Become Your Own Medical Advocate with Dr. Howard Elkin: Rational Wellness Podcast 292
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Dr. Howard Elkin discusses Becoming Your Own Medical Advocate with Dr. Ben Weitz.
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Podcast Highlights
2:05 Dr. Elkin had trouble admitting to himself that he was experiencing the symptoms of a heart attack after being a cardiologist for 25 years. He had no risk factors for heart disease and he had no family history, but even though he was experiencing chest pain, he went to work out anyway. He went through his weight lifting session without problem but after he did feel a heaviness in his arms. After calling his own doctor, Dr. Elkin decided to drive himself to Cedar’s Sinai Hospital Emergency Room, but not until after stopping for a cup of cappuccino. Dr. Elkin did suffer a minor heart attack even though two years earlier he had a coronary calcium scan with a score of zero. But the limit of this test is that it only detects calcified plaque and not soft plaque and soft plaque may be more problematic.
Dr. Howard Elkin is an Integrative Cardiologist with offices in Whittier and in Santa Monica, California and he has been in practice since 1986. His website is HeartWise.com. While Dr. Elkin does utilize medications and he performs angioplasty and stent placement and other surgical procedures, his focus in his practice is employing natural strategies for helping patients, including recommendations for diet, lifestyle changes, and targeted nutritional supplements to improve their condition. He also utilizes non-invasive procedures like External Enhanced Counter Pulsation (EECP) as a non-invasive alternative to angioplasty and by-pass surgery for the treatment of heart disease. Dr. Elkin has written a book, From Both Sides of the Table: When Doctor Becomes Patient
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 and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.
Podcast Transcript
Dr. Weitz: Hey, this is Dr. Ben Weitz, host of the Rational Wellness Podcast. I talk to the leading health and nutrition experts, and researchers in the field to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness Podcast for weekly updates, and to learn more, check out my website, drweitz.com. Thanks for joining me, and let’s jump into the podcast.
Hello, Rational Wellness Podcasters. Thank you so much for joining me again this week. We’re here today with my good friend, integrative cardiologist, Dr. Howard Elkin. Dr. Elkin’s written a new book, and we’re here to talk about heart health, and we’ll also talk about some of the personal health challenges Dr. Elkin has had to deal with, that he discusses in his new book, and especially, we’re going to talk about the importance of being your own medical advocate when you are a patient. We’ll also talk about Dr. Elkin’s philosophy on how to avoid heart disease and how to live a long, healthy life. Dr. Howard Elkin is an integrative cardiologist with offices in Whittier and in Santa Monica, California, and he’s been in practice since 1986. While Dr. Elkin does utilize medications, performs angioplasty, and stent placement, and other surgical procedures, the focus of his practice has been to employ natural strategies for helping patients, including recommendations for diet, lifestyle changes, and targeted nutritional supplements to improve their condition. Dr. Elkin has written an excellent new book, From Both Sides of the Table: When Dr. Becomes Patient, that has recently been published and is available on Amazon, in both e-book and softcover. Dr. Elkin, thanks for joining us today.
Dr. Elkin: Thank you so much. It’s always a pleasure to be here.
Dr. Weitz: Dr. Elkin, tell us about your experience as a heart patient after being a cardiologist for 25 years.
Dr. Elkin: Yeah, well, it caught me by surprise. If you read the first chapter of my book, which it’s Denial, It Ain’t Just a River in Egypt, because I didn’t have any risk factors for heart disease, no family history. Basically, I ignored my symptoms. I woke up one morning at like 2:00 a.m. with heartburn, and then it came back a few hours later. To make a long story short, I just, “This couldn’t be my heart.” I went to work the next day, or that morning, and actually by like 10:00 in the morning, I broke out in this cold sweat, had an EKG taken, since I am a cardiologist, and it was totally normal, so I did the next great thing, and that is … I only worked half-days on Tuesdays, Thursdays back then, so then I went to Gold’s Gym to work out. I figured I’d be on the West Side if I need to be hospitalized, because my doctor’s at Cedars. I went through my workout just perfectly, and then afterwards, I was on one of those ubiquitous ab benches doing crunches, and my arms felt like they were 50 pounds each. I ended up calling my best friend, Barry. I said, “Barry, my arms feel like they’re 50 pounds each.” He says, “Howard, your arms are 50 pounds each.” I said, “No, Barry. This is serious.” He said, “You should be calling your doctor, not me.” I called my doctor, Gary Cohan at Cedars, and he said, “Howard, I think you should get to the emergency room at Cedars right away.” I said, “Do you think it’s really important?” He said, “It would look really stupid for a cardiologist to drop dead of a heart attack before being evaluated.” If you want to read how I got to the ER, you have to … If you want to see how I got to the ER, you have to read my book, but-
Dr. Weitz: I did read your book. I can’t believe on your way to the ER that you stopped for a cup of cappuccino and a cookie.
Dr. Elkin: It was like, it was an out-of-body experience. It was like it was happening to someone else other than me.
Dr. Weitz: I can’t believe you even drove yourself in.
Dr. Elkin: I know. Listen, the first phone call I made was to my daughter, and she said, “Dad, are you driving?” I said, “Yeah.” She said, “Get off the road and call 911.” I said, “I’m not going to do that.” I did all the wrong things, and I write it in there because, hopefully, people are laughing with me, not at me because this is typical for a lot of men, and even doctors. I’m a doctor with 27 years experience back then, and I just figured this couldn’t happen to me. Rule number one, know your body. I was not a medical advocate at that time. I thought I was in great shape. I wasn’t overweight, I never smoked, I ate healthy, I worked out. I did all the right things, and I just figured it couldn’t be happening to me, but it did happen to me. Fortunately, I’m alive today to tell the story, and it really empowered me to come forward and write a book. I wanted to write a book as early as first part of the century. I had even a name. It was called, Reclaiming the Soul of Medicine, because I wasn’t happy with the current medical paradigm. I saw what was happening and I knew then that changes need to be made, but it’s like I had to actually … I came to an impasse. I had to actually become a patient to really write this book. I saw the pitfalls of the medical system as a patient, so it was really an eye-opener for me.
