New AHA/ACC Lipid Guidelines, Cholesterol Myths & Root-Cause Cardiology | Dr. Sanjay Bhojraj
Dr. Ben Weitz introduces the Rational Wellness Podcast and interviews integrative/interventional cardiologist Dr. Sanjay Bhojraj about the new AHA/ACC lipid guidelines and the evolving science of cholesterol, inflammation, and cardiovascular risk. Bhojraj explains why conventional cardiology’s LDL-centric, statin-heavy approach can miss key drivers of atherosclerosis, drawing from years treating repeat heart attacks. He reviews how plaques form through endothelial/glycocalyx injury, oxidized and small dense LDL, and immune activation leading to rupture and clotting. They discuss comprehensive lipid and cardiometabolic testing (ApoB, Lp(a), oxidized LDL, insulin, A1c, CRP, MPO, Lp-PLA2, homocysteine, uric acid, TMAO), insurance barriers, and a HEART framework (Hormones, Energy, Autonomic nervous system, Rest/Repair, Triggers). They cover statin benefits/risks, alternative drugs, diet approaches, supplements, and women’s heart disease risks.
01:01 Why Lipid Guidelines Matter
02:09 Meet Dr Sanjay Bhojraj
02:49 From Stents To Root Causes
07:01 Rethinking LDL And Statins
10:19 How Plaques And Heart Attacks Happen
19:01 Why Advanced Lipids Aren’t Standard
21:37 Cash Pay Vs Insurance Labs
23:42 Key Cardiometabolic Markers
26:34 ApoB And Lp Little A
29:16 TMAO Dysbiosis Debate
31:51 Uric Acid Homocysteine And CRP
33:23 Inflammation And CRP
35:06 Beyond Basic Lipids
35:45 HDL Function Matters
38:04 HDL Treatment Limits
38:54 Sponsor Apollo Wearable
40:27 Iron Ferritin Hormones
43:04 HEART Risk Framework
43:46 MPO And Vascular Markers
46:12 Statins Benefits Risks
50:31 Personalized Lipid Therapy
58:36 Diet For Heart Health
01:01:23 Portfolio Diet Basics
01:02:09 Plant Forward Middle Ground
01:03:07 Saturated Fat And LDL
01:04:46 Vegan Keto Diet Culture
01:06:24 Niacin Pros And Limits
01:08:24 Berberine And Fish Oil
01:10:52 Omega Ratios Membranes
01:11:56 Red Yeast Garlic Glycocalyx
01:15:31 Sterols Bergamot CoQ10
01:17:45 Women Heart Disease Clues
01:20:48 Mammograms And Vascular Calcium
01:21:36 How To Work With Him
Dr. Sanjay Bhojraj is an Integrative Cardiologist who is also certified in Functional Medicine by the Institute of Functional Medicine. He practices in Mission Viejo, California and his website is SanjayBhojraj.us/home.
Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure. Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.
Transcript:
Dr. Weitz: If you’re looking for clinically useful insights, not wellness hype, then this is the place for you. Welcome to the Rational Wellness Podcast, the podcast for functional and integrative practitioners who want to practice with greater clarity and precision. I’m Dr. Ben Weitz, and each week, I sit down with the leading clinicians, researchers, and lab innovators to explore the science, lab testing, and clinical reasoning behind modern root cause medicine.
This is a show focused on practical, evidence-informed insights that you can actually use in patient care. Please subscribe to the Rational Wellness Podcast on Apple, Spotify, or YouTube. Please tell your friends and colleagues, and if you could give us a ratings and review on Apple or Spotify, we would certainly appreciate it. Finally, to access the show notes and the full transcript, please go to my website, drweitz.com.
Hello, Rational Wellness podcasters. Today, we’ll be taking a deep dive into one of the most controversial and important topics in preventative medicine and cardiology today, which are the new American Heart Association and American College of Cardiology lipid guidelines and the evolving science of cholesterol, inflammation, and cardiovascular risk. For decades, conventional cardiology has largely focused on lowering LDL cholesterol as a cornerstone of heart disease prevention. But in recent years, a growing number of physicians and researchers have begun asking deeper questions. Is cardiovascular disease really just about cholesterol? Are we over-prescribing statins? What role does inflammation, insulin resistance, metabolic health, stress, sleep, nutrition, toxins, lifestyle play in heart disease? The guidelines do not [00:02:00] recommend running an advanced lipid profile, but isn’t this helpful in explaining the 50% of patients who have a heart attack but have a normal basic lipid profile? Joining us today is integrative cardiologist, Dr. Sanjay Bajraj. Is that how I pronounce your name?
Dr. Bhojraj: Ben, you crushed it. I’m just going to go ahead and say no, … to the questions from before, so I guess we don’t need to do any more podcasting.
Dr. Weitz: Okay, there you go. That’s easy. Dr. Bhojraj is board-certified in cardiology as well as in interventional cardiology, and he’s one of a handful of cardiologists who are also certified in functional medicine by the Institute of Functional Medicine So, Dr. Bhojraj- yeah … thank you so much for joining us.
Dr. Bhojraj: Hey, Ben. It’s my pleasure. Just call me Sanjay, please. It makes me weird-
Dr. Weitz: Sanjay …
Dr. Bhojraj: out when you call me Dr. Sanjay.
Dr. Weitz: Okay, good.
Dr. Bhojraj: Or Dr. Bhojraj.
Dr. Weitz: So how did you end up changing from being an interventional cardiologist to being on the functional medicine side of things? What made you see the light?
Dr. Bhojraj: Yeah. Well, the you know, you’re always wondering, is that light like the train coming at you or what, right? But, you know, it was a lot of what you said in the preamble actually was an interventional cardiologist, for those of you who don’t know, I am the stent doctor, right? And so I am the end user of a completely broken system of healthcare that basically we fix when you’re broken. That’s what we get paid for, and we don’t get paid to prevent, right? And so in that role for 15 years or so, I treated thousands of heart attacks, got to that point in my career on the 10 to 12-year mark where I was getting repeat customers. If you’re on Shark Tank, they’re always asking, “What’s your re- repeat customer order rate?” And this, that, and the other. When it comes to cardiovascular medicine, particularly interventional cardiology, when that happens, that means that, you know, a grandma had another heart attack, or a dad had to go to bypass or whatever it might be, right? So now they’re no longer, you know, digits on a spreadsheet like they are to administrators or researchers, but they’re names, right, that can haunt you over time. And [00:04:00] so I saw consistently some people that no matter w- how tight we had their cholesterol controlled, how tight their glucose was controlled, how ideal their blood pressure was, they still came in.
And in fact, I had one gentleman who year over year for about four years in a row came in in a narrow window of December 20th to 22nd, so right before Christmas and he had heart attacks every year, right during that time. Wow. To the point that one year I was going on vacation for Christmas, we were going to India to visit family, and I said, “Hey, you know what? If you’re going to have your cardiac event, why don’t you come in a little bit early this year?” Just kind of completely tongue in cheek. Imagine getting a cold call from your doctor. But he had b- he become a friend over time, so we were kind of tongue in cheek hanging out, and then he actually came in on December 18th with another cardiac event.
Dr. Weitz: Oh, my God.
Dr. Bhojraj: And so, I hate to put that stuff in the universe, but I’m like, “Man, what is happening here?” And that was right around the time I was being introduced to functional medicine, so now we’re talking about 2016, 2017, so almost 10 years ago. And what I realized, for those of you who are aware [00:05:00] of the functional medicine matrix, is that we have these nodes of transport and assimilation and this, that, and the other, but right in the center of that is the mental, emotional, spiritual side of things, right? And feel that that drives so much of cardiovascular disease, but just disease in general, imbalance in general. And once I kind of initiated the training with IFM and then got certified, I realized, man, there’s a huge component of what we’re treating is not really healing. It’s just fixing numbers, but not necessarily healing people.
And as I got deeper into the functional medicine world and started incorporating it into my practice, that’s when I saw the true shift happen in patients, right? Shift happens in patients, right? And so I realized, wow, you know, there’s probably a interventional cardiologists around the country, but there’s not that many that are looking at all these other aspects of things that we’ll talk about today and I actually have a new framework in which I kind of evaluate patients. But I realized that there was something truly, truly [00:06:00] missing, and cardiology, was basically focused so much on lipids and I mean, we are, probably 10 years away from them wanting a LDL of negative hundred, right? Like, when you look at kind of how these things are moving.
But, is that, to your point, really the only thing that we should be focused on? And there’s actually so much, and I’m actually writing a book about this, and as I’m looking at this literature, this knowledge has been in the scientific community. Some of these papers I’m pulling up are from, like, the ’80s and the ’90s or early 2000s, so this has been known for 20, 30, 40 years sometimes. But I think because there’s not a drug to treat it, right? And an easy way, like an easy lever to pull, that’s why we’re just so focused on LDL and statins whatever because it’s easy, it’s comfortable for us. People don’t generally want to learn something new, but particularly when it comes to doctors, any time you change a paradigm, it’s really earth-shattering for them. And rather than adapting, you know, a lot of times people just dig their heels in and double down which is, I think, what’s happening in [00:07:00] cardiology today.
Dr. Weitz: Yeah, that’s one of the things that was so disappointing to me about the new lipid guidelines is more and more information has been coming out that LDL is not the full story, that there’s all these other factors, that we have all these lifestyle factors that can play a role, that toxin can play a role, that we- all this research about the endothelium. There’s so much about cardiology that goes beyond just high LDL and take a statin and end of the story, and those guidelines are so narrowly focused on just getting your LDL cholesterol as low as possible as early as possible
Dr. Bhojraj: Yeah, and you know, I think we have to take the guidelines for what they are, right? So these are guidelines on the management of lipids, right? So of course they’re going to be focused on LDL. If you look at guidelines for management of atherosclerotic disease or hypertension, you know, I think we can kind of widen the lens a little bit. But I agree with you is that we are [00:08:00] so just narrowly focused on LDL.
And look, I mean, I am kind of equal parts conventional and integrative, right? So I’m not saying that LDL isn’t a factor. I mean, certainly it is a factor, but it’s not the end-all be-all, right? There are so many different terms in that equation. LDL is certainly one of them. And you know what? I think the remarkable thing is one of the biggest shifts, I think, which I’m kind of thankful for in a weird way, is that when you looked at the old guidelines, they were so dogmatic about doses of medications. So if you met a certain criteria, at that point we’re using something called the ASCVD risk calculator, and if your risk was high, you automatically went to, 40 milligrams of Rosuvastatin or 80 milligrams, like maximum dose, or ma- you know what they would call maximum tolerated dose, which is a whole other nightmare. and they were not even focused on the numbers. So we had people, that were exquisitely sensitive. Like, I have people who, you know, five of Rosuvastatin drops their LDL 50 or 60 points. So now you’re telling me to take that person [00:09:00] and put them on 40? Like, there’s barely any cholesterol left, right?
