Ep. 179 – Shocking Facts About Metabolic Health: How to Lower Your Risk of Chronic Illness with Dr. Philip C. Ovadia

Today, I am delighted and honored to be talking to Dr. Philip C. Ovadia. He is a board-certified Cardiac Thoracic Surgeon and Founder of Ovadia Heart Health. His mission is to help people stay off his operating table by optimizing their metabolic health to lower the risk of heart disease and other chronic illnesses.

In this episode, we take a deep dive into clinical medicine. We explain how it is possible to reverse conditions like high blood pressure and type 2 diabetes and become healthy without taking any medications. Dr. Ovadia defines metabolic health, talks about his journey from being morbidly obese to losing more than 100 pounds, discusses Gary Taubes’s influence on his health journey, and his seven principles for health and wellness. We also get into metabolic health markers, the hyper-palatability of processed food, metabolic syndrome, and the metabolic inflexibility of most Americans.

Dr. Ovadia’s approach to nutrition is all about bio-individuality and having enough protein in your diet to ensure satiety. I really enjoy connecting with other western medicine-trained health care professionals who have pivoted towards optimizing metabolic health and flexibility! Stay tuned for more!

“I have come to realize that almost every patient I operate on as a heart surgeon is a failure of the medical system.”

Dr. Philip C. Ovadia

IN THIS EPISODE YOU WILL LEARN:

• Problems that exist within the medical system.
• Dr. Ovadia shares his health journey and talks about his mission.
• Why much of Dr. Ovadia’s current education is coming from non-physicians.
• Dr. Ovadia talks about metabolic health.
• The physical effects of eating hyper-palatable processed foods versus eating nutrient-dense whole foods.
• Take control of what you eat rather than letting food control you.
• What metabolic syndrome is all about.
• The benefits of using a continuous glucose monitor.
• Why no one diet will serve everyone.
• Using metabolic health as a system to guide you to good health.
• The benefits of pushing for nutrient density to feel satiated.

Connect with Cynthia Thurlow

• Follow on Twitter, Instagram & LinkedIn
• Check out Cynthia’s website
• Check Out Dry Farm Wines: www.dryfarmwines.com/cynthiathurlow

About Everyday Wellness Podcast

Welcome to the Everyday Wellness podcast with Cynthia Thurlow! Cynthia is a mom of 2 boys, wife, nurse practitioner, and intermittent fasting and nutrition expert. She has over 20 years experience in emergency medicine and cardiology, but pivoted to focus on food as medicine. She loves to share science-backed practical information to improve your overall well being and is grateful to be interviewing leaders in the health and wellness field.  Her goal with Everyday Wellness is to help her listeners make simple changes to their everyday lives that will result in improved overall wellness and long term health.

Presenter: This is Everyday Wellness, a podcast dedicated to helping you achieve your health, and wellness goals, and provide practical strategies that you can use in your real life. And now, here’s your host, Nurse Practitioner Cynthia Thurlow.

Cynthia: Today, I had the distinct honor to connect with Dr. Philip Ovadia. He’s a board-certified cardiothoracic surgeon and founder of Ovadia Heart Health. We dove deep into clinical medicine, we talked about his own journey where he went from being morbidly obese to losing over hundred pounds and wanting to prevent as many patients ending up on his OR table as possible. We talked a great deal about the influence of Gary Taubes, in his health journey, the degree of metabolic health markers, the hyper palatability of processed food industry, how 88.2% of Americans are metabolically inflexible, the role of antiquated dogma in creating the degree of metabolic and flexibility we see, we dove deep into metabolic syndrome and labs that we need to be asking for.

He also defined some of his seven principles for health and wellness, and then his approach to nutrition is all about bio-individuality, which is certainly very aligned with my own. He really stressed the need for adequate protein intake to promote satiety. So, I hope you will enjoy our conversation. It’s actually a pleasure. I always love connecting with other traditionally Western medicine trained healthcare professionals who have been able to shift their focus optimizing metabolic health and metabolic flexibility in such a beautiful way.

Well, I’m so delighted to have you joining us on Everyday Wellness Podcast. I have a lot of questions on Twitter, in particular, people wanting to know more about how to leverage metabolic health. But I would love for you to talk to us about your journey. I know that the very beginning of your book, you mentioned a particular patient that really made a profound impression on you, and for the benefit of listeners, I was an ER nurse in my past life, and so, I did take care of a lot of very critically sick patients that we were trying to stabilize to send them to surgery. So, you’ve mentioned about a 39-year-old woman who had a dissection and so for anyone that’s listening, this is oftentimes a catastrophic event. Although most of what I saw as an ER nurse were older patients, people in their 70s and 80s, who had never seen a doctor. I trained in inner city Baltimore. So, there were a lot of people that never ever went to their family healthcare professionals, and really only saw care when they were very sick. But to imagine what it must be like as a cardiothoracic surgeon seeing a 39-year-old woman who had young children, and have such a just a profoundly sad outcome, and clearly how much you care about your patient population. I would love for you to kind of talk a little bit about that story because it really did even for myself, it’s very humbling when you realize that sometimes very young patients can get very sick and die of very unfortunate circumstances, but also how that is woven into the way that you look at metabolic health, your own health journey, I think it’s all incredibly impactful and valuable.

Dr. Philip: Sure thing, Cynthia, and it’s great to be here with you, and I think your focus on metabolic health and your background in cardiology is going to be the framework for us to have a very interesting discussion. The vignette that I opened the book with this unfortunate young woman who came in with an aortic dissection, as you said, a devastating medical problem, one of the true surgical emergencies, and no matter how good we are as surgeons and no matter how good all the ER staff and everyone that that patient might come into contact with that problem still has a very high mortality rate. Unfortunately, I am seeing it in patients who are younger and younger.

