Episode 70: Dr. Viral Ras Sheth, MD on Cholesterol: Statins, Genetics, Nutrition, and Lifestyle

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Dr. Viral Sheth:

So I’ve had patients who have LDL cholesterol is over 200. And I will do a calcium score on them and it’s zero. And those people have have very low inflammation in their bodies, very low inflammation in their arteries. And because of that this LDL cholesterol is not causing the damage that it could and we haven’t talked about the different kinds of LDL cholesterol. But, you know, the small dense LDL cholesterol, those are the patients who tend to have metabolic syndrome, I triglycerides, low HDL. Those are the folks who whose LDL cholesterol even though it may not be terribly high as wreaking havoc in because because they’re smaller, they’re able to get into the artery walls, they tend to get oxidized more quickly, and they cause more inflammation can lead to higher oxidized LDL levels two so yeah, so So not all LDL cholesterol is the same. And LP lay, by the way, is a form of LDL cholesterol. It’s got a Poby which LDL cholesterol has as a mark for risk which increases inflammation but it also has APR a which increases clotting. So help you lay has a double whammy in terms of causing accelerated or premature coronary disease.

Dr. Andrew Wong:

So what’s the deal with cholesterol? Is it bad? Is it good? People always ask how do I lower my cholesterol numbers or if it’s high, do I need to lower it? Are statins necessary which is a medication that’s used very commonly for lowering cholesterol? And also how can I lower my cholesterol naturally, using lifestyle factors and nutrition? Today’s conversation with the integrative and functional cardiologist Dr. Barrows Sheth takes a closer look at these questions and more, helping you to navigate your cardiovascular health with an integrative approach. Dr. Sheth is a leading cardiologists in Maryland with over 30 years of experience in cardiovascular medicine and nuclear cardiology, and he’s one of the few integrative cardiologists in the DMV. I am Dr. Andrew Huang, co founder of capital integrative health, we have a medical clinic, but it’s evolved into a community and one that is focused on community service as well, including with this podcast. This podcast is dedicated to transforming the consciousness around what it means to be healthy, but also to understand the root causes of both disease and wellness. And digging deep deep in these topics means serving our communities so that we can be empowered all of us to optimize our wellness. This is a really important conversation with Dr. Shad. Today, I really enjoyed it about how how you can approach cholesterol, what what it actually means how its associated with heart health, and what you can do to lower your lower your cholesterol if that’s something that is advised. This does not replace your medical treatment or going to see your doctor or practitioner. But please enjoy and share with your loved ones who may find this helpful. Welcome for all to the podcast. We’re so glad to have you on today.

Dr. Viral Sheth:

Thank you, Andy. It’s a pleasure to be on your podcast.

Dr. Andrew Wong:

So let’s talk a little about yourself first. You are a cardiologist. In fact, one of the few integrative cardiologists in the area, what drew you to become a cardiologist first? And then specifically, what kind of got you into the more integrative functional space?

Dr. Viral Sheth:

That’s a great question. So during my training, I saw a lot of acute cardiac disease. And at the time, the procedure is like bypass surgery, coronary stenting, arrhythmia ablations, they were just really getting started. So I saw lots of acute illness that we could do very little to treat. So I wanted to make a difference in both preventing and treating heart disease, which is still considered the number one killer in this country over the past 25 years. As a conventional cardiologist, the art of treating acute cardiac illness has advanced with technology, but the significant reduction in cardiovascular morbidity and mortality over that time, which has been about 71% decline, which is impressive, although is creased, it’s mostly from better prevention, and the use of pharmaceuticals to treat cholesterol, blood pressure and diabetes. But I became disillusioned with prescribing so many drugs I was I was almost feeling like a drug dealer sometimes. So I pursued integrative cardiology and a more holistic approach to prevention by promoting a healthier lifestyle for my patients with mind body, spirit and community taken into account. For my primary prevention patients. I also use and recommend nutraceuticals to help achieve prevention goals prior to reaching for pharmaceuticals. I’m most enjoyed the therapeutic encounters with my patients. By actively listening with empathy and compassion, I also recognize that a healthy work life balance is critical to preventing burnout and compassion, fatigue. So I practice what I preach, by finding time for myself. I tried to set an example with proper nutrition, exercise, contemplative practices, and healthy relationships. So that’s why I went into integrative cardiology. And that’s what I love most about it.

Dr. Andrew Wong:

Thank you. So great answer. It sounds like looking for different tools, but also really understanding intuitively that the mind body spirit are connected. And they’re all related to heart health, as opposed to just saying, Okay, this is cholesterol is high. Let’s put you on a pill. That could be part of the answer, but certainly not all the answer. Correct. So today, we do want to focus on, as you said, cardiovascular disease, cardiovascular health, you know, cardiovascular disease is number one killer, like you said, for both men and women in the United States. And I would say probably also, for a lot of places around the world is that is that accurate? How what is it? I don’t know, the global you know, statistics on that.

Dr. Viral Sheth:

Yeah. So I just recently read that in developing countries, in third world countries. cardiovascular death has, if not on the top, near the top of the of the list, in terms of morbidity and mortality. So as people, you know, become more industrialized, I guess. The incidence of cardiovascular disease is increasing worldwide, for sure.

Dr. Andrew Wong:

Yeah, so a lot of times as as potentially, some of the infectious diseases, some of these acute diseases get go down these other non communicable chronic diseases like heart disease, etc, go up

Dr. Viral Sheth:

obesity, especially diabetes, hypertension, they all contributed to coronary heart disease.

