April 10: Cardiovascular

April 10, 2024


Session Notes

Below is a summary of the key points and discussions from todays session:

1. **Compounding Pharmacies (503A vs. 503B)**:

  - Dr. Doug explained the difference between 503A and 503B compounding pharmacies. 503A pharmacies make medications on demand for individual patients with prescriptions, while 503B pharmacies can produce large batches for hospitals or other pharmacies without individual prescriptions. Dr. Doug emphasized the higher quality standards of 503B pharmacies and his preference for using them due to quality assurance.

2. **Essential Amino Acids and Muscle Health**:

  - Essential amino acids (EAAs) and their role in muscle building were discussed. Dr. Doug recommended using EAAs to stimulate muscle protein synthesis, especially for populations that struggle to build muscle. He mentioned a product called Fundamentals and another brand available on Fullscript called Perfect Aminos. The best time to take EAAs is during or immediately after training.

3. **Whey Protein vs. Creatine**:

  - Whey protein and creatine serve different purposes. Whey protein is a complete protein source, while creatine helps with muscle performance and recovery. They are not mutually inclusive and can be taken separately.

4. **Calcium Intake and Micronutrients**:

  - The discussion covered getting adequate calcium through diet and the importance of ensuring enough micronutrients. Dr. Doug recommended using a trace minerals product if dietary calcium is sufficient but emphasized the benefits of whole food sources like AlgaeCal over synthetic calcium supplements.

5. **Heel Drops for Bone Density**:

  - Heel drops were discussed as an exercise to increase bone density. Dr. Doug advised starting with a low number and gradually increasing to avoid strain on the body.

6. **Cardiovascular Health and Diet**:

  - The relationship between dietary fat, cholesterol, and cardiovascular health was explored. Dr. Doug clarified that dietary fat is not inherently bad and that saturated fat only affects LDL cholesterol levels in some people. He recommended a diet that supports overall health, including bone health, metabolic health, and cognitive function, even if it may increase cholesterol levels.

7. **Coronary Artery Calcium Score (CAC) and CCTA**:

  - The importance of CAC and CCTA (Coronary Computed Tomography Angiography) in assessing cardiovascular risk was discussed. Dr. Doug prefers the CAC as an initial test to identify calcium buildup in the coronary arteries. CCTA is used for further assessment, especially when CAC is zero, to evaluate soft plaque and artery narrowing. Dr. Twyman was mentioned as a resource for further information on cardiovascular health.

8. **Cholesterol Medication and Side Effects**:

  - The side effects of cholesterol-lowering medications, particularly statins, were discussed. Dr. Doug mentioned that while statins can reduce cholesterol levels, they can also deplete important nutrients like magnesium and CoQ10, potentially leading to fatigue and other side effects.

9. **LP(a) Levels and Cardiovascular Risk**:

  - Elevated Lipoprotein(a), or LP(a), levels were discussed as a genetic risk factor for cardiovascular disease. Dr. Doug noted that while LP(a) is a concern, a zero CAC score is reassuring, and further testing like CCTA can be considered based on individual risk assessment.



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Dr Doug: and osteoporosis? How do those 2 interact, and then the other one that comes up often is, what about poor metabolic health? What if I have diabetes? How does that impact my osteoprostis? And what can we do to kind of put those together? So I'd love to speak on those today.


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Dr Doug: And I think we should start with diabetes because we've talked a little bit about cholesterol in the past.


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Dr Doug: So then we can


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Dr Doug: let me go back up here. So Cheryl dropped in a question. Yeah, so we'll just start here with Cheryl's question, and then we can just drop them in as we go.


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Dr Doug: Does that work for everyone.


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susan rodney: Her great yep.


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Dr Doug: All right, good.


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Shelly’s iPad: Hey, Doug, I'm sorry to interrupt.


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Dr Doug: Hi, Shelley, yeah.


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Shelly’s iPad: Hi! How are you?


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Dr Doug: Good.


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Shelly’s iPad: I got one really quick question that I gotta jump off because I have a meeting. But


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Dr Doug: Everyone.


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Shelly’s iPad: You had mentioned in one of our threads in Health Nation. Regarding compound pharmacies, 503 a. And 503 B. Can you once again tell me which one is the one we want to go with.


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Dr Doug: 503503 b.


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Shelly’s iPad: Thank you. Okay.


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Dr Doug: Yeah, and you can. You can hop off. And I'll explain what all that meant to everybody else.


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Shelly’s iPad: You don't have to. I'm sorry I brought it up, but I'm not sure. No, no, no, it's it's a good.


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Dr Doug: It's a good topic. It's a good topic, for sure.


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Shelly’s iPad: Alright. Thank you.


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Dr Doug: You're welcome. Yeah, bye, Shelley. Hope you're doing well.


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Shelly’s iPad: Yeah, bye, bye.


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Dr Doug: So what Shelley was referring to is, we get a lot of questions about compounding pharmacies, because obviously we use compounding pharmacies, particularly for testosterone, since there is really no commercial product for women.


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Dr Doug: I've been using them for for years, and I'm very comfortable with compounding pharmacies. But a lot of doctors are not, and the reason why they're not is that the FDA really looks down on compounding pharmacies. They like to find pharmacies for doing things that they deem are inappropriate.


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Dr Doug: And there's some case law, some really nasty things that have happened coming from compounding pharmacies. So the scrutiny is legitimate.


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Dr Doug: The difference between 503 a and 503 B, that that Cheryl was just talking about is that there are local compounding pharmacies, like most of you probably have a compounding pharmacy in your local area. I have Asheville compounding, which is right down the road.


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Dr Doug: They are a 503, a meaning that in order for them to make a product, they have to have a prescription from a doctor. You know that this person needs this drug, and I want you to compound it for them. That kind of prescription. So they're really making each thing on demand for a specific patient, or they should be 503 B is, they have the capacity to make large batches of things, and then they can sell it, to say a hospital or pharmacy. Another


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Dr Doug: pharmacy, or whatever for distribution. So they don't need a prescription. The 503 B's that we work with do both.


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Dr Doug: So they act as a 503, a meaning that I can write a prescription for a patient, but they're filling it out. A large batch, which was made under a different circumstance and different scrutiny for quality than is an individual batch from a 503. A pharmacy.


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Dr Doug: Does that all make sense?


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Dr Doug: So the the benefit there is that you're gonna get higher quality standards coming from a 503 b pharmacy. And the challenge I have is sometimes actually oftentimes the local pharmacies are going to be less expensive because the the amount of


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Dr Doug: effort and testing that they have to do from a 503 B perspective makes the product more expensive. So people can get a cheaper product from a local compounding pharmacy. But I can't guarantee what's in it. So I have no idea how good they are. I have no idea what they're putting in it. I have no idea, like, are they, you know, doing it under sterile conditions I have no control whatsoever, so people will tell me all the time. Oh, my pharmacy is great.


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Dr Doug: but I don't know what that means. And guess who's on the hook for any complications that result. As from that that medication. It's me so local compounding pharmacies can be a challenge for us. So that's why, we use 503 b pharmacies exclusively


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Dr Doug: make sense


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Dr Doug: unless somebody really bends my arm.


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Dr Doug: Okay, so let me go through these questions, and then we'll get on topic.


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Dr Doug: So Cheryl, hi, cheryl, you have your camera on. Hi, Cheryl. So, Cheryl ask in the chat, she said. You mentioned using an essential amino acid drink this week. What is the best way to use it? And how will it impact bones? Great question. So, yeah, we had a Youtube video drop this week on that topic. And essentially, what essential amino acids are you also hear this talked about as branch chain amino acids? So Ea and BCA. You start getting into like the bodybuilding world when you say those things.


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Dr Doug: But essentially amino acids are the building blocks of protein. Right? So we need the amino acids to build protein. When you consume protein, whether it be from plants or animals, you're getting amino acids. That's essentially what you're doing.


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Dr Doug: So in the body-building world, the strength training world people have used these specific amino acids


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Dr Doug: as a tool to build muscle on top of the dietary protein they're getting, and there's a lot of evidence behind it, and it's pretty darn effective. The reason why I think it's effective is that when you get certain amounts of some of these amino acids, it will stimulate and drive protein muscle protein synthesis faster than if you just consume dietary protein, because dietary protein involves a lot of breakdown.


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Dr Doug: so, consuming them as a powder, you can sort of hijack the system and build muscle faster. So when I look at this population, I look at this population in general as a population that struggles to build muscle


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Dr Doug: right like it's harder. We can't lift as heavier weights. We might have a more difficult starting point, and we might not have optimized sex hormones like, we're not an eighteen-year-old dude in the gym.


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Dr Doug: So any tool that we can use to help build muscle. That is extremely low risk like that particular supplement, I think, has added value. So that's why I made that video. And then the guy that makes the product that I was talking about called fundamentals. He is a friend of mine. He's a super smart Md. That only does research and makes supplements. So I like his products.


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Dr Doug: There are lots of good products, though, so the only reason why I even recommended that one is a because I trust them. But B, because it's less expensive than most of the other products on the market


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Dr Doug: we did come up with. Oh, go ahead, Cheryl.


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Cheryl Edwards: What is the best time to take that drink?


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Dr Doug: Yeah. So in theory, you could take it either while you're training or immediately after your training. I have some right here, and I need to drink it, but, like immediately after, is going to in theory increase the utilization of those amino acids if you took it like, let's say, like at night before you went to bed. You probably aren't driving a lot of muscle protein synthesis while you're sleeping right? So your body's just gonna end up converting that into shorter


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Dr Doug: good.


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Cheryl Edwards: Okay. Yeah.


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Dr Doug: That's expensive sugar that way.


