Barton Health Wellness Lecture: Supplements & Cardiovascular Disease

Barton Health Wellness Lecture: Supplements & Cardiovascular Disease


– Everyone can hear me okay? Everyone at the back can hear me? Okay. Well, I’m truly honored to
have all of you here tonight. I’ve been doing this for a few years, this is the most people I’ve ever seen so hopefully you will enjoy this topic. I knew it was something when they asked me to give a lecture every year. I tried to think of one, not
only in myself as a doctor, but as a person and a
human and things that I would want to know, so here we go. So I chose to talk about supplements and cardiovascular disease. I think every one of us at some time has taken some over-the-counter
supplement medication and it turns out that
about 2/3 of Americans take a supplement and it’s
a huge amount of dollars so there’s almost a $122 billion a year that is wrapped up in
the supplement industry which makes almost 1% of
our gross domestic product. On top of that, the
supplement industry comes up with about 750,000 jobs a year. One of the things that I always
think about in my practice when people ask me about supplements is how are they regulated? I mean we know that
there is a very specific and stringent process with
the FDA for pharmaceuticals but some of my concerns when I tell people to take supplements is how do you know you’re getting a pure supplement? And so I went back and researched
what are the regulations and it turns out until about
1994 there really weren’t any. So you could market anything you want as a dietary supplement and
there was no FDA oversight. And then about 1994, they
started to realize maybe that’s not such a good idea
and there was a lot of lobbying in Congress because you can
see the number of dollars that are associated with this industry and eventually what they
came up was what’s called this Dietary Supplement
Health and Education Act which was signed by President Clinton. And that basically said
that if you had a supplement that you marketed before
1994, you’re good, you can keep marketing
it, there’s no oversight that needs to happen. But anything new that comes forward after that date, you have to write a letter to the FDA explaining why you think it’s safe and giving them a
rationale for why it’s safe and then you can go ahead and market it. But this is not the same
process that pharmaceuticals go through in terms of ensuring that the product is pure
and not contaminated. So some oversight but no where strict as near the pharmaceuticals. So I started thinking about my practice when patients come in to see me, what supplements do they bring in? And these are the ones that I get. I get vitamin D a lot
because that’s a common thing especially up here in
Tahoe, we go through periods of time where you don’t
have as much sun exposure. I get the fish oils,
the omega-3 fatty acids, calcium particularly in the older patients who are taking calcium for
prevention of fractures, they are always concerned
about the heart risk with that and then I get CoQ10 and red yeast rice. And those were the big ones that I wanted to focus on tonight and if any of you have any other particular ones you
want to ask me afterwards, I’ll try and do my best to
answer those questions as well. So let’s talk about vitamin D. The vitamin D is a fat-soluble vitamin so there’s A, D, E and K which
are fat soluble vitamins. And the term vitamin is
somewhat of a misnomer because you make vitamin D,
you make it from your skin and a lot of people think vitamin D it should be more of a
prohormone meaning that it’s a hormone in your body,
it’s not as much a vitamin. You can get vitamin D from intake, so there are some natural
foods that contain vitamin D, but there’s not a whole lot. Sometimes fatty fish,
particularly if you’re into the flesh of a fatty fish,
and then beef liver, cheese, egg yolks have a form of vitamin D that you can naturally intake. But most of the vitamin D in our diet is from fortified foods
and actually this is when they started
fortifying milk which helped to cure people of rickets
disease many years ago. You want about 400 to 800
international units a day of vitamin D, those are
the recommendations. But you can get vitamin D from sunlight. So most people get the
vitamin D that they need by synthesis of it in your body. You get it from ultraviolet
light, ultraviolet B in a certain wavelength. You’re supposed to spend very
specific five to 30 minutes between 10:00 a.m. and
3:00 p.m. twice a week and face arms legs or backs
and you don’t want to have sunscreen on that area to
allow the UVB radiation to synthesize the vitamin D. Now of course that’s going to be affected by a number of things; what
season you’re in particularly obviously when are you
going to have less exposure at the time of the day,
the length of days, cloud cover, smog, the
darker skin pigment, sunscreen use, etc. Anything that blocks the
UV radiation to your skin will reduce the level of
synthesis in your body. Although we’re advocating UVB radiation for synthesis of vitamin D,
you also have to balance that against the risk of skin cancers from excessive UV radiation. So here’s the vitamin D. Alright just to go over everything, so 7-Dehydrocholesterol is this cholesterol molecule in your skin that was sunlight gets converted to D3, can also get it from the
egg yolks, the fatty fish, you can get it from fortified foods. But the vitamin D that
you take in is inactive, it’s not ready to go, it has
to go through a series of… Oops sorry! Series of steps in your body,
so the first is in the liver and it gets what we call
hydroxylated which makes 25 hydroxy vitamin D, that’s
what we test for in your blood. When you get your blood
vitamin D tested and this one we use that because it’s pretty stable. Now you can’t overdo it with
vitamin D so from sun exposure, at some point this
process sort of plateaus but you can overdo it
from intake of vitamin D. That one is not as regulated
as closely by the body. So from this 25 hydroxy vitamin D goes through another step in the kidneys where it becomes the active vitamin D that circulates its effect in the body. Well what does vitamin D do? Well, we know that it’s
