Cholesterol: Natural Management Strategies

Joel Kahn, MD, FACC

You know, big controversy, people that are listening to this summit in our online, on Twitter and YouTube. I mean, you can pick any health practitioner and you’ll find different topics. I mean, I have a book in my office called The Great Cholesterol Myth by cardiologists trying to teach the public it doesn’t matter. I think very often what’s missing is one word and that cholesterol is a risk factor, not the risk factor. And what I mean by that is there are unfortunately exceptions, there are people that have high cholesterols, and we can measure it as total cholesterol. We can measure it as LDL cholesterol. We can do an advanced panel called the LDL particle number cholesterol and then we’ve got HDL triglycerides. And we’ll bring up one other genetic cholesterol lipoprotein in a minute. But we can measure and we will find some people that have high cholesterol and they seem to be doing well and they seem not to have much plaque and they seem to actually have a good lifespan. That doesn’t throw away hundreds and hundreds and hundreds of studies that say there’s clearly a relationship that if your blood cholesterol is high you are at more risk. And we’ve talked, you and I, about how you pick out silent atherosclerosis. All those studies show the higher your LDL cholesterol, the more likely you are to have significant silent atherosclerosis.

So don’t throw the data away just because there’s one exception to the rule. There always are exceptions in medicine to the rule. At times there are smokers that don’t get lung cancer. But the bottom line is when you look at an artery that’s causing a heart attack, a stroke, erectile dysfunction, or blood circulation. There’s cholesterol in there so it’s pretty hard to debate. If you had less cholesterol in the artery you would have better blood flow, feel better, and maybe have a longer lifespan. And decades of science say a risk factor is elevated cholesterol. And then we know that there are, I trained in Dallas where we had a genetic cholesterol program. Even when I was there in the 1980s, training in cardiology. And we saw kids that were nine years old with cholesterol of a thousand. Genetics are important and we have to always ask the question and it’s getting easier to be tested. Do I have high cholesterol because of my genes from my parents? 

But putting that aside, because maybe that’s one person out of 250, but that leaves 249 other people. They can’t necessarily blame their parents for their high cholesterol. That’s called Heterozygous familial hypercholesterolemia. It’s our lifestyle, it’s our diet, it’s our stress, it’s our weight, it’s our lack of exercise, it’s our poor sleep and our cholesterol is up. We have this huge opportunity to avoid getting on prescription medication and reducing or eliminating prescription medication by adopting a healthy lifestyle. One of the seminal pieces of data that is so easy to teach patients, in my experience, is your friend and my friend. I think we can say that Dr. David Jenkins, M.D., in Toronto. Who asked the question 25 years ago, if we add foods to an average citizen’s diet in Toronto, foods that are known to lower cholesterol and we put them together, he called it a portfolio, kind of a package. Can we really achieve a lower cholesterol just with foods? And he used soy-based foods like tofu and he uses nuts and seeds. Two of my favorite foods on the planet and he used high-fiber foods like oats.

Joel Fuhrman, MD

Just about like Nutritarian Diet.

Joel Kahn, MD, FACC

That was very close to the Nutritarian Diet

Joel Fuhrman, MD

It was just like the Nutritarian Diet.

Joel Kahn, MD, FACC

He published a paper too and the portfolio diet showing within a short period of time maybe a 25% drop in LDL cholesterol in an average Toronto volunteer citizen. But he didn’t have the power to study those people long-term. And a lot of people have never heard of the portfolio diet and there are very few books written on it. There are some nice websites that discuss it, but just recently the Harvard School of Public Health has grabbed onto the portfolio diet and they’ve studied their database of hundreds of thousands of people. And if you follow a Nutritarian Style Diet or in these publications’ portfolio style diet you have less heart attacks, you have less strokes, and you have less bypass surgeries because they have the numbers in the power to follow people. So we may never get a randomized study of the portfolio of diet versus some other substandard average diet. We don’t need that study. We’ve got all the data and these recent Harvard School of Public Health Studies have really elevated the portfolio diet. 

