Dr. Mark Houston on Preventing Heart Disease: Rational Wellness Podcast 131
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Dr. Mark Houston discusses Preventing Heart Disease with Dr. Ben Weitz.
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Podcast Highlights
4:11 There are a limited number of specific vascular responses to the many insults to our blood vessel walls that result in coronary artery disease. Dr. Houston said that there are 400 different risk factors for coronary heart disease and atherosclerosis. Whether it is E. coli or a heavy metal toxin or LDL cholesterol there are only three things the blood vessel can do to respond to these insults. There’s three of them called inflammation, oxidative stress, and vascular immune disfunction. When these responses occur in the artery wall, it creates biomediators that eventually lead to coronary heart disease or congestive heart failure, stroke, or any kind of cardiovascular illness.
5:47 There is much controversy over whether red meat contributes to heart disease, with a recent paper in the Annals of Internal Medicine, in which a group of doctors and researchers who call themselves the Nutritional Recommendations Consortium and who did an analysis of the literature and concluded that red meat and processed meat do not significantly contribute to heart disease and cancer, Unprocessed Red Meat and Processed Meat Consumption: Dietary Guideline Recommendations From the Nutritional Recommendations Consortium. Dr. Houston said that red meat is not the problem, but what the red meat has in it that causes problems. If the cattle are being fed corn and grains, which contains pesticides and glyphosate, and they are given hormones and antibiotics, then this will not be healthy to eat. On the other hand, if you eat meat from organic, grass fed cattle, that will have a different effect in the body and is healthy to eat. Numerous studies show that this type of red meat does not increase coronary heart disease of heart attack.
9:06 Red meat contains saturated fat, which has been shown to be associated with heart disease. Dr. Houston explained that there are different types of saturated fat based on the carbon length, whether they be 8, 10, 12, up to 20 carbons. The long chain C-12 and up are the ones that may have an increased risk of coronary heart disease and heart attack. But Dr. Houston did caution that even this link between saturated fat and heart disease depends partially on where the fat is coming from what it’s associated with, what other kinds of fats are in your diet, and the percent in your diet. The short chain fatty acids C-12 and below are not associated with coronary heart disease. Dr. Houston recommends to keep your saturated fat intake around 10% of your total calories and try to limit it to the short chain fatty acids.
11:41 Dr. Houston is not a big fan of coconut oil, since it is 92% saturated fat and it’s mostly longer chain fatty acids. He feels that there is not much data that coconut oil has any health benefits. This is in contrast to many Functional Medicine practitioners who feel that coconut oil is a healthier oil, partially because of the medium chain triglycerides that it contains.
13:10 One reason some people like using coconut oil is for cooking, since it’s high saturated fat content helps it to hold up to heat better than other oils without being oxidized. Dr. Houston is a big fan of olive oil and cooks with it at a lower heat, and he is careful not to bring it to a steaming point. He cautioned not to overcook at too high a temperature. He says that monounsaturated fats are healthy and he recommends pouring some olive oil on your food after you have cooked it. He also recommends cooking with grape seed oil and avocado oil, which both stand up to higher heat.
15:47 One of the advanced lipid tests on the market lists monounsaturated fats in the less healthy category and some physicians tell their patients not to eat them. Dr. Houston said that monounsaturated fats, like olive and avocado, are healthy and they help to reduce coronary heart disease. They may not be as healthy as eating omega 3 fats, but much healthier when compared to saturated fats or refined carbohydrates.
17:00 Polyunsaturated fatty acids include both omega 6 fats, like most vegetable oils, which are not quite as healthy, and omega 3 fats, like fish oil, which are very healthy. Polyunsaturated fats do break up in heat and can become unstable, because they have a lot of double bonds. Dr. Houston recommends that when you buy omega 3 fats, they should have tocopherol in the bottle to stabilize the oil in the bottle. And you should add some extra gamma-delta tocopherols to stabilize the omega 3 fats in your cells. Further, when you take EPA and DHA (omega 3s), you should also take a little GLA to balance out the fatty acid pathways. Dr. Houston also likes consuming tocotrienols, but these should be taken 12 hours apart from taking tocopherols, and when you take tocopherol, it should be mostly gamma and delta tocopherol and not much alpha tocopherol.
20:32 The average primary care MD will usually order a basic lipid profile that includes total cholesterol, HDL, estimated LDL, and triglycerides, but this is an inadequate way to assess lipids. Dr. Houston said that “Regular lipid testing is obsolete. Let’s make that very clear. Advanced lipid testing is state of the art.” The estimated LDL on a standard lipid panel doesn’t tell you exactly how many LDL particles there are, which requires LDL particle number. The standard panel doesn’t tell you about LDL particle size, which is important. It’s the small, dense LDL particles that are the bigger risk, that can more easily penetrate the endothelium and cause atherosclerosis and foam cells. Also, just getting an HDL is not as important as knowing HDL functionality, whether that HDL performs the reverse cholesterol transport that helps it reduce reduce coronary heart disease risk. So it is important to know HDL particle number and also size.
23:26 We used to think that only larger HDL particles were to be preferred, but the latest research indicates that the real small HDL are called prebeta and they dock to the macrophages and other tissues to literally remove LDL cholesterol and take it to the liver. Dr. Houston explained that all sizes of HDL are important, “You’ve got to have all of them to kind of transport from little to medium sized, to big through all these metabolic pathways, since they all can work through different metabolic pathways.” There are actually 100 different proteins and lipids in HDL and if you knock most of them out, then it not only becomes dysfunctional, but it can become pro-atherogenic. Patients who have very high HDL, say above 85, most of it will probably be dysfunctional. There is now a test from Cleveland Heart Lab that Dr. Houston is using in research to measure HDL functionality, Cholesterol Efflux Capacity, called HDL FX. This test is not yet available for clinical usage.
26:44 When it comes to VLDL, you want smaller particles and larger VLDL, which is what people think of as triglycerides. If you have a patient with high VLDL/triglycerides and low HDL and their LDL may be normal, but these patients have one of the highest risks for heart attack, because these patients usually have small, dense LDL. For treating triglycerides, we can use omega-3 fatty acids, niacin, and fibrates (if you choose to use a drug).
28:18 There is a particularly artherogenic particle known as Lp(a) that is included in advanced lipid profiles. The Biggest Loser trainer, Bob Harper had a massive heart attack, and his only significant risk factor was an elevated Lp(a). Lp(a) is not modified very much by diet or lifestyle and is generally considered to be genetic. There are some different techniques for measuring it, but 30 or less is considered normal and as you go over 30, the risk for heart attack goes up incrementally, as does atherosclerosis, coronary heart disease, clotting, retinal artery emboli, and aortic stenosis. You can reduce it using certain nutraceuticals, including niacin and high doses of N-Acetyl Cysteine. Dr. Houston said he also usually places patients with elevated Lp(a) on low-dose aspirin. Linus Pauling had a protocol using vitamin C, proline, and lysine in specific proportions, though there does not seem to be any published data on this. It is designed to stop the attachment of Lp(a) to the artery wall. In fact, most of the reports of nutrients to lower Lp(a) are anectdotal. Other nutrients that might help are vitamin C, L-carnitine, CoQ10, pantethine, and tocotrienols.
31:37 Homocysteine is another factor in an advanced lipid profile and it is a bad actor. It is more commonly elevated with MTHFR SNPs. It causes vascular damage, strokes, heart attacks, vascular dementia, kidney disease, and it’s elevated by a lot of things in your diet plus your genetics. The risk for homocysteine becomes dramatic at 12 and higher. He likes to get homocysteine to below 8 but 5 is optimal. To lower homocysteine we use methylated forms of B-6, B-12, B-9 (folate), and other nutrients like TMG. We use various nutrients in the methylation pathway. If needed, it can be helpful to order a methylation profile and see which enzymes can be helpful.
