Office Hours: Cholesterol and Heart Disease — What I’ve Changed My Mind About

0:29Welcome to Office Hours. your own health. And for many of you, your family's health too. And you might not feel it all the time, but you have far more power and agency than you realize. I'm glad you're here. This episode is brought to you by Function Health, empowering you to live 100 healthy years with over 160 lab tests at just$365 a year. Sign up today at functionhealth.com slash mark and use code mark2026 to get$50 towards your membership. Hey everybody, you know, from time to time, science changes and I change. I look at the data, I see what's changed and I change my thinking, I change my practice and I just don't want to keep you up to date because science is an evolving process.

1:10We're constantly doing research, we're constantly learning and old ideas may not always be the right ideas. And even though they can be pretty strong, like for example, that low-fat diets are good for heart disease, well that ain't true. And we know what happened with that, with snack about cookies and we went low fat and we all got fat and we all got diabetes and we all got more heart disease. So we have to look at the things that we hold on to, like these sacred idols, and we have to let them go if the science doesn't prove that they're true anymore. So today I want to talk about something I've changed my mind about over the years, cholesterol and heart disease.

1:50Now, heart disease is the number one killer of Americans since the 1950s, and yet so many are still approaching it with the same outdated framework that we'd use for decades. Now, for a long time, cholesterol was seen as the enemy. You got to get it as low as possible. You got to avoid fat. You got to take a statin. And that was what we're all told. That's what doctors are trained in. And that's the story most people still believe. You go to your doctor, they check your labs, they do a cholesterol test, and they do the wrong one, by the way. And that's why at Function Health, we do the right ones, including ones you never get from your doctor, like ApoB, which is far more important than all the other cholesterol tests, and LpA, which most people don't check, which is a highly important genetic marker.

2:28So you got to know your numbers, but you got to know the right numbers. So doctors check your old cholesterol number. They see your LDLs high. They go, LDL high. Let's get lower. Take a statin without really much thought. And that's unfortunate because it's a much more nuanced problem than just a statin deficiency that's causing heart disease. And the latest research shows that we need to think about this differently. And with my patients, I've also learned a lot and how variable people respond to different things. I've had people with extremely high cholesterol that do extremely well on an extremely high fat ketogenic diet and lower their cholesterol and other people who are the opposite, who will take a keto diet and actually make their cholesterol worse.

3:09So you've got to really look at individuals and figure out what's going on. Let me ask you this. If cholesterol were truly the main cause of heart disease, then why do half the people who have heart attacks have normal LDL levels? Now, I wrote about this in my book, eat fat get thin there was a study like 136 000 people had heart attacks went to er and 75 percent had a quote normal ldl level so that begs the question then what the hell is going on here the question opens the door to a whole new way of thinking about heart health so here's what i used to believe i got trained like every other doctor that ldl was the issue that you had a high cholesterol high ldl that causes heart attacks cause and effect and the goal was to lower your LDL no matter what at all costs get as low as possible we also learned that saturated fat is bad because it can raise your cholesterol particularly LDL cholesterol so the message is pretty simple but it wasn't accurate for most people real life clinical work really changed that simplicity now when you graduate from medical school you think you know everything but you start practicing medicine and after 30 or 40 years you really don't know that much and how everybody's different and there's not the simplicity that we think applies to certain things like LDL, heart disease, statin, cure.

4:25It's just not so simple. We've treated cholesterol like a villain, but the truth is really way more nuanced. All right, so what did the old model get wrong? Well, the new science that's emerging has identified a couple of key problems. The first is that total cholesterol is actually a poor predictor of heart disease. Up to 50 % or even more in some of the studies of people who have heart attacks have a quote normal LDL level. The risk really comes from something that's not being tested by almost every doctor in the country. I mean, I asked Quest, who is our lab testing partner at Function Health, how many cholesterol tests use the right cholesterol test, which looks at the quality and the size and the number of your cholesterol particles, not just the weight of them, which is what you get with your normal cholesterol test, but the quality and the size, whether they're small or big, whether they're dense or not, and how many of those particles do you have?