Dr. Andrew Wong:

So let’s talk about lipids and cardiovascular health. And I think most people, if they’ve been to a doctor, or even to a primary care practitioner, they might check a lipid panel as part of their annual checkup, you know, they might check sort of a basic lipid panel. Let’s talk about what lipids are, you know why they’re so important. And then just kind of basically kind of outline for our listeners why that’s so important for cardiovascular health to have a a balanced lipid panel. And I like first what it is and then kind of why it’s so important.

Dr. Viral Sheth:

So we order lipid panels, standard lipid panels most often, and they don’t necessarily have to be fasting. In case unless the person has had a really high fatty meal the night before. It’s not necessary to be fasting. And in the lipid panel, we get total cholesterol, we get triglycerides, we get low density lipoprotein concentration and high density lipoprotein concentration. Also, VLDL is part of that lipid panel, and it’s it’s a key component to atherogenic lipoproteins. But LDL cholesterol concentration is the focal point, a guideline recommendations on lipid lowering therapy. Rarely do we actually measure that number, directly. It’s usually inferred through a formula called the freeball equation. That’s how we get our LDL cholesterol number in the standard lipid panels, but you can order direct LDL concentrations, you can also order other types of lipid parameters, which we can get into now, as a conventional cardiologist, there is a the American Heart Association American College of Cardiology, have something have a a equation that we use to assess 10 year risk for cardiovascular events. That’s called the pooled cohort equation. And that you can get it on an app and you just put in the numbers. The problem with that, with that equation is that it’s more it’s more of a population based data and not really specific for individual patients. And because of that, it can underestimate and sometimes overestimate especially elderly individuals their risk of cardiovascular disease. Because of that, because of that knowledge, the ACC came out with 11 risk enhancing factors that can help the clinician and patient decide whether or not they want to be treated aggressively or not. In terms of statins, in addition to of course lifestyle, and those risk enhancers our family history, metabolic syndrome, chronic inflammatory conditions like autoimmune disease, post COVID, long COVID, those kinds of things, chronic kidney disease. Also, you know, they’ve also included preeclampsia for women history of preeclampsia and history of diabetes, gestational diabetes, as risk enhancers, as well as premature menopause, which I’m glad they did finally did that. Also, there are high risk ethnic groups, like for example, you know, Hispanics, African Americans, even South Asians that sometimes tend to get overlooked. The also included elevations and triglycerides about 175, as well as elevations in H S, CRP or C reactive protein of greater than 2.0. And April B, which is atherogenic. A marker on the surface of these cholesterol particles, which, if it’s you can measure directly integrate 130, that would also to be into a higher risk category. And also LP little a, which is a genetic marker. And if that’s above 50, that would also tip you into a high risk category. Also things like Ankle Brachial Index, if it’s less than point nine is a mark of a peripheral arterial disease, that should also would potentially bring you from an intermediate or moderate risk category into a high risk category to define these risks, you know, you have a 10 year risk that’s less than 5%, that’s considered very low risk. If you have a 10 year risk that’s between five and seven 7.5, that’s considered borderline 7.5 to 20%, it’s considered moderate risk, and above a 20% risk of having a heart event in 10 years considered high risk. And then we would treat patients accordingly based on those. Now, sometimes the moderate risk category, which is a lot of my patients, a lot of the patients who are in the same mindset that we are as integrative medicine providers would rather not take statins, if possible. So what I do often, and we haven’t had discussions about this, in the past, I heard it was called coronary artery calcium scores. And that score is above 100. That should, that puts them definitely into the high risk category. And those folks, I would encourage not only lifestyle, but also statin therapy, because the data is quite impressive in terms of, if you’re able to get someone’s LDL down to a certain goal, you can actually cause progression of the calcium and also prevent the calcium from rupturing, which will lead to heart attacks and strokes.

Dr. Andrew Wong:

What Thank you, thank you so much for what is the goal for the LDL, if someone does have a CAC of greater than 100? What are you aiming for there?

Dr. Viral Sheth:

So that’s a great question. So that is a moving target. So right now, the ACC American college credit America, the United States recommends less than 70. But European Society of Cardiology has gotten much more aggressive than that. And they’re recommending LDL cholesterol of less than 50. And if you had to event within six months, meaning unstable angina, mi strokes, within two, six months, the recommend the LDL is below 40. So they’ve taken a real aggressive stance to being more and then they have they have the data to support it. It’s not like as the point is out of out of thin air,

Dr. Andrew Wong:

that this is all comers are people with with moderate risk.

Dr. Viral Sheth:

Well, high risk, high risk patient high risk, okay. Correct. Score 100 over 100. To me, you go from intermediate risk to high risk. Yeah, in that scenario, I would want to be more aggressive at least get that LDL down below 70.

Dr. Andrew Wong:

So so let’s talk about let’s talk about the advanced panels in a minute. But the basic panel which you outlined as total cholesterol, triglycerides, estimated concentration of LDL and then concentration of HDL. What’s the difference first between LDL and HDL, I know everyone kind of gets confused on that.

Dr. Viral Sheth:

So So cholesterol circulates through our blood and in order for it to circulate it is packaged in these lipoproteins, and those lipoproteins can either be low in density, or they can be high in density. So, so low density, cholesterol is made in the liver. And it is it gets it and we need cholesterol by the way, for, you know, all of our cells to have a membrane to maintain membrane integrity. We also need cholesterol for most of our essential hormones. So it’s not something that is all bad. Clearly. It’s it’s definitely needed. But sometimes when you have LDL low density lipoproteins, they make because of their density, they can actually damage the walls of our arteries. And because of that they can enter into the wall doesn’t create inflammation, you know, and plaque formation and soft plaques, which have a tendency to rupture which leads to heart attacks and strokes. So, because of that LDL cholesterol is is the is most is the target most of the time and just plenty the data to support by lowering that number. We reduce endothelial dysfunction, reduced endothelial inflammation, oxidative stress, etc. High density labor protein is also made in the liver, but it’s more of a marker for risk than a target for intervention. We know that in the past, they’ve tried to raise HDL and they have with drugs by over 90% rise in Asia, but But by doing that they actually increase cardiovascular event rates. So, so the best way to raise HDL is with exercise. But if you have very low HDL and high triglycerides, that’s a marker for risk. And those patients believe it or not, you want to be aggressive by treating their LDL, because we you’ll see improved outcomes by getting their LDL down lower than by specifically treating the HDL.