And we could talk about circulating pools of cholesterol and whatnot, but you know, I think a lot of us who were kind of more rational thinkers in the lipid universe saw those old 2018 guidelines as kind of nonsense-y because it was a big departure from what we had done before. So now they’re moving back to levels, which I think is less bad, but I think it’s also, to your point, not really focusing on all the drivers of atherosclerotic disease, right? Statins are certainly a tool. PCKS9 inhibitors, certainly a tool. We have bempedoic acid and these missense RNA kind of cholesterol vaccines now, which are the high-tech tools, but also diet and lifestyle, right, become hugely important. And by and large, you know, what I say is you can’t fix a lifestyle disease without fixing the life that led to the imbalance that led to the disease, right? So- Right … so, there’s a lot more that we have to think about in the overall gestalt of a cardiovascular patient above and beyond [00:10:00] just get this LDL to goal. And that was like, you know, getting back to my origin story, that’s what I saw was that people again and again were coming in other episodes, with secondary, third, quaternary episodes, whatever. And despite that they had this ideal cholesterol profile, and that led me into the investigations of all the other things that were going on.
Dr. Weitz: So here’s what I’m thinking I want to focus on. start by talking about the mechanism of heart disease, how a heart attack happens, how cholesterol plaques start forming in the arteries. Then I want to go into testing, then may- maybe we can talk about the scans some of the medications. And then I want to talk about some of the diet and lifestyle and supplement stuff. Sure. So, we, know more about how cholesterol starts forming plaques in the arteries, and it’s not just about LDL cholesterol Right? It’s, we have this lining of the artery, the endothelium- Yeah … and [00:11:00] what’s going on there is so important. We also know that certain type of LDLs, smaller, dense LDLs, more likely to, end up forming a plaque. Inflammation plays a role. There’s all these other factors, so like you to talk a little bit about how plaques form and how a heart attack forms.
Dr. Bhojraj: Yeah. I mean, and this is such a fascinating topic, and our understanding of vascular biology is just changing every day, right? So imagine your artery, I’ve got this little test tube thing here, right? So imagine you’re looking down the barrel, for those who, who are listening to the audio, let’s, let’s just say you don’t even need a, a spec, but you’re looking down the barrel of a pen, right? And so you’ve got different rings there. You’ve got the opening where the little pen nib comes out, then there’s maybe the barrel that you grab onto, which might be a little bit thinner than the, the rest of the body of the pencil or the pen. So kind of similarly, inside the artery, you’ve got three layers of tissue. You’ve got the inside called the intima, the middle part called the media, and the outside called the adventitia. The adventitia on the outside is like the tough, elastic, fibrous tissue, kind of a ligament sort of, if you will, a tendon, the connective tissue. media tends to be the more muscular part of the blood vessel or, or that kind of the more passive area.
And then the intima kind of binds as, to your point, the endothelium. So the endothelium is like a single thick layer of cells that lives inside in the innermost part of the blood vessel, that part of the blood vessel that interfaces with the circulating blood, that’s going through, right? And I kind of think of that, like imagine like the old shag carpeting that we had growing up in my house, right? It’s just a single layer thick, and kind of you can get damage just like, you know, in certain areas where there’s heavily trafficked, you know, like I remember in my house from the laundry room to the kitchen, that part of the, the, the family room carpet was like matted down because that’s the main a- route that you walk, right?
And then- Right … behind the TV where you never walk unless you’re playing hide and seek as a kid, nobody goes back there. That area’s nice and fluffy. So [00:13:00] similarly, inside the arteries of our, of our v- circulatory system, you can have areas of differential wear and tear, and newly now there’s diagno- or described a even more inside layer on top of the endothelium called the glycocalyx. And so the glycocalyx is kind of like this web of antenna are sugars basically give information about what’s happening in the blood into the cell, and that actually changes the genes that the endothelium expresses for things like nitric oxide, which is a vasodilator, for things like epinephrine, which can initiate blood clots.
So a lot of different things are at play. So it’s a very complex mechanism. It’s not just a pipe like we used to think that it was. And so now in the circulating pool of blood, right, the little red blood cells are all floating around, you’ve got a lot of different components in there. You’ve got white blood cells, which are the cells that mediate inflammation and fight off infection we’ll talk about c- probably a lot more about white blood cells in the process of atherosclerosis.
You’ve actually got other particles called [00:14:00] lipoproteins, which are kind of the school buses of cholesterol. So I think one fallacy that people have is that cholesterol, we ha- we call it good cholesterol and bad cholesterol, but cholesterol is just like a molecule, right? It’s, it’s, it’s like a kid on a school bus, right?
but these shuttles that are, that are driving around, the cholesterol particles, those are what can be either more atherogenic, or we call it quote unquote bad, or less atherogenic and pick up stray passengers, we call that HDL or good cholesterol. So cholesterol is just a molecule. Like, just like oxygen is just a thing, right?
It’s neither good nor bad, it just exists. But there are certain shuttles that, that are drived around, that they drive around then that may be more pro-atherogenic or more pr- prone to scavenging. And what can happen over time is we actually on our cells have these things called LDL receptors. So I picture these like remember on the ga- the old game Hungry Hungry Hippos?
You know, where you’re just pressing the thing and trying to get all the white marbles? So each of our cells have these, endothelial receptors, or sorry, LDL receptors on the liver, but [00:15:00] then also in the blood vessel system, in the circulatory system on the endothelial side, so you can just natively capture some LDL particles and bring them in.
So that is one mechanism. But the other mechanism that can happen is that when you have high sugar, high oxidative stress, high, inflammatory load, whatever it may be, those LDL particles are very prone to damage, and so they get oxidized. They get, they get small, and they get dense, and they get angry. are the ones that are more likely to cause atherosclerosis because they have a couple of different mechanisms. Number one, that good old-fashioned LDL receptor can pull them in. But When they get damaged, they turn into what are called damage-associated molecular patterns or DAMPs, and that activates the immune system.
So now the immune system gets in play. Remember I was saying we’ve got those white blood cells circulating around. Now you’ve got these particles that the body is like, “Hmm, I’m not sure if this is a friend or an enemy,” right? And just like when I take my dog on a walk, when we see a new dog, he’s like looking around trying to [00:16:00] figure out what’s going on, and he barks, right, to see the other dog might react.
Well, similarly, when you’ve got these particles floating around that are damaged, your body doesn’t like things that don’t work correctly. So what happens is it activates the immune system, and those then get pulled in, oxidized LDL particles or small dense LDL particles, as we call them, get kind of pulled into the wall of the blood vessel.
They can either go in between the cells you know, we’ve got leaky gut, you can have leaky vessel, or they actually go through the cells and collect in that middle part of the artery that, that’s called the media, right? And so over time, you can get big collections of these. Remember how I said the wear and tear on the endothelium is a little bit- Right
different like the shag carpeting. So when you have different areas, particularly where there’s like a fork in the road, we call that a bifurcation, or certain areas where there’s been damage before, you can collect a lot of that, that, those LDL particles together, and they coalesce to form a plaque Right?
And then that plaque then, sorry, I’m getting a little nerdy here for you guys. Take a deep breath. We’re going to get through this- … for the listeners, right? as those [00:17:00] plaques kind of, as those LDL particles kind of come together and coalesce, we used to think of this as just a passive pattern. You know, like, it’s like, you know, ta- tapioca pudding in your blood vessel wall.
But what’s really happening is there’s a lot of enzymes in there, and your body is basically, your, those enzymes are trying to destroy the LDL particles, again, because they’re immunologically activated, that your body thinks that it’s some foreign material, and those same enzymes that kill off these LDL particles or are trying to damage the LDL particles can actually, digest or erode your blood vessels themselves. So if you get too thick or too big of a plaque, they can actually erode and rupture, and that’s what causes a heart attack when that happens. Now, the other process through which the body tries to-
Dr. Weitz: So just to clarify, the plaque ruptures and forms a clot, correct?
Dr. Bhojraj: Correct, yeah. So when the plaque ruptures and forms a clot, you’re exposing all these factors, proteins from the middle part of the blood vessel, that media, that aren’t supposed to be [00:18:00] visible to the blood flow. And so now the body realizes, “Boy, something bad is happening,” right? We gotta put a finger in the hole in this wall, and that’s where the blood clot comes from. Right. The other way this process kinda happens is as these plaques kinda form, your body says, “Hmm, something ain’t right here. You know, we’re, we’ve, we need to put a wall up around these prisoners.”
And so it actually, the, the s- the cells inside that media, that compartment of the, of the blood vessel wall, actually convert over to bone-like cells. cells that produce bones called osteoblasts, and they create a calcium rim around them, right? So it’s kinda like building a wall around the prison, so to speak, to try to limit the, the aggregation and the expansion of those plaques. So that’s where things like coronary calcium scores were done- Right … way before. So it’s, it’s an amazingly just a regulated system Is
Dr. Weitz: where we end up with soft plaque- Right … calcified plaque
Dr. Bhojraj: But that’s how you can end up with soft plaque and hard plaque and, or calcified plaque, and we can talk about that later, but that’s the process of atherosclerosis. I mean, it- Right … absolutely fascinating. [00:19:00]
Dr. Weitz: Great. So since we know a lot of these other factors play a role, doesn’t it make more sense to do an advanced lipid profile? And lipid, advanced lipid profiles have been around for quite a while. In fact, you know, they started out being developed by some of these other companies like Boston Heart and Cleveland Heart Lab, then they’ve been bought out by Quest and LabCorp. So you would think at this point that they would almost be standard, and yet we’re going backwards saying, “Well, okay, maybe measure ApoB, but forget about all these other factors.”
Dr. Bhojraj: Well, you know, unfortun- so number one, yes, I agree. don’t even call them advanced lipid profiles anymore because I feel like- It should be the standard, right? When you say advanced, it sounds like scientific, you know, sci-fi- Right, right … or, you know, scifi- science fiction or something. So I just call them comprehensive lipid profiles because- Right … they give you so much more information. You know, I think the big problem is that people who don’t have medical licenses really drive a lot of what we’re able to do in conventional medicine, [00:20:00] and
Dr. Weitz: so it’s really a function of insurance companies now-
Dr. Bhojraj: Yeah, you’re talking about insurance right? Yeah, of course. Yeah. you know, you know, like I can’t li- I’m here licensed in California, I can’t go to the state of Nevada and practice medicine because I’m practicing there without a license, but we let administrators with people, you know, who are represented by dots on a spreadsheet tell us, dictate what to do.
That’s a whole other conversation that pisses me off. I’m going to take a deep breath right now. you know, when it comes to comprehensive lipid profiles or advanced lipid profiles, we do get so much more actionable information, and I think kind of more so that- They are things that where you can really kind of get, I don’t want to call them quick wins, but kind of shorter term wins, where you can see how diet and lifestyle can impact your LDL particle size.
You can, you know, put somebody on niacin and see what happens. Put somebody on fish oil and see how their, their lipid membranes improve, or their, meaning their cell membranes improve. You can see kind of how their, you know, asymmetric dimethylarginine, kind of is affecting their nitric oxide. I mean, these are all things that we can [00:21:00] do.