33:43 TMAO is a new marker for heart health that was developed by Dr. Stanley Hazen from the Cleveland Clinic. TMA (trimethylamine) is a product that is found in L-carnitine, choline, and phosphatidylcholine, commonly found in fish, red meat, chicken, eggs, and dairy are converted into TMA (trimethylamine) by certain gut bacteria, which is converted into TMAO (trimethylamine oxidase) by the liver. TMAO has been associated with blocking reverse cholesterol transport along with other atherogenic effects. Therefore, supplements of L-carnitine, choline, and phosphatidylcholine (lecithin) would theoretically also raise TMAO levels, but these nutrients have often been found to be beneficial and Dr. Houston mentioned that he uses L-carnitine in his protocol for patients with heart failure and choline is also a beneficial nutrient for the liver and for brain health, so it is hard to believe that we should really avoid these things. Studies have consistently shown that eggs do not increase our risk of heart disease. Further, fish is one of the healthiest foods that has consistently been associated with improved heart health, so this TMAO hypothesis seems to run contrary to much of the science. Dr. Houston explained that when he has a patient with high TMAO levels, he will place them on a plant-based diet for a week or so and give them probiotics and prebiotics and this will usually drop the TMAO. It may be that elevated TMAO levels are really just an indication of gut dysbiosis, since if you change their gut bacteria, the person no longer overproduces TMAO.
38:18 Which diet is best for preventing heart disease? Vegetarian (plant based), Mediterranean, Paleo, Ketogenic, or does it depend upon each person? Dr. Houston said that if you go by science, the Mediterranean diet is best for heart disease, diabetes, and other health issues. This diet should consist of 10-12 servings per day of fresh, organic vegetables and fruits, cold water fish and high quality organic meat, and lots of monounsaturated fats like olive oil and nuts, and also lots of omega 3 fats both in the diet and as supplements. You want to avoid refined carbs like bread and cereals and also pasta, white potatoes, and white rice. Dr. Houston is not a big fan of the ketogenic diet because it raises your lipids and causes inflammation. Dr. Houston said that for patients who are heterozygous or homozygous for the ApoE4 gene, they should be on a very low saturated fat diet, such as a vegetarian diet, but with lots of omega 3 fats and monounsaturated fats like olive oil.
41:22 Micronutrient deficiencies can play a role in heart disease. Dr. Houston said that he will often do micronutrient testing through SpectraCell, which measures intracellular levels in a functional way. Take magnesium, which is primarily inside the cells, so serum levels are not very accurate to tell if their magnesium level is low. And magnesium is involved in 400 different biochemical pathways. When he has a patient with high blood pressure and he determines that they have 5 nutrients that they are low in and he repletes these micronutrients and their blood pressure goes to normal.
44:28 The most effective nutraceuticals/nutritional supplements for reducing plaque in the arteries are: 1. Omega 3 fish oil–4-5 gms per day of a high quality, balanced product with DHA, EPA, some GLA, and gamma-delta tocopherol, 2. A compound with nitrate, like beet root extract, that will raise nitric oxide levels, 3. Kaolic garlic, 4. Vitamin K2–MK-7 a minimum of 360 mcg per day, 5. Lactobacillus rhamnosus GG, 6. Luteolin, 7. Lycopene.
46:27 A Coronary Calcium Scan is a CT scan that looks for calcium in the arteries of the heart to screen for blockages. There is a perception that this is the definitive way to determine if you have any blockages or not. If you have a high coronary calcium score could mean one of two things: 1. You have calcium in a plaque in an artery, or 2. you have calcium in the arterial wall but not necessarily any blockages. On the other hand, if you have a low score on your coronary calcium scan, it doesn’t mean that you don’t have heart disease because you could have a soft plaque in the arteries that is not calcified. Dr. Houston talked about several patients who had 95% blockage in their LAD (the Left Anterior Descending artery, aka, the Widow Maker because a blockage in this artery) but a 0% coronary calcium scan.
48:33 Red yeast rice can be very effective and Dr. Houston often uses it, esp. with patients who are statin intolerant or who refuse to take a statin. Dr. Houston cautioned that a lot of red yeast rice comes from China, so be careful to use a quality brand. He usually recommends a relatively high dosage–4800 mg per day and he will often add berberine and other nutrients. There is scientific data that shows that red yeast rice will prevent a heart attack. Dr. Houston says that if he can get a patient on 4800 mg red yeast rice, berberine, a phytosterol and some niacin, he can reduce LDL particle number by 50%. When Merck Pharmaceutical made lovastatin from red yeast rice, they took everything out except that one compound. But when you take red yeast rice, you get a composite of other ingredients that are beneficial for cholesterol and also for heart disease. Red yeast rice also reduce aneurysms and it is anti-inflammatory. And Dr. Houston has found red yeast rice at even 4800 mg to be very well tolerated by his patients and has almost never seen a liver problem. However, he will usually use CoQ10 with as he always does with statins to make sure that it doesn’t lower CoQ10 levels. He likes to keep the CoQ10 level over 3 mcg/deciliter. Statins tend to deplete not just CoQ10 but also vitamin E, omega-3 fatty acids, tocotrienols, carnitine, vitamin K2 MK-7 and vitamin K in general, vitamin A, Heme A, and selenium.
52:28 Plant Sterols. One testing company that does advanced lipids measures levels of plant sterols as a way to categorized if you are a hyper-absorber or a hyper-producer of cholesterol. Dr. Houston said that he tried using this type of test and he found that if someone is a hyper-absorber you block the absorption, the liver starts making more cholesterol. He finds it better to just use a nutritional agent to block cholesterol production, like red yeast rice, and something to block cholesterol absorption, like plant sterols or berberine. Dr. Houston pointed out that berberine is a natural PCSK9 inhibitor, so you can either buy Repatha for $11,000 per year or you can buy some berberine for 30 cents a day. Also, berberine is a natural form of metformin and it also turns off mTOR and turns on AMPK, so it is a natural anti-aging agent as well.
54:22 Tocotrienols if taken with red yeast rice or statins will enhance their effectiveness. Tocotrienols block the production of the HMG-CoA enzyme for the messenger RNA. They also break down the increased catabolism of the enzyme. So it’s not a competitive inhibitor of HMG-CoA reductase. It is best to take the red yeast rice or statin at night with the gamma-delta tocotrienols, which will result in a 10% decrease in LDL and LDL particle number.
55:20 Niacin has gotten a bad rap and many primary care doctors will tell you that niacin has no benefit, but that is because of two large clinical trials that had poor design and other methodological flaws. One study was The HPS2-THRIVE Collaborative Group. Effects of extended-release niacin with laropiprant in high-risk patients, which was published in the New England Journal of Medicine in 2014. Here is an article written by Dr. Houston and Dr. Pizzorno on the flaws in this study and why niacin is an effective agent: “Niacin Doesn’t Work and Is Harmful!” Proclaim the Headlines. Yet Another Highly Publicized Questionable Study to Discredit Integrative Medicine. The other highly publicized negative paper on niacin was the AIM-High Trial, Niacin in patients with low HDL cholesterol levels receiving intensive statin therapy. This trial actually did show that niacin significantly reduced LDL cholesterol and triglycerides and raised HDL, but they concluded that it had no clinical benefit.
Dr. Houston emphasized that niacin is extremely effective at improving nearly every risk factor on an advanced lipid profile including the functionality of HDL, and there are many other studies showing niacin’s effectiveness, such as this study, Extended-release niacin or ezetimibe and carotid intima-media thickness, in which they found that “extended-release niacin causes a significant regression of carotid intima-media thickness when combined with a statin and that niacin is superior to ezetimibe.” Dr. Houston explained that the only downside to niacin is if you get really high doses you might increase your blood sugar, you might increase your homocysteine, and you may flush. But typically you can give a lower dose of an intermediate acting niacin and you will get really good effects that are beneficial for atherosclerosis. So, everything prior to these two inappropriate reports that had bad methodology, niacin worked great, so keep using it. Just make sure to get a good quality product.
57:46 Several years back, soluble fiber, such as in oatmeal, was touted to lower cholesterol. Dr. Houston recommends eating mixed fiber, both soluble and insoluble, and he said that fiber works through the microbiome. Gut bacteria use the fiber to make chemicals that reduce diabetes, cholesterol, blood pressure and heart disease.