Dr. Andrew Wong:

There was a specific study that came out recently about how actually a high HDL was not associated with, I believe, like beneficial outcomes. I know we always say that, you know, HCl is a good cholesterol, it helps recycle the LDL, but I know there was some recent study I forget the paper now, but there was a specific study that was saying, okay, HDL is not the, you know, the Savior that we thought it would be in terms of

Dr. Viral Sheth:

and remember HDL can be functional HDL and dysfunctional HV HDL. So if you have a lot of dysfunctional HDL, you’re not doing anybody any favors by raising it.

Dr. Andrew Wong:

Yeah. Yeah. And let’s how do we measure dysfunctional HDL? Or how do we, you know, get it more functional?

Dr. Viral Sheth:

So, so I’m not aware of any specific testing for this functional at all, I know, from studies where they tried to raise HDL with medications, that they realize that they’re raising the wrong kind of HDL, but in my experience, you know, healthy living, is what’s gonna raise your functional HDL, you don’t really measure it, you just, you just realize that you’re at risk, and you take the appropriate lifestyle changes.

Dr. Andrew Wong:

We are taping this during the holiday season. So I think it’s appropriate to, to talk about the alcohol question now. You know, we we, I think, have always been taught when we were students, I think, too, as, as you know, for the HDL, oh, like drink some alcohol, because that’s going to help the HDL, where’s the cardiology community on that?

Dr. Viral Sheth:

That’s a great, that’s a great question. And we’ve seen alcohol access, raise HDL, but my argument is, is probably dysfunctional HDL, because people who drink alcohol and access more than, you know, one to two servings a day, have a higher cardiovascular event rate. And actually, there’s been some recent data to show that even drinking one or two servings of alcohol a day increases your risk. So that’s kind of controversial for me to say that, but I’m a firm believer that if you don’t drink alcohol, I don’t recommend starting drinking. And if you do drink, and if you’re a woman, islands are no more than one serving a day. And if you’re a man, no more than two servings a day, and the type of alcohol I recommend typically is the Pinot Noir, red wine because it has higher resveratrol, which is the antioxidant and anti inflammatory, beneficial effects of alcohol, at least in theory.

Dr. Andrew Wong:

All right, thank you so much. And the other aspect of the basic lipid panel is that triglycerides, what’s the difference between say like cholesterol and triglycerides? Why is triglycerides important is one more important than another.

Dr. Viral Sheth:

So triglycerides are made in the liver, just like LDL cholesterol. Triglycerides are an independent risk factor for cardiovascular events. There’s no question about it. And treating triglycerides has been in the past a bit unsatisfying, because the drugs that we had in the past three triglycerides never really showed improvement in cardiovascular outcomes. So the best way to lower triglycerides, in my opinion, is lifestyle. So that means a diet that’s low in carbohydrates. That means exercise that means losing weight. Also looking for secondary causes of high triglycerides, such as, you know, things like hypothyroidism and you know, chronic kidney disease, diabetes, obesity, cigarette smoking. These are all secondary causes of high triglycerides. Also drugs like thighs, I diuretics, you know, estrogen, steroids, they can all raise your triglycerides, triglycerides. We can actually enter into the endothelium of vascular of blood vessels and lead to atherosclerotic plaque formation. So it’s good to have lower triglycerides. Now, they’re there. So phenol fibrates have been historically used to treat high triglycerides. But the outcomes data studies never proved them to be helpful in reducing event rates. They did lower triglycerides, but not event rates. The only and the only subset that there was benefit is in those patients who had diabetes, or who had metabolic syndrome, those people tended to do better with vibrates. There was a recent study, though, I’m sure you’re familiar with it, it was called the it was a reducer trial. So that was a study that looked at a specific form of fish oil called EPA, or I Casa pentyl. Ethyl. And this a two grams twice a day. And this was in patients who either had established cardiovascular disease or diabetes and one additional risk factor, what they found that there was a significant reduction in endpoints in terms of non fatal mi stroke. So there were there were there were reductions, and major coronary events with this drug on top of maximally treated, you know, statins, which you would use in this high risk category. Now, the problem was that the event rates weren’t related to lowering triglycerides. So it was independent of the triglyceride level before and after treatment. So they’re thinking that the breakdown products of EPA have other beneficial beneficial effects such as resolving inflammation to an interleukin 10 or improving an endothelial function and reducing oxidative stress and also reducing? Well, yeah, obviously oxidative stress, so so I’ll leave it at that.

Dr. Andrew Wong:

I we’re gonna get into nutraceuticals later, but I just have a piggy piggy back on that on that reduce a trial. So I think it’s reduced to trial, if you have a patient that’s asking you about the pharmaceutical version of fish oil, based on that versus a supplemental form of fish oil. Where do you see that balance? You know, happening is one better than another there?

Dr. Viral Sheth:

Yeah. So if your triglycerides are greater than 150, right, and you’ve had an event or you have diabetes, the pharmaceutical EPA, I think the SEPA is the brand name for it, is clearly has, has clear outcomes data to support its use. Above the over the counter official. The over the counter official is a combination of EPA and DHA. And the DHA DHA piece may increase risk, believe it or not, and EPA so it’s kind of like it’s a wash. So there really hasn’t been any major trials or studies to show improvement in outcomes with just over the counter fish oil when it’s combined. EPA and DHA.

