Key Heart Health Tests Unveiled

Joel Kahn, MD, FACC

Sure. And I’d certainly encourage people. You know, a big theme in this summit is natural approaches and nutrition, G-BOMBS, Nutritarian Diet but get some numbers at baseline and do your own study. And you know what we’re going to talk about right now, repeat them in two to three months. We just had a great study published on twins looking over just eight weeks and they picked twins. So they kind of eliminated genetic differences and put them on a whole food plant diet for just two months. Keep them on a healthy version of a standard diet for two months. And boy did the measures of inflammation and cholesterol and insulin use and all improve so much of the plant-based diet. So if you don’t know what the tests are, you won’t be able to do that kind of study in your own health. So that’s what we’re talking about. So, yeah, one of those numbers you have to know it’s on the standard American Heart Association language. You got to know your cholesterol numbers. And in the old days, we demanded people have a fasting cholesterol. Actually, things like the American Medical Association have indicated just to get the lab work done. If you can show up fasting, fine but it’s a value to actually have your cholesterol numbers done when you’ve eaten, because if they’re crazy, either you’re eating the wrong food or you’ve got some metabolic problem and you might come back and repeat them fasting. But something’s going wrong. 

So know your total cholesterol, your HDL cholesterol, your LDL cholesterol, and your triglycerides. And then you can, if you want, calculate something called the non-HDL cholesterol. This is really simple. But if you go to total cholesterol, let’s say it’s 200. And let’s say your HDL is 50, 200 minus 50 is 150. That’s your non-HDL cholesterol. That actually gives some insight into many studies. It’s actually a little better way to look at it. It’s not the best way, but it’s a little better way to look at it. And you don’t need to do that fasting at all. So, you know, again, we’ve got fancy methods. We’ll talk about those probably in a minute, but at least do the basics, you know, and have a home blood pressure cuff and have a scale. And we got to have some numbers. There’s kind of a trend in medicine called precision medicine where we can actually measure things accurately. But I’m all for just getting the basics done, too, because such a large portion of the population has been without a cholesterol profile for too long.

Joel Fuhrman, MD

Right. So when do you need the advanced lipid profiles then?

Joel Kahn, MD, FACC

Yeah. And there are tests called advanced lipid profiles. One version of that people may have heard of is called the NMR Light Bulb Profile, NMR. There’s another one called Apolipoprotein B (ApoB). But there are some studies two big ones that I’m familiar with where they compared the standard cholesterol profile to these advanced cholesterol profiles. They’ve really come down in price to maybe $30, $35, and your local lab or your local hospital will run these. You ask your doctor for them but particularly if you’re overweight, pre-diabetic, or diabetic, you can have two people with an LDL cholesterol of 120, which I would not consider ideal but it’s not shocking and alarming. And when you do the advanced lipid profile in people overweight, pre-diabetic, or diabetic, which is about three-quarters of all Americans and many people in other Western countries. The advanced cholesterol profile, the NMR cholesterol profile reveals a pathology that the standard profile didn’t show. So two people with an LDL cholesterol of 120 and you do the advanced profile one person the particles are just crazy high particularly when called LDLP or LDL particle number and you will have a clue that you need to work harder with that patient on their weight loss, exercise, nutrition and if needed supplements and prescription drugs. And if you just set the standard profile you might not have identified all that. And the interesting thing is when you do these advanced cholesterol panels they actually respond to lifestyle almost better than prescription drugs. So if you get busy with all that we’re learning at this summit, you can see within four weeks, eight weeks to 12 weeks significant improvements in the advanced lipid profiles.

Joel Fuhrman, MD

So it sounds like you’re saying that if you’re eating real healthy, in great shape, slim on a super healthy diet and your LDL is favorable, let’s say, below 100, then you wouldn’t need an advanced lipid profile. But if you have these questionable LDL of between like 101 and 130,  and your diet and your lifestyle are not perfect, maybe you should look into further what your risk really is. It is reflected by your LDL and you would consider the advanced lipid profile.

Joel Kahn, MD, FACC

Well said. Yes.

Joel Fuhrman, MD

What about like inflammation tests, like HSE or PE or myopia oxidase, things like that?