Dr. Weitz: We’ll get into the medical advocacy thing in a couple minutes, but I would like to talk about your particular case as a learning experience for why some people have heart attacks. Now, it’s my understanding that most patients who have heart attacks have an atherosclerotic blockage in one of the coronary arteries, and that occludes the blood supply to that part of the heart, and that’s what elicits a heart attack, but you didn’t have cholesterol plaque, you had a blood clot. How often does that occur? What are the risk factors for getting a blood clot? We’ve talked a lot, and we could talk more about the risk factors for atherosclerosis, but what do we need to know about the potential for having a blood clot like this?
Dr. Elkin: Great question. When I was a fellow back in the ’80s, we didn’t know about inflammation. It never even came up, so we just thought, you have this blockage, which is 50%, then 60%, then 70%, then 80%, then 90%, and then you eventually have a heart attack. That’s how little we knew about the natural history of coronary artery disease-
Dr. Weitz: Coronary artery.
Dr. Elkin: … and that’s based on the atherosclerotic model.
Dr. Weitz: Perspective, right.
Dr. Elkin: Exactly, so what happened, I did have a degree of atherosclerosis, but here’s what you have to understand, here’s what the audience needs to understand.
Dr. Weitz: What degree of atherosclerosis did you have?
Dr. Elkin: Like 40%, which is really- [inaudible 00:06:52]
Dr. Weitz: Okay.
Dr. Elkin: But here’s the thing, and I want you to know that prior to that, I had a coronary artery calcium scan two years before, which was zero. I had a zero score.
Dr. Weitz: Zero.
Dr. Elkin: Yeah.
Dr. Weitz: Okay.
Dr. Elkin: But because … That’s a very important test, and I employ it in a lot of my practice, but it also detects calcified plaque.
Dr. Weitz: Right. So non-calcified plaque, which could mean more unstable, is typically not going to show up on that test.
Dr. Elkin: That’s what I wanted to bring to your attention, is that there is stable plaque, and there’s unstable plaque. Now, here’s the million dollar question. When does stable plaque become unstable? We don’t really know. It’s not like there’s always a warning sign, so what I do in my practice is do appropriate testing, first of all, to assess one’s risk factors, and then another type of testing to help me prognosticate what’s going to happen, let’s say, in the next five years.
Dr. Weitz: Let me just stop you one second. For those who aren’t familiar, there’s a test called a coronary calcium scan. A lot of people use this test to basically find out if there is any plaque in their arteries, but as you just pointed out, that test is only going to see calcified plaque, and if you get a zero score on that test, it doesn’t mean you don’t have any plaque, I hate to tell you, unfortunately. It’s a great test. It’s good to know if you have calcified plaque, but you still could have uncalcified plaque. In fact, the calcified plaque may be more stable than the uncalcified plaque-
Dr. Elkin: Exactly.
Dr. Weitz: … and that’s an important factor, so how can we find out if the person has uncalcified plaque?
Dr. Elkin: Well, it’s a good question. First of all, what I do is I do specialized lipid testing, so there’s Heart Lab, there’s Boston Heart Lab. I pick a lab that really specializes in advanced testing. I’m not just looking at your total cholesterol, triglycerides, or HDL, and LDL. What I’m interested in is your particle number, your particle size, and we can get into that later. You and I’ve discussed that on a former podcast.
Dr. Weitz: Right. Now, those are all risk factors for plaque, but they don’t necessarily tell you whether or not you have plaque.
Dr. Elkin: No, no. Okay, so then let’s say I do have a coronary calcium scan and it’s zero. I might be a little more lenient with regard to treating these risk factors, but then there’s a new test called PULS, P-U-L-S, and that actually, it’s not a visual test like the coronary calcium scan, but what it does, it’s a biochemical assay, and it just requires two tubes that lets me know … It looks for nine different biomarkers, most of which you and I have never heard of before, but we’re not treating biomarkers. We’re treating an individual’s risk.
Dr. Weitz: Right.
Dr. Elkin: Based on this test itself, basically, you have high-risk, medium-risk, or low-risk. That’ll also help tell me what direction to go to. There isn’t a perfect test at all, but there is something coming out that you need to know about. The name of the company is called … I don’t know if I should be saying this, Cleerly, C-L-E-R-L-Y. They’re doing some preliminary work now at Harbor UCLA, which is where I send all my patients for coronary calcium scan, so Matt Budoff is doing this right now. This is going to be an amazing test because it’s utilizing scanning, CT scanning along with artificial intelligence.
Dr. Weitz: Right.
Dr. Elkin: We’ll be looking at, like instead of looking at, what’s your cholesterol? What’s your HDL, your LDL, your particle size and particle number? We’ll be looking at your plaque morphology. We can look at a plaque, whether it’s hard or soft, and be able to detect things from that which will help prognosticate your situation, so I’m hoping that will bridge the gap between stable and unstable plaque and-
Dr. Weitz: Is there an MRI or anything else that can detect unstable, noncalcified plaque?
Dr. Elkin: I recently looked into this. MRI is very useful for the heart, but it’s really not that useful right now for coronary artery disease.
Dr. Weitz: Okay. We really don’t have a test, other than an invasive test where they go inside your artery and look.
Dr. Elkin: Correct. Right, that’s the gold standard.
Dr. Weitz: Right, which is a … What is that called again? It’s …
Dr. Elkin: Angiogram.
Dr. Weitz: Angiogram, right.
Dr. Elkin: But here’s the important thing. You can use … Excuse me. I’ll often do coronary calcium scans like every two or three years on a given patient if they’re high-risk, and I want to see if their numbers are escalating. This is the important thing that the audience needs to know. If left alone, I can promise you, coronary artery disease is going to progress. It’s kind of like a cancer. It’s not just going to stay at bay, unless you do something proactive about it, which is where you and I come in, that we’re being proactive about this.
Dr. Weitz: Now, what about the blood clot that you had? Where does that come in?