Dr. Andrew Wong:

I know DHA is used also for brain health quite a bit. And there’s that combination often that happens with EPA DHA, but But EPA does seem to have more of an anti inflammatory effect. That seems to be a little bit more the difference there. Thank you. And we can talk about genetics a bit too, because I know for us, we see a lot of people that come in and say, Oh, my dad had high cholesterol, my mom or my siblings have high cholesterol. So I also have high cholesterol. How much of a role does genetics play in cholesterol numbers and

Dr. Viral Sheth:

so the two so the two big diagnoses for genetics and cholesterol, they’re commonly seen. One is some type of familial hypercholesterolemia, whether it’s homozygous and their LDLs are between, you know, between 305 100 or 205 100. Or actually, I take that back, homozygous I take that back homozygous people have LDL is between 500 and 1000. Those people are high risk for having early onset of cardiovascular disease, you know, patients in their 20s, having a mais that’s very uncommon, more common is heterozygous familial, and these are the people who have LDL cholesterol between you know, 205 100. And those people are also considered higher risk. And the guidelines do recommend statin therapy for people who have LDL cholesterol is greater than 190. That tends to be a genetic predisposition. More than anything else, whether it has to do with you know, mutations on PCs K nine gene or EB it’s unclear but but they’re definitely there’s a genetic component there and it puts them at higher risk. The other the other factor that’s genetic is LP delay. So LP little a clearly is To only genetically transmitted and lifestyle does very little to lower LP Lulay. And drugs are not very effective right now at least the ones that are on the market. But anyone that’s possibly effective as PCs K nine inhibitors, which are those injectable treatments for cholesterol PCs, Kanine inhibitors work by preventing the breakdown of LDL receptors on the liver. So they tend to, you know, uptake the LDL cholesterol So, and they’re quite effective, they can lower lower LDL by almost 50% or more. But they also have been shown to lower LP literally, to certain extent, there are other trials that have just completed phase two, looking at what we call antisense oligonucleotide technology. And with that technology been have they been able to show over 90% reductions in LP delay. Now, phase three trials are ongoing to see if that reduction actually reduces event rates because we’ve been fooled by you know, raising a helping make a difference. It doesn’t, or lowering triglycerides significantly, think it makes a difference. And it really doesn’t. So we need to see outcomes data before something like that gets FDA approval. Yeah, those main genetic diagnoses for for cholesterol?

Dr. Andrew Wong:

Yeah. How, how common are these genetic components, whether it’s a hyperlipidemia with LDL, you know, say over 200 without doing anything, or a LP little a lipoprotein a being high? How common are these things? How often do you see this in your practice?

Dr. Viral Sheth:

So the incidence where I’m a cardiologist, so I probably see, just from experience, maybe 10% of my patients have elevated LP Lulay and probably less than that have heterozygous familial hypercholesterolemia. So they’re not very common. You know, hyperlipidemia is heart disease is multifactorial. Cholesterol is one component. But you know, other things can cause inflammation, and you know, hypertension, diabetes, obesity, sedentary lifestyle, smoking, excessive alcohol, I mean, all those things contribute together. But in terms of genetics, and cholesterol and risk, LP, little a and heterozygous familial hypercholesterolemia are the most common.

Dr. Andrew Wong:

It sounds like to that cholesterol is if I’m saying this right, necessary, but not sufficient for the development of heart disease, you can have someone with cholesterol that is high, but let’s say they say their family never had heart disease or something, but they have high cholesterol. So what kind of pointing back to what you said earlier, that cholesterol is a parent hormone for the adrenal hormones for the sex hormones. It’s a major component of the cell membrane. So it’s, it’s an essential building block for our cells in our bodies, but yet, it can in the setting of an inflammatory environment, lead to vascular inflammation, and it’s the oldest function.

Dr. Viral Sheth:

So I’ve had patients who have LDL cholesterol is over 200. And I will do a calcium score on them. And it’s zero. Yeah. And those people have have very low inflammation in their bodies, very low inflammation in their arteries. And because of that, this LDL cholesterol is not causing the damage that it could. Yeah, so even, and we haven’t talked about the different kinds of LDL cholesterol. But, you know, the small dense LDL cholesterol, those are the patients who tend to have metabolic syndrome, high triglycerides, low HDL. Those are the folks who, whose LDL cholesterol, even though it may not be terribly high as wreaking havoc, in because because they’re smaller, they’re able to get into the artery walls, they tend to get oxidized more quickly, and they cause more inflammation can lead to higher oxidized LDL levels too. So yeah, so So not all LDL cholesterol is the same. And LP lay, by the way, is a form of LDL cholesterol. It’s got a Poby which LDL cholesterol has as a mark for risk which increases inflammation, but it also has APR, a which increases clotting. So LP Lulay has a double whammy in terms of causing accelerated or premature coronary disease.

Dr. Andrew Wong:

Right. I think there’s a bunch of questions that have been generated from your answers. So I will say that for the LP little a, have you found anything that has been shown to lower LP little a so?

Dr. Viral Sheth:

Yep, so as I mentioned, the injectables that are on the market now will reduce all people there by about 25%. But the newer drugs that are in test phase three trial can reduce LDL by over 90%. Now, there is one nutraceutical called Berberine, which has a mechanism of action similar to phpcs canine inhibitors. And there is some some data there to show it can lower your cholesterol using that mechanism, not so much about Help you away. But that will be potentially something that’s, you know, benign and natural and natural agent that you could start.