important for bones so you take the vitamin
D and its main function is that it causes you to
absorb calcium and phosphorus which are responsible for forming bone and also magnesium and zinc. If you’re deficient in
vitamin D, you get rickets and that was nearly a century ago, no one sees rickets anymore
except in third-world countries because we know that
vitamin D is important. But you see get older and
you get your vitamin D levels get deficient, then your body
starts to chew up the bone and to maintain adequate calcium levels and you can get osteomalacia
which is soft bone which can lead to fractures. Now what about the heart? Well, it’s not as clearly
defined what vitamin D does as we know for bone but
here’s what they think, they think that vitamin D is
responsible for blood pressure so there’s a intricate system in your body which we call the renin-angiotensin system and what it does is it
controls how much salt and fluid you absorb back in
to expand your blood stream and how constricted or tight
your blood vessels are. And when you’re deficient in vitamin D that system is not regulated
and it causes you to get too much fluid in your body
and constricted blood vessels to raise the blood pressure. So maybe there’s a
correlation with hypertension or high blood pressure. We also know that vitamin D
has a lot of these receptors on the inside of your arteries
so maybe it helps control the constriction and
dilatation of the arteries on what we call endothelial or inner lining of an artery layer. When you’re low in vitamin
D, then you get low in calcium and then we
know we need calcium to make your heart muscle contract so maybe the heart
doesn’t squeeze as well. When you’re low in vitamin
D and low in calcium you get release of a hormone
called parathyroid hormone and those of you that see
Dr. Cotrell for your bones will know a lot about
the parathyroid hormone. But parathyroid hormone causes
your heart muscle to thicken so if you have high
parathyroid hormone levels, your heart muscle gets
thick which is dangerous, you don’t want that. And then there’s also some
thoughts that maybe vitamin D helps with your body’s
management of glucose, maybe it helps insulin
secretion, maybe it helps your body process the
insulin that you have. So what’s a normal vitamin D? Well, this is not as clearly
defined as you would think. I mean one society versus
another has varying opinions of where your vitamin D should be. It turns out that anything less than 20 is considered deficient and
we know that you probably need something greater
than 20 on your blood test just to maintain adequate bone health. The desirable range is probably
somewhere between 20 and 50 but if you get over 50, some people think maybe that’s too high. Your labs usually when
you get your blood test if you’ve gone to see your primary and they’ve measured your vitamin D, they usually use 30 as
a cut-off and that seems to be sort of universally accepted. Some people think that’s too high but 30 is what we tend to report. So if you’re less than 30,
you’re considered insufficient. If you’re less than 20,
you’re deficient but 40 to 50% of adults if you use that
cutoff are either going to be insufficient or
deficient in vitamin D. So why do you care about
vitamin D in your heart? Well, they began to
figure out many years ago, almost a decade ago that people
who had vitamin D deficiency were clearly at an increased
risk of heart disease. So what I’ve shown here, not to bore you with too many statistics,
but I think it’s the best way to demonstrate it are Kaplan-Meier curve. So we use these in cardiology a lot to demonstrate time to an event. So on the y-axis here,
you have probability of cardiovascular disease
and on the x-axis, you have time which is in years. So if you look at two patient populations, the solid line are those
who had normal vitamin D and the dashed line here are people who are deficient in vitamin D. You can start to see over time that there becomes a higher probability
of cardiovascular disease whether that’s heart
attack, stroke or death. What was most striking
and it kind of goes back to what we were talking
about, maybe vitamin D is involved with hypertension is that if you look at the subset of
patients who had hypertension along with deficient vitamin D levels, a strikingly increased risk of probability of cardiovascular disease. These are what we call risk ratios. So what’s happened is now that
we’ve had sort of a decade of looking at this as there’s
been study after study that have looked at it
and then someone does what’s called a
meta-analysis where they read all the studies and
analyze all the statistics and produce you one graph which shows you the summary of all the individual studies. So you basically have a middle bar here and on this side you would say, you are at lower risk of
heart disease and on this side of it you would be at higher
risk for heart disease. So these bars represent
the median of that study and these lines represent the variance. And what I want you to
see from this is that if you look at all of
the cumulative studies that show risk of heart attack,
stroke, cardiovascular death with deficient vitamin D, they all lie on this side of the curve showing an increased risk
of cardiovascular disease with vitamin D deficiency. Here was something else
interesting I found. So this graph shows you
your risk versus value so you kind of like to
know well if it’s low and it may be I’m over 40, I’m okay, maybe I’m less than 30 I’m not. And what we can see is
that as you get lower particularly in that 20 and lower that that curve starts to expands,
your risk is going up. But you get somewhere out
in this range above 30 or so and it starts to plateau. Unfortunately, we don’t
have as many data points in the higher vitamin D levels
to give you the information like we do at MNT levels. So the big thing people
want to know is like okay, I get it, I’m low in vitamin
D, I have an increased risk for cardiovascular disease,
