# The LDL Theory Is Falling Apart — Focus on THIS Instead | Dr. Aseem Malhotra

**Channel:** Jesse Chappus
**Source:** https://www.youtube.com/watch?v=XtiPC5xMJpI
**Transcript page:** https://www.withtranscript.ai/video/XtiPC5xMJpI

## Chapters

- 0:00 — Rethinking LDL, Statin Benefits, Side Effects
- 7:29 — Familial Hypercholesterolemia, Lp(a), and Risk Markers
- 14:23 — Statin Inflammation, Benefits, and Risk Communication
- 20:04 — Pharma Influence and Insulin Resistance Hypothesis
- 24:33 — Metabolic Health, Diet Intervention, and Plaque Dynamics
- 29:31 — Limitations of Stents and Lifestyle Pillars
- 34:30 — Exercise Moderation, Smoking Cessation, and Stress
- 38:36 — Plaque Reversal Study and Raj Yoga Meditation
- 45:51 — Diet Strategies, Processed Foods, and Lipid Markers
- 52:36 — Essential Tests: Lipids, Blood Pressure, and Imaging
- 58:09 — Calcium Scoring, Plaque Stability, and Surrogates
- 1:06:40 — Fasting, Microbiome, and Supplement Recommendations
- 1:13:28 — Personal Journey: Cardiologist to Health Advocate
- 1:21:42 — Advocacy Backlash and Medical Persecution
- 1:29:17 — Policy Influence and Pharmaceutical Critique
- 1:32:29 — Final Dietary Guidance and Key Takeaways

## Transcript

**[0:00] Speaker A:** I trained as an interventional cardiologist. I love solving puzzles. When you've eliminated the impossible, whatever remains, however improbable, must be the truth. Guideline bodies still say that LDL cholesterol is the primary causative risk factor for heart disease. I'm coming here and saying at best it's a weak risk factor, at worse, it's not a risk factor at all. Chronically raised insulin is directly toxic to the inner lining of the coronary arteries, which is how heart disease develops. The furring of the arteries, this so called plaque buildup, these fatty deposits of immune cells and cholesterol, which are likely arriving there as a response to injury, not as the caus of the injury. And therefore the approach should be to try and manage insulin resistance. But from a drug perspective, no drug has really been developed to show improved outcomes with that. Two markers of the cholesterol profile which I think are reflective of insulin resistance, those are triglycerides.

**[0:46] Speaker A:** So these interventions for lifestyle rapidly improve your metabolic health and mental and physical health too, within weeks. Do it for six weeks. You will see a difference at the end of six weeks that will make you sustain it afterwards.

**[0:57] Speaker B:** Aseem, we've had major advances in cardiology over the years, widespread use of statins, yet cardiovascular disease still remains the number one killer worldwide. Why is this?

**[1:09] Speaker A:** To answer your question directly, Jesse, it's because the benefits of statins are very, very marginal. And essentially, if one looks at population data, certainly within Europe, there was a study published in the BMJ a few years ago that looked at whether millions more people being prescribed statins in the population had any impact on cardiovascular mortality, and they concluded it did not. And one can explain that when you look at the fact that from the randomized trials conducted by drug companies, which by definition are going to exaggerate the benefits because they are selected patients and who are least likely to get side effects, et cetera, the median increase in life expectancy over a five year period, even in the highest risk groups of people, those are people who've had heart attacks, is just over four days. When you combine that with the fact that real world evidence tells us that even in those high risk groups, up to 50%, maybe more of those patients stop taking their statins within a couple of years of prescription, you can actually give a rational explanation for why statins have not had an impact on cardiovascular mortality in the population.

**[2:29] Speaker A:** So their benefits are very, very small when you look at population health.

**[2:34] Speaker A:** And they are massively overprescribed because of the fact that Both the doctors and the patients have an exaggerated view of their benefits in their head.

**[2:44] Speaker B:** Okay, given what you just said, is this starting to make a turn for the better?

**[2:48] Speaker A:** Interesting. Really good question. I would have hoped so, Jesse. And certainly pre pandemic there was a shift I felt in part because of the work of myself and many other people in this space to highlight this gross exaggeration of the benefit of statins and the underappreciation of quality of life, limiting side effects to the extent where in 2015 or 16, if I remember correctly, there was a U turn on a recommendation that essentially everybody over 50 should be prescribed statins from the General Practitioners Committee, the Primary Care Physicians Committee, who basically partly because of a campaign, in main part because of a campaign I was part of, to say, hold on, giving more people statins is, is ultimately going to potentially have a net negative effect on society because one, people at low risk don't get that much of a benefit. It doesn't reduce mortality rates in that group.

**[3:48] Speaker A:** Side effects are significant and will actually increase load on primary care because of patients coming with side effects and also distraction from lifestyle, which we'll talk about later. And there was a shift, I think, towards people becoming more aware of it. But as I predicted, because the people who have the most power and control are essentially these big corporations, these pharmaceutical companies whose primary motive is to make profit when the pandemic happened.

**[4:23] Speaker A:** And the conventional narrative, we won't talk about that in any detail now, but the conventional narrative was that Big Pharma came and saved the day through their Covid vaccines. I predicted that they would then capitalize on that narrative by pushing their most lucrative drug, which are cholesterol lowering drugs, including statins. So I'm now seeing more and more people coming to me who are being told, who otherwise wouldn't have been told by their primary care physician in the US I see international patients through telehealth saying that they have been told they've been fear mongers. Fear mongered into going on a statin because of high cholesterol. Right.

**[5:04] Speaker A:** So I haven't got the actual data to see what's happening in prescription patterns, but what I'm observing is an increased push now to get more and more people on cholesterol lowering drugs.

**[5:16] Speaker B:** Okay. So we know they don't work very well. We know that you quickly mentioned they can deter from adopting a diet and lifestyle that could truly get to the root of this. You mentioned side effects.

**[5:28] Speaker B:** Let's go deeper into those and what people experience and how frequently.

**[5:33] Speaker A:** Yeah, so in terms of the. I'll reinforce this so we don't get misquoted or misrepresented. The side effects of statins are not life threatening, but they're quality of life limiting. And actually that's just as important, if not more important for most people. We're all going to die at some point. We want to have a good quality of life, right? But those quality of life limiting side effects, the most common are fatigue and muscle pain, which we know mechanistically now is probably because of statins causing mitochondrial dysfunction. So, and they, in my experience, Jesse, I would say I see anything from 20 to 50% of people at some point, at some point will experience a side effect from statins. In terms of the true prevalence, that's an area of controversy.

**[6:26] Speaker A:** Data does suggest anything from 10% up to 50%. There is, there are particular people who are more at risk of statin side effects, which I cover in my book A statin for your life. And they include people who are over 70. If you have a low body mass index, if you do a lot of exercise, if you have a vitamin, vitamin D deficiency, those are the types of groups of people that tend to have more like to. If you're of South Asian ethnic origin.

**[6:54] Speaker A:** So there's a large group of people that are vulnerable to side effects. The good news is they're reversible and people notice a difference from stopping the statin or lowering the dose within a couple of weeks. So if one isn't sure, one could just stop the statin for a while because the benefits are so small over a long period of time, they're essentially completely safe to stop. Not that I'm advising people to do that without talking to their doctor or making an appointment with me. So a proper informed consent discussion can happen.

**[7:21] Speaker A:** But that's the general, that's the general advice.

**[7:29] Speaker B:** So far our focus has been on the general healthy, you know, not healthy, but general person. What about people with fh? They have a genetic predisposition to high cholesterol. Any statin advantage there.

**[7:43] Speaker A:** Another really important group that we need to talk about. So fh, for people that don't know what that is, is familiar with hyperlipidemia. It's a genetic condition which affects about 1 in 250 people. And in those people they have genetically high LDL, so called bad cholesterol. And that's usually at least above 190mg per deciliter, or in UK terms, 4.9 millimoles per liter.

**[8:10] Speaker A:** And those people, on average tend to develop heart disease prematurely from original data that we've seen over the years. However, within that average increase in heart disease prevalence in that group of people, they're not homogeneous. There are different subgroups within those. Right. And just to give you some perspective, 70% of women and 50% of men with FH will not develop premature heart disease.

**[8:46] Speaker A:** We did research published in BMJ Evidence Based Medicine to try and see what was the defining characteristics or risk factors of the groups that developed heart disease with FH1 versus the ones that didn't. What we found is if you had no markers of insulin resistance, if your insulin levels were low and you had a normal waist circumference, your risk of developing heart disease with FH was only slightly higher than a healthy person with optimal metabolic health. In the population we found there was no difference in the LDL levels between the groups that got heart disease versus the ones that don't. Which again is another nail in the coffin for the LDL cholesterol heart disease causing hypothesis this. But the one key difference was lp.

**[9:28] Speaker A:** So lipoprotein AA seemed to be abnormal or high in the people that develop heart disease with FH versus the ones that didn't. So the conclusion is this. It's a nuanced approach. One size doesn't fit all and automatically people with FH shouldn't necessarily be going on statins at all.

**[9:46] Speaker B:** Talk more about the LPs in this respect and then beyond.

**[9:51] Speaker A:** Well, in this respect I think we know that it's a sub fraction, it's kind of a subfraction of ldl. Interestingly, when people's L, there's lots of other data about LDL not being causative in heart disease, including when you exclude LP from the equation as being abnormal. As a subfraction of LDL as a type of LDL particle, LDL is not a risk factor. That's just one bit of data. But there's also other data showing LDL is in the risk factor.

**[10:17] Speaker A:** When you correct for triglycerides in hdl, LDL is not a risk factor in my view, or worst is a minor risk factor, but effectively becomes irrelevant in other contexts. It's a really interesting one. I see patients all the time who come to me with this question about lp. And certainly observational epidemiological studies do show that as LP is higher, the higher the LPA goes, the increase your risk of cardiovascular event. But again, this is in a general population.

**[10:47] Speaker A:** I'm not aware whether this has been studied in people with normal triglycerides and hdl. I'm not aware of a paper on that. And it could be that it gets negated and therefore we can ignore it. But more important than that, Jesse, is one of the most important things we're taught in medical school, which I think many doctors are losing sight of partly because of a commercialized system which makes sense and is rational. Don't organize a test unless it's going to change your management plan.

**[11:17] Speaker A:** At the moment, we don't have any data on outcome benefits of lowering lp.

**[11:25] Speaker A:** Now, low carb diets apparently do lower LP to different degrees, but the question is, what do we do with that other than scare the patient saying they're slightly higher risk? What we need is some good quality data saying from a randomized trial, from an intervention, whether it's a low carb diet, whether it's a drug that when we gave patients with L.P. that was high, this intervention, we reduce cardiovascular events. We don't have that data yet.

