Dr. Jeffry Gerber - 'Cholesterol OMG'

good morning is everyone enjoying excellent so I'm in a bit of a pickle I am so because my patients seek my advice after starting non-standard diets the problem is that their previous doctors seen changes in the cholesterol profile that they consider it unfavorable and as a result they recommend more standard low-fat low-calorie diets and/or to take cholesterol-lowering medications like a statin so at this point the patients come running to me wanting me to tell them that they can stay on these non-standard diets and they don't have to take their medicine so the question is what am I to do so firstly am i a cholesterol expert well not a cardiologist I'm not a lipid ologist and not a researcher but I'm a primary care doctor that spent 27 years now in the trenches treating patients addressing cardiovascular disease diet and cholesterol and I'd like to share with you what I know now now as a disclosure I have no conflicts of interest other than saying that I'm working on a book with that Irish guy so what we're gonna do is look at the history and background as it relates to cardiovascular disease diet and cholesterol we're gonna look at advanced and standard lipid testing we'll look at it's some cardiovascular imaging and we're going to discuss these non - standard diets and I call them non-standard because they tend to be lower in carbohydrate higher natural fat higher in saturated fat higher nutrient density and food quality so look it seems we've been talking about cholesterol ever since the pathologist saw it growing in the blood vessel wall centuries ago and in the last century it's really gathered steam and here we have the Time magazine article from 1984 that talks about cholesterol in the bad news and then shortly after in 1986 the National cholesterol education program declares war on cholesterol and it's really been war ever since and this reminds me of the Cold War which occurs during the same time period so here we have this beautiful but eerie picture of the first experimental underwater nuclear nation that occurred in the Marshall Islands back in 1946 that's quite a picture now lucky for us the Cold War fizzled out and and gosh I hope we never see the likes of this again but when it comes to the war on cholesterol the war has been endless but actually it seems like we're living in the black and white now maybe the weapons have changed but the same war rages on and on so there's two components to this war on cholesterol and the first of it is the diet heart hypothesis that of course was made famous by an selkies back in the 1950s now I have to tell you he wasn't the only one there were many more that contributed and so this hot diet hearth hypothesis tells us that if we want to reduce our risk of heart disease of course we're supposed to reduce saturated fat in the diet cause it's going to lower our cholesterol and reduce car risk but over the past century that has essentially been disproven and Zoe Hart come talked about that yesterday the biggest issue is that most health care professionals still believed there to be this strong cause of a relationship and it just ain't so the second component is that of the lipid hypothesis that's been made famous famous by Big Pharma and also the Framingham Heart Study and the idea is that we should take medication like a statin to artificially lower our cholesterol to reduce risk but as you'll see the benefit is actually very small if at all especially for primary prevention but when you take these two components together the message is to lower cholesterol by any means necessary so we jumped to modern times present day and cholesterol remains the enemy and the weapon of choice again is statins now we have a new class pcsk9 inhibitors that have come out in the last several years and oh my are they expensive and they're controversial Pfizer actually dropped their they're wonder drug because it was too expensive it didn't work so stay tuned on that so here we have Sanjay Gupta back in 2013 and he's going over the American Heart Association guidelines now these guidelines represent a conspiracy I mean I mean a collaboration I always get that wrong excuse me but this collaboration is between the various heart institutions and the government to basically get people to take more statins and I can tell you that this has been echoed around the world at this point but rather than look at the obvious let's take a look at the not so obvious so the first is that the absolute risk reduction to take a statin is quite small meaning that you can give patients who are free of heart disease a statin and it only reduces their absolute risk of having a non fatal event by 1% that if at all very very small that's primary prevention the previous president of the American College of Cardiology Steve Nissen points out that the risk calculator is flawed and actually over eights estimates risk especially in the elderly the panels that came up with these guidelines had a very myopic view and they still have a myopic view when it comes to side effects that can affect up to 20% of the population and the some of them are serious long-term side effects like dementia diabetes rhabdomyolysis and liver toxicity the cholesterol story was controversial before the guidelines came