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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

Where To Find Dr. Tom Dayspring

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