I think the problem is that in the conventional world, number one, these tests aren’t generally covered by, insurance, and so there’s a penalty to do them. Patients will… You know, I was always disclosing to my patients, “Hey, I’m doing this, you know, o- other more complete lipid panel. It might be, you know, $200 more,” or whatever it is, which I practice in an affluent area here in Orange County, California, so people were willing to absorb that for their long-term health. But I also trained in Detroit, Michigan, where, you know, during the, the 2006 to 2010 era, when people were losing houses and things, right? Right. a lot of people don’t want to do anything their insurance doesn’t cover.
Dr. Weitz: And so it’s just- I, by the way, just for the sake of clinicians who might find this interesting, when you, have a patient and you’re ordering labs, and you put a, a fair amount of your patients through insurance, whereas some of us just practice functional medicine without insurance. But, do you find that it’s better for the patient to order the labs through a [00:22:00] conventional lab, have it go through insurance, have insurance deny it, and then they have to pick up the rest? Or Do you, already know what insurance is going to cover, or is it better to give them, say, “Here’s a lab that’s going to give you the discounted cash price?”
Dr. Bhojraj: Yeah
Dr. Weitz: Just pay that up front rather than have to pay the insurance price?
Dr. Bhojraj: Yeah. The, the straight cash pay is actually so much less expensive- Right … than going through insurance, right? Right. It is remarkable. Right. Some people, you know, they need to meet their deductible or whatever it might be, and so, you know, am, a very small kind of boutiquey practice, so I don’t have staff that deals with all these prior authorizations and things. So what I tell my patients is, “Look, if you want to deal with all that, that’s fine. You know, you can run it through insurance, put it through your co-pay.” But, like, for instance, vitamin D, you know, if you check a vitamin D level through insurance and whatnot, it can be, like, 250 bucks. Yeah. You can, you can get it direct to consumer for, I think, like, I saw it for, like, $23 or something.
So, you know, that’s also a part of the game of healthcare that drives me absolutely- Right … [00:23:00] nutty. It’s insane. Yeah … it’s, you know, you ask for… you ask Santa Claus for a pair of… you know, for a, a horse, and you get a pair of socks. You know, the, the, the visibility of this is kind of nonsensy. But to your point, I mean, it’s just more efficient, to be able get people to the labs because then, you know, you’re, you’re s- stuck in this six-month kind of round the…
you know- Yeah … going around chasing each other kind of game, whereas if you just say, “Hey, you know what? This is what it costs up front.” And I’m very cost conscious and, you know, I think that’s just kind of the training that I had where I trained. You know, I always disclose that to people. I always say, “You know, is this okay?” generally I think they’ll, they’ll be okay with it. but, you know, it’s so much more efficient to get to the diagnosis correctly, right? Right. Because the other aspect of that is if it takes six months to get the labs, that’s six months of treatment that you’re missing potentially, right? So- Right.
Dr. Weitz: So let’s dive into the labs.
Dr. Bhojraj: Yeah.
Dr. Weitz: What are some of the most important things you like to look at when you do your complete labs profiles?
Dr. Bhojraj: Perfect. So, I focus a lot on cardiometabolics as well. So- Right … you know, as we talk about cardiovascular disease, I don’t think you can not [00:24:00] mention, insulin resistance, and it’s- Right
Dr. Weitz: Glucose, insulin, hemoglobin A1C?
Dr. Bhojraj: Yeah, 93% of Americans are metabolically unhealthy, and that’s going to be a huge driver of cardiovascular disease, stroke, heart attack. We’re seeing epic numbers in terms of, metabolic associated, steato- steatic liver disease or whatever they’re calling fatty liver nowadays. I feel like every six months-MASLD M- MASLD, MAFLD, whatever they’re calling it at- Yeah … the time you know, this podcast going live. it’s all related. Now we’re, we… There’s this newly, described CKD, so cardio kidney diabetes, kind of continuum that, that’s happening, so we’re seeing all these things related. So, you know, for me, we’re doing a comprehensive lipid, sorry, comprehensive metabolic profile. So that’s, you know, basic electrolytes, basic, liver enzymes because oftentimes if you have fatty liver, you can start to see liver enzymes going up. I, also do a GGT, gamma-glutamyl transferase, as a measure of, like, toxic load.
I think toxins are something we forget about. Yeah. certainly a blood count, CBC, and, and, you know, you can [00:25:00] actually look at indices with- within the CBC, something called the SIRI, SIRI index, to look at systemic vasc- or systemic inflammation index. SII is the other one that you can calculate just based on those numbers. So it gives you an idea of what’s going on based on the neutrophils and platelets and all these different things. So those are kind of the conventional things that I look at. hemoglobin A1C is a big one as well, looking at the last 90 days of glycemic load. However, you also have to look at some measure of how much insulin it takes to get to that, that, glycemic number, right? So for instance, if you are normal, your insulin level should be, what, level, like, I think less than eight or something like that. but if it takes, like, 10 times the amount of insulin to get your glucose within normal, you’re already insulin resistant, and you’re on that path-
Dr. Weitz: So on insulin, you like it below eight?
Dr. Bhojraj: Yeah, I mean, I, you know, depends lab to lab where it gets measured and things- Okay … but that’s like 10, eight, that’s what kinda sticks- Right … out in my mind for fasting insulin.
Dr. Weitz: Is there a lower number you don’t like to see it go below, or i- is the lower the better?
Dr. Bhojraj: I mean, I think in my [00:26:00] practice, just with my patients, I just don’t tend to see low numbers. Okay. That’s ’cause everyone’s kinda coming to me with heart disease. I mean, I’m sure there’s a number if you’re less than two or something, we’d have- Yes … to be a little bit nervous, but you know, again, I just don’t see those patients. Right, okay. another thing that you can check is C-peptide, which is kind of like, you know, when you get a new electronic device you have to pull that little plastic thing out of the battery- Right
and so it makes contact. So C-peptide is like that little plastic nib on top of an insulin molecule that has to get cleaved off for the insulin to be activated. So C-peptide is another thing that you can check. Again, depending on time of day and expensive labs, you know, it gives you some insight.
and then we start to do some of the more advanced testing, so as we mentioned, looking at more comprehensive lipids, so not just triglycerides, HDL, LDL, and total, but looking at particle size, particle numbers, looking at oxidized LDL I think is important. Certainly ApoB is a, is a new metric that’s relatively inexpensive.
Right. ApoB is a cell surface protein that lives on all atherogenic particles. [00:27:00] So we have HDL, we have LDL, so high density lipoprotein, low density lipoprotein, and in between we have all of these, they call them IDLs, intermediate density lipoproteins. They’re atherogenic, we just didn’t really have a great way to…
Meaning they can cause plaque, we just didn’t have a great way to measure them, and now we have this ApoB which is one molecule of ApoB per atherogenic cell. So it gives us a really goody idea of the count of how many cells might be causing atherosclerosis in your body, and that’s now emerging as a more solid risk factor of cardiovascular risks, cardiovascular risk than just LDL alone.
Lp, which is a genetic marker of cardiovascular risk, and we’re starting to see now can be elevated in a much larger proportion of the population than we thought before. it also though is responsive to hormones and responsive to toxins, so that’s why you can’t just take this on its own. Why is Lpgetting popular now all of a sudden?
Dr. Weitz: cause we have drugs that will be coming to market soon.
Dr. Bhojraj: Exactly right …Well, we’ve been talking about Lp(a) probably for [00:28:00] 10 years but, you know, everyone in my old practice, all the conventional docs thought I was nutty for ordering them, but now lo and behold, there’s three, pharmaceuticals in, coming down the pipeline treat Lpspecifically, so now everybody is all concerned about Lp, right?
Dr. Weitz: mean- Right … it’s not just me. I, yeah, I’ve been arguing with other doctors for years saying, “Why are you ordering it? It’s hereditary, you don’t need it.” Right. And even these lipid guidelines say, “Well, you should order it, but only once.”
Dr. Bhojraj: Well, and, but I’ve seen such very… I mean, we can talk about that, but, like, testosterone can decrease. a guy on testosterone replacement therapy can decrease Lpin the clinical trials that have been, again, known since the 2014 era. You can drop it 18 to 22% with just replacing testosterone, right? Right. So there’s so many other things, but we’re so driven by pharmaceuticals, you know, not to put my foil hat on, but here’s my foil hat, right?
That we don’t, we often don’t think that anything’s a problem until there’s a solution they’re telling us we have- Right … for something that has existed, right? So, so anyway, getting back to lipid profile, I think that’s pretty [00:29:00] cool. Now, when we want to look at actual, like kidney function and things, so you can look at a couple of different things. SDMA, symmetric dimethylargine, is a study that you can look at for kidney function. ADMA, again, I think is a, is another me- measure of vascular health. We want to get that down. TMAO, which is a marker of basically a red meat metabolite,
Dr. Weitz: Okay. Let, y- let’s talk about that for a minute. Yeah. How of accurate do you think TMAO is? Because I’m a little skeptical. Yeah. So I think that really TMAO is a marker of dysbiosis, not necessarily- Yes … a marker of vascular risk, right? So what do I mean by that? Yeah. Right. There are studies that show if you have a high TMAO, you have a higher risk towards endothelial dysfunction, all of these things, but where does TMAO come from? It’s a metabolite of red meat, right?
Dr. Bhojraj: So as you look at the body, if you, if you heal the microbiome, if you get the good ratios back and all that stuff TM- TMAO goes [00:30:00] down, this toxic metabolite goes down, so too should your vascular risk, right? So I’m not one… You know, I don’t, I don’t think that you need to be vegan. At the same time, I don’t think you need to be carnivore to be healthy. I think there’s somewhere in between. But, but yeah, TMAO I think is more of a marker of dysbiosis than anything.
Dr. Weitz: Okay, good. I think that’s really important because TMAO has been used a lot recently to argue against Certain supplements like choline- Yeah which is essential for brain health. There was just a recent study showing that patients with lower levels of choline have a higher risk dementia and also L-carnitine, which we know is super important for heart health. And so- It’s,
Dr. Bhojraj: we give it for mitochondrial support, right? And choline is the precursor for acetylcholine, one of the most important neurotransmitters in the brain, right?
So-
Dr. Weitz: Right. And if patients, yeah, have a weak heart, combination of L-carnitine and certain other nutrients like D-ribose, can be super [00:31:00] beneficial.
Dr. Bhojraj: Yeah. that’s the, you know, that’s the mitochondrial support that you need- Right … for cardiovascular health, right? So I mean, think that, you know, with all of these dietary things, you know, w- we need to not just look at the number. Again, it’s, it’s, it’s almost like the, like what the conventional medicine world does to biomarkers. A lot of times I feel like functional docs kind of guilty of the same thing. “Oh, TMA- if TMAO is high, I have to do something to lower it,” not what is the milieu that’s creating this h- elevation in TMAO?
Right. Right? Like, if you’re really a functional practitioner, that’s what you’re looking at, is really, you know, okay, TMAO is high. We know that red meat increase it. It’s a metabolite. But why is it high? Why is it that some people s- eat red meat and have a normal TMAO, some people don’t, right? Right. Why do some people have a normal uric acid and others don’t, right? It’s, it’s all these- Right … underlying issues of oxidative stress and reactive oxygen species and all these other things that- Right … that we really need to go after.