out for instance in 2006 we had the Jupiter trial that was trying to tell us that we should put statins in the water meaning that everybody should take it for primary prevention and I tell you and what we'll talk about that later that that was the operative back in the 2000s these guidelines block innovation both on the medical and the nutritional side and it leaves us with one therapy to lower cholesterol and it leaves us with one question and one question only to statin or not to statin and as Prince Hamlet contemplates he must be cautious because he knows that his choice could have devastating consequences so before we get into the science let's look at the obstacles to changing in this current paradigm and the biggest obstacle is being human we're arrogant we're stubborn well unknowing unwilling to admit that we're wrong and were unwilling to change and then we take a group of like-minded individuals and the institutional and I institutionalize an idea through government and Industry and then these people capitalize from it both politically and financially you could be sure that at the end of the day very little is going to change and then two despite advances in science and technology when these groups remain resistant to change guess what we have to call it pure stupidity yeah so I want to take a minute and define stupidity if that's okay so there's no better way than doing it and describing it and talking to you about one of my favorite movies called idiocracy oh people have heard of that one so I warn you and it just that this is an old movie from ten years ago so idiocracy tells the story of evolution going in the wrong direction where there's a dumbing down of civilization no no no no one knows for sure quite why but maybe it has something to do with the fact that everybody's taking statins so here we have our hero Joe powers and he finds himself in the middle of a human hibernation experiment and he's catapulted 500 years into the future and he awakens to a world of stupid people so these people are so stupid that they can't make any decisions and that's actually the presidential cabinet but there's no worries because one of the food industry leaders named brando has basically taken over they've bought the FCC and the fda so that they can say sell and do whatever they want and so as a result we get this new food pyramid and we'll take a look and you see there's lots of Brando which by the way is a sports drink and we see there's Greece caffeine smokes and junk food ah that sounds kind of familiar and so Brando the thirst mutilator comes to replace water virtually everywhere yes water the basic essential element of life they even feed the plants with the bran doe thus leading to the great Dust Bowl and what the stupid people didn't understand is that the precious electrolytes were salts building up in the soil thus killing the crops now on Joe found out that they were feeding the crops with a sports drink he said if you simply give the plants water they would grow to which the stupid people replied you mean water like out the toilet Dust Bowl crisis resolved now Joe being the smartest man in the world eventually became president and whether or not he solves the statin and stupidity crisis you have to watch the sequel but I think it's a clever movie that points out some issues we face today so let's get back to reality and wake up and smell the bulletproof coffee and to realize that cholesterol is a this essential to life it's a it's a substrate to so much and you basically can't live without it and then when it comes to atherosclerosis we think of it as an innocent bystander namely there are other factors such as inflammation oxidative stress and advanced glycation that play a significant role and this is the idea that atherosclerosis is an inflammatory disease and when the pathologist looks in the blood vessel wall he saw it sees inflammatory cells foam cells macrophages and in Kalama Tory cytokines all components of this inflammatory response now you you think this approach to atherosclerosis is an inflammatory disease would be something new but it actually isn't it's been around for quite some time why why it's not new perhaps is that there hasn't been a specific medication to address it now maybe statins a little bitter they changed the indication oh well now we decided is treating inflammation but nonetheless this idea has been around again for a while and Russell Ross back in the 1970s described this as a an injury or a damage response and the insult was actually multifactorial so many things were involved certainly smoking being overweight diabetes sedentary lifestyle contributed but most importantly we think and I it is the is a really important factor and when you think about inflammation it changes again your approach to diet it's not all about saturated fat it's about treating inflammation and addressing it with Whole Foods low carb reducing especially industrial vegetable oils which because of their molecular structure are very plump prone to inflammation and oxidative stress now cholesterol is in there but it's just one small factor okay and you have to understand that cholesterol is actually reparative it's it's trying initially to repair damage and this is why we think of it as the fireman going to the