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Dr Doug: Oh, I was gonna say, I did come up with, we were talking about this yesterday in a team meeting there is a brand on if you guys are using. And oh, I should put it in the let me make a note. I'm gonna put it in the dispensary there is another brand called. I think it's called perfect dominos.


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Dr Doug: and it's on full script. I'll add it to the full script list.


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Cheryl Edwards: That's the one I use.


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Dr Doug: Who said that?


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Cheryl Edwards: I did show. Okay.


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Cheryl Edwards: what I use.


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Dr Doug: Could say that?


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Dr Doug: Yeah. And so it comes in in both the powder and tablets, which could be easier to consume than the powder for some people.


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Cheryl Edwards: Does it have to be taken on an empty stomach, away from protein and fat.


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Dr Doug: I don't think so, although arguably, if I'm training or taking it shortly after training, I'm probably in a more fasted state.


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Cheryl Edwards: Okay.


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Dr Doug: Yeah. So I would think it wouldn't matter, although I don't remember if the studies looked at that fasted or not, I think they just used, supplement or non.


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Breta Alstrom: Try then.


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Breta Alstrom: I'm sure.


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Breta Alstrom: with other branch tramino acids, so not necessarily fun to memo.


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Dr Doug: I was like, Who's who's that.


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Dr Doug: I wrote on.


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Breta Alstrom: Hi! Actually, when you combine Leucine with like whey protein, a lot of the studies have been done in like an elderly population that have been hospitalized. And so they're not mobile and actually prevents muscle protein breakdown, so it can be really helpful to have combined with a protein at any point during the day, but probably not before bed, like Dr. Doug, said.


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Cheryl Edwards: So you're saying to take that you can do essential amino acids and combine them with the way protein.


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Breta Alstrom: Yes.


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Cheryl Edwards: Thank you.


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Dr Doug: Yeah, absolutely. And so that's a great example. So Brett worked as a registered dietician in the hospital setting for a long time.


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Al Kral: I love it.


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Dr Doug: Information. Yes, ma'am.


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Sharon: Are any of these dairy free.


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Dr Doug: I think about that.


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Dr Doug: I would assume so because they don't have to come from dairy, and so I don't know exactly how they're made Brett, do you have any background on that.


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Breta Alstrom: Yeah, I don't think most of the I think most of the Eas and Bca's are dairy free unless you're getting like a protein shake. That's way based. That also has them included. And then that would not be dairy free.


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Sharon: So these 2 products you mentioned are dairy free.


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Sharon: I can. I would.


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Breta Alstrom: Maybe.


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Dr Doug: Yeah, I would look on, look on the package, but I don't know why they wouldn't be, because they're not made from from way.


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Sharon: Thank you.


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Dr Doug: Yeah.


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Dr Doug: Okay? Great question.


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Dr Doug: So Susan was asking,


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Dr Doug: what's the opinion on whey protein supplement versus creatine? Great question. And then second question is on calcium. So let's address that one first. So whey protein versus creatine. They are different levers, and they're going to serve different purposes.


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Dr Doug: So whey protein is a complete protein comes from dairy, usually well tolerated, and probably the most well studied. So if you look at, you know again, get into like the muscle building space body builders. Whey protein is gonna outperform. Any other protein pretty much hands down, although I've never seen it compared to the beef hydroscine that that I consume, and other people that don't don't tolerate way. Very well. I recommend eating over, say, a a plant-based protein.


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Dr Doug: so whey protein, probably the best protein source. If you're going to add something in addition to dietary, protein.


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Dr Doug: creatine, totally different thing. So creatine is something that's gonna work intracellularly in the the muscle cells. It's gonna help to retain water. It helps with muscle performance. It literally will help with performance while working out. It'll help increase recovery. And then there's other benefits, too. It helps with B vitamin metabolism. It can help with cognitive function. It is kind of also sold as like an anti-aging tool


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Dr Doug: creatine is one of those things that starts to decline as we age. So it's from an anti-aging perspective. It's one of those things that makes sense to add in as we're getting older, I pretty much recommend it across the board for everybody, but we usually run into capsule, fatigue, and powder, fatigue and cost fatigue, and so a lot of times it ends up getting cut out.


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Dr Doug: Yeah, I take it, it's in here with my aminos.


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susan rodney: Okay, yeah. That's to us


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susan rodney: wondering if you need the 2 of them. The


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susan rodney: They don't. They don't need.


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Dr Doug: Together. No, they are not mutually inclusive. You can take them separate. You could take one and not the other. They are totally separate levers.


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susan rodney: Okay. Great.


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Dr Doug: Alright, and then, Susan, your second question was on getting calcium through diet.


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Dr Doug: So if you are getting enough calcium through diet, then how do we get enough micronutrients? So this is something that we do deal with


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Dr Doug: and kind of 2 ways to handle this. So what we used to do is that if someone was getting adequate calcium through diet, then we would use


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Dr Doug: like a trace, a trace minerals product. There's a lot of them on the market. But basically a trace. Minerals product help get some of those things in there and then, potentially even add in some other things like, Make sure you're getting enough, Boron. Make sure you're getting adequate, you know. Vitamin k vitamin D, the other fat, soluble vitamins, etc, and that can kind of stack up. So you end up sort of with, like, 3 or 4 products. And you're like, it's a lot of stuff.


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Dr Doug: And then when we started switching people back to Al Jakal based off the conversations we've had lately. Then you're getting almost all of those micronutrients in one product or 2 products.


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Dr Doug: So now we kind of have this question of all right? Well, if it's coming from


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Dr Doug: Algae, and it's a whole food source of calcium, do we really need to worry about that.


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Dr Doug: and then like not, use that product and use something else?


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Dr Doug: Or do we just use it as a backup


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Dr Doug: and understand that dietary calcium doesn't carry the same risks as rock or synthetic calcium supplementation


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Dr Doug: kind of a gray area. But generally we're still recommending the out to cal products rather than going the other route of using trace minerals plus other micronutrients.


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Dr Doug: Does that make sense.


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susan rodney: It does, but I guess I just felt like I didn't. I thought about that. But if I'm actually getting, you know, if I drink. Let's say kiefer, and getting protein through that and calcium, you know. And then I take the algebra. I guess I just was. You know it's not. We don't know 100% whether you're overloading in calcium, even, you know, even with the D. I'm sorry the K 2 in the algecow, or, if you take it. That's why I was.


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Dr Doug: Yeah.


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susan rodney: I just didn't know if there was a good supplement right without.


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Dr Doug: Yeah. So then I would use.


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susan rodney: Out, to.


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Dr Doug: I would use something like a trace. Minerals from designs for health or any of the major companies have a trace minerals product, but just make sure that it has adequate boron in it, because a lot of times they'll give you like 50 micrograms of Boron, and we need 3 milligrams of Boron, which is 3,000 micrograms.


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susan rodney: Okay, I mean, I guess. Or the other question is, if you take the alga cow, then you and then you eliminate the other calcium based products rather food sources. I don't know which is better.


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Dr Doug: My preference for me personally would be to take them both.


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Dr Doug: because again, I'm not.


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susan rodney: Because.


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Dr Doug: What we find is that through. If you if you look at the studies. And I did a


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Dr Doug: in the Algercal video that went out recently on Youtube, I highlighted a study that looked at dietary calcium, and divided up in either quartiles or quintiles. I forget, but the highest of the quartile or quintile was associated with the lowest increase in vascular calcification. So they were looking at corner.


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susan rodney: Yes, I.


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Dr Doug: And there was the lowest amount in the highest dietary consumption of calcium. So


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Dr Doug: I'm on the side now, where, if it's coming from a whole food source. I don't really care how much it is.


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susan rodney: okay? And you definitely feel the alchical is going to give us the whatever 12 whatever recommended for us to process, the 1,200 milligrams.


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Dr Doug: Al Jakob by itself is going to be with 7, 7, something 7, and change 100 milligrams.


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Dr Doug: So you still need.


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susan rodney: And then.


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Dr Doug: And some from from food. Yeah.


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susan rodney: Okay. Okay. One other question.


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susan rodney: Sorry. The other thing. I just the the milk from vegetable sources like the almond milk and the ones. They're all fortified with calcium carbonate, and I had been


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susan rodney: getting that as my calcium source, even though I take the K 2. But is that not really advisable to drink that for your calcium because of the rock calcium you're getting. It's not really like dietary. If you're getting it from a fortified product. Is that right? It's different than a natural.


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Dr Doug: Right. So in general, I think that the kind of the nut milks you know, especially like the new, the new popular oat milk. None of them. They're obviously not milk right? Like there's actually lawsuits like the dairy. Industry is like, you can't hijack our name.


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susan rodney: But.


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Dr Doug: So they are. You know. They're a synthetic liquid that's based off of compressing something. Now I use. I will use almond milk in a smoothie if I don't have raw milk just because I don't like making smoothies with water. But that's not that, not that common. So for me. I'm using raw milk now for for a smoothie base. If I'm gonna have a smoothie which is honestly not that often, anyway.


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Dr Doug: So I'll consume some of it. And from that perspective I think it's okay to consume some, to consume it every day as a source of calcium. Then you have to count it as a supplement, right? Like it's calcium carbonate


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Dr Doug: just in liquid form.


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susan rodney: Work.


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Dr Doug: So I don't. I don't think it's gonna absorb any better, and potentially could even absorb worse, you know, because it's coming with then other antinutrients from the compressed almonds


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Dr Doug: so, or whatever it is, and then oat milk in general is just garbage. So if anybody is loving their oat milk, I would recommend.


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susan rodney: And Steve.


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Sharon: Are, are any of those cause. Some of those milks have have like other kinds of forms of calcium, like calcium phosphate.


