Ep.71 - Original Recording
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Kelly Ratheal: [00:00:00] for our whole lives live with estrogen, right? And we don't tend to see clinical coronary disease in females until 10 to 15 years after menopause.[00:00:08]
Generally, so if you have a heart attack before the age of 65 as a female, we say this is early. This shouldn't be happening. Right? but in men, it's if [00:00:16] you have a heart attack before 55, and so there is a difference in we think that we have a little bit of protection from estrogen and after that estrogen goes away.[00:00:24]
There's a decade or decade and a half when we accumulate disease at a faster rate.
[00:00:32] Welcome to the wild and well, a collective podcast where we believe empowered health is your superpower. We have combined our expertise in medicine and [00:00:40] nutrition to bring you the latest research, expert insights and success stories of people on a mission to live a big life. So buckle up and get [00:00:48] ready to learn how to live wildly well.
Christa: I'm so excited to have you with us today, [00:00:56] Kelly, and you're just a wealth of knowledge when it comes to heart health and just cardiovascular health in general, and I think it's [00:01:04] really important. For younger people to start to understand before cardiovascular disease [00:01:12] starts. And so I want to know, first off, what kind of, you know, in medicine you have all different areas to specialize.
So what really drew you to [00:01:20] cardiology? And then beyond that, how did you go from cardiology in terms of like a reactive cardiology? [00:01:28] practitioner versus a preventative. And yeah, I'd just love to know your journey.
Kelly Ratheal: First of all, thanks for inviting me. This is new for me, so we'll do our [00:01:36] best today.
I am a general cardiologist with a focus on preventive care and lipidology. That's my sort of side [00:01:44] subspecialty. So, I decided on cardiology After a long journey aiming towards surgery [00:01:52] I knew that I liked the cardiovascular system the most. It just made sense to me. I liked the fact that it's important throughout life.
[00:02:00] And so I really thought I was going to be a heart surgeon or a vascular surgeon and went all the way up through that. process in medical [00:02:08] school and was applying to surgical residencies and I realized Work life balance was important, as a female, and I didn't have family [00:02:16] yet.
I didn't have my own kiddos yet. I thought, let's pause and see if there's a better decision because I knew that I was really risking having a good balance. So [00:02:24] that was part of the decision. But what I realized when I took the time to look at cardiology as an option, which, For people who [00:02:32] don't know the background of medical school training, all physicians go to medical school, but then you choose what your specialty will be in [00:02:40] that.
The big categories are surgical specialty or a medicine specialty. And so. Both specialties can work on the heart, but I [00:02:48] was looking at the surgical aspect, and so moving to cardiology was investigating the medical aspect and cardiologists, like [00:02:56] many people are probably aware, do procedures and can save lives in during acute events or heart attacks.
And so there was a lot of procedural [00:03:04] excitement, if you will, that came with cardiology as well. And so I thought, okay, maybe I can get my. Operator fix, if you will, liking to [00:03:12] be good at a physical skill and perfecting those skills was something that I enjoyed. And so I said, Okay, I think I can accomplish that in cardiology.
But what else am I going to get? [00:03:20] That's work life balance would be better just because of the nature of the training and the nature of what day to day work tends to look like in this, those different [00:03:28] specialties. And I came to this realization that I could also teach people about how to. [00:03:36] not end up on the operating table and not have a heart attack and not have to put stents in.
And that was really, I think [00:03:44] the turning point from cardiology to prevention and cardiology. So the work life balance made a difference at first [00:03:52] and then it turned into something that I thought was, bigger and better. So,
Sheree: I love
Christa: that. I think still to the fact that you have [00:04:00] really focused on preventative and aspects of that is still different from where a lot of [00:04:08] cardiologists sit. And. Terms of like, they're seeing patients that have already had an event or, the fact that you're being pretty aggressive in your [00:04:16] approach to preventative, I think, is really cool because that's not typical.
I don't think in this area.
Kelly Ratheal: Yeah. I think a lot of physicians [00:04:24] agree now that. We need a more preventative mindset because the majority of what is killing us at the end of life, we can live good long lives, but [00:04:32] what's killing us now is chronic disease. And a lot of times, it's much earlier than we would like.
And so we really need to affect that part of [00:04:40] the population that risk category is how do we not die of chronic disease early or earlier than expected. And so trying to [00:04:48] get. 20, 30, 40 year olds into a cardiologist office to talk about what their risk is a, an odd concept. And I think a little off putting to [00:04:56] patients cause they think, well, I don't need a heart doctor that just says there's something wrong with me.
And so Krista and I have talked about this, we need to [00:05:04] rebrand a little bit because sometimes being a doctor is a good thing. And sometimes it's scary and patients say, well, I don't want to need a heart doctor. So my other hat, [00:05:12] is I'm also an internist. You have to be an internist to be a cardiologist.
And so, I'm a medicine physician can understand [00:05:20] and can help patients understand, well, how do we maintain our health? Right. And so that's another conversation. If we have disease already, then we still want [00:05:28] to, take those steps to prevent further disease and events that could kill us or harm our quality of life.
But if we don't have [00:05:36] disease yet, how do we keep it that way? Because it's insidious most of the time and patients end up somewhere in their mid forties and they think, Hmm. Things are different [00:05:44] than 10, 15 years ago. And now I'm being told that I have hypertension and my cholesterol is not great.