**[11:58] Speaker A:** Bottom line, Jesse, is it can be part of an assessment tool. I think it's useful, but I think that we have to look at everything else. Markers of insulin resistance, for example, markers of chronic inflammation like high sensitivity crp. And then we paint a whole picture. And then of course, you've got calcium scores, which is great if you're over 50 as a male, over 50 as a female, very well validated test to tell you essentially whether you've got any buildup of plaque in your arteries, but also gives you a predictive score better than any other test of a heart attack or stroke risk in the next decade.

**[12:37] Speaker A:** So what I will do is then use all of this information and then you have a conversation with the patient to make a plan around lifestyle, essentially and drugs if necessary, but it's usually lifestyle.

**[12:48] Speaker B:** You mentioned inflammation there and I've heard you talk about statins, the benefit there likely being from their anti inflammatory effect or anti clotting. Yes, bring that in.

**[13:00] Speaker A:** Well, heart disease actually is more likely described as a chronic inflammatory condition that is influenced by clotting factors and insulin resistance. So those are the three major inputs which are slightly overlapping.

**[13:12] Speaker A:** Because you combat the insulin resistance, clotting actually gets better. You can't combat the insulin resistance, the inflammation also gets better. Okay, so in terms of the statins. Yes. Myself and two of the cardiologists in 2021 published a systematic review in BMJ evidence based medicine, looking at 35 randomized controlled trials using statins, using some of the new injectable cholesterol lowering drugs and ezetimibe which is a drug that stops the absorption of cholesterol into the bloodstream.

**[13:47] Speaker A:** And we found there was no clear relationship with lowering LDL cholesterol and preventing cardiovascular events, which completely goes against our indoctrination as doctors, as medical students, that the lower the ldl, the better. And of course, that information has come from biased research funding, essentially, in my view. So I think it's not an independent analysis. We did an independent analysis. We could be wrong, but certainly we are not connected to the drug industry. And this is what we found was peer reviewed, et cetera, and it does fit with the other data we've already talked about.

**[14:23] Speaker A:** So therefore, yes, heart disease is more likely described as a chronic inflammatory condition influenced by those factors. And therefore anything that lowers inflammation potentially could give you cardiovascular benefit. Statins are the drugs that have been most tested in randomized trials that give you that small benefit. 1 in 100 if you're high risk, primary prevention or low risk, 1 in 39, preventing a heart attack over five years if you've had a heart attack already.

**[14:50] Speaker A:** But what we do know about statins is you're absolutely right, they do have anti inflammatory and anti clotting properties, which is likely where you get that small benefit.

**[14:58] Speaker B:** I think at this point, it's important to point out you are a cardiologist who bought into statins fully at one point in your career, and now that you've had time to fully dig into the research and dive deep for the truth here, only then has your position pivoted.

**[15:16] Speaker A:** Yes. Oh, yeah, absolutely. Jesse. I was probably, you know, I was in traditional follow the evidence, which means I would read up on guidelines. I was obsessed with patient outcomes. And actually, I remember when I worked as a junior doctor in Manchester where I did my initial training before I started my sub specialization in cardiology, I was the golden child of the junior doctors amongst the attendings because I was on it all the time with my drug prescriptions, even prescribing statins to patients in the ER before they're about to go to the cardiac catheter lab to have an angiogram for a suspension suspected heart attack. So that was me. Absolutely.

**[16:01] Speaker A:** And it was only through my clinical experience over time and seeing patients coming in with what I was diagnosing as clear side effects, that I started to look into the data a bit more and realized that, you know, we've got this cholesterol hypothesis very, very wrong.

**[16:16] Speaker B:** Now, with your new perspective, if you were forced to flip the script and argue for statins, is There anything there?

**[16:25] Speaker A:** I think it's about giving the right patient the right treatment at the right time. I would argue for informed consent and that's what I do with my patients. So if a patient comes in the way to approach this, which is actually the gold standard of ethical evidence based medical practice and informed consent, which by the way is not the default for 99.9% of doctors because we're not conditioned to explain information to patients in the way they can understand that is more honest and ethical in terms of the benefit of the drug is telling patients who are highest risk based upon industry. So you also have to express uncertainties in what we call shared decision making. So I will say to a patient and even my letters, I write this back to primary care physicians when they come to see me as a specialist. Right. Based upon, I use these words based upon industry sponsored data that has not been independently verified and therefore likely best case scenario in selected patients who didn't get side effects over a five year period, taking a statin religiously every day will give you a 1 in 39 benefit in preventing a heart attack and 1 in 83 benefit in delaying your death or saving your life.

**[17:42] Speaker A:** That's before we even talk about side effects.

**[17:44] Speaker A:** And by the way, the side effects, the one clear one which is now accepted in literature, 1 to 2% of those patients will develop type 2 diabetes, probably reversible, but still not ideal from taking a stand. So that's the information I'll give to patients and they will come back with an answer. Now many of those patients just say, okay, I'll take my chance, I'm high risk or whatever else. But many say no. They say, doc, I don't fancy those odds. Is there anything else I can do? That is my approach rather than a black and white, take a statin versus don't take a statin.

**[18:14] Speaker B:** One thing I think it's important we point out is absolute versus relative risk and how statistics can be manipulated for outcomes to look a lot better than they are.

**[18:28] Speaker A:** Yes. So in simple terms, if you look at a trial, let's just say for example, you have a trial, a randomized trial, two groups of 100 people, okay? They're all matched for age. Say they're middle aged men, right? All matched for age, risk factors, etc. And you follow them up for five years in one group you give them the statin and the other group you give them a placebo, a dummy pill if you like. The patients don't know what they're getting, right? So it's what we call just to remove the chance of bias, a double blinded randomized control trial. You follow them up for five years. In the group that took the placebo, essentially the dummy pill, two out of 100 of those people who were followed up developed a heart attack. And the people that took the statin, one of them developed a heart attack.

**[19:15] Speaker A:** So you've reduced.

**[19:16] Speaker A:** The relative risk reduction is you've reduced the risk of a heart attack by taking a statin by 50%. Basically one out of two over 100, right? 50% less likely to have a heart attack. That's what we call relative risk reduction. And people aren't told, they're just told, oh, if you come in as a patient, if you take this pill, you're 50% less likely to have a heart attack. It sounds great. So in people's minds, it exaggerates the benefit of the pill, but the actual true benefit is only 1 in 100. You've had to treat 100 people with a statin for one of them to benefit. You don't know who that one person is going to be. And that's what you should be telling patients. You should be saying your absolute risk reduction or numbers needed to treat is 1 in 100, which means 99% chance it's not going to give you any benefit whatsoever.

**[20:02] Speaker A:** It's another way of looking at the statistics.

**[20:04] Speaker A:** But patients are not told that, and I think they're not told that, mainly because when patients are fully informed, they choose less treatments, Jesse. And that's not good for the drug industry, who are essentially, in my view, a tyranny. They are, you know, we're living in a corporate tyranny.

**[20:21] Speaker A:** They have the most power. They exert their power not just to enhance their profits, but if people challenge them or tell a greater truth or give an alternative, and I've been a victim of that. You Google me, you'll find on my Wikipedia page you'll see smears about me. This is part of their modus operandi to essentially discredit people like me if they can. So that the narrative is continued along the lines of statins are life savings.

**[20:52] Speaker A:** Cholesterol is a major risk factor for heart disease. You've got to get it lower, et cetera, et cetera. But you know, it's not the truth, it's a manipulation. And our job, my job as a doctor, my duty is to do improve my patient outcomes by practicing ethically to maintain trust and for us to progress as a society for health purposes. So that's my line. That's what I'm sticking to.

**[21:18] Speaker B:** And to make it clear, you're not somebody who's saying don't take a statin. You're just saying I want to really look at the research and find out the truth here.

**[21:27] Speaker A:** Absolutely, 100%.

**[21:29] Speaker B:** Well, given everything we've gotten into to this point, we really got into the weeds on statins.

**[21:33] Speaker B:** Let's zoom out, look at the macro and talk about the 30,000 foot view of statins.

**[21:41] Speaker A:** Yeah. So it's one of the most prescribed lucrative drugs in the history of medicine. It's estimated between 200 million and 1 billion people globally are prescribed statins. Jesse. And I can guarantee you that the overwhelming majority of those patients, if not all of them, don't know the true benefits and harms of the drug. That's what we're talking about here. This is not small fry. This is a really big deal.

**[22:11] Speaker B:** Okay, let's talk about heart disease now in a conventional sense, how conventional doctors look at that disease forming in the body.

**[22:21] Speaker B:** And then we're going to dip into your alternative view on the real cause.

**[22:27] Speaker A:** Yeah, I think that the conventional view is still, you know, guideline bodies still say that LDL cholesterol is the primary causative risk factor for heart disease. I'm coming here and saying at best it's a weak risk factor, at worse it's not a risk factor at all. So that's quite a jump. Right?

**[22:49] Speaker A:** So the, you know, what my research, what other people's research has shown, extensive research, not just based upon cherry picking one bit of data. It's like looking at the totality of evidence. Right. There's not about selective reporting. I think the people who are pushing this narrative have engaged in selective reporting because of ideology, because of a fixed view.

**[23:15] Speaker A:** We've got to remember, you know, certainly amongst medicine, unfortunately, changing one's mind can be quite difficult. Even though it's part of evolving science and good practice. Just because we're human beings, that's part of being human. But what actually is at the root of heart disease, which is not being challenged, it's just there's no market for the message is insulin resistance essentially your body becoming resistant to the hormone insulin over time, which we know through different mechanisms, is directly, chronically raised. Insulin is directly toxic to the inner lining of the coronary arteries, which is how heart disease develops. The furring of the arteries, this so called plaque buildup, these fatty deposits of immune cells and cholesterol, which are likely arriving there as a response to injury, not as the cause of the Injury and therefore building up these pimples or whatever you want to best to describe it for a layperson.

**[24:12] Speaker A:** Within the inner lining of the artery, insulin resistance drives that and probably responsible. I think certainly some studies suggest that in 86% of people, some degree of insulin resistance who've had heart attacks, some degree of insulin resistance is there.

**[24:33] Speaker A:** And therefore the approach should be to try and manage insulin resistance. But from a drug perspective, no drug has really been developed to show improved outcomes with that.

**[24:44] Speaker A:** But there is a lifestyle approach which we know is effective. And that's a. Basically the very simple way of putting it is a low carb diet. Low carb diet is the best proven dietary intervention, any lifestyle intervention, actually to rapidly improve markers of insulin resistance, which include basically blood pressure, glucose through HbA1c, which is a marker of prediabetes or type 2 diabetes. Two markers of the cholesterol profile which I think are reflective of insulin resistance. Those are triglycerides and hdl. So you want triglycerides to be low, HDL to be high, so called good cholesterol and waist circumference. That's your belly fat and your visceral fat. And if all of those are in the normal range, you have minimum insulin resistance. If not normal levels of, you're not insulin resistant.