Dr. Elkin: Well, that’s part of the making of an unstable plaque, or who knows? It’s called a plaque rupture. Here’s the important thing too. Most heart attacks are not 90% blockages that we thought when I was a fellow. They’re actually 40, 50%, 60% blockages that are stable, and then all of a sudden, for unclear reasons, they rupture. They rupture, and then a blood clot develops, and then you’ve got a heart attack.
Dr. Weitz: Okay, so the assumption is, do we know that, that the blood clot that you had came from a ruptured plaque?
Dr. Elkin: We can pretty much bet that it did.
Dr. Weitz: Okay.
Dr. Elkin: I had a 90% … The blood clot occupied 90% of the lumen of the artery. I mean, 10% more, I would have been dead.
Dr. Weitz: Right. Now, when you ended up in the hospital, they removed the clot. Did they have to remove the rest of the plaque in the artery?
Dr. Elkin: No. What they do … We don’t really have a Liquid Drano right now for coronary plaque, so what we do, if there’s a big enough clot, and believe me, mine was huge, we do what’s called a thrombectomy. We actually take a catheter and we aspirate the blood clot. Then we put in a stent to secure the patency of the vessel. I mean, and here’s-
Dr. Weitz: They don’t actually Roto-Rooter the inside of your artery. They just put this stent in and it pushes out and keeps the artery open.
Dr. Elkin: I was on call this weekend for my hospital, so I had a patient come in with an acute heart attack. He had a total, 100% blockage. He would have died, had we not intervened successfully. Then when I brought … The next day, I said, “Okay. Now the work begins. What I did, by putting in that stent, did save your life, okay? But I can promise you, if left to its own devices, and you don’t make any changes in your lifestyle, this is going to progress.” I tell people, “Now the work begins, and it’s all about lifestyle, prevention.”
Dr. Weitz: Right. Now, tell us about some of the things that happened when you had to advocate for yourself as a patient. I’d like to see, maybe, if we couldn’t take the discussion to another level and maybe talk about, what might be some of the problems with the healthcare system? I have a couple of thoughts for, maybe, things we can do.
Dr. Elkin: Well, let’s see. We’ll start with the first hospitalization-
Dr. Weitz: Okay.
Dr. Elkin: … when I had the actual heart attack. Here I am in the hospital and I felt fine. The doctor comes to see me at the very end, on the day of discharge. This doctor was probably about 10, 15 years younger than me at the time. He was young and very overweight, very overweight. Said, “Dr. Elkin, I don’t know what to tell you, but I will never be in the shape that you are in now, so when it comes to rehab, you’re on your own.” I said, “Okay. I can handle that. I’ve put together cardiac rehab programs before.” Then, he said something that I will never forget to this day. He said, “You know what? You got a new stent in there, and everything’s going to be great. You have a new stent. You’re going to be fine.” As he left, I said to myself, “Okay. This BS is absurd because if I’m going to be fine with this great new stent, why did this happen to begin with and what’s to prevent a reoccurrence?”
Dr. Weitz: Right.
Dr. Elkin: I knew right there and then that it was up to me to-
Dr. Weitz: Let’s not just talk about medical interventions. Let’s talk about root cause. Let’s talk about prevention. Let’s talk about lifestyle.
Dr. Elkin: Exactly. If you read my book, you’ll see that I outline all these risk factors, both the major players that I call them, and the minor players. I really didn’t fit any of them, except for the part about stress, and I researched stress and its affect on coronary disease and also cancer. It’s well-outlined. It’s a whole chapter in my book, and then I also outline-
Dr. Weitz: Yeah, I read that chapter. I think it’s interesting. There’s a whole series of psychosocial causes of heart disease. Stress, depression, even unhappiness, lack of connection with other people, all these things are factors for heart disease, and I think they’re really underappreciated.
Dr. Elkin: Yes, I totally agree. I think, in my case, that played a big role. I really do. What I worked on, as an outpatient, was I really had to employ some … I’m the kind of person, give me all the problems in the world, I got big shoulders, I can take care of it. Once you read that, what I was going through, you’ll see I was going through above and beyond the amount of stress, and frankly, I wasn’t handling it all that well, so meditation became a big part, and also slowing down and smelling the roses. I have to work on that today. I tend to be an overachiever, and there’s good and bad to that, but you can drive yourself crazy with it, and so I really had to learn to … Every morning, the first thing I do, I don’t even get out of bed. I sit up in my bed and I do 20 to 30 minutes of deep breathing, visualization, and meditation, and prayer. I’m not a religious person, but I do have a spiritual practice, and I believe that carries me through.
Dr. Weitz: Right. Let’s get back to the medical advocacy thing. I think the thing that you emphasize in your book is how patients can often get swept under the system, moved on, not get the proper care, not get the proper testing. A lot of this is, I think, because the insurance companies are the ones driving the boat in healthcare, for the most part. I’m not sure that everybody realizes that. I think, a lot of times, people think, “Well, the doctors are running everything,” and that’s not the case, right?
Dr. Elkin: I’ll give the perfect example, is my second hospitalization when I had back surgery that was, basically, botched up. They didn’t really correct the problem, number one, and number two, I ended up with permanent nerve damage. Here I am on, I think it was the third day post-op, and they wanted … My insurance, the nurse … There’s a discharge planner, and his or her job is to get you ready for discharge, be it home, or rehab, whatever. She says, “Doctor, we tried everything we could, but your insurance won’t let you go to rehab. They want you to go to a nursing home.” I said, “Are you freaking kidding me? A nursing home at my age?” “Well, we tried everything we could.” I said, “No you didn’t.” I spent the next three hours on the phone, doped up on opiates with pain, fighting-
Dr. Weitz: This is after your back surgery.
Dr. Elkin: Yeah. Like two, three days later. I pleaded with them and I just said, “Under no uncertain terms. I will sue you,” so the next morning, I was wheeled over to rehab. Now, I had to do that on my own, and I’m a doctor. Can you imagine, the average person would be-
Dr. Weitz: Oh, I see patients all the time, they have to wait months and months to get to see a specialist, tests are denied. I’m a chiropractor who treat patients for lumbar cervical disc problems. To get an MRI for the lumbar spine, from most insurance companies, they require X-rays, which are usually worthless, and at least six weeks of chiropractic or physical therapy, and then only if the patient meets certain criteria will they consider paying for an MRI.
