It was fascinating. Within an hour, even that session of Pilates one hour, which is also it’s a great exercise, but it’s meditative as well, you feel your stress levels, you just feel like a different person. Dr Aseem Malhotra FRCP is an NHS-trained consultant cardiologist and visiting Professor of Evidence Based Medicine, Bahiana School of Medicine and Public Health, Salvador, Brazil. He is a founding member of Action on Sugar. In 2015 he became the youngest member to be appointed to the board of trustees of UK health charity The King's Fund. June Davison puts some of your questions to Professor Richard Hobbs, head of Primary Care (Health Sciences) at the University of Oxford and a part-time GP. We now know that heart disease is linked to two biological processes, he says: “Insulin resistance and chronic inflammation.” Insulin resistance is when cells don’t easily absorb glucose from your blood – from sugar and high GI foods – so it’s chronically raised. “Insulin itself directly damages the inner lining of the heart arteries,” he says.

Dr Malhotra said he had a family history of high blood pressure and relatives who had major risk factors of heart disease. “Knowing that 80 per cent of heart disease is environment and lifestyle and up to 20 per cent genetics, it means there’s something I can do about it, he said. So that should be the lifestyle approach. And actually heart disease, most of heart disease is rooted the biggest risk factor if you like is insulin resistance. And you asked me the question about what you look on the cholesterol profile, which is a marker of insulin resistance and that’s having high triglycerides and low HDR cholesterol. And the rule of thumb is you want triglycerides to be lower than your HDL in general, to have your cholesterol levels optimized. And the way you do that, lifestyle. And then your triglycerides should be ideally less than one [inaudible 00:45:25], which the equivalent I think in the US is I think 150 milligrams per deciliter. Mark, you would probably correct me on that if I’m wrong, but I think that’s the range, you should be less than 150. And the HDR to be similar. So above 150, right? So greater than one [inaudible 00:45:40]. And if you have those all in range, which as you said earlier on actually having all those markers in normal range for the average American adult is only about 12% of adults. 88% of adults in the US don’t have those in the normal range, which is very troubling, right? And this isn’t just older people. Only one in four adults aged between 20 and 40, Mark, in the US have those in the normal range. And this is what we’re dealing with. But the good news is, again, those are really indirect markers of insulin resistance. Well, what’s really striking to me is even at major, major heart hospitals around the world, the heart disease prevention diet, the cardiology diet they get when they go in the hospital is a low fat, high carb diet.

DR ASEEM ON RIGHT CARE CARDIOLOGY

In the world’s ‘blue zones’ – areas of notable longevity and almost no heart disease – "They weren’t pounding in the gym, running marathons. They were just moving all the time, not being sedentary." Nor he adds, were they taking statins. Sometimes, if you think a tablet might cause a nightmare, it can increase the risk of having one. For some types of statin, it’s better to take them at night, because that’s when they have a bigger effect on reducing cholesterol. However, the most important thing is that you take them regularly, rather than not at all. Are there any food or drinks I should avoid? Listen, my insulin levels are like less than five, pretty much about two. I have a 6% body fat. Yes, I’m bragging, but I’m pretty metabolic healthy, exercise a lot, I eat really healthy. And I went to Sardinia last summer and I’m like here I am for a week, I’m just going to eat whatever and I’m going to eat the pasta, the bread, I’m going to drink the wine. And I was treated well and had a very abundant diet and I gained like five pounds and I got the belly fat. So even if you are extremely healthy, if you start to eat more of that stuff, you’re going to start accumulating that and unless you are just doing a marathon every day, it’s really tough to keep up with that carbohydrate load that we have. And so- Well, exactly. Well, that’s [inaudible 00:36:27]. In the real world, when you look at studies and surveys, in one study in the US, statin usage survey, 75% of people stop taking the pill within a year of prescription. And when you ask the patients why, 66% of those said it was because they had side effects. So that makes me think, hold on a minute, there’s something that doesn’t add up here. And I don’t think it’s about… They talk about something called nocebo effect. If the patient is going to be aware of potential side effect, they’ll imagine it. And of course that exists, but a lot of the awareness of side effects of statins, Mark, in the mainstream only came out really in the last several years. I mean, they were prescribed for a very long time under the belief those side effects didn’t really exist. So I don’t think these patients were imagining it, I think it’s more likely they genuinely suffered side effects.

