemical markers so very briefly about atrial fibrillation this is disease I see my clinic all the time they're two reasons why people get actual fibrillation one is on left it's an electrical disease often you see this in people that heart surgery people are athletes but from the jury the population is systemic metabolic disease and all the things we talked about before contribute to atrial fibrillation arterial stiffness diastolic dysfunction obesity diabetes sleep apnea so this is a this is a systemic disease it causes an irregular heartbeat makes you more likely to have a have a stroke the treatment is often you know blood thinners we you know intervention intervention into the heart and the treatment for majority people is lifestyle is Edwards of lifestyle management and I believe so strongly in lifestyle management after a study that we that was published by by an Australian group that we've actually started a lifestyle management clinic for atrial fibrillation in our Macquarie University where I work and AF is associated with significant increased of stroke dementia myocardial infarction and significant increased risk of more increased risk of mortality so - - serious disease it's a disease doesn't get old and with the metabolic syndrome this is an example of someone who came to see me he'd been in a or for years that's a fairly long time to be an atrial fibrillation he lost over 25 kilograms um we do the weight last week successively cardioverted the electrical reset heart back to normal sinus rhythm he's got no need for some of the medication some of the strong antiarrhythmics for AF and hopefully we'll be able to take him off his blood thinners - blood thinners you know as well which is the standard way of reducing stroke risk in atrial fibrillation so you know this person's aren't done very well in with with this this was basically the study done by an Australian who have been Adelaide and they showed that you if you have atrial fibrillation if you were able to lose greater than 10 percent of your body weight you know the majority of people were actual for atrial fibrillation you know free after sort of follow up over and over five years so the extra fact for most patients weight loss should be the first-line treatment in atrial fibrillation that message has not got through to a lot of our medical community yet and if you know medical people but patients they every should be really pushing you know weight loss - you know weight loss to treat their treat their disease that is it thank you very much

Channel: Low Carb Down Under

Views: 54,610

Keywords: Low Carb Down Under, LCDU, www.lowcarbdownunder.com.au, Low Carb Sydney November 2018, #LowCarbSyd, Jason Kaplan, Low Carb High Fat, Ketogenic Diet, Cardiology, cardiovascular disease, Insulin Resistance, Metabolic Syndrome, cardiac disease, Coronary Calcium Score, Statins, PURE Study, Lipids

Id: HAFg_W-TqXg

Length: 26min 50sec (1610 seconds)

Published: Thu May 16 2019