5:22And you know what they said? Less than 1%. 1 % of their tests do this. The second big aha that came, actually, since I graduated from medical school, probably in the late 1990s, maybe early 2000s, was the insight, particularly from Harvard and the scientist Paul Ritker, who wrote a very seminal paper in the New England Journal of Medicine that it was inflammation, inflammation that was causing heart disease, not cholesterol. He even showed that if you had a high cholesterol and low inflammation, your risk was pretty low. But if you had a high cholesterol and a high inflammation, your risk was higher.

6:03Even if you had a high inflammation and a normal cholesterol, your risk was higher. So the inflammation is what's going on. So your arteries are inflamed, and that's what causes the cholesterol to get deposited. Cholesterol isn't bad. It's bad when it gets oxidized or turns rancid. When you look at data from Harvard, Cleveland Clinic, and these large meta-analysis, actually the CRP, this is another test, your doctor's own check, and it's on the function panel. this high sensitivity C-reactive protein is important, maybe more important than LDL in predicting heart disease. Now, what is causing this inflammation?

6:32And this is what most people don't realize. Aside from a certain subset of the population who has a genetic cholesterol disorder, which is independent of your metabolic health and who do get heart disease, and that's a very small number, maybe it's 10%, the real problem is what we call metabolic dysfunction. This means prediabetes, insulin resistance, anywhere along the spectrum where your body is not dealing with sugar and insulin very well because you're eating a high starch and sugar diet and you're not exercising or you have extra belly fat. I mean, you have a little bit of belly fat, you're starting to get this problem and you get high insulin resistance.

7:06And that means your cells don't respond to insulin, so you need to be more and more and more to make it work. And that causes what we call atherogenic dyslipidemia. And that's a mouthful, but what it means is athero means plaque. So So atherogenesis means plaque, atherosclerotic, vascular disease, hardening the arteries, whatever you want to call it, clogs in your arteries from plaque, from cholesterol deposits. That is caused by these small, dense cholesterol particles. It's not the cholesterol itself. It's one there when you have insulin resistance, and that drives inflammation. Now, what's really important to understand is that LDL is an LDL is an LDL.

7:45There are different types of LDL. There's large, there's medium, and there's small sizes. is and then there's the number of particles so think about like you know the weight of a cholesterol would be if you get your cholesterol number of 100 or one ldl 130 and that just means the weight of your cholesterol but it doesn't tell you how many ldl particles that is made up if it could be a thousand small particles or it could be a hundred large particles but you don't know that unless you do the right test and that's really again why we did function health now we have to understand it's not it's not just cholesterol as a simple problem it's nuanced and there's many different types of cholesterol, there's different sizes, there's different types of HDL and LDL.

8:23And so you have to really have a more nuanced understanding and what's causing it. But the real take home here is that here's the headline. It's sugar, not fat, that's causing you to die of heart attacks. It's sugar, not fat, that's the problem. And that's why I wrote a book called Eat Fat, Get Thin, why I wrote a book called The Blood Sugar Solution, why I've written End of Detox. sugar is the boogeyman, not fat. Now that doesn't mean that some people don't respond well to fat. They don't. Some people don't. So there's a lot of variation in the population, but in general, this is the big issue.

8:57It's a metabolic dysfunction that affects 93 % of the population is causing this heart attack epidemic. So it's not that cholesterol doesn't matter. We're just asking the wrong questions. All right. So what is the new science? What's really causing heart Now, one of the friends of mine sent me this email. He's an older guy. He's like 78. And he sent me this email like, hey, this great new discovery, this new lab test that you can get that tells you your risk of heart disease is more predictive than any other testing possibly you could get for heart disease. And I'm like, wow, this is interesting.