Dr. Weitz: And uric acid is another important marker for metabolic health
Dr. Bhojraj: So yeah, so, Dr. Perlmutter wrote Drop Acid and everybody- Yeah … you know, it was a brilliant book. It’s [00:32:00] funny, I, like I, the, the, the substance of the book is so different than the to- the topic, right? Or the- … the title. But really, as I see it, uric acid is a marker of oxidative stress, right? so again, if you’re giving a system something that it can’t use or can’t use efficiently because you’re lacking certain co-factors, you know, the body is amazing in terms of how redundant it is and how many different systems they have. I mean, anybody who’s taken a biochemistry class knows, you know, you’ve got to remember the urea cycle, the Krebs cycle, the this cycle, the that cycle, right? There’s so many different cycles. So, you know, we’re going to use things as best we can. like homocysteine being like one of those examples, which is something that I check on labs too. But, you know, is it an… I- independently, you know, homocysteine is a, is a risk factor because it’s, you know, de- detrimental to the endothelium
Dr. Weitz: Why isn’t homocysteine measured more?
Dr. Bhojraj: I don’t know. I mean, guess most people think that the methylation cycle is too complex kind of think about. I mean, like when know, you just give a methyl donor and [00:33:00] you can bring homocysteine down, that can be methylfolate you know, any number of things depending- Right on where the markers are. you know, getting back to the panel, I think homocysteine is an important thing to at least have some insight on. CRP, Lp-PLA, myeloperoxidase, you know, some people still question those
Dr. Weitz: I can’t believe the guidelines didn’t even measure CRP
Dr. Bhojraj: I, you know, CRP, just, I don’t get it.
Dr. Weitz: It’s, it’s well-validated, right? One, one to three, and three or more. Like, that’s been bla- like tattooed on my brain from when I was in conventional cardiology fellowship. We just don’t check it. There are clinical trials. There was one with, Rosuvastatin that looked at, you know, how w- who gets the most benefit from statins, and it was the people with elevated LDL, with the elevated CRP- Wait, that was the Jupiter Trial?
Dr. Bhojraj: Yeah, exactly. Yeah. you know, so we know that inflammation, right? CRP is a- Right … is basically, it’s a metabolite of IL6 and IL1 beta, so it’s a, it’s a surrogate inflammation load. But just, I don’t know. And we have a clinical trial within cardiology called the CANTOS trial. This is probably about six, [00:34:00] eight years old by now, so it’s not even a headline anymore. But it was an anti-L- IL1B antibody, so it was a biologic against this component of inflammation, and it was a positive trial. Only problem is the drug itself was like $40,000 a month or some nonsense thing. you know, but I remember the, the primary author, who I think was Val Fuster, who’s like one of the OGs of cardiology, you know, was like, “You know, this proves that inflammation is an important part of atherosclerotic cascade, and, you know, definitively.” And I got all excited because, hey, maybe they’ll start seeing, you know, the conventional world will start seeing things the way we see it in the functional world.
Dr. Weitz: Right.
Dr. Bhojraj: And then it just stopped. It didn’t go anywhere. And then there was a colchicine trial, you know, again, anti-inflammatory, was positive initially, and you know, they’re still not giving credence to inflammation. So, you know, I’m not sure why CRP is not part of the lipid guidelines, because certainly it’s a risk-enhancing factor, and it gives you more insight into what’s going on. It’s like imagine watching TV- Mm-hmm … or like with one eye, right? Yeah, you probably, you know, or [00:35:00] going to a sporting event or something, you know, with one eye.
Yeah, you can probably get the gist of it, but s- you know, God created stereo vision for a reason, right? And- Right … and so we have all of these newer, tests and things that give us so much more insight into what’s going on. You know, I tell people like a standard lipid profile, it’s like a black and white TV. Like yeah, it’s great. I mean, it, you know, it was probably in their era when you were converting from radio to television, black and white was amazing. But now there’s 8K screens that give you so much higher definition, right? So why would you go back to a black and white TV? It just doesn’t make sense. So, you know, cardiology and cardiovascular medicine, that’s what they do. They’re happy with this black and white TV, even though we’ve got a shiny color plasma, you know, whatever l- whatever the new technology is, LED, OLED, whatever. but they’re, they’re just not changing with the times. And-
Dr. Weitz: By the way, what’s the status of HDL these days? Because for a while- Of what? … there was a lot of talk HDL
Dr. Bhojraj: HDL-O
Dr. Weitz: Yeah. So there’s a lot of talk about HDL. HDL is, is really important. It’s gotta be as [00:36:00] high as possible. Then we realize that when it’s really high, it’s not good, it’s not functional. Right. And in an attempt to come up with a functional, HDL functionality, and is, and, s- right now we’re not really sure if, as best I can take it, how important HDL really is.
Dr. Bhojraj: Yeah, and y- when you look at kind of the affinity for how much, when you look at the particles now. Mm-hmm. So getting back to the lipoproteins, LDL is a particle, HDL is a particle. You know, the HDLs are much smaller than the LDL particles are. So the HDLs are kind of like the short bus, if you will, and the LDLs are the big buses. you know, I remember in the once upon a time days, as the lipid guidelines have changed over the years, when I had come out of training, they said an HDL greater than 60 was a, a negative risk factor. So I would joke around with my patients, “Hey, your HDL is 65. You should look, you should go out and start smoking because you’re protected,” right?
I mean- … the dumb stuff that we said in the once upon a time days. Right. But now to your point, we’re [00:37:00] realizing that elevated HDL, you know, is not really protective because we’re getting a lot of non-functional HDLs, and this is work that’s come out of these functional labs, like for instance Boston Labs that you mentioned has an HDL, panel where you can get an HDL map and see how many of the functional HDLs you have, how many of the non-functioning HDLs you have.
And, you know, how do we measure that? You know, you don’t look under a microscope and it says HDL on there. You’re looking for, certain kind of markers on the cells, in, in this case something called ApoA. and, and you know, what we’re learning is that although you may have a lot of ApoA particles, they may not all be as protective, right?
So it’s like Animal Farm: all animals are created equal, but some are more equal than others. So all HDL particles are not created equal, and some are less equal than others. with HDL now, I think there’s a lot of misunderstanding out there that, yeah, a high HDL is good. I mean, certainly a high HDL is better than a low HDL. But at the same time, it might not be you know- [00:38:00] Whew, you know, exhale, take in a- Right … deep breath. You’ve got high HDL that we thought you, that it was-
Dr. Weitz: So how much do you address HDL when you work with patients?
Dr. Bhojraj: Well, you know, the problem with HDL is there’s nothing, th- there’s not a lot that you can do to move the needle. Like you can use- Right … maybe niacin sometimes that gives a bump. Rarely fish oil gives a bump. I mean, these are all the theoretical things that we learn in cardiology school that in real life I have maybe, like, had two patients who were niacin responders, I saw an improvement in their HDL.
So that’s not to say it can’t happen, it’s just infrequent in my experience. So, you know, LDL is a much easier marker, you know, move. It’s a much easier needle to pull, particularly with all the medications that we have out there, the supplements that we have out there. And I think, you know, ra- like the incremental benefit that you’re going to get from raising HDL is much less than lowering LDL, right? And so that’s why I think we’re really, you know, focused so much almost to a fault on LDL.
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Dr. Weitz: Here’s another thing that’s often not measured, especially in men, and can be really important, is iron and ferritin.
Dr. Bhojraj: Yeah. Yeah, so ferroptosis has become a big deal, you know, getting iron overload. It is a- another marker of inflammation really, right? So as you look at iron and TIBC and all these metrics, you know, we’re learning more and more about the interplay all of these things, but iron is certainly a big deal. You know, but sort of, you know, the, the ster- the sex hormones, the pet hormones, progesterone- Right … estrogen, testosterone. I mean, [00:41:00] like I said Testosterone for guys was vilified forever, because it would increase your risk of everything, right?
Like, so now with the TRAVERSE trial that came out recently really washing a lot of that stuff away, we’re seeing that just like women were disserviced by the women’s health study showed that, you know, at the time that synthetic estrogen was bad, go figure, really, like something- … that’s not natural given to you, that is bad, right? So we have all this testosterone-
Dr. Weitz: Yeah, not only synthetic, actually horse estrogen.
Dr. Bhojraj: was it equine or was it, I think, or
Dr. Weitz: was it- It was equine, yeah …Premarin.
Dr. Bhojraj: synthetic? Oh, so I mean- Yeah … even worse, right? So- So giving you an animal protein- And sy-
Dr. Weitz: and synthetic progestin, yeah … like an
Dr. Bhojraj: animal hormone was not good, you know, there’s a lot of back and forth on the testosterone whether it was good or not. Now we’re seeing that, you know, it improves metabolic health, improves muscle, it has, you know, really important, functionality on lipids as well. So now I think we’re, we’re, we’re going to see a little bit more awareness. And then also, as I mentioned, you can actually drop Lp(a) in some studies by 18 to 22% with testosterone.
The problem is the gatekeeper of that, [00:42:00] which is the cardiologists, are generally not the ones that are going to be comfortable dealing with hormones. And so now you’re dealing with the fragmented medical thing is like, “Okay, like I’m a, I’m a this-ologist. You need the other-ologist,” right? Right. “For thing,” right? So we need to try to bring it under the same umbrella, and that’s where, like, holistic guys like me, you know, so helpful because, you know, I do have to think of these things from all standpoints. you know, with hormones, FSH is a hormone, f- follicle-stimulating hormone. You don’t think of this normally with guys, but as guys start to put on more adipose tissue, your FSH goes up, as does your cardiovascular risk.
As you lean out, you drop your FSH, cardiovascular risk improves. There’s some studies that say that per- perhaps even your Lpimproves. So now we’re seeing, like, and the reason that’s important is this thing that was genetically determined, as is indicated by the guidelines, isn’t as rigid as we thought it was, right? So- Right … so if you’re really looking, aiming to reduce someone’s cardiovascular risk, you have to think of all of these other indices that you have [00:43:00] to, that you have to improve, and that’s really what’s going to lower the risk, right? So it’s hormones, it’s energy, it’s looking at the autonomic nervous system, it’s resting heart rate-
Dr. Weitz: Obesity, yeah
Dr. Bhojraj: and it’s, it’s, so, so my framework, I call it the HEART framework. This is the book I’m writing. So H is hormones, E is energy/mitochondria/microbiome, A is autonomic nervous system, R is rest, so repairing and, and eating the right foods, and then T is triggers, that include toxins and traumas, right? And unless you’re kind of dealing with all of these things, that’s really holistically how you need to approach a cardiovascular patient. Not just pump up a blood pressure cuff, look at the labs and say, you know, “You’re going to die tomorrow,” right? And then, you know, put numbers into a, into a calculator. I mean, there’s all these other levers that we can pull to re- to reduce cardiovascular risk.
Dr. Weitz: Talk to me for a minute about MPO or myeloperoxidase.