give me the vitamin D supplement I want that to go away,
but it’s not the case. And what we know clearly is there’s this inverse relationship so the lower your vitamin D levels are,
the higher is your risk of cardiovascular disease and
that is also probably true for hypertension it looks like. If you’re less than 15,
you’re at the highest risk. 1.52 times as likely to
have cardiovascular disease but low levels of vitamin D as opposed to those in the normal range. And I have to tell you
there’s a lot of people that say well those people
are deficient in vitamin D because they’re not out exercising, they’re not out in the sun,
they’re not out and active. So there’s concern on that front as maybe the low levels of vitamin D
is sort of an epiphenomenon. So how do we figure this out? Well it turns out it’s hard
because most of these vitamin D analysis that we get from
evolved inbound studies so people have gotten
calcium and vitamin D and the primary outcomes of these studies were looking at fractures
and these weren’t sort of pre-specified cardiovascular endpoints. We’re sort of polling data out of it and trying to determine
whether that applies. So here’s what we know. You can take vitamin
D, but it doesn’t seem to lower your blood pressure,
it doesn’t really seem to affect your cholesterol,
maybe it reduces your risk of heart failure? There’s no reduced risk of heart attack, it doesn’t reduce your risk
of stroke, and there’s no reduction in overall
cardiovascular mortality. So even though I can
tell you your level is 15 and you’re deficient
and that’s a higher risk of cardiovascular disease,
supplementing your vitamin D from a cardiovascular
standpoint doesn’t seem to mitigate that risk. Please don’t stop your vitamin
Ds because your primaries will yell at me because
of calcium in your bone but that is the data as
we have it as of 2017 as is vitamin D supplementation official from a cardiovascular standpoint? Of course, we always like to have trials that are purposely designed
to assess a question and that’s the main focus of it and the best one that I
can see that is going on is called the vital, so
vitamin D and Omega-3 trial. It is 25,000 healthy middle-aged adults which is what most people
are that are taking this. They’re going to get
2,000 international units of vitamin D daily with and
without omega-3 fatty acids and we’re going to look
what’s the incidence of cardiovascular disease,
stroke, & cancer over five years and we should have that data in 2018. So there should be an upcoming update with a randomized
controlled prospective trial which truly will answer the question. So that’s vitamin D. Let’s move on to fish oils. So fish oils are these omega fatty acids. These are what we call the
polyunsaturated fatty acids. For those of you get… I always get confused; saturated, monounsaturated,
polyunsaturated. So basically when we’re
talking about the saturation it has to do with the molecular
structure of the fatty acid. So you have all these carbon atoms on here and then usually these
carbon atoms have a hydrogen and if all the carbons have
hydrogens, it’s saturated but you can see here this line
is what we call a double bond between the carbons are
attached to each other twice. And these double bonds when
there’s multiple of them, make it polyunsaturated
and we give the three because you go one two three carbons in, that’s the first double bond
you always start at this end. So that’s an omega-3 fatty acids. Of course there’s omega-6 you go into one two, three, four, five, six carbons and you get the double bond. So that’s how we define them. These are the good fats, the
ones you get from the avocado, the salmon; the good
fats they tell you to get are these poly unsaturated fatty acids. Well most of the ones that
I deal with are the Omega-3. This is the fish oils,
this is the flaxseed oil that people are taking. So you get three types that we use, there’s alpha linoleic acid,
ALA, that’s in walnuts or the flaxseed oil. There’s EPA and DHA, those are the marine-based
ones from all kinds of sources. Phytoplankton, algae, fish: the salmon, the herring,
mackerel, anchovies, and sardines … a great selection there. At least one of them is
edible…and krill oil is the other. (audience laughing) So, if you look at all the
supplements that are used in the United States, fish oils are by far and away the most common. Alright, so you look at a
lot of common glucosamine, melatonin, CoQ10, echinacea,
ginseng, whatever, fish oils are by far and
away the most commonly used. So what are the benefits? Well, you guys can look on Google yourself and you pull up a fish oil supplement and there’s a laundry list
of things that they say they can do for you. And I don’t know that I’m the expert to say each one of those is true or not, I can only tell you from a
cardiovascular standpoint what I believe is true. Well, certainly, we know they’re involved in brain development and
essential brain function that’s why a lot of
formulas fortified with it and people take supplements
when they’re children and their brains are
growing, I’m hoping it helps. But look, reduce waist circumference, eye health, inflammation, healthy skin, may reduce liver fat,
reduce anxiety/depression, hyperactivity disorder, may
reduce the risk of Alzheimer’s, asthma allergies, bone health. I mean there are a number
of things that are marketed that fish oils will do to help you. Well, what about your heart? In 2002, kind of when
fish oils were becoming a much more prevalent supplement, the American Heart Association
put out a statement, and they tend to do this
periodically over time. And they put people
into three populations; so if you had no documented
coronary heart disease, they would say it’s probably a good idea to eat fish twice a week. So that’s where the incorporation of fish into your diet particularly the the salmon and the others became prevalent. If you have heart disease,
so you’ve had a heart attack, they want you to get about
a gram a day of the EPA and DHA and preferably from oily fish but if you can’t do the oily fish, then the supplements were probably okay but you should check with your doctor. For a specific type of