**[25:36] Speaker A:** And it's called optimal metabolic health. And 93% of adult Americans now, Jesse, have suboptimal metabolic health. And what's interesting about metabolic health is it isn't just the main driver of heart disease, it's also after smoking, the main driver of cancer and also the most important risk for developing Alzheimer's disease as well. So it's important. That's what we should really be focusing on with lifestyle.

**[26:10] Speaker A:** And I think if we do that, we'll get better outcomes. Now why am I saying, why am I not guaranteeing better outcomes and saying it's most likely is because we don't have the highest quality level of evidence in terms of randomized controlled trial data saying that we'd intervened on insulin resistance and we follow those people up. That hasn't been done as far as I know. It might be studies ongoing because obviously that needs funding, et cetera, et cetera. So who's going to profit from that?

**[26:35] Speaker A:** To tell people to avoid ultra processed food and sugar, eat steak and vegetables and improve your gut microbiome, who's going to benefit from that financially? So this is part of our screwed up corporate capitalist system. Unfortunately, Medical knowledge is under commercial control, but most doctors don't know that and that Knowledge base amongst doctors is coming from people producing products to sell you, essentially.

**[27:08] Speaker B:** So if we zoom in on the vessel, you mentioned insulin resistance.

**[27:12] Speaker A:** Yes.

**[27:12] Speaker B:** So we have elevated blood glucose causes elevated insulin.

**[27:17] Speaker A:** Yeah.

**[27:17] Speaker B:** When it comes to that micro damage in the vessel, is it both of those that are causing it?

**[27:24] Speaker A:** Great question. Probably, yes.

**[27:27] Speaker A:** Interestingly, when I did my research during COVID because I wrote a book called the 21 Day Immunity Plan, and I did a lot of work being an advocate to try and understand what were the lifestyle risk factors for Covid. One of the most interesting papers I found, again, it's mechanistic, but it's interesting is that one high starch or glucose meal or sugary meal independently of. Of so raised insulin and glucose independently. They affected markers of clotting. So glucose raised on its own without raise insulin interferes with clotting in an adverse way, increases the clotability of the blood. And the same thing happens with raise insulin. So I think it's probably both. There are multiple mechanisms. Insulin, for example. Raise insulin will cause the, the, the, the, the.

**[28:18] Speaker A:** The first cell to be affected on the inner lining of the arteries is called the endothelial cell. So dysfunction of the endothelial cell, which produces something called nitric oxide, which helps dilate the vessel. And if the vessels are not able to expand or dilate, they're also more likely to get stiff and more likely to get damaged. The endothelial dysfunction is the beginning of coronary arteries developing. And those are those things you've talked about, including smoking, including chronic stress, which we'll. We'll come on to. The other interesting thing that a lot of people don't know about, Jesse, is this clogged by pipe hypothesis is they think that heart disease is gradually progressive over time, and then it becomes, you get. And over time it becomes completely blocked and then you have a heart attack. That isn't actually what happens. Number one, it's not chronically progressive necessarily.

**[29:10] Speaker A:** It's. It's actually, it's dynamic and it can reverse, which I'll explain a bit a little about later. So please remind me about that. But the other interesting thing is most heart attacks happen at blockages that are not severely narrowed. A severe narrowing is considered about 70% blocked.

**[29:31] Speaker A:** That's physiological. That when you. When the demand on the heart muscle increases from, say, exercise, that's when the blood supply doesn't meet the demands of the heart muscle in terms of oxygenation, when the vessel is more than 70% block. And that's when people get what we call angina Chest pain. But the blockages that are likely to rupture, like pimples bursting and cause a complete blockage, which causes a heart attack where the blood supply is completely reduced for several minutes.

**[30:01] Speaker A:** And then you get damage to the heart muscle, which is a heart attack. Essentially 86% of those plaque rupture causing the heart attack happen at blockages that are less than 70%. And that's probably one of the main reasons why heart stents. And I trained as an interventional cardiologist, essentially keyhole heart surgery, putting in these little metal scaffolds and expanding them in the artery where the blockages are. Those stents do not prevent heart attacks in people who have what we call stable disease, stable angina.

**[30:33] Speaker A:** So blockage is over 70, 80, 90%. Because one, that blockage that's 90% is not the most likely to cause a heart attack. Two, you're disrupting the vessel when you actually put the stent in, and that causes a heart attack in maybe 1% of people. And then you're ignoring. You're not managing where the another plaque, which might be 20 or 30%.

**[30:54] Speaker A:** And putting a stent in there doesn't do any benefit either. Anyway. You wouldn't do that because you're going to cause complications of the procedure overall if you start stenting people with the significant blockage and you don't know which one's going to rupture anyway. Okay. Those are the plaques that cause the, you know, the heart attacks.

**[31:11] Speaker A:** So what we need to do is, and this is what I've written about, is we institute a lifestyle approach which is likely to pacify all of those plaques and potentially reverse them and reduce the risk of a heart attack occurring.

**[31:23] Speaker B:** Okay, so far, what we have, insulin resistance causing the pimples in the vessel.

**[31:28] Speaker A:** Yeah.

**[31:29] Speaker B:** We can get rupture more likely in the smaller ones. Do we know what actually triggers that rupture?

**[31:36] Speaker A:** We don't. It's like a ticking bomb. It's something that just builds up over time. But, you know, things like stress can trigger it for sure. A lot of people suffer a heart attack after a life event.

**[31:49] Speaker A:** So it could be that there's this when then suddenly a stressful event, you know, a high carb, sugary meal theoretically could, as we've talked about, increasing the clotability of the blood. Right. So I think those are the kind of things that will trigger it for sure.

**[32:05] Speaker B:** One of the things the body does as it incurs blockages is forms, collaterals. Talk about this safety mechanism that our body uses.

**[32:15] Speaker A:** Yeah. So actually it's a great point because as I talked about earlier, there was a thinking that these clogged pipes develop over time and then you get 100% blockage and then you get a heart attack. That rarely happens. If it's increasing slowly, if that blockage is occurring over time slowly, and it doesn't rupture, becomes a stable plaque. What happens is the heart adapts and there are extra vessels that grow to bypass that blockage.

**[32:42] Speaker A:** And I've done angiograms in patients, for example, that have got a complete. No heart attack, a complete blockage of one of their three major arteries. There are three major sort of arteries, the left anterior descending, the circumflex and the right coronary artery. And I've seen people with right coronary arteries completely blocked, but the left anterior descending has got an extension to it that overcomes the blockage of the right coronary artery. And those are collateral vessels. And that's fascinating, fascinating to see. They'll probably give some protection to those people. But you can't predict. You can't predict necessarily. We don't know how do you increase collateral flow.

**[33:20] Speaker A:** But it's just, it's like an adaptation mechanism. For some people. The key thing is to avoid heart disease in the first place and then potentially reverse it or manage the risks.

**[33:30] Speaker B:** Well, let's jump into reversal. Somebody is developing these pimples, either small, large, at that point, what's the best they can do to reverse that?

**[33:40] Speaker A:** In my patients in general terms, Jesse, I look at four things. I look at the diet. So we get them on a diet that's anti inflammatory, low carb. Because part of the puzzle of heart disease is chronic inflammatory. And looking at the best data we have, I know nutrition science isn't great, but the best available evidence, and that's why I write about my book, it comes from some benefits, clearly from the traditional Mediterranean diet.

**[34:08] Speaker A:** So it's extra virgin olive oil, it's oily fish, and the omega 3s from that, it's, you know, polyphenols from non starchy vegetables, it's nuts and seeds, and it's minimizing the starch and the sugar. So I call it a low carb Mediterranean diet. That's my first line approach from a diet perspective.

**[34:30] Speaker A:** It's not being sedentary. I think we've overdone the exercise story.

**[34:34] Speaker A:** I think a lot of that's come from the food industry as well, from McDonald's and Coca Cola, the biggest promoters of exercise. So they can deflect from their Bad diet that they're promoting. If you look at these communities with high longevity, these people weren't pounding in the gym, they were just outside. Essentially they were walking. I think walking is underrated, massively.

**[34:54] Speaker A:** I think walking is, is a phenomenal way of keeping the circulation going without overstraining your body. Because on exercise, by the way, let me just briefly talk about this. This gets a lot of eyebrows raised and a lot of people ideologically don't want to accept it. And these are especially the people who are OCD about exercise. And you're talking to a guy that is guilty of this. Myself, I've overtrained, I've caused injuries because I have been. My day is not complete unless I've worked out okay. I'm that kind of guy. You know, my ex wife used to complain that we were on vacation, I was getting out of bed early to go to the gym. You know, I'm that guy. So I get right. It's like a drug, okay. Working out in many ways. In fact, that's one of the reasons I do it. I think it's great for mental health, but you can overdo it.

**[35:43] Speaker A:** And actually, you know, one bit of information came to me from one of the top sports science cardiologists in the country and let it once and I was like, oh, this is so interesting. I haven't been able to look at that specific data. It's. I'm sure it's there, but in essence he said something along the lines of the 11% of elite athletes. Elite athletes by the time they hit 50 will have calcium scores over a thousand. Jesse. Okay, their event rates may be lower, but they've developed coronary artery disease. And it makes sense to me that if you are training really hard, especially with under recovery and high stress, it's probably very bad for your heart. So I just say keep the exercise simple, keep it moderate. If you can do two 30 minute brisk walks a day, amazing.

**[36:29] Speaker A:** Even one 30 minute brisk walk a day is really good. Walking the dog, for example, great. Okay. Yeah, Add in a bit of resistance training as well. Good for your joints as you get older, et cetera. From a heart disease point of view, I don't think there's any clear data that that is dose dependent. Once you hit moderate exercise, definitely better than being sedentary. Once you get moderate regular exercise. I don't think there's any strong data that you know, and we know that from Olympic athletes, you know, elite athletes, from ex Olympians. Elite athletes don't live any longer than people who play golf, for example, or cricket.

**[37:06] Speaker A:** Okay, so just giving some perspective there.

**[37:11] Speaker A:** The third component, well, of course the 4th is 4th still important to mention is smoking. I used to mention on the ward rounds to patients, this is true. Stopping smoking after a heart attack has much greater impact in preventing a further heart attack than all the medications we give people, including aspirin, etc. So if you're a smoker and within five years of stopping smoking, if you're middle aged, your risk of a heart attack becomes the same as someone that's never smoked in their entire life. So that's a very powerful intervention for smokers.