Dr. Bhojraj: So myeloperoxidase is, is an enzyme that’s secreted by activated white blood cells that help kill [00:44:00] bacteria and all these things, and it gives us some insight into, kind of the state of, the state of the union in terms of inflammation. It’s not a standalone, for vascular inflammation plaque. Lp-PLA2 is probably the most sensitive for vascular inflammation, but you look at these together, like whenever you order a, a inflammatory vascular panel, myeloperoxidase, HS-CRP, and Lp-PLA2 come together, and you get a overall sense of what’s happening.
So if like two or three of them are elevated, you know that there’s a high inflammatory state. If there’s just one that’s elevated, you need to look for causes. Like I had a patient the other day who had severe arthritis in like all his joints, hips, head, shoulders, knees and toes, I mean, basically all the joints, and his HS-CRP was like four.
But then when we look at his vascular inflammatory, you know, Lp-PLA2, it was normal. and I said, “Well yeah, that makes sense.” We call it highly s- you know, sensitive HR- HS, right, CRP, because it’s so sensitive to any inflammation. but but myeloperoxidase, Lp-PLA2, you have to do these kind of together [00:45:00] to, to sort out what’s happening.
Now, there are some emerging markers, some interleukins and things that, that you can check that are more vascular specific. They’re not yet so easily commercially available, so I don’t check those yet. But, you know- Right … it’ll be interesting as, as those become a little bit more, as the, as what im- the evidence base of those kind of fills in a little bit more, you know, how will that complement-
Dr. Weitz: Right
Dr. Bhojraj: an Lp-
Dr. Weitz: What do you take if you have a patient and most of their lipid profile, you know, their comprehensive lipid profile looks pretty good, but there’s just a high MPO?
Dr. Bhojraj: Mm-hmm. I mean, you look for like dental, you know, often than not it’s going to be dental inflammation or something going on. You know, you can do a little fish oil, a little turmeric, some anti-inflammatory stuff and see what happens. But again, I need to see the way I, in my practice, I need to see two of the three elevated before I would kind of act. If you got three of three elevated, then that means, you know, the eye is popping out like the old, you know, Warner Brothers cartoons. Then you’re like, “Okay, s- like something’s going down. We need to get a little bit more aggressive about being anti-inflammatory.” And that could be foods. [00:46:00] That could be, you know, stress, like physical, emotional stress. That could be a lot of different things that contribute to that.
Dr. Weitz: Yeah, I think polyphenols may have some potential- Yeah, absolutely … for MPO modulation.
Dr. Bhojraj: Yeah.
Dr. Weitz: so let’s talk about, medications.
Dr. Bhojraj: Yeah.
Dr. Weitz: So statins are the number one most prescribed medications. and, what’s your opinion of statins? how effective are they, not just in lowering LDL, but in preventing heart attacks? And, and then what about the side effects? Yeah … it’s commonly thought that statins potentially have a lot of side effects, blood sugar, muscle damage, affecting the brain, and yet they keep coming out with these studies saying, “No, there’s no side effects.
Everybody’s crazy. They just think that they’re having side effects.”
Dr. Bhojraj: Well, so a couple of things. I think statins are probably the number one over-prescribed medication. I think that we need- Okay. Over-prescribed …
Dr. Weitz: we need to
Dr. Bhojraj: be doing. Yeah, I mean, I think that it’s, it’s a lazy [00:47:00] medicine. It’s an easy kind of lever to pull.
They’re int- like, now they’re super cheap. Like, a month’s supply is, like, five bucks, you know, so it’s an easy go-to. You’re,
Dr. Weitz: you’re saying if insurance covers the rest of it.
Dr. Bhojraj: If insurance, yeah- Yeah … if insurance covers the rest. But even if you get, like, a, what, a, one of those, like, cards, like GoodRx or whatever, they’re, they’re relatively inexpensive.
I mean, I remember when a month’s supply of branded cholesterol medicine was, like, you know, 300 bucks a month or whatever. Right. Okay? those are in the bad old days, you know, it was a big deal. Now they’ve gotten intensely cheap, so now that it’s cheap, it’s kinda like, well, you know, you have those people that say, “Put it in the water,” and all this stuff.
Yes, right. You know? Which, which I don’t think is a great idea. The poly pill. So, so number one, I think- Yeah … when you look at, you know, I think the question behind the question here is when you look at the absolute risk reduction of statins, right? As my teenagers say, it’s kinda mid, right? Sure. It’s kind of unimpressive.
Yeah. you know, potentially for all the risk that you’re putting someone on. You know, when we look at the, the data, right? And there’s a great [00:48:00] tool, it’s, it’s, it’s taken from this really kind of weird institution called the Mayo Clinic. So for the listeners- … out there, you know, like, who believes Mayo Clinic, right?
But, like, Google Mayo Clinic statin decision aid, or statin decision tool, or whatever it is. And this is something that I would go through with my patients all the time and say, “You can put in your name, your, your date of birth.” Not your name, “Your, your age, your cholesterol numbers, your comorbidities,” and it would let you know kind of at an absolute level how much risk you’re saving yourself.
And it was always so unimpressive, right? It would be like, you know, it may save you two out of 100 times, you know, it may add a couple days to your life, you know, and we’re starting to see these epidemiological studies being done. a lot of times they re- will report relative risk, you know? Oh, yeah, if you have…
And I, and I say it like this, like, say you’re completely bald, and you have one hair on your head. And I give you a medication increases the number of hairs on your head by 100%, you’d be like, “Oh, sign me up,” right? Yeah. But really when you look at the absolute numbers you go from [00:49:00] one hair to two hairs, right?
I mean, that’s not getting you a date on a Saturday night. Right. So we have to look at these, we have to look at these numbers kind of a global perspective. So I think that the studies on improvements with- with cholesterol for primary prevention, meaning somebody who’s never had a cardiovascular event, hasn’t had a stroke, hasn’t had a heart attack, bypass, stenting, whatever it is, it’s kind of less impressive than I’d like it to be.
And you see that evolution. So in, from the 2018 guidelines to the current guidelines, they actually switched a, a major thing. They switched the calculator tool that we use, or that we’re supposed to use to car- to calculate cardiovascular risk. So we used to use something called the ASCVD risk score.
Atherosclerotic cardiovascular disease risk score is what it stood for. And what they found was that overestimated your cardiovascular risk, right? In a lot of populations, but also underma- underestimated in others. Why? Because not everybody is a 40-year-old white male, right? We have female patients- That’s-
and we have minorities, and like people like me of [00:50:00] Southeast Asian and Filipino descent, we have much more aggressive cardiovascular disease than somebody of European ancestry or African ancestry, right? these calculators that taken to be gospel really ha- a disservice on both ends of the spectrum, you know, for the, you know, it might overestimate your risk, it might underestimate your risk.
Now they have this new PREVENT calculator, which is going to be an imperfect tool. You know, sorry break it to you. It’s going to be an imperfect tool, but it’s a tool that we can use. It’s probably better than the last one, but it’s not as good as the next one is going to be. So this is always an evolution the point of that is to say is that, you know, put- we try to be as objective as possible, but I think really what we need to do is kind of like what I do you know, take a much more precision approach by looking at these advanced biomarkers and seeing, you know, is this something is really going to make a difference here?
So for instance, I just got consulted on a patient that had a beautiful CT angiogram, what’s called a Cleerly test, you know, very minimal plaque. She is [00:51:00] 64, 65, somewhere in there, has a mild elevation in her cholesterol, and her doctor wanted to put her on one of the injectable cholesterol medications. And just kind of looking at her advanced lipid profile with her practitioner, who’s a very conscientious practitioner, I said, “You know, I just don’t see that we’re going to get a lot here other than putting this person at risk for a ton of side effects.”
Like, I think, you know, we wanted to, we could go a more natural route. We could, you know, maybe what I had actually suggested was improve this person’s hormone regimen, get her on a little bit more estrogen and see what happens to her lipids, because the lipids are very, very, affected by hormone levels.
but, you know, if we’re going to do anything, maybe just two and a half milligrams of Rosuvastatin. Again, if, right? If we want to do something and, you know, that is outside of standard of care, and I have to put all these disclosures and sign and things. But, you know, when you put your head on correctly and you look at the, the 10,000-foot view of someone like that, you’re much more likely, and I think this happens with a lot of patients, to your point, you’re much more likely to cause ser- side [00:52:00] effects, either serious annoying, than you are to see any significant benefit.
and you know, you’d mentioned about side effects and glucose and this, that, and the other. Doctors read that that literature, I think incorrectly, right? Because what a lot of those papers say is that, and there was just one that came out a few months ago, maybe about six weeks ago, about, about Alzheimer’s and cognitive issues, what it says is that the rate of cognitive, decline or cognitive issues amongst people who are on statins is no different than people who are not on statins, right?
So top line says no difference. There’s no, there’s no change, right? But when you look a little bit more deeply at those numbers, there actually are differences in certain subpopulations that just gets washed out when you put everyone together, right? So when you look at things like stratifying people by what’s called an APOE subtype, which is a gene that is more associated with Alzheimer’s, you start to get different numbers, right?
When you start to look at [00:53:00] people who have a predec- a pre-decess- or a preceding, vascular dementia pattern, you start to see different numbers, right? what happens that I think for the most part, docs are looking at the headlines without looking at the nuances, and it’s the patients that are suffering, right?
Because, you know, I would never tell somebody, “Your back pain isn’t because of your statin drug,” because that’s what the literature says, because even placebo can cause back pain in some people, so who am I to say that this person isn’t having that? And oh, by the way, when I went on certain statins, I had a ton of back pain, and I came off, and it got better, right?
So- Y-
Dr. Weitz: you know, I’m a, I’m a chiropractor, and, Yeah … I s- I think it’s been very underestimated the extent of musculoskeletal symptoms that can arise from statins.
Dr. Bhojraj: mean, I 100% agree. And then, you know, and statins are a direct mitochondrial toxin, right? Right. I mean, they deplete the CoQ10 pool, and mitochondria becomes dysfunctional, and your electron transport chain doesn’t work.
You start to get less energy. You get [00:54:00] hypertensive. You know, so for me, I, you know, is a very important decision if I’m going to put somebody on a statin for primary prevention, again, someone who’s never had an event.
Dr. Weitz: Right.
Dr. Bhojraj: You know, the one where I struggle a little bit more and I get a little bit more conventional is on the secondary prevention.
So you’ve had bypass, you’ve had stroke, you’ve had something happen, right? There, I think the literature is a little bit more robust, certainly in terms of use of statins. But again, you have to put people on appropriate support while they’re on statins, so like CoQ10, gamma-glut- like GG or- GG, yeah … GGC it’s called.
You know, like I think also it’s important- I was just going to go there … looking membrane optimization, like mitochondrial membrane optimization with like, you know, sphingolipids you know, and all of other things become super important. So, you know, you can’t just tell somebody, “You’re making this up,” right?
I mean, that, that’s wa- Right … it makes for, pardon my French, but a really shitty therapeutic relationship- … when you tell somebody you’re making it up. But it also, you know, when they’re not feeling heard, but they’re also [00:55:00] experiencing symptoms, like just because you don’t believe something doesn’t mean it’s not real, right?
