I am delighted to have Dr. Bret Scher joining me on the podcast today! Dr. Bret is a board-certified cardiologist and lipidologist in San Diego who is helping to change the narrative around health and prevention. He is the host of the Diet Doctor Podcast, and he also does telemedicine cardiology.
Dr. Bret is a forward-thinking cardiologist who is very well-versed in the medical literature. I have the greatest respect for him and believe he is changing the future of medicine moving forward. I feel fortunate to have interacted with him on social media and to have had the opportunity to be a guest on his podcast.
In this episode, Dr. Bret shares his background and talks about how he started in preventative cardiology with a low-fat veganism approach and later evolved to focusing more on low carb, ketogenic diets and lifestyle medicine. We discuss the broken medical system, the contributors to it, and the outdated dogma that continues to be perpetuated. We dive into the cholesterol paradigm and what you need to be aware of that could help you figure out whether or not you need to be concerned about your lipid values. Dr. Bret shares his views on biohacking, and we also discuss metabolic flexibility and the future development of preventative cardiology and metabolic flexibility.
I hope you enjoy listening to this helpful and informative episode. Stay tuned for more!
“We are starting to see a groundswell of people saying we do need to have a broader perspective of what it means to be healthy.”
– Dr. Bret Scher
IN THIS EPISODE YOU WILL LEARN:
- Dr. Bret talks about his evolution as a cardiologist, and how his practice was initially influenced by the perspective of Dr. Dean Ornish.
- Why is it so hard for health care professionals in the U.S. to shift their focus and change the dogma around metabolic health?
- The perspectives of hospital-based physicians are slowly starting to shift towards lifestyle and prevention.
- Dr. Bret talks about the valuable pieces of technology he utilizes with his patients.
- There is a benefit to using tech devices, but it is easy to take things too far and assign too much importance to them.
- Why is it helpful to count net carbs with whole foods and total carbs with packaged and processed foods?
- Dr. Bret shares his take on seed oils.
- Dr. Bret unpacks cholesterol and the different types of LDL.
- Looking at Coronary CT angiograms for those who want to quantify whether or not they have any plaque in their arteries.
- Dr. Bret unpacks the issue with saturated fat.
Connect with Cynthia Thurlow
Connect with Dr. Bret Scher
- On the Low Carb Cardiologist and DietDoctor websites
- The Diet Doctor Podcast
- The Diet Doctor YouTube channel
The Unhealthy Truth, by Robyn O’Brien
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 an opportunity to connect with Dr. Bret Scher. He is a board-certified cardiologist and lipidologist in San Diego. He’s helping to really change the narrative in terms of looking at health and prevention, and is head of the podcast, dietdoctor.com, and also does telemedicine cardiology. He’s someone that I’ve been fortunate to have interacted with on social media. I’ve had the opportunity to be on his podcast. I respect him enormously. He’s so well versed in the medical literature. On so many levels, he’s the kind of cardiologist that I wish I had had an opportunity to work with when I was in cardiology as an NP.
Today, we really dove into his background, how we started in preventive cardiology with a Dean Ornish-type approach, which is low-fat veganism, how we evolved into being more focused on low-carb ketogenic diets, as well as lifestyle medicine. We talked a bit about the broken medical system and the contributors to that, as well as antiquated dogma that’s been perpetuated, like, that is bad, and that saturated fat in particular, meats are unhealthy. We did a deep dive into the cholesterol paradigm and things that you need to look out for beyond just LDL, specific, more advanced lipid analysis that can be very helpful to tease out whether or not you need to be concerned about your lipid values. We talked a lot about metabolic flexibility, we dove into a bit of biohacking and his personal philosophies on how these can be helpful for many patients, and perhaps create anxiety, and stress, and others, and then really wrapped it up talking about where we see preventive cardiology and metabolic flexibility going in the future. So, I hope that you enjoy this podcast. This is one that I found particularly joyful to record, because it harkens me back to my cardiology days, but also demonstrates and really focuses in on someone that I look to as really changing the path of medicine moving forward. I hope you enjoy it. Well, I’m so thrilled and delighted to have you on the podcast. I’ve gotten a lot of requests to have you on in particular, because you are a forward-thinking cardiologist. So, welcome.
Dr. Bret: Thank you. It’s a pleasure to be here. I’d really enjoyed having you on my podcast. So, it’s nice to flip the table, so to speak.
Cynthia: Absolutely. It’s very humbling. I do have to mention, for anyone that has not listened to that podcast, we were in temporary housing and to my horror I realized it, I looked like maybe I was a hoarder, because there were so many boxes behind me, but I tried to overlook that. Hopefully, your listeners will as well.
Dr. Bret: Right.
Cynthia: Let’s dive into your background, because as a cardiologist your training was pretty unique. My understanding is that you train kind of an Ornish focus perspective and for listeners that may not be familiarized with Dr. Ornish’s teachings, I would love for you to talk about how that initially influenced the way that you were practicing.
Dr. Bret: Yeah, it’s a great point. I did a cardiology fellowship that was a combined general and preventive cardiology fellowship at Scripps Clinic. It was modeled after the Dean Ornish style of practice, which is a very low-fat, plant-based basically vegan diet. But that’s not it. It was also social connections and getting people to quit smoking, and exercise, and stress management, all these other wonderful things that people just loved and really enjoyed. Then the diet part, they like what tried to white knuckle their way through the majority of them.