If you forget to take your dose, do not take an extra one to make up for it. Just take your next dose as usual the following day. Let me just finish this thought. And the JUPITER trial, which is one of the largest trials looking statins and heart disease found that if the statin lowered the LDL cholesterol, but not the CRP, in other words, if the C-reactive protein or the inflammation marker was high and you lowered LDL, it didn’t really have an impact. Only if the inflammation was lowered. And so we now know that the underlying risk for heart disease are inflammation and in some resistance which drives something that we call atherogenic dyslipidemia or a kind of cholesterol profile that makes you prone to heart disease. So tell us about a new way we need to be thinking about cholesterol rather than just a simplified, oversimplified dogma of LDL, statin, LDL, statin, LDL, statin, [inaudible 00:20:12] all day long. What is the things we should be looking at and what are those things and what are the causes of abnormalities in the real biomarkers of cardiovascular disease? Muscular aches and pains are the most common. It’s natural to associate symptoms with a new tablet but we all get muscle aches from time to time, so it’s difficult to know if they are due to medication or just to do with everyday life. Most people experience no side effects from statins. For some, though, they are an issue. If this is the case, ask your doctor about trying a different statin. Yeah. I mean, the challenge is that most doctors are very busy and they are seeing patients and doing good work and they want to do the right thing. And they don’t have time to go into looking at all the data and analyzing and sifting through it and sorting through it. And so they’re hearing the sound bites. They’re hearing the sound bites that generally come from continued medical education. And I was once skiing and I joined a chairlift and sitting on this chairlift with this woman, I’m like, “Hey, what do you do?” She’s like, “Well, I’m in pharmaceutical marketing.” I said, “Oh really?” I said, “What do you do?” She said, “Well, I put on conferences for doctors.” So essentially a lot of the medical conferences are funded by the pharmaceutical industry and they’re putting their speakers on, they’re having their spin on the data. And so the average doctor really is very hard pressed to actually get into the nuances of what all this data shows.

Statins: a patient’s view

Dr Malhotra, 43, argues this has introduced an “illusion of protection” for the public who think they can carry on eating junk food as long as their cholesterol levels remain low and they take statins – as well as for a medical profession that largely ignored the benefits of an improved lifestyle on heart health. I mean, I don’t watch the news anymore, it’s just too stressful for me. And yet it’s so simple, it’s free, it’s accessible. And I’ve been practicing meditation for years and it’s such a key thing to help regulate your life and your biology in so many ways. It improves its stem cell production, it reduces inflammation, it improves neuroplasticity, brain connectivity. The data is just so powerful on this. And if an anybody’s really interested, you can listen to the podcast I did with Daniel Goldman about his book, Altered Traits, which studied advanced meditators using very advanced imaging technology, looking at their brain function and their brainwaves and seeing what happens when you have somebody who’s been meditating for a long time, but really you don’t have to be a professional meditator where you’re living in a cave for nine years, just 20 minutes a day or 20 minutes twice a day is very powerful. An exceptionally rare, but serious, side effect is severe muscle damage, producing pain and weakness in the muscles. It can be reversed if treatment is stopped and most people who develop it make a rapid recovery. If you look at the average increase in life expectancy from taking statins from industry sponsored data, so we take that with a pinch of salt because industry sponsored studies, which are most of the statin studies in general are designed and the results are geared to kind of exaggerate the benefits and minimize the harms. But if we take that at face value, okay? Even- Eat a healthy diet and avoid foods high in saturated fats. Plant sterols and stanols– which are added to certain drinks and foods – can help to reduce your cholesterol by up to 10 per cent.

I think that’s really important. But either way, I think doctors should be aware, patients should be aware that these potential side effects, which aren’t serious or life-threatening at all, but interfere with the quality of life and that’s of course, very important for people, are very common and you shouldn’t be afraid of discussing with our doctor and having a trial period potentially after discussing with your doctor of them. The other thing that we didn’t mention is when we talk about all this issue about management of heart disease with statins is that for many people, it gives them the illusion of protection so they think I can eat what I like- your personal and family medical history suggests you're likely to develop CVD at some point over the next 10 years and lifestyle measures have not reduced this risk If you take simvastatin, you shouldn’t drink grapefruit juice as it increases the concentration of the drug in the blood stream, increasing the risk of side effects. If you take another type of statin, limit your intake of grapefruit juice to very small quantities or you may want to avoid it altogether. I’m on 80mg of atorvastatin but my cholesterol still isn’t low enough. What else can I do?Consequently, "meditation, yoga or something that reduces your stress levels will have a big impact." He cites an Indian study that found forty minutes of daily mediation had the strongest impact on heart disease reversal – "more than diet, more than exercise." They were promised to be the big miracle cure. In the 1970s Nobel Prize winners Joseph Goldstein and Michael Brown [ whose discovery of the receptor in cells that takes in cholesterol became the basis for statins] were predicting we may see the end of heart disease by the beginning of the 21st century.

The son of two GPs, from the age of eleven he knew he wanted to be a heart specialist – fittingly, a desire inspired by love. His older brother, Amit, was born with Down’s Syndrome. Aged 13, he developed myocarditis after a stomach bug and died within days. The risks of any side effects also have to be balanced against the benefits of preventing serious problems. Statins are prescribed to people with cardiovascular disease and to those at high risk. Some people ask whether statins are safe and are worried about side effects.

I’m on 80mg of atorvastatin but my cholesterol still isn’t low enough. What else can I do?

He says statins are vastly over-prescribed. He believes debilitating side effects are common, mainly muscle pain and fatigue. (This remains another highly contested issue. An Imperial College London study in 2020 showed that side effects are rare and even caused by a ‘nocebo’ effect – symptoms brought on by the belief a pill will cause you harm.) The foods we should eat? "A combination of oily fish, nuts, whole fruit and vegetables, extra virgin olive oil - and whatever else as long as you’re minimising the sugar and low quality carbohydrate, the breads and the pastas." Which in American [crosstalk 00:24:54] like, how would you translate that to American units [crosstalk 00:24:57].