hey guys, this is part two with Dr Ethan Weiss, cardiologist and professor of medicine at UCSF and
someone who's been on a low carb diet for almost five years. so we're going to quickly recap what
we talked about last week, the conclusions on cholesterol, saturated fat and low carb diets,
because a lot of you guys asked for a quick summary, and then we'll look at what Ethan
eats on a regular basis, which is a really interesting example of someone on a low carb diet
who is also a heart health professional. so in our conversation last week, a common theme in Ethan's
answers was ApoB, which for people who are new to this, fats like cholesterol and triglycerides
travel around in our bloodstream, in our plasma, inside these tiny cargo ships called lipoproteins,
and some of those can cause problems if there are too many of them, they lodge themselves into the
artery wall and that's what we call plaque. so ApoB is a blood test that gives us a count of
the number of those problematic lipoproteins. so for example, I asked Ethan about this idea
that high cholesterol is okay as long as it's in the background of a low carb diet, and his answer
was essentially that he goes by apoB, because multiple lines of evidence have consistently
tied it to cardiovascular disease, robustly, in randomized controlled trials, genetics,
Etc, in every context that's been tested to date. if an exception pops up one day, it would need to
be demonstrated, and until it is, he basically treats any elevation of ApoB the exact same
regardless of which diet the patient happens to be on. very similar for this other idea that high
cholesterol is okay as long as HDL-cholesterol is also high and triglycerides are low,
I asked Ethan about that, his answer was also that he boils it down to what's your ApoB. he also said
that HDL-cholesterol is a pretty good marker of risk populationally but probably not a mediator,
probably not a cause of risk, so there's no point trying to change it directly. now, a lot of
viewers asked, how can that be? how can something be a marker and not cause disease directly?
the best example I can give you is carrying around a lighter in your pocket, it's probably a decent
population marker of lung cancer, people who carry a lighter in their pocket everywhere
probably have a higher risk of lung cancer than people who don't but carrying around the lighter
itself doesn't cause cancer, right? similar with HDL-cholesterol, it can reflect a number of risk
factors but changing HDL-cholesterol directly doesn't seem to provide any benefit. as for
triglycerides, they also appear to be mainly a reflection of the lipoproteins that carry them,
which are a subset of the ApoB-carrying lipoproteins, so Ethan said the simplest
way to think about it all is what's your ApoB? now, interestingly a brand new trial that just
came out today looked at thousands of patients who had their triglycerides lowered with a drug
called a fibrate and lowering triglycerides by about 25 to 30 percent without changing ApoB,
the total number of problem lipoproteins, of those cargo ships, didn't have a significant effect
on the risk of cardiovascular disease, so this adds to the picture that targeting triglycerides
directly, trying to get that metric lower or better, may not help much for heart disease,
the goal is to actually get the lipoproteins themselves, the apob, that key number,
in the healthy range. Ethan had an identical answer when I asked him about saturated fat,
the intake of saturated fat and whether a high intake is a problem on a low carb diet, Ethan´s
take was that saturated fat has been demonstrated to raise ApoB so he basically looks at ApoB, if
it looks really good, and he gave the example of 60 milligrams per deciliter as a reference range,
then he's not as worried if the patient is eating a bit more saturated fat, but if ApoB is high then
he does recommend moderating it. we also talked about the calcium score, the calcium scans,
and Ethan said that the score rises later in life, it's kind of a late marker of disease,
for that reason having a calcium score of zero early in life, at a young age, say 30 or 40,
doesn't tell us much, because that's kind of the norm at that age. on the other hand, for
somebody older, say maybe 60 or older, then that is meaningful if they have a calcium score of zero
because it does suggest good news, either the person has low susceptibility to the disease
or maybe they weren't exposed to the risk factor, either way they seem to be doing pretty well for
their age. on the other hand, for a younger person who has a high calcium score, that's a concern
because it's unusual. and by the same token, a calcium scan is not a very good test of whether
my cholesterol levels, especially if I've only had high cholesterol for a few years, of whether
that's causing plaque to grow in my arteries or not because calcification shows up later, it's a
marker of an advanced stage of the disease. and we also touched on statins briefly and how they can
raise the calcium score at the same time as they lower risk, they lower heart attacks and strokes,
so a lot of viewers asked about that, and statins have a plaque stabilization effect
and the calcification may be part of that, maybe part of that repair or stabilization process. we
have a whole video all on the calcium scan coming up soon, it's in the works so stay tuned for that.