Like- Right … so, you know, I could maybe not believe in clouds, but clouds exist, right? Or I can, I can maybe believe that people didn’t go on the moon, but maybe it really happened. I don’t know. But, but you know, th- that, that dismissive nature of, of f- you know, “Well, it’s, it’s not really associated,” or, you know, “Your back pain is probably related to something else,” I think is just a bad look for doctors in general it disrupts the therapeutic relationship.
But, you know, I think again, when you, when you look at these clinical trials that are showing, you know, insulin resistance and, you know, further, cognitive decline and things like that, you know, for me, it’s like why take a chance, right? Like, particularly when you look cognition through a mitochondrial lens, you’ve got mitochondrial dysfunction, you know, you’re going to have brain function after a while, brain dysfunction- Right
after a while, right? So, so anyway, think that we have to be much more, what’s the right– aware of who is the right person for a [00:56:00] statin.
Dr. Weitz: Right.
Dr. Bhojraj: And, I mean, just so people know, for full disclosure, I have never had a heart attack. I have never had a stroke. I am on a statin because I’m South of, Southeast Asian descent, and, you know, I s- I joke around what God gave us in medical literature and good looks, he took away in cardiometabolic health.
Right? like, I know for me, a decision I made was that I put myself on one you know, I feel comfortable with it. I do support myself with other mitochondrial support and things. but again- Yeah … it’s a discussion that needs to happen with a patient. You know, now in my current practice, I’m able to spend 90 minutes on an intake with a patient, not seven minutes like I had- Right
in my conventional time. So it’s, it’s so important to have the discussion back and forth because, look, if you say, “There’s no way I’m going to ever in my life do a statin,” okay, we’ll figure something out, right? We have so many other options. If you say, “You know what? I don’t mind a statin, but I also want to be on supplementation,” even better. We’ve got a, we’ve got something that we can do for you there, right? Right.
Dr. Weitz: So I think you have to put more personalized- You can put them on Zetia. You can put them on bempedoic acid.
Dr. Bhojraj: The, yeah, I mean, like, we’ve never had so many tools. Like, again, I remember, like, when I, when I came out of training, [00:57:00] you know, options for therapy were statins or statins. Like, literally all we had. Right. And then Zetia came out, Ezetimide came out, which, you know, blocks the uptake, and now we’ve got bempedoic acid. We’ve got the PCKS9s. We’ve got the missense RNA kind of cholesterol vaccines. There’s so many other options, for people to use, it’s just… You know, I guess it’s, it’s the best time ever if you’re going to have high cholesterol. But also optimizing diet and lifestyle is what we need to do upfront and then decide whether what more we need to do to optimize cholesterol.
Dr. Weitz: I know one integrative cardiologist, and he’ll tend to use a lower dose statin and he’ll add
Dr. Bhojraj: Zetia. Yeah. Yeah, I mean, I think, you know, the, the risk of side effects is always dose responsive, so if you’re on 10 of something or 20 of something, you’re more likely to have, you know, side effects on 20 than 10. That’s just the nature of- Right … of it. You know? I mean, that’s not to say you can’t have something at 10 or 5 or something, that’s just kinda how pharmacodynamics and pharmaki- kinetics work. So I think that whatever you can do. In the lever, I try to pull the [00:58:00] most on is lifestyle and diet. I just had a patient today where, you know, he’s on, like, 20 milligrams.
He came to me on 20 milligrams of rosuvastatin. I said, “Okay, let’s put you through a diet and lifestyle program, kind of then re-check what’s going on, and then we can make adjustments. But the goal for you,” and he was a higher risk, he’s had stents and stuff, “is that, you know, maybe not getting you off the medication completely, but if we can even decrease your dose, that’s a win, right? If we can improve your insulin sensitivity, that’s a win. I’m not saying you’re going to be off of all of your medications, but if we can get your body working on its own as much as possible, that’s, that’s a win.”
Dr. Weitz: So let’s talk about diet, and let’s finish with nutritional supplements.
Dr. Bhojraj: Yeah.
Dr. Weitz: So when it comes to diet, do you recommend different diets for different patients? Do you generally like a Mediterranean diet? Do you like a– There’s specialized diets for lipids. is your take on diet?
Dr. Bhojraj: Yeah, so I think, you know, there’s not like a one-size-fits-all when it comes to diet because [00:59:00] all of our genes are different, our nutrigenomics are different. So, you know, a lot of times I’ll start with just the Mediterranean diet, which is, you know, high the, the omega three fats and very plant forward. You know, if you’re already eating meat, it’s like fish you know, well sourced, a little bit of red meat here and there. I think, you know, Mediterranean diet as it comes to w- as it comes… as it goes with diet is probably one of the most studied diet plans that show cardiovascular benefits. Right. So it’s kind of hard to veer from that.
you know, I think just the, the simple things are getting rid of processed foods. Your, your, your food should only have one ingredient. Like broccoli is made out of broccoli, right? Chicken is made out of chicken. Right? so, you know, you want dihydro, mono, whatever, you know. Right. Like you don’t want any of these preservatives in there- Right
because your body just wasn’t designed for that, right? Your body, like I kind of jokingly say we all need to go back to the 1826 diet, which is, you know, the foods that were available 200 years ago are really kind of what your body was designed to eat. So- Right … you know, as much as we can. You know, you have to be a little bit cautious, particularly at the [01:00:00] level where I’m at on like ketogenic diets.
I know that those are, you know, pretty popular, but if you have some genetic types like an APOE4 gene that can actually set your vasculature on fire and, be inflamed. For some people, it works really well. For others, it doesn’t. So, you know, like I’m, I’m kind of a very, it’s really unsexy where I’m at with diet because I’m a very middle of the road guy.
Right. In terms of integrative cardiologist, there’s one dude that says you have to be vegan to be healthy. and if you don’t, if you’re not vegan as a cardiologist, you don’t read literature is kind of what this guy famously says. Another one is like, you know, just eat animals head to toe, snout to, snout to tail-
kind of all that. I mean, I think that these extremes are not necessarily something- Right … that any human was programmed for. So I’m kind of like a 75/25, so 75% vegetables, 25%, protein. I do eat animal protein. I eat red meat. you know, like I don’t eat it like with every meal, but like two or three times a week I’ll, I’ll have, you know, like have it, and I think it’s important to have it sourced correctly. Right. Inflamed animals make inflamed meat, right? Right. So if I get something that’s like [01:01:00] grain-fed and stressed out and all that stuff, all those hormones- Right … and things kind of come down into the-
Dr. Weitz: Right …
Dr. Bhojraj: the food that we eat. So as much as you can, grass-fed, open farm, kind of all that stuff, you know-
Dr. Weitz: if for example, the cow is eating grass, it’s going to have higher omega-3 content. Yeah, exactly. And it changes the whole-
Dr. Bhojraj: It changes the milieu of what you’re taking- Yeah … into your body. So we don’t often things of, think about what we ate ate, right? But that’s an important kind of thing. and then when it comes to veggies-
Dr. Weitz: What do you think about the portfolio diet?
Dr. Bhojraj: What’s that?
Dr. Weitz: The portfolio diet. It- You know about that one?
Dr. Bhojraj: Which one’s that one?
Dr. Weitz: Oh, so it in- it includes, soy, it includes, plant sterols, it includes nuts, And, one other, I, those three I know for sure Well, but- Maybe fiber.
Dr. Bhojraj: Yeah, I mean- But yeah, I mean, again, if you look at the basis of it, it’s all getting you the, the healthy omega-3s it sounds like, right? And soy, you know, has some benefits and, you know, and, and, you know, nattokinase is fermented soy and kind of-
Dr. Weitz: And plant sterols …
Dr. Bhojraj: yeah, so I mean, [01:02:00] I think you know, whatever flavor of ice cream, you know- Nuts have
Dr. Weitz: been shown to reduce cholesterol …
Dr. Bhojraj: yeah, exactly. So, you know, so you just have to eat the right nuts, right, like walnuts pecans and things. But- Right … you know, I mean, I think they’re so, just gets so confusing, right? And ev- everyone, and I live in SoCal, it’s like everybody has their own, you know, conflict-free unicorn tear diet or whatever they’re doing, right? So it gets a little bit nutty. But, you know what I mean, I think that some of the, some of the, the essentials that you can divine from all of these is, you know, healthy vegetables, you know, eating a very plant forward, but not plant exclusive diet is kind of one of the things that I do.
Right. You know, palm size full of meat, four ounces of meat in a meal I think is plenty. you know, we’re seeing a lot more of this, you need to be slamming like 100 grams of protein or 120 grams of protein, everyone’s protein deficient. It’s kinda hard to take that in, I think, and you have to, I call it, look at the protein package.
So if you’re getting that from like, you know, White Castles or In-N-Out Burgers or fast food- … you know, that’s not going to be the most healthy kind of thing, right? So, you know, you have to just [01:03:00] integrate and use as many variant, variable plants, like, sources, like, you know, some plant sources of protein I think are fine, as well.
Dr. Weitz: By, by the way, since you brought up red meat and we have saturated fat- Yeah … and the recommendation is usually to lower saturated fat, can you explain how saturated fat- raises cholesterol levels?
Dr. Bhojraj: Well, so, you know, it’s interesting because there’s literature that shows that it actually increases your LDL, cholesterol, and I don’t know the mechanism molecularly through which that happens. But some of the more recent, data suggests that it actually increases the less atherogenic type of LDL, and this was from a review article in our own Journal of American College of Cardiology from about two years ago. So, you know, think that when we look at diet, you know, it gets confusing.
Some of the, the seminal studies that were done, like in the ’60s and ’70s- Right … you know, the data was kind of fudged a little bit and- Yeah … and, you know, and omitted things to advance the narrative that they were trying to [01:04:00] get at, right? Right. The whole answer, if you think- And this is the whole rFCEB thing about beef tallow-
steak and, you know … and all of these things. Yep. And so, you know, for me, do, do try to limit intake of saturated fat. So for instance, when I buy beef, it’s like the 93% lean or whatever you know, whatever. You know, I don’t know if it’s real or not, but the packaging sure looks important- … so kinda fall for it every time.
you know, think it’s so much more than just saturated fat. It’s the environment, right? It’s the how inflamed are you already- Right … as to how much that fat is going to lead to new inflammation, right? so, you know, I’m not saying sit here… certainly I don’t, you know, like, eat spoons full of beef tallow some might, you know, suggest-
that you do. I don’t think that’s necessarily the healthiest thing. Right. but, you know, I’m also not 100% obsessed with, oh, my gosh, we are overdoing this or overdoing that. Just something right in the middle, which again, is unsexy. Right. But I think, you know, it, ultimately, it’s so much more tactical for people than like, you know, like vegan.
I tried to be vegan. Like, watched that Forks Over Knives documentary however many years ago it came out, and I tried to vegan. Right. I lasted maybe six weeks. I was, like, [01:05:00] hangry and, like, just not a good person to be around, and then I started- Right … to eat unhealthy vegan. You know, like, anytime you’ve got vegetables in the shape of meat-
meaning, like, you know, vegetable hamburgers, like, just eat the hamburger, dude. Yeah. You know, then you look at the ingredients and it’s all chem- you know, it’s like a science experiment. I don’t think I would be very good at a ketogenic diet either, like the discipline that it takes. I’ve had one person successfully- Right
do that, and he was, like, a Navy SEAL, Army Ranger type military dude that just discipline was his superpower. So he has done keto for the better part of, I think it was, like, eight years or something. And more importantly, he had the right genetics for it, so he had the genetics where his body was able to process fats correctly, so he did it successfully.