**[37:40] Speaker A:** And then I think the one that is maybe one of the most important that is missed is stress.

**[37:49] Speaker A:** Chronic stress, to a reasonable level, and I know it's subjective, is the equivalent of smoking 20 cigarettes a day when it comes to heart disease. And most of us, most people are not dealing with it. I know this all the time because invariably every patient I see that comes to me with a diagnosis of raised calcium score or heart disease, I've had a heart attack. All of them in the preceding five years have had stress levels that have been at least a 6 or 7 out of 10.

**[38:17] Speaker A:** What's the mechanism, though? This wasn't very well understood. We knew stress wasn't good, but it wasn't very well explained. The mechanism is likely chronic inflammation and it can even be explained from an evolutionary perspective. So tens of thousands of years ago, we're in the jungle.

**[38:36] Speaker A:** Stress is acute. Stress is life saving when we're escaping from a saber toothed tiger because we need to get the hell out of there. And acute stress, in that sense, what we know physiologically what happens is it increases clotting factors and inflammatory factors in the blood, so that if we're attacked, the risk of us bleeding to death becomes reduced. Now imagine that chronically turned on at a low grade, and that's probably the mechanism of how it contributes to heart disease. But this is where the reversal comes in, if you're happy for me to mention it. Now, Jesse, please. Is that the best available evidence of reversal? So right about my book, A Starting Free Life Comes from India. And this was called the Mount Abu Healthy Heart Study, something along those lines. It's a long name for the title of the paper. I actually met the cardiologist that did this study and he started it in the early 2000s.

**[39:39] Speaker A:** There were no statins involved. And these were patients that came to him who had significant moderate to significant heart disease diagnosed from the gold standard test, which is a Coronary angiogram, an invasive coronary angiogram. And they had at least a 50 to 70% blockage in multiple areas of the heart. And they didn't want to have a bypass, coronary artery bypass operation. They didn't want to have stents either from a preference point of view, an ideological we want to avoid medical intervention, or because they couldn't afford it. He put them on this lifestyle plan. There was hundreds of patients in middle age and they were devout Hindus. And so their diet plan was actually a high fiber, more than 50 grams a day of fiber, high fiber, vegetarian diet, not vegan, but vegetarian. It was two 30 minute brisk walks a day and something called Raj yoga meditation for 40 minutes.

**[40:37] Speaker A:** Two years later, he repeats the angiograms. Extraordinary findings. Literally at the time, unbelievable. And if you tell this to most cardiologists, they would say it's not possible. They've never seen anything like this.

**[40:51] Speaker A:** I actually had to go to India to see for myself these angiograms and meet the guy. And it was real. These are genuine. On average, of the people that had adhered to the lifestyle plan, there was about a 20% reduction, Jesse, in the blockages, which is unreal. 70% became 50, 50 became 30. There was also lower event rates as well, which obviously is important, so less hospitalizations with angina, heart attacks, etc. And then when he did a multivariate analysis, so trying to dig out, was there any independent factor of the lifestyle intervention that reversed heart disease. And the only independent factor significantly that was associated with reducing the reversing the blockages was 40 minutes of Raj Yoga meditation a day. Now, that isn't just meditation. What he did in this ashram, essentially this place in India, Mount Abu, which by the way, if anybody wants to go and visit this place, is extraordinary.

**[41:53] Speaker A:** It's actually free. It's paid for by charities. So people basically go there and they, they live in this ashram for seven days. They take family members with them and, you know, it's essentially these lectures to explain these Raj Yoga meditation. But it's a way of thinking. It's almost like a spiritual awakening to reduce anger. What's driving your anger, family members involved, to support you. Why? You know, because it's, again, it's, it's a mindset as well as the breathing techniques that are adopted. And that's what he did.

**[42:22] Speaker A:** And it has plausible biological mechanism.

**[42:27] Speaker B:** Okay, so 40 minutes a day. Do you know specifically what that period of time looked like?

**[42:32] Speaker A:** I think it was a mixture. It could be 2020 or 40 minutes in one go.

**[42:36] Speaker B:** But what kind of meditation? Do you know what they were doing?

**[42:39] Speaker A:** Yeah, well, it was a meditation of essentially meditation where you sit and you think and you're with your thoughts and you are trying to reduce anger and anxiety. There is a breathwork technique as well, which I incorporate, which is part of the Raj yog, but it's a form of diaphragmatic breathing and I work with a cardio specialist nurse that teaches patients how to do that. But essentially, and I do it every morning for 20 minutes and it's been shown and proven it's the best evidence based breathing technique for improving cardiovascular parameters like blood pressure, heart rate and, and I think that's essentially the best people can do.

**[43:21] Speaker A:** I myself, Jesse, still haven't gone. I need to do the course because by the way, you might have it in the States. People can look it up. They're all over America. You need to look for these Raj yog meditation centers and basically go there and essentially it's just a week. You get trained up in a week. I haven't had time to do it yet, but I will at some point.

**[43:41] Speaker B:** Okay, so far in the research then for reversal plaque, this is the only way we've seen it done.

**[43:48] Speaker A:** Yeah, as far as we know. I mean, there is the Dean Ornish study on the vegan diet, but the only thing with that is there's a big margin of error when you're interpreting angiograms, looking at plaque regression.

**[44:04] Speaker A:** And if I remember correctly, and I think Dean's got a lot of done a lot of amazing work with a multiple lifestyle. And I don't think they differentiated all the different components in terms of what was driving it, but it was about 1.3% or something. Now what's interesting is the cholesterol LDL again in the Mount Abu Heart Study did not show any independent association with lowering that with reversal. So again, it's more evidence that it's not the LDL cholesterol and it almost certainly isn't the vegetarian or vegan diet per se. Maybe the fact that it's an otherwise healthier diet because you're not eating lots of ultra processed food and sugar, although there was a reasonable amount of starch in there, albeit very high fiber.

**[44:47] Speaker A:** It was quite clear from his own analysis in that paper that it wasn't the vegan diet, the vegetarian diet, basically from not Dean Ornithis study, but the other one. And even Dean Ornish's study didn't show as far as I remember. And Dean Forgive me if I'm wrong here, but it's been a while since I looked at that paper, but I remember there wasn't a clear independent association with, with lowering LDL from that diet plan and the in the improvements.

**[45:12] Speaker B:** Okay, so when it comes to the meditation, they were able to show a reversal. How quickly did that happen?

**[45:18] Speaker A:** Oh, well, they repeated the angiograms in two years and then they did it again at five years and it was sustained. Okay. I mean I still been able to

**[45:25] Speaker B:** continue long term to see if they would completely reverse.

**[45:29] Speaker A:** I don't think they did any more angiograms after that.

**[45:32] Speaker A:** Jesse.

**[45:33] Speaker B:** Okay, somebody wanting to be really practical with what we talked about here, the stress reduction piece, the potential there for reversal. What's the easiest way for them to jump into this at home?

**[45:44] Speaker A:** Probably go on YouTube first of all and look up Raj yoga meditation and look up diaphragmatic breathing.

**[45:51] Speaker A:** I mean that'll be a free way, an easy way.

**[45:55] Speaker A:** I always think it's better to see a practitioner, but if you can learn it from YouTube and follow it then great. I think at home you basically have to just eliminate all ultra processed foods, which is anything packaged that has five or more ingredients, usually with additives or preservatives and sugar free sugar. So no juice, no candy, no potato chips. I mean the way to do this if you're going depends where you're starting from. But I would say you do this for six weeks cold turkey to break the addiction to starch and sugar and then you can maybe modify things. But it also depends where you're starting from. Jesse as well. Right. If you're very, if you're just got one metabolic health marker and you're otherwise slim and you're moderately active, you may not need to go that extreme. So it depends where you're starting from.

**[46:41] Speaker A:** But just eating a healthier diet already is going to make a big difference.

**[46:45] Speaker B:** Sticking with the diet piece, somebody wanting to jump right in and take this to the extreme. We have ketogenic, we have carnivore. You're a fan of low carb. How do you feel about pushing it to the other side of the spectrum?

**[47:00] Speaker A:** Listen, ketogenic is fine. Essentially this ultimately when you're doing this for six weeks, you're probably going to be in ketogenic diet anyway. For me personally, I did this for a couple of years. The only thing I would find my metabolic markers got better. And it may have been a stress thing as well, but I found that for me personally, Jesse, and I don't Eat processed carbs and it's very high fiber.

**[47:22] Speaker A:** Because I work out, I found that my resistance training was a bit harder. So I will eat high fiber porridge in the morning with berries and nuts and seeds, etc. But only have the carbs in and around the workout. And then I, you know, I essentially avoid it the rest of the time. So it depends where you're starting from. I was already slim, etc. So you know, for people that are already overweight, got belly fat, then it probably isn't going to be an issue for them. When I asked patients how did you feel and your workouts when you went keto? And they were like, no, it was great. I was like, oh, that's interesting because I had an energy slump.

**[47:54] Speaker A:** They didn't. So again, it varies from person to person in terms of keto is fine. And I think what you find is the worse the metabolic syndrome, the markers of poor metabolic health, the more extreme you need to go with the diet. So I would say keto would probably be right for them. When it comes to Carnivore, that's an interesting one. I'm not averse to Carnivore. I'm great friends with Sean Baker, I know Paul Saladino, I know Anthony Chaffee. These are the, the big names pushing the carnivore diet out there. And I've seen a lot of people, patients who've felt that their autoimmune conditions have got better, which is fascinating. I think that's a really interesting area of research from a heart disease perspective.

**[48:35] Speaker A:** I think that the only thing I would say is the Carnivore diet doesn't necessarily fit with the anti inflammatory component of the, you know, the nuts and, well, not the nuts and seeds, but the non starchy vegetables for example. And if it's Carnivore, it tends to be higher in saturated fat, which I obviously busted that myth of saturated fat and heart disease. But there was an interesting paper by Ronald Kraus who's like one of the gurus behind saying that saturated fat isn't a big deal. Where they found in a subset of people if your saturated fat intake was more than 18% of calories, so very high saturated fat levels, it actually caused atherogenic dyslipidemia. Erase triglycerides.

**[49:15] Speaker A:** And I've seen a few patients like that, which is very interesting. Not most patients, but a few. So those people, I always say the default is reduce, go more olive oil based as your base fat. And then I'm not too fussed about what else you eat?

**[49:30] Speaker B:** What are your thoughts on seed oils? A lot of talk in our world about these traditionally doctors recommending them to bring LDL down, which it does. I know talk about your thoughts conventionally, what I just shared there about the LDL piece and then how you see them because there's other people saying they're part of the driver of insulin resistance, which again is driving heart disease. So a lot of different connections.