and finally we talked about this idea that ApoB lipoproteins in and of themselves are harmless,
it's only if they are oxidized and circulating in this oxidized form that it's a problem,
and Ethan's answer was that he thinks trying to measure the concentration of oxidized
lipoproteins in the plasma, in circulation, and trying to change that metric is a distraction
because the best tests to date have not shown a benefit for cardiovascular risk,
plus if we keep ApoB in the healthy range, the total number of those problematic lipoproteins
in the healthy range, their concentration is lower and they're less likely to get oxidized anyway.
Future data may change that of course, that's always the case, but right now that's what
the strongest data indicates. so that was last week's video, let me know if that summary helps,
don't worry if everything is not a hundred percent clear in your mind, let me know if you have other
questions below but these are very frequently asked questions so all of this is going to come
up again in the future for sure. now, let's look at the second part of our conversation
where I asked Ethan what he eats, and he shared it with us, bear in mind this isn't medical advice,
it's not imposing on you what you have to do, it's just an example of how someone does it
what I'm eating is like a ton, a ton, a ton of vegetables and a ton of fish, I probably have
12 or 13 servings of salmon a week, and I yeah I probably should have my mercury tested. I was
gonna ask exactly that. I try to get, I try to to make sure that there's reasonable mercury testing
in what I'm eating and I try not to eat a lot of tuna or other sort of bottom-dwelling fish
that would probably have a lot more mercury in them. yeah tell me more about the the details of,
on one side what you eat, and then the diet that you recommend. you talk with your patients about
how to eat and you give dietary advice as well? on low carb diets? I give very scant dietary advice
to my patients, for a while I felt uncomfortable doing it because I had this conflict because I
had this company and I really just didn't want to be selling my own stuff to them, I want them
to be confident and comfortable that I'm giving them the best advice independent of what might be
better for me financially, but even now that I'm not really as involved with that company I still,
I give kind of high level advice where I will say that I think if you got a bunch of these
diet tribalists in the same room, that you might find like three or four things that they could
agree on, and that those are the things that I would sort of emphasize to them, so
those would be the obvious stuff, like avoiding highly processed foods, like if you take a bag of
Doritos that´s sitting in the kitchen across from my desk here at work and look at what's in it,
I don't recognize 90% of the ingredients, and you also understand that that bag of
Doritos was engineered to be incredibly tasty and addictive, and it's also the kind of thing, if I
came back here in 25 years and opened that bag of Doritos it would probably still taste good which
is kind of, just defies logic to some extent, so it's probably not too controversial that
highly ultraprocessed foods are probably things to avoid. does it mean never? no, nothing is never,
that's an absurd concept. so that one. I think avoiding a lot of added sugar, I don't eat any
added sugar, but avoiding added sugar is probably a reasonable thing. again, if it's a birthday
party you want to go out and have a piece of birthday cake, I love a piece of birthday cake,
but I think we add a lot of sugar to our food and it's probably unnecessary, I think sugar sweetened
beverages are a complete and total waste, I think it was Malcolm Gladwell that talks about
consuming five different liquids or four different liquids: coffee, tea, water and wine. for me,
I'll have an occasional tequila, so that's it, I don't really have the need for anything else.
occasionally I'll have a flavored water but that's kind of it. and then the last thing is, and this
is something I do talk about with my patients, I think there's probably good evidence, and this
probably speaks to all of this stuff, particularly the processed food part, that the more meals that
you make yourself at home or that somebody who lives with you makes versus the number of meals
that you're either ordering or going out and buying somewhere, at a restaurant or a fast
food or whatever it is, I think that probably has a bigger impact on health than almost anything.
so I think if you can find, and it's not easy, although it's not nearly as hard as people think,
to be able to make your own meals, I've been making... one of the biggest changes I made
in my life when I started doing low carb was that I started making and bringing a
salad to work every day in this stupid little container, because I still have
the same one and I fill this thing up with a bunch of vegetables and some nuts and some salmon or
whatever leftover protein I have from the night before, and I've been doing that and it takes me
about six minutes in the morning to do it, it's really not a huge deal and what it means is I'm
not going out to a food truck or ordering from ubereats or eating some crap here in the kitchen
and I do think that's had a meaningful impact on my my health. I couldn't agree more. vegetables,
do you avoid starchy vegetables? I would imagine it's low on that and more maybe the greens?