Dr. Bret: Some really took to it, but the majority I found tried to white knuckle their way through it. Then that was the teaching that that’s the way to do it. That’s the one way to help people improve their cardiovascular health and to practice preventive cardiology. When I got down into practice, that’s where my brain was and that’s how I was practicing. It was a very unique setting, because people came to this program knowing what it was. Then you get out into the “real world,” and you’re just seeing people from any swath of life, and trying to convince them that this is the way to go to improve their life. Patient after patient just wouldn’t comply. You write in your chart did not comply with lifestyle modification or lifestyle modifications aren’t having the impact we were hoping, and then out comes the prescription pad, because that’s what’s next when lifestyle doesn’t do it. Well, maybe I was a little slow on the uptake and I’m a little embarrassed looking back, but eventually, I caught on and thought, “Hmm, if all these patients aren’t able to stick with it or if it’s not having the effect, maybe it’s me, maybe it’s my advice. It’s not actually the patient’s fault.” You laugh and I laugh thinking about it, but it’s actually a huge revelation for a doctor to get to that point. There’s the old saying, “If you’re in a class, and 99% of the people are getting A’s, and one kid is getting an F, okay, probably that kid’s fault. But if 99% of classes getting F’s and one kid’s getting an A, probably not the kids fault at that standpoint.” Doctors at some point need to have this revelation and that’s fortunately the revelation I had, which led me down this path to then start my own wellness clinic.
At first, I thought all I needed is more time with the patients. I just need more face-to-face time, let’s get out of the regular clinic system and have more time with them. I was fortunate enough to be working with a friend of mine, who was an amazing health coach, but had experience in low carb and ketosis. For some of our more challenging patients, he would say, “Hey, why don’t we try a ketogenic diet on this guy, because there’s metabolic health not improving? He’s not losing weight. He’s having trouble sticking to his lifestyle program.” Of course, at first, I thought he was crazy. But luckily, he challenged me, “Have you read about it, have you researched it?” I said, “You know what? I haven’t. I’m just going off of everything I learned from my training background.” From there, I just opened my eyes for me to learn that there was scientific literature supporting low-carb nutrition for metabolic health that existed, but was really almost literally swept under the rug, you could say in training programs and education, because nobody talked about it. In fact, it was the opposite. People would say, how bad health fat in general was in any animal product and it has no place in a healthy diet. Yet, the exact opposite was taught. We had this literature existed and that just sent me down the rabbit hole to complete my training as I say it, because it was clearly not completed before. That completed my training to open my eyes to other options that exist to really help people improve their cardiovascular health, their metabolic health, their life in general.
Cynthia: Well, first, I love that you talk a lot about lifestyle medicine, because I think in many ways, that’s what’s missing from a more traditional kind of allopathic focus is that, we’re taught to find the disease, treat a symptom, prescribe medication, and then move on. I think the nutrition, the sleep quality, the stress management, the exercise is equally important. That really isn’t emphasized in our training. That’s the first piece. Secondly, I’m so grateful that you were open to the idea of thinking beyond, where your training had been. For many people that are listening, I think many of us were on this path. I started feeling in cardiology once I came out of the haze of having two kids two years apart and just being exhausted all the time, seeing something is broken. I’m writing more prescriptions, the patients are getting younger, they’re insulin resistant that are clearly metabolically unhealthy. I used to beg. I used to try to find any way to connect with my patient, I would say, “Okay, so, tell me about your kids.”
They would talk about their six-year-old, they’re so excited. I want you to be healthy watching your child grow and mature. I don’t want you to be in a position where you don’t have the energy to play ball with them, or you don’t have the energy to take them to events, you don’t have the energy to be an active participant as a parent always looking for an angle. That nutrition piece is really, really powerful. Why do you think it’s taken a long bit of time and certainly there are many physicians that are very outspoken talking about low-carb diets, talking about ketogenic lifestyles, talking about metabolic flexibility or inflexibility, if you will? Why do you think that it’s so hard to change dogma here in the United States? I’ll just keep it to the United States, because it could apply to a lot of the Westernized world, but why do we think it’s so hard to get healthcare professionals to shift focus?
Dr. Bret: Yeah, that is a great question and really a multilayered answer. On the one hand is what people were taught, what people have done depending on the age of the physician for 10, 20, 30, 40 years it’s what they’ve done. It’s hard to learn new things especially if you’re in a busy practice, where learning is not necessarily rewarded. Seeing patients quickly is rewarded. From that standpoint, it’s just hard for people to change. The other aspect though is how to say this nicely, like, where’s the money coming from? The money is not coming from lifestyle. The money’s coming from pharmaceutical companies. Education is frequently sponsored by pharmaceutical companies, research is sponsored by pharmaceutical companies. It’s going to have a definite pharmaceutical twist. You look at the people, who are on the Cholesterol Guidelines Committee and you look at their conflicts of interest. This is long as the document itself about the guidelines. I mean they are all working for the different biotech companies or the pharmaceutical companies that may not mean that they are a shill for the pharma company and that they’re just trying to make money for the pharma company. I’m not saying that, but it definitely means their mindset is drug first mindset, because they’re so invested in their education in their whole life and career with pharma company. So, their mindset is pharma first. That’s the other problem that we’re fighting.
Then the third thing is just the dogma that’s been taught for so long and just ingrained in society that animal products and meat are bad, plants are good, period, end of story, no room for nuance or combination. You don’t even get me started on the healthy whole grains, the American Heart Association, heart symbol for healthy Honey Nut Cheerios. That just shows how backwards our society and medical society really has been when it comes to nutritional teaching. It’s far too simplistic, it’s far too black and white, and that’s been hard to undo all that decades and decades of that. Then, I guess, you could think the last piece of the puzzle is the big organizations that had been making recommendations for so long. How does this major organization say, “Oops, we were wrong and we need to undo what we were doing,” Saying it, how do you back out of that room? That’s challenging, too. You put all of those pieces together, one of those pieces by itself is a little bit difficult to overcome. Put all of them together and that’s why this ship is turning so slowly, but at least, we can say it is starting to turn a little bit. We’re starting to see this sort of groundswell of people saying, “Wait, we do need to have a broader perspective of what it means to be healthy. We do need a broader perspective of what it means to have a healthy lifestyle and a healthy diet.” I’m not talking about this specific food or this specific food, but talk about your whole nutritional composition as what’s healthy, not specific foods. We are starting to see that groundswell. Gosh, I wish it was a lot faster. But it certainly is a lot bigger than it was 10 years ago, when I was still firmly entrenched in the old teachings.