Dr. Andrew Wong:

Alright, so we talked a bit about cholesterol and triglycerides and why they’re so important in terms of measuring them for Heart, heart disease risk, we talked about some calcium coronary artery calcium scores, as well as kind of, you know, different markers for maybe looking at cholesterol on a deeper level, you mentioned lipoprotein a, what are some of the other kind of advanced markers you might do on an advanced lipid panel that you know if your patient wants to see like a deeper dive into this,

Dr. Viral Sheth:

so So the most important predictor of events in advanced lipid panel is not the density of LDL, or, but the particle number. So LDL particle number takes into account both dense LDL and large fluffy LDL. If you’re, if your particle number is below 1000, it doesn’t really matter what the dense LDL is, or the because you’ve gotten it low enough that you’re not going to, you’re going to reduce event rates. So particle LDL particle number, out of all the advanced lipid panel markers is probably the most important. That doesn’t mean don’t look at LDL density, as well. Also, things like a Poby and non HDL are also important. And those folks who have, you know, the atherogenic meal, you have metabolic syndrome and diabetes, those are also but the treatment is saying lowering the LDL, first lowering the LDL particle number first, to below 1000.

Dr. Andrew Wong:

Do you ever look at a CRP or homocysteine or fibrinogen, any of those?

Dr. Viral Sheth:

So CRP is remember I mentioned it’s one of the risk enhancers? Yeah, so if it is above two, but the only change in elevated CRP is to lower the LDL, so but there was this plenty of data to show high CRP or independent markers for cardiac event rates. There was a guy named Rick care who has really done a lot of publishing on that and but, but statins are the go to drug for elevated CRP in addition to healthy lifestyle. homocysteine, I don’t measure, because there’s no data to show that treating it makes a difference, at least in terms of cardiovascular event rates. I haven’t been measuring fibrinogen levels.

Dr. Andrew Wong:

But let’s talk about Thank you. Let’s talk about statins now. So that is the most widely prescribed medication for cholesterol, I believe, what are the pros? What are the cons of statins?

Dr. Viral Sheth:

So the pros of statins are really overwhelming in terms of clinical trials now. That those may those clinical trials are funded by the pharmaceutical pharmaceutical industry. And sometimes the fudged the numbers, and they tell you that there’s, you know, a, you know, 30% reduction. But they don’t tell you, they’re talking about absolutely, they’re talking about relative risk reduction, whereas the absolute risk reduction is really one or 2%. And that type of fudging of the data, I think, has left a lot of people feeling very skeptical of these trials in the pharmaceutical industry in general. But I will tell you, though, for those folks who are at higher risk, Statins have been shown to be very effective in prolonging life. There’s really no question there. Now, in terms of side effects, right, there’s a there’s a, there’s a, there’s a a condition called the no SIBO effect, I’m sure you’ve heard of that. If somebody goes into treatment, thinking that they’re going to have a side effect, they’re much more likely to have the statin induced side effect, which is my Algis. So it’s all about, you know, speaking with the patient, doing, you know, shared decision making, and, and reinforcing the benefits, but not so much the bad the side effects, and that can have a real impact on the side effects of statins. Now, some of the other things we can do if someone has side effects, as we can hold the drug and reintroduce it at a lower dose, maybe instead of every day, you know, three days a week, we can try a different drug. We can try a non statin for example. medicines, like the PCs can inhibitors if they’re at high risk, or just as dead in mind and not at high risk, which is doesn’t have the same side effect profile as Dan’s do. So, so yeah, so, so stands. The other concern people have is the risk of diabetes with statins, right? So there is there is there is data to show that high dose statins can increase the risk of developing type two diabetes by about I don’t know about by about a month or two and people who are who are at risk with metabolic syndrome and pre diabetes, but what that tells me is that these Good, are we going to be developing diabetes eventually, over the next month or two. So the benefits of taking a statin, if you have diabetes, far outweighs the risk of developing diabetes. In those folks. The other concern people have is with, you know, you know, cognition, and the data we’re cognition is really very, very tenuous, there’s really no hard data to show that statins reduce that lead to premature dementia or anything like that, especially at lower doses. Statins just don’t do that.

Dr. Andrew Wong:

So I have two follow up questions. That one is about CO q 10. And the other is about about getting off statin. So let’s talk with the cookie 10 for a second, I heard in the past anyway, that in Europe, sometimes they’ll package the statin with a co Q 10 supplement and nutraceutical we know that statins will inhibit HMG co reductase, which also would produce cookie 10. So there’s always a potential concurrent reduction and Coenzyme Q 10. Where are you with? I know different people have different opinions on this, but where are you with? CO q 10. And D prescribe that to all your patients that are on statins? So that’s,

Dr. Viral Sheth:

that’s a great question. So co q 10. Is and you you wake ubiquitous molecule in our body. It’s mostly found in the heart and the myocardium. And lower CO q 10. Well, Kochi 10 does lots of things. It’s an anti inflammatories and antioxidant. It improves endothelial function and material health. But it can be depleted. And people who have congestive heart failure, or who had were on statins in particular. And because of that, there’s some anecdotal data to suggest being sub sub menu co q 10, maybe 20 milligrams a day, will help prevent, you know, the side effects of statins, myalgias, etc. And also the other benefits we talked about in terms of improving heart health. So I’m a big proponent of CO q 10. And it’s on my vitamin sheet. I think it’s the second one on my vitamin sheet. And it’s one of those things that I think there’s really very little downside, and tremendous upside.

Dr. Andrew Wong:

So a ubiquinone or Ubiquinol, depending on the form. It sounds, I didn’t realize that it was named because it was a it’s a ubiquitous molecule in the body. I guess it’s whoever scientists name that.

Dr. Viral Sheth:

Sure. And get a quickie that was about, well,

Dr. Andrew Wong:

statin. So you know, Hey, doctor, if I’m on a statin, can I get get off that statin?