cholesterol abnormality called triglycerides, those
are the fat in your body, some people have very high triglycerides and the fish oils can be very
effective in reducing those. In fact, there’s a prescription fish oil called Lovaza that we
tend to use for people that have very high triglycerides. So even then we knew that and that was recommended at that time. So how do fish oils help? Well, sometimes they
think their antiarrhythmic so someone has a heart attack
and they can have a scar in their heart which can
produce lethal heart rhythms, they think that the fish
oils can help stabilize the membranes of those
damaged cardiac cells and reduce their risk of having some type of a rhythmic genic
death like cardiovascular or cardiac arrest. Maybe they figure blood a little bit because a heart attack is a blood clot that occurs in your artery
and maybe there’s sort of weak blood thinners
that can help prevent that. We know they lower triglycerides,
so that’s a good thing because having high
triglycerides is associated with increased risk of
cardiovascular death. Maybe they prevent the plaques
from growing in your body so cholesterol deposits in
your artery and forms a plaque, maybe they help reduce them. Maybe they’re anti-inflammatory. There’s a molecule called
nitric oxide which is released in your blood cells so your
arteries’ cells are not just, they’re living organisms
and they produce hormones that cause them to expand and nitric oxide causes the arteries to dilate,
maybe it helps with that. And maybe the fish oils can lower your blood pressure a little bit. These are all the postulated mechanisms of why they may help these patients who have cardiovascular disease. Well a decade and more
goes by and it’s time for another scientific statement because fish oils become
more and more prevalent. And this is again from the
American Heart Association. Here’s our primary prevention
group, so these are people that have no prior heart attack. Use of omega-3 supplements
in the general population without coronary heart disease. There’s really no trials,
there’s no data to pull from. I don’t have prospective trials that’s why we’re waiting
for that vital trial. There’s no information,
there’s no hard science, evidence-based science for
me to tell you about that. So we can’t make a recommendation. Probably isn’t going to hurt you, but I don’t have any evidence to tell you that it’s
beneficial at this time. What about patients that are at high-risk? So you’ve got, you’ve had a stroke, maybe you’ve got problems in your legs, you got peripheral vascular disease, you got diabetes, you
got high cholesterol. Is taking fish oils good for me? Well, it turns out there
were four clinical trials and there were mixed results. Three of them said there was a benefit, no benefit, excuse me, one of them said there was a slight benefit. In cardiology, we kind of give things levels of evidence recommendations
so class one would be overwhelming evidence to
do it, it’s good for you. Class two would be yeah sometimes there’s evidence, sometimes not. In class three would be no, don’t do it. And within each class, we
kind of do an A or a B. So A would be higher end,
B would be lower end. So this sort of falls if you’re high-risk into the 2B like maybe
there’s some evidence but it’s not really strong, that doesn’t look like it’s
supposed to help you at all. Now what about the high-risk patients? What about the ones that we knew in 2002 that we think it would benefit? Well, it sort of stayed the same. There’s been five trials
that have completed because this is a much higher
patient risk population, not a high level though, only
a thousand milligrams a day. Most people tend to take
a higher dose of that. Maybe it reduces the coronary
heart disease death risk, that’s the big benefit and
that’s what we saw in 2002, those were the patient
population we were targeting. And again, they think
it’s probably related to a reduced risk of
death from what we call ischemic heart descent, so a heart attack in a
rhythmic genic episode. Doesn’t reduce the risk of recurrent heart attack in these patients. We do think that the
benefit of the fish oils tend to outweigh the risk,
so we’re going to give that a class 2A. That means there’s some
good evidence and most of us are in agreement that if you have had coronary heart disease
before, that this should may be beneficial for you. One of the things that’s
really interesting as I started going through this data, is as you look at the older
trials, the ones that were done 10 years ago and the
benefit is overwhelming, it’s much higher than
the ones we’re seeing in the recent trials. And how can that be? And we think it’s because
we’re better at it now, so we’re better at telling
people what to eat. So we tell people you would intake things like the Mediterranean diet and make sure you’re shifting away from
trans-fats and saturated fats and into the polyunsaturated fatty acids because those are beneficial. We’re better at treating heart disease now than we were 10, 15 years ago. So people when they have a heart attack, we put a stent in which
were which mitigates the heart damage that we used to get. And we also have better
medications so we have people on statins to control their
cholesterol, beta blockers to lower their blood
pressure, aspirin to help reduce the heart attack
risk and ACE inhibitors, another type of blood pressure medication. So our medical therapy is better. So maybe the benefits are still the same, we’re just not seeing
the same risk reduction as we used to because
we’re better at taking care of heart patients than we used to before and telling you more about your lifestyle than we used to be able to 15 years ago. Let me go back here. A couple things I just
wanted to mention real quick. So here were a couple other
interesting data points, there’s no benefit in secondary prevention so if you’ve had a stroke
doesn’t help you get another, prevent you from having another stroke. And we also have Atrial
fibrillation, a very common irregular heart rhythm.