**[50:00] Speaker A:** Yeah. I think first of all we can say without a shadow of a doubt that any dietary approach to lowering LDL has failed to curb heart disease. So that's one thing. Is it harmful? There is at least one study showing the Sydney heart study, and I think there was another study, the Minnesota study, if I'm not wrong. Ansel Keys did unpublished data showed that the people are lowered through dietary they use some sort of safflower oil, margarine, I think. But the people in the intervention group who heart attack patients who lowered their cholesterol from this approach had higher mortality, cardiovascular mortality and probably through the mechanism of being pro inflammatory.

**[50:40] Speaker A:** So I think it's harmful. Are seed oils harmful when not heated? Probably less so I think they're definitely toxic when they're used for frying purposes.

**[50:52] Speaker A:** And we know they produce these aldehyde compounds which are carcinogenic and linked to Alzheimer's. So I would say avoid as much at all costs if you can. Seed oils, absolutely.

**[51:05] Speaker B:** Overall, you're not a fan of lowering ldl, but there's also talk in dividing LDL into small dense and large fluffy. Any value in looking there or any

**[51:17] Speaker A:** problems with the small dents specifically? I think there's over investigation again, just people paying extra money for no reason because I think that your triglycerides in HDL are basically a mark of your LDL particle size anyway. So what are you going to do about it? You know, don't order a test unless it's going to change your management plan. The other interesting thing as well, Jesse, which we didn't mention research we found this will throw a few people off. But this again another reason for you can say, okay, lowering LDR doesn't prevent heart disease, but what's the harm? Well, there is a potential harm because we know that from observational data the higher LDL when you hit over 6 when you're over 60, the longer you live because LDL is probably involved in the immune system and likely has some benefit in being protective against cancer and infection.

**[52:03] Speaker A:** So I think there is a potential harm to lowering ldl actually.

**[52:07] Speaker B:** What about oxidized LDL just for complete. Bring that in.

**[52:12] Speaker A:** Yeah, I mean, that's just the postulated mechanism of how LDL can be maybe cause injury to the inner lining of the arteries.

**[52:22] Speaker A:** And that again links to LDL's interaction with Sugar. So we still come back to triglycerides and hdl. Once your triglycerides and HDL have normalized, then you're essentially eliminating the oxidized LDL in most cases.

**[52:36] Speaker A:** So it's an academic thing more than anything else.

**[52:39] Speaker B:** You've brought up calcium scores, angiograms.

**[52:43] Speaker B:** Let's go into different forms of testing and where those might be beneficial.

**[52:48] Speaker A:** Yeah. So I think I try to keep it simple. Unless there's somebody got very unexplained symptoms or they develop heart disease prematurely and you haven't got an idea, then I wouldn't go in any. I'd keep it very simple.

**[53:00] Speaker A:** Your basic fasting cholesterol profile, triglycerides, hdl, total cholesterol, ldl. Although to be honest, you probably don't need to measure LDL and total cholesterol. It's just for interest sake. Right. That's what we want to look at.

**[53:13] Speaker A:** And your triglycerides should be. And you'll have to help me here a little bit, Jesse. I'm trying to remember. I think in the US terms it's less than 150mg per deciliter. In UK it's less than 1.7 millimoles per liter. I think that's the equivalent. And your HDL should be above again, I think it's, if I'm not Wrong, in the US units it's more than 50, but you can calculate it. For UK, it's more than 1 millimole per liter. Ideally you want your triglycerides less than your hdl. So the ideal way of looking at it when you convert to millimoles is triglycerides are less than HDL.

**[53:53] Speaker A:** And if your ratio is more than 4, that's at your highest risk and less than 1 is lowest risk. So that's what you want to measure there. From the cholesterol profile and then the blood test I would recommend. The other blood test I recommend is HBA1C to make sure you're not pre diabetic. So you want your HBA1C to be less than 5.7%.

**[54:11] Speaker A:** From 5.7 to sort of 6 is considered pre diabetic or 6.5 and then above 6.5 is type 2 diabetic. But these are again all reversible or improvable. I would measure blood pressure. And blood pressure, ideally should be less than 120 over 80. Between 120 over 80 up to 140 over 90 is what we call pre hypertension.

**[54:38] Speaker A:** And your wrist starts to increase gradually for stroke as that increases and heart attack. And then you want to measure your waist circumference. But actually, rather than getting to the weeds about actual what measurements, I think a very useful tool is your waist circumference. Should be less than half of your height. So if you're 180cm tall, just under six foot, you want your waist circumference at the belly button to be less than 90 centimeters.

**[55:08] Speaker A:** And if all those are normal, I think you're in great shape from a heart disease perspective.

**[55:14] Speaker B:** Talk to the angiogram, coronary calcium score, stress tests, some of these advanced tests that people might be getting.

**[55:22] Speaker A:** Yeah. So let's start with stress tests. So traditionally.

**[55:27] Speaker A:** Okay, let's take a step back. First and foremost, a good doctor makes his diagnosis mainly from the history, and that is a conversation with the patient. A bad doctor orders tests without speaking to the patient or taking a good history. Let's start there. And the reason for that is 80% of the diagnosis, Jesse, comes from the conversation.

**[55:53] Speaker A:** Right. The symptoms, the patients are describing, There are certain patterns that have been recognized over centuries. Decades at least, but centuries that fit with the likelihood of a disease process when it comes to heart disease. And we'll get on to explaining what the stress test would be helpful. The classic symptoms are a vagina of a blockage, not an acute heart attack.

**[56:18] Speaker A:** And acute. Acute heart. We'll just talk about acute heart attack, actually. So this is where people should be worried. An acute heart attack is classically a central heaviness or crushing feeling lasting for more than 10 minutes, associated with sweating, sometimes radiating, traveling up into the neck or into the shoulders.

**[56:40] Speaker A:** And that is a red flag. And that is when you call 911. All right. A milder form of that is what we call angina, which is a patient comes in and they say when they're doing exercise or they're stressed, they feel the same tightness or squeezing the center of the chest on the left, not on the right. It's a tightness or heaviness, and it's then relieved by rest.

**[57:00] Speaker A:** And those depending on how severe and how often they are coming. That's when you would potentially do a stress test. Sometimes you do a stress test if people have atypical symptoms, a sharp pain, a stabbing Pain isn't necessarily in the center. That's when stress test becomes also helpful as an exclusionary tool. The traditional test would have been an exercise treadmill test.

**[57:24] Speaker A:** You get an ekg, put people on the treadmill, you get them walking briskly, getting their heart rate up to what we call 80% of maximum target heart rate. So that's 220 minus your age and 80% of that. So if you are 40 years old, for example, 220 minus your age is 180. 80% of that is. Let's figure 18 times 8. Right. So it's 180 divided by 10 times by 8. So 18 times 864 plus 80 is 144. Sorry to sit in my head. Right.

**[57:59] Speaker A:** So you want your heart rate to get up to over 144 and you not get chest pain and the EKG to be normal, not show changes, will be the different changes you look for.

**[58:09] Speaker A:** SC depression, for example. Right. So that is a positive treadmill test, which would suggest a significant blockage of over 70%, in which case the gold standard test to look for that is a coronary angiogram, which is injecting dye takes about 20 minutes. You pass tubes up to the heart, use X rays, patients awake, local anesthetic, and you inject dye. So I did thousands of these, and that tells you that's the gold standard to look for any significant blockages. The more useful tests. One of the problems with an exercise treadmill test, Jesse, is what we call false positives. And they have up to a 50% false positive rate. So that means that the test looks positive, but the ultimate result is that there's nothing wrong and that can cause anxiety, et cetera, et cetera. So you've got to use a test appropriately. What would be better than that, it's obviously more expensive, is what we call stress echocardiogram, which is where you do an ultrasound scan of the heart and you get people on a treadmill or on a bike.

**[59:07] Speaker A:** And then when your heart rate gets up above 144 in this particular patient, you look at the heart muscle and you see how it's pumping. And if there's a blockage, the heart muscle stops pumping as well. In the area of the blockage where the blood vessel is supplying, that's what we call stress echo.

**[59:25] Speaker A:** That's non invasive. Again, very safe, quite useful tool. Calcium scores are usually done, Jesse, in patients that don't have typical symptoms. Patients you're not predicting have got a significant blockage. Because if you're predicting a significant blockage, you should go straight for an angiogram.

**[59:45] Speaker A:** But with a calcium score, it's now used as a risk tool like checking your cholesterol or checking your blood pressure. And actually, I would say I'm a bit biased because I use them quite a lot. But by the way, declaration. I'm not getting paid to promote calcium scores by any device company. Just so you know. It's important for me to mention that. But I would say that many people, if not Most people over 40 these days if you're a man and over 50 if you're a woman, because the validation of the test really is only in those groups because you can miss soft plot in younger people if you're a male over 40 or a female over 50. Calcium scores, great. If you're worried about heart disease. The reason why it's also so useful is it gives you a score anything from zero, which is normal, to over 1,000.

**[1:00:38] Speaker A:** Less than 100 is what we call low risk of a heart attack or stroke in the next decade. 100 to 400 is moderate risk. More than 400 is considered high risk.

**[1:00:49] Speaker A:** It's a great snapshot tool. It can be repeated not more than once a year because of radiation. But you can then see from an intervention, if you have a calcium score done, let's say it comes back at 250 and you're like, well, no severe blockages. Not high risk, not low risk. What do I do, doc, here go on my protocol.

**[1:01:10] Speaker A:** Let's repeat it in a year. And then you will see that the calcium scores remain stable or even improved, maybe reversed. And then you can be confident that what you are doing with your lifestyle is actually having an impact. And I think that's a great way of using the calcium score as well, serially to see and to reassure patients that that what they're doing is working.

**[1:01:30] Speaker B:** Let's talk more about the soft plaque versus hard and tie it back to the pimples we were talking about before.

**[1:01:37] Speaker B:** When does plaque solidify and become calcified? And then we can go from there.

**[1:01:44] Speaker A:** We don't know for sure, Jesse, on that. The presumption is over time it can become calcified because a calcium is a response to the inflammation.

**[1:01:56] Speaker A:** So it's probably something that happens over time. It probably doesn't happen quickly. I think soft plaques develop more earlier on. I don't know. I haven't seen data on serial looking at when the soft plaque becomes a hard plaque.

**[1:02:08] Speaker A:** But my experience doing angiograms, you see these people that have usually had coronary artery disease for many, many years. They're more likely to have more calcified plaques. In theory and likely in practice. The calcified plaques are more stable and less likely to rupture. They're also the hardest to stent because the stent isn't removing the plug.