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Sharon: One had calcium citrate, I thought, but.


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Dr Doug: Yeah, but they're all. They're all either crushed rock like calcium carbonate, you know. They're made from crushing up limestone or they're synthetic, like calcium citrate right like it's just a synthetic form of calcium. And so when you look at the studies on calcium supplementation specifically citrate and carbonate, and you could argue some of the other ones. Maybe they'd be different, but not well studied. They're you're gonna spike blood levels of calcium much higher with those forms than you are with whole food forms.


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susan rodney: Good enough, thank you.


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Dr Doug: Yeah.


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Dr Doug: let's hear. So Craig was asking about heel drops great question. So we've been kind of batting this around internally with what we want to recommend for people.


00:17:50.628 --> 00:18:12.528

Dr Doug: It's like, it's easy for me to say, like, we'll just do 100 of them every day, but it actually kind of rocks. Your body right? Is anybody doing heel drops? Can I see you raise a hand? Who's doing heel drops? Yeah, like, it's not insignificant. What that does to your body. So I would say, start low, go slow and build up over time, I would say a goal like I think I think we came to a consensus of like 50


00:18:12.528 --> 00:18:23.598

Dr Doug: 50 a day every other day, or 3 times a week, or something like that. I think the studies I want to say that they did 50 a day for whatever the period of time of the study was.


00:18:23.648 --> 00:18:43.368

Dr Doug: But I know I mean even for me, like I've got some subtle back stuff like I wouldn't. I don't think that would feel very good. So just listen to your body and understand, too, it's not insignificant what you're doing. It's impact. That's why it works. So rather than just looking at what is the main goal I want to go for. Let's just start slow


00:18:43.778 --> 00:18:57.367

Dr Doug: and start low. Take it easy. Work your way up. They're easy to do anywhere. Which is the nice thing you could also potentially do them like on carpet or on a mat versus doing them on a concrete floor. You can change a lot of the variables there.


00:18:58.228 --> 00:18:59.777

Dr Doug: That's a good question, Greg.


00:19:01.028 --> 00:19:01.748

Sharon: Ups.


00:19:02.378 --> 00:19:04.008

Dr Doug: Excuse me, who said that.


00:19:04.248 --> 00:19:05.967

Sharon: I did. What! What are you jumping.


00:19:06.268 --> 00:19:06.568

Dr Doug: Should.


00:19:06.568 --> 00:19:07.818

Sharon: I'm sorry I'm new, so.


00:19:07.818 --> 00:19:29.267

Dr Doug: That's okay. No problem. So heel drops. Yeah, I would encourage you to watch the video on Youtube for the whole, the whole spiel. But a heel drop, basically is you literally, my camera can't get to the floor. But basically you are rising up on your toes like ballerina, not on your toes toes, but like on the balls of your feet, and then just letting your weight drop, literally drop into the ground.


00:19:29.268 --> 00:19:43.837

Dr Doug: so that would be one heel drop, and then you can just keep going. The way they describe it in the research studies is to land with a slightly bent knee. If you land with a truly hyper extended knee. It's pretty impactful. No pun intended.


00:19:43.858 --> 00:19:55.777

Dr Doug: So you have to be careful a little bit with that. But it was studied in multiple studies, and all of them showed well. Almost all of them showed an increase in bilateral density with that intervention alone. So it's pretty compelling.


00:19:55.778 --> 00:19:58.685

Cheryl Edwards: Is it? Is it okay to do them with shoes on with.


00:19:58.928 --> 00:20:13.177

Dr Doug: Depending on the shoe. You're going to reduce the amount of impact that you're seeing. So most shoes are designed to reduce impact. So you could start there. But I think if you really want to get the most out of it, you're going to want to do it barefoot on a hard surface.


00:20:14.378 --> 00:20:20.081

Al Kral: I think the study you mentioned that showed the goals. They said they did 200 a day.


00:20:20.398 --> 00:20:21.707

Dr Doug: There's a lot. Yeah.


00:20:21.708 --> 00:20:23.158

Al Kral: Tried. It was a lot.


00:20:23.158 --> 00:20:28.060

Dr Doug: There's a lot. Yeah, it's like a caprise caf rays.


00:20:28.878 --> 00:20:30.958

Al Kral: Doing, 4 4 fifties.


00:20:31.848 --> 00:20:37.138

Dr Doug: Yeah. And that's okay. And I think Don's doing that, too. But work up slowly.


00:20:37.138 --> 00:20:39.017

Al Kral: Wondering why my back started hurting again.


00:20:39.018 --> 00:20:40.338

Dr Doug: Right?


00:20:40.778 --> 00:20:42.748

Dr Doug: Yeah. But you are getting impact. So it's good.


00:20:42.748 --> 00:20:43.897

Al Kral: Yeah. Oh, yeah.


00:20:44.008 --> 00:20:44.948

Al Kral: Hi.


00:20:45.538 --> 00:20:46.648

kate elliott: Can I ask a question.


00:20:46.968 --> 00:20:47.928

Dr Doug: Hi, Kate, yeah.


00:20:47.928 --> 00:20:52.248

kate elliott: Hi there. So I just fractured my T. 11.


00:20:52.548 --> 00:20:52.848

Dr Doug: Car.


00:20:52.848 --> 00:21:01.158

kate elliott: Months ago. T. 10. I can't remember, anyway. So the heel drops. Should I beware? Be a little careful with those.


00:21:01.158 --> 00:21:03.158

Dr Doug: How, how long ago was it.


00:21:03.158 --> 00:21:06.508

kate elliott: It was January second, so.


00:21:07.178 --> 00:21:09.138

Dr Doug: Yeah, 4 months or 3 months.


00:21:09.921 --> 00:21:25.988

Dr Doug: So yeah, yes, be careful. You know, I can't tell you exactly when it's okay to start, because I don't know what your X-rays look like you know I would chat with your doctor and make sure that they're okay with you, starting some exercise and loading it. And again. Just once once you get clearance, just start easy.


00:21:26.168 --> 00:21:26.908

Al Kral: Hmm.


00:21:26.908 --> 00:21:30.157

Dr Doug: But you have a you know that that fracture is that your first fracture.


00:21:30.778 --> 00:21:35.647

kate elliott: No, I had a T 11 2 years prior to that.


00:21:36.467 --> 00:21:37.287

Dr Doug: that's it.


00:21:37.708 --> 00:21:38.128

kate elliott: No.


00:21:38.128 --> 00:21:39.739

Dr Doug: You got work to do, Kate?


00:21:40.008 --> 00:21:48.378

kate elliott: I know I have recovery to do. Well, I think we we talked about it. They were not just falling. They were


00:21:48.498 --> 00:21:56.377

kate elliott: ski related with my dog getting tangled up, so they were legit wipeouts.


00:21:57.038 --> 00:21:59.017

Dr Doug: Those happen too.


00:21:59.018 --> 00:21:59.487

kate elliott: Yeah.


00:21:59.958 --> 00:22:04.242

Dr Doug: Okay, fair enough. But yes, start at, get, get permission, and then start low.


00:22:04.548 --> 00:22:04.994

kate elliott: Thank you.


00:22:06.218 --> 00:22:14.377

carylofquist: The other thing that that helps with heel drops is keeping the core engaged. When you're doing the heel drops that really helps protect the back.


00:22:15.308 --> 00:22:16.587

Dr Doug: That's good. Thanks. Gary, yeah.


00:22:16.588 --> 00:22:17.167

Al Kral: And Ben's like.


00:22:17.168 --> 00:22:21.467

carylofquist: Yeah, I learned that from Nick truby. Yeah.


00:22:21.468 --> 00:22:25.797

Dr Doug: Oh, there you go. Yeah, Nick, is our exercise physiologist.


00:22:26.698 --> 00:22:27.698

Dr Doug: smart guy.


00:22:28.088 --> 00:22:31.658

Dr Doug: all right. So then, oh, yeah, on Nancy, you have your hand raised.


00:22:34.828 --> 00:22:35.418

susan rodney: You're.


00:22:35.418 --> 00:22:36.408

Dr Doug: You're unmuted.


00:22:36.528 --> 00:22:42.428

Dr Doug: Oh, you're not unmuted. Hmm, alright! While Nancy's figuring that out, I'll read this next one.


00:22:42.578 --> 00:22:50.167

Dr Doug: John was asking if someone is going off forte, but doesn't want to use reclast. When would your team need to start working with them, and how long


00:22:50.188 --> 00:23:08.437

Dr Doug: to avoid the losing the gains from Forteo. Great question, John, and the answer is, it depends. I would actually prefer to, if someone's planning on going off forte, and wants to try to not use reclast, which is a bisphosphony for those that don't know. I would want to start working with them while they're on it. Actually.


00:23:08.438 --> 00:23:33.357

Dr Doug: because we wanna get all the things in place, and it can take time to ramp everything up. So my preference is, I just had this conversation with a patient yesterday. Who's she needs to have surgery and her doctors demanding that she starts forte. And I said, That's great. Actually, it will just amplify everything that we're doing right it just. It is the most powerful tool for for osteoblasts that we have so great. Let's just do all the things. Let's stimulate your osteoblast, and then we'll put them in super drive.


00:23:33.448 --> 00:23:43.368

Dr Doug: So I would prefer to work with someone while they're on it, and then we can monitor them very closely with more frequent lab testing as they come off of it, and make sure that they're not losing bone quickly.


00:23:45.138 --> 00:23:52.847

Dr Doug: Patty asked about chocolate. Chocolate's one of those things. I don't ask questions about Patty. Same with coffee. Don't want to know.


