At the time of this recording, it is February. And that means it's American heart month. A time when the nation turns its focus to heart disease. The number one killer of Americans. In fact, one person dies every 33 seconds in the United States from cardiovascular disease.
According to the publication circulation. Almost 18.6 million people across the globe died of cardiovascular disease in 2019. That's a 17% increase over the past decade.
It is well-known that a healthy diet is one of the best weapons you have to fight heart disease.
Healthy diet helps patients manage their controllable risk factors for cardiovascular disease, like cholesterol, blood pressure, glucose levels, and weight. My name is Coleen Sloan, I'm a registered dietician and pediatric PA. and this is the exam room nutrition podcast, where each week i'm giving you answers to common nutrition questions to help you become a more compassionate [00:01:00] confident clinician So for today's episode, I'm going to clear up some confusion regarding the most appropriate diet for preventing and treating cardiovascular disease. We'll discuss whether eggs are as bad for our cholesterol.
As we once thought we'll differentiate between the different sources of dietary fat and which ones affect our lipids the most. You'll learn how to analyze the results of your patient's cholesterol levels and which labs you should order beyond a standard lipid panel to help assess your patient's risk thoroughly. We'll address two popular diets right now the keto diet and the carnivore diet and what the research shows about their effect on heart health you'll learn about a food pairing secret weapon to improve blood vessel health and why it's important to focus on the patient's entire diet and health status not just one component So get comfy and join me in welcoming michelle rothen steam to the show Michelle is a registered dietician with a master's degree in clinical nutrition from nyu She's the owner of [00:02:00] entirely nourished a nutrition counseling private practice that specializes in heart disease prevention and management Her passion is translating nutritional sciences into an easy to understand language that can be implemented for the longterm she is the author of the truly easy heart-healthy cookbook and a Forbes health advisory board member. Michelle. I can't wait for this conversation. Thanks so much for being here. Welcome to the show.
Thanks for having me. I'm happy to be here.
So I cannot wait to learn from you because cholesterol and dietary fat and LDL is kind of like a hot topic right now. And Dietary fat kind of goes in and out of popularity.
throughout the years. and in case there are some people who are not in cardiology, maybe they're in family practice or internal medicine I would love for you to help us understand the difference between cholesterol levels and LDL and HDL levels and exactly what part of the diet affects those numbers.
Sure. So when we're looking at, you know, your average lipid panel, your total [00:03:00] cholesterol is going to be a combination of all the types of cholesterol. Your LDL is that cholesterol that's associated with atherosclerosis. But now we know that if we dig a little bit deeper, some of that LDL can be more athrogenic than others.
and so if we were to just look at a basic lipid profile and we took your total cholesterol, subtracted it by your HDL cholesterol, we would get your non HDL cholesterol. And that's a better surrogate for how athrogenic that LDL actually is. And in that regard, we want it to be ideally less than a hundred milligrams per deciliter and someone who is at high risk.
LDL is still important. If somebody in the general population, we're still looking for that to be less than 100 milligrams per deciliter. And your HDL, we've seen that when it's too high, it actually becomes dysfunctional. So, while it's considered good, it's not relative to LDL. LDL and HDL need to be looked at separately because LDL.
[00:04:00] optimal HDL, but your LDL is high, that can still cause atherosclerosis. So LDL is very important. if you want to go more into that, APOB is even more atherogenic because of the way that it sits on the LDL and causes that plaque to form in arteries. When it comes to diet, we know that a high saturated fat diet doesn't allow LDL to be broken down by the liver.
It lowers the amount of LDL receptors on the liver, and therefore it causes more LDL to be in the bloodstream. So, we want to make sure that we're not having a very high saturated fat diet where it would promote more LDL formation in the arteries.
So let's break down just briefly the different types of fat because, you know, this is also a big debate amongst social media influencers and, sometimes as clinicians we can tell our patients, hey, you should Follow a low fat diet or let's cut out all fats.
I would love to hear your thoughts on if [00:05:00] that's a good recommendation or not
So let's understand what does fat do in the body, right? I think that's an important component. So it gives us energy, but also if you look at it from a nutrient sufficient matter. So what I mean by that is in order for us to absorb fat soluble vitamins and even fat soluble carotenoids. So these antioxidants, which help defend our body against oxidative stress, which is a component of plaque formation in the arteries, we need to make sure.
That we are including healthy fats in our diet, right? So we don't want to eliminate fat because then we can become nutrient deficient and key nutrients that our body needs for immune function, for blood clot regulation, for heartbeat regulation, for all the things that it does. That we don't really think about, and so when we look at fat, we do want to include heart healthy fats.