Cynthia: Yeah, no. I think you bring up so many good points. For anyone that’s listening that wasn’t aware of all of those variables that contribute to, why it takes a long amount of time to make these changes. I know that 10 years ago, I read a book by a woman named Robyn O’Brien called The Unhealthy Truth. I talked very openly that that book changed my life. I was so mad when I read that book and I thought, “I trained at a big research institution, I stay up on my CME, I’m working for this very busy cardiology practice, how did I not know this?” From there, it really inspired me, because I had a child with food allergies and started looking a little more deeply. I do believe, irrespective of what initials we have after our names or what titles we have, it’s really important to be lifelong learners. That really shifted my perspective. I think over the last five to six years, I’ve really started to see some changes. I know a lot of the cardiologists in my practice were supportive of my desire to want to talk about nutrition and they would humor me and say, “Cynthia’s really interested in the nutrition piece.” I said, “It all starts with food.” That was always the mantra that I came from. Then I fell into the fasting bucket and that really shifted things until I literally couldn’t go back to work anymore and continue.
All I was doing in a very busy interventional cardiology practice, that’s all I did was write scripts, whether in clinic or in the hospital. I applaud cardiologists like yourself that are changing the face and the way that we look at preventive cardiology really looking at prevention. I think most of us probably trained in some degree of preventive medicine, but we never practiced it. I know, technically, I trained as an adult primary care NP. I never practiced adult primary care. I always did acute care. I was always in the hospital, I was always dealing with sick patients, and I worried about the prevention. That’s someone else’s problem. But I’m really realizing it’s all of our problem, because someone needs to take ownership of it. Because our patients in many ways, we’ve conditioned them whether it’s been the contributions of the pharmaceutical industry, the food industry, our own conditioning when we’re interacting with them. They come to us with symptoms expecting a pill to fix their problems. Just say them, “Oh, I want you to sleep more, move your body, eat less often, eat less carbs.” They’re like, “Well, wait a minute. This isn’t what I bought into.” So, it’s really shifting a lot of perspectives in ways that make people uncomfortable.
Dr. Bret: Yeah, and you’re so right. It’s so easy to just think about your lane, the whole stay in your lane. I work in the hospital, I’m going to fix them up and send them out, and let their primary doctor take care of everything else, that’s starting to shift as well. Now, a diet doctor, we have a number of hospital-based physicians listed on our doctor map, which is great, because what it means is, these are hospital-based physicians interested in teaching about nutrition, teaching about lifestyle, and not just trying to put a Band-Aid, fix the acute problem, and send them back. But rather start the conversation now in the hospital. Maybe they’re going to be more receptive, maybe they’re going to be less receptive, who knows, but you don’t know unless you try. I’m really encouraged to start and see that trend that hospital-based physicians are getting involved with prevention as well, because it’s so important we all need to start the discussion, and talk about it, and bring it back to lifestyle.
Cynthia: Yeah. I’m sure that you see this all the time. We would sit back– not that we got to eat lunch very often, but we would sit in the doctor’s lounge, and maybe we were discussing a case or discussing an interesting patient, and I would say, “Okay, well, I diagnosed three people with diabetes today” and that was a running joke. But it was truth because one of the labs that was done very frequently, one of the hospitals that I worked in was a hemoglobin A1c. For anyone who’s listening, it gives a snapshot of blood sugar control over the last 90 days. If it’s particularly high, there’s no question someone has diabetes. We would play the game of what’s the highest hemoglobin A1c you’ve seen this week?
Dr. Bret: [laughs]
Cynthia: People would, 12, 15, 20 outrageous numbers, because you realize this person, if this didn’t just happen, it isn’t just the hospitalization, your blood sugar has been out of control. But on many levels, having those discussions and empowering our patients, and this is definitely something I wanted to touch on with you about probably two months ago, three months ago, and this happens to all of us on social media. You stick your neck out, and you start to shift the paradigm, and make people think, and maybe you trigger people, eventually, you’re going to get some hate on social media, which I generally try to avoid, because I don’t like drama. This particular female cardiologist came after me, because I was encouraging people to ask for glucometers, even metabolically healthy people and/or if they could financially afford it that a continuous glucose monitor, which I believe is one of the most impactful biohacking/technology devices we can utilize ourselves personally, or even with our patients. This person came after me [laughs] on social media and then a week and a half later, I realized that this individual had a connection with a pharmaceutical company about a drug to deal with diabetes. I started to recognize that there was a vested interest in making sure that she was calling people out in this area, but I’d love to touch on what are some of the technology pieces that perhaps you’re utilizing with your patients right now that you feel are particularly valuable. I know glucometers, continuous glucose monitors, I think are incredibly invaluable.
Dr. Bret: Yeah, obviously, start with CGM since you brought it up. I agree, they are so valuable. There as valuable psychologically as they are physiologically. To have that accountability partner right there, the app on your phone screen to know that you’re going to see that rise if you stray or if you eat things, maybe you shouldn’t. That’s one part, but the other part is the education. If there’s one thing we’ve learned is that people respond differently to different foods, there’s no one response, there’s no one diet. Some people can have a bunch of sweet potato and not see much of a bump in their blood sugar. Some people just look at a sweet potato and their blood sugar is going to go up.