But we can actually ask the question, did we really need that? We had your data on whole food plant diet, and nutrient-rich foods. Yes, you can. Absolutely. Except for these few people with genetic disorders. One out of 250, you can very quickly, I’m sure, in your clinic in San Diego in three or four weeks but even in the clinical practice where people aren’t staying in. Change your diet, and repeat the blood work. I mean, Rip Esselstyn did it with firefighters within seven days that their cholesterol fell significantly by providing them healthy foods like bean chilies and lentil soups instead of typical firefighter food. But we see it in practice all the time, and for a lot of people, that’s all they need. They will get their numbers down to a pleasing level where they do not need prescription drugs. My standard statement in most patients is We’ll start the drugs in two or three months, but I hope I don’t need to. I want you to try and do this with food alone. And of course, throwing in fitness and stress management would help. 

And those are the really the key foods, you know what I mean? Garlic has a special role but G-BOMBS will do an amazing job. Fiber, fiber, rich foods and it will come down. You know, we’re just poisoning ourselves with the Western diet. We hear that over and over. But it’s so true, you know, it doesn’t matter. Yeah, we know it matters. We know that over time. I was involved in a research study that was published in 2012. Some people are born and their LDL cholesterol is a few points lower than average Americans because of their genetic input from their parents called Snips. And some people have an LDL cholesterol just a little higher than average. And you can do these kinds of genetic studies. Now, they’re called Mendelian randomization. And we did this over time. And people that even if you modestly lower your blood pressure, modestly lower your cholesterol, you see a significant difference. It’s far more powerful than drugs particularly if you start early in life. If you start in your teens, 20s, or 30s, raise your kids on a Nutritarian Diet You’re going to provide disease-resistant kids, if not disease-proof kids, as they get older. So it is a function of time. 

The only challenge to add is that there has been data that when you’re five years old or three years old or an infant, your LDL cholesterol may be hanging around 25 to 30. And that’s really important to know because the skeptics will say, Dr. Kahn, how can you lower this patient’s LDL cholesterol to 40 with lifestyle, diet, and sometimes if needed prescription drugs. Isn’t that bad for them, for their brain? And we say, but during the period that children are growing, the fastest in their brains, are developing their LDL cholesterol is often well below 50 in all. So we have now seen that if you really want to accelerate that juvenile plaque that’s soft, black, let’s try and get our cholesterol levels back like when we were children before all the stresses and the processed food and the weight gain and the artery damage starts to set in. And so the challenge is, can we hit low enough goals with diet alone? And there are people that can and absolutely and then those that don’t we have a huge armamentarium of drugs nowadays and usually can use very low doses safely and without side effects. If they combine a real effort at the Nutritarian Diet and exercise, and then just a little whiff of medication to hit these low numbers, then we can really, really reverse atherosclerosis even more rapidly with that dual approach in certain people.

Joel Fuhrman, MD

And let me reiterate because you mentioned G-BOMBS and I just want to make the point because maybe someone doesn’t know that G-BOMBS stands for Greens, Beans, Onions, Mushrooms, Berries, and Seeds Six foods that let’s say what they do, they lower cholesterol, they lower blood glucose, they reverse diabetes, they lower blood pressure and they lower cholesterol and they prevent cancer. And they work synergistically there in each individual who is powerful enough to do those things alone but when you put a dietary portfolio together that includes all those foods in them all the G-BOMBS, the magic happens. And you get dramatic benefits against cancer, against blood pressure, against cholesterol, against stroke, against heart disease, and against aging. So that’s the key, is to put the right foods into your body. And when you do everything right with the salt out of it, the magic happens. The common man Olympians from the Amazon tribe separate civilizations. They don’t salt their food and their toddlers have the same blood pressure as the teenagers. In this country, teenagers have higher blood pressure than toddlers. In natural populations toddlers at the same blood pressure as teenagers, and the same as middle-aged and elderly. They don’t see the blood pressure rising as people age like they do in this country. It’s not because we think aging causes the damage where it was, Dr. Kahn was saying it’s the long-standing chronic exposure to causes that causes more damage as you age, not aging per se. You could reverse things as you age if you do all the right things.