Dr. Elkin: It’s crazy, yeah. I could give you … I advocate for my patients as much as I can. There’s several medications that are extremely expensive in the cardiovascular field. Okay. What I have to do to get these things approved is ridiculous, and I’m talking to … I talk to a peer-to-peer … Let’s say I’m going to get a stress echo or a nuclear stress test on a patient, and my nurse can’t do it, then they do, what you do is called a peer-to-peer. Now, that doesn’t mean I’m talking to a cardiologist. I could be talking to a gynecologist, pediatrician, but they call that peer-to-peer. I have to explain to them what I want to do and why I’m doing it. Then if it doesn’t meet their little script, I’m going to have problems. Now, because I’m so like a pit bull, I’m successful in probably 95%, 96%.
Dr. Weitz: Right, but this forces you to spend an incredible amount of your time and energy, your staff’s time and energy just to get tests that are medically indicated by a specialist, and they’re not being denied by another cardiologist who’s assessed the case and decided they don’t need it. This is just some insurance company that’s trying to save money, and that’s all they care about, and they have some unqualified person on the phone reading from a script, telling you that you can’t get test A or B.
Dr. Elkin: Bingo, you got it. That really is a problem.
Dr. Weitz: Or approve drug A or B.
Dr. Elkin: Yeah. It’s not getting better. In fact, it’s gotten worse.
Dr. Weitz: Okay. I want to get on my soap box for a minute here. It’s not going to get better, and here’s the reason why. What matters are, number one, patients. Patients have very little power in the healthcare system. Now, you screamed and yelled, and you got some of the things you needed, and patients need to do that, but unfortunately, patients are pawns. Doctors, unfortunately, are pawns too. They have very little control in the healthcare system. They are controlled by insurance companies, and most medical practices … Your practice and my practice are exceptions, but most doctors these days are practices owned by a hospital system, and the hospitals are running it to try to make a buck. I understand that, but it affects the quality of care. It affects what tests they can do. It affects what procedures they can perform. It affects what drugs they can prescribe. It affects how they can refer out. The key, the big players in the healthcare system are the insurance companies, the hospital systems, and big pharma. It’s the insurance companies, number one. The insurance companies’ goal is to maximize their profit over the short term. In order to do that, they want to provide the least amount of care and charge you the most for premiums. That’s completely opposite of what the patients’ needs are. The patients’ needs are to get the best quality care at the most reasonable price, and those interests are completely opposite each other, and they won’t ever be aligned unless we transform insurance companies, make them non-profit, get rid of insurance companies. What the problem, in my opinion, is the insurance companies.
Dr. Elkin: Absolutely. I could not agree with you more. When I wrote my book, and it was a 10-year process, it was really, yeah, I could get my story across because I set the stage by leading by example, how to be my own medical advocate, but it’s also I want to educate, and inform, and hopefully, inspire people, but it’s taken on a different … I’m on a crusade now since I launched it in October, and that is, wow, well, whose job is it? Because, and I tell people on social media, I said, “We can’t expect our legislators, the government, Medicare, HMO, PPO, corporate-level doctors that are owned by hospitals, and chain pharmacies to take care of us, so who’s going to do it?” I say, “It’s an inside job.” We have to be more involved.
Dr. Weitz: Well, I think, I totally agree with you, given the present system, that it’s the individual that has to do what they can. I think that it’s the job of people like you and me to educate some of the legislators and the public that what’s happening behind the scenes, because they don’t know why they’re not getting approved, a drug, or a test, or why the doctor’s in and out of the office in five minutes and doesn’t have time to answer their questions. We’ve got to let everybody know that it’s the insurance companies who are controlling things.
Dr. Elkin: Exactly.
Dr. Weitz: They’re deciding what’s going to be covered, how much they’re going to pay, what kind of quality care you’re going to get, and so I don’t think everybody understands that.
Dr. Elkin: I’ll give you another example. My hospital, we now call … They don’t just buy out practices. They absorb them. I’m not quite sure what that word means. Anyway, so I’m one of the few lone rangers, dinosaurs.
Dr. Weitz: Right. You have an independent practice. You haven’t let your practice be purchased by the hospital.
Dr. Elkin: No, not at all, but I do admit patients there and I do procedures there, so I’m an active member of the staff. The difference between what I offer and the offer, they have to see … Because I have four or five colleagues in that hospital as cardiologists. They say, “We can only spend seven minutes with a patient. The nurses are knocking on our door, ‘You have to get out.'” Seven minutes, face-to-face with a patient. Now, I don’t have a time limit. Sometimes, I spend seven minutes. Sometimes, I spend 10 minutes. If someone’s lost his spouse or significant other, it may be 15 minutes. Part of what I do is display my humanness in taking care of patients, spiritually, emotionally, as well as physically.
Dr. Weitz: But you also have an integrative practice, and you have a broader philosophy.
Dr. Elkin: Right. It employs different tactics in order to-
Dr. Weitz: One of the reasons why you go to see a doctor and you leave with a prescription in five minutes is that that’s the easiest way to get in and out of the room.
Dr. Elkin: Right.
Dr. Weitz: For a doctor to go in a room and engage a patient in a complicated discussion, start letting the patient talk, and actually listen to them takes time. The easiest thing to do is find out what their main complaint is and write a scrip, and then you get to leave.
Dr. Elkin: I think the biggest … I see this all the time. Let’s talk about statins for a second. I’m not downplaying statins. There is definitely a role for statins in the cardiology world, but I think there’s over-statinization, a little term that I made up. Because it’s easier for a doctor at a very busy corporate-level practice to say, “Hey, your cholesterol is really high. Take Lipitor, take Crestor.” What they’re really saying, “We know you can’t do this on your own, so take this pill.” What we’re doing is we’re disempowering patients versus getting them involved with their own care. It happens all time.
Dr. Weitz: Right. We’re not even going to ask you to change your diet because we just assume you’re not going to do it.
Dr. Elkin: Which is go low-cholesterol, low-fat.