People always ask me well, if it’s helps with arrhythmias
maybe it will help me from getting an AFib episode
and it doesn’t appear that there’s a lot of
data to support that. One outlying factor was
people that have heart failure with what we call reduced
ejection fractions. The ejection fraction
is how much of the blood is pumped out with each
heartbeat and when you have heart damage or a heart attack, it lowers because you’ve lost some
of the heart function and we call that heart failure with reduced ejection fraction. And maybe it’s people taking
fish oils in that population, it can help reduce your
risk of hospitalizations from congestive heart failure. There was one study that
showed about an 8% benefit, but that was the only one. Alright calcium, so calcium
is obviously essential for maintaining bone health. You go to your primary
care as you get older, they want you to take 800, 1600
milligrams a day of calcium plus vitamin D for your bones. Whether or not that
helps prevent a fracture is a whole other lecture that I’ll defer to them, but commonly used. And calcium does all kinds
of things in your body, contraction of the blood vessels, relaxation of the blood
vessels, function of muscles, functions of nerve
transmission, hormone secretion. There’s all kinds of roles
for calcium in the body. But 50% of older men, 70% of older women are using calcium supplements
for prevention of fracture and I get a lot of people
that come in and say well, geez you know I read on the
news, like, I see that people who take calcium maybe at
higher risk of heart disease and I’m taking this calcium,
is this safe for me to take? So let’s take a look at it. Here’s more of your
favorite statistical curves, but I think they’re important to see. So this is from the
British Medical Journal and this was the effect of
calcium supplements on risk of myocardial infarction which we call heart attack cardiovascular events. Again, this is cumulative
risk of heart disease and this is time so the
people in red get the placebo which is kind of the sugar
pill and the people in blue get the calcium and
everyone can see right here so risk of myocardial infarction
– heart attack – is higher in the patients who are taking calcium. And the risk ratio of 1.31
means that they’re about 31% more likely to have a heart attack. Doesn’t seem to translate for stroke, doesn’t seem to translate when you combine all the endpoints of heart
attack stroke or sudden death and death look to be similar as well. So there was a signal here
that may be taking calcium increases your risk of heart attack. However, it’s maybe not as clear as we thought it was and sometimes you get
it’s hard in medicine because statistics can be so misleading. But here was the Journal of
Bone and Mineral Research and basically we’re looking at
those risk ratio plots again. So if it was truly that
taking calcium would increase your risk of heart attack,
we’d expect all of those boxes to be back over on this
side and what we find is they’re all right in the mid-line which doesn’t really tell us anything. It’s not statistically significant, they need to be over on this side and hopefully those bars that
are associated with them over on this side as well to really
good inference of the data. So what can I tell you after
reading through all the data and reading through the most recent review which was published in the
Annals of Internal Medicine. If you’re taking 2,000
to 2,500 milligrams a day from food or supplemental calcium sources, it’s not going to increase
your risk of heart attack as long as you’re a
generally healthy individual. You start exceeding
excessive amounts of calcium, I think there is some
concern for increased risk. I did have one patient who
was fearful of her bones and was taking an incredible amount of calcium supplementation
and did develop calcification of one of her heart valves
which had to be replaced. But I think as long as you
are staying within that range which I believe is where
most people are when they’re taking a calcium
supplement prescribed by their physician that
you should be totally safe based on the data that’s available. Alight, CoQ10, CoQ10 is a short name, the big name is ubiquinone. It’s what we call a
coenzyme so it’s involved in biochemistry and making
energy for your body. And certain organs that have
a lot of energy requirements tend to have higher
levels of CoQ10 in them and one of them is the heart. Also sometimes we know that CoQ10 can be depleted in the body
and probably the biggest culprit of this are the statins. So this is why we think sometimes people get muscle aches and muscle
inflammation from the statins. Is it because it reduces the
ubiquinone in the muscles which makes them weak and inflamed? It’s not approved by the
FDA for any treatment of any medical condition but
it’s generally well tolerated And most people don’t come in and tell me that they’re having any side effects from their CoQ10 supplements
but just for thoroughness I put on there, here’s the
things that can be seen: nausea, vomiting, appetite suppression, stomach aches, rashes, and headaches. So is there any benefits? I personally only use CoQ10
for people who are on statins. I don’t do it for everyone,
but when you get someone that’s kind of had a heart attack and there’s overwhelming
evidence to reduce their cholesterol with the
statin and they’re starting to get muscle aches, then
I usually put them on CoQ10 because I personally believe it helps, somewhere around 200 to
300 milligrams a day. We combine that with fish
oils to 2,000 milligrams a day of fish oils because the two of them seem to have an anti-inflammatory
effect for people to take the medication, but I don’t