fire to put out the fire but it gets consumed by the fire and so here we can track the progression of atherosclerosis we're looking at the blood vessel so there's advanced testing in here that we can talk about just blood tests such as H s CRP the the plaque test and the cardiac mpo and we'll mention those but also what would an engineer do if the pipes were broken he would have a look inside so that's why Iver and I talked about the importance of cardiovascular imaging actually any cardiovascular imaging so we'll mention that so when patients come to see us in the office we start with addressing the diet what they were doing wrong what they can do right how we can change things and the most important thing that we've come to realize in our 27 years of doctoring is that real food is what's important reducing sugar carbs starch inflammatory vegetable for inflammatory vegetable oils for natural fats and saturated fats we're dealing with an inflammatory disease it's a bit complex but the solution seems to be fairly simple so lab testing with respect for time we can't go into all these things so we're just going to focus on standard and an advanced lipid testing and some cardiovascular imaging so this is lipoprotein when we talk about cholesterol we're really talking about lipoprotein and you can see that lipoprotein contains lipids cholesterol triglyceride proteins fat soluble vitamins minerals and nutrients and as I see it lipo protein serves two purposes number one to distribute these fat soluble micronutrients and nutrients in a water-based system that's actually really cool what it does okay the second purpose is to actually repair damage to blood vessel wall there's nothing good or bad about it it just is now we do talk about these big blue boats that is based on standard testing the VLDL the LDL and the HDL and there's bad and good cholesterol I try not to use those terms but just to think of it is that when you look at ratios there are ratios that are more associated risk versus less associated risk and I think what's really important when it comes to cholesterol and and lipoprotein all this stuff is really associational and I think that's important to consider now we can do advanced testing where we're now looking at not just the concentration but the particles with inside these boats and so it seems that the large particles are more a face more associated with a lower risk smaller particles with greater risk but again that's also associational and we have things like in the green they're the LPA I call that the LDL with an attitude we'll talk about that and then we can also look at the protein factors a Bobi 108 boa one so standard lipid testing it's been around since the 1970s I think there's three schools of thought regarding lipid testing in general the first is that we shouldn't even bother measuring it because it's so predictable and it's an absolute distraction from what the root causes are and I think that's really important and as I think Ivor and Ted and all the insulin people talked about that it may be more important to look at insulin and metabolic disease than bad cholesterol okay the ratios can tell you something about metabolic health but it's just a proxy really to insulin so the first that's the first school second school of thought is that standard testing is is reasonable it's been around for a long time we do it in our office it's a thirty dollar test and the idea is that we should be looking at it differently in other words we don't do the standard testing just to look at the bad cholesterol we're looking at the ratios that tell us about metabolic health now the standard testing does calculate LDL based on the freed waldek equation but actually if you're LD if your HDL in your triglycerides are relatively within range the freed wall LDL calculation is is pretty good so we like that the third school again is advanced testing and I've done it for so many years now I'm not so fond of it but there are studies that show if you're just an LDL person and you're looking at LDL only the LDL particle count seems to better predict risk than if you just look at LDL but again we're looking at the big picture so then you can do things with the ratios and the one we particularly like is the triglyceride to HDL so we want that less than two and again I think that is the most exquisite measurement of metabolic health of nutritional status Big Pharma hates it because there's no medicine in fact they tried to have an HDL failed miserably it actually low it raised HDL but killed people because it blocked mechanisms I mean it blocked pathways it's just crazy okay so we can look at the nine HDL cholesterol which is essentially total - HDL it negates LDL calculation and that's in the 2013 guidelines it's it's it's just another measurement similar similar to LDL the most poor important part is at the bottom measuring metabolic health and these slides show glucose hba1c but I should also have you know insulin and hyperinsulinemia on there shame on me for not including it but you could say that everything above it is a distraction and we would just want to be looking at measurements of metabolic health those biomarkers so as I said you know you can go on a diet and predict what's gonna happen to cholesterol so we'll look at that