Dr. Weitz: Right.
Dr. Elkin: Which was the thinking 25 years ago.
Dr. Weitz: Let’s go, let’s spend a few minutes talking about, right now, the focus in cardiology is pretty much on LDL cholesterol. HDL doesn’t seem to be quite as important. All the controversy about LDL cholesterol seems to have fallen away, and there seems to be pretty much a unanimous thought that the goal of cardiology is to lower LDL cholesterol as much as possible. Lower your LDL to 70, lower it to 40. Lower it as much as possible and that will decrease arthrosclerosis, which is a major killer. What’s the problem with that thinking?
Dr. Elkin: First of all, it’s kind of like one-size-fits-all, which is one of the many problems I see in traditional medicine today and the corporate world, because I have to look at the risk. Now, do I ever want to go below 70? 70, okay, 70 is kind of the approved level.
Dr. Weitz: We’re talking about for LDL.
Dr. Elkin: LDL. LDL, sorry. The lousy one. HDL, the healthy one.
Dr. Weitz: Right.
Dr. Elkin: It’s been this way for a few years now. We want to get people that have had coronary disease, history of coronary disease, have had stents. I’m one of them. Or a heart attack, or a stroke. The aim is to get the LDL in the 70 range or so, and that’s not new information. We’ve known that since the ’90s with the Forest study and other studies, so-
Dr. Weitz: I’ve heard prominent doctors saying the goal should be 30 or 40.
Dr. Elkin: Okay, but now … Thank you. With the advent of a new class of medication, it’s called PCSK9 inhibitors, which is basically Repatha and Praluent, which came out within two weeks of each other, now, they can decrease your LDL cholesterol by as much as 50 to 60% in as little as four to six weeks. Now, if we combine the two, we can get your levels 20 and 30, and below.
There’s a very prominent lipidologist, I won’t use, say his name, who advocates this. They even came out with a study saying, “Well, we’ve got two-year studies, and this can affect the brain.” Okay. People are on statins for years, possibly for life, so I don’t know what the long-term studies are on mental … We know the LDL cholesterol plays a positive role in neuroplasticity and also in building myelin sheath, which helps to protect the nerve cell, so LDL isn’t some bad, horrible villain. It actually is necessary, and especially in the brain.
I tell people, I don’t want a good heart with a bad brain, so I don’t go for the 20, 30. Now, do I ever go lower than 70? Yes. Now that I’m using the PULS test, if I’m finding people that are still at high risk despite doing all that we can, I may inch it down a little bit lower, but not 20 and 30. I don’t feel comfortable with that because there’s no long-term studies, and I do believe there’s a role for, that we do need LDL cholesterol for the brain, and most people in the functional medicine world agree.
Dr. Weitz: We also need cholesterol for hormone production.
Dr. Elkin: Hormones, Vitamin D, bile acids, several things.
Dr. Weitz: Yeah, Vitamin D, Vitamin K, CoQ10. There’s a whole series of nutrients-
Dr. Elkin: Absolutely.
Dr. Weitz: … that are produced by that mevalonate pathway that statins and PCSK9 inhibitors block that won’t be produced by the body anymore.
Dr. Elkin: It’s just so easy to give a drug, as opposed to really, like you say, take the time out to educate the patient.
Dr. Weitz: Yeah, so-
Dr. Elkin: It’s not that hard to do. I’ve been doing it for a long … You and I have been doing this for a long, long time, but the average doctor, if you got to get them out in seven minutes … By the way, they’re typing the note while in there, so you’re not really … I’ve tried that before. I cannot type, and look at the patient, and have my thoughts together.
Dr. Weitz: Yeah, Now, the other thing we need to touch on is that the connection between LDL cholesterol and heart disease is nowheres near as strong many doctors today are claiming that it is.
Dr. Elkin: I think, well, again, we’re looking at primary prevention versus secondary prevention. Secondary prevention, or in those patients that we know they have coronary disease. They’ve had a heart attack, they’ve had a stroke, they’ve had a stent, they’ve had bypass surgery, or they have high calcium scores. Now, I will tell you, in mainstream cardiology, this is from Cedars-Sinai, there are controversies in cardiology, that I go to every year. Last year, they were saying that if your calcium scan is greater than zero, you should be on a statin. I swear to god.
Dr. Weitz: Right.
Dr. Elkin: Can you imagine? I have a patient-
Dr. Weitz: Well, they would do, remember the polypill that’s been discussed?
Dr. Elkin: Yeah.
Dr. Weitz: This is a pill, so this is the idea of mainstream medicine’s prevention is-
Dr. Elkin: Hypertension.
Dr. Weitz: Yeah. Is not, eat a healthy diet, exercise, stress-reduction, sleep, take supplements as needed. Their idea of prevention is take this one pill that includes a statin, metformin, a blood pressure medication, and maybe one other thing.
Dr. Elkin: My question is-
Dr. Weitz: They want everybody to automatically take this.
Dr. Elkin: I know. How do you know what’s working, what isn’t when you have a combination pill? I like to know what’s working and what’s not.
Dr. Weitz: People have discussed putting statins in the drinking water.
Dr. Elkin: Yeah. When statins are in children … I even get adolescents with hereditary problems. It’s just too easy, and because less time is spent in patient care, it’s more reliance on drugs and procedures.
Dr. Weitz: “Please give me some statins with my fluoride and my chlorine.”
Dr. Elkin: Right, right. We could talk about this forever, and this is a problem, so that’s why the book is really … Yeah, my story just is a starter, and the meatiest part of the book is the fourth part, portion, which I actually go over, first of all, what is a medical advocate? But nutrition, and supplementation, and exercise, and stress management, and also aging in today’s world. [inaudible 00:33:37]
Dr. Weitz: Oh, let’s talk for another minute about this LDL cholesterol.
Dr. Elkin: Yes.
Dr. Weitz: Outside of statins, we also have something called diet, and so what kinds of recommendations you make for diet? Now it’s pretty much not only gospel that LDL cholesterol is a cause of heart disease, but LDL cholesterol is caused by eating meat and saturated fat. What do we know about the studies, the research that saturated fat is actually the cause of arthrosclerosis?