And these are more unsaturated fats, particularly our mono and our polyunsaturated fats, [00:06:00] because they help with the absorption, but they also help protect our brain, protect our heart and have an anti inflammatory effect. On our blood vessel lining on our endothelium, so we don't want to avoid heart healthy fats, but they're not something that we eat as the only sole macronutrient.
We need to balance our macronutrients where we have heart healthy fats, where we have lean protein and where we have complex carbohydrates in order for our body to thrive, for our heart to thrive, for our blood pressure, cholesterol, blood sugar, inflammation, all of our cardiometabolic risk factors to be optimal.
I think that was a great explanation. does dietary cholesterol actually affect serum cholesterol?
Great question. So our bodies actually are really good at making sure we have a certain amount of cholesterol in the blood. So when we eat a lot of foods with cholesterol in the average healthy individual, our [00:07:00] liver just doesn't produce as much. Our body kind of regulates that. that amount. so it doesn't have a direct effect on our cholesterol.
so when we think about that, you know, we don't want to have an abundance of very, very high amount of cholesterol, but our bodies can regulate how much we make based off of how much we're consuming. I think it's also important to note with that is that there are. Genetics and people who are known as hyper responders.
So when they do have excess or a little bit too much of dietary cholesterol, it does impact their serum cholesterol. So that's about 30 percent of the population. So, as you are doing your risk assessment on the individual, looking at their lipo protein, a looking at their family history can give insight into that, amount that you would recommend to your patients.
now that we have a good understanding of the different types of dietary fat, I would love to know what type of diet or a specific diet do you recommend [00:08:00] for my listeners who are providers to tell their patients to follow if we've got elevated LDL, total cholesterol, what diet should they go on?
Because there's a lot of different options out there.
Yeah, so there are several diets that will help with optimizing the cholesterol panel, and they all have very specific commonalities. So we look at the Mediterranean diet, the TLC diet, the portfolio diet, and the DASH diet, and all of those can help to lower cholesterol, as long as we are including the foods that help bind LDL cholesterol.
So having adequate amount soluble fiber to help excrete the LDL cholesterol. so choosing one of those we know is a plant forward diet, but also making sure that we're getting enough protein in those diets, making sure we're getting enough of the healthy fats so that we're also making sure that we have good muscle tone and that if weight loss is a goal, we're concentrating on preserving lean body mass.
I think it [00:09:00] also is important to get into that idea of sustainability. So you have to meet your client where they are. If somebody is on the carnivore diet, and then you're just like, Hey, switch completely over to plant based or vegan. First off, you don't need to be vegan to lower your cholesterol levels.
It's an option, but it's not an option that always works for everyone, depending on their preferences in their lifestyle, but it's important to meet them where they are and. do a couple changes at a time because a lot of people go on extremes and when you go on extremes a it's really hard on your gut.
It's really hard on your heart. It's really hard on your liver. You have to do things in steps for it to a be sustainable, but also be implementable. So I always say, let's, let's start small, and implement small strategies and assess the challenges. And if you need additional support, refer to a registered dietitian who specializes In cholesterol management that can help achieve those goals.
I love that you went there because as with any diet, whether it's for weight [00:10:00] loss, diabetes management, cholesterol management, it is about finding out what will work for the patient. Because in general, a lot of these diets that have been around for a long time, these meal patterns are pretty similar, but one style might work better for one patient versus another.
And I really love that you still brought it back to that counseling skill that dietitians are so good at. And that is really just helping the patient figure out what works for them, what they like and what they could do forever. Cause that's really what we're hoping to, to change their meal pattern and to change the way that they eat and that it just becomes their normal style of eating.
That it's not this quote diet that they're following for six weeks and then they just go back to their normal eating style.
Yeah. And I also think a big part of it is explaining the why what's happening, right? When you eat certain foods, why do we need it in certain volumes? Why do we need to pair it with certain foods? What's happening under the scenes in terms of metabolism and what your body is doing with those nutrients, because that helps people to also kind of click [00:11:00] and say, okay, this makes sense.
And now I can take that information and apply it to what I'm doing going forward. I think that's also very helpful.
Now, you said something interesting, and you mentioned pairing certain foods with other foods. Now, it's really important to pair a protein with a carbohydrate, especially for blood sugar management and weight control, it improves satiety. I'm curious though, with cholesterol management,
other, other foods that you focus on pairing together that would improve cholesterol levels?