Dr. Viral Sheth:

Yeah, so that’s a great question. So if somebody is at high risk, they’ve had an event, a secondary prevention, or if the calcium score is over 100? I would say no. And I was hoping you’d be on that statin for the next 50 years. Because that’s how long you live, you keep taking the statin. But if you’re at intermediate risk, and you can change your lifestyle, you can you know, nutrition, we haven’t talked about nutrition, but yeah, let’s talk about that. So the like a Mediterranean diet lowers LDL cholesterol, any any type of diet that’s plant based, will lower your LDL cholesterol, exercise, tremendous impact on lowering LDL cholesterol. Yeah, I mean, you know, you stay away from you know, sweets and starches and saturated fat Remy cheese fried foods, they all lower your LDL cholesterol. So a lifestyle change can have a dramatic impact on LDL cholesterol. And in that scenario, we could potentially stop taking or reduce the dose of a statin and somebody who’s an intermediate risk that they don’t necessarily need to be on a stand for the rest of their life.

Dr. Andrew Wong:

That’s good. That’s good to know. Good give people hope to. So there is it sounds like a big nutritional connection, big exercise connection to lipids and cardiovascular disease. Would you say that one of the root causes of high cholesterol would be more of an inflammatory lifestyle and nutrition and by reversing that, and flipping that on to like a Mediterranean anti inflammatory, plant forward type of diet, you would have lower cholesterol by getting to the root cause of that.

Dr. Viral Sheth:

Absolutely. So the SAD diet, you know, the standard American diet is the exact inflammatory diet you’re talking about, you know, a lot of processed foods, a lot of you know refined sugars, saturated fats, cholesterol, with very little in terms of, you know, fruits and vegetables, whole grains like gouves, that standard American diet is definitely in flat pro inflammatory and increases cardiovascular risk. I think we’ve done a good job of educating patients on that. And I think people are more inclined to go with a plant based diet. There are all kinds of plant based diets out there. There’s the Mediterranean diet, which has outcomes benefit data. It was its prospective wasn’t randomized trial, but there is reductions in cardiovascular event rates with the Mediterranean diet. There’s also the DASH diet, which is also similar, but it also lowers blood pressure because a very low sodium diet. There’s also, you know, there’s the there’s the vegan diet, right. So that is also a plant based diet. It’s more extreme. But it’s also thought to be better for the environment. So you can pick and choose which plant based diet as long as it’s plant based. I’m okay with it.

Dr. Andrew Wong:

You’re not a dead sound like you’re a big proponent of a carnivore diet for

Dr. Viral Sheth:

Yes, production. Let’s let’s talk about keto. Right, yeah, sure. So keto. So for me, the keto diet has really one benefit. And that’s weight loss in six for the first six months. Some people for that because of genetic markers, can have their LDL cholesterol climb above 200 on a keto diet, not everybody. So you need those people need to be monitored, especially if you have diabetes, who will be monitoring them as well, because they’re really doing very low thing to become hypoglycemic, that type of thing. So, keto is not for everyone. keto can have some improvements in cholesterol early on. But it’s such a hard diet to maintain long term that Yeah, so for me keto is good for weight loss in the first six months. But after that, you should transition to more plant based diet,

Dr. Andrew Wong:

right? Because otherwise keto plus high carbs, which will feed back and equals sad, right, then it just becomes a SAD diet again, basically, trying to think of another acronym for glad diet, but kind of think of that next time. What are some nutritional superstars just to get more practical about it for listeners? Like what what foods do you like for lowering cholesterol? Like if they said, Hey, Dr. Chef, I’m going out to the grocery store, what should I buy? At the grocery store?

Dr. Viral Sheth:

Yeah, so yeah, so I think the key is going to the grocery store,

Dr. Andrew Wong:

and just going just just go

Dr. Viral Sheth:

do that anymore. Now, yeah, my wife is ordering groceries online, I’m like, wait a second, that’s the whole point of going to a grocery store is actually picking the vegetables and the fruits that you think are you know, are organic, and that have, you know, that are fresh, etc. And so I think going to the grocery store is so important. I think actually picking out, you know, colorful fruits and vegetables is very important. And you know, and whole grains, you know, unless you were let us sensitivity to gluten. Whole grains are very helpful. As our as our you know, beans and legumes, also very helpful in terms of managing your cholesterol, your state, your cheese is the biggest culprit when it comes to increasing our cholesterol. So that’s something I try to focus on with our patients is to cut back on the amount of cheese to 13.

Dr. Andrew Wong:

I think a lot of people don’t realize that because they’ll eat like a kale salad, but then they’ll put like tons of cheese on it or something or broccoli with a bunch of cheese,

Dr. Viral Sheth:

goat cheese or whatever. Right. So yeah, so yeah. So I mean, I think going to a good nutritionist is also a good place to go. If you want to really focus on diet in terms of specifics of growth going to the grocery store. What did they say, if you go to a grocery store, you show all the healthy foods are on the sides or on the back in the middle are all the process moves us to the middle of the grocery store? And just walk around the outsides?

Dr. Andrew Wong:

Absolutely, definitely. That’s really good advice. And definitely seeing a nutritionist. Shout out to our amazing nutrition team here at our clinic, but um, and you, for you like do you do?