Dr. Mark Houston is an internal Medical Doctor and a hypertension and cardiovascular specialist. He is the director of the Hypertension Institute in Nashville, Tennessee. Dr. Houston is triple board certified in hypertension as an American Society of Hypertension specialist and Fellow of the American Society of Hypertension, Internal Medicine, and Anti-aging Medicine. Dr. Houston teaches at the Institute of Functional Medicine and the A4M programs. He is a prolific writer and has written What Your Doctor May Not Tell You About Hypertension, What Your Doctor May Not Tell You About Heart Disease, Nutritional and Integrative Strategies in Cardiovascular Medicine, Nutritional and Integrative Strategies in Cardiovascular Medicine, and his two latest books, Vascular Biology for the Clinician, and Precision and Personalized Integrative Cardiovascular Medicine. You can contact Dr. Houston through The Hypertension Institute web site HypertensionInstitute.com.
Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or go to www.drweitz.com.
Podcast Transcript
Dr. Weitz: This is Dr. Ben Weitz with The Rational Wellness Podcast, bringing you the cutting-edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Please subscribe to The Rational Wellness Podcast on iTunes and YouTube, and sign up for my free E-book on my website by going to drweitz.com. Let’s get started on your road to better health. Hello Rational Wellness Podcasters. Thank you so much for joining me again today. For those of you who enjoy listening to The Rational Wellness Podcast please go to your Apple Podcast app or wherever you listen, whatever podcast app you use, and give us a rating and review. That way more people can find out about the Rational Wellness Podcast. Also, you can find a video version if you go to my YouTube page and if you go to my website, drweitz.com, you can find a full transcript and detailed show notes.
So, our topic for today is how to prevent and reverse cardiovascular disease. In the 1950s and 60s, Ancel Keys and other researchers told us that eating too much fat, especially saturated fat such as found in red meat, butter, and cheese is the cause of heart disease. Saturated fat raises LDL levels which leads to cholesterol buildup in the arteries, end of the story. Thus, the lowfat mantra was born as a way to prevent heart disease, though, as we have learned after 30 or 40 years it didn’t really do all that much to prevent heart disease. We’ve learned that most of the cholesterol in the body is produced by the liver and it’s made from glucose. We have learned that consumption of refined carbohydrates and sugar is a greater contributor to raise our lipids and contribute to heart disease.
But did you know that inflammation in the walls of our arteries increases the likelihood of cholesterol to be found lining our arteries, what we call atherosclerosis? That inflammation can be caused by many things including heavy metal toxicity, pesticides, mold toxins, chronic infections, food allergies, and consuming hydrogenated vegetable oils among other things. As we will learn today, cardiovascular disease is not just a metabolic disease but also an immunologically mediated condition. Dr. Mark Houston is our special guest today. He’s an internal medical doctor and a hypertension and cardiovascular specialist. He’s the director of the Hypertension Institute in Nashville, Tennessee. Dr. Houston is triple board certified in hypertension as a fellow of the American Board of Hypertension. He’s also board certified in internal medicine and anti-aging medicine. He has a masters degree in human nutrition and a Master’s of Science Degree. Dr. Houston teaches doctors around the world about cardiovascular medicine as part of the Institute of Functional Medicine and A4M programs.
Dr. Houston is also a very prolific author, having written What Your Doctor May Not Tell You About Hypertension, What Your Doctor May Not Tell You About Heart Disease, Nutritional and Integrative Strategies in Cardiovascular Medicine, Nutritional and Integrative Strategies in Cardiovascular Medicine, and his two latest books, Vascular Biology for the Clinician, which has just recently come out and Precision and Personalized Integrative Cardiovascular Medicine, which will be out in November. Thank you so much for joining me, Dr. Houston.
Dr. Houston: Thanks Ben, it’s good to be with you.
Dr. Weitz: Excellent, excellent. So, can you talk about some of the specific vascular responses that cause coronary heart disease?
Dr. Houston: Absolutely. The cardiovascular world’s literally been turned upside down as far as causes, insults, and how the arterial wall responds to all those insults. And as you rightly pointed out we’ve been mislead down the bad food path for 40 years and now we’re having to go back and reorganize our entire thinking process about that piece. But there’s about 400 risk factors for coronary heart disease and atherosclerosis.
Dr. Weitz: Wow.
Dr. Houston: Obviously we’ll talk about some of the top ones today, but the concept that I like to get across to people is that these insults that are coming in, the blood vessel can’t name them. It just sees what’s coming in and it may say, “Well, it’s an amino acid sequence or a fatty acid sequence.” So, E. coli, as far as the vessel’s concerned can look just like LDL cholesterol. So the response is limited, it’s very limited. In fact, there’s only three things the blood vessel can do to respond to these insults. There’s three of them called inflammation, oxidative stress, and vascular immune disfunction. When those three go off in the blood vessel it can create all kinds of biomediators that eventually lead to coronary heart disease or congestive heart failure, stroke, or any kind of cardiovascular illness.
Dr. Weitz: Recently in the news there’s been quite a bit of back and forth about the role of red meat in heart disease and cancer with a recent paper in The Annals of Internal Medicine, where a bunch of researchers did a reanalysis of the existing research on red and processed meat and concluded that the evidence for harm from red meat was very limited and does not warrant recommending that citizens reduce their red meat and processed meat intake in order to reduce their risk of heart disease. They shot back with a rear affirmation, I think it’s World Cancer Council, that you do want to reduce your intake of red and processed meat in order to reduce your risk of cancer. We’ve got this back and forth on whether or not red meat is a factor in heart disease. Where do you come down on this controversy?
Dr. Houston: Well, it goes to show you can try whatever you want to in any journal wherever you go to read it. Pardon the noise. Here, let me get this. He’ll be gone in just a second, my apologies. So, let me try to give you the real truth about red meat. The meat is not the problem. The red meat is not the problem. It’s what the red meat has in it coming from other sources related to the cow, okay?
Dr. Weitz: Okay.
Dr. Houston: If you have cattle that are eating corn, being fed bad food, given hormones, getting pesticides, and organicides, and gosh knows what else into their body, that’s going to go into the meat. Whereas if you get organic food and you don’t put any hormones or pesticides out in what they eat, the red meat is absolutely benign and doesn’t cause heart disease. So, as you pointed out earlier, toxins, infections, pesticides, and hormones are probably the issue in all the bad stuff that’s happened with coronary heart disease and red meat. So, in my opinion, based on having looked at this very carefully also in the last two years, organic red meat is fine to eat. You can find numerous studies that say it does not increase coronary heart disease or heart attack.
Dr. Weitz: So, essentially what everybody’s forgetting about is the quality of the food when we are just looking at these macronutrient discussions. We’re not looking at the quality of the meat, we’re not looking at the quality of the carbohydrate, or the quality of the fat so what you’re saying is if we’re consuming a high quality red meat that’s organic, from grass fed cattle, that’s going to have a totally different biochemistry and a different effect in our body than eating feedlot cattle that’s shot up with antibiotics and hormones.
Dr. Houston: Exactly. In general what we like to do is stick with something that’s fresh and organic whether it’s a vegetable, or fruit, or meat, or some other kind of fat. Exactly.
Dr. Weitz: Right. So, since we’re on the topic of red meat part of the conversation about red meat has to do with the role of saturated fat. What’s your opinion about the role of saturated fat? Does saturated fat raise LDL cholesterol and does it play a role in the pathogenesis of atherosclerosis?
Dr. Houston: Well, I have written several articles in the period literature as well as in the book, On Integrative Strategies in CVDs, to talk about what is really the truth about saturated fats. So, this is what the literature is clearly showing now. A saturated fat is not just a saturated fats, there are different varieties within that. What determines what type of saturated fat is going to cause heart disease or not cause heart disease? And the primary issue relates what’s called carbon length. Carbon length 8, 10, 12, and on up to whatever, 20-something. The long chain fatty acids, that is probably C-12 and up, are considered long chain. Those are the ones that may have an increased risk of coronary heart disease and heart attack, but even that’s somewhat questionable depending on where the fat’s coming from, what it’s associated with, what other kinds of fats are in your diet, and the percent in your diet. But if you eat C-12 and below, the short chain fatty acids, there’s no evidence that any of those cause coronary heart disease or heart attack. So what I typically tell people to do is keep your total saturated fat intake around 10% or so of your total calories and try to limit it to the short chain fatty acids. It doesn’t mean you can’t have some long chain, it’s just don’t make those an abundant piece of your diet.