have any data to support that. So that’s sort of my way of doing it. There’s no data to show it
helps you in heart failure, there’s no data to show
that it prevents you from developing heart
disease, no data to show you that it lowers blood pressure. For people who take coumadin,
which are some patients in the population, it can interfere with your coumadin
levels so if you do start that supplementation, it’s
really important for you to let your physician know
who’s managing your coumadin because it can alter your levels. The final one I want to talk
about is Red Yeast Rice. I spend a lot of time
talking to people about this because people really hate the statins because there’s so much
marketing that goes on out there about statins. Are they safe,
are they not safe? And people are always looking for a
homeopathic or a natural way to lower their cholesterol. And Red Yeast Rice is
probably the biggest one. Red Yeast Rice is a Chinese medication and it comes from fermented rice. So there’s a specific fungus
or mold that grows on this rice that produces a compound
which is called a Monacolin. And this Monacolin K that
it produces is molecularly almost identical to lovastatin which is Mevacor which is one of our statins or cholesterol-lowering medications. In fact it’s so close that
the FDA has been all over this supplement because they’re concerned that your marketing this
supplement which is so close to a pharmaceutical and it gets banned and then other companies make
it under a different name and then they catch that
one and it’s banned. So I don’t know that I
could tell you a company that’s out there right
now that is producing this active Monacolin to
the degree that you need it to reduce your cholesterol. It has to be somewhere around 2% to 3% Monacolin K to be able to
have an effective reduction on your cholesterol. But, if you can get
the right one, it works and I have patients who
have gotten the right one and it has worked. You usually take about
2,400 milligrams a day that can reduce your LDL,
your bad cholesterol up to 22% but the problem is there’s no purity, there’s no assay you can’t
tell what active ingredient of this Monacolin K you’re going to get when you purchase this
over-the-counter supplement. So certainly using a health food store like maybe Grass Roots or
something where they have a bit more information on the supplement may be beneficial and something
you would want to ask them. You need to be a little careful
though because sometimes with these Red Yeast Rice,
they can have toxins in them which can be dangerous to
you because of the mold and the fermentation
process, so make sure you… I just wouldn’t randomly
pick up Red Yeast Rice and start taking it, I’d try and get it from a reputable source, and make sure you’re aware of the Monacolin content, and the potential for toxins. Alright, well that was
a lot of information in a short time, but I
want to kind of cap off what I think are the
highlights from all this data. We know vitamin D levels
less than 20 increase your risk of cardiovascular disease. I think there’s pretty
good data to support that and most people wouldn’t dispute that. The problem is we don’t
have a lot of good data to say that taking the
supplements reduces your risk of cardiovascular disease
and hopefully that vital D trial will help shed
some more light on this. If you have had coronary heart disease, so you’ve had a heart attack before, there does appear to be good data to taking at least a 1000 milligrams a day of omega-3 fish oils, may help reduce your risk of death from heart disease. Calcium supplements of 2,000
to 2,500 milligrams a day are probably safe and healthy for you in terms of prevention of fracture and should not increase your
risk of cardiovascular death. CoQ10 helps me in patients
reducing the side effects of the statins but as of the literature, there isn’t a lot of other cardiovascular risk reduction benefits from it. Red Yeast Rice we just talked about can be an effective supplement
to reduce your cholesterol but keep in mind it’s got
to contain the monacolin K, the active reduction molecular structure that’s similar to the lovastatin. And with that, I think I’m going to stop and open up to some questions. Yes. – [Woman] Would you
recommend the CoQ10 with the Red Yeast Rice since it’s like a statin? – I’m going to talk about statins. When people come in and… So let’s backtrack a bit. So first thing you got to realize about whether or not to take a
statin is do you need to? And there are published
guidelines for who should take a statin and who shouldn’t. And that is all dependent on your 10-year cardiovascular risk. So I think part of the problem
we got into in medicine and in cardiology as we
told you statins are great, everyone should take a
statin, it’s going to make you live forever and that’s probably not true because we’re giving people with such low risk of heart disease of medication that the risk of the medicine probably outweighs the benefit. So unless your 10-year
cardiovascular risk is over a certain point,
then there’s probably no reason you should be taking a statin. And diet and lifestyle are still the most important things to
reduce your cholesterol. For the people that are at high risk and there’s four subgroups that we use and we prescribe a statin,
I almost hate talking to people about the muscular side-effects because everyone calls me,
it’s like my joints hurt like well, you probably
worked out, you’re sore. So the published incidents
of muscular side effects from the statins is
not supposed to be more than 5% to 10% at max
and they’ve actually done some really elaborate
studies where they’ve taken people who said they’re statin intolerance and like 50% of those people truly weren’t statin intolerant,