Dr. Viral Sheth:

I do want to mention one other type of diet. Yeah, it’s called the caloric restriction diets that are out there now. So there’s intermittent fasting. Yes. Yes. Which, which I think, along with fasting, mimicking, mimicking diets have been shown to reduce blood pressure, BMI, total cholesterol, LDL, cholesterol, triglycerides, and C reactive proteins. The exact mechanisms are unclear, probably has to do with you know, your resting your gut, improving the flora in your gut, reducing T M A Oh, which is a marker for which gets absorbed increases cardiovascular risk. So I it’s not for everybody. But for the motivated person. Like, you know, for example, myself. I’ve been doing I think that we had this conversation before. I’ve been doing this intermittent fasting for about five years now. And I lost 20 pounds and how to maintain that weight loss. And just to give you something anecdotal about that, was about 10 years ago, I had a calcium score done and it was 05 years ago, went up to 15. So at that point is when I started this intermittent fasting, I recently did a calcium score about a month ago and it’s down to one. So there’s there’s definitely proof in the pudding in terms of different diets and caloric restriction as improving cardiovascular health, at least for me, but there’s also Other data out there?

Dr. Andrew Wong:

Nice? Well, it’s nice to have the data as trial, but it’s nice to have the personal experience too. So that’s really great. Are you still doing the one meal a day or

Dr. Viral Sheth:

I am, so I’ve gotten quite aggressive with that I’m unable to because I drink fluids during the day, you know, zero calorie fluids during the day. Most people do, you know, eight hours between noon and eight where they eat. And you know, the other times they don’t eat, then they eat a healthy, healthy calories, obviously, but two meals a day is typical,

Dr. Andrew Wong:

right? And also, just as a disclaimer, for those listening, it’s not like more intermittent fasting is necessarily better. It’s not like one size fits all, it depends on each person in terms of how much they have to tolerate, you know, how are their adrenals working? Are you stressed out, you know, things like that. So, a lot, a lot of things happening, how people sleep. But that’s, that’s really great. I also wonder about, you know, cholesterol being lowered from a lower carb diet from increasing insulin sensitivity, you know, there’s some some mechanism for for insulin being lowered, and then sometimes that will lower cholesterol to

Dr. Viral Sheth:

yes, no, absolutely. So improving insulin sensitivity can definitely reduce inflammation. And by reducing inflammation, you’re going to reduce cardiovascular event rates. So and you know, reducing your carbohydrates will also help with weight loss, and help with truncal obesity, which are all signs of insulin resistance. So improving insulin sensitivity, with lifestyles is really important cutting back on carbs. Absolutely. There are, there are, there are drugs on the market that do that also. But, and I wanted to mention, since we did talk about low carbs, and maybe diabetes, there’s two agents on the market now, anti diabetic meds that have been shown to actually reduce cardiovascular event rates. One is GLP, one Victoza and the other one is a Jardiance, which is an stLt, two inhibitor. So both of those have been proven to reduce both heart failure and major adverse cardiovascular events. So, you know, in addition to Metformin, so those are the three go to agents that I usually recommend to my patients who have insulin resistance, diabetes, etc.

Dr. Andrew Wong:

Nice. Yeah. Metformin makes it makes a lot of sense. Also, let’s talk about supplements. And I think I want to get back to exercise too. But let’s talk about supplements nutraceuticals, as well, are there any specific nutraceuticals that you would think about for cholesterol? Do you add them onto a statin to use them instead of a statin?

Dr. Viral Sheth:

Sure. So you know, as I mentioned in my opening statement, that I, for people who are low to moderate risk, I really want to focus on lifestyle, and then nutraceuticals. And then if we’re still able to get to agreed upon goals, then we can consider pharmaceuticals. So the depth, the lifestyle pieces that we’ve talked about the diet, the exercise, by exercise is important. The guidelines are between 150 to 300 minutes of moderate intensity exercise a week, or which you know, which is like walking at a brisk pace, or 75 to 150 minutes of vigorous exercise, like running or playing singles, tennis, etc, you know, a week will help, hopefully, or the guidance will help you reduce your cholesterol as well as improve all the other parameters parameters, including inflammation, but in terms of pharmaceuticals, so So what am I, someone has, let’s say, a calcium score, you know, between zero and 100, right, so that, you know, low to moderate risk. So those folks I will, in addition to lifestyle, recommend, you know, fermented garlic, so fermented garlic has all kinds of benefits, it does lower your cholesterol reduces inflammation, and it’s also an anti platelet agent and lowers blood pressure. So, and, and also, it’s been shown to reduce calcification of the corners. I mean, there’s real science to show that that’s typically, you know, 600 milligrams twice a day of the coyote brands that I recommend that comes from Japan. And that’s where the science that’s where the data comes from. Also, you know, we talked about Berberine Berberine has efficacy and lowering cholesterol, as well as blood sugar and blood pressure. Very mild typically add that on to pharmaceuticals to help people get the goal. red yeast rice sureties rice is a standard derivative. My experience with red yeast rice has not been good in terms of efficacy for lowering LDL cholesterol. Maybe because it’s not FDA approved. Maybe we don’t we don’t I mean it comes from it’s a Chinese herb, so maybe it’s not as pure as we think it might be. So I have not had great success with lowering LDL cholesterol.

Dr. Andrew Wong:

What about vitamin K to anything? Iris.

Dr. Viral Sheth:

Yeah, so vitamin K two. And by the way, in terms of my personal use of nutraceuticals. So I do take vitamin d k two in combination. I also take magnesium every day to lower inflammation and blood pressure. So there is really there’s, there’s there’s science with K tuner reduction of calcification in the coronary. So, yeah, so maybe that’s one of the reasons my calcium score went from 15 to one. So I was taking k two, I mean, I don’t know for sure, but probably contributed to

Dr. Andrew Wong:

that plus getting on the intermittent fasting train. It sounds like any other lifestyle recommendations, you know, all this can be very stressful for someone to listen to like, which they eat and how much they exercise and, you know, what’s my, what’s my CAC score? What’s my cholesterol? What do you recommend for lifestyle in terms of stress reduction? Because we know that that’s,

Dr. Viral Sheth:

that’s huge, you know, you know, work life balance is one of my go to things now was that wasn’t like that before, I was a workaholic.