When I started my career as a heart surgeon, in my training as a heart surgeon about 20 years ago, it was exceedingly unusual for me to operate on patients who were less than 60 years old, even seeing patients in their 50s was considered somewhat unusual at that time. Now, today 20 years later, it is not uncommon that operating on patients in their 40s and even their 30s. What I have come to realize through my professional journey, through my personal journey is that, almost every patient I operate on as a heart surgeon is a failure of the medical system. Most of the problems that we deal with as heart surgeons are preventable and unfortunately the healthcare system has evolved in such a way that we have simply lost sight of that, and we don’t even really think it’s possible to prevent these problems anymore and our focus is on only dealing with the problem to once they occur.

Cynthia: It’s interesting to me because part of my own journey as a practitioner, I was probably had been an NP for 10 years. So, we’re looking at 2010 timeframe and at that time I had two young children and I was trying to find angles with which to connect with patients and whether I was in clinic or whether I was in the hospital seeing patients and I was always trying to bring them back to an area of focus and I kept saying to my colleagues, there’s something that we’re missing because I have patients that we’re defining as vascular pass, meaning, they’ve got cerebrovascular disease, they have cardiovascular disease, they have peripheral vascular disease, they have terrible brittle diabetes, and we just keep throwing more medication, and it’s not getting better. I don’t think it’s a lack of compliance. I think there’s something more at bay here. Many of my colleagues were supportive that I kept talking about nutrition, and food, and how it all starts with food. Then there were a few, more seasoned colleagues that would kind of pat me on the shoulder like, “This is cute, Cynthia. I think it that all starts with food.”

And yet, now we come full circle and we start to recognize if we look more closely at recommendations that we’ve been making to patients about meal frequency, about heart healthy grains, a lot about the lack of regard for stoking our metabolism, not focusing enough on lifestyle medicine. I agree with you. There is a ton of failure on so many levels and I think providers are weary. Most if not all the individuals that I have the honor of being able to connect with across social media and then at meetings and events that I go to, people really want to do what’s best for their patients. They just oftentimes were not given the resources or the education during their programs to really know what they need to be recommending. So, I’m so very grateful that you’re using your platform to be able to speak about this from a different perspective, and I think as a surgeon you get to literally see the interior of people’s bodies and be able to look at the damage that occurs over time, if someone is not cognizant of the cascade of events that occur when our bodies go from being able to use specific types of fuel efficiently to getting to a point in time where the standard mantra that I would say to patients was, “Oh, well, you’re just a certain age now, this is to be expected, you’re losing skeletal muscle mass, your metabolism needs to be stoked.”

Then, the recognition that now a lot of the things that we have said to patients are just incredibly false and could not be farther from the truth. Although, again from good intentions, it’s a lot of the education piece that was really missing. So, I know that your own health journey has had a huge net impact on your desire to really educate your patients, and as you even mentioned in your book, encourage them to put off having surgery to really do the work upfront as opposed to heading direct– and obviously some people don’t have the option of not heading to surgery. But for those who perhaps have a little bit of time where they can make some changes that will have a positive net outcome or not going directly to prescription medication. I would love for you to touch on your own journey because I think, especially, coming from someone that you describe as being metabolically unhealthy to now being at a point in time where you and your wife are really savoring this newfound health that you have been able to embrace.

Dr. Philip: Yeah, sure thing. I want to reiterate a very important point that you made there. I am very critical of the healthcare system. But that is not necessarily a reflection on the individual physicians. The physicians largely are trapped within this system and we only get educated in a certain way, and we only get messaging and ongoing education that reinforces those concepts and I was a perfect example. So, five years ago when I was over a decade into my career as a cardiac surgeon, I was very unhealthy. I was morbidly obese, I was pre-diabetic, and I realized that I was going to end up on my own operating table at some point so to speak. That was with a background of a lifelong struggle with obesity, I was overweight as a child, and it continued to worsen as I went through college and medical school and all my training. That was despite following what are all the mainstream advice, all the recommendations.

I grew up in a household that very much listened to the US Dietary Guidelines. My older brother is a type 1 diabetic. We did not have sugar in the house. We ate all of the low fat, skimmed milk, margarine instead of butter, and we had our healthy whole grains, our sugar free cereals every morning, and as I said, I was very active as well as a child. I was always playing sports and riding my bike so. Then, as I went through my education and I went through school, I, myself, tried the recommendations many times. Eat less, move more, eat a low-fat diet, and I would have some short-term success and lose a little bit of weight, and invariably would end up gaining that weight back and more. And thankfully, about five years ago, I started to get exposed to some alternative ideas, I guess, we can call it. My introduction was really via Gary Taubes and I was fortunate just by happenstance that he was a guest speaker at one of the meetings I was attending and I immediately read his books, Why We Get Fat and The Case Against Sugar at the time, and they made perfect sense to me, and I tried them, eliminated sugar, I went low carb, and I had great personal success for the first time in my life, I was able to lose weight and keep it off.

Now, over five years, I’ve lost over 100 pounds. I’ve maintained that weight loss. I reversed my pre-diabetes, and I think more importantly I was curious enough to ask, “Why didn’t I learn this during medical school? Why wasn’t I hearing this information from the American Heart Association or the US Dietary Guidelines.” Of course, that leads to a lot of different rabbit holes you can head down. But the bottom line is, I was seeing every day patients who were failed by the system. I started to recognize that, and now I am on a mission to get that information to as many people as possible and help people learn how to stay off my operating table. Because as I said earlier, no matter how good I am as a heart surgeon, no matter how good all the other heart surgeons are out there, patients are always better off if they never need the heart surgery in the first place.