Joel Kahn, MD, FACC

Yeah, inflammation. You know, you can’t sit through a medical lecture today on heart disease, brain disease, cancer disease, and obesity without hearing the word inflammation. The middle word is flame, fire, and irritation. And this is a concept that goes back at least 150 years in medical science and pathology. In reality, we can’t look in our arteries and see if there are white cells invading our arteries that would be a sign of inflammation. We have to do it for blood work and the most famous blood test to evaluate, and now we’re talking about going beyond just your blood pressure, your blood cholesterol, your blood glucose, and your scale into diving deeper to understand, are you at risk? You want to stay healthy. You want to have a youthful appearance, youthful energy, and youthful arteries. You better judge your inflammation. So high sensitivity, C-reactive protein. And just in contrast, decades ago when people were evaluating for like strep fever and rheumatic heart disease, there was a test called the CRP, C-reactive protein. But now we specify HSCRP, high sensitivity, and that’s more of a cardiovascular test than it is for just arthritis and other conditions that affect the human body. And there are thousands of studies that say it’s at least as important to measure HSC-reactive protein as it is to get that cholesterol panel, the basic or the advanced. And a few studies actually say it’s even more important to measure it. And then if it’s elevated, it’s taken the last 10 to 20 years to answer the question. If you find out you have inflammation and you can figure out how to lower it with an anti-inflammatory diet like yours, the Nutritarian Diet. Drop some weight, get in the gym, manage your sleep and you can get your C-reactive protein down you actually lower your chance of strokes and heart attacks and bypass and stents and dying. So this is a very important number nowadays. Now, if you’re in an advanced clinic, there are actually four or five other inflammation tests. But again, I want to just hit a quick little note of importance here. At least get one, the high-sensitivity C-reactive protein, the others are called MPO, Lp-PLA2, oxidized LDL, and TMAO. So there are other inflammation tests. But ask your doctor, they will be able to order you HSCRP or order yourself online.

Joel Fuhrman, MD

Sounds good. And then you have other types of risk that people have, like their insulin resistance to gaining weight or their poor diet or their homocysteine, might be a little bit less. I think the insulin resistance we might have talked about just maybe touched on that. But go into more detail on homocysteine for sure.

Joel Kahn, MD, FACC

For sure. And what we’re talking about, if people come into my office where we have a consult, I show them a picture that I actually took out of a medical journal maybe 12 years ago that shows an artery full of plaque and there are daggers all through the artery and actually there are about 17 daggers. And I’ve added about 10 additional ones. So your is thinking about smoking high cholesterol, high blood pressure, diabetes, and your family history. These daggers add about 20 more causes of atherosclerosis. It gets a little complex but do not get frustrated this is very well-known stuff, almost 16 is one of the daggers in this picture I have even from 12 to 15 years ago. It’s an amino acid that the body makes in a cycle. The cycle has a fancy word called the methylation cycle. And if your diet’s off particularly too much meat, if your vitamins are off, particularly you’re missing B12 and folate, something you don’t perform and teach people to pay attention to. Folate comes from leafy green foliage, so plant-based eaters should be getting plenty of folate, but B12 can be an issue. So if you’re low in B12, low in folate, and the third input is your genetics, you could inherit a problem metabolizing homocysteine from one or both parents, and that’s a very easily testable blood test called your MPHR blood status. But your homocysteine may be very high and homocysteine damages that endothelium, that inner lining of arteries. Homocysteine is associated with strokes and heart attacks, erectile dysfunction, and may be shortened lifespan. There are actually thousands of articles about homocysteine and the most important thing to bring up about it, it’s an easy blood test. You go to your doctor and say, or you order it yourself online, which is not widely available. I want to know my homocysteine and I care if it’s seven or 27. 27 would be way outside the norm. It responds very well to eliminating the red meat in your diet. You can’t alter your genetics but taking adequate B12 and folate. And then it comes down. And then if you retest the arteries, they look healthier. So homocysteine may not be as important as whether you smoke or not or whether your cholesterol is 300 versus 150. But it’s pretty high up on the list and it’s treatable and modifiable. So we should be teaching more about how to identify and lower your homocysteine level.

Joel Fuhrman, MD

Right. So usually a homocysteine above 15 is more of a concern, correct?

