Welcome. Today, we're going to talk about supplements and specifically fiber. I, by
the way, do use psyllium so I think that might help you know my position on it. I
do think there are some questions about exactly how much good it does but I
don't think there are that many questions about how much harm you can
get from psyllium and clearly not how much it costs. This is a raggedy looking
bag. Here's why I use psyllium in a smoothie that I make every day. It's a
really ugly, used to taste bad, but I've gotten used to it.
It's an unattractive smoothie, but you know it's sort of like the taste that
you hate once a day. It's got natto in it, not nattokinase. Natto, a source of
vitamin K2. It's got several other things in it. I've got a video on that, I'm not
going to get too deep into that. But what we will do is get into psyllium and
fiber. So on the right, you'll see a couple of the articles that we looked at
in terms of developing some of the summary for the science around psyllium/
fiber. One of them is a clinical trial. Long-term Cholesterol-lowering Effects
of Psyllium as an Adjunct to Diet Therapy in the Treatment of
Hypercholesterolemia. The other one is Dietary Fiber is Beneficial for the
Prevention of Cardiovascular Disease An Umbrella Review of Meta-analysis. Now
there's actually a technical term about umbrella review and meta-analysis. I'm
not going to go there. I'm just going to say basically it's a relatively good
meta-analysis that's I'm going to leave that at that point on that title. The
other thing I'll say is this. As you see, in both of these titles where at least
specifically in the first title but you get some of that in the second title as
well in the meta-analyses, these studies and a lot of the studies with psyllium
and fiber are based on an assumption that there was very prevalent 5, 10, 20
years ago but there's a lot of debate on right now.
What assumption is that? That assumption is that the higher your cholesterol, the
greater your heart attack and stroke risk. So as you know, that whole argument
is now a debate, and it gets into some further detail like, wait a minute, which
cholesterol? Total cholesterol? Remnant cholesterol? LDL? You know, I think at the
end of the day, I think very few of us are going to argue that remnant
cholesterol is a problem. Most of us would argue that HDL is a good thing to
have. A lot of people would say it's neither good nor bad.
It doesn't help. It's just a marker. We're not going to talk about that debate
today either. But the real big debate in terms of cholesterol is LDL, really a
risk factor. Just to let you know in full disclosure from my perspective what's my
position in that area. I don't think it matters nearly as much as 99% of doctors
out there. I don't completely agree though with some folks like I think it's
Nir Ali, he's a doctor cardiologist that you'll find on YouTube
where he says, no, higher LDL is better. I think that's a fairly weak case but I do
think this simple easy logic half the people having a heart attack have an LDL
that's a little bit higher than the standard recommendation. So it's outside
of normal and that doesn't make sense the other half. Here's why it doesn't
make sense because the other half have cholesterol levels LDL levels would be
considered quote totally normal, totally no risk yet they're having a heart
attack. So there's something going on and the
fact that it's almost half-and-half also indicates that the levels of LDL that we
focus on tend to not be as big a driver as most of us think. So
let me just add one other distinction in this area. There's a thing called
FH (familial hypercholesterolemia) and given what I do, you might imagine
I've got a lot of patients with that. Now these people have determinants. One
of the key diagnostic risk factors is having an LDL 180 or above, not total
cholesterol, LDL 180 above or above with or without statins. So those folks, again
just brief genetics in that space, they're about 2,000 snips (snips meaning
single nucleotide polymorphism), a lot of people think of that as the mutation.
It's not really a mutation. We're not going to get into all that either but it
is a genetic variation. There's about 2,000 genetic variations that relate to
familial hypercholesterolemia, and I can tell you when these people have LDL
levels of 200, 300, 350, 400, there does appear to be some added risk. But even
then, the sum is the key point here, most of these people even though they have
these high levels of LDL tend to not have their heart attacks until they
start getting other risk factors like smoking like most often insulin
resistance. So just to help you understand, I don't necessarily buy some
of the assumptions that go into the majority of the research around psyllium.
It's not just cholesterol. They look at other things as well like death, race, so
we'll start getting a little bit deeper into this as we get into the details. So
getting enough fiber on a low-carb diet according to some people is hard. I don't
think so. In fact, what I would suggest is that... I
have plenty of people you know this whole debate about plant-based versus
animal-based, and I have a lot of people that see me, a lot of my patients...
plant-based, vegan, you name it, and they also say, well, it's impossible to go
low-carb on a plant-based diet. No, it's not. In fact, I've gone through episodes
just to demonstrate it, and I've got a lot of patients who do it all the time
who are completely vegan but also still low-carb and even keto. So a lot of
people that are plant-based and low-carb even people who are the ultimate
plant-based is in vegan and the ultimate low-carb as in keto. So you can do that. I
know I'm maybe conflating 2 different issues. They're saying getting enough
fiber. The bottom line is you can get enough fiber on a low-carb diet. Study
number one. Eligible subjects men and women with serum LDL cholesterol
concentrations between 3.36 and 4.91... these are
obviously the rest of the world, not the US numbers... millimoles per liter.