real quick so low carb high fat versus low carb low fat low calorie so on the low carb high fat triglycerides plummet HDL goes up the ratio gets much better LDL particles go up now here's the catch the LDL it's variable so we have some patients where the LDL actually goes way down and every healthcare professional is happy they'd say I don't know how you're doing this but you know that diet has to be dangerous doesn't mean well the markers look good sometimes LDL stays the same and the big problem is that the LDL goes way up and and even in some it can be sustainably elevated and so the question is does that rise in LDL on this diet confer a risk so it's my opinion that it doesn't and this is the million-dollar question the problem is that we really don't have long term outcome studies looking at heart attacks stroke and death on these low-carb high-fat diets we do have some associations and some Jess suggestions but we you know in 2017 we have to do science science it's hard to do RCTs on diet nutrition but I think those are the issues but again you know that's just one number we're trying to address all the biomarkers so with low-fat low-calorie again it's very predictable all the numbers go down including the good HDL the low-fat low-calorie diet doesn't affect the particle size and on the right that profile that lipid lipid profile really looks like someone that I consider undernourished okay and so if you're going to compare these two profiles you know I would choose the one on the left and you know I've been eating this way for 17 years and so my particle count is high but my other metabolic markers look good so let's hope that I stay healthy so advanced lipid testing there's all kinds of labs and it breaks down basically to look at the LDL particle count and size and we're just going to jump into that so we're no longer measuring the total concentration of cholesterol but the particles and these are injuries three standards and we put them in the green yellow red light version so you can just follow carefully and I don't know if I agree with these numbers completely so for instance the LDL particle count should be under a thousand based on industry standard well guess what that's like lowering your LDL cholesterol to under 100 and I don't know why we need to be doing that so something to think about the next three bullets there show you that we're trying to address the particle size so large particles are favorable and you want a majority a minority of the particles to be small you want the particle size to be over twenty point six nanometers and you can do ratios and so I think that perhaps the particle count should be greater than 50% large rather again they just want to get these numbers as low as possible you know just cholesterol is bad let's you know if we if we could get rid of it we wouldn't have a problem well that's just wrong okay then we can do advanced testing additional tests so April be 100 there's also April a 1 which to me are just like proxies to the non HDL cholesterol and HDL so it's kind of like you know upgrades in the movie matrix and sometimes they're good but sometimes those there's robots are really sturdy and they they do a good job so we have the LPA which is the LDL with an attitude as an independent marker of risk we're not sure what it means especially on low-carb diet and then we have these advanced inflammatory markers I don't know that you have to do all them I think the H s CRP is good the plaque tests the cardiac myeloperoxidase they're newer tests but again they're all associational we love tests that just you know to see the disease is most important so we'll talk about three patients and this is interesting so this is low kärpät see this is the easy story guys okay it's going to get harder as we go so patsy was considering bariatric surgery and she discovered a low-carb diet and then discovered me in town here in Denver and she was somewhat reluctant you know to go on this high-fat diet but she actually had some other medical problems she was pre-diabetes to pre-diabetes hyperinsulinemia some thyroid conditions so we encouraged her and we like to be people's personal health care trainers as I put it and put her and got her on the right path and a year later she loses 80 pounds yeah great story remember this is the easy one so as you can imagine her numbers just got completely better so these are standard testing before and after so before what we see with her standard lipid testing her triglycerides are a little bit high at 163 her fasting glucose is in the diabetic range at 131 and the a1c on the bottom is 5.7 now as you would imagine after the numbers got better across the board absolutely fantastic look her triglyceride to HDL ratio we have an 84 to 66 got completely better her a 1c went down a 4.8 okay that's and her blood sugar was awesome so we can look at the advanced lipid testing well she has high particles you know 1459 it's large particles LPA is high in the redzone know what that means inflammatory markers are okay the HSC RP is a little bit high at 2.9 and we have a lot of patients that often have a persistent elevation in their HSC RP and we're not sure where it's coming from but in general it's something that we want to watch and try to figure out if we can change it so