But, you know, I, you can get as you know, uppity about your diet, and I feel like in SoCal, you know, the diet that you’re on is almost like a status symbol. It’s like the watch that you wear or the car that you drive. “Oh, I’m on the, I’m on… You, you’re not on the conflict-free kale diet?” Like, you know how much kale gets angry at each o- You know, like it’s some of the stuff that comes up with is absolutely nutty.
Dr. Weitz: But, but you [01:06:00] know, again, I think, you know, Mediterranean diet, DASH diet, plant-forward, you know, good sources of protein, bump up your omegas.
Dr. Bhojraj: Yeah. You know, it’s, it’s like tale as old as time. It’s like a, you know, it’s like a 69 vet. Who doesn’t love the 69 Corvette, right? Great. It’s timeless, right? So I think with diet, you can get to all of the specific this, that, and the other mitochondrial diet plan, this, that, and the other. But at the same time, I think that the absolutes are absolute.
Dr. Weitz: Great. Let’s go over supplements.
Dr. Bhojraj: Yeah.
Dr. Weitz: Let’s start with niacin, which, by the way, was critiqued in the American Heart Association guidelines, and I think wrongly so, because I think niacin can be very beneficial for the right patient.
Dr. Bhojraj: that’s exactly right, for the right patient, right? And again, I kind of shared with you my experience with niacin has been pretty hit or miss. I’ve had, like, two people who are, like, responded really well to it. Niacin takes a while, to take effect, so we’re talking about on the timeframe of six to, like, eight months sometimes. And so I think that, you know, in the ADHD cardiologist [01:07:00] world where you can give a statin and within, like, two weeks you’ll start to see a difference, that’s probably why niacin, you know, is not so well-used.
the clinical trials, like-
Dr. Weitz: But can’t niacin do things that statins can’t do?
Dr. Bhojraj: What’s that?
Dr. Weitz: Can’t niacin do things that statins can’t do?
Dr. Bhojraj: Well, I mean, it’s said to increase your LD or your HDL as you were talking about before, also increase particle size, of LDL. So the smaller- Right … LDL particles tend to be the more atherogenic.
Dr. Weitz: Right. The larger ones tend to be less atherogenic. So in someone who has really small LDL particles, you can use- Right … niacin to try to increase their- Yeah … HD- or their LDL size. So, you know, that is not something- And it can lower Lp(a).
Dr. Bhojraj: It can by about, like, 10 to 12%, I think, was the, was the metric that I’ve seen most recently.
Dr. Weitz: studies 30%.
Dr. Bhojraj: Okay. I mean, again, it just depends on the responder, non-responder population- Sure … and all these things, but it can do things. I, you know, think it’s certainly something that once you get past the flushing- Mm … always can happen with niacin, like, it’s relatively low [01:08:00] toxicity. I mean, you have- Right, sure … to make sure your liver’s funct- liver is functioning okay and all those things. Right. So it certainly, don’t think it’s something you shouldn’t try. You know, the problem with the guidelines though is when you look at who funds the guidelines and, you know- Right and the disclosures of the people on there, like, everyone, Pfizer, Pfizer, Pfizer, you know, whatever. Right. … Glaxo, Glaxo. So, you know, again, you gotta look at who is funding the- Right … the people that are the experts, right? Right. You know, I think niacin is worth a try. I’m a big fan of berberine in my population of patients.
Right. I think it has so many benefits. Re- resensitizes insulin. It works as a natural PCKS9 inhibitor, so it works naturally the way some of the injectable cholesterol medications do. It kind of switches m, the mTOR-AMPK kind of pathway so that you’re able to be a little bit more metabolically flexible. So I end up using a lot of that one. fish oils, a big fan of fish oil. I know that there is some concern about atrial fibrillation risk, but, you know, if you’re following, that was from, a, oh, what was the study? it was the, it was the,
Dr. Weitz: Right, so prior to that study there were a couple of studies that- Look, [01:09:00] that showed that fish oil appeared to reduce AFib- Yeah until that study came out, or reduced arrhythmia. And since then, there’s been other studies showing that it, there is no increased risk.
Dr. Bhojraj: Right. So, you know, this is how, you know, bad news travels fast and good news kind of gets orphaned, right? So-
Dr. Weitz: like to think that the only study on fish oil that’s going to be published by New England Journal of Medicine is the one that shows it’s bad.
Dr. Bhojraj: Yeah, and that was the, that was the VASCEPA trial, you know, icypenethyl. you know, and then there’s a whole other universe of was that the right oil and was that the right- Right, right … you know, there’s mineral oil- Because we have
Dr. Weitz: prescription-
Dr. Bhojraj: There’s a lot of, there’s a lot of- E- EPA- … question about that
without DHA … I’m not going to go down that rabbit hole, but- Right. But that’s a question that always comes up with fish oil. Again, I have, you know, certainly I have patients who have AFib that are on fish oil. They have a lot of other reasons for AFib. I c- I can’t really point to any one person that the only reason they had AFib is because of fish oil.
Dr. Weitz: But, but I use fish oil a lot in [01:10:00] my practice. I think it’s- And,
and you don’t have a problem with patients with AFib who are on fish oil?
Dr. Bhojraj: I mean, if they already have AFib, then it’s not, it’s not the fish oil’s fault, right? They already have AFib. Right, right. I think the, the one concern is that you can have a little bit more of a blood thinning effect with fish oil.
like when I get acupuncture and I’m taking my fish oil, you know, my acupuncturist is always like, “Hey, you’re bleeding a little bit more.” And I said, “Oh, it’s just the fish oil, no big deal.” that being said, as an interventional cardiologist, I’ve had s- people on such big blood thinners for other reasons that the relative risk of a serious event happening from fish oil I think is kind of low.
Dr. Weitz: Right. That’s not saying everybody in the history of humans it’s low, but just in my experience- Right … I haven’t really had somebody that had an untoward reaction or a bad reaction because they were on fish oil, right? They were probably on some other bigger gun anticoagulant or antiplatelet. Is it, what,
what’s your preferred dosage for f- E- EPA, DHA?
Is it two grams? Is it four grams?
Dr. Bhojraj: I mean, again, I’m seeing, as a cardiologist, people who have cardiometabolic dysfunction, so I start at four grams, Okay … you know, [01:11:00] almost exclusively. I rarely, you know, if somebody is, like, maybe a little bit more frail or a little bit older, we’ll start at two. You know, you can check an OmegaQuant and look at 6:3- Right
6 ratios and things, and then I might kind of back off a little bit. But I mean, natively, like somebody who comes to me without already being on therapy, they’re almost always flipped. Like, super high omega-6, low omega-3. So-
Dr. Weitz: Absolutely …
Dr. Bhojraj: you know, like I’ve… Again, that might just be a selection of the patients that I see, but that’s
kind of what we’re seeing. No, very, very common. People have like- Yeah … you know, 20:1- I mean, it’s 16 … 30:1. Yeah, 16, 20. 6- Like, I mean- Yeah … it’s, it’s crazy you know what people don’t realize is that’s an issue of cell membrane health. Where does- Right … where does omega go? It goes to your cell membranes, and so it makes them stiff and rigid.
And so, you know, things aren’t getting in and out of the cell the way that they should. But when you have a healthy membrane, the ion channels open and everything flows like
Dr. Weitz: it’s supposed to be flowing. And fish oil’s going to make those cell membranes more fluid.
Dr. Bhojraj: Exactly, yeah.
Dr. Weitz: What about red yeast rice?
Dr. Bhojraj: Red Yeast Rice, you know, for [01:12:00] me, kind of see it as a natural statin. I know that it has a number of other different mechanisms that it works on, and there’s a, there’s a, a gentleman the cardiovascular space, Mark Houston, who loves Red Yeast Rice.
Dr. Weitz: I know him very well. I’ve had him on the podcast many times
Dr. Bhojraj: So, oh, perfect. So Mark, I mean- Yeah … he’s a huge fan. He talks about, I think there’s like- Yeah seven or eight different mechanisms through which, Red Yeast Rice works. Yeah. For me, I’m just kind of like, you know, just if you’re going to go on Red Yeast Rice, just go on a statin. Like, it’s the same, like feel like
Dr. Weitz: There is even some data to show that combining Red Yeast Rice with a statin has benefits.
Dr. Bhojraj: Yeah. I don’t say that I’ve- I don’t think I’ve done that, to be honest with you. Right. But again, I think that’s my bias. I just- Right … you know, I’ve just never had great experience on Red Yeast Rice. And when you look at my population of people that are coming in with heart attacks and strokes, and like again, I see-
Dr. Weitz: Right
Dr. Bhojraj: kind of a sicker population of people. The standard of care is still just straight statins. Right. So, you know, if they wanted to, to add it, maybe, but you have to watch liver function closer and kind of all of these things. I just- Yeah … I get a little bit [01:13:00] nervous about, again, that’s that conventional side of me- Right coming through. Like, that’s my- Sure … kind of middle ground right here- Absolutely … is that I just get a little bit more nervous. For a primary po- prevention patient, meaning somebody- Right … who never had an event- Right … it may be reasonable. Right. You know, that’s a discussion that I can have.
Dr. Weitz: What about aged garlic?
Dr. Bhojraj: Aged garlic is great. I mean, you can almost never get into trouble with aged garlic. a lot of the, the, the arterial support and, and, glycocaolix support will have aged garlic in there. So I’m, I’m- Right … a fan. I don’t think, you know, think it’s great.
Dr. Weitz: Yeah …you know, so Are you a fan of Arterosil for glycocalyx support?
Dr. Bhojraj: What’s that?
Dr. Weitz: Are you a fan of Arterosil for glycocalyx support?
Dr. Bhojraj: Yeah, so Arterosil, Arterosil and, Glycanox or whatever their other one is, like, it’s like Shaq, Kobe, Michael- … Jordan, Scottie Pippen. I’m a Chicago guy- Right … so Glycanox and Arterosil kind of
Dr. Weitz: like Yeah, Vascanox is a formula for nitric oxide.
Dr. Bhojraj: Yeah, so don’t think you can really treat one without treating them both. Like, you need to treat nitric oxide if you’re going to treat the glycocalyx. So just kinda love those two together. Oddly, [01:14:00] I’ve had really good, a run, a really good run with that for my post-menopausal women that have that big shortness of breath. I put them on Arterosil, and almost within, like, week, a week or two, their breathing improves significantly, Oh … because as in that perimenopause state, as the estrogen drops, the glycocalyx, preferentially degrades in the pre-capillary arterial bed. I… Sorry, super nerdy. Oh, no,
Dr. Weitz: this is great. I- Yeah love this.