Dr. Bret: There’s a huge variety and how do you know? This concept of healthy whole grains, healthy fruits, healthy vegetables, well, sure, populations in general can eat those foods and be healthy. That is a far cry from saying those foods are healthy for everybody. Learning about that is so important, because otherwise you’re just shooting in the dark and assuming you are like these general populations in these general studies as opposed to being an individual. I think that’s so important. But as some people have pointed out on social media, there’s a bit of a downside, too. You can take it too far. You can say, “I’m wearing the CGM and to me, it’s like a video game and I want that straight line blood sugar.” Anything that causes a little bump up, that’s bad, it’s out. Well, that’s maybe going a little too far. We have a whole guide on CGMs at Diet Doctor that I wrote with, that comes with guidelines about what to look for. It’s normal to have your blood sugar go up and come down. But when it goes up, if it’s under 120, great. If it comes back to normal within the hour, great. If it’s up to 140 and comes back in two hours, yeah, okay, you’re starting to push the boundaries and anything past that, bad, if you wanted to assign a good and bad term. So having some parameters like that can really be helpful. Then you can understand how your body reacts to different foods, to combinations of different foods and use that tool for I think maximum efficacy. So, that’s definitely one.
Other tools in tech is really interesting. You can talk about the sleep tracking rings, the activity monitors on your wrist. For some people, these are going to be great, because they’re going to show that maybe you’re not doing as well as you thought you were. For other people, it’s just going to be one more frustrating piece of the puzzle that is, one more tech thing they have to figure out. Part is knowing who you’re working with. I don’t give a certain tech thing to everybody, but what I do want to do is engage with somebody to see if they’re the type of person who’s going to benefit from more data, who’s going to benefit from tech, who’s going to benefit from some accountability partner that they wear on their wrist, that’s really going to help open their eyes. For those people, I think that can be really, really helpful. Same thing for monitoring ketones. I don’t think everybody needs to be in a ketogenic diet. I don’t think a ketone level is necessarily your goal. Now, if for some reason, you or your healthcare providers decided it’s best for you to be in ketosis rather than just focus on low carb and metabolic health benefits, but to actually be in ketosis, sure, then the ketone monitor’s very helpful for showing that. But that doesn’t mean you need to prove that you have a ketone level above 0.5 to be healthy. Those two don’t disconnect. It’s one of the things I find so interesting about tech. There’s such a great benefit to so many things, but it’s also easy to take it a little too far and assign too much importance to it. So, part of it is finding that balance with people.
Cynthia: I think it’s really important for anyone who’s listening that you know yourself, I have several female clients, who tend to run a little bit more higher anxiety and so what we’ve agreed for them is that they do a CGM every quarter. For two weeks, they’ll do a CGM, and then they don’t wear it again. Or, if they are going to wear a biohacking device, whether it’s an Oura ring or they’re monitoring how many steps they take, they’re only allowed to check it a certain amount each day. I think it’s really important, because we don’t want to add to anxiety. We don’t want people to get to the point that they don’t participate in their real life, because they’re so focused on the data. Now, I’m a little OCD by nature. I love data. I have and I’m laughing as I’m like, “I’ve got an Oura ring on, I have an Apple Watch, I have an Apollo Neuro.” But for me, it’s a checking in point during my day. So, I don’t ever do it. I only wear my CGM. I wore it pretty continuously for about eight months and then I needed a break. But what I found interesting and I’ve been low carb for a long, long time, and I’m very happy. My body’s happy there, I sleep while, etc., my hormones are pretty well balanced. But what I found interesting was when I started wearing my CGM, I actually needed smaller portions of protein and a little more fat, because if you have a huge portion of protein, you can get an exaggerated blood sugar response in response to that meal. I found that I had to augment my macros a bit.
The other thing I found really interesting is in this low-carb world that I’ve existed, I usually have one higher carb day per week. I mean it’s not a lot of carbs. It might be 75. Certain carbs, my body just did not like. I use the example of plantains, which I loved. Every time I eat plantains, it didn’t matter how I made them, my blood sugar would spike to 170. I was like, “Oh, I would never have known.” I didn’t get sweaty, my pulse didn’t go up, I had no symptoms to suggest I was intolerant of those. I think it can be very insightful, even for individuals that are relatively metabolically healthy. It’s certainly one of those instances that I sometimes will say, maybe you just wear or use a glucometer for a week or two. Maybe the CGM you wear for two weeks and you put it away much to your point. There are people on social media, who don’t want to see any blood sugar response. It’s almost like a badge of honor. My blood sugar only deviated by five to 10 points the entire day and I’m like, “Wow, that’s really interesting.” But I agree with you that we should see a rise and a fall. It’s so much more of it is the response to our meal, and then making sure your blood sugar is coming back down in a timely manner. Sometimes, I’ll even say, a la Marty Feldman, who’s in Australia and is wonderful. He talks a lot about this threshold of no more than 25 or 30 points after eating a meal. If you see levels higher than that, it can be indicative that your carbohydrate intake was too high. So, just lots of different ways that people can use that information beneficially without being obsessive about it.
Dr. Bret: I like your point about using a tool intermittently. Just because you’re using a tool doesn’t mean you have to use it the whole time. A personal experience for that, come summertime when the berries and the fruit just look so good, I strap the CGM on again, because I wanted to see increasing my fruit intake what the response was going to be. Started shifting more towards a higher protein diet to see what the shift or to see if there’s going to be any change. That was fortunate for me, the adding extra berries, adding extra fruit didn’t make a difference. Increasing my protein even as high as 40% for a little while didn’t make any bit of difference for the CGM. But I wanted to know that. I didn’t want to guess. I wanted to know. So, you use the tool to test it. You use it for a specific purpose and it can be very helpful that way.
