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

Dr. Mark Hyman
Welcome to Office Hours. This is our dedicated one on one space to go deeper, get clear, and explore what truly moves the needle for your health. I'm Doctor Mark Hyman, and each week, we're gonna pull back the curtain and share the insights, the research, the lessons that don't always make it into our conversations with guests. Because at the end of the day, you are the CEO of 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. 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. We'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, ain't true. And we know what happened with that, with snack book 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 onto, 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 wanna talk about something I've changed my mind about over the years, cholesterol and heart disease.

Now heart disease is the number one killer of Americans since the nineteen fifties, and yet so many are still approaching it with the same outdated framework that we used for decades. Now for a long time, cholesterol was seen as the enemy. You gotta get it as low as possible. You gotta avoid fat. You gotta 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 APO B, which is far more important than all the other cholesterol tests, and Lp, most people don't check, which is highly important genetic marker. So you gotta know your numbers, but you gotta know the right numbers.

So doctors check your old cholesterol number. They see your LDL's 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. Now 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. So 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 Then. There was a study of like one hundred and thirty six thousand people who had heart attacks, went to the ER, and seventy five percent had a 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 it as low as possible.

We also learned that saturated fat is bad because it can raise your cholesterol, particularly LDL cholesterol. So the message was 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 thirty or forty years, you really don't know that much, and how everybody's different, and there's not the the simplicity that we think applies to certain things, LDL, heart disease, statin, cure.

It's just not so simple. We've treated cholesterol like a villain, but the truth is really way more nuanced. Alright. 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 fifty percent, 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 in 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.

And you know what they said? Less than 1%. 1% of their tests do this. The second big that came actually, since I graduated from medical school, probably in the late 1990s, maybe early 2000s, was the insight, purely from Harvard and the scientist Paul Ricker, 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. Even 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 caused 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? And 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 ten percent. 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 this 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, and that means your cells don't respond to insulin, so you need 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 atherogenesis means plaque. Atherosclerotic vascular disease hardening the arteries, whatever you wanna call it, clogs in your arteries from plaque and cholesterol deposits. That is caused by these small dense cholesterol particles. It's not the cholesterol itself. It's when they're 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. There are different types of LDL. There's large, there's medium, and there's small sizes, 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, one thirty. And that just means the weight of your cholesterol.

But it doesn't tell you how many LDL particles that is made up of. It could be a thousand small particles or it could be a 100 large particles. But you don't know that unless you do the right test. And that's really, again, why we did function help. 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. And and 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 Endo 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. It's it's the metabolic dysfunction that affects ninety three percent of the population that's causing this heart attack epidemic.

So it's 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 disease?

Now one of the of the friends of mine sent me this this email. He's an older guy, he's like 78, 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, is interesting. 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 forty years. Probably thirty plus years. And this is called ApoB. 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 thirty years, guys. Finally recognized ApoB is a causal factor for heart disease. It's not just associated with it.

And the beautiful thing about it, you can do the lipoprotein fractionation, which is important. I think it's also important to track ApoB, and we do that with Function Health. This 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 twenty percent of the population, have an elevation in this particular number.

It'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 don't smoke, gotta exercise, Don't eat sugar, starch, get rid of belly fat.

Get your cholesterol other cholesterol numbers optimized through a whole set of different interventions we're gonna 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, and it's it's especially worse if your cholesterol is abnormal. Medication's 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 no. They're not so bad if you eat the little small ones. Anything that's 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, I 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 kinda went crazy, and I had, you know, wine, and I had lots of pasta and whatever, bread, and I gained, like, five or 10 pounds, and it went right to my belly. And 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, ninety three point two percent 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 six point eight percent 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 I kinda wanna just touch base this for a minute, and 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 one hundred and thirty six thousand 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. Seventy five percent 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. Your 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 five to one. 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. 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. The main reason, the main reason, sugar. I mean, I know it sound 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 a 152 pounds of sugar, a 133 pounds of flour a year. That's almost a 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 are 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. But 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.