Cynthia: No, it’s so very true, and I’ve had the pleasure and the honor to interview Gary and Nina Teicholz and several of the big science writers and always an honor to connect with people like that. I think for each one of us, there’s probably a book or a person that really got the process started. There was a book I read by Robyn O’Brien called The Unhealthy Truth, and that changed the entire trajectory of my career as an NP, ultimately leaving clinical medicine five years ago. So, I applaud you for doing the hard work because it is much, much harder to do the lifestyle piece than it is to take another pill. Unfortunately, I think that’s part of the conditioning that we’ve given our patients is that a pill is going to fix things as opposed to really honing in on the nutrition piece, and stress management, and sleep quality, and being physically active.

Unfortunately, we’ve got a whole generation of individuals that think it’s the latest powder or pill that’s going to solve all their problems. So, I think Gary has probably had a tremendous impact on a whole generation of healthcare professionals and my husband, who’s an engineer, and usually requires a bit of someone like Gary to convince him to move a mountain. So, he just started reading The Case for Keto, his latest book and he’s completely absorbed in it and finds Gary absolutely fascinating.

Dr. Philip: I was just going to say that’s one of the interesting things that I’ve seen along this journey is that much of the information, much of the education that I get is from non-physicians. Unfortunately, again, the healthcare system tends to look down upon the non-physicians and say, they can’t possibly teach you about health. But when you look at the influences of Ivor Cummins and Dave Feldman in this space, and Gary and Nina, as you mentioned they are able to look at these problems without the biases that physicians, I think, and other practitioners come into with and they are able to take that step back and really look at the data and science in a different way and come up with different conclusions that end up making a lot of sense.

Cynthia: I think it’s so important. One of the things I learned growing up with my parents for all the wonderful things that my parents did, they encouraged me to question a lot and my training was much the same way just happened to be, it’s just part of the mantra from where I went to school that you think for yourself, and I think that one of the things that we all need to do and embrace is thoughtfully thinking that perhaps what we know may not be all that there is to know and not having an ego. Putting yourself in a position and saying, I’m just not willing to think outside this degree of cognitive dissonance. I think on many levels, we’re in a time, certainly in my lifetime, where I’ve never seen the degree of cognitive dissonance that I’ve seen over the last several years. So, I think it’s even more important for us as healthcare professionals to be open to the possibility that there might be a fresh perspective on our– in the way that we think about nutrition or cholesterol or any of the really– in many ways, a lot of the dogma that we’re starting to realize we need to really take a fresh perspective on.

Now, when we’re talking about metabolic health and this is a question I ask often of guests, what is your definition of metabolic health? Because this comes up quite a bit. I know the formal definition, if we want to look at, these are the five parameters we need to use. But really looking at where we have gotten off course and the things that or the lenses with which we need to examine metabolic health? Where do you start from when you’re talking with your patients about this?

Dr. Philip: Yeah. What I start with my patients, the simplest concept, the simplest way to explain metabolic health is that when you are metabolically healthy, your body is properly utilizing the inputs that you are giving it and that is mostly in the form of what we eat and when we eat, one of three things ultimately is going to happen to that food. Our body’s turn some of it into energy for immediate use to fuel all of our activities, all of the little cellular activities that are going on within our bodies constantly. Our bodies use that food to build and rebuild our tissues, another process that’s constantly going on, and then we’re supposed to store some of it in case we’re in situations where food, where energy is not immediately available to us.

Unfortunately, for various reasons, mainly the types of foods that we are primarily eating these days, that balance gets thrown off, and we end up storing too much of it, and we can’t even tap into that storage. Both because we rarely are in a situation where food isn’t available and we’re not eating. But even when we are, the hormonal, the cellular environment that’s now predominant doesn’t allow us to tap into those energy stores.

Cynthia: It’s interesting. I did a talk about a week and a half ago, when I was talking about the UNC School of Public Health Study from 2018 that mentioned that 88.2% of Americans were metabolically inflexible and I’m sure that statistic might– would probably be higher now given the last 20 plus months of the pandemic and on so many levels I think that when we’re talking about metabolic health, it’s really the way that our bodies are designed to thrive. I know a lot of the information that I used to give patients about calories in, calories out which makes me cringe. It actually makes me cringe. The recognition that we don’t need to eat frequently to stoke our metabolism in fact it will actually do the opposite effect. The more frequently we’re eating, the more frequently we’re consuming sugar sweetened beverages. There was a really interesting study done recently by Satchin Panda and the input was an app on the phone kind of looking at meal frequency and the bulk of the people in the study were eating at a rate of eight to 10 times a day.

That’s not just sugar sweetened beverages or fatty coffees. That’s the degree of meal frequency that many people think is normal that they have a snack mid-morning after breakfast, and they have a snack in the afternoon, and they have a snack after dinner, and not to mention all the sugary beverages that they’re consuming all day long, which doesn’t allow our bodies to be able to tap into fat stores for energy. We’re just keeping insulin elevated all day long. As I like to remind people insulins not a bad hormone. In fact, it’s great hormone when it’s working properly. But it’s not a hormone, we want to be evoking with a consistent pattern. It should be one or two meals a day, maybe three utmost, four-to-five-hour intervals as opposed to this snacking culture that we have become.