Cynthia: Yeah, and it’s amazing. I think that this is an example where biohacking can be so beneficial, because it can validate behavior or it can allow us to course correct to say, “Hey, this is not working for me. It does not serve me well.” I personally don’t do any grains and I don’t do gluten. I don’t do dairy, because they just don’t work well for my body. It’s interesting how triggering that can be. When you go into a social situation, I’m like, “I’m great with protein, I’m great with non-starchy veggies, that works well for me.” I don’t judge what you choose to eat. I just know what it does to my body when I do eat those things, it’s just not worth the net impact.
Dr. Bret: Yeah, and all these packaged products and eating out that things are supposedly clean and healthy, testing those, because you cannot trust what’s on a lot of these packaged products or what they say they’re cooking with when they’re eating out and what’s in the sauce or whatever. So, yeah, testing that can certainly help.
Cynthia: Absolutely. Are there a couple ingredients for you that are complete deal breakers, when you’re talking to your patients and talking about processed food, things on food labels that you advise them to avoid at all costs?
Dr. Bret: Yeah, well, when they’re adding fiber in, a lot of that fiber is not going to work the same way as natural fiber. That’s why I think when it comes to this whole debate of net carbs versus total carbs, I think it is helpful to use net carbs when you’re talking about Whole Foods. If you’re talking about vegetables, and fruits, and nuts, okay, using net carbs there make sense. But when you switch over to packaged and processed foods, that’s where I think switching to total carbs makes more sense. Because you don’t know how the fibers are going to act. Some synthetic fibers or added fibers do raise glucose and insulin are absorbed and count for calories, some don’t. Rather than having to learn it all and be so specific, because not everybody likes to be that detail, just count total carbs from that standpoint. I think that one helpful hint. No sugars or alcohols are generally okay, but again, you have to be cautious with those, one, from a GI standpoint, but two, you know how you respond. I don’t know that I can say something like if you see this run the other way, other than the longer the ingredient list, the worse it is. That’s a pretty safe assumption. But there are lots of questions about, “Is this food keto?” Rather than saying, is this food, keto, I’d say, “Does it fit for you and your lifestyle and fit for whatever carb level you are set for yourself, and how do you respond to it, how does it fit in your overall plan? That’s a better question. So, for me, the simple of Whole Foods, fewer ingredients, you’re never going to go wrong.
Cynthia: I think that’s really important. especially when we’re talking to patients and trying to meet them where they are. For a lot of people, maybe it’s been such a huge pivot for them to eat less processed foods. They need to find a keto dessert, or a keto bread, or one of those types of products that are out there. There’s no shame in that. I always think about the ingenious, Maria Emmerich, who comes up with these protein-sparing breads. It’s amazing what she does in the kitchen. I always applaud her, because she’s helping people still feel like they can enjoy eating something indulgent that’s not nearly as unhealthy as its conventionally processed counterparts. I think I was thinking about things like seed oils, because that seems to be an area that I will sometimes say to my patients or clients, if you do nothing else, read the food labels and really try to avoid soybean oil, and canola oil, and some of the things that are already so highly inflammatory and hugely problematic, especially when we’re talking about a population. I think the last statistic I read was that, 88% of the population is metabolically unhealthy. Really thinking about, what are the things that are driving more inflammation, which is going to just inflame our bodies more. I know many doctors don’t like any of us saying the word ‘inflammation,’ because it can mean something positive and something negative in terms of whether it’s acute or chronic, and it’s the chronic stuff that we really have to worry about.
Dr. Bret: Yeah. Seed oils is a great topic. Again, at Diet Doctor, we have a whole guide on it. I recently did a podcast with six different experts in different fields to really try and cover the topic as best we can. I guess, I take a little bit different take to seed oils and many in the low-carb community. Look, as a doctor, I do not recommend my patients eat seed oils. Personally, I completely avoid seed oils. I think the whole debate over seed oils stems from being afraid of saturated fats. You have to avoid saturated fat, so what other fats do you use when are you cooking, and what do you use for salad dressings, and you can’t use saturated fats? Okay, you use seed oils. Well, no, first of all, the whole debate is wrong. Yes, you eat saturated fats. We got to get over that. Saturated fats are perfectly fine, especially within the context of a healthy low-carb diet. Avocado oil, olive oil are great choices. But then the question becomes, “Do I have to be vigilant about avoiding all seed oils when I eat out, and salad dressings, and is it proven to be that harmful?” My take on it is, it’s actually not proven in human clinical studies to be so harmful that it has to be completely avoided. There is really disturbing mechanistic studies. No question about it. It is really disturbing. But when you look at the human data with clinical outcomes, it’s just not there. I would stop short of saying seed oils are the cause of all this trouble and is the number one thing to be avoided. But at the same time and I know maybe it sounds like I’m talking out of both sides of my mouth at the same time. I say, there’s still no need for them and you shouldn’t add them. But if you eat out a couple times a week and they cook in seed oils, that’s not going to harm you. If eating out those two times a week improves your enjoyment of life and enhances your ability to stick with your nutritional program, it helps your life in some way.
If you try to make your own salad dressing as much as you can, but you’ve run out and you need to get some things, you get some store-bought salad dressing and you use it sparingly, that’s not going to hurt you. I think it’s blown out of proportion and has been twisted in terms of what is even the purpose of the discussion is. We go into much more about this in the podcast. I would recommend people listen to it. It’s an hour and a half podcast or something with the six individuals. But that’s my general take on, like sure you should absolutely avoid them. But if you can’t, it’s okay. The evidence is not that strong that they’re going to hurt you in small amounts even though the mechanistic data is very concerning that doesn’t always translate to human outcomes.