00:23:53.577 --> 00:24:06.677

Dr Doug: I honestly haven't looked into it. And I really don't wanna know the only thing I worry I do worry about with chocolate is making sure it comes from a clean source because it apparently it can be really contaminated, which just yeah.


00:24:07.368 --> 00:24:10.498

Dr Doug: but I don't. I don't ask questions. I don't want to know the answer to.


00:24:10.798 --> 00:24:15.127

Patti Komara Patti's All American: Okay. So you don't wanna look into a study, and if it's bad, just let it go.


00:24:15.498 --> 00:24:26.617

Breta Alstrom: You know, talked about chocolate last week. So check out the video from last week. So it was all about toxins and how to manage


00:24:26.828 --> 00:24:33.108

Breta Alstrom: the toxic world, and your anxiety levels about being exposed to toxins. So I would check that.


00:24:33.758 --> 00:24:34.567

Dr Doug: All right.


00:24:34.768 --> 00:24:38.368

Dr Doug: Do you know what the summary is, Brettis, from my own knowledge.


00:24:39.052 --> 00:24:40.708

Breta Alstrom: On chocolate, or on.


00:24:40.708 --> 00:24:41.997

Dr Doug: On on chocolate.


00:24:41.998 --> 00:25:08.797

Breta Alstrom: On chocolate. I actually think I just posted something to the slack about that. But, I do think there's some forms of chocolate that are better than others. So one that I know Carrie mentioned that was like a little bit more contaminated, was like the Who chocolate Hu, and so there's looking into different brands and kind of seeing like, which are the the least contaminated, and then sticking with that. So I'll I'll get back in Hsn. Real quick in slack, and see if I can find that and post it in the chat.


00:25:08.798 --> 00:25:10.147

Dr Doug: Okay, thanks, Brett.


00:25:10.238 --> 00:25:13.098

Dr Doug: Nancy. Did you figure your audio out there?


00:25:16.758 --> 00:25:18.437

Dr Doug: She's looking. She's working hard


00:25:19.198 --> 00:25:26.517

Dr Doug: while Nancy continues to work on that. We'll move on. David was asking, is there an annotated bibliography of research that is cited?


00:25:27.103 --> 00:25:31.562

Dr Doug: No, that would take a lot of work. David.


00:25:32.108 --> 00:25:40.297

Dr Doug: so the Youtube videos have bibliographies of studies that we review and they're linked to the pubmed articles.


00:25:41.468 --> 00:25:49.088

Dr Doug: my book has an annotated bibliography, but doing that for everything we talk about. I don't have a research team for that. That takes a lot of money.


00:25:51.691 --> 00:25:53.178

susan rodney: I said.


00:25:53.178 --> 00:25:55.307

David Callen: Was. I was dreaming. I was thinking.


00:25:55.308 --> 00:25:56.248

Dr Doug: I know it would be.


00:25:56.248 --> 00:25:58.368

David Callen: Into that. You just quoted it.


00:25:58.368 --> 00:25:59.427

Dr Doug: I know it would be


00:26:00.128 --> 00:26:07.977

Dr Doug: but, man, if I could just have somebody follow me around and just take note of all the things I say, and then we could cite them and put them somewhere. It'd be amazing.


00:26:08.380 --> 00:26:11.827

Dr Doug: But that does. That takes takes people and money.


00:26:12.188 --> 00:26:13.128

Dr Doug: More money.


00:26:13.648 --> 00:26:18.181

David Callen: But you're saying, at the end of your videos, probably at the bottom there,


00:26:19.363 --> 00:26:25.138

Dr Doug: All the Youtube videos. When I talk about a study there, the link to the pub met article is in there.


00:26:25.428 --> 00:26:26.688

David Callen: Okay. Thank you.


00:26:26.688 --> 00:26:32.102

Dr Doug: Yeah, totally that I can do, because I have to read them. So if if I read them I can grab the link.


00:26:32.888 --> 00:26:33.930

David Callen: Wonderful. Thank you.


00:26:34.278 --> 00:26:48.688

Dr Doug: And I do. I do have a research team. So when we go through this stuff, I do have a researcher that's answering these questions essentially for me. And they're putting, you know. I'll get a list like for every video where I talk about 3 studies, I probably get a list of 15 or 20 articles.


00:26:48.718 --> 00:26:54.658

Dr Doug: So I do have. If you have a topic that you're really interested in, I could pass that along. It's


00:26:55.488 --> 00:27:00.438

Dr Doug: it's still very time consuming, but it's at least making it less of, or more efficient, more efficient.


00:27:00.438 --> 00:27:07.688

David Callen: Well, it's the link helps tremendously. It sure beats having to take a picture of the of the TV screen.


00:27:07.688 --> 00:27:09.178

Dr Doug: Yeah, yeah, I know.


00:27:09.178 --> 00:27:09.908

David Callen: And so.


00:27:09.928 --> 00:27:11.688

Dr Doug: Anyway. Thank you.


00:27:12.038 --> 00:27:38.424

Dr Doug: Yeah. And then that is another tool. For if you guys are using AI or chat Gpt for anything, taking a study from pubmed. If you can just copy and paste the entire content of the study and drop it into Chat Gpt, and ask it to summarize it and 10 bullet points, and it'll you know, you could even say like, summarize this at a fifth grade level with 10 bullet points, and it'll like it's a really cool way to to consume content quickly.


00:27:39.418 --> 00:27:51.677

Dr Doug: Cause I don't know about you, but I get bogged down reading these articles and looking at this stuff like, if I need to look in the deep, I can. But just getting a summary is really helpful to know if it's even worth your time reading.


00:27:51.918 --> 00:28:09.648

David Callen: And it's very helpful having you doing this because how many doctors have seen that haven't been doing it, and they don't tell us they haven't been keeping up with the research, and when I go, do the research, then they accuse you of picking and choosing. If you come up with different conclusions, so appreciate it.


00:28:09.648 --> 00:28:12.847

Dr Doug: Your Google search does not trump my degree. Actually.


00:28:13.478 --> 00:28:15.428

Dr Doug: kind of does. Yeah, it kind of.


00:28:15.428 --> 00:28:16.448

David Callen: I I understand.


00:28:16.768 --> 00:28:28.998

David Callen: Probably I understand that. Well, I'm just studying me as a whole different ball game. When I look at everyone else here in our zoom chat that they all have different scenario. Situations. So yeah.


00:28:28.998 --> 00:28:54.918

Dr Doug: Yeah. Well, Lauren, I see your hand just a sec so I had a gosh! Was this a patient of mine? I get comments in so many places. But I just had another person yesterday who was saying that they were essentially like they were harassed by their doctor for refusing to take medication, and then they were harassed by their doctor for requesting to get labs specifically on hormone levels. And they said that if if they're


00:28:54.918 --> 00:29:00.938

Dr Doug: if they're working with another doctor who's doing hormone levels. That's a bad doctor. I was like.


00:29:01.498 --> 00:29:03.860

Dr Doug: what an asshole


00:29:05.167 --> 00:29:13.537

Dr Doug: I just don't understand. I don't understand that thought process at all. It's just trying to limit information to to what make your day more efficient. I don't get it.


00:29:14.183 --> 00:29:16.657

Dr Doug: Anyway, that's a soapbox.


00:29:17.113 --> 00:29:19.427

Dr Doug: Lorna, what were you gonna ask.


00:29:21.518 --> 00:29:25.438

Lorna Nichols: the the initial topic you mentioned starting out.


00:29:26.238 --> 00:29:28.518

Lorna Nichols: I got. I got a


00:29:28.628 --> 00:29:32.218

Lorna Nichols: I loved your video interviewing the heart doctor.


00:29:32.488 --> 00:29:33.877

Dr Doug: Yeah, just twine.


00:29:34.383 --> 00:29:34.888

Lorna Nichols: Warning


00:29:35.248 --> 00:29:39.127

Lorna Nichols: a ultrasound of my carotid artery.


00:29:39.128 --> 00:29:39.978

Dr Doug: Perfect.


00:29:39.978 --> 00:29:41.968

Lorna Nichols: I'm still trying to get


00:29:42.208 --> 00:29:43.898

Lorna Nichols: a Ccta.


00:29:44.208 --> 00:29:50.818

Lorna Nichols: The insurance I've got to. I'm trying to get somebody to, anyway, it'll depend, maybe, on the crowded artery.


00:29:50.958 --> 00:29:51.788

Lorna Nichols: But


00:29:55.518 --> 00:30:00.887

Lorna Nichols: I'm wanting I'm I'm in that crux of gosh! Maybe I shouldn't be eating so much fat.


00:30:01.419 --> 00:30:09.577

Lorna Nichols: Because I'm eating all this good stuff, and everything has fat in it. And I'm you know. Do you have? I mean, it's a big topic. You could go off.


00:30:10.368 --> 00:30:13.797

Lorna Nichols: But is there anything on the top of your mind that you can throw at me about that.


00:30:13.958 --> 00:30:41.478

Dr Doug: Oh, yeah, for sure. So let's I'm gonna put some of these supplementation questions on ice. So let's bring these back next week. And let's just switch to talk at least about cardiovascular disease cause. This is a topic that we do. I talk about it a lot, and it's it's always at the end of our consultation. So usually by then people's brains are exploding. And it doesn't really sink in very well. So like Lauren. I don't even know how much we talked about it when you and I chatted.


00:30:41.508 --> 00:30:42.677

Dr Doug: But yeah.


00:30:42.678 --> 00:30:44.707

Lorna Nichols: You mention nitric oxide.