Joel Kahn, MD, FACC

Absolutely. Now, some people, you know, will not go the full way with their diet or they will and they don’t respond as completely as we judge they need. And there is a role for supplements. I mean, you know, prescription drugs we can use. We probably need to sign into a different summit to talk about that one but you know, there is a role for supplements added to your lifestyle and there’s plenty of science. I probably reach a little bit more than others for red yeast rice. I worry a little bit about the quality of the supplement I’m suggesting to a patient but there are many, many research studies, some as big as 5000 people put on red yeast rice, which is a tablet or a capsule, and it can lower LDL cholesterol. It has an action that’s a bit like a statin-like Lipitor. And so you do have to watch a little bit for muscle aching and liver enzyme problems, even though it’s a supplement. But sometimes that’s a little tweak on top of the diet that works. We mentioned a few times Coenzyme Q10, probably the most science-based supplement in the cardiac portfolio can lower LDL and total cholesterol. Niacin is a supplement, vitamin B three. It’s inexpensive and since the 1960s was actually very popular in the 1960s, lower cholesterol. Well, in the last decade, certainly in standard cardiology clinics, it’s gotten less commonly used. I still use it. Maybe after the break, we’ll talk about lipoprotein(a). And I still use niacin, as do other clinics and see like.

Joel Fuhrman, MD

I use sterols. I use plant sterols. 

Joel Kahn, MD, FACC

I was going to bring that but of course, eating seeds is a natural source of plant sterols. But then you can purchase supplements that have higher amounts of plant sterols that will lower your total and LDL cholesterol. And there are others, bergamot, berberine so working with somebody that knows their supplements or doing your research and reading, Dr. Fuhrman,    Dr. Kahn, drjoelkahn.com sites. You know, you might be able, but again, work with your health care practitioner. Dr. Fuhrman and I don’t know the details of your health as we’re putting this conversation together. And as I say, some of my sickest heart patients just really need aggressive control. The goal is in six months to reduce and get off of medication but we might have to start up early on with medication. That’s standard cardiology nowadays, you are in the hospital with a heart attack. You go home on the highest-dose statin made in America. And the real data was that that may actually help people for 30 days but I see people a year later and there’s nobody ever reconsidered, dropped the dose, taught them alternatives, talked about nutrition. So work with your health care practitioner don’t go wild with throwing all your pills out but constantly ask the question, is there anything else I can do? Or do your own research. Read The End of Heart Disease by Dr. Joel Fuhrman and I’ll flash this up I’ve got a book called The Plant-Based Solution that kind of goes through our food-based and supplement-based ways to improve your cholesterol. So cholesterol does matter for a lot of people. 

Last statement you and I discussed something called silent atherosclerosis in a different segment of this summit. And I just throw this out, American medicine, you are a 45-year-old woman and your cholesterol is 230. The doctor may reach right for the prescription pad and write you a prescription for Lipitor or Crestor. And you may be on that drug for decades. In 2007, a group of doctors got together and actually questioned that these were academic doctors. It was called the shapes inside and said, we’re putting people on medication for life some of them don’t have atherosclerosis and they may never get it that just doesn’t make sense. So they suggested back in 2007, take that woman, and do a carotid ultrasound. If that CIMT is as clean as can be and youthful, probably there’s no justification for prescription drugs. And as we learned a little bit more, they added the calcium score to the equation. And it now is a statement by the American Heart Association. If you have a calcium score of zero discuss with your doctor that you don’t even qualify for prescription medication. So it’s gone from the Shape Society hypothesis to enough data that testing for silent atherosclerosis and passing the tests that you don’t have it, is a very scientifically justifiable way to work with your nutrition, work with your fitness, work with the supplements we talk about work or the portfolio diet work or Nutritarian Diet and don’t rush to prescription meds. On the one hand, we have somebody that just got discharged from the hospital with a heart attack, and on the other hand, we have somebody that has lots of time to improve their numbers using all the methods we talked about, mainly food-based.

