Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr. Warrick Bishop and I'd like to welcome you to my podcast and videocast station. And today I've got with me Dr. Karam Kostner, friend and colleague, and we'll be talking about lifestyle and cholesterol. Welcome, Karam. How are you? Very well, Warrick. Thank you for inviting me to talk about this interesting and important topic. Oh, well, this is one that comes up all the time. It's really, really tricky. You give them a script full of drugs and advise them to go and take these things for the rest of their lives. And really what they want to know is what can they do to make a difference? So what about exercise? What do you say to your patients about exercise-related issues in lowering cholesterol and heart disease prevention? Look, exercise is very important to prevent heart disease and for people who survive heart disease. And it is obviously important for many, many different functions of our body. It can only be recommended, but it doesn't do much to lipids, interestingly. So it's good for your cardiometabolic fitness. You know, it's good for your muscle mass. It's good for your oxygen saturation in the body, but it only has a very small effect on bad cholesterol. And sure, it increases your good cholesterol slightly, but that is not as important as lowering your bad cholesterol. So it's good for the heart, but it doesn't do much to cholesterol. Probably lowers triglycerides, I think. And together with raising the good cholesterol, the HDL, it certainly does lose that tummy. They can tend to lower their triglycerides as well. That's true. If they lose weight, they certainly do that. Yeah. So exercise, certainly the information about it is that it's nothing but good for you. So you should do it. but it won't reflect in your lipid panel. Is that right? That's correct. So just on a personal note, when I speak with patients, I really do tell them that I'd love to see them exercising, but it's very hard to prescribe exercise. And I always say to them, it's so important to find something you enjoy doing. I can't possibly tell you to do 30 minutes of walking or 30 minutes of cycling or 30 minutes of rowing if you don't like. that particular activity, you'll never do it. You just can't sustain it. So I guess you're like me, when you're trying to find exercise for your patients, you want them to find something they enjoy and they can do four, five, six times a week if possible. Yep. So that brings us on to food and food comes up all the time and people want to know what to eat. And if you're... got a Facebook account, then people are always telling you what to eat. And there's so much information out there. So I'm going to just throw it wide open and say, well, Karim, if I was seeing you as a patient and my cholesterol was up and you wanted to get it down, maybe you've done a heart scan and I've got a lot of plaque in there and my cholesterol levels are elevated. You put me on some medication. I say, well, Karim, what else can I do when it comes to diet and eating to help my cholesterol? come down. Let's run that as a consultation. And that might be informative for people listening. Very happy to talk about that. Look, with food, it's important to realize food is very important. You know, food is medicine, as Hippocrates already said many, many centuries ago. But the problem with food is that there is so many people out there who make it confusing. And the other problem with food is that for a healthy individual who eats things in moderation, they can virtually get away with a lot more than somebody with heart disease and high cholesterol who is pre-diabetic, for example. So we almost have to individualize our recommendation when it comes to food. But today you asked the question about high cholesterol and food. And there is a couple of constituents in many diets that actively lower cholesterol. And I'll give you some example. Plant sterols are an example, for example. And fish is an example. And soy protein is an example. And fiber is an example. So diets that contain a lot of these ingredients will actively help by lowering cholesterol. And the best example is probably a portfolio diet, which was developed by Canadian GP. So it's called Portfolio Diet. It's a diet that is close to a vegetarian diet, but allows a bit of fish and other meats in moderation. But it's a diet that contains a lot of plant sterols, antioxidants, fish, dark chocolate. And with this type of diet, you can lower cholesterol by up to 30%, you know, which is almost like a weak statin. Yeah, okay. So avocados and nuts come up frequently in discussion. Absolutely. What have you said with avocado, nuts and say olive oil? Yes, they're all good fats. You know, they're all monounsaturated fats. They are sort of good fats as we classify them. Nuts have been shown by a colleague of ours, David Cajun, especially macadamia nuts to lower cholesterol and other nuts, slightly lower cholesterol as well. But avocado is also beneficial. It's a beneficial fat, as are some other constituents of a Mediterranean-type diet, for example. So when we're talking about these foods that can lower cholesterol, what are some of the foods that will raise cholesterol and throw my diet out the window? Well, that's a good and important question as well. Saturated fat, and that's been in the media and in various diets in the last couple of years. saturated fat is not good because the body can easily transform it into cholesterol and fatty acids and other fats. So butter, cream, fatty cuts of meat, fast foods and processed foods are not what I recommend to my patients because they not only increase your LDL cholesterol and triglycerides, but they also have pro-oxidative effects which render lipids more sticky to artery walls. Now, when it comes to cholesterol containing foods such as milk, eggs and cheese, we have learned that even if you incorporate these cholesterol containing foods in your diet, your cholesterol doesn't necessarily change that much because your body recognizes that it gets cholesterol with these foods and simply produces less cholesterol. Every cell in our body can produce cholesterol. And if you have an egg or two a day, the body will produce less cholesterol than if you don't have any cholesterol in your diet. It is a bit more complicated than that because some of us are very good absorbers of dietary cholesterol, which is about 20% of the population. And in those patients, cholesterol will increase a bit more than in the rest of us if we have too many eggs and too much milk and too much cheese. But generally, these foods can be recommended even in people who have high cholesterol. but it's more the saturated fats that are a problem in my opinion. Yeah, okay. Because we're seeing more and more people