Joel Kahn, MD, FACC

I agree. I don’t get too excited around 11, 12, or 13, even though maybe the ideal one is under eight in your blood work. But boy, when I see 27 or 32, maybe 5 to 10% of the population, we can fix that and that’s always what we’re dealing with. We can fix it with diet, but we’re probably going to need a B-complex vitamin.

Joel Fuhrman, MD

So what I usually do is if the person’s homocysteine is elevated, they’re eating healthfully and they’re presumably eating it a full in their diet, then I’m going to evaluate the B12. Well, maybe even MMA to see the Methylmalonic Acid and see if the person needs more B12 and then maybe at that point check for the MTHFR, MTHFR deficiency, or a genetic defect where they would need to need to take some type of metafolic, not to just take folic acid but actually take metafolic because we’re showing and genetically they need that to get their homocysteine down. But in my history, I’ve had people who are like fanatical vegans who didn’t believe in supplements, who didn’t take B12. Like T C Fry, who passed away of B12 deficiency and I saw his blood test. His B12 was total and in the hospital was almost nonexistent but his homocysteine was super high. And he’s on a vegan diet, a vegan whole-food diet. The guy has heart disease with no B12, with taking no B12. I had two people actually came to my practice with advanced heart disease on vegan diets with severe B12 deficiency that still refused to take B12 for some reason. They were so fanatical that, but in any case, certainly it’s an important point in the homocysteine can be a sign of B12 deficiency, as can an elevated homocysteine, as can an elevated MMA. MMA is Methylmalonic Acid which also rises in B12 deficiency.

Joel Kahn, MD, FACC

Right. Well, I think you and I practice very similarly, and that’s exactly how I approach it.

Joel Fuhrman, MD

You know? Good. All right. Well, and what about, do you evaluate insulin resistance or do you just assume the person is overweight and you talk about it with them?

Joel Kahn, MD, FACC

Yeah. And, you know, insulin resistance comes up all the time when people are watching YouTube and listening to health experts. It is measurable. If you get a fasting insulin and it’s very high, you probably are insulin resistant. You might be pre-diabetic, you might be a Type 2 diabetic, and you know you’re not going to be a Type 1 diabetic because Type 1 doesn’t make insulin to any measurable amount unless they’re injecting. There is, for example, QuestLab, a big lab in this country that does something called the insulin resistance score. You got to be fasting. You want to be under 33 out of 100 and some of the other labs do something called the Homa. Homa, it’s a calculated number. So, yes, you can measure insulin resistance in clinical practice in an inexpensive way and you want to correct it, you want to improve it. Whole food plant-based diets and weight control and exercise are consistently excellent at improving insulin resistance. So that little molecule brings your sugar down quickly and efficiently and doesn’t have to overwork and burn your pancreas out.

Joel Fuhrman, MD

Well, isn’t insulin resistance like what would be just a body fat number or body fat percent with the body part percent pretty much accurately determining insulin resistance as well? But only a person who is low in body fat.

Joel Kahn, MD, FACC

It’s certainly correlated. There’s no doubt if we grabbed 100 people with a waistline over 40 inches and a hundred people with a waistline of 32 inches of middle-aged men, we’re going to find much more insulin resistance. And that’s why some people do a waist-hip ratio or just talk about pant size or, talk about your BMI or get a DEXA scan and actually measure how much visceral fat you have. They’re all going to correlate with insulin resistance. There might be a few exceptions for somebody.

Joel Fuhrman, MD

The constant of symptoms, right? High blood pressure, lipids, insulin resistance, overweight, eating poorly. They will just call those risks are pretty much wrapped onto each other, right? Yeah. All right. Well, let’s pause here again. Thank everybody for joining us for this summit. And we’re going to pause here and move on for the people that want the advanced package. And if you could look below. If you want to join us for that further questions here with Dr. Kahn just go a little further.

Joel Kahn, MD, FACC

Yes, I’ll be great.

Joel Fuhrman, MD

Okay. Thanks, everybody. And thank you guys for being part of this summit. And Dr. Kahn, let’s move on a little bit further here like you mentioned it briefly, but I want you to give a much more thorough explanation of TMAO and how strong the risk is that for heart disease, and how do people control their TMAO.