what about imaging so all this stuff you could say it's just it's it's just associational so can we see the disease now I wasn't quite doing the calcium scores a couple years ago so but what we still do in our office is a proxy test is a carotid Doppler ultrasound now you might have heard of them as C IMT so the test comes together the C IMT is an intimate thickness test and we've read the literature and it doesn't appear to correlate with risk which is kind of the lining of the wall but as a proxy as as general approximation what we're looking for and this ultrasound is plaque in in the pipe itself and so pat-pat see in those little yellow balls she has somewhat just threshold amount of plaque so you know we want to follow that year-to-year it's totally non-invasive because it's just an ultrasound but I think Patsy's doing okay I don't think there's any reason to lower her cholesterol I think she needs to continue to work on her diet she hadn't achieved her weight-loss goal easy story this one's more complicated so here's primal Erik P I love that picture so Erik was always into health and fitness and he was absolutely absolutely complying with everything his doctor would tell him to do so again back in the 2000s you remember Jupiter trial well Erik's doctor decided that we need to get your cholesterol as low as we can so you know basically Erik went on every cholesterol-lowering medication including a statin niacin ezetimibe and and the response was predictable in every single way it does lower cholesterol but unfortunately he had every side effect that was possible including a true liver out toxicity from the statin so at this point he became fed up you know I just need to find another way so he discovered the primal diet and he went back to see his doctor he stopped his medication and wait till you see what happens to his cholesterol by the way he felt great he lost 10 pounds he's a big crossfitter I can't keep up with him there but look at the guy so it's interesting because look at his profile before he went on any cholesterol medication well it's not so bad as HDL is a little bit low his LDL by mainstream standards a little bit high blood sugars aren't too bad but here's the punch boom his LDL exploded went up to 191 on this primal diet oh the God this guy's gonna like drop dead tomorrow and he's got children oh yeah but but look at his ratios his triglyceride it was so good and his HDL went up a little bit maybe go a little bit higher his a1c was 5 you know everything looks good let's look at his advanced testing oh my particles exploded 2159 I see patients with higher particle count than that it's all large particles when we look at his inflammatory markers they're actually not so bad hello so what are we going to do with this one well let's get some cardiovascular imaging no plaque whoa I've been bugging him to get a calcium scan ok there's that's called a disconnect okay and I think I ever talked about the calcium score doesn't correlate with cholesterol so here's the same thing so this is this is what are you going to do with a patient like this are we dealing with a disease of cholesterol concentration or cholesterol quality or does it have nothing to do with cholesterol yeah maybe that's a better answer so we have patients that are uncomfortable with the high LDL and we we work with them you can do nutritional things you can reduce saturated fats which to mono saturated fat oily fish intermittent fasting but the question and that'll bring it down that'll bring you the LDL in the particle count down but the question is does that reduce risk so we're not that convinced that it does and so we have to watch these patients really carefully and that's what we do with Eric and he's again remained healthy we want to continue to follow more imaging and again he has side effects from medication so I know he's not too worried about it so the last one is Wheat Belly Tom so Tom had a quadruple bypass he's a cardiac patient and he's doing fine now but he admits he didn't go to the doctor much and after he had this event well he decided it's time to turn his life around so he discovered Wheat Belly diet and he lost thirty pounds that's this experimental airplane and he loves to fly and but what he also did that I don't know that I agree with is he stopped all his medication after his heart event including statins so this is great I'm gonna do without medication well he stopped the statin and his LDL went up and he says what's with this Wheat Belly Diet I want to refund it's not it's supposed to be good for me not bad for me so at this point he found me and and and he came in for some advice so let's look at his profile again really interesting this one Tom didn't have high cholesterol ever okay look at his LDL before he had his heart attack before he went on medication is 84 okay where is the problem go down to the bottom look at his a1c six point six now one of his doctors was at least smart enough to check it but they didn't specifically counsel him about it ah the distraction so now look what happens after now this is interesting when he stopped his statin after the heart event this is what frightened him his LDL went up to 139 but now he lost 30 pounds on wheat belly his a1c improved to 5.8 but he needs to continue to work on