Dr. Weitz: So, which sources of saturated fat have the shorter chain?
Dr. Houston: What you want to do is you’ve got to read labels, that’s the problem. And labels, as you know, can be very, very deceiving. I think if you look at high quality meats of any sort, particularly if you’re talking about organic red meat or organic veal, organic chicken, organic turkey. Fish, obviously, don’t have hardly any saturated fats. They’re mostly monounsaturated and omega-3. Mostly omega-3s. Then you’ve got the end up just getting the good fats, doing that alone.
Dr. Weitz: So where does coconut oil fit into this? Because we know that coconut oil is a vegetable source of saturated fat and the arguments have been going back and forth on coconut oil. It’s been lauded by many in the functional medicine community as a wonder fat, and then we’ve got The American Heart Association still telling people not to consume coconut oil.
Dr. Houston: Yeah, that’s a loaded question. The coconut oil story is also very controversial. Coconut oil is 92% saturated fat, it doesn’t really have any other kind of good fats in it.
Dr. Weitz: Is it the shorter chain or the longer chain?
Dr. Houston: No, it’s the long chain. That’s the problem. It’s 92% long chain fatty acids. So, I wouldn’t recommend you consume a lot of coconut oil for that reason. A little bit just like what’s mentioned earlier is fine, but don’t get hung up on drinking a lot of coconut oil or consuming coconuts because they probably may not be healthy. There’s really not much data, honestly, that coconut oil has any really good health benefits. But on the other hand, a lot of it could be detrimental.
Dr. Weitz: Interesting, interesting, because I think a lot of people in the functional medicine world have put coconut oil in the healthy oil category.
Dr. Houston: I’d much rather you consume omega-3 fatty acids and olive oil, monounsaturated fats. They’re much healthier, with better data. When you get the coconut oil, you kind of don’t find much out there that’s going to help you for heart disease.
Dr. Weitz: Now, one of the reasons why people say they like coconut oil is because the saturated fat, because it’s saturated, it’s not going to react to oxygen or other things. Therefore, if you try to cook with a polyunsaturated oil, or you try to cook with an olive oil it goes rancid and gets damaged. Whereas, a coconut oil, because it’s a saturated fat, is not going to have that happen.
Dr. Houston: Another great question, what kind of oil should you cook with, and why or why not? The Europeans really laugh at us when we say we don’t cook with olive oil. They said, “No, no, no. We cook with olive oil all the time, just don’t boil it.” Because you will destroy it. We overcook everything. I cook with olive oil, but I don’t bring it to a steaming point.
Dr. Weitz: So, what is the temperature cutoff?
Dr. Houston: You get it warm, but if it starts…
Dr. Weitz: What is warm? Are we talking about 350?
Dr. Houston: I don’t know what the boiling point of olive oil is. The point is, you keep it on low simmer and when you see the olive oil starting to steam, you’ve gone too far. Now, you can cook with other oils obviously. Grape seed oil is good, you could cook with olive oil, and you can cook with coconut, or you can cook all these things; point is, just don’t overcook things. The other point is, if you want to cook with olive oil, go ahead and cook with it, pour off the olive oil if you think it’s bad, and then put some olive oil on your food when you put it on your plate. That’s fine.
Dr. Weitz: But you look at some of these charts and they’re very confusing. Extra-virgin olive oil has this temperature, another chart has the boiling point at a different temperature. Is it 325, is it 375? If you’re going to say baked vegetables, do we know what a safe temperature is if you’re going to use olive oil?
Dr. Houston: I don’t know that I have the temperature because you’d have to put a thermometer in your pan, and even then you’re not sure with all the other stuff in the pan whether it’s going to steam or not. Just don’t let it start steaming and you’re okay. Low temperature, sauteed.
Dr. Weitz: What about avocado oil for high heat cooking?
Dr. Houston: Avocado oil is fine, it’s a monounsaturated fat and it’ll tolerate the heat a lot better. It’s a good oil to use.
Dr. Weitz: By the way, since we’re on monounsaturated oils, we’re going to get to advanced lipid testing, but one of the companies that does advanced lipid testing now puts monounsaturated oils as less healthy. Do you know about this controversy?
Dr. Houston: Yeah, I do. I hear it all the time. And I hear a lot of physicians telling people not to use a lot of monounsaturated fats. That’s also not true. Monounsaturated fats, olive oil, nuts, olives are all healthy. There’s plenty of data to support the use for them in reducing coronary heart disease. Here’s the trick though, what’s your comparator? So, if I want to compare monounsaturated fats to omega-3 fatty acids, they don’t look as good. But if I want to compare them to saturated fats, they look really good. If I want to compare them to refined carbohydrates, they really look good. So, it’s just your comparator. But, overall, monounsaturated fats are very healthy.
Dr. Weitz: Okay, since we’re on this topic what about since we just talked about MUFAs, what about PUFAs?
Dr. Houston: Okay, so, polyunsaturated fatty acids, those do break up in heat because they’re a lot of double bonds, and they can be more unstable. So how do you get around that problem? Well, two things. One, when you buy omega-3 fatty acids you want to be sure it has a tocopherol in with it. Because, see, vitamin E, tocopherol, particularly gamma-delta tocopherol stabilizes the PUFAs, or the omega-3s in the bottle. But you also need it to stabilize it in your cell membranes. Whatever you consume when you’re using omega-3s, be sure that your product contains tocopherols, omega-3 DHA, EPA, but also another one, GLA. Because you’ve got to have those pathways lined up so you don’t distribute them inappropriately.
Dr. Weitz: Interesting. You know, I was using the gamma-tocopherol every time I took my omega-3s and was recommending it. I recently switched over to tocotrienols after talking to Dr. Barry Tan and seeing the amazing research on tocotrienols.
Dr. Houston: Yeah, I know Barry very well and his data is incredible with all the forms of vitamin E. The tocotrienols don’t necessarily stabilize polyunsaturated fats, though. They have other tremendous health benefits. I take his gamma-delta tocotrienols, but also I take the gamma-delta tocopherols.
Dr. Weitz: Okay, so you take them both, but just not at the same time?
Dr. Houston: This is really important for your audience. If you take your tocotrienols and your tocopherols at the same time, and it’s more than 20% alpha-tocopherol, it’ll block the absorption of the tocotrienols. So, you’ve got to take them about 12 hours apart.
Dr. Weitz: Right, and when you take the tocopherols you want a higher gamma, right? You don’t want to take the alpha-tocopherol.
Dr. Houston: Yeah, you don’t want a lot of alpha. You want mostly gamma and, or, delta.
Dr. Weitz: I’ve really been enjoying this discussion, but I’d like to pause for a minute to tall you about our sponsor for this podcast. I’m proud that this episode of the Rational Wellness Podcast is sponsored by Integrative Therapeutics, which is one of the few lines of professional products that I use in my office. Integrative Therapeutics is a top tier manufacturing of clinician design, cutting-edge nutritional products with therapeutic dosages of scientifically proven ingredients to help our patients prevent chronic diseases and feel better naturally. Integrative Therapeutics is also the founding sponsor of TAP Integrative. This is a great resource for education for practitioners. I’m a subscriber to TAP Integrative. There’s videos. There’s lots of great information constantly being updated and improved upon by Dr. Lise Alschuler who runs it.
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Dr. Weitz: Okay, so it’s common for primary care doctors to order a basic lipid panel, which is total cholesterol, estimated LDL, HDL, and triglycerides. Sometimes in conversations with patients they’ll say, “Oh, yeah, yeah. I looked and all my lipids were fine.” Can you explain why this lipid profile is not an adequate way to assess for heart disease risk?
Dr. Houston: Absolutely. Regular lipid testing is obsolete. Let’s make that very clear. Advanced lipid testing is state of the art.