00:30:45.298 --> 00:30:47.038

Dr Doug: We did. Yeah. So


00:30:48.048 --> 00:30:49.048

Dr Doug: where to start


00:30:50.118 --> 00:30:51.978

Dr Doug: when it comes to


00:30:52.018 --> 00:30:54.677

Dr Doug: cardiovascular health and diet.


00:30:55.118 --> 00:31:02.637

Dr Doug: we have to talk about cholesterol, and I know I've talked about that in this format, so I don't want to dig into all the different things on cholesterol.


00:31:02.838 --> 00:31:12.837

Dr Doug: But the summary I have around dietary, fat cholesterol and bone. Health versus cardiovascular health is that we have to come to some consensus.


00:31:13.088 --> 00:31:27.967

Dr Doug: We are all taught over the last several decades that cholesterol is bad and dietary fat, particularly saturated. Fat will cause heart disease. And it's going to be a problem. You're going to develop plaque, and you're going to die. Right? So then we're all told to eat a higher carbohydrate, low, fat diet


00:31:27.978 --> 00:31:48.788

Dr Doug: turns out that that's part of why we are all struggling with obesity and overweight, although not so much in this group, but in the population in general, that that diet also has negatives. So a dietary fat was wrongly villainized, and so, Lorna, when it comes to your particular diet around, are you developing plaque in your artery


00:31:49.178 --> 00:31:50.878

Dr Doug: versus in your heart?


00:31:51.217 --> 00:32:17.877

Dr Doug: Or you're getting all the protein that you need from animal sources for your bones. This is the little iconic quagmire right? And so the dietary, fat in general is not gonna provoke elevation in lipids in most people, so we'll put the whether or not lipids are bad or not. On on the side of something else, lipids by lipid cholesterol. So dietary fat in general is not gonna be bad. In fact, usually the more dietary fat you consume the better your cholesterol looks.


00:32:17.878 --> 00:32:39.607

Dr Doug: It's the saturated fact that for some people can provoke an elevation and Ldl cholesterol, you could still argue that that's actually not a problem. But let's just assume that someone has some disease that your arteries show some buildup because most do, or that you have some coronary artery or the arteries that lead to your heart disease, and you wanna reduce your cholesterol through diet as much as possible.


00:32:39.918 --> 00:32:42.848

Dr Doug: reducing saturated fat, for some people will do it.


00:32:42.908 --> 00:32:56.938

Dr Doug: We can test that genetically. There's some very clear genetic variations or snps that we can predict. If you're going to have a bad response to saturated fat for people that we have. Excuse me, genetics. We will intentionally bring that down pretty darn low.


00:32:57.138 --> 00:33:14.298

Dr Doug: because we know that they're likely gonna see inflammation as a result of consuming saturated fat for other people that increase their consumption of animal protein and their Ldl cholesterol goes up. Then you can still trial, bringing down saturated, fat, and still consume animal protein. You just have to change the protein right?


00:33:14.298 --> 00:33:38.528

Dr Doug: So like a lot of people in. This is true for my wife's program, too, with weight loss, you sort of give them permission to eat bacon and ribeyes, and then all of a sudden, they're having a ribeye for lunch and dinner. That's a lot of saturated fat, and so, if we go back ancestrally, those cuts are pretty rare. If you were to slaughter an animal, consume all of the parts, most of the parts, especially a wild animal, are pretty lean.


00:33:38.528 --> 00:34:03.367

Dr Doug: So getting a really marbled ribeye is something that didn't really exist in nature before the last. I don't know 50 years. So I think that's sort of an aberration of what we really probably should be consuming. Not to say that you can never eat a ribeye. I love a ribeye, but eating leaner cuts, wild game grass fed game is going to be leaner, tougher. All those things make a difference.


00:34:03.707 --> 00:34:28.278

Dr Doug: The leaner cuts in general like a filet, or like lean ground beef from a if cost is an issue. Then you're gonna get less saturated fat. So you can still do that and and get less saturated fat and get the protein that you need. I always say it like, look at the diet that's gonna fix the most problems. So if you're eating the diet that improves your bones, improves your metabolic health decreases your risk of dementia and


00:34:28.278 --> 00:34:48.038

Dr Doug: potentially increases your cholesterol, I would actually take that diet over the diet. That doesn't serve all the other things, but will bring down your cholesterol because we see this a lot in the plant-based community, because we know that if you eat a plant-based diet your Ldl. Will come down. That's great. However, if you lose bone, lose muscle and develop diabetes as a result of that.


00:34:48.148 --> 00:35:03.677

Dr Doug: then that wasn't great. We can control cholesterol with other means, if we had to, and we don't necessarily need to. But if we needed to, we can pharmacologically control cholesterol. So again, I would rather eat the diet that's going to support the most things possible as we age?


00:35:04.618 --> 00:35:05.948

Dr Doug: Did that answer your question?


00:35:06.168 --> 00:35:23.767

Lorna Nichols: That that was wonderful. The carotted artery. When I when I get the results in my portal online, it there's gonna it's just gonna scare the hell out of me. And I do you have any comments about that test to prepare me for the getting the results.


00:35:24.408 --> 00:35:34.947

Dr Doug: Yeah, so I don't. I don't order a lot of them. I probably should if we were just to get everything. But I try to get what's the lowest hanging fruit going to give us the most information for the least amount of effort.


00:35:35.078 --> 00:35:40.528

Dr Doug: So for me, I prefer to look at the coronary arteries, because it's a Ct, it's quick and it's easy.


00:35:40.648 --> 00:35:46.938

Dr Doug: The benefit of the ultrasound is that it's usually also inexpensive. It's usually also quick, and there's no radiation.


00:35:47.178 --> 00:36:04.957

Dr Doug: The downside is that I never see a like a 0 carotted artery duplex, right? The ultrasound always shows some thickening, and we don't really know is that really plaque? Is it remodeling of the artery like? It's kinda hard to differentiate those things on ultrasound. So


00:36:05.588 --> 00:36:20.857

Dr Doug: for me, it doesn't help me as much. Now you heard Dr. Twyman talk about that. He utilizes that test, and that makes sense because this is all he does. He gets all the things. So for him it helps him to differentiate a little bit. But for me, I want to know what's going on in the arteries in the heart


00:36:20.948 --> 00:36:29.318

Dr Doug: that test. The crowded ultrasound in my experience is always positive. It's just a matter of how much. And then, with that graded, how much.


00:36:29.418 --> 00:36:33.647

Dr Doug: I wonder how much variation there is from scan to scan.


00:36:33.748 --> 00:36:47.488

Dr Doug: but also how much of that is actually plaque burden, or how much is just thickening of the arteries over time do we have a reference point? Do we know what it was 2 years ago, 5 years ago, 6 months ago? We don't, because this is your first one. So it's hard to interpret


00:36:47.638 --> 00:36:48.938

Dr Doug: is my point.


00:36:48.938 --> 00:36:54.457

Lorna Nichols: So the Ccta. That's the gold standard of that's just get that. And the questions answered.


00:36:54.458 --> 00:37:00.618

Dr Doug: Well, I wouldn't call it the gold Standard, because the way that we do it, the Ccta. And Alan, I saw your question, your hand.


00:37:00.618 --> 00:37:01.437

Al Kral: Call him.


00:37:01.438 --> 00:37:11.168

Dr Doug: The way that we do the Cctas generally. We'll also do the coronary calcium score first, so I'll say that again. Slower the coronary artery, calcium score or cac


00:37:11.388 --> 00:37:14.748

Dr Doug: is the the first imaging test we get done.


00:37:14.818 --> 00:37:25.077

Dr Doug: If someone's never had any imaging done, because it can answer our question very simply, and that study is just looking for calcium in the coronary arteries or the arteries that go to the heart.


00:37:25.078 --> 00:37:44.837

Dr Doug: And if you have calcium buildup, then you know that you have probably longstanding plaque. If you have a lot of it, it kind of answers our question to say, like, you have longstanding disease, and it's significant. So we actually don't really need to ask any more questions. So for those patients in general, we're not getting a Ccta, which is the next step, because we kind of already know the answer


00:37:45.348 --> 00:37:48.727

Dr Doug: for someone that has a 0 on on Cac.


00:37:48.758 --> 00:38:01.137

Dr Doug: Then a Ccta is the right next test, in my opinion, because it tells you about actual narrowing, and it tells you about soft plaque, and because of the technology of the clearly company.


00:38:01.148 --> 00:38:11.058

Dr Doug: they can give us a 3D representation and show even in very minimal plaque, like, I have a 6% stenosis of one of my arteries. It's tiny


00:38:11.268 --> 00:38:39.087

Dr Doug: and it's good good for me to know, because I know that I have some plaque. So I am doing something about my cholesterol. If someone has a 0 which I've seen a couple of, and their cholesterol is 300. I don't care cause they're not developing plaque, so it tells us a lot about what's going on in the heart. The downside is, it's done in the hospital setting. It's expensive. It takes Iv contrast. And then the clearly on top of that is another, you know, $950. So it's not cheap.


00:38:39.178 --> 00:38:49.347

Dr Doug: But it's an amazing test if you have the resources to get it. So it's definitely not gold standard. It is very much advanced, and something that Twyman and myself, and


00:38:49.548 --> 00:38:51.388

Dr Doug: hopefully, more and more people would do.


00:38:52.348 --> 00:38:57.557

Lorna Nichols: If I can't get the clearly part, just the Ccta. Is it still worth it? I mean, it's still good right.


00:38:57.558 --> 00:39:13.377

Dr Doug: Without the clearly the Ccta. Isn't that helpful? It's a broad stroke, it'll tell you, because you get the images. The images don't help me. But a radiologist will look at the images and say, Oh, there's a 20% to 40% stenosis in this particular artery


00:39:13.598 --> 00:39:23.658

Dr Doug: which is helpful. But I've seen that read be very different than what comes out on clearly. And I trust clearly, because it's a very sophisticated algorithm.