Joel Fuhrman, MD

Sounds good. All right. Well, thanks, everybody, for joining us for this summit. And stay tuned, though, don’t hang up for those of you who have the added package to move on to the next for a little more information, stay tuned we will proceed in just a minute. And those of you who couldn’t otherwise continue to follow and to learn more from the summit and to learn how to use this information in your life so you don’t have to live with fear in your future because fear itself is a risk factor. Just fear is a risk factor. And what this type of lifestyle intervention and way of living and thinking does for people is it gives them confidence, it removes fear, and it makes them live with protection and be able to enjoy their life without emotional distress. So it’s better for you peace, the ability to be peaceful and content with yourself that you know you’re taking good care of your health. So take the best care of yourself and okay, let’s pause here for a second, and then we’ll go on. 

Joel Kahn, MD, FACC

Perfect.

Joel Fuhrman, MD

All right. So we’re talking here about everything people can do. We have to go a little more about two things. One more about lipo a, lipo little a, little more about holiday heart. So people know that when they make these choices to binge or to cheat they could cause a problem that they got it, you know, so that’s food addiction leads to problems that people have. And so we do have a tremendous effect to affect our risk in the short term, not just in the long term. And also let’s continue to give more information about lipo a.

Joel Kahn, MD, FACC

Yeah, we were talking about cholesterol balance and holiday heart, one minute, it’s actually a medical term for people just knocking down particularly too many cocktails, too many wine glasses, and going into fibrillation or some other blood pressure rise. Alcohol is one of those hot topics that it clearly can be attacks and dose-related. And holiday heart is a dose-related toxicity. So if one of your kids is getting married and you want to raise a wine glass for a toast and enjoy it, that’s probably once in a while. Okay. But be aware that the holiday heart syndrome can precipitate abnormalities in heart rhythm particularly. But lipoprotein(a), if we had to redo it, it’s the worst word in the world. It’s also known as lipo a, you mentioned that Dr. Fuhrman, or LP Little a but let’s just spend a couple of minutes. This is an inherited cholesterol. We’ve been talking about cholesterol that, if it was rare, it only be worth maybe one more minute of conversation. But 20 to 25% of people inherit from their mom, their dad, or both the ability to have two factories in their liver. One factory makes LDL cholesterol and we’ve talked about LDL cholesterol. Doctors check LDL cholesterol. You’ve learned some on the summit on how to lower your LDL cholesterol with a portfolio diet or Nutritarian diet basically. 

But 25% of people have a second production line and they make a second cholesterol called lipoprotein(a). I’m going to just show that for a minute because people have a hard time with those word lipoproteins and then there’s a lowercase a. So it’s called lipoprotein(a) or LP(a) tough word to say. And that’s a book that I wrote on the topic two years ago, I think. But 25% of people and what we’ve learned since 1963 is that lipoprotein(a) can be present in the blood at a low level, but in 2020 5% of people can be very high. It’s a simple blood test that all labs do to find out if you’re one of those one in four people, one in five people, but it can cause inflammation. You’ve heard a lot about inflammation in the summit. It can cause atherosclerosis, hardening of the arteries, juvenile and calcified heart clots, and it causes blood clotting. And blood clotting is the final pathway to a lot of strokes and heart attacks. So it can be a nasty particle and just like regular cholesterol. I have plenty of patients that inherited a very high level of lipoprotein(a) and they don’t have bad arteries, and I actually spend most of my time reassuring them. Lifestyle, lifestyle, lifestyle and we checked you in 3 to 5 years but for some people this is the reason they’ve had a bypass, a stroke, or a heart attack. 