Dr. Weitz: That message has not… It either hasn’t gotten out, or the fact that the insurance doesn’t want to cover it…
Dr. Houston: Well, that’s even not an issue anymore. All the advanced lipid testing companies that we use, they’re covered by insurance and if they’re not they’re only like $60. So, it’s not that you can’t afford them. But here’s the really important part about advanced lipid testing. Let’s take each lipid just individually because you have to do that. LDL cholesterol, different sizes, different atherogenesis, some are modified. So, let’s say you have a big, fat LDL and a real tiny LDL. Let’s use the garbage can analogy because people get this. Two garbage cans sitting in your back yard, if you look at them and say, “That’s my LDL.” And I say, “Well, which one’s bad?” And they go, “Well, I don’t know. They’re both bad, aren’t they?” I say, “No, no. Take the lid off the garbage can. One side’s got tennis balls in it and the other side’s got golf balls.” And I say, “Well, which of those would you like to have.” And they go, “I don’t know.” I said, “You don’t want the golf balls because that’s the small, dense LDL. That’s when it penetrates the endothelium, goes into the sub endothelial layer and wreaks havoc, causing atherosclerosis and foam cells. The big ones on the other hand don’t necessarily get through as easily.” So, if you have a lot of little ones the second issue is LDL particle number. The driving risk for coronary heart disease and heart attack is LDL particle number, number 1, and LDL size, number 2. That’s the LDL sort. You can’t get that on a regular profile. Second one is HDL. Well, HDL on a regular lipid profile is a static number. It tells you absolutely nothing. It doesn’t tell you about the size, it doesn’t tell you about how many particles there are, and it doesn’t tell you about its functionality. So, the latest discovery in HDL cholesterol is the functionality is what determines whether or not it’s atherogenic or not. Second is HDL particle number, which is very important. But you don’t get either one of those on a regular lipid profile. You get a static HDL, which means nothing. It can be low, it can be high, and you see that number you can make no predictions whatsoever whether that HDL is good, bad, or ugly and what’s going to be protective to the patient.
Dr. Weitz: So you want larger HDL, right? That’s more protective?
Dr. Houston: Well, generally, that’s what we thought. We thought that larger was better than smaller. But it turns out that all of them are important because they all have a different process. The real small HDL they call prebeta, that’s the one that docks to the macrophages and other tissues to literally remove cholesterol, LDL cholesterol, from the tissue and then take it to the liver and dump it. You’ve got to have all of them to kind of transport from little to medium sized, to big through all these metabolic pathways. So, actually, all the HDL’s are important, and it’s hard now based on data, because it’s getting complicated again, which size is better than the other.
Dr. Weitz: Oh, that’s really interesting. That’s kind of new news.
Dr. Houston: It is new, it’s the functionality.
Dr. Weitz: And by functionality, it’s producing reverse cholesterol transport?
Dr. Houston: Exactly right. RCT, reverse cholesterol transport, also called CEC, cholesterol efflux capacity, determines functionality. But the functionality of HDL is probably a hundred different things, so there’s like a hundred proteins and lipids in HDL. So, if all of them are working good it’s totally functional, but if you knock half of them out it’s kind of limping along. If you knock all of them out it’s not doing anything. In fact, HDL, look at this, if you knock everything out becomes not only dysfunctional, it becomes pro-atherogenic.
Dr. Weitz: Wow.
Dr. Houston: So now you can have an HDL that’s actually inflammatory or causing heart disease. That’s really bad. Now you’ve got nothing protecting you.
Dr. Weitz: And I think I’ve heard you say that if you have somebody that has a super high HDL, there’s an increased risk of that, right?
Dr. Houston: Yeah. If your HDL is over 85, most of it’s probably dysfunctional HDL; in a male, probably if it’s over 60. But this is another new, kind of, just came out like two months ago. There’s a U-shaped curve with HDL. People who have low HDL may be okay, people that are right in the middle, and then it goes up again it gets worse. So at either end you’re probably looking at an HDL that may not be working. So, it’s kind of got to be at a certain number. I think in the study it was like 32 to 35 was kind of the number that was at the bottom of the curve.
Dr. Weitz: Do you measure HDL efflux, cholesterol efflux capacity?
Dr. Houston: There’s a new test from Cleveland Heart Lab that does that. It’s not available clinically yet, but we’ve been using it now for about six months in a couple of research trials. The name of it is HDL FX, which stands for functionality. Cleveland Heart Lab has it, they’re in phase B trials right now. It probably will be out sometime in 2020 for the commercial use. That’s all we’ve got for RCT right now.
Dr. Weitz: You know, I’ve talked to a Dr. Sri Ganeshan, who has the MitoSwab test and I think that he’s just come out with a cholesterol efflux test.
Dr. Houston: I hadn’t heard of that one. I know the one with Cleveland is validated with clinical trials, and so as far as I know that’s the best one on the market right now.
Dr. Weitz: Okay. So you mentioned LDL and HDL particles. Normally we think larger is better, now we find out with HDL that’s not necessarily the case. But with VLDL, which most people don’t talk about, actually, larger is worse. Right?
Dr. Houston: That’s right. VLDL is basically what people think of as triglycerides, but VLDL comes in all sizes, too. And the big, fat VLDL’s are very atherogenic but also they cause thrombosis.
Dr. Weitz: Wow. So, I’m not sure everybody puts a lot of importance on VLDL, but you’re saying that we should?
Dr. Houston: Yeah. When you see somebody that has high triglycerides or high VLDL, and it’s the big fat one, can accommodate with usually a low HDL. That group of people are usually metabolic syndrome, diabetes, obesity. Those people are the ones that had the discordance between LDL and the LDL particle number. So, here’s what happens. You go to the doctor’s office, he orders a routine lipid profile. All your triglycerides are high, your HDL is low, but your LDL’s okay. Well, it’s not okay because the LDL that that patient has is the small and dense, but increase LDL particle patient, that patient has one of the highest risks for heart attack of anything. And they’re ignoring that. But, yeah, all of these need to be treated. All the triglycerides. We use all kinds of things for that, omega-3 fatty acids, niacin, if you’re going to go to a drug–fibrates.
Dr. Weitz: Can you talk about the importance of Lp(a) for heart attack risk? There was a recent information about The Biggest Loser Trainer, Bob Harper, who had a massive heart attack and apparently elevated Lp(a) was his only significant risk factor.
Dr. Houston: Yeah, Lp(a) is genetic. There’s very little you can do to change it. Exercise, weight reduction, eating better doesn’t usually modify LDL… Excuse me, Lp(a) very much. So, when you’ve got this genetic type you have to get a lab that knows how to measure it, number one, because many a labs don’t give a good quality measurement of Lp(a) so you get deceived into whether you’ve got a problem or not.
Dr. Weitz: Really? So there’s different ways to measure it?
Dr. Houston: Yeah. Some measure mass, some measure different technology. So, you’ve got to find out whether your lab is consistent and has the best technique. That’s number one. Now, assuming it’s elevated, it’s a matter of degree. 30 or less is normal. Incrementally over 30 the risk for heart attack goes up. If you’re like 40, not too bad. But if it’s 150, yeah, you’re in trouble. And what Lp(a) does is it causes atherosclerosis, coronary heart disease, MI, clotting, retinal artery emboli, and aortic stenosis. So, it’s a bad actor. And there’s not many things we have to lower it. Niacin and NAC are the two that seem to be the best
Dr. Weitz: And how much do you think it’s reasonable to lower it?
Dr. Houston: Well, you try to get it down as close to 30 as possible. It’s hard to do that, but you’re going to have to use high doses of niacin, high doses of NAC, usually put them on low-dose asprin to kind of help block some of the clotting effects. There’s a whole list of stuff, Ben, that has been reported to lower Lp(a). Most of it’s anecdotal. I mean, we’ve got vitamin C, carnitine, CoQ10.
Dr. Weitz: Yeah, a lot of people talk about this vitamin C thing. I guess there was one study on that.
Dr. Houston: A lot is Pauling’s Protocol.
Dr. Weitz: Right.
Dr. Houston: It makes sense, the protocol basically stops the attachment, we think. Lp(a) to the vessel wall. But I can’t find any data that Linus Pauling ever published that documents that in humans. They probably got some rat studies, whatever. I’ve used it on people just because sometimes you don’t have anything else you can do and it’s pretty benign. Vitamin C, proline, and lysine in the right proportions.
Dr. Weitz: Right. I had a patient who came in today and in about a year we got it down from about 96 to 60 with niacin, a fairly modest dosage. One time I had a patient, couldn’t get her Lp(a) to budge and I sent you an email, this is several years ago, and you said, “Pantethine and tocotrienols.” And, bam, perfect. It was unbelievable.