I don't eat them routinely like I would eat non-starchy vegetables but my position on them has
changed a lot, like I said, I ate sweet potatoes last night, I had them again for breakfast, lunch,
I just threw in my salad because it looked like it'd be fun to throw them in there, so I don't
avoid them completely but I definitely, it's not a regular thing for me, mostly non-starchy.
what what are some some vegetables that you might have on a typical day? my typical vegetables are
celery, cucumber, some greens, mostly arugula, anything that's around, if I can find it, but
those are the sort of typical ones that I'll put in a salad every day. we will roast cauliflower,
broccoli almost every night, asparagus, those are the regulars. that makes sense, and what about
oil, what are your thoughts on oil? I use two oils, I use olive oil for salads and for dressings
and for things that require taste and I use avocado oil for cooking, and that's kind of it,
and I use it abundantly, I don't have any concern over having more of it, in fact it's probably
where I get a big big chunk of my daily intake of dietary fat, I think olive oil is nirvana,
it's perfect, I think it's an incredibly healthy food, probably as much evidence for the health
benefits of olive oil as there is for almost any other food or food-like thing that we have
in nutrition science. and so I yeah I think olive oil is the best. you mentioned nuts, you mentioned
fatty fish, avocados and things like that? olives? avocado every day. olives pretty much
every day in my salad. okay, that makes sense. yeah, half an avocado in my salad every day.
and what's your stance on the more concentrated saturated fat sources like butter, fatty meats,
coconut oil, palm oil, things like that? I don't ever use coconut oil or palm oil, just because,
again, for cooking at high heat I use avocado oil, I'll occasionally, if I'm making an
omelette or something, and by the way, I eat eggs, I don't eat a ton of eggs but I eat eggs,
but if I'm making an omelette, for flavor I might throw a little teaspoon, tablespoon of butter,
I don't completely avoid it but I hardly ever use it, and obviously if a recipe called for it,
I would use it, but not that many recipes do. so it's not a staple but it's something that
you don't avoid religiously. yeah, no. got it. what about salt? so for salt I use the same logic
that I use for apob and food, and that is that if you can eat a lot of salt and it doesn't have an
impact on your blood pressure, then no problem. so I happen to be one of those lucky people, I have
low blood pressure and I'm not eating 10 grams of salt a day, but I'm probably having three to five
of salt? that's pretty low. it's probably pretty low isn't it? yeah it´s about half
sodium so that would be 1.5 to 2.5, that's like under the recommendations, that's like the safe
range. then maybe I´m not having as much. I don't have any salt in the morning, my breakfast is the
same every day, I have this plant-based yogurt that I really really like and then I throw berries
in there and avocado, sorry walnuts, and some sunflower seeds, it's super boring, I have the
same exact, and a cup of coffee. so I don't have any... I don't think there's much sodium in the
yogurt, there might be a little bit, but I don't have a lot, and then for lunch I salt my salad and
then whatever I'm making for dinner I salt it generously. so that's Ethan's example, that's
what he does, now for people who may be worried about the heavy metal contamination, the pcbs,
Ethan brought up the issue himself but we have a whole video going over that in some detail, going
over the evidence, going over the safe ranges and all that. also, I realize some of these Foods may
not be the cheapest, it´s just an example, we can take the logic and play around with it,
there's plenty of room for flexibility. so those are some practical examples of how to do a low
carb diet while at the same time minding our heart health. a lot of you guys ask if low carb diets
automatically mean high cholesterol? are we forced to choose between being diabetic and having high
ApoB? of course not. this isn't Sophie's Choice. most of us can have it all at the same time.
as long as there isn't some genetic limitation underlying, right?
a healthy lifestyle should optimize every aspect of Health, that should be the expectation.
we don't have to settle with our health. all right? take care, I'll see you next week