It's a great question. So when I'm looking at cholesterol management, I am as a cardiovascular dietitian, I'm really looking at optimizing your entire heart health. Right. So when we talk about that, we're looking at blood vessel health, too. So someone who has high cholesterol may also have high blood pressure or if they've had high cholesterol for a long period of time or they have an elevated coronary artery calcium score indicating plaque formation We know that this is an extra burden on the heart and an extra burden on the cardiovascular [00:12:00] system So when we're looking at pairing, we're also looking at optimal blood flow and optimal blood vessel health So another pairing that I focused on from a cardiovascular perspective is the sodium to potassium ratio.
So sodium constricts the arteries that potassium vasodilates the arteries. It opens it up. And so, if you have a very high sodium diet and a very low potassium diet, your blood pressure is going to be elevated. If you have a higher potassium compared to sodium diet and certain meals and pairings, that's going to actually help.
improve your blood vessel health and improve your blood pressure. So that's another example of what I mean when I say the pairings of food,
So I think that's a really interesting thing to think about that I'm pretty sure most clinicians don't have on front of mind when they're discussing health with their patients. So I would love to hear what are some things that you would pair
Okay, so, in one of my client sessions the other day, someone was mentioning how much they love cottage cheese. It's [00:13:00] really hard to find a low sodium cottage cheese. So here's an example, right? So your cottage cheese, is high in sodium. So let's pair something higher in potassium to help offset it.
So this could be cantaloupe. This can be a banana. this can also be walnuts and a banana to help just with The macronutrient balance as well. and that will help with the sodium to potassium ratio.
So interesting. I think that's really helpful. All right. I want to ask you a big question. And even in pediatrics, I get this a lot. So please explain to us eggs and their effect on cholesterol.
Good question. So we've seen probably every flip flop study and people are always just so confused about this topic. So I get this a lot. the reason why it's confusing is because it's not a yes or no answer. And I'll explain that when I go through this in a second. So when we have eggs as part of a heart healthy diet, and we are being mindful of how much saturated fat you're consuming,
then you can include four to seven full [00:14:00] eggs a week, and we don't really see a negative impact at all. It doesn't really affect cholesterol levels. It's perfectly fine to consume, but then we see. Other studies that show that people who are hyper responders who have a genetic susceptibility to high cholesterol when they have the cholesterol and the saturated fat from the eggs that can actually increase their cholesterol.
So individuals who are LDL. high libeprotein A WHO have a genetic component. They may want to reduce their egg yolks to about two to three a week so you can still include it, especially if you enjoy it. But you do want to limit it a little bit more, depending on your risk profile. It also just depends what else you're eating and that's a big component, right?
If you're not having any other real big sources of saturated fat, it can be included. to include in your diet. When it comes to egg whites, those do not contain saturated fat. Those don't contain that dietary cholesterol. So it's not going to have that impact on your cholesterol levels. So
You can have a lot more of that to meet your protein needs. If you were [00:15:00] to include the oak too.
So helpful. And I hear it all the time that people are so confused with eggs and
again, nutrition is nuanced. So it's hard to give like a yes or no blanket statement when it comes to a lot of things with nutrition. All right. So I want to move into two pretty popular diets, at least right now.
And I'm curious as to what the research shows about the keto diet and the carnivore diet and their effect on lipid levels.
So I want to preface with defining the ketogenic diet, because if you look at the research before it became trendy, the keto diet was used for treating epilepsy in Children. And when you look at the definition of that in the research, we're really looking at keeping carbs to, like, 5 percent of your diet or 10 percent very, very low.
So you're making your body go through ketosis, which is essentially taking fat and. creating carbs from it. And the [00:16:00] ketones from the fat are excreted through urination. and so that's the old definition of the ketogenic diet. Now we're seeing a lot of keto diets that are Mediterranean keto, or that aren't really true keto.
And they are. Semi low carb, and some of them actually aren't semi low carb. So we need to define what a ketogenic diet is, because I find that many people will say, Oh, I was doing keto. But then when you look at it, it wasn't really that definition of it. so with that being said, if you are on a very high fat diet, there's going to be a lot more protein, a lot more fat per se than carbohydrates.
And with that your LDL cholesterol can skyrocket if you're on the carnivore diet where all you eat is meat there's no way to do that in a way where you don't have a lot of saturated fat, but then one step further when we eat a lot of red meat, such as the carnivore diet, our gut produces a metabolite called TMA, and it turns [00:17:00] into TMAO by the liver.
And that's been associated with arterial stiffness and promotion of plaque in the arteries. so from a heart health perspective, these two diets defined by the way I define them are not going to be heart healthy because a they're very high in saturated fat, but also it can lead to constipation. If you're constipated, it's a one reason why cholesterol levels will be high because you're not excreted.
reading it appropriately from your body. and then you're also going to be nutrient deficient. You're not going to be getting a lot of the micro nutrients that your body and your heart needs for optimal arterial health and to keep your arteries elastic. so from a heart health perspective, they are not diets I recommend because they will, increase your LDL cholesterol.