It’s interesting as my business travel started to pick up, I’m starting to observe more behaviors in airports that I’d forgotten about and there’s food everywhere. Before you get on the plane, while you’re on the plane, I actually took a red-eye out to Las Vegas for an event and the gentleman who sat next to me had a not a snack sized, but a full-sized bag of Doritos, and a Fanta orange soda, like 10 o’clock at night. So, technically, really not the red-eye, but close to the red-eye. So, very late flight and I just recall, I thought to myself, there’s just no way that’s going to be good for anyone’s metabolism, anyone’s body to beating a hyper palatable type food late in the evening. So, I’m curious when you’re speaking to your patients and talking to them about food choices, I’m sure the concept of hyper palatable, highly processed foods does come up because this is the other kind of meal frequency, and then I think these hyper palatable foods have really made it challenging for a lot of people to get the nutrients their bodies need and to decrease the frequency with which they’re eating.

Dr. Philip: Yeah, exactly and in my book, I outline seven principles of metabolic health that I work with my patients on, but first and foremost of that is eat real food. I think that ends up having a couple of effects on people. As you said, it eliminates the processed foods, which are hyper palatable and are designed to make us eat more. We should not– the food company hire scientist to design these foods to make them more hungry– to make people more hungry. That is their goal as a food company to sell more food. I don’t necessarily think that’s evil. It just is what it is. Any business is there to increase their profits. The side effect is that it’s going to make people unhealthy, but unfortunately, that’s not a concern of the food industry.

The other, the flip side of that, that I like to emphasize with patients is when you were eating whole real food, when you’re eating nutrient dense foods, it makes you hungry less often. As you said, the standard today is that people eat six to eight times a day. The only time they’re not eating is when they’re sleeping. If we can get people to eat in a way that they will be hungry less often, that is going to achieve all of these things that we are looking for to support their metabolic health, not having their insulin levels constantly elevated. I agree with you. Insulin itself isn’t bad, it’s just having insulin elevated all the time is bad.

I also think that, that becomes a sustainable situation for people. The reason that just counting calories fails is because it ends up leaving people hungry all the time. No matter how much willpower we think, people may have, ultimately, you’re going to give in to hunger. It is literally a life sustaining force within your body that you need to get the nutrition that your body needs to function, and that’s why we get hungry. So, when you can get that nutrition with nutritionally dense real food that we have been eating as humans for the entirety of our existence that is going to make you hungry less often, and that is going to allow your body to self-regulate so that we don’t get metabolically unhealthy, and then everything that comes downstream of that obesity, heart disease, diabetes, cancer, Alzheimer’s disease, all of these things that result from poor metabolic health.

Cynthia: I couldn’t agree with you more. There was a really good book that I– It’s one of those like, there are five or six books I would say that changed the whole trajectory of the direction my life was going in. There’s a book by Michael Moss, Salt Sugar Fat, and they talk about the bliss point. For the food industry scientists, they’re looking for at what point can they make the food the most irresistible. So, you start to realize the food industry, I think it’s a $427 trillion a year industry, almost all profitability in terms of the money that they generate. So, they’re really more concerned about continuing to keep us buying their products as opposed to making them more, you know, to even think about them being helpful in any degree.

But when you recognize that the science is working against your own innate satiety signals in your body and brain chemistry, and so, when people talk about food addiction, it really is an addiction. Because all the normal biological processes of communication between your brain and your gut are rerouted. I think that one important point here is that for individuals that are addicted to these hyper palatable highly processed foods that really struggle, there is a withdrawal period. There’s no question that, whether it’s the dairy, whether it’s the wheat, whether it’s the sugar, we could make arguments or the combination of all the above, it can be incredibly challenging. So, I love that you’re focusing on the aspects of consuming foods that are aiming for satiety, so that you’re twofold to be thinking about eating anything else as opposed to the nutrient devoid, highly processed hyper palatable foods that will give you the complete opposite.

It explains why in many instances, when you look at someone that’s morbidly obese, and they bring in for me a food diary, and I’m looking at all this food, and the recognition that their brain never gets the signals that their body is full, whether it’s leptin resistance, dysregulation of other hormonal processes, and I’m sure this is something you can speak to as well. You just start to realize that it all really comes down to hormonal imbalances that are driving a lot of these maladaptive behaviors as it pertains to consuming healthier foods. It’s kind of this reprocessing of their body, their tastebuds. You mentioned in your book talking about how your wife went gluten free, and then you went gluten free, and you felt so much better, and that kind of lent itself to this domino effect about continuing to make better food choices in your personal life.

Dr. Philip: Yeah, exactly. This is something else that I just point to my personal experience oftentimes when I’m talking to patients. When I was morbidly obese and metabolically unhealthy, food was always on my mind. I would be going into the operating room, and I knew it’d be a four to six-hour operation and I was worried about what can I eat now, what it’s going to be open later, when will I eat again, and, and I just constantly thought about food. Now, I barely ever think about food. I eat nutritionally dense foods. I eat whole real foods primarily and that keeps me from not being hungry. If I’m in situations, whether it be doing a long operation or traveling like you mentioned, which I do often, I don’t have to think about eating. When I happen to get hungry and there is good food available, what I consider to be good food available, I’ll eat.

One of the most powerful things about changing these habits is taking that control. You are in control of what you are eating, not that the food is in control of you. For most of us, unfortunately, for most people walking around as you said earlier, 88% of us are not metabolically healthy in the United States. The food is in control of them.