HSCRP, we talked about. Ferritin, something that is can go up in certain people, particularly if you have severe and some resistance. IL-one, 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 on 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, 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.

Really important. And large studies have shown this. Large meta 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. They looked at blood levels of fats. They looked at dietary intake. And it was really quite an extensive study. And they could show no correlation at all with saturated fat.

Trans fat, for sure, increased the risk. That's hydrogenated fat. And omega three fats lowered it a little bit. The saturated fat were neutral. Now 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 it what matters most to check for you now is something called apolipoprotein b or apo b, 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. Again, asked a question.

How many tests that you get from doctors around the country include insulin? Took 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. Other The thing I mentioned, you wanna look at triglyceride to HL ratio. That's your triglycerides HL should be one to one or or even less. And then there's a really easy test. It's the tape measure test.

You basically get a tape measure, and you remember measuring around your fattest part of your belly, and if it's too much fat there, and you're not your waist isn't good, you're in trouble. And there there are some benchmark numbers we can give you, but basically you know if you got that in there. Just or you could use a mirror test so 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, all those things are critical. Those matter. What mattered in 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. And 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 a one c. They're not checking your blood sugar.

They're not looking at some resistance scores. They're not looking at triglyceride ratio. They're not looking at HSCRP. They'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 doctors, 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 toffee. Then 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. So twenty percent 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 seventy five percent of Americans are overweight.

When we check their blood tests, ninety three percent of Americans have poor metabolic health, meaning they're insulin resistant. That's the twenty percent 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.

And and 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, I eat a orange, it's fine. But if I eat a 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 a much better predictor of heart disease risk than just a static blood sugar. Alright. So what can you do about this today?

First thing you do is get the right test. Tests don't guess. You 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 wanna know your triglyceride and HDL ratio. And also, would really recommend a lipoprotein fractionation. It's 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, very safe. And you get a quick idea of whether or not you have plaque development, and then you can manage it. Because 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? It's not like if you have high blood sugar, really you know you have diabetes. That's pretty black and white. But 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 to actually image to figure out what's going on. When you test, you have to remember you wanna track your trends over time, not just one point in time. And that's what's so beautiful about a function membership is every year, a 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, you can change things, you can adjust your diet, lifestyle, see what changes happen. And and that really helps you manage things. So you gotta really understand what you're doing in order to manage it. I think some investor dude said, you know, what what gets measured gets managed. So if you don't measure, you can't manage it.

The second thing you want to do is 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 three fats. Get 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, know, work on your lifestyle. Exercise, building muscle. Really important. Was in the gym this morning for an hour. It was really painful.

My trainer was crushing me, but I know it's helping me. And it helps to build muscle. It helps lower APOB. It corrects insulin resistance to your muscles to become a better sync. 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 just keep going moving throughout the day.

Get your steps in. Now what about supplements? Well, I wanna 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 need to 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 be 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 three fish oil, the lower triglycerides, and inflammation, and your blood blood pressure. I recommend Omega three Rejuvenate by Big Bold Health. I'm an investor in the company, transparently. It's started by my mentor, Jeffrey Bland, who's a father of functional medicine. Extremely high quality, very pure, really important to get the right one.

Next, you want a good quality multivitamin mineral, Cover all the gaps, folate, zinc, magnesium. Co q ten is also really important for heart health. Really supports mitochondria, vascular health. Really helps blood pressure and mitochondria. Magnesium, really important.

Helps relax your blood vessels. Helps with insulin, blood sugar regulation. Your 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 other compounds that come from food like soy. Be very helpful in lowering LDL cholesterol and just balancing your lipids. And you can get, you know, 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. It 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 it 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 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. Remember, you are the CEO of your own health, and every choice you make can move you closer to healing and vitality. I wanna keep these episodes as relevant and useful as possible. So tell me, what do you want to explore next? What questions are you wrestling with?

What breakthroughs are you chasing? Share your ideas in the comments on social media or through the link in the show notes. I'm listening. Until next time, keep taking charge, keep asking questions, and keep showing up for your health.

Dr. Mark Hyman
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