Dr. Houston: Yeah, well, like I said there’s about 15 things on my list for Lp(a). When I get backed into the wall I start whatever I can and see if it works.
Dr. Weitz: Well, that worked unbelievable.
Dr. Houston: That’s great, good news.
Dr. Weitz: How important is homocysteine? That’s often part of an advanced lipid profile.
Dr. Houston: Yeah, the protocol that we use has homocysteine on the advanced lipid tests along with C-reactive protein. But homocysteine is a bad actor, too. Most of the studies you read, it’s kind of poo-poo homocysteine. It’s obviously not a big problem, don’t worry about it.
Dr. Weitz: Homocysteine is a protein found in the blood that’s independent of cholesterol as a cardiovascular risk factor.
Dr. Houston: Yes, and this is very common with MTHFR, heterozygote, homozygote, causes vascular damage, strokes, heart attacks, vascular dementia, kidney disease, and it’s elevated by a lot of things in your diet plus your genetics. But the risk for homocysteine becomes dramatic at 12 and higher. That’s when the curve shoots straight up. I like to get it below 8 in everybody I can, but if I can get it to 5 that’s where the curve becomes fairly flat.
Dr. Weitz: 5? Wow.
Dr. Houston: If you can get there. The risk at 8 is pretty low, but it’s starting to go up. 12, through the roof. So, if you see it up over 12 you’ve got to work hard to get it down.
Dr. Weitz: So to lower homocysteine we’re using methylated forms of B-6, B-12, B-9. Are there any other nutrients that can be beneficial if that sort of B vitamin strategy doesn’t get you where you want to go?
Dr. Houston: The cocktail, as you know, is methylated folate, B-6, and all the others. There’s about 10 things in that methylation pathway and there’s, as you know, there’s all kinds of snips you have to measure. Not just MTHFR that can be the problem, and if you find out which snip’s missing you kind of know which one to give the most of. What I typically do, I start with a balanced methylator and I see what their homocysteine does. If I’m not getting there then I’ll order a methylation profile and start looking at all the enzymes and then you can attack it directly.
Dr. Weitz: Okay. Good, good, good. So, I’d like to bring up TMAO. This is a marker for heart health that was developed by Dr. Stanley Hazen from the Cleveland Clinic.
Dr. Houston: Yeah, so TMA and TMAO, we’ll distinguish what those are, trimethylamine is a product that you get primarily in carnitine, maybe phosphatidylcholine, and then the bacteria feed on that stuff and they convert it to TMAO which is trimethylamine oxidase. That’s a conversion in the liver. So, the TMAO has been associated with blocking reverse cholesterol transport along with other atherogenic effects. As Dr. Hazen felt that it was a risk factor for atherosclerosis and therefore you should limit the consumption of things that cause TMA to go up. Well, there’s a lot of controversy about that issue as well, whether it’s cause and effect or whether it’s just an association. But if you do consume a lot of carnitine and a lot a PC in your diet, you can raise TMAO. It’s no question about it. But then there was a study for Mayo Clinic, because you know they’re always butting heads with Cleveland Clinic, and they found that if you took carnitine you reduce your risk of heart attack even though your TMAO may have gone up. So you’ve got to balance all this stuff out. What I typically do, I measure…
Dr. Weitz: And we know that L-carnitine is super beneficial for the heart, right?
Dr. Houston: Absolutely. Yeah, particularly in heart failure. So, it’s not that you don’t want to use it and then you’ve got a balanced TMAO, but what I typically do if the TMA goes up, I’ll put them on a primarily plant-based diet for about a week or so. Kind of get them cleaned up, give them some probiotics, some prebiotics, and then try to get everything back to what I want to. Because I use a lot of carnitine, taurine, and D-ribose in my heart failure patients. And if you stop the carnitine, for example, because that’s transporting the long chain fatty acids into the mitochondria for beta oxidation you could end up causing them to do not so well.
Dr. Weitz: And cold water fish contains high levels of TMAO.
Dr. Houston: It does.
Dr. Weitz: And we know how beneficial fish is and how it lowers your risk for heart disease. So, this whole TMAO thing really doesn’t seem to accord with all the other things we know. Also, you’re talking about choline. And we know how beneficial choline is for liver health, brain health.
Dr. Houston: Yeah. I’m not sure I buy totally into the TMAO issue yet, because there’s too many benefits of the things you just mentioned, balanced with the studies of fish. You know that doesn’t pan out. So I don’t know really what the story is. [inaudible 00:36:38] find out about.
Dr. Weitz: Well one way that some people have analyzed it is the TMAO is produced by the gut bacteria.
Dr. Houston: Right.
Dr. Weitz: It may just be a marker for having an unhealthy, dysbiotic gut.
Dr. Houston: Exactly. If you’ve got dysbiosis and the wrong bacteria in there, if you clean up the gut, and that’s generally what a plant-based diet will do. It’ll convert very quickly, usually a couple of days. Get your microbiome cleaned up. The next time you challenge them with PC or carnitine their TMO won’t go up. So, I think the dysbiosis is a good explanation for it.
Dr. Weitz: Okay, so now you’ve just mentioned the vegetarian diet. Now the question is, what is the best diet to lower your risk for heart disease? Is vegetarian diet better, Mediterranean diet, ketogenic diet, or does it depend on each person?
Dr. Houston: If you go by science of published data there’s no question a Mediterranean diet is the best for heart disease, and diabetes, and other issues. And it’s not a vegetarian diet, it’s a plant-based diet meaning you eat a lot of vegetables and fruit. That’s at your base of your so called pyramid. But you also eat meat, particularly fish. You just cut out all the refined carbs. A lot of omega-3s, and MoFAs, and olive oil, and nuts in the Mediterranean diet. So that’s what I tell people to do most of the time. Then we’ll throw in some fasting mimicking diets, some fasting stuff, and we get great results with everything doing that.
Dr. Weitz: Okay. So when I’ve looked at some of the studies on the Mediterranean diet one of the confusing things is it’s a little fuzzy exactly what it includes. I mean, we all know about olive oil, and fish, and fruits, and vegetables. But other than that, is bread included? Is pasta included? Is there a lot of legumes? What about cheese and dairy products? And if you look at the different studies they all have different criteria and this may partially be because it depends on which part of the Mediterranean, is there really a Mediterranean diet?
Dr. Houston: Yeah, you’re exactly right. When you say Mediterranean you have to define what Mediterranean diet. Is it the one they use in Spain, or Italy, or somewhere else? Greek?
Dr. Weitz: Right.
Dr. Houston: Sometimes it’s better not to name our diets, it’s better just to say, “Here’s what I want you to eat.” So, let’s just do that. 10 to 12 servings of organic fresh fruits and vegetables a day. Mostly vegetables, 8 to 4. That’s the ratio, okay? High quality organic meat, cold water fish, salmon, mackerel, cod. Complex carbohydrates, get away from refined carbs. That’s usually anything white like bread, pasta, white potatoes, and white rice. And just make sure that your percentages of those things, a lot of monounsaturated fats, olive oil, and nuts, and a lot of omega-3s both in your diet but also as a supplement. Because you just don’t get enough just taking the food probably.
So if you do that you don’t really do a ketogenic diet, which is another thing I don’t recommend because it raises your lipids, and causes inflammation, and it’s just not a healthy diet for heart disease. If you’ve got a brain problem, yeah, maybe different. The problem is when you do the ketogenic diet a lot of people get their saturated fats and other fats up really high and then they don’t get everything else balanced.
Dr. Weitz: Interesting. So, patients who are heterozygous or homozygous for ApoE4, I often hear people talk about they need a special kind of diet from everybody else. What’s your opinion about that?
Dr. Houston: Yeah, the ApoE4 or E4 are the ones that have a high risk for coronary heart disease and Alzheimer. The do have a differential response to what they eat, particularly different types of fats. And those are the ones who can really have a dramatic effect, particularly with saturated fats. So in that case I would really augment them with omega-3s and monounsaturated, maybe reduce their saturated fats a little more. Definitely keep them off long chain fats and no trans-fats at all, zero.
Dr. Weitz: Now, is that a group that you might put on a vegetarian diet?