that so you know the important things at the bottom here his metabolic markers advanced testing now I only have his advanced testing on the statin just to illustrate what the statins do they lower LDL and they lower LDL P so you know his doctor would say well you know 1108 know we better get it under you know under a thousand because that's what we're trained to do his particles are actually large but that's not from the statin that's probably from his diet I think one issue is on the bottom his cardiac NPO is off the charts so that is a inflammatory marker but again it's just associational I think it kind of Flags his his markers but we can look at imaging now we know he already had had a quadruple bypass so he has significant disease but just for giggles I did the carotid IMT and carotid Doppler and he has 50% lesions in the carotid so he's an individual that generates plaque and when you look at this it's really historical data and so what are we going to do with him he doesn't want to go back on the statin and so when would I recommend to patients there is present-day data to support the use of statins for secondary prevention in patients that have already had its heart attack and there's a small mortality benefit now some even challenge that but you know I'm trying to work with the healthcare system I'm not trying to leave it and so we're trying to create a balance here and so this is the advice my patients are often stubborn about medication you're all like ooh boo big farmer well guess what it saves lives so we're again we're trying to work in the system so lastly you saw this slide yesterday and just to show you the the calcium score and so again you literally see the disease itself there's a little radiation it's a CT of the heart and so the individual and right has calcium which is really atherosclerosis you're looking at the disease itself and that is in the left anterior descending artery we call that the Widowmaker artery so that individual is risk and then I ever already gave you the punchline on the left that's my calcium score and you know what I'm 56 now and I've been sticking with the diet now for 17 years and I have a perfect score of zero that's awesome and you know my I get a set a 15 year warranty that I won't drop dead right now from a hearted event but there's still a small chance but you know I'd like to think that the zero score is because of all the things that I've been doing right and again I have I have a high particle count so that's really our approach we're almost done to cardiovascular disease and how I think we should appropriately addressing root causes so I'd like to finish finish with a little politics now I promise to behave so you know health care the cost of health care is always a hot topic and so is the administration sit there arguing about who's going to pay for this expensive health care system and who's going to have access to it the cost of health care continues to rise and people are getting sicker and sicker you know and the problem really lies at the core we're dealing with the system of sick care we're putting out the fires rather than preventing it and so the idea is that that's not necessarily bad it keeps people alive but it's really expensive and it's not working now don't take my word for it what does the American Heart Association have to say well they came out with a report last week noting that the prevalence of heart disease is on the rise at a rate much faster than they predicted in fact by 2035 they're saying that almost half of the population are going to have a cardiovascular disease hmm something's going wrong there I think our group has some solutions right so the solution is prevention lifestyle addressing the root causes addressing inflammation and the idea is that we want to prevent or we want to keep people healthy so they don't have to prematurely get into this expensive expensive healthcare system I think that's the better solution and it's easy to say but it's hard to implement and we have so many roadblocks to this I mean just imagine retraining healthcare professionals which you know I am and I'm partial to them but what a great place to start because the problem is our health but we have to get Big Pharma we have to get the the food industry involved the pharmaceutical industry and then government policy you heard from Tony just earlier so government policy is the real big one and so we have organizations here the PhD and the nutrition health coalition excellent groups from Sam Feltham and from Nina tide Schultz that are trying to bring about change and we actually had a great meeting last night it was a little late as our conference at ended late but we're talking about global change but until that time that we can bring about change the question remains can we make America healthy again and the rest of the world thank you

Channel: Low Carb Down Under

Views: 60,402

Rating: 4.861702 out of 5

Keywords: Low Carb Down Under, LCDU, www.lowcarbdownunder.com.au, Low Carb Breckenridge 2017, #LowCarbBreck, Cholesterol, Statins, Low-Carbohydrate Diet, LCHF, Low Carb High Fat, Cardiovascular Disease, Nutrition, Jeff Gerber, Denver's Diet Doctor, Nutritional Ketosis, Ketogenic Diet

Id: XWJQKaNpvvI

Length: 36min 57sec (2217 seconds)

Published: Sat Sep 09 2017