00:39:23.998 --> 00:39:33.308

Dr Doug: So honestly for me, unless you were having symptoms unless you're having chest pain or shortness of breath, then I wouldn't get the Ccta by itself.


00:39:34.608 --> 00:39:35.378

Lorna Nichols: Thank you.


00:39:35.628 --> 00:39:36.168

Dr Doug: Yeah.


00:39:37.039 --> 00:39:40.277

Dr Doug: I think Barbara had her hand up, Alan, and then we'll come to you.


00:39:40.278 --> 00:39:40.978

Al Kral: Okay.


00:39:40.978 --> 00:39:50.668

Barbara berger: Hi, yes, thank you. Yeah. W. One quick one on that Ccta. So I had one long ago. Well, I think it was 2,020. Is that a repeated test?


00:39:50.728 --> 00:39:53.858

Barbara berger: When you know you have this 2 kinds of plaque.


00:39:54.268 --> 00:40:13.218

Dr Doug: For sure. Yeah. So what I tell people that have a 0 coronary calcium score that have some disease on Ccta, we can make some decisions around. Okay, how aggressive do we want to be with either pharmacologic therapy or nutraceutical therapy or even diet. But let's continue to check this over time.


00:40:13.218 --> 00:40:32.777

Dr Doug: So my plan for me, like I said, I have a 6% lesion. I did it last year. I'll probably repeat it in, you know, 2 to 3 years and see what's happening, and see if I need to be more. I'm using a drug personally called Zedia or Zetamide, which works for some people, but not for others, but for me. It does bring my Lvl down pretty significantly, and it has essentially no side effect.


00:40:33.588 --> 00:40:41.417

Dr Doug: So I'm doing that. But I'm not on a statin. Now, if I went from 6% to like 15% over 3 years, then I would start a statin.


00:40:41.518 --> 00:40:46.498

Dr Doug: So I think it's really helpful to repeat that study, to, to monitor for progression over time.


00:40:46.718 --> 00:40:53.608

Barbara berger: Okay, okay, so I put this in the chat earlier. But I also watched that video with Dr. Twyman


00:40:53.658 --> 00:40:59.498

Barbara berger: and my, you know, now I see the everything's intertwined. Now my question is.


00:41:00.138 --> 00:41:06.308

Barbara berger: the cardiologist had me on nias niacin to try to boost my


00:41:06.338 --> 00:41:10.057

Barbara berger: hdl because we have that genetic apo


00:41:10.098 --> 00:41:17.398

Barbara berger: a life away. Deficiency that messed up my liver, my ats, my alt's


00:41:17.998 --> 00:41:19.317

Barbara berger: are out of range.


00:41:19.318 --> 00:41:19.608

Dr Doug: Yeah.


00:41:19.898 --> 00:41:29.827

Barbara berger: Now it's all connected, so no one seems concerned that my Alt's are in the red level at 30. Well, it was 39. Now it's 35, cause I stopped the nice. And


00:41:30.718 --> 00:41:34.168

Barbara berger: how connected is ostio with


00:41:35.078 --> 00:41:39.218

Barbara berger: the liver, I mean, how is all this working together now?


00:41:39.468 --> 00:41:40.403

Dr Doug: Yeah,


00:41:41.568 --> 00:41:53.718

Dr Doug: it's connected for sure. You don't want your liver to be throwing red flags of inflammation and dysfunction. Niacin can certainly do that especially extended release, Nysin or non-flushing niacin.


00:41:54.208 --> 00:42:04.588

Dr Doug: So I don't use niacin for that reason. The other issue with Nican is that there's no study that shows any mortality benefit, meaning that it will change. It'll affect your lipids.


00:42:04.888 --> 00:42:06.917

Dr Doug: but it doesn't change the events.


00:42:07.018 --> 00:42:09.237

Dr Doug: and it's been studied pretty aggressively right.


00:42:09.238 --> 00:42:11.287

Barbara berger: Yeah, I saw a study on that.


00:42:11.288 --> 00:42:15.597

Dr Doug: Yeah. So it's not like, it's treating numbers, and it's not treating disease. So so that's why.


00:42:15.598 --> 00:42:19.701

Barbara berger: But I'm off of it now, but I still can't get the liver back to normal.


00:42:19.958 --> 00:42:28.767

Dr Doug: It'll get there. It'll get there unless there's another reason, unless that was a red herring, and there's something else going on, but also thirtys for Ast. And Lt, is not that high.


00:42:28.838 --> 00:42:29.987

Dr Doug: you know. That's like.


00:42:30.678 --> 00:42:32.198

Dr Doug: still pretty normal.


00:42:32.198 --> 00:42:35.447

Barbara berger: Yeah, that's what the doctor said. I'm not concerned. Well, I am.


00:42:35.718 --> 00:42:42.897

Dr Doug: Yeah, no, fair enough. But like, when you're looking at true, like liver dysfunction, your your alt and ast will get into the hundreds and thousands.


00:42:42.898 --> 00:42:43.763

Barbara berger: Oh, okay.


00:42:44.628 --> 00:42:47.868

Dr Doug: So like when you see, like an alt of 3,000. You're like.


00:42:47.868 --> 00:42:49.017

Barbara berger: Oh, okay, I'm at. I was.


00:42:49.018 --> 00:42:49.518

Dr Doug: So probably.


00:42:49.518 --> 00:42:50.667

Barbara berger: Okay, yeah. Gotcha.


00:42:50.668 --> 00:42:55.428

Dr Doug: Right? So you're still technically even, I think you're probably in reference range or just outside of reference range.


00:42:55.428 --> 00:42:56.288

Barbara berger: Outside, yeah.


00:42:56.288 --> 00:42:56.678

Dr Doug: Yeah.


00:42:56.678 --> 00:42:58.787

Barbara berger: Okay, I feel better. Thank you.


00:42:58.788 --> 00:43:04.018

Dr Doug: Yeah, of course. Hold on, Kate. I'm gonna talk to Alan, and then we'll go back to Kate.


00:43:04.048 --> 00:43:06.218

Dr Doug: I know you guys can't see each other like I can.


00:43:06.528 --> 00:43:07.937

Dr Doug: Yes, Alan, yeah.


00:43:07.938 --> 00:43:11.075

Al Kral: Yeah, I've been getting a carotid artery artery


00:43:11.718 --> 00:43:15.838

Al Kral: scans for a lot of years, and it always says normal


00:43:16.188 --> 00:43:19.177

Al Kral: and like a hundred, 25 Ccs.


00:43:19.468 --> 00:43:21.937

Al Kral: Is that like? How open it is?


00:43:22.368 --> 00:43:28.627

Dr Doug: Boy, I'd I'd have to look at the scan again. I don't order them very often, so I probably shouldn't answer that with any degree of certain.


00:43:28.628 --> 00:43:30.469

Al Kral: But it says normal. So.


00:43:31.078 --> 00:43:35.938

Dr Doug: Well, then, the challenge I have with normal, too, is that normal for age?


00:43:35.938 --> 00:43:36.617

Al Kral: I don't know.


00:43:36.618 --> 00:43:44.317

Dr Doug: So when you look at from an aging perspective, they'll say the coronary calcium score when it comes back. Normal might not be 0,


00:43:44.348 --> 00:43:55.158

Dr Doug: because the average population will be nonzero at some point. It's almost like the same thing to say. Really, you could argue that osteoporosis is normal for one hundred-year-old. But that doesn't mean that I want them to have it.


00:43:55.348 --> 00:44:00.627

Dr Doug: So we need to. We need to understand what that means. And I can't answer that clearly with an ultrasound, because I don't look at them.


00:44:00.768 --> 00:44:04.458

Al Kral: I guess if it stays at a hundred 25 CC's, it ain't getting worse.


00:44:04.598 --> 00:44:12.197

Dr Doug: I guess I don't know. It's a good question for Twyman. He does on Instagram. He does a live Q. And a. I think every day.


00:44:13.153 --> 00:44:16.808

Dr Doug: So if you guys follow him on Instagram, and you could ask him fun questions like that.


00:44:17.638 --> 00:44:19.277

Dr Doug: Okay? And then Kate.


00:44:19.688 --> 00:44:28.688

kate elliott: Alright! I'll try and make it quick here. So on the nyason I was on the active B complex and


00:44:29.328 --> 00:44:35.511

kate elliott: I'm not sure if you heard Dr. Doug, but I ended up in the er because.


00:44:36.228 --> 00:44:37.217

Dr Doug: You yesterday, Kate!


00:44:37.218 --> 00:45:07.058

kate elliott: Yes, yes. So anyway. Yeah. First trip to the er I looked like a tomato. I didn't know what it was all about. You know. A $1,000 later, anyway. Then it just became apparent because I had 2 other incidents where they had me take Benadryl. I skipped the er visit and my brother in law brought up this flush with the niacin. So anyway, we think that's it.


00:45:07.695 --> 00:45:12.478

kate elliott: So I think the reason they had me on that was to increase the H


00:45:12.527 --> 00:45:16.847

kate elliott: deals, I'm not sure. Is there a B complex without nyacend?


00:45:17.078 --> 00:45:26.197

Dr Doug: There are, and bread, I might be able to look something up. But so here's what's interesting. So we've had a couple of patients have flushing with that active B complex.


00:45:26.638 --> 00:45:30.668

Dr Doug: What's interesting is the amount of niacin in that is almost nothing.