Dr. Elkin: Okay. That thinking dates back to the ’50s and ’60s. They were really flawed studies, and it was really made big-time in the ’70s, in which the culprit was saturated fat and heart disease. I want you to know that no studies have shown that saturated fat by itself causes death from heart disease or death from any cause. Yet, this has been promulgated forever. The Heart Association still recommend this.
Dr. Weitz: By the way, nobody has ever come up with a mechanism by which saturated fat will raise cholesterol levels in the body or lead to arthrosclerosis because saturated fat doesn’t necessarily contain cholesterol, and most of the cholesterol in the body is produced by the liver, not coming from the diet.
Dr. Elkin: Right. Saturated fat isn’t always the villain either. It can actually help decrease the size of the LDL particle, which we haven’t gotten into. It could increase your HDL, the healthy one.
Dr. Weitz: And we have the Minnesota heart study, which was one of these several large-scale studies where they actually looked at a very large number of people. These were patients in a mental institution, and they were able to give them specific foods to eat so they could carefully control. It turned out that the patients that had … Some patients were given saturated fat, and some patients were given, I think it was corn oil or canola oil. It turns out that not only did the patients who were consuming saturated fat not have an elevated risk of heart disease, but the patients who were consuming the omega-6, corn oil, I think it was, or safflower, or canola oil, one of those omega-6 fats, actually had an increased risk, and they also had an increased risk of cancer.
Dr. Elkin: Which is, now those of us in this functional-
Dr. Weitz: They had higher problems with mortality.
Dr. Elkin: Right. Because those seed oils are pro-oxidant. Now that we know that inflammation is the real culprit behind coronary disease and all the diseases of aging, by the way, we now know that is a no-no, but yet the Heart Association is still touting canola oil as a very good, heart healthy.
Dr. Weitz: Right, so-
Dr. Elkin: We could watch a three-minute video …
Dr. Weitz: … let’s emphasize that, is these polyunsaturated oils, which everybody is touting as a way to promote health, are very easily oxidizable. They have lots of free spaces where oxygen can combine with the hydrogens, and so you’ve got to be really careful of consuming these polyunsaturated oils. If they get oxidized, it’s the oxidation and the inflammation associated that is going to cause these fats to build up in the arteries, and saturated fats are less oxidizable.
Dr. Elkin: Right. This is what your doctor won’t tell you, maybe because they don’t really know it themselves. They haven’t been taught this. See, doctors are really good at … I think the average doctor wants to help their patient, but they’ve had a skewed education in how to get there, and I’m not-
Dr. Weitz: Well, I will say, studies on diet are so difficult to do. You know?
Dr. Elkin: Right.
Dr. Weitz: We’re relying on these studies from the 1960s because today, it’s very, very difficult to conduct these studies. Pretty much all the studies on diet now are simply asking people what they ate over-
Dr. Elkin: The last few days.
Dr. Weitz: … the last week, or month. 90% of people are horrible at remembering and being able to relay what they ate or how much they ate. I think studies show that like 90% of people underestimate the amount of calories they consume, the amount of carbohydrates they consume. People don’t know portions, so it’s hard to get the data from the dietary studies.
Dr. Elkin: It’s true. Another thing that I really emphasize in my book on the section on supplementing … patient, because there are a lot of purists today that will still say, “We get everything we need from our diet.”
Dr. Weitz: Right.
Dr. Elkin: Well, the diet of today ain’t like the diet of 20 years ago.
Dr. Weitz: Exactly. Factory farms that are overutilizing the soil, that are fertilized with industrial fertilizer. The soil is lacking in minerals. Food is stored in frozen containers. It’s cooked, it’s processed, so it’s very, very difficult to get the amount of nutrition from a diet that we used to be able to get. Most of the fruits and vegetables are raised in a hybrid fashion, so they’re sweeter, so they have less blemishes, and they often have less nutrition. We need to try to, as much as we can, increase the nutrient density of our food by eating more organic fruits and vegetables, and pasture-raised meats, and wild fish, and nuts, and seeds. We need to make sure we get those nutrients so we can have enough antioxidants so we don’t have this extreme amount of free radicals and oxidized LDL, but that’s hard to do from the diet, so doing some reasonable nutritional supplementation, it makes a world of sense.
Dr. Elkin: I’ll just give you an example. I was talking with Dr. Kara Fitzgerald, who’s very big now in longevity. She wrote the Younger You, Me book. Anyway, she was just saying about Vitamin D, also is a fact that I didn’t really know about. It can help improve not just your immune system, but actually longevity, has a positive affect on longevity. I wrote her back and said, “Yeah, did you see this story that came out about three or four weeks ago on Vitamin D, that we really don’t need it, that you don’t need to draw levels?” She said, “Yeah.” We talked about how deeply flawed that study is, and that’s a problem with these peer-review articles on supplementation. They’re deeply flawed, and people need to know that. What happens, you walk away saying, “Well, I guess, there’s no sense in taking supplements, so I should wait until I get sick, and then my doctor will give me drugs.” I don’t think that’s necessarily the point, but that’s what people walk away with.
Dr. Weitz: Yeah, no, Vitamin D has an amazing array of benefits for the human body. One thing, the first study that was, actually, been able to show that we could reverse epigenetic aging, the Fahy study, the primary interventions were growth hormone, DHEA, and metformin, but it also included Vitamin D and zinc, and those could also be significant players there, and they were able to reverse epigenetic aging. Of course, Kara Fitzgerald conducted her own study, and also with a nutrient-dense diet, she was able to reduce epigenetic aging. Also, with certain targeted supplementation.
Dr. Elkin: This is the take-home information is that you have to go above and beyond if you want vibrant health. It’s not just … We have focused on sick care, the medical profession. We do a pretty good job of it, but let’s face it. We spend all this money on the last two years of life, last two years of life.
Dr. Weitz: Right.
Dr. Elkin: We spend more on gross national product than any other civilized country. I think we’re like number 28 or 32 on the list as far as … We don’t do well.
Dr. Weitz: No, we don’t.