**[1:02:27] Speaker A:** When you're putting a stent in, you're putting a little. You're passing a balloon and a deflated balloon on a wire in the middle of where the blockage is, is. And you're inflating this balloon. Right. And if the balloon doesn't inflate on a calcified plaque, sometimes the balloon actually bursts because the calcium is so hard. And. And that theoretically means that plaque is probably not going to rupture and cause a heart attack because it's now stabilized and it's covered in calcium. It may be causing angina, and that might be why you want to put a stent in, but it isn't going to cause a heart attack. So in many ways, a calcified plaque is a more stable plaque, and the more reassuring plaque, the soft plaque develops earlier. It doesn't have what.

**[1:03:11] Speaker A:** Because the pimple bursting is related to the outer layer, if you like. If it's very thin.

**[1:03:20] Speaker B:** Right.

**[1:03:22] Speaker A:** It's more likely to just burst. Whereas if it's thick and hard, that's when it doesn't tend to burst and cause exposure of its contents of the plaque, the immune cells, the ldl, oxidized cholesterol, LDL to the blood, which then causes the bloodstream to see foreign body, toxic. I'm going to form a clot there. So that's how the clot forms and then can completely obstruct the vessel.

**[1:03:48] Speaker B:** Would it be fair to say that the calcified plaque is older pimples that have solidified and become more structurally sound?

**[1:03:59] Speaker A:** Yes, but the reason people are going to say. But hold on, that doesn't mean a high calcium score. Zen is good. No.

**[1:04:07] Speaker A:** The more calcified plaque, the more soft plaque you have.

**[1:04:11] Speaker B:** Okay, so there's a correlation there.

**[1:04:13] Speaker A:** It's a surrogate. It's a surrogate marker of soft plaque.

**[1:04:16] Speaker B:** And the raised potential to reverse a calcium score, you quickly touched on that.

**[1:04:22] Speaker A:** Yeah, it's interesting. I think a calcium score, I've seen that happen in some of my patients. But soft plaque, I mean, certainly one of my patients had a carotid. The same process in the heart arteries happens in the neck vessels, which, you know, go to the brain, and if they cause blockages that can increase the risk of stroke. One of my patients, and it was pretty extraordinary.

**[1:04:45] Speaker A:** Irish lady a few years ago, she followed my protocol, except her stress levels had come down by some other means. But she didn't do the meditation, just a diet. And she had a 70, 75% blockage in one of her carotid arteries, having had a mini stroke. And five years, she emailed me, went to the same lab, the same radiographer that did the ultrasound five years later had gone less than 25%.

**[1:05:17] Speaker A:** And she said, thank you, Dr. Malhotra. I just followed your plan. I was like, wow, that's amazing. It's just one patient. It's an anecdote, and it could be coincidence, but I like to think that the plan I recommended probably played a role.

**[1:05:31] Speaker B:** Speaking about the carotid arteries gets me thinking about cimt. Isn't that an ultrasound that can be done on those?

**[1:05:39] Speaker A:** Yeah, that's looking at thickness of the carotid artery, and that can be a precursor to blockages developing.

**[1:05:48] Speaker A:** I think if we've got access to calcium scores. Jesse, I don't think it's any use to do a cimt. I think just get the calcium score done because you can have people with a normal CIMT and have got a raised calcium score. You can have people with a thickened CIMT have a normal calcium score. The calcium score is most validated in terms of predicting events in the future, as far as I'm aware. Not the cimt.

**[1:06:10] Speaker B:** As a cardiologist, are you aware of this talk of an ear crease on the earlobe and that being associated with certain heart conditions?

**[1:06:19] Speaker A:** I'm aware of it, Jesse, but you probably know more than I do right now about it.

**[1:06:23] Speaker B:** I just know there's some kind of association. I just wondered if.

**[1:06:26] Speaker A:** Yeah.

**[1:06:26] Speaker B:** If there is anything to be concerned if somebody's looking there.

**[1:06:29] Speaker A:** Yeah, I don't. I'm not. I won't be able to quantify what that risk is, but it's a marker definitely of heart disease.

**[1:06:36] Speaker A:** So if somebody has that ear crease, then, yes, they should be investigated.

**[1:06:40] Speaker A:** And probably a calcium score would be the thing to do.

**[1:06:42] Speaker B:** So we went into diet. We want to go low carb. We want to get metabolically healthy again.

**[1:06:50] Speaker B:** How does fasting, if it does play a role into this?

**[1:06:54] Speaker A:** I think if fasting played a. Plays a role, it's probably by improving insulin resistance.

**[1:07:02] Speaker A:** For fasting. Also depends on the person. For some people, fasting can increase if their stress levels are already high and they're exercising. I think fasting may be a Bad idea because it increases cortisol, so it can make the stress worse. So it really depends how you feel, why you're doing it, when you're doing it.

**[1:07:23] Speaker A:** I think the data on markers associated with improved longevity is probably better. But on the fasting side I think that the best data, and Valter Longo is probably the person to look up for this. There are two approaches. One is a three day water fast to do that once or two or three times a year. And the other one is a fasting mimicking diet for people that can't do the water fast, which is basically 800 calories essentially of keto vegan.

**[1:07:53] Speaker A:** So it's no animal products, no animal protein or animal fat and no starch and sugar. So you're basically reducing the pathways that are in the cell responsible for metabolizing animal protein as well as keeping the insulin down. That encourages autophagy, which is essentially a detoxification of the cell. And that has to be done for five days on three consecutive months. They've shown from some really interesting data, Jesse, that when people did that over a two year period that decreased one's age by two years, a 50 year old became 48, something like that.

**[1:08:39] Speaker A:** So I think that's really interesting and it probably indirectly has some role in heart disease because one of the major causes, if not something in European men of premature death is dying of a heart attack. So it probably is having some benefit. That's the evidence, best evidence based approach, I would say to fasting.

**[1:09:05] Speaker A:** But some people have found that it's amazingly helps them lose weight and get their metabolic health. And they do a 16 hour fast every day and they might have one or two meals a day as a result of it. And they come to me, they say they feel great and their metabolic markers are good and they don't feel stressed. I'm like, great, carry on. Didn't work for me, didn't sue me at all actually.

**[1:09:24] Speaker A:** I tried the fasting 16 hours and working out and I was a wreck, absolute wreck. And again, you've got to also be look at your hormones as a guy. One of the things that's there in the literature, if you're keto and you're working out and you're fasting a bit, even within 10 days, it can have significant negative impact on your testosterone levels. I may not do that, but if you start to feel that your sleep's getting impaired, your libido is going down, then you've got to do something, you got to work on the stress, stop the Fasting or reduce the exercise or all three.

**[1:09:58] Speaker B:** What are your thoughts on the microbiome and any connection there to the heart?

**[1:10:02] Speaker A:** I think there is a wide body of literature on it's all linked to chronic inflammation. I'm not a microbiome expert so you'd have to speak to somebody else about that. But I do think it plays a big role. Yeah, absolutely. I think cutting out the ultra processed food and the sugar has an automatic benefit on the gut microbiome and interestingly not because I knew this by, by default I found that the low carb diet I recommended was actually endorsed by Tim Spector who's one of the leading microbiome experts in the world who endorsed my I think second book immunity Plan, maybe the first one as well, I can't remember. We, you know we've been, we've collaborated on campaigns together in the past but you know he said that essentially the diet plan I was recommended was excellent for the gut microbiome. So I'm quite happy about that.

**[1:10:53] Speaker B:** Let's talk supplements in general and then any specifically related to the heart.

**[1:10:59] Speaker A:** Well, I think in general the evidence based supplements I've seen for health and again it's going to be tailored to different people and we've also got to be, you know, the supplement industry aren't as big as big pharma but they're also profit making industries. Right. So there's a lot of, there's clearly a goal to, from a, from a financial perspective for them to get more people taking more supplements, that's a no brainer. So we've got to be wary of that and see the wood through the trees. I think that the supplements from a heart disease perspective first the ones that I think have a good evidence base behind them and aren't going to do harm are vitamin D, vitamin C and keeping your vitamin D levels in the upper range of normal, low vitamin D levels. Vitamin D deficiency and some studies have been associated with a six fold increase in developing heart disease.

**[1:11:48] Speaker A:** So I think vitamin D is protective.

**[1:11:50] Speaker A:** I think vitamin C doesn't do any harm. It's good for the immune system. There is some historic literature saying the vitamin C may protect against heart disease. I take about 2 grams a day myself, you know, 1 gram with each meal and I up it if I'm feeling like I'm getting sick. And the vitamin D levels as well, I think those are two important ones I think for stress.

**[1:12:12] Speaker A:** I think magnesium is wonderful. Magnesium glycinate is easier on the stomach. I have that with my food and there's one called magnesium L Threonate, which has better absorption in the brain and does make a big difference. And I've used it in some of my patients with PTSD who are like veterans from Iraq war, and this has transformed them. So I think magnesium from a stress point of view can be helpful subjectively in terms of the way people feel.

**[1:12:43] Speaker A:** I can't think of any other ones off the top of my head. Jesse, I don't know if you've got any ones you want to ask me about, but those are the three reasonable key ones I think that are useful.

**[1:12:53] Speaker B:** Well, a couple that come to mind.

**[1:12:54] Speaker A:** Sorry. One more.

**[1:12:55] Speaker B:** Go ahead.

**[1:12:56] Speaker A:** Omega 3, potentially the data isn't that strong in terms of outcome benefit.

**[1:13:03] Speaker A:** It has obviously a natural blood thinning properties. I think if you can do two to three portions at least of oily fish a week, which would be wild salmon, it would mean mackerel or sardines. And I think that that would be great. There may be a. We think there's a better benefit of the omega 3 as a synergy with the olive oil, with the food, etc.

**[1:13:24] Speaker A:** In terms of its potency. But yeah, those are the ones really.

**[1:13:28] Speaker A:** I would suggest fish oil was one

**[1:13:30] Speaker B:** of the ones I was gonna bring up in the blood thinning. So glad you went there.

**[1:13:34] Speaker B:** The other one related to the heart is K2 and you hear that it helps put calcium where it's supposed to go. And we talked about the calcifying of the blood vessels. So just making the connection there. Often taken with vitamin D. What are your thoughts?

**[1:13:52] Speaker A:** Yeah, not against it. I haven't seen any good quality data there on that, Jesse, to be honest with you. And one of the things you have to be, I think vitamin. Keeping vitamin D levels in the good range is more important than whether. Whether or not you've got K2 on board. I could be wrong.

**[1:14:08] Speaker A:** I'm waiting for someone to contact me and saying, look at this data. But one of the things about K2 and I've seen it happen with me again, but it also happened in some of my patients, it can actually increase anxiety levels. So if people start meeting palpitation, feeling more anxious, start, stop the K2. I actually got fasciculations. I went see a neurologist because I was getting muscle fasciculations, twitches, and I stopped the K2 and it disappeared.