00:45:30.998 --> 00:45:51.148

Dr Doug: So it's it's really interesting that we've seen that. So we switched from a product from the company ortho molecular. We used methyl B complex, which is a similar product. We switch to active B complex because it has better forms of B, 6. It has the p. 5. P. Version of B, 6. And it has a couple of the things that we like. It has 10 micrograms, more of


00:45:51.268 --> 00:45:55.988

Dr Doug: niacin or 10 milligrams, I forget. But anyway, from 50 to 60


00:45:56.088 --> 00:46:00.667

Dr Doug: it is a subtle difference, and I've never seen flushing on the other product.


00:46:00.848 --> 00:46:06.327

Dr Doug: And so in the other people that reported Flushing, they continued to take it, and it went away.


00:46:06.808 --> 00:46:24.535

Dr Doug: And and so I don't think anybody else went to the emergency department. So I'm sorry you went to the emergency department. flushing feels uncomfortable. I've I've played with nice, and I've taken, you know, a thousand milligrams and 2,000 milligrams. And yeah, I know what Flushing feels like. And it feels like you're gonna die. So totally get it.


00:46:24.808 --> 00:46:25.648

kate elliott: Yeah. Crazy.


00:46:25.648 --> 00:46:31.457

Dr Doug: But I can't explain why that particular product does it? But yes, there are other products that have no niacin in them.


00:46:31.458 --> 00:46:35.878

kate elliott: Okay, I think I think they've switched me over so quickly on


00:46:35.938 --> 00:46:48.817

kate elliott: the J. So my Lipa protein, A, I think it's called, is super high. It's in 200. So I have that genetic thing going on. My cac was 0 on calcium. But.


00:46:48.818 --> 00:46:49.378

Dr Doug: Perfect.


00:46:49.378 --> 00:47:02.018

kate elliott: I wonder? So my question is is, I think you're going to put me on estrogen, and you wanted me to have that Caac before that. So I think we're Ok. There. But is there a concern


00:47:02.038 --> 00:47:18.057

kate elliott: with my, and I think my Ldl. Is high, too. My ratio is good, but the Ldl is high. Do I need to take extra precaution? Should I definitely for be pursuing that Ccta. Before I take estrogen or no.


00:47:18.342 --> 00:47:22.608

Dr Doug: Kate, can we dig in? Can are you comfortable? Talking about yourself in this audience?


00:47:22.608 --> 00:47:23.488

kate elliott: Absolutely. Yeah.


00:47:23.488 --> 00:47:31.987

Dr Doug: And recording it and sending it out to the Internet. Ok, so remind me how far out you are from outside of menopause.


00:47:32.398 --> 00:47:36.447

kate elliott: I'm 62, so it's a bit about 11 years.


00:47:36.448 --> 00:47:56.798

Dr Doug: Yeah. So you're right in that. So if we, if we divide people, if we divide women from, you know, 10 years out from menopause, 10 to 2020 to 30. There was a recent study that I did a video on that basically says that if you look at that, women's health initiative data within 10 years. Starting estrogen is protective of heart disease which makes sense


00:47:57.008 --> 00:48:09.067

Dr Doug: 10 to 20 years. It's neutralized meaning. There's actually no increased risk in your age group, and then 20 plus years out. Then there isn't. There is an increased risk, and it's real. It's not big, but it's real.


00:48:09.278 --> 00:48:33.958

Dr Doug: And so so technically, you don't have increased risk. Now, what does that mean? Clinically for me? I still wanna get the corn artery calcium score, because if you've been diabetic for 40 years, and you have terrible arteries like, are we increasing your risk? And maybe you know, with just that one study doesn't necessarily show that group. So I would wanna know that now that's not necessarily you. And if your Cac is 0, then it's compelling enough to say that


00:48:34.018 --> 00:48:41.667

Dr Doug: the research says that you don't have increased risk. Your Cac. Is 0. You really don't have any other risk. Factors other than elevated Ldl and Lp. Little a.


00:48:41.778 --> 00:48:53.037

Dr Doug: So should you get the Ccta first. It just depends on how many eyes you want to, dot and t's you want to cross. It would make me feel better if I could wave a magic wand and have the Ccta data then? Absolutely.


00:48:53.128 --> 00:49:18.778

Dr Doug: But it's, you know, going running through insurance, getting the Iv. Going to the hospital paying $1,000. It's all the stuff, right? So if I could have it, I would prefer to have it. But if you're comfortable without it. Then I'm comfortable without it, too, because technically, I'm probably one of the only doctors that's actually asking. So I'm also one of the only doctors that will prescribe it. So we're we're in this really big gray area here.


00:49:19.578 --> 00:49:31.727

kate elliott: Hmm, is there a problem? Just my last question is I I have no problem going after that Ccta test because I'd be interested with my genetic markers that are higher.


00:49:31.918 --> 00:49:44.147

kate elliott: So. But is there a problem with too much radiation? I've had a mammogram then I've had the Cac. And then I had also the cat scan on my vertebra. All in 3 months.


00:49:45.218 --> 00:49:57.567

Dr Doug: Yes, there is an issue with too much radiation. The funny thing about radiation is that the safe level of radiation is 0, which we can't do because there's radiation just by living on the planet.


00:49:58.286 --> 00:50:00.377

Dr Doug: So yeah, you know. And


00:50:00.538 --> 00:50:22.508

Dr Doug: gosh, if if we weren't pushing the time limits on starting estrogen, I would say. Well, let's let your body sort of off offload some radiation right? We actually even we have a radiation protocol, too, that you. I don't know if we sent it to you or not before you got your cac. But we've created a radiation protocol that can help to offload radiation. So, yeah, it is. It is something to consider.


00:50:22.978 --> 00:50:23.678

kate elliott: Okay.


00:50:24.328 --> 00:50:24.888

kate elliott: Yeah.


00:50:24.888 --> 00:50:26.907

Dr Doug: But also the longer you wait.


00:50:28.918 --> 00:50:34.408

Dr Doug: the longer you wait the higher your risk. You got a while, though, because you're 11 years versus somebody who's like 19 years.


00:50:36.838 --> 00:50:41.037

Dr Doug: Tough, tough grey area. Cheryl, did that answer your question? I know that you were


00:50:41.318 --> 00:50:49.338

Cheryl Edwards: She answered. Quite a bit of it. I have an elevated lp, little a 2 with a 0 calcium score and stellar lipids, and should I be worried.


00:50:50.413 --> 00:50:52.868

Dr Doug: I'm sorry. Say that. Say that again. You kind of broke up for me.


00:50:52.868 --> 00:51:01.038

Cheryl Edwards: Oh, I have a slightly elevated lp. Little a 129 animals, calcium score of 0 and stellar lipids.


00:51:01.767 --> 00:51:20.637

Dr Doug: Stellar stellar was the part I didn't hear so lp, little A is interesting one, so we've been measuring it for a long time, and I find that there's a pretty strong correlation between people that have lp, little a. That's elevated, and family history of of coronary disease, events, etc.


00:51:20.798 --> 00:51:22.438

Dr Doug: but it's not a hundred percent.


00:51:22.648 --> 00:51:41.937

Dr Doug: so I can't tell that you have. Like you, you meet the threshold for having Lp little a the number isn't so relevant as just like, have it? Don't have it. You have it so. You have that risk factor. But if your lipids have been good, and for me, I would still want to know, like I would still get a cac for sure as a minimum.


00:51:43.068 --> 00:51:44.638

Cheryl Edwards: Which I did, and it's 0.


00:51:44.638 --> 00:51:51.527

Dr Doug: Yeah, which is great. And so then you could go down the pathway of getting a Cctta. But again, just decide if it's worth it, for you.


00:51:52.028 --> 00:51:53.118

Cheryl Edwards: Okay. Thanks.


00:51:53.118 --> 00:52:02.877

Dr Doug: Yeah, yeah, again. So if you look at people like famous people like Peter Otia longevity doctor, he gets a Ccta with clearly on every patient that walks in the door.


00:52:03.148 --> 00:52:12.657

Dr Doug: So it is becoming more standard. But this is a guy that has a cash practice that costs 100 k. To work with. So that's the kind of population that he's dealing with.


00:52:13.237 --> 00:52:15.427

Dr Doug: Barbara, you've had your hand up for like an hour.


00:52:15.748 --> 00:52:16.128

Delain's iPad: Is not.


00:52:16.128 --> 00:52:16.798

Dr Doug: Was getting.


00:52:16.798 --> 00:52:18.668

Delain's iPad: Another water.


00:52:20.048 --> 00:52:21.077

Dr Doug: I didn't catch that.


00:52:23.318 --> 00:52:25.078

Dr Doug: Oh, I think we just lost Barbara.


00:52:26.198 --> 00:52:27.517

Dr Doug: She clicked end no.


00:52:27.518 --> 00:52:29.517

Barbara berger: No! You spoke to me already.


00:52:29.518 --> 00:52:40.767

Dr Doug: There, you? Oh, you're good, Ok, great, all right. So we have a few minutes left rather than me looking. We have 46 messages in the chat


00:52:40.808 --> 00:52:48.408

Dr Doug: rather than me. Looking through that, what other questions do we have around? Lp. Little a coronary, calcium score ccta. Anything else there for anyone.


00:52:50.508 --> 00:52:52.147

Al Kral: Does it cost a grand.


00:52:52.548 --> 00:52:57.668

Dr Doug: Yeah, they clearly cost $950. I think something like that.


00:52:57.668 --> 00:52:58.458

Al Kral: Dan.