Dr. Elkin: As a nation, we’re not performing well.
Dr. Weitz: Yeah.
Dr. Elkin: It’s not getting better, I think. I also just read that the longevity is going down in this country.
Dr. Weitz: Absolutely. There is no doubt.
Dr. Elkin: We’re going in the wrong direction, folks.
Dr. Weitz: Yup, absolutely. Yup. Oh, yeah. Especially the last three years since the pandemic, and people staying home, and the average person gained 30 pounds. When you consider that people like me, who continued to work out through the pandemic and didn’t gain any weight, that means if the average is 30, a lot of people gained a lot more than that. Alcohol usage shot up.
Dr. Elkin: Right.
Dr. Weitz: I was looking at a set of labs from a patient who went to UCLA. I was looking down at their liver enzymes, and one of their liver enzymes was, I think it was their ALT was 65. I thought, “Wow, that’s elevated.” Then I looked at the reference range, and it said, “70.” There was an asterisk at the bottom and it said, “New reference ranges,” so what that means is-
Dr. Elkin: It’s supposed to be 35.
Dr. Weitz: Exactly, exactly, but because so many people have been overeating and overdrinking, and not exercising, and not breathing in oxygen through their mask and everything else, that the health of the population’s getting worse, so they just changed the lab ranges. When you go and get labs done, you need somebody with a keen eye like you or me, who could discern what an optimal level is, and not just look at the lab range, because those lab ranges simply reflect the average person. Because the country’s gotten unhealthier, we simply increased the lab ranges, so now you’re normal.
Dr. Elkin: People, the first question they ask me, they expect me to talk about low-fat and low-cholesterol. When I immediately go into sugar, the most inflammatory thing you can ingest, they’re like, “Well, my doctor never told me this.”
Dr. Weitz: Right.
Dr. Elkin: All these metabolic issues, nonalcoholic fatty liver disease, which is now the number one cause of liver transplant. This problem is escalating because people are so metabolically unhealthy. It’s a shame.
Dr. Weitz: People, unfortunately, assume if you eat fat, cholesterol’s fat. Eat fat, get more cholesterol. That’s what causes heart disease, and the fact is, is 90% of the cholesterol in the body is manufactured by the liver. The liver manufactures cholesterol from glucose.
Dr. Elkin: Right, right. Yeah, it’s a problem because this is what is still, is promulgated in the country, and that’s why-
Dr. Weitz: Another big part of changing the healthcare system is not only changing the way healthcare is driven by for-profit insurance companies, and mind you, I understand. I’m sorry I’m hitting this multiple times, but I’ve been waiting for an opportunity to talk about this. Yes, the capitalist, for-profit motive is a great motivator for people to work hard, and I totally understand that, but when it comes to the companies that are controlling the healthcare system, that particular motivation is running contrary to what the needs of the public are, and so we need to change that. We need to start putting a focus on prevention, and the insurance companies are not going to do that. People go, “Well, doesn’t my insurance company care if I get heart disease in 20 years?” I’m sorry, they don’t. They want to maximize their profit this quarter, so the stock can go up, so the CEO can get his bonus.
Dr. Elkin: Right yet again.
Dr. Weitz: In 20 years, who knows? In a year, you might be with another insurance company, you might be on Medicare. They don’t care at that point.
Dr. Elkin: Right. That, kind of where I end up being the crusade with the book because I figured, okay, for you and I, we practice this kind of medicine. We believe in functional medicine. We believe in trying to find the actual root of the cause, of the cause rather, and employing lifestyle is number one, except in the case of emergency.
Dr. Weitz: Right.
Dr. Elkin: Yet, it’s not what’s happening globally, so I figured, okay, how many people can I possibly get on a one-on-one basis? Because this is what I teach all my patients.
Dr. Weitz: Right.
Dr. Elkin: It’s not unique to just one or two. Everybody that comes to me, they come to me because this is the way I practice, but how many can I possibly do on a one-on-one? It ends up being a great reason to have the book because they could at least read about a different way of life.
Dr. Weitz: You can reach thousands and thousands of people that way. Absolutely.
Dr. Elkin: You have to search for a medical provider that has your same interest. If you believe in supplements and they don’t, that’s a conflict of interest right there. There are plenty of people that are practicing functional medicine. You have to do a little research to find them, but we’re out there. I’m not the only one.
Dr. Weitz: Right.
Dr. Elkin: You know, so …
Dr. Weitz: Yeah, and unfortunately, when it comes to supplementation, you can’t necessarily blame medical doctors for not understanding some of the benefits of supplements. The problem is that the leading medical journals, and I don’t know why this is, but they have a tendency to only publish the negative studies on supplements. You know?
Dr. Elkin: Right. It’s not just like- [inaudible 00:48:12]
Dr. Weitz: 10 recent studies on Vitamin D, eight out of 10 have positive results. One of the two that didn’t show positive results, that’s the one that’s getting published in New England Journal of Medicine or the AMA Journal, and so that’s what conventional doctors are being fed, “Oh, there’s no benefit to fish oil. Oh, there’s no benefit to Vitamin D. Oh, there’s no benefit to …”
Dr. Elkin: Also, Ben, what you’re talking about is that most-
Dr. Weitz: Red yeast rice. Right? You saw that study showing that all these nutritional supplements that modulate lipids have no benefit.
Dr. Elkin: When you are in medical school, you really aren’t taught to think. You’re not taught to be an independent thinker, so you really, unless … Doing the fellowship helps because you do what’s called Journal Club, and you learn to scrutinize studies, but when doctors are in practice, they don’t have time. They forgot how it was to scrutinize a study, so if the study has the negative result, that’s what sticks in their mind and that’s what they tell their patients.
Dr. Weitz: Yeah, and unfortunately, a lot of doctors are not necessarily reading the journals.
Dr. Elkin: No.
Dr. Weitz: Even if they do read their journals, they tend to have very few positive studies on supplements, but most of them are not reading the journals because they’re so busy having to write in charts, and deal with insurance companies, as well as see a zillion patients. Then, a lot of their information comes from pharmaceutical reps who drop by the office with the latest information about the latest drug.