9:32I wonder if I'm going to learn something. I click on it. And I'm like, oh, okay. Well, I've been testing this for 40 years. Well, probably 30 plus years. and this is called APO-B. Again, it's not part of a regular cholesterol panel, but it is the most reliable marker of your risk of heart attacks. Why? Because it's a surrogate marker for poor metabolic health, meaning insulin resistance, prediabetes, blood sugar issues, belly fat. This is what goes up when you have some degree of this and it shows you all the bad cholesterol particles in your blood almost in the same time. Now in 2023, 2024, the guidelines for cardiology have finally recognized, I've been doing this for 30 years, guys, finally recognized ApoB is a causal factor for heart disease.

10:19It's not just associated with it. And the beautiful thing about it, you can do the lipoprotein fractionation, which is important, but I think it's also important to track ApoB. And we do that with function health. These ApoB really shows you how many of these damaging little cholesterol particles, these small, dense LDL particles like BBs that go and damage the lining of your arteries and allow the cholesterol to deposit. Another really important test that I mentioned earlier called lipoprotein little a or LP little a. One in five people, which is 20 % of the population, have an elevation in this particular number.

10:50It's a genetic problem. There are drugs coming that can help it. There are ways to lower it through lifestyle supplements and certain other treatments. But when you have it, it's really important to regulate and address all the other heart disease risk factors. Your blood sugar, your blood pressure, obviously you don't smoke, got to exercise, don't eat sugar, starch, get rid of belly fat, get your other cholesterol numbers optimized through a whole set of definite interventions we're going to talk about. But really, really important because you can't directly change it right now very well. So, but it is a very strong independent risk factor for heart disease.

11:24And it's especially worse if your cholesterol is abnormal. medication is coming but metabolic and lifestyle health are really the key but as I said earlier the real problem the real problem causing our epidemic of heart disease is not a high fat diet it's sugar and it's insulin resistance that results from eating a lot of starch and sugar when I say sugar I mean anything like anything that's got sugar or starch it could be bread it could be rice it could be potatoes or they're not so bad if you eat the little small ones anything is starchy if you are someone who's susceptible and most of us are you can get in some resistance i mean i'm i'm pretty healthy my body fat's about 10 i exercise every day i eat pretty good occasionally have a cookie or ice cream but it's not my staple and i and i'm pretty lean but when i went to italy you know last summer i kind of went crazy and i had you know wine and i had lots of pasta and whatever bread and uh i gained like five or ten pounds and it went right to my belly.

12:21And then as soon as I came home, it went right away because I went back to my basic habits. But most people don't do that. And when you look at the data, this is from Tufts, 93.2 % of Americans have some degree of metabolic dysfunction. And it shows up as high blood pressure, high cholesterol, or abnormal cholesterol, high blood sugar, having had a heart attack or stroke, or being overweight or obese. That means that only 6.8 % of Americans don't have that. Think about it. Research shows also that insulin resistance is a problem, even if your cholesterol is normal. And I kind of want to just touch this for a minute.

12:54And I talked about this study in my book, Eat Fat, Get Thin, but it was a very interesting study where they mentioned where they took 136 ,000 people who showed up in the ERs across the country for heart attacks. And they measured their total cholesterol, LDL, triglycerides, HDL. And what they found was really fascinating. 75 % had normal LDL, but almost nobody had normal triglycerides or HDL. And the higher triglycerides and the lower your HDL, the more you had a higher risk for heart attack. Now, what do those numbers mean? Those numbers are a great and simple way to test your degree of insulin resistance.

13:27Your triglyceride divided by your HDL. Your HDL should be over 60, ideally, over 50 if you can manage it. Your triglyceride should be less than 100, and even under 70 is better. And if your ratio of triglycerides to HDL is one, that's great. If it starts to go to two or three or four or five, that's bad. So if your triglycerides are 150 and your HDL is 30, that's a ratio of 5 to 1. That's a disaster. Even if your total and LDL cholesterol are perfectly normal, you will have an extremely high risk of having a heart attack. You wouldn't take a prescription without knowing the problem, right? But that's how most people approach nutrition.