They are randomly assigned to receive either 5 grams of psyllium or a
cellulose placebo 2 times daily for 26 weeks while continuing diet
therapy. In the results, you saw a serum total and LDL cholesterol concentrations
4.7% lower and 6.7% lower in the psyllium
group than in the placebo group after that 24- to 26-week period.
The probability of that happening is just a pure random. Chance is about
births less than one in a thousand. That's what P is, less than 0.001. That's
what that means. Other outcome measures did not differ significantly between
groups. So that is one of the key study types that you'll see when you hear
people say psyllium or fiber has been proven to decrease heart attack and
stroke risk. From my perspective, that's a that's not a huge change in total and
LDL cholesterol. It's clearly not enough change to translate into a major impact
on life expectancy. So again, that's what you tend to see. I don't put a lot of
weight on all of those studies that are in that category.
Here's study number two. A PubMed search from January 1, 1980 to January 31, 2017,
was conducted using the following search strategy fiber or glucan
psyllium or fructans and meta-analysis or systemic review. So only the
English-language Pubmed's were used. It provided quantitative statistical
analysis on cardiovascular disease, lipid concentrations, and blood concentrations.
You're seeing I'm talking about this is where they're getting into studies which
show a little bit more of an end result as opposed to just looking at LDL and
trying to assume that that's going to drive in results So the result on study
number two. All 31 meta-analyses comparing highest versus lowest dietary
fiber intake reported statistically significant reductions in the relative
risk of cardiovascular disease. Mortality relative risk was 0.7, 0.72, 0.83. In other
words, people that had higher levels of fiber in their diet were about had about
4/5 or 80 percent of the cardiovascular disease mortality rate as people that
did not have fiber. That's the information that I look at, and say, hmm,
I've heard both sides of this argument To me, it's still a little bit soft but
not that soft. That to me is enough to say, you know what, the taste I hate once
a day. Here's some other things that
they looked at as well. Coronary heart disease, again 0.76 to 0.93. You know 80 to
85 percent relative risk or disease rates there. And stroke as well. So again
that makes you think that it is having an impact on vascular health the fact
that you're seeing it with cardiovascular disease, coronary heart
disease, and stroke. Meta-analyses are on supplementation studies using beta
glucan or psyllium fibers also reported statistically significant reductions in
both total serum and low-density lipoprotein, cholesterol concentrations.
Again that last sentence where they're looking at cholesterol, again
I understand why they are. If I were doing that study, I would look at that as
well if that information were available but I'd end up the same way. I end up now
knowing or at least given the position that I have, the LDLs maybe not a major
driver, probably not a major driver. Not sure what to do with that information. So
as we know, LDL is important but not nearly as important as carbs and
cardiovascular inflammation. The greater issue here is reduced glucose absorption
and decreased insulin secretion. That's one of the things you begin to wonder. Is
that what's going on? Is fiber actually decreasing our absorption or in some
other way impacting glucose metabolism? Significant fiber in the diet is seen as
decreasing the glycemic index of food which may again be the issue decreasing
absorption, therefore, decreasing the insulin response, therefore, decreasing
the concentration of both glucose and insulin in the bloodstream.
Both of which are very inflammatory or inflammation causing it. Decreases the
swings in glucose with cardiovascular inflammation is number one cause of
heart attack and stroke Swings in blood sugar are by far the number one cause of
cardiovascular inflammation. Things begin to make a little bit more sense. There's
also a gut biome issue which may also speak to insulin resistance. And if you
don't know what that's talking about, there have been studies where you see
that in terms of fecal transplants both in lab animals and in humans where the
donor of a fecal transplant had diabetes or significant prediabetes. The receiver
of that fecal transplant will often result in prediabetes.
So in other words, there's something in our gut biome tends to drive insulin
resistance as well.
Continue to get great feedback regarding the webinars, and here's what. You know on
the Internet, when you hear a webinar, you expect for
somebody to try to sell you something. We're not doing that. We're trying to
tell you something. People are coming in with their labs from Quest - inflammation
panel, OGTT, insulin survey response - and then they're finding out,
do I have inflammation? So I have insulin resistance? And where does that fit
in terms of other folks? We're getting ready to start one for CIMT as well. So
again, people are really excited about finding out their own status. Looking
forward to seeing you there. Thanks.