Dr. Houston: Yeah. Yeah, you could do that.
Dr. Weitz: Okay. So you’ve also written about micronutrient deficiencies that can play a role in heart disease and for those not in the functional medicine world that seems a really strange idea.
Dr. Houston: Yeah, right. So, most people are micronutrient deficient in something if you check it. Let’s just pick one of the micronutrients that’s really common, magnesium. Magnesium’s like 400 biochemical pathways. You say, “Well, would you rather treat every 400th pathway with something or just give them some magnesium and be done with it?” Well, how do you know if their magnesium’s low? Well, you’ve got to measure it. And as you know, magnesium is primarily inside the cells so if you measure just regular blood magnesium you don’t know what their magnesium content is. So, we measure intracellular magnesium. And we use a company, called SpectraCell which has the micronutrient testing. It measures your intracellular levels in a functional way, which is much better than the so-called bell shaped curve, because how do you compare to somebody else? If you measure your own lymphocytes and what they need to be adequately functioning based on repleting micronutrients that’s missing. About 30 things they measure. We do this in everybody because it really fits right in with the disease. I’ve seen this happen over and over again. They come in and they’ve got high blood pressure and they’ve got like five deficiencies missing, and we just replete their micronutrients and they’re blood pressure goes to normal. I mean, it’s pretty simple.
Dr. Weitz: Amazing.
Dr. Houston: Yeah.
Dr. Weitz: Yeah, so with this understanding of heart disease you mentioned immunological reactions, and inflammation, which is an immunological factor. Essentially, part of heart disease is really an immunological mediated, really an autoimmune disease. And then when we start thinking about the other diseases, you know, the major diseases, the chronic diseases, we know that cancer is immunologically mediated. We’ve got all these autoimmune diseases that are on the rise and even when you look at gastrointestinal conditions Dr. Pimentel has recently shown that IBS, which is one of the most common conditions has an autoimmune component. It’s apparent that you really need to take a broader approach, to use a Functional Medicine approach if you really want to address heart disease.
Dr. Houston: Exactly. I tell everybody if you understand cardiovascular medicine and vascular biology, it crosses all the boundaries. Because those three finite responses, inflammation, oxidative stress, and immune dysfunction, as you mention every organ has those finite responses. So, in essence inflammation in the brain, inflammation in the heart, those two circuits connect very quickly. And then the gut connects to the cardiovascular system. If you don’t get everything kind of lined up and get all those three finite responses in control, you’re not going to do well.
Dr. Weitz: Okay. So we’ve talked about diet, we’ve talked about advanced lipid profiles, I’d like to use some of our time to talk about nutraceuticals. The use of targeted nutritional supplements. What are the best supplements to use to reverse plaque in the arteries?
Dr. Houston: We’ve done now for the last 10 years a protocol for plaque reversal and plaque prevention, but also we can now reduce coronary calcium score, which people used to think you couldn’t do. But we’ve documented you can.
Dr. Weitz: Really?
Dr. Houston: Here’s what we do, omega-3 fatty acids, and you’ve got to get high doses. Four grams, five grams a day and it’s got to be a high quality that’s balanced. DEHA, EPA, GLA, and gamma-delta tocopherol. Second is a compound that’s got nitrates in it. You can get a nitrate compound like Neo40, beetroot extract, whatever, but it’s a beet compound. And that supplies nitric oxide through a different pathway, very different from arginine.
Dr. Weitz: Okay.
Dr. Houston: Kaolic garlic has been studied at UCLA and vitamin K2 MK-7.
Dr. Weitz: Okay.
Dr. Houston: Now, the recent study has shown that you need a minimum of 360 micrograms a day.
Dr. Weitz: 360?
Dr. Houston: 360, that’s the new number.
Dr. Weitz: So, we’ve been underdosing.
Dr. Houston: Yeah. Get a good quality, get it to that dose. There’s a couple of other things we use. There’s some very specific probiotics, Lactobacillus rhanmosus is good. And then luteolin, lycopene. There’s about six things that clearly reverse plaque. There’s a few things we’ll throw in for other people that have soft plaque versus hard plaque. But if you do that basic program you’re going to see some reversal.
Dr. Weitz: And so you mentioned coronary artery calcification scan. What percentage of patients… So, if you have a high score on that, for sure that indicates you have plaque. But let’s say you have a low score. You could still have plaque that’s just not calcified, right?
Dr. Houston: Yeah, so let’s talk about that because it is very confusing. A high coronary calcium score, CAC, means two things. One, you’ve got calcium in the arterial wall, or you’ve got calcium in a plaque that’s obstructing. You can’t tell which of those two it is based on the score.
Dr. Weitz: So you can have calcium in an artery wall that’s not part of a plaque?
Dr. Houston: That’s right. And that’s where you don’t know how to predict whether they’re high risk for obstructive coronary heart disease and you have to do additional tests to find out.
Dr. Weitz: So why would a coronary artery have calcium in it if it’s not…
Dr. Houston: Well, it’s aging of the artery number one. It’s got micronutrient deficiencies like the ones we mentioned, K2 MK-7, D, and A. That’s calcifying arteries but your bone’s not calcified, so those two are at the opposite extremes. So when you see a calcium score that’s high you’ve got to to the next value and say, “Okay, is it in the artery or is it just in the wall?” And you do echo, exercise EKG, nuclear scans, or you can do an arteriogram to find out. Now, you’re right on the other one too, which is if your calcium score is zero or low, it doesn’t mean you don’t have heart disease because it may not be calcified in the artery… I mean, in the plaque. So, I’ve had a couple people who’ve had like 95 block in their LAD and they had a 0 calcium score. But it was soft plaque, it hadn’t calcified yet.
Dr. Weitz: Can you explain what the LAD is?
Dr. Houston: It’s the left anterior descending artery, it’s the widow maker. That’s the one that supplies the inferior lateral part of the heart. If it goes out, you’re gone.
Dr. Weitz: Okay. So, how effective is red yeast rice for improving our cardiovascular risk?
Dr. Houston: Red yeast rice is a great product and we use a lot of red yeast rice. Again, you’ve got to have a high quality because a lot of its come in from China and it’s spiked with something. A lot of companies don’t make the high quality. If you get a good quality, though, it works like a charm. We use really high doses in people that are like statin intolerant or just refuse to take a statin.
Dr. Weitz: What do you consider high dosages?
Dr. Houston: High dosages is 4800 mg per day. And we use it with berberine and some other things to enhance the effect.
Dr. Weitz: Tocotrienols?
Dr. Houston: … LDL particle number and they say, “Hey, look, I can’t take a statin because my muscles ache.” If I get them on high dose red yeast rice, berberine, a phytosterol, and some niacin I can get their LDL particle number down 50%, which is what most of the drugs will do.
Dr. Weitz: Wow.
Dr. Houston: And there’s actually data that red yeast rice will primarily prevent a heart attack and also secondarily prevent another heart attack if you’ve already had one. So the data’s there. And actually The Annals of Internal Medicine has written a couple articles that it’s a good alternative to statin if they can’t take it.
Dr. Weitz: Now, some people say that red yeast rice is really just a natural version of a statin, and if you’re going to be intolerant to a statin you’re going to be intolerant to red yeast rice. If you don’t want to take a statin, why should you take a red yeast rice? Can you answer that question?
Dr. Houston: Yeah, and none of those are actually true statements. Red yeast rice was the compound that Merck Pharmaceutical used to make lovastatin. But what they did, they took everything out except one thing. So, red yeast rice is a lot more than just a statin. Statin is in red yeast rice but it’s not the whole answer. So, when you give a statin, you’re giving just that piece. If you get red yeast rice, you’re giving a whole composite of things that are going to help cholesterol, but also heart disease. Red yeast rice actually reduces aneurysms. It’s anti-inflammatory. I mean, it does a huge number of things. So, red yeast rice is not a statin, perse. When you give high doses, because it’s not just a statin you don’t get the same side effects you get with a statin. Rarely, even at that 480 milligram dose do I get any muscle problems. I almost never get a liver problem. It’s very well tolerated.
Dr. Weitz: So, do you always use CoQ10 with red yeast rice?