Joel Kahn, MD, FACC

Oh, yeah. We know doctors love abbreviations and names and TMAO is another one to write down trimethylamine N-oxide. Nobody’s going to be tested on that. Something that was rarely ever talked about before. 2011, when a research group at the Cleveland Clinic, led by a cardiologist, identified that they had developed a blood test and they could measure this. It’s called a metabolite part of your metabolism in the blood. And people with clogged arteries had higher levels and people with clean arteries had lower levels in the Cleveland Clinic. And then they went to the basic science lab and found out some fascinating findings that we make a lot of TMAO when we eat a lot of egg yolk. There’s something in egg yolk called choline and we all need a little bit but we don’t need too much that chicken egg yolk. And when you eat a lot of red meat, there’s something called carnitine, which is pretty much exclusive, not completely, but pretty much the red meat. And you make a lot of TMAO and then if you change your diet, it comes down. Or if you eat vegan, it isn’t there to any high level at all. They show that TMAO isn’t just a blood marker, but actually seems to cause hardening of the arteries, seems to cause inflammation, seems to damage kidneys, and cause fibrosis. So they’re from that first paper are now thousands of research papers that TMAO predicts and probably causes disease. And I think it was around 2015, maybe 2016, that QuestLab introduced the ability for any clinician to order at a TMAO level on a patient. I’ve ordered thousands and thousands and thousands of them. And, you know, you pretty much confirm what I just said. You see a meat eater or an egg eater, the other thing is some people take supplements with a high dose of choline and a high dose of l-carnitine. And you can see in all those settings that super high double levels. It is really amazing physiology because you just bring them back in three or four weeks and they change your diet or they reduce or eliminate their supplements. But work with your health care provider when you’re doing these things and the level comes down very quickly, it’s very quick physiology. So there is no.

Joel Fuhrman, MD

What does it stand for, again? The TMAO. What does it stand for?

Joel Kahn, MD, FACC

Trimethylamine N-oxide. I mean it’s really cool. You eat, and then the science, you eat an egg yolk full of choline, eat a steak full of l-carnitine it gets in your intestines and on the border of your wall there’s an enzyme and there are bacteria involved. And we believe the bacterial mix of a vegan is different than the bacterial mix of your average American meat eater. And we just don’t have that bacteria to any degree that a meat eater does. Anyway, it gets converted, the choline and the l-carnitine into a little molecule, it gets into the bloodstream called TMA, then it gets the liver and it shows up finally in the bloodstream as TMAO, a Trimethylamine N-oxide. So of course, in the modern medical world, the Cleveland Clinic is working on things that are patentable that could help. This could be a drug and such there’s done out to this date. The Mediterranean diet has been shown to bring it down. And better than that, you know, is going to be a whole food plant-based diet that will really bring it down and check your supplements even monster energy drink a lot of people pull in the gas station young people, but not exclusively. You’ll see the first ingredient in a monster energy drink and some of the others are l-carnitine. And it could be shooting your TMAO up.

Joel Fuhrman, MD

It helps explain why some people even eating animal products, even if they’re watching the fat intake or saturated fat, they’re eating low-fat animal products, just the protein component, the choline, and the carnitine could still drive TMAO high, and still, obviously, you’re producing heart disease irrespective of your cholesterol level. You know, even if your cholesterol is not bad, you can still produce significant heart disease from the meat intake of these animal proteins, right?

Joel Kahn, MD, FACC

Yeah. We’re all about trying to give people natural approaches to their heart disease, identifying it, and reversing it. And people don’t understand that, wow, there’s that diet-heart connection and it’s testable and TMAO is just one part of what you test for, like the homocysteine and the insulin resistance. But again, it’s important because it’s easily modifiable. We can fix it. We can make it better either all the way to normal less than 6.3, I think, or nearly all the way to normal, and might just be a small dietary or supplement transition.

Joel Fuhrman, MD

All right. Thank you, Dr. Kahn, and thank all of you for joining us. We hope you benefit from this in-depth discussion and stay tuned for obviously more informative and important information that’s applicable to your life that can protect your future health. So, we look forward to seeing you in the next episode.