14:04They try keto, paleo, plant-based, fasting, just hoping something sticks. In my practice, I've seen it over and over. Diet isn't the issue. It's the missing data. And that's where function comes in. It gives you access to over 160 lab tests for your heart, hormones metabolism nutrients toxins and more for just 365 a year so you can be precise and you can choose the foods that actually address what your body needs because food is truly medicine get tested at functionhealth.com track your data and then make your plate let's talk about the other piece here the inflammation model why is there inflammation there's a lot of reasons environmental toxins, your microbiome, stress, infections, lots of reasons.

14:48The main reason, the main reason, sugar. I mean, I know it's not like a broken record, but this is the problem. The biggest driver of inflammation in our society is our starch and sugary diet. 60 % of our calories is junk food. The average American eats about a pound of sugar and flour a day. It's about 152 pounds of sugar, 133 pounds of flour a year. That's almost three quarters of a pound of flour and sugar per person per day. Now I'm not eating that much. So some of y 'all eating a lot more. The key is if you eat that, it's going to drive the deposition of belly fat, visceral fat. We call it visceral adipose tissue.

15:25But this is angry fat. It's not just regular fat holding up your pants. It's angry fat and it's inflamed fat and it's spewing out tons of inflammation. When you have inflammation, guess what happens? You oxidize the LDL. Like, you know, when your oil goes rancid or nuts go rancid, that rancid fat is dangerous. It's harmful. It's oxidized fat. It's like a car rusting. And that causes damage to your blood vessel lining. And that leads to the ability for the cholesterol to enter the arteries and form these plaques that end up causing heart attacks. Now, there's a lot of other markers of inflammation that you can see.

16:07HSCRP, we talked about, ferritin, something that can go up in certain people, particularly if you have severe insulin resistance. IL-1, which is a cytokine homocysteine, also can be elevated. So a lot of clues you can get for inflammation. So just to reiterate a little bit about diet, there are people who are sensitive to saturated fat. And I want to just be clear that not everybody responds the same to the same diet. We're all different. But on the whole, if you're overweight, if you have belly fat, fat, you're more likely to do better on a high-fat diet than a low-fat diet. You're more likely to do better on a low-sugar starch diet than a low-fat diet.

16:43Really important. And large studies have shown this. Large analysis, the PURE study, Framingham data, show that dietary saturated fat is not the primary driver of heart disease. I think there was a study I reviewed in my book. There was like 72 different studies. There were randomized controlled trials, population studies, blood levels of fats. They look at dietary intake. I mean, it's really quite an extensive study, and they can show no correlation at all with saturated fat. Trans fat, for sure, increased the risk. That's hydrogenated fat. And omega-3 fats lowered it a little bit. But saturated fat, we're neutral.

17:15Now, that doesn't mean for some people it's not a problem, but it's in general, that's the case. Now, as I mentioned, the thing that's far more dangerous is refined starches and sugar. So bottom line, you know, think of sugar as a recreational drug. That's what I do. Okay, so what do I think now? I think now that heart disease is primarily, for most people, without these genetic lipid disorders, is primarily a metabolic, meaning blood sugar regulation, and inflammatory disease first. Cholesterol is just a bystander in this whole process. And what matters most to check for you now is something called apolipoprotein B or ApoB and what we call lipoprotein fractionation, which we do on Function Health Panel, and lipoprotein little a, which we do on the functional panel and HSCRP, which we do on the functional panel and measure of insulin resistance, which we check fasting insulin.

18:06Again, I ask the question, how many tests that you get from doctors around the country include insulin? It's like less than 1%. Never checked. Almost never checked. It's probably the most important test for understanding your health and longevity. There's an even better test we offer through function, which is an insulin resistance score, which uses newer technology to get a very predictive result that's better than even taking a glucose tolerance test. The other thing I mentioned, you want to look at triglyceride to HL ratio. That's your triglyceride to HL should be one to one or even less. And then there's a really easy test.