Dr. Elkin: I have this thing. When a pharmaceutical rep comes, I’m very nice, but I’m going to ask … They don’t know that I’ve already researched the drug before they come in the door. Then, I have a series of questions. They say, “Hmm. That’s a really good question. Let me speak to my research division and we’ll get back with you.” It happens all the time.
Dr. Weitz: Why don’t we touch on one more topic, and then we’ll wrap this up? You mentioned hypertension or elevated blood pressure. What is the ideal elevated … What is the ideal blood pressure, optimal blood pressure, and what level would make you feel like you need to prescribe medications? What dietary factors can move the needle on blood pressure?
Dr. Elkin: It’s a very timely question. I want people to know that hypertension is still the number one risk factor for heart disease. I always label it number one. I did in my book and I do when I speak, because it affects the endothelial health, which we’ll talk about in a minute. I believe whether you’re 20, 30, 40, 60, 80, or 100, the ideal blood pressure is 120 over 70. Do I get that in every patient? Absolutely not. Because I would have to use multiple drugs and-
Dr. Weitz: What about 110 over 70?
Dr. Elkin: That’s even better.
Dr. Weitz: Okay.
Dr. Elkin: That’s even better, but here’s what people need to know. I think this is 2016. I forget when the new blood pressure standards were released. Anything greater than 130 for the top number or the systolic number, or 80 on the bottom, which is diastolic. Let’s say you have 131 over 81. That’s hypertension. That is hypertension, so lower is better in this case.
Dr. Weitz: Yeah. I think it used to be up to 140 over 90.
Dr. Elkin: When I was a student, 140 over 90 was considered borderline.
Dr. Weitz: Right.
Dr. Elkin: That clearly is not borderline. That is hypertension. 130 over 89 is considered borderline, so you’re right. We want it to be lower. People worry about low blood pressure. Believe me, there’s no concern about low blood pressure, unless you’re symptomatic. I think lifestyle is important. I think minerals, potassium, magnesium are very important in helping to lower blood pressure. This whole thing about sodium, it’s just been controversial since I was a student, about sodium restriction. It seems to bounce back and forth all the time. It really depends if you’re a sodium, if you’re a salt-retainer.
Dr. Weitz: How do you know that?
Dr. Elkin: Well, if you eat a lot of salt, you have to play around with your diet and experiment. I would say if you’re eating a lot of processed foods, that’s going to have a lot of salt. Anything processed has salt and sugar.
Dr. Weitz: What you’re saying is, give sodium restriction a try. Bring your sodium levels … When you do decide to try sodium restriction, what amount of milligrams of sodium per day do you recommend, 2,500, 1,500?
Dr. Elkin: Yeah, I think the CDC and the American Heart Association have two different standards, but yeah, 2,500 to 3,000 is enough. I don’t usually go much different than that. I might even go as high as 5,000. It depends on the individual. Certain diets require salt. If you’re on a ketogenic diet, you need to have salt. Then, certain people actually need salt because they have dysautonomias. They have autonomic nervous system problems, so again, it’s not one-size-fits-all, but I do, CoQ10 I find to be useful, fish oil. These all have an additive effect. These are the ones I try to use much, I try to use first. Exercise is essential. Exercise actually relaxes the arteries. There’s less pressure for the heart to pump, so that will lower your blood pressure. Not just aerobic exercise, also resistance training on a regular basis will also do the same. Again, it starts off with lifestyle. Do I use medication? I do use medication if I can’t get it down with these simple measures, but because I do think blood pressure control is still the number one risk factor, and I want to make sure we do it. And sugar. Sugar also has a positive role on blood pressure. No one even suspects that. They always think it’s salt, salt, salt. Modest salt restriction, if you’re hypotensive. If you’re not, I don’t care how much salt you eat, so modest salt restriction. Plenty of potassium, which is going to be found in fruits and vegetables, and other foods. And magnesium’s important, CoQ10, and fish oil.
Dr. Weitz: Okay.
Dr. Elkin: There’s a few other things. Olive leaf extract. I have my own product called PressureWise, which has olive leaf extract, quercetin, and grape seed extract. There are other supplements out there that can be additive as far as lowering blood pressure.
Dr. Weitz: Cool. Thank you, Howard. Let’s wrap it up. How can people find out about you, and having you help them with their health journeys, and where can they get the book?
Dr. Elkin: Here’s my new book. You can see this.
Dr. Weitz: Okay.
Dr. Elkin: If you want to read about it, I have two websites. One is heartwise.com. That’s my practice website, but the one that really is solely about the book is beyourownmedicaladvocate.com. It’s a big name. Beyourownmedicaladvocate.com. You’ll read about the book. You’ll read about, I did a pre-launch with people that read the book and reviewed it beforehand. That takes you directly to my Amazon page where you can buy the Kindle version for 9.95, and the softback for 18.95. Please get the book, share it with your friends, and if you would be so kind as to write me a review, I would appreciate it.
Dr. Weitz: Then they can contact you, if they want your help, from your website, heartwise.com?
Dr. Elkin: Yes, yes, of course.
Dr. Weitz: Okay. Thank you, Dr. Elkin.
Dr. Elkin: All right. Thank you so much. It was great. Always a pleasure.
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would certainly appreciate it if you could go to Apple Podcasts or Spotify and give us a five-star ratings and review. That way, more people will be able to discover the Rational Wellness Podcast. I wanted to say thank you to all the patients that we’ve been working with at our Weitz Sports Chiropractic and Nutrition Clinic, who many of whom, most of whom we’ve been able to help with a range of various health conditions, from various types of gut disorders, to thyroid and hormonal issues, autoimmune diseases, and various other cardiometabolic conditions. I very much appreciate you and I’m excited about going forwards, helping you to improve your health on your journey towards optimal health. I wanted to let everybody know that I do have a few openings now for new clients. You can take advantage of that by calling my Weitz Sports Chiropractic and Nutrition Santa Monica office at 310-395-3111, and we can set you up for a new consultation for functional medicine, nutrition, and we can get that going as early as the new year, so give us a call. I’ll talk to you next week.