Dr. Bhojraj: It, it’s super cool. So I’ve, I had, you know, a few patients now who are in that perimenopause, menopause state that came with shortness of breath. You know, they go to a conventional, car- cardiologist. They get a stress test. Stress test looks okay. They may even get an angiogram because their symptoms are so bad.
with an angiogram, remember, you’re only seeing the large, like, the highways. You’re not seeing all the side roads. Right. and so they come to me. I just had a woman, like, what, like, maybe two weeks ago this happened to, and I just put her on a little Arterosil. and within, like, a week, I get an email, “Oh, my gosh, I feel so much better.”
Dr. Weitz: So- One cap twice a day? Or one cap-
Dr. Bhojraj: With her I was just doing one cap once a day, actually. So- [01:15:00] Once a day … a lower dosing her. Okay. Just kind of a toe in the water. She was kind of a slight woman, though, like, in terms of her stature, so I didn’t want to overload her out of the gates. but now she’s on one twice a day, and she, her life is, like, returned back to her. So, you know, it’s really powerful, and, I mean, I think that has aged garlic in there and just a bunch of other support. So, you know, a- as my conventional colleagues look at me and think I’m crazy, I’m like, “The proof is in the pudding.” Like, I’m making people feel better. We’re getting people off of medicines doing great again. Right. You know? So yeah, fine. I have to be crazy, I’ll be the crazy one, but I’ll be the crazy one who’s also helping people.
Dr. Weitz: What about plant sterols?
Dr. Bhojraj: You know, I don’t really use them that much. Okay. Like, I haven’t seen a lot of mix. There’s also some, there’s mixed data on plant sterols that can actually drive some people’s LDL up, higher. so, Tom Dayspring, I don’t know if you know him, but he’s a, a-
Dr. Weitz: Yeah, yeah, yeah … like O.G. He comes on Peter Attia’s podcast.
Dr. Bhojraj: Yeah, like he’s like the Snoop Dogg of lipids. I mean, that guy is just like, he- he’s O.G. in the lipid world. you know, he talked about some mechanistic things, and so I stopped using plant sterols a while ago because you can potentially get this [01:16:00] paradoxical bump in more atherogenic lipids. so I don’t tend to use those. I think the only time- Right … I would ever use them, if they’re already part of a formulation- Right … like I think, I think like Arterosil might have plant sterols in there. I don’t remember. One of the formulations that, that I used to use or that I use has that built in- Yeah and it’s such a small amount that- Right … you know, it’s not that big of a deal.
Dr. Weitz: What about citrus bergamot?
Dr. Bhojraj: Oh, bergamot, love it. You know, I- I think that it also, like I use a lot of the berberine-bergamot combos. or I’ll add bergamot on top of berberine, so do like bergamot. Again, this is for primary prevention patient whose lipids are just a little bit abnormal and you’re optimizing diet and lifestyle. Right. I think berberine-bergamot is a great combo.
Dr. Weitz: What about tocotrienols, which is a form of vitamin E?
Dr. Bhojraj: Vitamin E, yeah. So I, or vitamin A. Yeah, haven’t used a lot of that. I know that- Okay … Mark Houston is a big fan of that. Just hasn’t been part of my quiver at this point.
Dr. Weitz: Okay. And you mentioned CoQ10- Yeah which you like to put, add when patients are on statins, and do you also add the GG you mentioned? [01:17:00] I do.
Dr. Bhojraj: Yeah, there’s, you know, Designs for Health makes a really good, and Apex makes a really good, support, so I’ll, I’ll use those. I like the Apex product, a bit. I don’t know if I’m, I should name names, but,
Dr. Weitz: No, that’s fine
Dr. Bhojraj: okay. So, so I really like the Apex product. I’ve had really good results. That’s what I would personally take. What is it called? it’s like CoQ10 Max or something like that. Okay. I can find the name-
Dr. Weitz: Right … for you. Yeah, yeah, yeah. That’s what that, I think that’s it.
Dr. Bhojraj: but, but, yeah, I think that works. Yeah, CoQ10 Super Max, I think it’s called. it’s got the geranylgeraniol all that stuff in there, so that’s the one that I use.
Dr. Weitz: Yeah, I just recently interviewed Barry Tan.
Dr. Bhojraj: Oh, okay. There you go.
Dr. Weitz: Yeah.
Dr. Bhojraj: Yeah.
Dr. Weitz: He’s, he’s the, GG and tocotrienol guy. The GG.
Dr. Bhojraj: Yeah, yeah.
Dr. Weitz: you know, y- one more quick thing. You mentioned women’s health. feel like women’s heart health is not often addressed, that women don’t necessarily have the same kind of heart disease that men do.
Dr. Bhojraj: Yeah, no, 100%, and talk [01:18:00] about this a lot, is that women are horribly underserved when it comes to cardiovascular health, and it surprises me still that most people don’t realize that the number one killer of women is not cancer, but rather cardiovascular disease. Right. And menopause, I go on these menopause podcasts and, you know, I say, “You know, y- really, you know, hot flashes don’t kill you. They make you feel like you want to die.” Right. But the real danger of menopause is the cardiovascular risk- Right … because now what happens is that those protective hormones, estrogen, progesterone, that you had kind of bathing your blood vessels and making them happy now start to deter- to kind of- pull back a little bit, and now you start to get the, a same, a similar risk profile to men than in women, so you stop getting protected.
So if you look at, like, the slope of the, of the increase incidence, so it goes from this flat to a more kind of higher slope, and that tracks, like, what happens with guys at that age. So it’s almost like a masculinization of the arteries. and so, you know, for me, that menopause, perimenopause is really a call to action to optimize [01:19:00] cardiovascular health, and one of the easiest ways to do that is hormone replacement, for women. but you’re absolutely right. Symptoms are not the same, so women don’t tend to have the elephant on my chest pressure, jaw, shortness of breath, cold sweat. It can be all sorts of different things. It can just be an uneasy feeling. It can be a belly feeling. you know, a lot of times it gets misdiagnosed as anxiety, unfortunately, and so women are put on Xanax instead of, you know, told get a stress test.
I had a woman who had a chronic toothache for, like, six months. and she went to the dentist, got the tooth pulled, like, all this stuff, like, went through this horrible thing, and then finally her primary doc said, “You know, why don’t you go see,” I was a new cardiologist in town. You know, he goes, “I don’t know what it is.
Let’s just do a workup.” And as she’s telling me, she’s like, “Yeah, every time I exercise or walk up a flight of stairs, I get a toothache.” I’m like, “That is not a toothache. That’s your anginal equivalent.” We ended up taking her to the cath lab. She had a 98% mid LAD lesion that I ballooned and stented and fixed, and all of a sudden miraculously her tooth went away, her toothache went away, right?
Wow. So, you know, so I tell, you know, especially my female patients, anything from nose to pelvis basically, [01:20:00] any sort of new sensation is cardiovascular until proven otherwise, right? So I really do take that seriously. I think we really kind of underestimate that. And the literature shows that women get less stress testing, less…
They go to the cath lab less for the same type of symptoms. And the scarier thing is that for the same amount of plaque, getting back to our discussion way back when about plaque, for the same amount of plaque, women have a higher risk of rupture. So if I have a 20% plaque in my artery versus a woman who has a 20% plaque, she’s almost twice as likely to rupture that and have a heart attack than I am Right?
for women, our female patients, and we all have, you know, wonderful women in our lives, moms, spouses, partners, whatever, sisters, aunts, un- you know, aunts, whatever, you know, we have to do a better job for them, right? And keep them around longer, and that means, you know, more screening. you know, in fact, one of the most underused tools to diagnose vascular disease in women is a mammogram, believe it or not.
You can see calcium, calc- vascular calcification on a mammogram. That can indicate that there’s a higher risk of [01:21:00] calcification and atherosclerosis in the other vascular territories, Oh, interesting … you know, some… Yeah, and some states are now mandating, I think Maryland most recently just had a mandate that if radiologists see vascular calcification, they have to comment, “Vascular calcification noted in the arterial bed of the breast tissue.”
And that should trigger then some sort of further evaluation, cardiovascular evaluation. In fact, I’m involved with a startup works on that. so it’s, it’s really interesting. It’s information that you’re getting anyway for women- Yeah … that are getting mammograms, but now you can use that old tech in a new way, to prevent what really kills women, not breast cancer, but heart disease.
Dr. Weitz: That’s great. Thank you so much, Doc. How can people get a hold of you, in touch with you, work with you, et cetera?
Dr. Bhojraj: Yeah. So I’m, on socials. I’m, I’m on all the socials platforms as DrSanjayMD, so D-O-C-T-O-R-S-A-N-J-A-Y-M-D. and I do see patients. I actually just last week opened up my telehealth practice, so if you’re here in the state of California, we can do a full telehealth. If you’re outside of California, we can do an education consult [01:22:00] where there’s a couple of different nuances, guidelines, but we can be almost as useful as if you were here in Cali. so you can go to my practice website called LagunaMedicine.com. practice is called the Laguna Institute of Functional Medicine, but the website is LagunaMedicine.com.
But I would love to hear you guys… There’s so many different ways to work with me. I have a number of programs online that reduce cardiovascular risk. I have another one that helps people, reduce or, h- helps people transition off of GLP-1 meds, which we didn’t talk about too much, but I’m not a huge fan of.
Okay … and, and, I just released a breathwork course to help reset your nervous system because- Oh, cool … it’s such an important aspect. So maybe we’ll, we’ll do, like, a coupon code or something for your people, for, for the breathwork program. But it’s really remarkable just in 10 minutes a day you can completely ch- retrain your brain, to be much more calm and relaxed, and as goes your brain, the rest of your body follows.
Dr. Weitz: And you said you’re working on a book. When is your book going to be out?
Dr. Bhojraj: Well, at, so I’m writing it this summer-
Dr. Weitz: Oh, okay …
Dr. Bhojraj: so we’re hoping, for maybe a late 2026, early 2027. It’ll probably be self-published, but yeah, we’re looking at heart [01:23:00] disease in a completely new w- well, I guess in a different way. New in the sense that the papers, like I said, that I’m pulling are from, like, 10, 20 years ago, so it’s knowledge that we’ve had. It’s just not stuff that’s been popularized, and so now that we have these functional medicine tools, looking at hormones, energy, kind of all of these other aspects, really the other things that drive heart disease.
I say it’s the 70% of things that drive heart disease that aren’t the 30% of things that we think drive heart disease, right? So, it’s really kind of focusing on people as a more holistic unit, not thinking of the heart as separate from the brain, as separate from the this, but it’s all one integr- an interrelated web and, that’s what I love so much about functional medicine, is it really kind of lets you see kind of from a 10,000-foot view how all these pieces fit together and how you can really optimize someone’s health.
Dr. Weitz: That’s great. Thank you so much, Doc.
Dr. Bhojraj: Hey, it’s been a pleasure. Thanks for having me.
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 very much appreciate it if you could go to Apple Podcasts or Spotify and give us a five-star ratings and review. As you may know, I continue to accept a limited number of new patients per month for functional medicine. If you would like help overcoming a gut or other chronic health condition, and want to prevent chronic problems, and want to promote longevity, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111, and we can set you up for a consultation for functional medicine. And I will talk to everybody next week
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