they didn’t have any muscle problems, so it’s a widely
over published side effect. If you fall into a risk
category where your 10 year cardiovascular risk is over 7.5%, then I would tell you
that your first choice is to take a statin. And you don’t have to take
80 milligrams of lipitor in most cases, you’re
just trying to reduce your LDL cholesterol by say 30%. There’s nothing wrong with taking CoQ10 and a statin together at all. In fact in Europe, I think
they do it pretty consistently with people that they prescribe statins. I don’t know how to advise you
on Red Yeast Rice and CoQ10. I don’t think it’s going to hurt you. – [Woman] When you take the
Red Yeast Rice, you said there’s a toxin in it or something? – There can be, it just
goes back to the fact that these medications, Red
Yeast Rice I believe has been around for a long
time and is not regulated. So the purity is an issue of it. – [Woman] So what about people
who have immune problems or something, do you suggest they
take that or don’t take this? I don’t think, I very
rarely will put people on Red Yeast Rice, I try and convince them and I give them the material
information available to have them on a statin. I would say if there were any concerns that you have an immunocompromised body then I would probably not put unregulated supplement into it, No, I would not do that for the risk. – Yes sir. – [Man] You hear a lot about krill oil– – Well, you know krill
oil is what it falls in the omega-3s and one
of the concerns we had about the omega-3s is that, companies that were mass producing them think of the bigger fish,
you get the more omega-3s, but the problem with the bigger fish is you get higher levels of mercuries and heavy metal in the fish. So krill oil, as I
understand it, still contains the omega-3s, but you have
the lower risk of containing the heavy metals in the krill oil. – [Man] That’s all it is? Okay. – I read somewhere online
that there’s a problem with like overfishing
krill now because everyone wants the krill oil, but
I can’t attest to it. Yes ma’am. – [Woman] What about low dose aspirin? Okay, that’s a great subject. So low-dose aspirin –
81 milligrams a day – you have two groups: you
have primary prevention and secondary prevention. So primary prevention
of heart attack stroke or cardiovascular death
with aspirin therapy alone is again based on your 10
year cardiovascular risk and I believe the United
States Preventive Task Force says if your 10-year
cardiovascular risk is over 10%, then you benefit from 81 milligrams daily. Anyone who has had a heart attack, stroke, peripheral vascular disease
for secondary prevention should be on 81 milligrams
a day of aspirin. What goes into that
calculation of your 10-year cardiovascular risk is your
blood pressure, your age – your age is probably the
biggest driving factor – whether you’re a smoker, diabetes, gender, and I think that’s it. And you can calculate that online if you type in your 10-year, AHA American Heart Association
cardiovascular risk as long as you know your
cholesterol and blood pressure from a blood panel, your wellness labs, then you can calculate that yourself and read all about it. And it will tell you when you do it, you do not need to be on a statin, you do not need to be on an aspirin and your blood pressure looks good or if you’re having problems
in there it’ll tell you, you should benefit from
one of these therapies, you can calculate that on your own. – [Man] What about when
your doctor puts you on 320? – Well, there’s different
indications for 325 so sometimes we use
higher doses of aspirin for people who have had
a recent heart attack. So what aspirin does is
aspirin inhibits a blood cell in your body called a platelet
so you have these blood cells called platelets that circulate around and when your blood vessels
are injured they stick to it and start a blood clot. When you have a heart attack, what happens is the cholesterol plaque
in your body breaks open and it spills all this
cholesterol material into the bloodstream and those platelets come and stick to it and
it starts the blood clot in your artery which
makes the heart attack. So we use the aspirin to make
those platelets less sticky so that if that cholesterol
plaque breaks open, they don’t stick to it
and form the blood clot. And sometimes we use
higher doses of aspirin if we want those platelets
more inhibited than others. Yes. – [Woman] Do you have a favorite brand for supplements or vitamins? – I don’t, for fish oils
I do, I tend to ask people to use the Nordic Naturals, I think that’s a good brand of fish oils. I heard on the news that
there’s the doctor’s favorite coenzyme Q10 like ubiquinol
or cardiology approved, I don’t know, I just try
and tell people to go to a place that’s at least reputable so someone’s doing some
research along the line as to okay this is a good
company, this is not. I will tell you in medical
school none of this is taught to us. We learn traditional pharmaceuticals, we learned about beta
blockers and statins, and the whole supplement
industry and homeopathic approaches to medication is
not taught in traditional Western medical schools, so I don’t. Yes. – [Man] Can you explain
the thought process behind recommending CoQ10 so widely
in the medical community even though there’s not
academic research to support it. It’s a lot of money in it and like I said, this is
the data that I was able to extract and I was trying to give you evidence-based literature. I
try and do that with people because to me, no one wants
to take a pill everyday. It’s annoying and you don’t want to do it. So I try and say if you take
this medication every day, this is what you’re going to get, this is why you’re doing it. So you’re taking this cholesterol medicine because I can tell you