**[1:14:31] Speaker B:** Interesting. I'd never heard that.

**[1:14:33] Speaker A:** Yeah. And I think it's one of. I looked it up and it is one of the side effects.

**[1:14:37] Speaker B:** I want to come back to your story, early on, we mentioned the fact that you were very conventional. Talk about the pivot in your career.

**[1:14:45] Speaker A:** Bit of a convention.

**[1:14:46] Speaker B:** What switched you on to thinking differently?

**[1:14:49] Speaker A:** Conventional, but always a rebel.

**[1:14:53] Speaker A:** Always a rebel in terms of questioning authority, being curious. Since I was a kid, since I was at school, I was on my report cards. So I probably had the capacity, through my curiosity for this conventional in the sense that I was when I was in this phase where I was a heavy prescriber of statins in secondary care. You got to remember this is in hospital setting, right? These are high risk people.

**[1:15:20] Speaker A:** It was probably because I was so obsessed about passing my postgraduate examinations quickly because cardiology is one of the most, if not the most competitive, all subspecialties in medicine. And you've got to pass your exams quickly, first time, the competitive exams to succeed. So I was obsessed with becoming a cardiologist. So I worked really hard and then I knew my shit, pardon my language, right? I was really on it, on all of the literature and the data and everything.

**[1:15:45] Speaker A:** So I think that was probably why I was, you know, a conventional prescriber. But at the same time, I was also subject early on in my career, which I think helped me. One of my earliest jobs as a junior doctor, Jesse, was when I just completed my, I think you call it residency in the us, right, when you've done one year. So my first job after residency was what we call senior house officer in a hospital, which was purely for what we call care of the elderly. So the people that came to a hospital to be admitted, they have to be over 65. They usually transfer from other hospitals. What was fascinating is the care of elderly physicians, the very first thing they would do in a patient coming in with whatever condition, with a collapse, with confusion, is look at their medications and reduce the medications.

**[1:16:35] Speaker A:** I remember learning at that point that up to 25% of all hospital admissions in people over 65 are because of over medications or side effects or interactions of drugs. So I was exposed early on to iatrogenic harms, to the harms of over medication. And I think that helped a lot.

**[1:16:52] Speaker A:** And then it was a gradual process because I want to be the best possible doctor I can be, which means being curious, being a good diagnostician. A good doctor is a good diagnostician, right? You know, I was also inspired by the story of Sherlock Holmes. And many people don't know this, but Sherlock Holmes, the fictional greatest detective ever, was written by Arthur Conan Doyle, who was a medical doctor that trained in the same medical school I went to. And he modeled the character of Sherlock Holmes on one of his professors of medicine, who he found the most amazing diagnostician. Where he would sit in a clinic with this doctor and the patient walks through the room and before they've even sat down, he's already start to make a diagnosis by looking at the clothes they wear, their shoes and which journey they take and thinking which demographic are they far from, what are their hands, are they coughing a little bit or it could be tuberculosis, whatever.

**[1:17:43] Speaker A:** So the byline of Sherlock Holmes was in the same way, how he used to solve his murder mysteries is the same thinking of us making a diagnosis, solving a puzzle. I love solving puzzles. When you've eliminated the impossible, whatever remains, however improbable, must be the truth.

**[1:18:05] Speaker A:** So because of that, I was always curious about, you know, the. And I prided myself on making diagnosis and when patients came in and certainly from a heart disease perspective, because I was tested with heart disease and cardiology and seeing the obesity epidemic and coming across. And also part of it is the fact that why did I go down the diet route? An interest in there is because I myself learned to cook when I was 16. I like, I appreciate the importance of healthy, tasty food. My dad told me to cook. I've been cooking since then. You know, I was known in medical school to cook the best chicken curries. And you have 30 people over my apartment, you know, and whatever, where we were staying in our halls to eat my chicken curry. So I was really into the food stuff. And then I was appalled with what we were being served in hospitals.

**[1:18:51] Speaker A:** And that's where things started for me to look into the research. And then I found research showing dietary changes like stopping smoking can rapidly improve heart disease risk and death from heart disease. I was like, wow, why was I a turtle that taught this in medical school? So that's how things started for me, really.

**[1:19:06] Speaker A:** And someone who's generally, you know, because I'm health conscious, I was a sportsman, I like good food. I was. And knowing that that's where most of what health is determined by those factors, not the medicines people prescribe you, that's when I decided to become a big advocate for that message. And that's how things started to turn. And then you come across.

**[1:19:29] Speaker A:** Another moment for me was the BMJ 2012 started too much medicine campaign. This article was written that was fascinating. There were, I think, three authors, but the lead author was the editor of the bmj, Fiona Godley, who ended up becoming friends of mine when I started writing for them. And they Were basically saying too much medicine is one of the greatest threats to public health. And I was like, holy shit.

**[1:19:51] Speaker A:** Part of my language. That's big deal for a medical journal saying that we are over prescribing because of corruption in medicine and big pharma influencing that. So there were several things that happened that got me into this advocacy role and I started ready for medical journals myself, doing my own research and publications, etc.

**[1:20:12] Speaker B:** As somebody that had invested so much time, so much energy into your craft, becoming a cardiologist, starting to flip over some of these rocks and see the other side. What did that feel like?

**[1:20:24] Speaker A:** When you learn something, it's enlightening. You know, one of the predictors of good mental health is lifelong learning. Jesse. For me, I want to learn something every day that enhance, reduces human suffering or gives greater meaning to our lives or improves our health, which is mental, physical and social well being, which I think everybody wants. So that part was fascinating. I enjoyed it. I love learning anything that's going to be interesting and help me and my patients, okay, reach a higher state of being.

**[1:21:04] Speaker A:** But it was also interesting to see the psychological responses to talking about this stuff. And certainly when we started writing about it, you know, getting, you know, I think that I became most well known, I suppose, in the mainstream for being one of the leading figures in the world highlighting the harms of excess sugar. Certainly a Dr. Wise. I was influenced by a brilliant professor in UCSF called Robert Lustig, you may have heard of him.

**[1:21:31] Speaker A:** And we became friends and he mentored me. And then I started amplifying his message and doing my own research on sugar in the uk.

**[1:21:40] Speaker A:** So the backlash came from the food industry there.

**[1:21:42] Speaker A:** When I wrote that saturated fat doesn't cause heart disease in a opinion editorial in the BMJ peer reviewed in 2013, all hell broke loose globally. There was a huge kind of. It was massive attention. Front page of three British newspapers, Fox News, cnn, everyone cardiologist overturns three, you know, three decades of dogma that saturated fat causes heart disease. But the backlash, wow. The ideological backlash, you know, the group think this is heresy. How dare he, you know. Oh, yeah, that was a challenge that I wasn't prepared for until it happened. But then I learned over time that one of the lessons in public health advocacy is as soon as your work threatens an industry or an ideological cabal, you will be attacked, sometimes unrelentingly and viciously.

**[1:22:33] Speaker A:** And that's really been my modus operandi. Operandi. I will not do it for the sake of it. It's not for my personal benefit to do this. It's. I'm a slave to my conscience. I'm a slave to data. I'm slave to truth. I'm slave to ethics, and I'm just a manifestation of that. I am the sum of my influences.

**[1:22:50] Speaker A:** I'm a medium for a message. That's what I see myself. I have to detach myself from it. So that's just over time. That's what you know.

**[1:22:58] Speaker A:** But a life lived in darkness has no meaning and you don't make progress. And, of course, science evolves anyway. You know, that's one of the things I think we need in medicine more. We need more of a culture of humility.

**[1:23:14] Speaker A:** And patients want that. Patients want you to be honest with them. Right? You're sharing your journey. They don't want arrogance. They don't want. If you make a mistake, you own up to it. My feedback, you know, touch wood, Jesse. I've so far probably been lucky. And I had a single patient complaint in my entire career, which is very unusual.

**[1:23:35] Speaker A:** And my patient ratings recently are the highest in London in private practice.

**[1:23:42] Speaker A:** And it's not because I think I'm particularly smart. I just. I look at the history and I'm empathetic and I just. For me, ethical behavior is most important. That's it.

**[1:23:55] Speaker B:** You're doing this from a good place, seeking the truth. But you have taken a couple of big arrows. The RCP suspending your fellowship. You're involved in a case, I know, with Zoe Harcombe and Malcolm Kendrick, both previous guests of the show. Talk about the specifics there.

**[1:24:14] Speaker A:** Yeah. So talking about Malcolm Kendrick and Zoe, who are great friends of mine and brilliant people and Doctors, Stroke Scientists, 2019, the Mail of Sunday, which is a Mail on Sunday, which is a major newspaper in the uk, they did what could be described as a hatchet job article, front page, linked to myself, Zoe Harcomb and Malcolm Kendrick around our advocacy on informed consent on statins. And we were misrepresented. And essentially that piece said that we were spreading, in quotes, deadly propaganda because we said statins don't work. As a result of that, I lost my job in the National Health Service, which I was very proud of working in and wasn't able to get it back, they decided to sue the Mail on Sunday for libel.

**[1:25:08] Speaker A:** I decided not to get involved in that because I didn't think it was worth it and I wanted to carry my advocacy and campaigning on statins, which I did, I think, quite effectively. They were told ponce would on a libel case. They can't talk about it anymore, at least until the case is done. I'm so glad they succeeded. Last year, two years ago, they were found in favor. They won their libel case and probably got awarded quite a lot of substantial amounts of money. And I'm very happy for them. Moral victory for me.

**[1:25:35] Speaker A:** So that was hard, of course, and I'm just in private practice now because of it. But you just have to keep marching on. And then the other fellowship with Royal College of Physicians that was suspended because I wrote a peer reviewed article in the Journal of Insulin Resistance about the COVID vaccines calling for their suspension. But the reason that there was a complaint to the Royal College of Physicians from six anonymous doctors or several anonymous doctors was because the fact that. And I always do things by the book, right?

**[1:26:05] Speaker A:** For me, if you're going against the grain, you got to be able to back it up. I've got to be able to back it up myself and realize that I've not left any stone unturned. And therefore when I realized there was a potential problem with the code vaccine, I did my own research and wrote this extensive peer reviewed article going into a lot of detail on the cardiovascular potential harms of it and even the benefits of the vaccine. And you know, that was well publicized. And I was invited to speak in the British Parliament by a member of Parliament called Sir Christopher Chope, who was the head of a special committee looking at vaccine injuries.