Cynthia: Well, I appreciate your pragmatism, because I think in this space, where we can get very dogmatic, and this is good, this is bad, you have to be low carb, or there’s something wrong with you. I think the bio individuality piece is without question that someone may do carnivore for a couple months, and then they may pivot, and embrace a plant-based lifestyle for a few months, and then they may dive into low carb and ketogenic diets, or paleo, or primal. Really, the one thing that all of those diets in their purest form is that they’re eating less processed foods and that’s a good thing. But I think we’ve gotten so fixated on labeling, like, we want to put everyone in a bucket like, “Oh, you’re a low-carb doctor, so, I’m going to put you in this bucket. This Nurse Practitioner is straddling two buckets. So, she’s not really sure. She has an identity crisis. She’s not sure where she fits.” But I think it’s really important to acknowledge how important it is to just be pragmatic and not be dogmatic on so many levels.
It would be without question that one of the most common requests that I got when I reached out on social media and shared that we were connecting was to really unpack cholesterol. I know within my Nurse Practitioner years, things have shifted quite a bit. What I was taught during my training, even though I worked at a big preventive cardiology center is very different than the conversations I even have now. Again, this goes back to, when did this shift start happening from a historical perspective, where we got so misguided? We got really fixated on bastardizing fats and not really looking at the true culprit that was behind the scenes that was driving the real issues of inflammation, and obesity, and cardiovascular disease. Where did we really get so misguided? Where did that stem from?
Dr. Bret: You can say it all started way back with the Ancel Keys stuff. The science that wasn’t really science that was just loose observations, and published and promoted as end-all be-all science or go all the way back to Eisenhower and his heart attack when he was smoking three packs a day, but everyone had to blame it on his fat intake. You can stem that far back. But the point is, it’s grown. You can’t blame everything just on those incidents because it has taken on a life of its own and grown, and evolved into pharmaceutical companies and for lowering LDL. If your tool is a hammer, you look for nails. I think a lot of that has impacted it and the ease of it. If you just want to focus on fixing somebody’s LDL and you can write them a prescription, and you have done your job, you helped your patient, you pat yourself on the back, you get paid more from Medicare. All these incentives pile on top of it that you can’t blame the doctors really for going that direction on the one hand. But it really is just so short sighted to think that that is the end all, be all.
When you look at huge populations of mostly metabolically unhealthy people following low fat, generally unhealthy lifestyles, and you see a small improvement by lowering LDL cholesterol, that does not mean LDL is the most important thing. That’s where the conversation, I think, fortunately is starting to shift, although again, not nearly quickly enough. But there was this recent paper published in JAMA, in recent, maybe in the past six months or something based on the Women’s Health Initiative study. They followed these women for 20 some odd years and they looked at what were the risk factors that were most predictive of someone getting a heart attack in the future? It wasn’t randomized study. It was just observational. But they said, “Okay, this many women had heart attacks. Let’s go back and see what the abnormalities were that were most closely associated with the increased risk.” LDL is on the list over the hazard ratio of 1.3 to small increased risk. It’s on the list. ApoB, a better measure than just LDL, but still measuring something similar was there at 1.7. The lipoprotein insulin resistance score, so meaning that basically the lipid findings most closely associated with insulin resistance and metabolic dysfunction, that was above 6. That was five times more predictive than LDL by itself. But yet, we talk about LDL at least five times more than we talk about metabolic dysfunction and insulin resistance. So, those are flipped.
Then if you look at disease characteristics, diabetes was a 10, metabolic syndrome was a 7, and hypertension was up there. These were all profoundly more impactful than LDL, yet LDL gets the majority of the conversation. Again, it’s not the LDL is nonexistent and is not on the list. It’s on the list. Just think it has to be put in perspective with metabolic health and other factors.
Cynthia: I think that’s really an important distinction. I know when I was still practicing for this large group, if someone had a heart attack, we got really diligent about looking at the overall LDL numbers. Tweaking and adjusting medications to get those numbers where we wanted them to be, convincing patients the statin-induced myopathies, the muscle achiness would get better with time. “Oh, we’ll put you on a different one.” But recognizing and the running joke in cardiology was we’re going to put statins in the water. I mean, no disrespect. For anyone who’s listening, it was a running joke, because they can be incredibly effective at lowering values you are looking at on a lab report. It doesn’t mean the patient feels good, it doesn’t mean that it’s impacting future events, etc. But one thing that I think is really important for people to understand is that, not all LDL was bad. There are advanced lipid analysis you were alluding to some of that.
Let’s unpack a little bit about there are different types of LDL, some are more atherogenic, some are more disease producing more inflammatory than others. If anyone’s listening, if they don’t have cardiovascular disease and you’re told that your LDL is high, these are the types of tests you should really have a conversation with your healthcare professional, how important these are to do. I myself have been called a lean hyper responder, despite having a super healthy diet and being metabolically healthy. We did the advanced lipid analysis and so, I just happen to be one of those people that has high LDL of 160, which sent my primary care provider into apoplexy until I asked for the VAP, to ask for this advanced lipid analysis. Let’s unpack that for listeners that they understand, appreciate why this is important to be able to have that advanced information.
Dr. Bret: Yeah. The testing comes by different names depending on which lab. It could be just advanced lipoprotein NMR, it could be a VAP like you mentioned. But the point is that you’re not just looking at the total amount of LDL cholesterol. But instead, you’re looking at either the ApoB or the LDL particle number, which are better markers than just the total LDL cholesterol, because you want to know how many LDL particles you have and how many will be called remnant particles you have, too. That’s where you start talking about the VLDL, which usually doesn’t come up on a regular test. Even more, so, it’ll tell you the size of the LDL particles. Because if there’s one thing you don’t want, it’s the small LDL particles, or the oxidized LDL particles, or the glycated LDL particles, which comes with higher blood sugar. Those are the things you want to avoid for sure. You want your LDL particles to be the larger, less dense LDL particles.