Dr. Andrew Wong:

I mean, being a being a balanced for work, life as a cardiologist is amazing. For one.

Dr. Viral Sheth:

Yeah. And it’s not easy to

Dr. Andrew Wong:

get to doctor.

Dr. Viral Sheth:

And I remember working like crazy hours in the first day of my vacation, which was like, basically two weeks a year, I would get sick, because my cortisol levels would drops and not so stressed. And then my infant, and then it was just, it was it was not a healthy way to live. So yeah, so managing stress. I’m me personally, I’m big into contemplative exercises. So I do a lot of mindfulness, meditation I do I meditate, at least between 30 That 30 minutes to an hour a day, depending on how much time I have. I also do walking meditation, or when I’m on my elliptical, I’m quieting my mind, and I’m able to, and that just the fact you’re able to quiet your mind, it helps in terms of managing the day to day stresses that happen, so that you’re able to actually recognize those thoughts and emotions. And by recognizing them, you’re able to let them go through you and they don’t sit with you. And they don’t lead to higher cortisol levels and Adreno epinephrine levels. And so there’s such that to that. So there’s that aspect, there’s also something called mindfulness based stress reduction, which is actually a seminar course that you can take. I think it was developed by what’s his name again, Dr.

Dr. Andrew Wong:

Kabat Zinn at Mass Amcrest. Yes, yes, exactly.

Dr. Viral Sheth:

And again, not it’s, it’s not supposed to be spiritual. For me, it is a very spiritual experience. And I think that makes a big difference in my outlook on life, and how I manage the stressors in my life, I’m able to take them more in stride. without, without it overwhelming me like it used to do.

Dr. Andrew Wong:

That was my first foray into meditation was taking it MBSR class offered at the hospital, like a free class for employees. That was really nice to an eight week course. And I noticed a big difference with that. And I’m still trying to do meditation. But that’s, that’s really, that’s really great. Because you can’t really necessarily control the events today, but you can influence how you respond to them. And meditation. Mindfulness is a big part of that. Exactly. What is one thing you wish everyone knew Dr. Sheth about cardiovascular health in general? I know this is kind of a very broad question.

Dr. Viral Sheth:

Yes. I just want to say that that was a very good question. That that, that they were actually the American College of Cardiology, and the American Heart Association, came out with this statement. And that is 80 to 90% of all cardiac cardiovascular events can be reduced by achieving healthy lifestyle goals. And for the rest of the 10 to 20%, will require pharmaceuticals, specifically to genetic risks that we talked about. So that’s quite an unbelievable statement to come out of a society, you know, one of the cardiology societies are the two main cardiology societies. And what that tells me is that clearly as providers, you know, we could do a better job with educating our patients. And clearly, you know, society in general has to also take the lead, and, you know, encourage healthy lifestyle. And, you know, I always tell them, I always say to my patients, my goal is if you’ve ever seen me in the office, I never want to see you in an emergency room with an acute coronary condition, because that’s my goal. And the way you achieve that goal is a combination of healthy living, and necessary pharmaceuticals.

Dr. Andrew Wong:

Yeah, yeah. That’s, that’s so great. I’m glad that that they the society made that statement. Thank you, Dr. Schatz, so much for coming on. Today has been a very informative and fun talk with you talking about cholesterol and heart health. One closing question we have is, What is one thing under $20 that you think has changed? Is your health for the better? I know you’ve talked about a couple things already, but what’s kind of one fairly inexpensive practical thing? Is that

Dr. Viral Sheth:

a one time spend or is that a daily spend,

Dr. Andrew Wong:

it could be either whatever is your choice.

Dr. Viral Sheth:

So for daily spend, I would say, maybe getting, becoming getting a gym membership. Or the other option is to walk to your local farmers market or grocery store and spend that $20 on, on, you know, fresh on whole foods. And the benefit of walking to the grocery store or the farmers market, and the trade hours spent on it, but this is actually one of my difficult questions I was looking at, it wasn’t really it was not much. The other thing I thought about was getting a buying a baseball cap because that, I mean, I use all the time I usually buy when I go to places, you know, you know, exotic places or you know, etc, or to tennis, tennis tournaments, etc. And, you know, keeps an eye on your eyes, but also reminds you that you need to exercise at least for me,

Dr. Andrew Wong:

so, okay, the baseball cap is that that trigger in your brain to say go and exercise. That’s so great. Well, thank you so much for all for coming on today. Dr. Sheth, how can listeners learn more about you and work with you? We know you’re local here in the DC DMV area.

Dr. Viral Sheth:

Yeah. So if you go to the cardio Care website, you can you know, make an appointment to come see me. You know, it’s easy to do

Dr. Andrew Wong:

cardio care.com Is that right? Cardio care.com yes.com. Okay.

Dr. Viral Sheth:

And you have offices in? I see patients in Chevy Chase, in Germantown and in rockville.

Dr. Andrew Wong:

Okay. And do you do telehealth that we’re still recruiting just during the pandemic? How does that work?

Dr. Viral Sheth:

Yeah. So, you know, I send you a zoom link, and we do to help.

Dr. Andrew Wong:

Okay. All right. Well, thank you so much for coming on.

Dr. Viral Sheth:

Thank you so much. Take care. Thanks for having me, too.

Dr. Andrew Wong:

Thank you for taking the time to listen to us today. If you enjoyed this conversation, please take a moment to leave us a review. It helps our podcasts to reach more listeners. Don’t forget to subscribe so you don’t miss our next episodes and conversations. And thank you so much again for being with us.