Cynthia: I think that patient empowerment is really important. I know that when I did this recent lecture, I said to the entire room, which included a lot of healthcare professionals and physicians, nurses, etc., and I said, “Okay, we’re going to go through what metabolic syndrome, what that represents.” for anybody that need some re-familiarity, and I definitely want to touch on this with our listeners. But I said before you even think about that as being the be all end all you need to know your fasting insulin. There’re other biomarkers. It’s really important that you’re empowered and I actually took a hit recently by a female cardiologist on social media, shaking your finger at me and telling me I was harming patients, because I was encouraging people to get glucometers, and CGMs, and to really know the net impact of sleep, and stress, and certain food choices on their blood sugar. I just said I think that’s really an empowering exercise.

Let’s unpack what the definition of metabolic syndrome, so it’s typically in most instances, it’s looking at waist circumference, triglycerides, HDL, the presence of high blood pressure or hypertension as we like to call it and a fasting glucose. When you’re sitting down with your patients either in a pre-op setting or maybe they’re coming in because they’ve been referred by their primary care provider or another specialist. Are you having these types of conversations where you’re defining for them? Because I know that as I was pivoting out of cardiology, I was making sure this is part of everyone’s charts. But I found for a lot of people, they’re like, “Oh, well, they’re at the point– the recognition that insulin resistance is driving almost all of these processes.”

Making sure our patients are empowered, so they understand like their waist circumference as a female is greater than 35 inches or greater than 40 inches in a male that’s one criterion for metabolic syndrome, which is kind of an umbrella term for five or six variables that can come together. You have to have three to have the diagnosis, but important for people to understand just to be aware like what are your numbers and what are your risks?

Dr. Philip: Yeah, exactly. If anyone is curious about it, I actually have a simple calculator on my website. You can go to ifixhearts.co and it takes you through the five measurements, and we’ll assess your metabolic health for you. But exactly that concept is very important because in my role as a heart surgeon, these patients are coming to me and they are almost universally metabolically unhealthy and no one recognizes this. It’s rare to see in a chart the diagnosis of metabolic syndrome. Yet, they all essentially meet the criteria of it. We really have lost focus in the healthcare system of what it means to be healthy because everyone is unhealthy. As practitioners, we look around and we see all these patients, and the patients themselves look around at everyone around them, and everyone else around them is unhealthy. So, we no longer recognize that this is even unhealthy. That is part of the messaging that I’m trying to get out there, I know that you’re trying to get out there, and so many others that we need to get back to–

We need to tell our patients that it is possible to be healthy. It is possible to reverse some of these conditions like type 2 diabetes and high blood pressure. The only answer shouldn’t be, take your medication with the known invariable worsening of that condition over time. Any endocrinologist, any physician out there who deals with type 2 diabetics understands that when they start the patient on the first medication, usually, something like metformin, that it’s going to progress over time. It’s just felt to be inevitable that it will progress over time, and eventually, that patient is going to end up on insulin, and have all the complications that come with that. Going blind, the needing amputations, the cardiovascular disease that they end up on my operating room table for.

But you look at an organization like Virta Health that has published their data showing that at two years 60% of their patients are off of medications and have normal blood glucose levels. So, you wonder why this isn’t more commonly known throughout the healthcare system. Many of my colleagues that I talked to about this and I mentioned something like Virta Health, and they literally have never heard this before. That study should have been a landmark study, and yet it was ended up having to be published in quite frankly a second-rate journal that no one reads and it was never publicized by CNN and the mainstream media that it should have been publicized by.

Cynthia: No, we should be applauding those kinds of data points. I think it’s really disheartening, but I’m grateful to know such a large amount of physicians, and advanced practice nurses, and PA’s and other nurses that are fighting the good fight alongside some incredibly talented engineers and science writers that are trying to bring greater awareness to this. Now, one marker in particular I want to talk about because I think it’s really woefully understood. We talked about triglycerides and I recall my standard response to most of my patients was I think you have a process carb problem, what are you talking about? I would say, if you’ve got triglyceride level of 300, 400, higher than that, we’ve been having conversations about my concern for them developing pancreatitis, but really identifying the process by which our body will produce more and more and more triglycerides as oftentimes in the setting of not having some familial predisposition or epigenetic predisposition, but really thinking about how the dietary component to triglycerides becomes problematic.

I always kind of my mindset these days, I really like lower. I don’t want under 150. I want it under 100, I want it under 75, ideally less than 50. I just think it’s important for people to be aware that the focus for so long has been on LDL and I’m sure we can probably have a conversation about particle size and advanced lipid analysis because a lot of the questions that came from Twitter where I don’t understand why I should or should not be as concerned about LDL lipid, the lipoproteins looking at density and particle size. So, maybe we can touch on that because that was a question I got asked frequently. Why is there not a focus on LDL as being a component of this metabolic syndrome and me then saying, “Well, really, we need to be focused much more on low HDLs and elevated triglycerides as a marker of metabolic inflexibility.”

Dr. Philip: Yeah, exactly. I agree with you. I think triglycerides are one of the most important markers and specifically when you start to look at to triglyceride to HDL ratio. But again, one of the things I point out to my patients and to my colleagues is that, when you look at those five markers of metabolic health, triglycerides and HDL are two of the five markers. LDL cholesterol is not one of the markers of metabolic health. There’s very good reason for that. LDL by itself is not a very good predictor of health outcomes of any sort of, cardiovascular disease or otherwise. Whereas triglycerides and HDL, again, when you look at going back to the Framingham risk score, it’s the first risk predictor of cardiovascular disease, LDL cholesterol was not included in it. Because they knew that LDL cholesterol was not a very good predictor of outcomes. Yet consistently in the studies, most recently, the Women’s Health Initiative data that came out showed that insulin resistance, triglyceride to HDL ratio being a marker of that was much, much more predictive of cardiovascular risk than an isolated elevated LDL cholesterol was about five to six times the risk could be attributed to insulin resistance and high triglycerides with low HDL.