18:38It's the tape measure test. You basically get a tape measure and you measure around your fattest part of your belly. And if it's too much fat there and your waist isn't good, you're in trouble. And there are some benchmark numbers we can give you. But basically, you know, if you got that in there, it's just, or you can use the mirror test. You don't even need a tape measure. Just jump in front of the mirror up and down. And if your stomach jiggles, you probably have this problem. All right. So let's kind of reiterate the things that make the most important are the quality of the diet you're eating, whole foods, low glycemic, anti-inflammatory, good fats, exercise, managing stress, getting up sleep.

19:15All those things are critical. Those matter. What mattered less than we thought is the total cholesterol. is your LDL alone in the dietary fat intake is not as important as we thought. The cholesterol in your food is certainly not important. In 2015, the Dietary Guidelines Committee said, listen, guys, we got it wrong. What did they say? It was kind of a funny determination. They said, cholesterol is no longer a nutrient of concern, meaning eat your eggs, don't worry about it. So in functional medicine, we don't really treat the numbers. We treat the whole body. We treat the system. And the system that drives heart disease is your metabolic health.

19:51And people who have poor metabolic health have heart disease. You know, guys, there's always more studies coming out, but there's an amazing study in 2024 looking at metabolic cardiology. And they showed that metabolic syndrome prediabetes increased your heart disease risk by fourfold. That's 400 % independent of your LDL cholesterol, right? We're always focused on LDL cholesterol, but your doctors aren't checking your insulin. They're not checking your A1C. They're not checking your blood sugar. They're not looking at some resistance scores. They're not looking at triglyceride HL ratio. They're not looking at HLCRP.

20:20They're not looking at all the things that matter. And again, that's why I co-founded Function Health, because people need to get access to their own biology and know their numbers and know their data. And they're not getting that from their doctor, sadly. Next thing I learned, which I think is really important, is that people think, oh, if you're normal weight, you're fine. But there is a problem that we call TOFI. Bit on the outside, fat on the inside. Or I like to call it skinny fat. You look skinny on the outside, but you're fat on the inside. And this means you can be normal weight. Your body mass index can be normal, but your body composition is bad, meaning you have more body fat than muscle, particularly belly fat.

21:03So 20 % of people who are normal weight have insulin resistance and have the same heart disease risk as obesity. And that is why we see the data that 75 % of Americans are overweight. when we check their blood tests, 93 % of Americans have poor metabolic health, meaning they're insulin resistant. That's the 20 % right there. So it's really a problem. Now, the good news is we have new technologies that can help us understand what's happening with our metabolic health and blood sugar, like a continuous glucose monitor. I really love those because they can help you understand what's happening and how your different foods affect you.

21:38And everybody needs to do this at least for a short period of time, because when you understand what your body's doing and how it's reacting to different foods, then you can modify your diet. Then we'll say, well, you know, if I eat an orange, it's fine. But if I eat a plum, it goes way up. Or if I have this bread, I'm fine. But if I have that bread, I'm not fine. So you can actually see how your body responds. And it's much better predictor of heart disease risk than just a static blood sugar. All right. So what can you do about this today. First thing you do is get the right test. Tests, don't guess.

22:12You can ask your doctor for these tests and they may or may not do them, but you can get all of them on your basic panel at functionhealth.com. So just to reiterate, the tests you want to get are apolipoprotein B or APOB, lipoprotein little a, HSCRP, fasting insulin. Of course, you want to know your triglyceride and HDL ratio. And also I would really recommend a lipoprotein fractionation as part of the basic panel function it looks at your particle size particle number quality of your cholesterol really important and then a calcium score which i think is important for most people as a baseline again we offer that through function health through our partner ezra which you can do imaging it's very cheap very quick uh very safe and you get a quick idea of whether or not you have plaque development and then you can manage it because you know cholesterol is just a surrogate marker it doesn't tell you if you have the disease you have to actually image to see if you have the disease, right?

