**EP403: 5 Things That Get Missed on Risk Assessments**
**Warwick:** G'day, it's Warwick here and welcome. My name is Dr. Warwick Bishop. I'm a cardiologist, I'm an author, and a keynote speaker. I'm the CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible. Heart disease is huge in Australia. Every 20 minutes, someone suffers a heart attack. Most of these could probably have been avoided if only we knew what to do.
This podcast is all about helping you understand blood pressure, weight, and cholesterol for better health. If you enjoy this podcast, I would be honoured for a five-star review. You can share it with your family and friends. It may well save someone you love. Welcome to my podcast and videocast station. I'm super glad you've tuned in.
Today is a really important one: five of the most overlooked health markers. Now, I don't want to sound like I'm on a soapbox, but one or two of these you may have heard from me before. So don't tune out; tune in. If you haven't actioned these, then pull your finger out and start to get organised. If you have, then think of someone who you can share this information with, so you can be an authority about telling them how they can look after themselves to get their own best health journey.
Well, it turns out that more often than not, people are thinking about cholesterol, weight, and blood pressure, and they're not thinking about these five markers that I'm going to discuss today. I'll tell you what they are at the beginning, I'll talk about each of them separately and in some detail, and then I'll tell you at the end a little tip or a bit of feedback from one of the podcast listeners who said I need to be organised and let you know what I'm going to tell you about, then tell you what I'm going to tell you about, and then tell you what I've told you about. So I hope that makes a bit of sense. If you've got any feedback, I'd love to hear it. You've probably noticed I try to take it on board.
Today, I'm going to talk about calcium scoring. I'm going to talk about insulin and a fasting test called HOMA, all in capital letters. You could pronounce that HOMA, but you could also call it a homeostatic metabolic assessment. We're going to talk about triglycerides, and in particular, the triglyceride to HDL ratio. We're going to talk about the very bad cholesterol—not the bad one, which is LDL, but the very bad one. I think we've got dibs when it comes to naming it the very bad cholesterol in our book, *Cholesterol Explained*. Karam Koster and I have been writing, and it may well be released by the time you're listening.
So, lipoprotein little a, number four, and we're going to talk about waist to hip ratio. So, the five things are calcium scoring, insulin resistance, triglyceride to HDL ratio, lipoprotein little a, and waist to hip ratio.
Let's jump into calcium scoring. Well, I bang on about this all the time, but truth be told, it is probably, in my opinion, and probably from the literature, the single most effective predictor for cardiac events that we have. And yet we're not using it routinely. How does that make any sense? We know that we've got 30-odd years of really robust data that when we do a coronary artery calcium score, if we find a zero score, almost regardless of other risk factors that individual has, then that person will have a very low risk over the next five years. It doesn't mean zero. You can't say zero. As soon as you do say zero, then in medicine, you get struck by lightning, but very, very low.
So, a zero score, we tend to say to people, "Come back and we'll do it again in five years." I'm not going to go into specific clinical depth here because, well, this is a 10-minute podcast and I don't really have time. But a zero score is a great reassurance and a great starting point.
The flip side is, if we do see calcium in the arteries—and remember, if you're wondering how does calcium end up in the arteries? What actually happens is that there's wear and tear within the arteries somewhere. That cholesterol moves in with some inflammatory cells as part of a healing process, as much as anything. And as part of that healing process, scar tissue can form, as you might be aware. With that, there becomes the focus or the substrate for calcium to be deposited. Calcium then gets deposited within an atherosclerotic plaque, or the plaque related to cholesterol. The inflammatory cells and a bit of scarring all together is the atherosclerotic plaque, so we can use calcium as a very sensitive marker of the presence of plaque. Plaque being that buildup, so a zero score generally tells us that there's a low risk of significant plaque in the arteries, and that person has a low risk for the next five years.