Quite frankly the only reason that we became so focused on LDL cholesterol was because of the medications that lower LDL cholesterol. I graduated medical school in 1998. It was kind of the height right when statins were becoming as big as they are. The most prescribed medication of all time and that remains the case 20 years later. But when you go back to the literature from the 1980s and the early 1990s before that became the case, the risk factors for heart disease that are talked about are exactly our insulin resistance, high blood glucose level, so all of those things. We only became so focused on LDL cholesterol when the statin pharmaceuticals became so prevalent.

Cynthia: I know you were graduating from med school when I was graduating from nursing school. So, from my perspective, I think it’s important that we’re having this conversation because the first five to 10 years I was an NP. You can imagine in cardiology, I mean, we’d be looking at those numbers and driving down– driving up their statin doses, and trying to deal with the side effects, and recognizing the down toward negative net impact on many levels of having lower total cholesterol ties in with morbidity and mortality. For me, the amount of people that could tolerate whopping doses of Zocor, Crestor, etc., was a rarity. More often than not, the mindset was some is better than none. So, they would come up with these crazy dosing schedules of you take it twice a week, because they just couldn’t handle the myalgias, or the muscle achiness, or elevated liver enzymes.

When I think about some of the things that were said in conversations, you work in a hospital and occasionally you have a kind of a gallows humor. I think that’s how many of us exist sometimes in very stressful environments and we would have a lot of anxious people that would come through understandably if there’s a concern for your heart that’s a very stressful thing. We jokingly say, we need to have Xanax in the water. Then a few years later it started with ‘everyone needs a statin.’ We should just have statins in the water supply, which makes me cringe. It was said jokingly, but it makes me cringe when I think about that now because we’ve gotten so far off base from what really the area of focus should be. So, I’m curious, are you using much continuous glucose monitors or CGMs? Are you recommending those routinely to your patients right now, I would imagine that you are?

Dr. Philip: Yeah. In my metabolic health focused telemedicine practice, it is routine that patients get continuous glucose monitors usually when they start the journey and then kind of intermittently along, I’m not sure we all need to be walking around wearing these things every day. But I think they’re very instructive at the beginning of someone’s journey towards metabolic health because it gives them real time feedback that I eat this food and this is the response. Then as we’re continuing to refine what they’re eating and as their metabolic health is improving, again it gives that feedback. So, they see the differences, they see that maybe foods at the beginning of their journey that they weren’t able to tolerate, they are now, have a better metabolic response to the whole real foods that we talk about things like a handful of blueberries for instance.

Someone who is metabolically unhealthy at the beginning of their journey, they’re going to see a very concerning response to that handful of blueberries and their blood sugar is going to go up very high, and it’s going to stay elevated for two hours, and that is concerning. But then we get them metabolically healthy and six months, a year later, whatever it is, they can eat that handful of blueberries, and they have a minimal sugar response– minimal glucose response to it and it comes down quickly. And I say, there’s no problem with eating the blueberries. This is one of the issues that certainly comes up in the low carb community is that we think that all carbs are problematic in all situations and I disagree with that. I think that when you are metabolically healthy and if you’re active and you have good muscle mass, you can tolerate some carbs. They need to be the right types of carbs, the unprocessed carbs, but this continuous glucose monitor can help with that.

At the larger level, the fact that we don’t utilize these continuous glucose monitors more, the fact that you got attacked by that certain female cardiologist who has attacked me as well, because we are trying to give this information to patients, and empower patients to have this information, and to use it is just emblematic of what has gone so wrong in our healthcare system these days.

Cynthia: I could not agree with you more and I always say knowledge is power. So, the more information you have, you can work in conjunction with your healthcare professional, and on so many levels and given the fact that the current system is so broken, I encourage everyone to know what your fasting insulin is, know what your fasting leptin is, make sure you’re doing a little check in. Most of my female clients I’m working with, we’re doing a CGM once a quarter or twice a year. I myself wore one for almost intermittently on and off for almost a year, and then I needed to take a break, and it was incredibly enlightening. Even as a metabolically flexible individual who does carb cycle and does exercise, I was surprised at certain foods, their net impact on my blood sugar.

My beloved plantains that I would have on a higher carb day, I can have sweet potato, I can have squash, there’s a lot of other starchy vegetables I can have. But for whatever reason, my body doesn’t respond quite as well to plantains. But I wouldn’t have known that information had I not actually gone through this. Now, one thing that I really appreciate in your book that you talk–, you talk about different types of nutritional kind of paradigms. There’s a “camp” everywhere and I say camp in quotes. But people have gotten very dogmatic about whether it’s paleo, or keto, or low carb, or vegan, or carnivore, and I do fervently believe that throughout our lifetime we may embrace for a period of time one of those kinds of nutritional buckets. But I think it’s the combination, it’s the trial and error to find what works best and the listeners know that two and a half years ago, I spent 13 days in the hospital with the ruptured appendix and was very sick, and when I came out, thankfully, my gastroenterologist is completely on board, very aligned with us. The surgeon said, “Just go eat a highly processed crapoholic diet” and I said, “There’s just no way that’s going to happen.”