And at least recently, less than 1% of doctors draw those blood tests routinely. In Europe, they’re starting to do it more often. In America, I’m starting to see it a little bit more often. QUEST, LabCorp, hospital office, anybody can do it. It can be covered through insurance. It’s inexpensive. Get it done. You can order it online and pay for it yourself if you want to. Because the challenge is as of 2024, we do not have an FDA-approved drug that uniquely lowers this cholesterol. We have Lipitor and Crestor to lower total cholesterol and LDL cholesterol, but we don’t have but within the next couple of years, we do have a whole range of drugs that will be released. They’re all being studied right now. They’re looking very optimistic. But the FDA requires we have to prove that they improve outcomes, strokes, heart attacks, and survival. And the studies will take a little longer. 

Unfortunately, regular cholesterol response, the lifestyle we’ve talked about that this cholesterol very minimally responds to diet changes, exercise and the only supplement that really lowers it is niacin. Niacin used by an experienced health care professional with you can lower your lipoprotein(a) until we get these drugs. In fact, Lipitor, Crestor, and statin-type drugs don’t lower lipoprotein(a) and they sometimes raise it. So when I have patients on statins, I’ll check lipoprotein(a) and sometimes working to get them out a lower dose or even off of statins. I can bring the lipoprotein(a) down and if I can’t, I can use niacin. So it’s an exciting field because I think we will be, if we fast forward three or four years, you’ll see lots of people on prescription medication for lipoprotein(a), and maybe one day we’ll be able to do what’s called gene editing and actually turn off the gene. But don’t get upset if you know you have lipoprotein(a). Get tested, find out if you have a high calcium score, find out if you have an abnormal C, and if you don’t worry too much about it. You don’t have to keep checking the blood test over and over. If it’s normal, just do it once and find out you are normal.

Joel Fuhrman, MD

Especially if you have, like you’re doing everything right and you still have high blood pressure. Things are going looking good, you know. We are actually developing heart disease of the high blood pressure in your past. Know your lipoprotein(a) for sure, right?

Joel Kahn, MD, FACC

Yeah. There’s one other common, lipoprotein(a) which we have hardly talked we’ve talked about heart valves, leaky heart valves, and blocked heart valves. There’s a fairly common condition called aortic stenosis. Your major heart valve and the outflow of the heart have little leaflets and they get thickened and calcified. They don’t open well and you get short of breath and it drives a big surgery or a big catheter procedure to fix it called tavern lipoprotein(a) causes that. And if you go into surgical clinics that are people having surgery and you check their blood, you find a very high frequency of lipoprotein(a). So we have to raise awareness. We have to get tested, and then we got to wait for some solutions to work. Well, when we do this summit in 10 years because you’re getting younger and I’m working on getting under, we will have, you know, wonderful things to say about lipoprotein(a) therapy. It is frustrating that it’s not a very good lifestyle-related conclusion, but if you got lipoprotein(a) inherited and you manage your blood sugar, your insulin resistance, your blood pressure, your cholesterol, your weight, your sleep, get that under control. You’ve done a lot of the work to manage lipoprotein(a), so I’m glad we could bring it out. It’s just a topic that’s so fascinating.

Joel Fuhrman, MD

Yeah. It’s important that we cover all of the major points in a comprehensive fashion. We don’t leave any important points out. It’s a very important point that people should not be ignoring.

Joel Kahn, MD, FACC

Right? Absolutely.

Joel Fuhrman, MD

All right. Well, thank you, Dr. Kahn, and thank you all for joining us at the summit. And we’ll see you in the next session. And please give us your feedback and comments and wishing you all the great health recovery and great health outcomes in your future. We want to hear from you about those things. Thank you. Bye-bye. Thank you, Dr. Kahn.