Now, there’s still plenty of debate within the cardiology world whether larger LDL particles are harmful in and of themselves and that’s whole another debate. But it’s clear, there’s no debate that you want to avoid the small particles and the oxidized particles. But how do you know that if you just get a standard lipid profile? Well, if your HDL is low and your triglycerides are high, chances are you’ve got the small particles, but you’re still guessing, and you’re not going to be able to follow it as closely. That’s why I think getting advanced testing is very important. One thing that’s interesting is, most societal guidelines for the American College of Cardiology, American Heart Association, they recommend against the advanced testing. From their perspective, it makes sense, because it doesn’t necessarily add to the question, does this person need a statin or not? That’s how you’re framing it. Do they need a statin and what effect does a statin have? All you really need to see is the LDL. That’s unfortunate. But if instead you want to know what impact is this person’s lifestyle have on their lipids, then absolutely, you need to know the advanced testing.
Because as we saw in the Virta Health trial, where LDL-C went up by 10%, with a low-carb ketogenic diet. LDL-C went up, ApoB did not change, and the calculated cardiovascular risk went down 12%. All you do is look at the LDL-C, you’re going to be like, “Lifestyle is not working. Sorry, it’s going the wrong way.” But if instead, you get more detailed analysis, you see that the ApoB is not changing, you see that the VLDL is going down, you see that the small LDL is going down, and you see that the calculated cardiovascular risk is going down, all of a sudden you say, “Huh, your lifestyle is working. You are getting healthier and reducing your cardiovascular risk, even though this archaic measure of LDL-C went up by 10%.” So, absolutely, when you’re talking about lifestyle, the advanced testing makes a big difference and I highly recommend it.
Cynthia: Yeah, absolutely. Because I had plenty of seemingly relatively healthy middle-aged men and women, who really had a strong desire not to be on statin therapy or on cholesterol lowering medication. This was very often a reasonable request. The other thing that I think is interesting is looking at coronary CTAs or CT angiograms for individuals that want to quantify whether or not they have any plaquing in their arteries. So, let’s talk a little bit about that. I got quite a few questions about that as well where people really want to understand what’s the value, can I ask for this, is it reasonable, I really don’t want to be on additional medication?
Dr. Bret: Yeah. First, I’m differentiating between a calcium score and a CT angiogram. Calcium score is pretty ubiquitous and anybody can really order one nowadays. Even if insurance doesn’t cover it, it should be about 100 bucks or something. It’s a quick test, you’re in and out, no IVs, no contrast, low-dose radiation. It will tell you, if you have calcium in the walls of your artery. It doesn’t tell you anything about the inside of your arteries, but it’ll tell you if you have calcium in the walls of the artery. If you do, the calcium likely got there because of vascular injury and healing response to that so that shows that there is atherosclerosis and that there is vascular injury occurring. Just having that puts you at a higher risk for cardiovascular events. Now, again, it’s all a prediction model. The higher the score, the higher the risk. Now, that’s different than saying the CT angiogram. A CT angiogram is a much more involved test and a better test for a lot of people. Maybe not for everybody, but for a lot of people, because what that involves is you do get an IV, you do get contrast injected. It’s a higher radiation exam, but still relatively low, especially when done in an experienced institution, who can modulate the dose and are very cautious about that. It will show you not just the walls of the artery, but the insides of the artery.
If you have calcium in the walls of your arteries, and is only in the walls of your arteries, and not causing any plaque in the inside of your arteries, that’s very different than if you have this mixed calcified plaque and soft plaque in inside the arteries. I get this a lot on patients that I’m seeing, because you have calcium, does that mean you need a statin? Well, it means you need to focus on lifestyle and reducing cardiovascular risk in a broad fashion. A statin may or may not be part of that. But if you have soft plaque in the lumen of your artery in addition to that calcium, for me, that’s a little bit more of a push that it’s an all hands on deck kind of treatment, which could include a statin in addition to aggressive treatments.
Now, is that completely evidence based, has that been looked at? Well, no, not really. Because let’s be honest, people aren’t looking for ways to not prescribe statins. Those studies aren’t being done very much. It’s mostly how to prescribe statins. Although, fortunately, we’ve seen this one trial at Walter Reed showing if your calcium score was zero or for these people in the study, if their calcium score was zero, their 10-year risk was unchanged, whether they were on a statin or not. At least, for that population, it’s good news that a statin didn’t seem to benefit anything. But CTA does give you much more information with a slightly higher radiation dose with a higher cost. If insurance doesn’t cover it, it could be $800 to $1,200. Most primary care doctors aren’t going to be comfortable ordering it. It’s a much more specialized test. Some will, but the majority of tests are likely ordered by cardiologists for that.
Cynthia: It seems completely reasonable. I know years ago, I would occasionally have, I refer to affectionately as the worried well. I’m sure that you have a few of these in your practice. They want it to be as absolutely clear about their risk profile even based, we would run the Framingham, like all this data that we would try to run for them, they still wanted to know with some degree of certainty. Before we wrap up today, I definitely want to touch on the issue with saturated fat. On so many levels, saturated fat has gotten such a terrible name and I still feel even on social media, even on Twitter, which tends to be the place, the manosphere, where there’ll be these very rigorous debates on what is considered or construed as safe, unsafe, whatever the dogmatic principles are that are embraced at that given moment. The joke now is becoming, even when you just provide anecdotal evidence for something that works with your patient population, they’re like, “What about a study? Can’t you quote a study?” I’d just try to explain to people that some of it’s just based on clinical practice. But obviously, you’re so well steeped in the literature, I thought it would be helpful to wrap up talking about saturated fat should not be demonized on any level.