you’re going to reduce your risk of heart
attack or stroke by 40%. And that data is just
not out there for CoQ10, just couldn’t give it to you. Well thank you, thank you. – [Woman] Like the flaxseed,
I know that you probably don’t have to risk of mercury with that. What about mill flaxseed or does it need to be the flaxseed oil because don’t you get
the oil with the mill– – Yeah, I don’t know the answer to that to be honest with you, flaxseed actually has really high
concentrations of omega-3s. There was a chart I almost put in here that had all the different foods and stuff and the omega-3 concentrations
and flax seed is at the top. – And would that be the grain itself– – I think it was the flaxseed
oil that I looked at, I don’t know about the
grain. I don’t know, I think it was the oil that they use so I know the oil for sure, but I’m sure the grain is great too. – [Woman] So people can’t take the omegas because they’ll get aversions to it– – Yeah, I mean that’s the
problem with the fish oils. There are some… The Nordic Naturals to me
tend to be a little lighter on people’s stomachs so you
don’t get that awful burp an hour later after you
take it, but flaxseed oil is fantastic, there’s
nothing wrong with that. Yes. – We always tell people
going for surgeries to stop their vitamin
supplements especially fish oil and garlic,
is that evidence-based? – Well, the garlic I don’t know about but the fish oils, yes they are concerned and that’s maybe why we
think maybe they’re helpful is because they’re that
antithrombin genic, they help thin the blood a little bit to reduce your risk of heart attack so I don’t think that’s a bad idea at all to stop the fish oils because
of the potential for them to be a weak anticoagulant, kind of like the (mumbles) stop the aspirin. Yes. – [Woman] was wondering about the people they use in this study. I attended a conference
at UC Medical Center and they stated that, just 20
minutes of secondhand smoke would cause the blood
platelets to become so sticky, that’s in a nonsmoker, you
could have a heart attack. So I was wondering when people
you talked about in 2002, and I can’t remember what year smoking was banned from the north, but would there be any correlation with that? – Yeah, I don’t know, I mean certainly– (background noise drowns out other sounds) Don’t smoke (laughs), please don’t smoke. Yeah, the secondhand
smoke is a major problem. So cigarettes do horrible things to you so not only do they make
your platelets sticky, they starve your blood
cells from getting oxygen and they constrict your blood vessels. So you deliver less oxygen to your heart through a constricted blood
vessel with stickier platelets. I don’t know how to answer that– – [Woman] You don’t know
what the study or group– – I don’t know whether the earlier benefit that we saw had to do with
less secondhand smoke exposure, but secondhand smoke
exposure is just as bad as is firsthand smoke exposure. Yes. – [Man] Celebrex or Mobic,
can you focus on the dangers? – So Celebrex is what we
call the COX-2 inhibitors so we thought these were the best things. A lot of people have
arthritis and so we give them anti-inflammatories to
help with the arthritis, but if you take Advil,
ibuprofen, motrin, any of those, they’re non-selective and we
know that ibuprofen, Advil those medications increase your risk of heart attack and stroke. In fact, if you look on
it, there’s a black box warning on those medications. So they came up with
the second generation, the COX-2 inhibitors for the… They call it COX-2 because
the enzyme it inhibits and it’s supposed to be purely selective for the area that’s
inflamed so you don’t get the other undesirable side effects whether it’s the increased risk
of heart attack and stroke, whether it’s the ulcerative
disease in your stomach. It was just supposed to target
the area of inflammation and there were multiple
brands that were put out there was Bextra, there was
Vioxx, there was Celebrex and I maybe even missing one. But it turns out, and
a lot of this came from Cleveland Clinic, is
that people were dying because of these medications. And so they pulled a number
of them off the market. Vioxx, I know was a big one, Baxter I think was pulled off the market, Celebrex has remained. Celebrex it looks like if you’re taking 100 milligrams a day you’re probably okay, 200 to 400 milligrams a
day starts to show that increase cardiovascular risk signal. So if you’re going to take Celebrex, I would only take 100 milligrams a day. – [Man] Is Mobic better or safer? – I don’t know about Mobic. All of the anti-inflammatories
that you use, the theory is that they
raise your blood pressure. Maybe that’s some of the side
effects of the medications. That’s how it increases
your cardiovascular risk. All of them have an adverse
cardiovascular safety profile. It’s tough, what do you
do, you got arthritis and the last thing we
as physicians want to do is get people hooked on
opium opiate medications for pain control, but sometimes it’s tough when all you can tell them
is Tylenol for arthritis. – [Woman] Please tell us about Aleve. – Aleve is… I consider the lesser of all evils. But still it’s the same thing, it’s a non-steroidal alright
so there’s still the risk of the side effects of the non-steroidals. But Aleve out of all of
them, if you feel have to take some time, I try and tell them to take the minimal dose Aleve. I think a single tablet is 220 milligrams to take that once a day. What you don’t want to be
taking is ibuprofen and Advil multiple times during the day. Alright, well thank you. I appreciate your attention. (audience applauding)

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