How To Lower Heart Disease Risk Using Diet and Pharmaceuticals

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In part 2 of this two-part episode, Faraz Khan and Dr. Tom Dayspring discuss how to lower heart disease risk using diet, lifestyle and pharmaceuticals.

If you have not listened to part 1, make sure to go back and listen to that to get all the basics out of the way.

Dr Tom Dayspring is a pre-eminent world expert on lipids (that includes LDL, HDL, LDL particle counts, LDL particle sizes, ApoB) and so much more. Since heart disease is the #1 killer of Americans worldwide, it’s important for you to learn this information.

What To Do When Cholesterol and ApoB Numbers Don’t Match

If you have normal cholesterol and high ApoB, or high cholesterol and normal ApoB – then these numbers are discordant.
When particle numbers (ApoB, LDL-P) match up with cholesterol metrics (LDL-C, non HDL-C), they are said to be concordant
In the case that they are discordant, particle numbers are more accurate
So always rely on ApoB or LDL-P

How Is Cholesterol Carried In LDL particles?

Big LDL particles have more cholesterol on them
Small or dense LDL particles have less fat and cholesterol on them
LDL particles usually carry 80% cholesterol and 20% triglycerides
If there are too many triglycerides in an LDL particle, then these particles get depleted of cholesterol
When LDL particles are depleted of cholesterol, you need way more of them to carry the cholesterol
As triglycerides go up, you get discordance between LDL-C and ApoB
LDL particle number is the #1 driver of cholesterol into the artery wall

Does The Size Of LDL Particles Matter?

Some experts believe that having smaller LDL particles is more dangerous because smaller particles get into the artery walls more easily
However, people with small LDL’s are usually dealing with insulin resistance and a whole set of risk factors in their blood
Small LDL’s associated with diabetes and hypertension
Most people who have big LDL’s don’t have insulin resistance
The primary factor in heart disease is not size but number of LDL cholesterol particles
Could small LDL be more inflammatory?
It’s best to evaluate the lipid numbers keeping in mind all the metrics and the lifestyle of the patient

Are Your LDL Numbers Genetic?

It’s true – there is a genetic component of LDL
Genetics determines which proteins you make. These proteins can be lipoproteins.
However, lifestyle plays a part too.
Toxins, heavy metals and gut microbiome also factor into LDL numbers

How Does Your Diet Change Cholesterol In Your Body

Cholesterol in your diet may or may not be used by the apoproteins in your body
The vast majority of cholesterol is made by your own cells
80% of absorbable free cholesterol came from the liver and bile – and not from the food you eat
Most cholesterol from meat is deactivated form – it’s bound, not free cholesterol
This cholesterol cannot be absorbed unless your pancreas secrete a de-esterifying enzyme
The only people who have to worry about eating too much cholesterol are ones that have high genetic hyper-absorption
Fats handled differently from cholesterol
Fatty acids linked to different problems (esp. saturated fats, see below)

Why Do So Many People Have High Cholesterol?

Every cell in your body needs fats to make cholesterol
Saturated fat is worse than other types of fat for overproducing cholesterol
If your cholesterol gets too high in the cell, your cell transports it outside the cell into the HDL particles in serum
This causes the HDL’s to become bigger
First – big HDL deposits cholesterol to gonads and adrenal cortex
Second – HDL can also deposit cholesterol to fat cells
Third – HDL can deposit the cholesterol to the intestine to be excreted
HDL can also take cholesterol back to the liver – this is called direct reverse cholesterol transport
HDL can bump into LDL – and hand over cholesterol to LDL to transfer back to liver

So What Really Causes Atherosclerosis

LDL’s can attack and get inside the blood artery walls even without inflammation
LDL pass through the endothelium
Even though oxidative forces are bad, it is not the primary way
Enough LDL’s bind and becomes messes, the white blood cells attack them
This mechanism causes cytokine and growth factors to be released by white blood cells
Anyone with autoimmune disease has a high incidence of atherosclerosis
Inflammation is not required for atherosclerosis, but can exacerbate it
Bottom line of the story: Keep ApoB low, LDL-particle low and inflammation low as well

How To Lower Heart Disease Risk Using Pharmaceuticals?

It’s important to upregulate the clearance of ApoB the LDL receptors
The pharmaceutical drugs are ezetimibe, PCS K9 inhibitors and bempedoic acid
Induce LDL receptor up-regulation by liver
The extra LDL’s will grab the extra ApoB particles, internalize them or excrete them into the intestine
Some of the drugs listed above make the liver produce more LDL receptors
The other strategy is to make the LDL receptors last longer
All the drugs above don’t affect ApoB production very much
Reducing triglycerides can be helpful especially in insulin resistant people

How To Lower Heart Disease Risk Using Diet?

Low carb diet is helpful for insulin resistance
Mediterranean low carb diet can be helpful
When changing diet, retest markers in 2-3 months to review if diet has changed anything
A blood test measures if you are a hypersynthesizer or hyperabsorber of cholesterol
If you are a hyperabsorber – then not much can be done from a diet perspective
For overabsorber – Ezetimide would be drug of choice
If you are a hypersynthesizer, then reduce saturated fat in your diet
For hypersynthesizer – statins and bempedoic acid work well
Try reducing saturated fat and test again after 2 months