Dr. Bret: Yeah. This is where people really lose sight of quality of evidence unfortunately. Because one, there’s no such thing as one saturated fat. There’s food that contains saturated fat. In these observational studies, how do you know if they’re eating a big plate of spaghetti with meat sauce that also got sugar, and not fillers, and all sorts of other things, or if they’re eating a spinach salad with grass-fed beef on it. Those are both saturated fat in these observational studies. Also, this whole concept of healthy user bias, so they talk so much about that you absolutely cannot control for. You cannot control for all the lifestyle factors that people have that make them health or unhealthy. If people are being enrolled in these trials in the 1980s, 1990s, and early 2000s, where the overwhelming message is saturated fat is bad, saturated fat is bad, well, who’s more likely to be eating saturated fat? The person who’s more concerned with their health or less concerned with their health? When you take the general population studies, then what kind of diet are they eating the saturated fat in? Caloric excess, combined high-carb, high-fat diets.
In that subset, we can say diets that contain saturated fats– the saturated fat-containing foods that are hypercaloric, high carb, high fats are bad diets. It doesn’t mean saturated fat is a bad food. Those are two very different statements. Then when you try and unpack that a little further, you can look at randomized control trials. The Cochrane Database did this review of randomized controlled trials on saturated fat-containing foods. There was no difference in who lived or died first of all. Whether you eat the most or the least saturated fat, no difference in who lived or died. There was a small difference in the risk of heart attack. Then when they looked at even further, though, that was only present when you compared the top to the bottom amount of saturated fat and LDL went up significantly. Now, we’re unpeeling the onion even more and getting down to, “All right, so, saturated fat is maybe only concerning in this one subset.” Of course, those tend to be hypercaloric, mixed high-fat, high-carb diets.
When you ask the question, is saturated fat clearly harmful across the board? The answer is no. We definitely do not have that evidence. There are observational trials showing that people eat more saturated fat have less heart risk. How do you explain that if saturated fat is such a dangerous food component? Then you have randomized control trials and intervention trials that don’t limit saturated fat. Let people eat as much saturated fat as they want that show health improvements with health improvements in diabetes, improvements in lipids, improvements in overall cardiovascular risk. How do you explain that if saturated fat-containing foods are so bad? We really have to first get away from talking about saturated fats. We have to talk about natural fats, because “Oh, we are right, saturated fat, a cake, and candy, and a baked good too or is it chicken, fish, steak?” Even olive oil has some saturated fat in it. In steak, it tends to be more monos than saturated anyway, especially if it’s grass-fed It tends to be a little bit higher in monos. This whole concept of saturated fat is off.
We’ve talked about the dietary context. If you’re not hypercaloric, if you’re eating relatively low carb, and you’re eating whole foods, there is zero proven risk to saturated fat-containing foods. I think that’s the message that– It took me what five minutes or whatever just to explain this. It’s so much easier just to say, “I avoid saturated fats, they’re bad,” [unintelligible [00:49:22] good. So much easier. Instead of me having to get all up in arms and raise my blood pressure trying to explain that saturated fats are not harmful for five minutes. It’s a big difference in the explanation. But that’s in my mind from what I see in the literature, that is the true explanation that I think is also most helpful for people. Because if eating steak, if eating cheese, if eating butter is going to help you stay on a low-carb diet that’s going to help you improve weight in a healthy weight loss manner, improve your metabolic health, feel good, feel energetic, then why would you want to avoid that? There’s no way evidence that you should.
Cynthia: Yeah, and I think the two things that are really critically important irrespective of gender life stage is sustainability and satiety. If you can make food satiating, truly satiating, like, “I’m full, I can’t eat another bite,” and it’s something you can sustain week after week, month after month, and feel good about yourself, you can come back to it after you’ve gone on vacation after the holidays, etc., then that’s really the sweet spot. For each one of us that may look a little bit different, for you it might be a little more protein, a smaller portion of healthy fats. For me, I do really well doing moderate carbs, low-ish carbs, and higher protein with some smaller plant based. I hate using it to describing plant-based fats, but my body prefers plant-based fats to animal-based fats. It’s just what works best for me. But finding that those two things sustainability and satiety are critically important.
Dr. Bret: Yeah, I agree so much. I agree so much. That’s how we got into this problem in the beginning by thinking there’s one diet for everybody. But that diet actually did not help people feel full. The diet increased hunger and that just set off a whole cascade of events. There’s this whole debate to the dietary guidelines caused the obesity epidemic and caused the diabetes epidemic. Well, it depends how you define that. It certainly set up the atmosphere for that to occur by making people hungry, by creating this whole influx of low-fat healthy treats. It created this atmosphere, because people were hungry and people had cravings. You’re right. It so important to address that with your diet. Animal-based foods or higher fat plant-based foods can be very important in addressing that hunger. So, absolutely, one of the key components to healthy nutrition.
Cynthia: Absolutely. Well, it has been a true honor and a privilege to connect with you today. Your podcast is fantastic. It’s definitely one that I listen to each week. How can listeners connect with you? What’s the easiest way to go about doing so?
Dr. Bret: Yeah, well, thanks. I really appreciate it. I love having this discussion with you and hopefully, your listeners enjoyed it as well. Best ways to find out more about me, a lot of my work now is at dietdoctor.com, where I’m the Medical Director there. I do still see patients in a virtual practice in certain states, where I have licenses. You can find more about that at lowcarbcardiologist.com. Then, of course, the podcast, The Diet Doctor Podcast and The Diet Doctor YouTube channel as well. I do a lot of videos there about like journal club-type articles, concepts, and news stories that are breaking that need a little further explanation I think you could say. So, yeah, dietdoctor.com and then the YouTube Diet Doctor channel.
Cynthia: So grateful for your contributions. Thank you so much.
Dr. Bret: All right. Thank you. It’s been a pleasure.
Presenter: Thanks for listening to Everyday Wellness. If you loved this episode, please leave us a rating, and review, subscribe, and remember, tell a friend. And if you want to connect with us online, visit the link in the show notes.v