incorporating saturated fats in their diets when they move to some of these keto type diets. Correct. And they will actually lose weight on these diets short term. You know, it's difficult to adhere to these diets long term, but they will lose a couple of kilos and that will support them in continuing with these diets. which are often not very healthy long-term. So we're confounded with diets and the difficulty with getting good information about diets is actually collecting the data. And we were talking about this previously and the issues are tracking exactly what someone eats and food diaries and comparing, and it becomes very complicated, doesn't it? It does. And, you know, trials with pharmaceutical... With pharmaceuticals, you take a tablet or you take a placebo, the nurse counts the pills every couple of weeks, and we know exactly how many tablets people have taken generally and what happens. And it's all sort of in a very clear sort of format and concentration. With diets, it's a bit more complicated. I don't remember what I have eaten three days ago. You know, and a food diary that you write at the end of the day is not going to be as accurate as we want it to be in science. And that's where some of the controversies with these sort of food trials come in and difficulties come in. I think one of the difficulties with advising people is that often diets, particular diets are advocated as the right diet or the best diet. And they don't recognize that, as you alluded to earlier on, everyone's a little bit different. And everyone needs something specific or particular. And for example, I'm in my mid fifties and I just want to maintain my weight with a bit of exercise. And so what I would eat could be different to my son who's 17 and lifting weights and wanting to bulk up. And that could be different from someone who's 72 and diabetic. And that could be different to someone who's got renal failure. Do you see what I mean? And I think the, The thing that is very frustrating for me is the messages that come out advocate one diet is the right answer for everything. And yet I think exactly what you're saying is our requirement is to tailor a diet to an individual person's dietary goals on each occasion. Look, you're absolutely correct. I mean, that was a very good, very good summary. And the other problem, of course, is that the people that see you and me as patients who have cholesterol in their arteries, who have had a heart attack or a stand or are close to it, they need medication because diet is important, but it will take 15 to 20 years to reverse some of these changes with diet. And it's not going to be as effective as some of the medications. But if you're in your early 20s or 30s and you've got a mildly elevated cholesterol and you're obese and you want to make some changes and adopt a diet that leads to a healthy weight, absolutely. And in those patients, obviously, you've got much more time and they will obviously get away with just using a diet initially. But in many of our patients, it can be seen only as an adjunct to all the other things that we do. And yeah, that's the difficult thing about it. So we might wrap up there because this is a topic that could go on a long way. There's lots of twists and turns in diet and where it goes. But I think what we might do is wrap up there. I think we'll recognize that exercise is fantastic for your heart, for your mind, for cardiovascular risk. Doesn't alter your lipid panel or your blood results very much. Maybe lowers your... triglycerides and maybe raises your HDL, and that's a good thing. The food, probably steer clear of those saturated fats and focus more on the fats that are healthier. Nuts, olive oil, avocado, and look at fibery foods, oats. We talked about legumes or touched on legumes. I think you mentioned garlic. If not, we can throw that in the mix as well. Yeah, absolutely. Good, healthy mix of that. I often say to my patients, throw in plenty of greens as well, because whatever you do, I think eating greens is good for you. And I think, as you say, if your cholesterol is elevated and you've had a problem with your heart, you probably need to do these things and take a tablet. And if you're young enough to implement these changes before a problem, then you may well save yourself a problem in the future. It's an interesting space. That's a very good summary. Yeah, I would agree with that. Is there anything else you'd like to add? As your patient today, what would you like to say to me before you see me next? Your weight is normal, which is half the battle is won. Obesity is a big driver for cardiovascular disease and diabetes, so anything that works and helps you maintain a healthy diet is okay. If your risk factors are well controlled and you're seeing a cardiologist like myself or you, then, you know, you don't have to fuss too much about diet. You can have most things in moderation. And if you're really looking for a specific diet to lower cholesterol in primary prevention or as an adjunct, look at the portfolio diet because it's probably the best diet to lower cholesterol. And we'll talk about triglycerides separately. That should be a discussion in itself. Look, I might ask one passing question before I catch up with you in three months' time to check my cholesterol. What about alcohol? Can I drink alcohol? How's that going to affect my cholesterol levels? Look, that's also a bit controversial because in higher amounts, alcohol increases triglycerides in very large amounts and increases weight, you know, especially abdominal obesity. and increases cancer risk slightly. But alcohol in moderation, when it comes to lipids, doesn't do much. You know, unless you have hypertrichysteridemia and drink a lot of alcohol, it increases your HDL, which is the good cholesterol, a little bit. In moderation, especially as red wine, but probably also other alcohols, it does not pose a problem, in my opinion. Okay. But the problem lies with the moderation. Well, that's great to know because I might go and have a glass of wine at the end of the day. I might join you in a different part of the country. In a different part of the country. Karim, it's been an absolute pleasure talking to you. I'm going to wrap it up there. We've done about 15 minutes. We've done exercise and food, cholesterol. It's a great journey. I always learn some stuff. chatting with you this way. I hope those who are listening have got something from it. If you have any questions, please drop me a line at members at drorockbishop.online. If you've got any suggestions for future podcasts on the same address, please let us know. Otherwise, until next time, I wish you the very best and please don't die from a heart attack. Goodbye. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