I went carnivore for nine months. It was literally the only thing that allowed me to get nutrition in without wrecking my digestive system, and it took about 18 months before I could really handle fiber again, and I genuinely missed vegetables. But I do think that all these different nutritional philosophies, people can try them out, find out what works best. I don’t think there’s a one size fits all nutritional paradigm and that’s one thing I stress quite a bit that bio individuality. You can’t apply the same kind of nutritional philosophy to every man or every woman, and certainly women get a little bit of a tough rap heading into perimenopause and menopause that sometimes the game changes in terms of what your body can tolerate or not. But I love that you kind of addressed some of the major kind of more common even the Mediterranean diet as options for people to consider.

Dr. Philip: Yeah, exactly. When I set out to write this book, I intentionally was not writing the Dr. Ovadia diet plan. Because of all those factors that you mentioned, there isn’t one right diet that’s going to serve everyone. Even as individuals, the “right diet,” again, in sort of quotation mark is going to change over time. I think the most important thing we need to focus on is metabolic health as a concept, as a system to guide you. If the food you were eating is supporting your metabolic health, no matter what it ends up being, I’m in favor of it.

Now, we know certain generalities like processed food is not going to support anyone’s metabolic health. Certain people maybe can tolerate it for a period of time, but over the long run, no one’s metabolic health is going to benefit from eating processed food. So, that’s why I like to stick with the big concepts like eat whole real food, and I gave in the book some outlines of within each of these dietary strategies, there are certain things that are metabolically healthy, and quite frankly there are a lot of things that are not metabolically healthy about all of these dietary strategies, and find what works for you. As you said, it takes experimentation, it’s not going to be the same for everyone. I personally do best on a mostly carnivore diet, and that’s what I’ve maintained for the past almost three years now with various forms of low carb and keto before that. But that doesn’t mean that I only work with carnivore patients and I tell everyone that I work with that they need to be carnivore. I do truly work with vegans, carnivores, and everything in between, and my focus is on metabolic health, and let’s find what is going to optimize your metabolic health.

Cynthia: I love that you’re open to different philosophies, because I do find as I’m sure you do as well, sometimes, in the social media space, people get into one bucket, and the degree of cognitive dissonance they don’t want to consider alternatives. They think if it works for them it must apply to everyone else. I do find in some ways like I’m just going to pick the ketogenic diet or lower carb diets, that becomes– sometimes can be an area of where people can struggle because let’s be clear, there are very delicious, higher fat foods that you can integrate into your diet that can be a little hyper palatable and I always think about cheese and nuts. Very easy to overeat them and you can be doing a great job with low carb or keto diet.

If you overeat either of those things, which again, as I’ve always stressed, it’s easy to do, you can derail some of the efforts that you’re making, but that really focusing on satiety, adjusting your macros, I remind people all the time when you are focusing on protein, fat as a condiment, if it’s not part of the– if you’re having a large ribeye, you’ve got plenty of healthy fats in there, you don’t need to have half an avocado on top of that. But really just pushing for nutrient density so that you’re satiated, and if people are satiated, their blood sugar is stable. They’re not going to keep looking for potato chips, and ice cream, and everything else. I’ve been doing intermittent fasting for about six years and the one thing I’ve come to find out during the course of the pandemic is A, my body does better not eating in the evening. I’m better off closing my feeding window late afternoon, which is more aligned with chronobiology and the sleep-wake cycle.

Number two, the other thing that I’ve come to find out is that, for me, it’s a lot of animal-based protein. That is what I find most satiating and non-starchy vegetables. For me personally, if I aligned myself with that and adjusting my carbohydrates that works well, but I think our patients have gotten so accustomed to being told what to do that it can make them uncomfortable to do any experimentation or like that, that doesn’t feel as comfortable for them as being told like, “This is what you’re going to eat every day and I don’t want you to deviate from those.” So, giving them permission to have the ability to do a little bit of trial and error. You may experiment a keto, you may experiment with low carb, you may experiment the Mediterranean diet, I think everyone should be gluten free as a role or even thinking about carnivore. I think all of those are great options.

Dr. Philip: Yeah, I think so. I think giving people the framework to work within and that’s what I try and do with my seven principles of metabolic health allows them to find what works for them. I think the other important part of that discussion is finding a partner, a practitioner to work with that understands that and supports that. Far too often, whether it be a doctor that you go to, or a nutritionist, or other healthcare practitioners, they are too restrictive in their kind of thinking, and they think that there’s only one way to do this, and one of the things that I’ve said many times on social media and elsewhere is that, a practitioner, a physician who isn’t curious, I think is the most dangerous type of physician or practitioner, and you just need to find the people that can work with you on this. That in and of itself can be a bit of a struggle, a bit of a battle because if you just go to whatever physician or a practitioner that you connect with through the system, you know, just as 88% of the adults in the United States are metabolically unhealthy, probably about the same number of physicians are not interested in metabolic health and that’s how we ended up this way. So, you need to seek out the practitioners that are knowledgeable about this, are curious enough, are asking those questions, and are willing to work with you to support your metabolic health journey.

Cynthia: Absolutely. I couldn’t agree more. I want to touch on a couple of questions that were asked ahead of time on Twitter. Several people were asking, what are your screening parameters? Are there specific screening tests that you like to use and specific to coronary calcium scores, do you feel that there’s value in using that as a risk screen?

Dr. Philip: Yeah. In terms of screening parameters, I typically start with the five metabolic health screening parameters that we talked about. I of course go deeper and add the fasting insulin levels and things like that. When we’re specifically looking at coronary artery disease, I think the calcium score is a great tool but also understand that it has its limitations. I don’t think it’s all that useful when people under 40, if it is a zero. What I basically tell my patients under 40 is that, if you get a zero on a CAC score it’s a great starting point, but we need to keep a close eye on it every couple of years, maybe, five years at the most. As opposed to if you’re in your 60s and you get a zero, you and the statistics show, the study show that’s pretty much a 10-year virtual guarantee less than 1% risk of developing a cardiac event with a CAC score of zero in your 60s.