They may actually even lead to insulin resistance because that saturated fat can make yourselves more insulin resistant to
Such a good explanation. And I love that you had touched on that those diets are pretty high in saturated fat because this also has been something that's been brought up often in the, social media [00:18:00] world because there was an article that came out years ago that kind of. put forth the question of saturated fat not being as harmful as we once thought it was.
So I would love for you to kind of touch on, on that and the history of saturated fat and if we should still be encouraging our patients to eliminate foods higher in saturated fat or not.
So I think a lot of what we need to be looking at is the whole diet. When we're looking at just one nutrient, we lose focus on, well, what else are we eating? What are we replacing that saturated fat with? How much of it is in our diets? And really looking at the biological mechanisms of what happens when we eat saturated fats.
I also think that there's a big component that we're not really Looking at and when we talk about clinicians risk assessment for cardiovascular disease, it's imperative to really dig into the medical history of somebody, right? So, heart disease can skip generations.
So asking someone, [00:19:00] Hey, did mom or dad have a heart attack under 65 is a fine question to ask and should be asked. test. However, I want to make sure people are also testing for lipoprotein A. It's very common to have a high lipoprotein A, which increases your risk of heart disease. And a lot of people have multiple genes that If they have a high saturated fat diet, it will accelerate their plaque promotion and they can have a premature heart attack.
and I think that that's a big component from that personalization standpoint that many people over skip. I've had a lot of individuals who are thin, who are athletes. a lot of my patients have heart attacks and at a young age, and they come to see me and no one has checked their lipo protein a and it is through the roof.
Some of them have a normal life of protein a but their other genetics are high. and we need to be looking at individuals cholesterol levels, irregardless of their body size, irregardless of you know how they look on the outside because there can still be a lot of plaque in the inside. And we need to be doing more of a [00:20:00] thorough risk assessment in order to really reduce this burden of cardiovascular disease.
I would love to hear what labs would you just love for primary care clinicians to be ordering that would be an excellent screen for heart disease?
So definitely the lipid profile. you know, you did mention pediatrics and I always say, , if anyone in the family has had high cholesterol at a young age, we need to be screening that earlier because there could be FH in the family, familial hypercholesterolemia.
And we need to know about that earlier so So that's one we need to do a lipid panel. standard lipid panel. if you wanted to add APOB, that's great. lipoprotein a is good to assess from a, what do we need to do from a proactive standpoint? If someone has an elevated lipoprotein a, we need to be a lot more strict on lipid optimization. but lipoprotein A is not screened enough. And while we don't have any medications currently on the market, there are many in research that are looking to suppress that gene, [00:21:00] but knowing that it's there tells us that we need to be more aggressive in that cholesterol management.
And so knowing is important in our proactiveness going forward. If we have some individuals who are like, I don't want to go on a set and I don't want to go on a stat in, and they're very resistant to that, which is very common. You can also ask to do a coronary artery calcium scan. You can assess for hardened plaque in their arteries and refer to do that.
it's Very cheap way to assess kind of do they have advanced atherosclerosis,
and I think that's really helpful for individuals who are kind of like, I don't really know what I'm supposed to screen for or what I'm supposed to measure. I'm also curious if you can give us a few questions that would go beyond like the basic ones of, did your mom or dad have a heart attack?
Do they have high cholesterol? What type of questions might direct us to a patient who would be higher risk that we need to get more history on?
Yeah. family history is always an important question. I also think the lab parameters are important and [00:22:00] not ignoring that. So if somebody comes into the office and they have high blood pressure instead of being like, Oh, it's probably just white coat syndrome. Don't worry about it.
You should be telling them, Hey, it's high in the office. I want to make sure that we are assessing if this is true white coat syndrome, or if it is hypertension, high blood pressure, because we need to address that timely. So encourage them to get a blood pressure cuff at home, log it for, you know. A week or two, and then send those results back to you because if it's still high at home, you're missing a hypertension case and high blood pressure leads silently to so many issues from kidney issues, stroke, dementia to atherosclerosis also.
and so we need to be on top of that. 120 over 80 is great or less, but 110 over 70 is looking to be the new ideal. So we really need to be assessing that. We also need to be assessing trends. If somebody's cholesterol is still considered normal, but it's trended up 40 points or 30 points in the [00:23:00] last year, we need to be assessing that.
We also need to be measuring waist circumference. I teach my clients how to measure their waist circumference, which is your belly button, not your pants size. And I have them measure it.