23:04It's not like if you have high blood sugar, really, you know, you have diabetes. That's pretty black and white. If you have high cholesterol, I've had people with the worst cholesterol profiles you could possibly imagine, and they have completely clean arteries. So you have to actually image to figure out what's going on. When you test, you have to remember you want to track your trends over time, not just one point in time. And that's what's so beautiful about a function membership. It's every year, the dollar a day, you track your numbers over time, you get twice your testing and you see what's going on and you can modify things.

23:37You can change things. You're going to adjust your diet, lifestyle, see what changes happen. And that really helps you manage things. So you got to really understand what you're doing in order to manage it. I think some investor dude said, you know, what gets measured gets managed. So if you don't measure it, you can't manage it. The second thing you want to do is eat in a way that lowers inflammation and helps to correct insulin resistance. How do you do that? cut out the biggest source of both, which is sugar and starch. Refined starches, eat more whole foods, eat more anti-inflammatory foods, lots of colorful fruits and vegetables, lots of omega-3 fats.

24:10Get rid of ultra-processed food. They're not even food. Food is defined as something that supports the health and development and growth of an organism. Ultra-processed food does the exact opposite. So it technically isn't even food. We shouldn't be eating it. It looks like food, but it ain't food. Next, you know, work on your lifestyle. Exercise, building muscle, really important i was in the gym this morning for an hour that was really painful my trainer was crushing me but i know it's helping me and it helps to build muscle it helps to lower apob corrects insulin resistance your muscles become a better sink also strength training is not the only thing cardio is also important learning to regulate stress because that can also affect heart disease risk sleep really important all those things are really important and i just keep going moving throughout the day get your steps in now what about supplements well i want to be really clear here supplements are not one size fits all they're not a replacement they're called supplements for a reason not replacements and and you really understand what's going on to get a personalized prescription what you need depends on your health history your medications you're taking your labs your unique biology your genetics so not medical advice here but you should basically check with your doctor before starting anything new but there's some basic principles that are pretty safe first you want a good high quality omega-3 fish oil to lower your triglycerides and inflammation and your blood pressure.

25:24I recommend Omega-3 Rejuvenate by Big Bold Health. I'm an investor in the company, transparently. It's started by my mentor, Jeffrey Bland, who's the father of functional medicine. Extremely high quality, very pure, really important to get the right one. Next, you want a good quality multivitamin and mineral, cover all the gaps, folate, zinc, magnesium. CoQ10 is also really important for heart health, really supports mitochondria, vascular health, really helps blood pressure, mitochondria. Magnesium, really important. helps to relax your blood vessels, helps with insulin, blood sugar regulation.

25:56Your heart rhythm also is helped by that. I like magnesium glycinate, or if you're constipated, you can use magnesium citrate. There's also plant compounds that work really well. Fiber is great, plant sterols. Also, are there compounds that come from food like soy? Can be very helpful in lowering LDL cholesterol and just balancing your lipids. And you can get fiber as a supplement or just eat more fibrous foods, which I do. Now, I've changed my mind about cholesterol because the science has changed. And the truth is, when we look deeper, when we look at things like inflammation, insulin resistance, ApoB, metabolic health, we actually are finally getting a clear picture of what really causes heart disease.

26:33It ain't cholesterol by itself. It's all these cascading factors. Here's the most important part. By understanding your numbers, by knowing what's going on with your biology, you have the power to change your heart health right now. You're not really at the mercy of your genetics or your numbers. You can understand your biology, you can take charge of it, and sometimes yeah you might need medication but you can regulate everything in such a powerful way using these foundational principles so i'm sure you know someone who's had a heart attack or has heart disease please share with them share with anybody who's worried about their cholesterol who's on a statin the more we understand the whole picture the healthier we're all going to become the better our society is going to be and obviously we're going to lower our health care costs and everybody's going to do better thanks for joining me for office hours i love diving into these topics with you.