00:52:59.658 --> 00:53:13.897

Dr Doug: That's just the clearly side. So that's just the AI algorithm looking at it. The scan will depend on the hospital, and that's the biggest variable is. Every hospital is different. It could cost $1,000. Some hospitals will charge like $5,000. It's impossible to know


00:53:14.028 --> 00:53:30.397

Dr Doug: you can try to price it out. But that's even hard, like transparency and pricing in our medical system is terrible. So we basically, we write the order as if it's gonna get covered by insurance, and as far as I know, it's always been covered by insurance.


00:53:31.178 --> 00:53:35.558

Dr Doug: That side of it. Even mine was covered by insurance, and I don't have any risk factors, so.


00:53:35.558 --> 00:53:42.117

Al Kral: There's the. When she sent me the list. There was no nowhere within a couple of 100 miles of me that did it.


00:53:42.968 --> 00:53:44.130

Dr Doug: Oh, that's interesting!


00:53:44.518 --> 00:53:45.988

Al Kral: Michigan, I would have to go.


00:53:45.988 --> 00:53:53.968

Dr Doug: Technically, any hospital can do it. It's just a matter of whether or not it's a hospital that has worked with clearly before.


00:53:54.788 --> 00:54:14.637

Dr Doug: So if you wanna do it just find a hospital that can do the Ccta. Just make sure. Make sure. Make sure that you walk out of that hospital with a disk in hand that has the images on it like, take a laptop and stick that disk in there and fire it up yourself, because getting that disk after the fact is nearly impossible.


00:54:16.798 --> 00:54:25.398

Barbara berger: I have one more on that light. OA! My! So they upped my rovers, and


00:54:25.468 --> 00:54:28.207

Barbara berger: to 20 from 10.


00:54:28.208 --> 00:54:28.778

Dr Doug: Yeah.


00:54:29.278 --> 00:54:35.387

Barbara berger: It. It's only making it worse. My, my Hdl. Is 39. My Lvl. Is


00:54:35.428 --> 00:54:42.387

Barbara berger: 63. So this is like, I'm tired all the time. Isn't that has something to do with low cholesterol.


00:54:42.848 --> 00:54:50.227

Dr Doug: It can. Low cholesterol is interesting. I mean, cholesterol is a natural molecule. That's why I don't always treat it


00:54:50.804 --> 00:54:55.598

Dr Doug: but we have to also. Then compare that with what's happening in the arteries. So if somebody has.


00:54:55.598 --> 00:54:56.078

Barbara berger: It's good.


00:54:56.078 --> 00:55:09.428

Dr Doug: Disease, then we do treat it so. The drug that you're on is the same drug that I use if we're going to use a statin. So receiva statin is probably, I think, the best statin out there.


00:55:09.428 --> 00:55:32.868

Dr Doug: Really, squash cholesterol. Can it have downstream impact? It can, although it's probably not coming from the cholesterol. It's probably coming from other side effects of the statin, because statins will deplete magnesium will deplete Co. Qq. 10. Other metabolic things that you need. So it's probably not related to the the reduction in cholesterol. Because if you look at people that are on Pcs. K 9 inhibitors, the injectable ones.


00:55:33.239 --> 00:55:47.908

Dr Doug: Their Ldl cholesterol is like 0, you know, for for like a week after taking it, and that's not a side effect of that drug, so I don't think I don't think that's it. It's probably more of the magnesium and the Cocq 10 and the other mitochondrial dysfunction that can occur with stens.


00:55:48.568 --> 00:55:51.518

Al Kral: Tuesday or Ldl was 60.


00:55:52.248 --> 00:55:53.155

Barbara berger: Yeah, yeah.


00:55:53.458 --> 00:55:54.238

Dr Doug: Do that.


00:55:54.828 --> 00:55:56.735

Al Kral: Why would they up your dose if it was.


00:55:56.948 --> 00:56:02.968

Barbara berger: I know that's what. No. And actually, I'm just looking right now. It's 54. My h.


00:56:04.258 --> 00:56:06.788

Barbara berger: no, my HDL is


00:56:09.638 --> 00:56:11.197

Barbara berger: yeah, 54.


00:56:11.548 --> 00:56:12.847

Al Kral: What's your old deal.


00:56:14.158 --> 00:56:17.858

Barbara berger: No, no, that's 54. The Thi Hdl is 39.


00:56:18.018 --> 00:56:18.748

Barbara berger: Correct.


00:56:18.748 --> 00:56:19.243

Al Kral: Thing.


00:56:19.738 --> 00:56:22.898

Barbara berger: It's going down. Everything's going down. It just seems.


00:56:22.898 --> 00:56:23.568

Dr Doug: Yeah, it.


00:56:23.568 --> 00:56:24.288

Barbara berger: Reloading.


00:56:24.288 --> 00:56:31.397

Dr Doug: It can have a negative impact on Hdl, too, which is one of the arguments around statins to say that well, statins potentially can increase


00:56:31.408 --> 00:56:46.477

Dr Doug: risk from a metabolic perspective. Because it can make metabolic health worse, which will drive Hdl down and triglycerides up. Yeah, which is arguably more important from my perspective for cardiovascular risk than is Ldl cholesterol, particularly in women.


00:56:46.768 --> 00:56:55.977

Dr Doug: And so if you look at the statin studies, there's never been a statin study that showed like primary benefit of statins for women in prevention of disease and events.


00:56:56.348 --> 00:56:58.057

Dr Doug: I should rephrase that of events.


00:56:58.058 --> 00:57:04.307

Barbara berger: You've mentioned that. But, I asked, can I? Can I reduce 20 to 10 safely again?


00:57:04.498 --> 00:57:04.998

Barbara berger: Whoa!


00:57:04.998 --> 00:57:07.389

Dr Doug: That's that's up to you and your doctor.


00:57:07.688 --> 00:57:11.810

Barbara berger: No, they're they're okay with it. I you know I don't think doctors care about me.


00:57:12.948 --> 00:57:18.718

Al Kral: I had. I had read that anything under 120 total cholesterol is dangerous.


00:57:18.728 --> 00:57:27.537

Dr Doug: Yeah, not necessarily. And again, it just depends. Because if you look at the Pcs K 9 data, they're all under 120 right, their clusterall is bumped to 0,


00:57:27.588 --> 00:57:35.658

Dr Doug: and so I think that the side effects from statins with high intensity and high doses, the side effects are going to be higher.


00:57:35.808 --> 00:57:37.598

Dr Doug: potentially because of the dose.


00:57:37.718 --> 00:57:41.537

Dr Doug: But it doesn't have to do with the cholesterol. But


00:57:42.099 --> 00:58:00.568

Dr Doug: you know, could you go from 20 to 10? I mean, I usually prescribe 5 or 10 for most people, because it's for me the the statins not necessarily about the reduction in cholesterol. It's more about the the effect of having the statin on board the anti inflammatory effect, the plaque stabilizing effect. I think that's why it works more so than the actual reduction in cholesterol.


00:58:00.568 --> 00:58:11.268

Barbara berger: That was yeah, very disappointed when they did that. But I that was 3 years ago. And now I asked, can I please reduce it again, and they say, but you got the sticky plaque, and


00:58:11.518 --> 00:58:16.697

Barbara berger: I don't know what to think. That's why I'll ask for another Ccta and see how I'm doing.


00:58:16.698 --> 00:58:19.497

Dr Doug: Yeah, I think that's a reasonable approach, for sure.


00:58:19.498 --> 00:58:25.378

Al Kral: I have friends that are on 80 milligrams. How insane is that 80.


00:58:25.868 --> 00:58:39.838

Dr Doug: Depends on their scenario. So for people that have had an event. So let's say you've had a heart attack, or you have, you know, like I have a patient that has like a 85% stenosis on Ccta, you know, like, I wouldn't mind driving as cholesterol to 0.


00:58:40.018 --> 00:59:05.858

Dr Doug: You know I wouldn't necessarily do it through a statin. But reduction of a risk factor that we can control is not is not crazy as long as they don't necessarily have side effects, and that's that's the thing. And so, if you know for primary prevention, if you're let's say you're a 45 year old woman with a cluster. All of you know, 300 and Ldl. Of 200. And you you're eating Ribeye Stakes every day. But your Ccta is 0. Should she be on a high intensity? Statin? Of course not.


00:59:06.078 --> 00:59:20.538

Dr Doug: But if you're a 70 year old guy with an 85% stenosis, and you've already had your first event, and you have a stent in there and like you're like a walking picture of what a second heart attack looks like. That would likely be fatal man. I'm gonna put that guy on a statin for sure.


00:59:20.558 --> 00:59:23.077

Dr Doug: So it just depends on the scenario.


00:59:24.858 --> 00:59:26.978

Dr Doug: It's easy to easy to be judgy


00:59:27.988 --> 00:59:30.113

Dr Doug: alright everybody. I gotta run


00:59:30.918 --> 00:59:40.277

Dr Doug: We will. Let's pick this up, and then let's talk about diabetes. People want to talk about diabetes. Is this fun? I know it's not fun, but it's real


00:59:40.408 --> 01:00:00.747

Dr Doug: talk about that. Alright thanks everybody. And I apologize too. I have not been able to spend any time in slack. I I know I've I've never promised to, but I try to. My schedule should lighten up in the next 3 to 4 weeks, ish, we're getting through a big lump of patience and getting my PA on boarded and getting her seeing more patience. So I have more time to do other stuff.


01:00:00.838 --> 01:00:06.667

Dr Doug: so that'll get better. But I'm loving the back and forth. The conversations. The support in there is awesome.


01:00:07.458 --> 01:00:08.828

Dr Doug: Okay? Alright.


01:00:08.998 --> 01:00:09.758

Dr Doug: bye, everybody.


01:00:09.758 --> 01:00:10.398

Al Kral: Bye.


01:00:10.768 --> 01:00:11.318

karendunham: Thank you. So.