And you'd be surprised of how many times people are like, Oh my God, I had no idea that I had a 42 inch waist. My pants are 36. I thought it was just bigger, but not that much bigger. Measure it. Know your baseline. We need to be proactive. We need to be assessing all of these things and realizing that heart disease is the number one killer and highest in mortality because it's not just one risk factor.
Cholesterol is important. Blood pressure is important. Blood sugar management is important. We need to be looking at inflammation. We need to be looking at gut issues. All of this is important. so, you know, another question might be, you know, how are your bowel movements? Do you go to the bathroom every day?
do you strain? Are you bloated? we need to be assessing that because I can't tell you how many times people I asked them about if they're a regular and they're like, yeah, I'm regular. [00:24:00] And then once we start adding things in, they're like, Michelle, I did not know what regular was until that. And they're like, I never paid attention to it.
Why aren't. Doctors talking about bowel movements. so that's also a really important question that should be asked.
Those are super helpful, and I love that you kind of dig deeper and actually take a holistic approach to heart disease and management, because you're right. It isn't just about one lab, one food. It really is considering the whole picture. So my favorite question to close out with is asking what are some of the worst pieces of advice that you've ever heard clinicians give to their patients?
So I've heard many physicians say, you know, you need to lose weight, go Google the best diet for you, or you need to lose weight. I did the keto diet. You should try it. It's the worst advice because that's not helpful. And you can lose weight, but it could also be not healthy. So you can lose the weight, but then your cholesterol goes up, your blood [00:25:00] pressure goes up, your triglycerides, your blood sugar goes up.
And now you're confused. Cause you're like, but I lost this weight, but now all my labs are bad. So which one do I need to do? You need to do both. You should never go on a diet. That's going to increase another cardio metabolic risk factors. the diet should be enhancing and optimizing everything and not on the expense of another.
so instead of using anecdotal, if you truly don't know what the best diet is, and you can't advise your patient, the best thing you can do is say, I think you should get personalized care from a registered dietitian who can help guide you further. You will help save so many lives by doing that.
This is what we study. This is what we love to do and we're really good at it. So I would refer to a registered dietitian versus in that five minutes trying to tell them to Google it because Google will put you down a really bad rabbit hole and it could do a lot more harm than good.
Couldn't agree [00:26:00] more and what a great place to end because every episode I always recommend referring to the nutrition professionals, to the experts, registered dietitians. So I love that you ended with that piece of advice. Michelle, this has been so extremely informative and helpful. I would love for you to share where people can find you or where they can get more information about working with you.
Sure. Thanks so much for having me. You can find me on my website, entirely nourish. com. over there, I also have all my links to my social. I'm most active on my Instagram, which is heart. health. nutritionist. And I welcome you to follow along with me. Thanks for having me so much.
All right. My friend now it's time for my nutrition notes. Michelle had mentioned that when you are recommending a dietary change for your patient, you want to focus on two things. That the diet is sustainable and implementable. Now by definition, sustainable beans able to be maintained. So if you are drastically changing a patient's diet, for example, telling the patient who eats fast food daily [00:27:00] to follow a plant-based diet, the likelihood that they will be able to maintain and enjoy that new eating pattern for years is highly unlikely.
We never want to put a patient on a diet where they can only manage it for three to six weeks. As Michelle said that, we'll do more harm than good. So start with small achievable changes. That brings me to the next thing that the diet should be. Implementable, which means able to be put into practice or simply said doable. This is where you can involve the patient and ask them.
What changes would you like to focus on first? This allows them to consider their lifestyle, their preferences, and choose what they think they'll be most successful with.
Now, give them options here. For example, you might say. We really need to work on lowering your cholesterol and blood pressure levels to do that. We could focus on limiting your intake of fried foods and sweets, or we could focus on increasing your fruit and vegetable intake. Which one do you think is realistic for [00:28:00] you to work on in the next two weeks? And let them choose. And in reality, whichever option they choose ultimately will improve their cholesterol and blood pressure. But it feels less overwhelming for the patient to just choose one small thing that they can work on instead of completely overhauling their diet so try to create sustainable and implementable changes that the patient can follow Make success easy for them They'll become less frustrated if it feels like something they can achieve and at the follow-up appointment assess their challenges If they struggled Ask them what is making this hard for you Work with your patient to help them achieve cardiovascular health that could save their life. Thanks for listening and thank you for caring for patients with such enthusiasm and attention to detail especially their nutrition your patients are lucky to have you. Well that's all i have for you today so as always let's make our patients healthier one exam room at a time. I'll see [00:29:00] you next time.