There may still be a little bit of plaque in the arteries but not calcified, so there's some limitation of the test. It's not as valuable in younger people because they may not have had the time to calcify their arteries, but nonetheless, it's a really important piece of information—a really useful test. Once we see calcium, though, here's the nice thing: we can break it down a bit. We can break it down into a little bit, or a lot, or something in between, and we can then start to measure that up and match that up with the person's other cardiovascular risk factors, whether they be their cholesterol levels, their blood pressure, or their diabetic status, and starting to pull as many pieces of information together as possible to inform our best decisions for the individual.
So, who should have a calcium score? Well, because of that lower age possibility of people not having had time to develop calcium in their arteries, generally the recommendation is 40 years of age and above, particularly if you have an intermediate risk on standard traditional risk factor calculation, or if there's a family history, or if there's some apprehension to cholesterol-lowering therapy. In my ideal world, unless there's a reason to do it earlier, such as really high cholesterol, really bad family history, or real concern about taking lipid-lowering medication, my ideal world would see men 45 to 50 have a calcium score as a rite of passage, and women 55 to 60.
The same, if my universe was the universe that existed when Shane Warne went through those ages, then I feel fairly confident to suggest we would have identified issues that could well mean he may well have not gone through the heart attack that he did and may potentially have even still been with us now. So, really, really important: coronary artery calcium score.
Let's go on to insulin resistance and fasting insulin and the HOMA, homeostatic metabolic assessment tool. I do this pretty routinely on my patients because I think it's super important. I don't believe you need to wait until blood sugar levels are elevated to worry about diabetes because I think insulin has a bit of play in the whole system.
So, what does that mean? Well, what we can do is measure a fasting blood sample, measuring insulin and glucose, and we put that into a calculation. That calculation is called a HOMA. And that HOMA is pretty neat.
What you need to do is multiply—oh, let me try and remember—you need to multiply the insulin in international units by the glucose in millimoles per liter and divide it by, well, who would have guessed, the number 22. Doesn't sound immediately logical, but people have done the research, and if you use that little calculation, you can get a really good feel for whether people are dealing with carbohydrates well and whether their insulin is working well or not.
This is super important because high fasting insulin levels are associated with metabolic gain, fatty liver, pre-diabetes, type 2 diabetes, cardiovascular disease, and all that metabolic syndrome that I've talked about lots of times before. Remember, though, that a HOMA—that insulin times glucose divided by 22.5—is not a standard test, and yet it's covered by Medicare. So ask for it. It won't put you out of pocket, and it's really informative. Super handy. Don't forget to write it down, and don't forget to ask your doctor so you can talk about it and get it done yourself.
The next of the five that we're going to talk about is the triglyceride to HDL ratio. This is really easy, and it's a powerful marker, again, of metabolic health. Now, the HOMA insulin resistance measurement will line up with this, almost certainly. If it doesn't, there's something wrong, but it will tend to line up.
So, you take your insulin level and you divide it by your HDL in whatever units you're using, and it'll give you a great idea as to what's going on. If your ratio is greater than 2 in millimoles per liter, or greater than 3.5 in milligrams per deciliter, then you quite possibly have insulin resistance. And that would therefore be reflected in your HOMA that we were talking about. But it knocks on to how your body handles carbs, your liver health, your lipid clearance, your weight, overall metabolic function, risk of high blood pressure, and diabetes. So keep an eye out.
One of the really interesting things that we cover in the book that's possibly just come out or about to come out, called *Cholesterol Explained*, which I wrote with my good friend, Dr. Karam Kostner, who's a professor of lipidology and cardiology, co-writer Penny Edman. One of the really important things that we flag is that triglyceride to HDL ratio, when you look at the particle size of the LDL particle. We know that the LDL, bad cholesterol, LDL particle can have different sizes. It can be small and dense, which tends to be a bit nasty. It can be large and fluffy—think balloons and happiness.