**[1:26:42] Speaker A:** And when the flyer was put out in small print there was fellow of the Royal College of Physicians. This is going to sound very ridiculous to someone in America hearing this. That was the basis of the complaint which I had. I had a fellowship that by def. You know that that is bringing the college into distribute. I'm invited into the British Parliament as a doctor to speak at an official meeting and present the case on a PowerPoint presentation of why the vaccine should be suspended that resulted in me getting initial suspension then ultimately removed. I was so disgusted with the rcp. I actually. People don't know this, I'll tell you this now. I was so disgusted and disappointed with their behavior that I actually resigned my fellowship while serving a six month suspension. And that doesn't mean anything. It's of no real consequence. Only people who've done great work get awarded this fellowship anyway.

**[1:27:39] Speaker A:** So not having the fellowship doesn't affect my practice. But it basically meant I couldn't go and use the library in the Royal College for six months, which I never used anyway.

**[1:27:48] Speaker A:** I know it sounds funny, right? It sounds a bit ridiculous, right? Very British, you can no longer use the library now, Dr. Marcher, during your suspension, right? So that was what happened. I then hijacked the BBC in 2023 when I was asked to talk about statins. And I said, actually, the elephant in the room about excess deaths here is probably the COVID vaccine, right? Wrote to them saying, I've decided I want to resign my fellowship.

**[1:28:19] Speaker A:** Because I was just. I felt disgusted and disappointed when I was treated. I don't really want the fellowship. They, I think, were insulted. They said, Dr. Malhotra, while you are serving a suspension, you can no longer resign your fellowship. But by the way, since your. Since this has happened, we've had further complaints about your appearance on the BBC.

**[1:28:44] Speaker A:** So this then dragged on for a while and ultimately, you know, they. They took away my fellowship. But, you know, so. So that's the.

**[1:28:52] Speaker A:** It was just a symptom of medical persecution, Jesse, to be honest, which I've experienced in my career, over my career for a long time. It's amplified, I think, more recently and hopefully things will resolve. The truth. Truth and justice will prevail. But I'm ready to, you know, stand my ground on this.

**[1:29:14] Speaker A:** This is about ethics and duty to patients.

**[1:29:17] Speaker A:** That's it. That's all I'm obsessed about. I think groupthinkers and the pandemic and fear has unfortunately, I think, taken many parts of the profession of. I think we've lost our way a little bit. I think we were losing our way before the pandemic anyway because of lack of addressing the commercial corruption of medical information. So this is just, you know, the chaos before order, Jesse. That's what I think, and it is what it is. I've taken this path. I have to accept what comes my way. It's not easy, but it's worthwhile and it's meaningful.

**[1:29:57] Speaker B:** On a positive note, I believe more recently you've joined the Maha movement.

**[1:30:03] Speaker A:** So I was actually appointed as the first chief medical advisor to Maha Action, which is a nonprofit founded by Kennedy Bobby himself, who I've known for a while, who's supported me on my advocacy for a few years, initially wanted me to be with him in hhs, potentially as his chief medical advisor. But because of America First Population policy, and I respect that as a British citizen, they couldn't give me that role. The White House said that that can't happen.

**[1:30:28] Speaker A:** So this was the next best thing. But I have, you know, I'm friends with Bobby and he listens to me and as well as Jay Bhattacharya. So, you know, I've exchanged a lot of information over the last couple of years of policy changes that should be implemented and I'm pleased to see, I'm sure it's not just me, other people are involved as well. A lot of the things I've recommended are starting to be implemented. The food pyramid change, adopting a vaccine policy that's more in keeping with Europe rather than the US and giving too many vaccines, unnecessary vaccines to kids, the mRNA, stopping the research funding or the investments certainly into mRNA, half a billion dollars worth.

**[1:31:08] Speaker A:** All of those have been things that I've supported.

**[1:31:11] Speaker B:** Given this trend with policy, we still

**[1:31:13] Speaker A:** have to work on the western hypothesis though, so that's still work in progress.

**[1:31:17] Speaker B:** Given this trend with the policy, do you see it continuing to head in this direction?

**[1:31:22] Speaker A:** Yes, absolutely. There's only one way it can go. Listen, there's going to be pushback from big pharma. We've seen that, right? We are under a big pharma tyranny. So they are going to do their best to push back, but I think their days are numbered.

**[1:31:39] Speaker A:** They wrote their model, their own model is numbered, which is they can manipulate data for profit. There needs to be independent and even for their benefit, they're producing drugs. Most of the new drugs are copies of old ones, hiding data unharmed. It's ultimately self destructive. It doesn't take a rocket scientist to figure that out. Jesse. So we need to create conditions where they're actually truly innovating and focusing on producing products that are beneficial. With more funding into basic science research, not spending 20 times more on marketing than they do on the research.

**[1:32:17] Speaker A:** This is what they do. They spend 20 times more on the drug companies on marketing than they do on basic science research.

**[1:32:29] Speaker A:** So the model is failing.

**[1:32:31] Speaker B:** As we come to a close here, I want to come back to diet, specifically saturated fat, because as somebody adopts a lower carb diet, a lot of times they're going to take on more animal products. Saturated fat is going to go up. You've made it clear that it's not connected to heart disease. But for somebody right now that that's a hang up of them adopting this diet.

**[1:32:57] Speaker B:** Speak to that piece.

**[1:32:59] Speaker A:** Yeah. So the reason saturated fat doesn't cause heart disease is multifold. One, we've got randomized controlled trial data showing lowering saturated fat doesn't prevent heart attacks in high risk and low risk groups. We've got epidemiological, high quality observational studies over decades showing no association with saturated fat and heart disease.

**[1:33:14] Speaker A:** And then on a mechanistic level, we've Already explained, LDL isn't that important. But interestingly, even if you accept LDL might be important. Saturated fat raises HDL as well. And it's a total cholesterol divided by HDL ratio that is after triglycerides. And HDL is what's used in risk, calculating cardiovascular risk moving forward. So even if LDL goes up a little bit and it's going to vary according to whether it's dairy saturated fat or coconut oil saturated fat, even olive oil has 14% saturated fat in it. The ratio is not adversely affected.

**[1:33:49] Speaker A:** So that's all they need to know. I would not worry about that. But the triglycerides and HDLR and getting into resistance down and certainly when insulin resistance is down, I don't think there's any clear, you know, I don't think people need to worry about saturated fat at all. It shouldn't however, replace, in my view, extra virgin olive oil as being good quality as your base fat because that has positive benefits mechanistically and from randomized control trial data and observational studies as being, you know, cardio protective.

**[1:34:23] Speaker B:** Any other specific foods, olive oil aside, when it comes to living healthy and again, specifically for the heart, people want

**[1:34:31] Speaker A:** to consider, yeah, I think lots of non starchy vegetables, I think oily fish, garlic has some blood thinning properties. I mean, I can't cite good quality evidence, but it's a food and it's mechanistic and it tastes good. So I eat two cloves of raw garlic every day.

**[1:34:50] Speaker B:** How does somebody go about navigating the conventional medicine world, adopting a diet and lifestyle like this and trying to explain to their doctor this new way of living and eating and any potential changes in their blood work.

**[1:35:07] Speaker A:** See that as a way of educating your doctor. I learned from my patients, I've learned a lot from my patients. It's a two way process. Doctors don't know everything. We've definitely learned that in the last few years. If we did, we wouldn't have this massive worsening burden of chronic disease.

**[1:35:25] Speaker A:** And I think that's a reflection of some of the limitations of modern medicine. So I think you can get resources, you can get a copy of my book, A Statin Free Life. You know, I have patients coming with exactly the same issue where they've gone back to their doctor. The problem is the doctors aren't that bothered about lifestyle, but they're worried about the blood work. So when the LDL goes up, they get, you know, they get flattened.

**[1:35:50] Speaker A:** And I just say I, they can see me. Jesse, they can arrange an appointment with me through telehealth and I will write a letter and that usually goes to the doctor and the doctor leaves them alone because they won't. The primary care physician won't. Overall a specialist.

**[1:36:06] Speaker B:** So anybody tuning in from around the world can work with you?

**[1:36:09] Speaker A:** Absolutely, absolutely.

**[1:36:11] Speaker B:** And what's the best way to do that?

**[1:36:13] Speaker A:** The best way to do that is to. There's an email address which is conciergehuman, which is hu-u m2n.com which is the name of the clinic. And they can. Or they can just look. If they're not sure, just look at my website, drasim.com and they'll find a way to get in touch and make an appointment with me. And they're very happy to talk about cholesterol, statins, lifestyle, everything, understand their tests, what they can do moving forward, hopefully limit their fear, give them a feasible plan to work with.

**[1:36:45] Speaker B:** Okay, last question for today. We've shared a lot here, a lot of details, which is great.

**[1:36:51] Speaker B:** What are three takeaways for somebody feeling overwhelmed right now at the end, that they should apply right away to start building that momentum?

**[1:37:01] Speaker A:** I think broadly well, three takeaways. One is these effects in the lifestyle changes have rapid effects. So these interventions for lifestyle rapidly improve your metabolic health and mental and physical health too, within weeks. Oh my God, it's daunting. How long are you going to do this for? Do it for six weeks. You will see a difference at the end of six weeks that will make you sustain it afterwards. Don't underestimate the power of reducing your stress. Not just for breath work, but just social interaction is so important.

**[1:37:39] Speaker A:** Actually prescribe hugging. I tell patients with their partners, boyfriends, girlfriends, you know, even friends, you know, hug for 20 seconds 10 times a day. Very beneficial.

**[1:37:55] Speaker A:** And I would say the 3 3rd takeaway is good health doesn't come out of a medicine bottle. Most of what determines your longevity, your health and your happiness has nothing to do with doctors. Unfortunately, I think medicine is best for acute illnesses. I think we've done amazing things. Road traffic accidents, emergency heart surgery, defibrillators, antibiotics for infections, insulin for type 1 diabetes.

**[1:38:24] Speaker A:** These are where the big gains have come. In medicine for chronic disease, it's going to be lifestyle first.

**[1:38:31] Speaker B:** Aseem. I want to acknowledge you for the work you're doing. You're a truth seeker. You're somebody that speaks the truth. Putting your flag in the ground and saying, this is what I stand for, even if it's not easy. Your work is much appreciated. We're going to link up your contact info, your books, your social media, everything in the show notes. Thank you for this, Jesse.

**[1:38:54] Speaker A:** Appreciate it. Thank you.

**[1:38:56] Speaker B:** Thank you for watching. Stick around here for this other great interview. You don't want to miss it. I'll see you over there.

**[1:39:02] Speaker A:** A lot of coronary artery disease is very silent. That plaque is silently sitting there in millions of people without them even knowing. And there are ways to find this out. Now we have the technology.

**[1:39:14] Speaker A:** It's just not being done. And those who already.