Dr. Houston: I use CoQ10 because anything that remotely smells, looks, or tastes like a statin, it’s going to lower your CoQ10 through that pathway. Particularly when you get to high doses of anything. So you give a CoQ10 with it. What you do is you measure their CoQ10 level before treatment, and you start measuring it. I like to keep the CoQ10 over 3 micrograms per deciliter. That’s what’s really normal, lab’s it’s all over the place. But, obviously, if it’s not above that level, or it starts to drop, you need to give them CoQ10. And it’s not just CoQ10 that gets depleted by statin, there’s 10 things that statins deplete. So you’ve got to measure all this stuff and then treat it. That’s why in traditional medicine, most cardiologists, lipidologists, they give statins and they don’t even know if they deplete 10 nutrients.
Dr. Weitz: What are the 10 nutrients that get depleted?
Dr. Houston: You’ve got CoQ10, vitamin E, omega-3 fatty acids, tocotrienols, carnitine, vitamin K2 MK-7 and vitamin K in general, vitamin A, Heme A, selenium. I think that’s 10.
Dr. Weitz: Wow.
Dr. Houston: Yeah, and they all go down depending on the dose.
Dr. Weitz: Amazing. You mentioned plant sterols. Now, one of the companies that’s doing advanced lipid testing is measuring whether you’re a cholesterol absorber or a producer.
Dr. Houston: Yeah.
Dr. Weitz: And they’re doing this by measuring levels of plant sterols. I’m a little confused if plant sterols are still a good idea as a result of looking at some of that data.
Dr. Houston: Yeah, we used to do that and try to base our treatment on that. It never did really work very well.
Dr. Weitz: Okay.
Dr. Houston: Let me tell you why. If you’re a hyper-absorber and I block the absorption, guess what? The liver starts making more cholesterol. Now you’re a hyper-producer. If you’re a hyper-producer and I block that, guess what? You start reabsorbing more. So, you’re chronically chasing your tail. Best way to treat those people is to just go ahead and block both pathways.
Dr. Weitz: Interesting.
Dr. Houston: Yeah.
Dr. Weitz: Meaning it would be helpful to use something that reduces the production of cholesterol by the liver, like red yeast rice, and then also use something like a plant sterol that helps block the absorption of cholesterol.
Dr. Houston: Or berberine. Because you know berberine is great to block cholesterol, plus you get a lot of other great benefits. Did you know that berberine is an actual natural PCSK9 inhibitor? You can go out and buy Repatha for $11,000 a year or you can buy some berberine for 30 cents a day.
Dr. Weitz: Yeah, berberine is amazing.
Dr. Houston: It’s amazing.
Dr. Weitz: It also goes head-to-head with metformin. I use it as an anti-aging agent.
Dr. Houston: Yeah. Well, it does. It actually turns off TOR. So, it does everything that you just said plus a lot more. It turns on AMPK as well, which is good for the metabolic pathway and aging.
Dr. Weitz: Interesting. So we talked about tocotrienols a little bit, but I also use them with the red yeast rice or if the patient’s taking a statin, tocotrienols will enhance the effectiveness of that, right?
Dr. Houston: They do. The tocotrienols are phenomenal agents and I think probably everybody ought to be taking those. But here’s how they work for cholesterol, they block production of the HMG-CoA enzyme for the messenger RNA. And then the other side they break down the increased catabolism of the enzyme. So it’s not a competitive inhibitor of HMG-CoA reductase. It actually reduces the increase that you get when you get red yeast rice or statin. So, you get about another 10% decrease in LDL, LDL-P, they’re given a gamma-delta tocotrienol at night with whatever you want to because production tends to be higher at night.
Dr. Weitz: Interesting. So you’ve mentioned niacin as a beneficial agent. I’ve had a number of discussions with primary care doctors and they all tell me, “Oh, no. Niacin doesn’t do anything. There’s no benefit.” Why is there so much controversy about niacin?
Dr. Houston: Well, niacin got a very bad rap when two large clinical trials came out a few years ago. Joe Pizzorno and I, and several others, Mimi Guarneri, wrote scathing articles back to the journal saying, “Your studies were terrible. You’re misleading people. You have not put the nail in the coffin of niacin by any means. Here’s the reason and you should still be using it.” So let me tell you first of all, continue to use niacin. It works. And the reason it works is multifactorial. It not only makes every lipid parameter better, I mean, if I do an advanced lipid profile on you everything I measure, niacin improves it. Everything. There’s not one thing that goes wrong including functionality of HDL. And then the only downside to niacin is if you get really high doses you might increase your blood sugar, you might increase your homocysteine, you may flush, get a little rash, whatever. But typically you can give a lower dose of an intermediate acting niacin and get really good effects that are beneficial for atherosclerosis. So, everything prior to these two inappropriate reports that had bad methodology, niacin worked great, so keep using it. Just be good to get a good quality.
Dr. Weitz: Yeah, I think one of the reports, one of the studies used niacin along with a drug that blocked the flushing effect.
Dr. Houston: Exactly. That was Merck’s multi-billion dollar drug, and the drug didn’t work. It was supposed to stop the flushing. I’ll say this now because I can get away with it because the published study’s out there. The drug that they had used, they had done studies in experimental animals that suggested that it increased atherosclerosis.
Dr. Weitz: Wow.
Dr. Houston: Now, they never said that and they weren’t about to say that it does in humans because it was an animal study. But it was a little bit, dare we say, deceiving.
Dr. Weitz: Yeah. So soluble fiber, there was a lot of talk about soluble fiber, and I should eat oatmeal. What’s the word on soluble fiber?
Dr. Houston: You should eat a mixed fiber. Soluble and insoluble. We never really understood why fiber works so great for everything, but as you notice it works through the microbiome. Fiber literally gets rid of a lot of the dysbiosis, bacteria use it to make great chemicals to reduce diabetes, and heart disease, and blood pressure, and cholesterol. Those little rascals do a lot of good job for us if we keep them healthy.
Dr. Weitz: I guess the thought was that the soluble fiber would glom on to the cholesterol and take it out of your system.
Dr. Houston: Well, it might do a little bit of that but it turns out that it’s probably most if through the microbiome.
Dr. Weitz: Right, okay. Great. Awesome. So, I think that’s the questions I had on my mind. What would you like to tell our audience in terms of closing thoughts, and then in terms of getting a hold of your books and or signing up for some of your programs?
Dr. Houston: Excellent, thank you for asking. All of the books that I’ve written are on Amazon so they’re easy to find.
Dr. Weitz: And Barnes and Noble I’m assuming, as well?
Dr. Houston: Yeah. They’re at bookstores, Amazon. The newest one that’s coming out is really incredible, up to date text book of cardiovascular integrated medicine. As you know precision and personalized medicine is the keyword now for everything. But we’ve got like 35 authors, I did the editing on the book. And it’s the who’s-who of their specialty. If you’re a healthcare provider, this is the book for you. Watch it coming out, it’s Wolters Kluwer, probably December. Educate yourself. Get the books and read them. But the second thing I would say to you today is come to some of the conferences that we do. A4M, American Academy of Anti-Aging Medicine. We teach an advanced cardiovascular course. We also teach sort of an entry intermediate course as well. But Module 16 is the advanced course, and it’s basically like a masters degree. We’re giving dual certification now for people that complete all four modules. It’s like getting a masters from a university.
Dr. Weitz: Okay.
Dr. Houston: That one’s good. The other one we do at A4M is Module 2, which is kind of the intermediate cardiovascular course. The advanced course is four 24-hour courses.
Dr. Weitz: Wow.
Dr. Houston: So it’s four weekends at 8 hours a day for three days. That’s 96 hours.
Dr. Weitz: Wow.
Dr. Houston: The other module, which is sort of an intermediate course is one three day module that’s 24 hours. You could come in depending on your level of expertise to either one of those. We’d love to have you at A4M for those.
Dr. Weitz: That’s great. Are you still teaching for IFM, as well?
Dr. Houston: Not so much with IFM as I was 15, 20 years go. Still do a lot with AIHM, Mimi Guarneri’s group out in San Diego, which I’m sure you know about. And also with The Natural Medicine Conference that they do also in San Diego.
Dr. Weitz: Great, awesome. Thank you Dr. Houston.
Dr. Houston: My pleasure. Thank you, Ben.