LDL, small and dense, honestly, it doesn't matter at the end of the day. If you've got too much LDL, you can be in trouble. But that separation between small dense and large fluffy is an extra add-on and problem for people who are worried about cardiovascular risk or the development of cardiovascular disease. And it turns out if your triglyceride to HDL ratio is less than 1.3, then almost all the LDL particles in your bloodstream will be the large, fluffy, or the better LDL particles to have.
Doesn't make them safe; it's better, but doesn't make them completely safe. And as you increase above that ratio of 1.3, you get more and more small, dense particles. One of the reasons that that's really important is many people seem to spend an awful lot of money on getting particle size measurements for their LDL cholesterol. It's a complete waste of time if you understand that simply looking at the triglyceride to HDL ratio will give you that answer without the cost.
Next, we're going to talk about lipoprotein A. We cover this in *Cholesterol Explained* because Karam Kostner is a world expert in LP(a), and guess what? So is his dad before him. This is genetic expertise in lipids, which is just amazing. What is lipoprotein little a? Well, it's a particle that looks a lot like the LDL particle, the low-density lipoprotein particle, which we call the bad cholesterol particle, but lipoprotein little a is the very bad cholesterol particle.
So, be aware of it. It is implicated in premature coronary artery disease. It's nastier than LDL cholesterol because it's stickier, more atherogenic. It can lead to clot formation. It can even cause events in people with normal-looking cholesterol levels. So this is a real nasty pass to keep an eye out for. Apart from causing heart attack and stroke, it's also in high levels linked to the development of aortic valve disease.
It's rarely tested, so if there are bad hearts at a young age in your family, please think about asking to get an LP little a done. I would tend to do it routinely for people who have really high calcium scores and no good explanation. The test in Australia is not rebated by a Medicare rebate, so you do need to shell out. It's about $65, but the really nice thing is once you've measured it, you're pretty well at that level for life. It doesn't go up and down a great deal. So, you know, spend the money if there's a reason, and you know where you are.
At the moment, there's no clear treatments for it. But Karam, Professor Kostner to you, is in the midst of involvement in trials testing these, testing a new, if you like, a new group of agents that look like they're going to be beneficial in lowering LP specifically. So keep an eye out.
Lastly, we're going to talk about waist to hip ratio. It does turn out that, in fact, your belt is a lie detector. In fact, it is the truth belt of your metabolic health. So if your belt is going out, if you are increasing your waist to hip ratio, you could be in trouble because waist to hip ratio predicts that fat that smothers your organs and strangles your organs when you're asleep and during the day. That's called visceral fat. That's the inflammatory stuff. It's nasty, and you don't want it.
That waist circumference is related to insulin resistance, inflammatory burden, cardiovascular risk, and dementia. It's just not good, and it's not sexy in your budgie smugglers. So be aware of that waist circumference. And I've touched on what to do if you think you've got excess weight, insulin resistance, or metabolic syndrome. It's reducing carbs, it's doing exercise.
If you want more information, I do have a weight loss course on my website, Dr. Warwick Bishop, and on the Healthy Heart Network website. Go to resources, check the drop box, go to weight loss course. It's about 20 bucks, but it's got videos, hints and tips, lots of explanations. Watch your waist; watch the hazardous waste, I could even say.
So, bringing it all together, what are the big five that you need to look out for? Well, look out for getting a calcium score. Check that insulin resistance by the HOMA test and your triglyceride to HDL ratio. Think about lipoprotein little a—it runs in families. Could it run in yours? And watch that hazardous waste.
So, I hope that helps. Dig deep. Look after yourself. Simple habits that are sustainable can make a massive difference. I'm going to talk about sauna in one of the podcasts around this series. So if you are interested in sauna—or sauna, if you're from that part of the world and that's the way you say it—I'm going to try and find 10 benefits for you.
So, till next time, please share this with someone you care for. Please maybe leave me a nice review. Please live well. Continue to be interested in your health, and I hope you live as well as possible for as long as possible. Take care and bye for now.