Like everything else, it needs to be properly understood, it needs to be put in the context of what is your situation, are you metabolically healthy or not, what other risk factors might you have? I do frequently look at other cardiac risk measurements like the lipid subfractions, the NMR panel, the Lp(a) measurement, the oxidized phospholipids measurements that are now available, all of these things I think should be taken into consideration. I think the important thing is that most physicians just stop at LDL– LDL-C, which is a calculated, not a very great measurement of cardiovascular risk. So, we need to go beyond that. I also stress the importance of, I, as a heart surgeon, the patients that seek me out are usually worried about heart disease. But I also try and make them realize that it’s not just heart disease that we need to be worried about. That is, I think another powerful part of the metabolic health measure.

When you look at the leading causes of death in the United States, seven out of the 10 every year, and last year it was eight out of 11, when we had COVID in there are relatable to metabolic health. So, what I love so much about metabolic health is the patients come to me and they want to lower their risk of heart disease, and we do that by improving their metabolic health, but at the same time we’re lowering their risk of all these other chronic diseases that plague our society.

Cynthia: Oh, it’s such a valuable way to reflect on health and wellness. Now, I got a lot of questions about LDL and you touched on the advanced lipid analysis. So, let’s just briefly unpack particle size and buoyancy and how that impacts and like you mentioned, the typical LDL that you see in a traditional lipid panel doesn’t give you the whole picture. And this is really important, because a lot of people reach out on social media, because they’re aware of my background, and I always say, ask for these other tests. You need more information. You don’t know enough about the LDL to determine whether or not you really need to be concerned, and the tie-in to that is, what are some of the things that can drive LDL up that may not be directly related to cardiovascular disease?

Dr. Philip: Right. Yeah, so I agree. My most important message there is, you need to go beyond the LDL. If you’re going to your physician and all they are taught, the only number they look at is your LDL and they make all their recommendations based on that. You need to push back on that or find another physician. It can be as basic as looking at the rest of that cholesterol panel, and looking at the triglycerides and the HDL, and factoring that into the risk factor. For many patients, it is looking at these other particle sizes, the NMR panel, the Lp(a), all of those other things that becomes a very nuanced and individualized discussion. But LDL shouldn’t be the stopping point and then deciding when you bring in things like a CAC score or a carotid intimal thickness ultrasound test. There are lots of other things that we can be doing and should be doing.

Then, as you mentioned, what else influences your LDL? Thyroid is a very commonly missed thing that people come to me and they have a high LDL cholesterol and especially they’ve been doing low carb for a long time. Especially, women as you know, they can be hypothyroid unrecognized, and you correct the hypothyroidism and their LDL gets better. So, there are lots of different ways to go about this. The final point that I make to patients is even if we do think that LDL cholesterol is important and we need to lower your LDL cholesterol, drugs aren’t the only way to do that. There are modifications that can be made in your dietary strategy that can have fairly significant impacts on LDL. Then, again when you go to Dave Feldman and you look at his work, and some of the personal experiments he’s done on himself and shown 20% to 30% reductions in LDL cholesterol in just a couple of days.

One, it shows you that drugs aren’t the only answer, but it also starts to make you question, how reliable can LDL be if it can modulate so quickly with these different dietary strategies? So, that’s of my summary on LDL, and ultimately for me LDL ends up being almost more of a screen for the physician, the type of physician they are, then for the patient. If your physician cannot look at anything beyond LDL, doesn’t think that there’s any other information that’s important besides the LDL cholesterol, that’s a warning sign that that’s probably a physician you don’t want to be working with.

Cynthia: I could not agree more and I say this from coming deeply from someone who has had a high LDL for most of their life. I laugh because Dave Feldman and I talk about the lean hyper-responders. I hope to be able to participate with his research at some point. I concur 100%. One of the things I learned as a new NP many years ago was, if you’d see an abnormal lipid panel, first be thinking about insulin resistance, be thinking about thyroid issues, you have to fix those first, and then look at it from a different lens. I agree a 100%. This has been an amazing conversation. I’m so excited about your book. I think it’s going to help so many individuals. Please let listeners know how to connect with you, how can they support your book, obviously we will have links to your website so they can do the metabolic syndrome screening, which I think is really important. Everyone should know your numbers, you should be readily familiar with them, so you will know whether or not you need to make some adjustments to your lifestyle sooner rather than later.

Dr. Philip: Sure thing. So, the book is available widely on Amazon and other platforms. It’s called Stay Off My Operating Table, and we’ll make sure that all the links are included. I work with patients in a number of ways. My telemedicine practice, I see patients from across the United States is at ovadiahearthealth.com. O-V-A-D-I-A heart health dotcom. Then for patients that either don’t need one-on-one care or I can’t work with one-on-one because of geographic or just other limitations, I also have a group coaching program. It’s called the Stronger Heart Society, and that’s at strongerhearts.co, and we meet twice weekly and we discuss all these issues around metabolic health and heart health.

Cynthia: Oh, that’s great. It’s been such a pleasure to connect with you. Keep doing the amazing work you’re doing. We need more healthcare professionals that are taking a stand and helping to flip the switch on metabolic health here in the United States and beyond.

Dr. Philip: Yeah, thank you for having me on, Cynthia, really excited to finally connect with you. I’ve been a big fan of everything you’ve been doing for a long time as well. So, you know, you as well keep up the great work.

Cynthia: Thank you.

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