And I've gained 15 pounds and maybe I [00:05:52] have prediabetes and, they, it doesn't happen overnight. And if we're not talking about how to keep those parameters normal and [00:06:00] maintain our health. Not just avoid disease, but maintain a healthy metabolism and healthy body composition and [00:06:08] healthy sleep. Then it'll catch up to you.
So it's a lot of education. But I think the more we can teach patients that [00:06:16] it's okay to come in and have those assessments. If there's a specialist that offers that, it doesn't mean that, you need a heart [00:06:24] doctor because you have heart disease. It means you went to the person with the. With the background to teach.
Sheree: Yeah, it's something that I always talk about. It's [00:06:32] like, right, it's prehab before rehab. We want to make sure that we are supporting our body, whether that's from a physical standpoint in terms of [00:06:40] exercise. So we don't injure ourselves. It's the same with looking after the heart and we want to make sure that we've got that beautiful organ functioning in an optimal [00:06:48] level.
And this is really the difference with. functional medicine and the approach that we can take versus I guess traditional medicine in a lot of ways. And so it's beautiful [00:06:56] that you bring in this practice of preventative medicine and like bringing in clients or patients, I should say for you [00:07:04] in an earlier stage of life.
And like Krista said right at the beginning, it's how do we get people into this a little bit earlier? And so are you able to [00:07:12] share? Before we dive into some of the risk factors and things that might put people into a state of maybe fear, like, oh my gosh, that's me again, operating from [00:07:20] now I'm 40.
I've got all these things. Where did this come from? If someone like myself, like I've just turned 30, came into the office, like, what would be some of the [00:07:28] advice that maybe you would share? Or so where would you start with someone in this preventative medicine approach?
Kelly Ratheal: Sure. So we would [00:07:36] review what we call traditional risk factors.
And so we can talk about those, but we'd go through kind of, do we have any of the major [00:07:44] boxes checked as far as traditional risk for chronic diseases? And when I say chronic disease, everybody should know that that generally means. [00:07:52] Cardiovascular disease, cerebrovascular disease. So those are dementias for the most part diabetes and cancer.
Okay. So those are the [00:08:00] four largest chronic diseases and that's what kills most people. And cardiovascular disease is still the number one killer. So we want to prevent those things. And [00:08:08] if we're not checking any of the major boxes for traditional risk factors, the next thing we do is we delve into what we call risk enhancing [00:08:16] factors. And so those are going to be things that we've learned over the years through studying patients that they do convey [00:08:24] some risk of developing chronic disease, it's really that they weren't included in our initial Cardiovascular risk calculators.
So there's [00:08:32] a, there are several tools available and patients can look them up online. But if you want to assess your likelihood of heart attack or stroke or death [00:08:40] from those things in the next 10 years, that's where sort of risk assessment from the heart standpoint began in terms [00:08:48] of. objectifying it.
And then we have guidelines based on what risk level are you and what should we do with those risk factors? How aggressive should we be [00:08:56] in order to reasonably mitigate that risk and maybe change your chance of having a poor outcome? And so those traditional risk calculators [00:09:04] use are Seven or eight traditional risk factors and then risk enhancers have been better understood more recently.
And so they're not part [00:09:12] of the calculators, but we have to realize that they do play a role in risk, and they can increase that risk from what you might have [00:09:20] gotten with the basic risk calculator. We talked about family history that plays into a risk as well. That's very important, especially if [00:09:28] it contains some of those outcomes that we're trying to avoid.
In females, we talk about when did we start menarche? What are our childbearing [00:09:36] years like? What were our pregnancies like? And then on through perimenopause and menopause because all of those phases of life lucky [00:09:44] us, we have risk factors that are separate from men and different at all of those phases.
So that needs to be addressed in females when we're looking at [00:09:52] lifelong risk. And then some of what we would do. We're talking about evaluation in general. So for 30 year olds, we go through all of that [00:10:00] information. It takes a while. And we would do basic labs and imaging if we need imaging and that kind of [00:10:08] depends on what we found in our risk evaluation.
But I have set of labs that I do that's pretty standard for most new patients and [00:10:16] it gets me the. metabolic info and lipid or cholesterol molecule info that we would need for risk assessment. There's some others in there, [00:10:24] but those are the major topics if you will.
Christa: So you mentioned, and Men, obviously, overall, I would say, possibly [00:10:32] what a statistic show that they have higher cardiovascular risk.
Overall.
Kelly Ratheal: Men and women develop heart disease and die of heart disease the same. [00:10:40] So, it kills women and men both number 1, it's the number 1 problem for a long time. It was not recognized in women as easily. And so women [00:10:48] would end up with treatment later in the disease process or not at all. And so that's because sometimes we have atypical symptoms and when I [00:10:56] say atypical, not the elephant sitting on your chest description if you're having heart attack.
And sometimes it's because we don't seek care because we don't think [00:11:04] that heart disease affects women, which is not true. So we think it can't be my heart. I have to make the kids lunch and get everyone out the door and then, but sometimes it's your [00:11:12] heart. Yeah. So interesting.
Christa: Yeah. Let's go through for, particularly women because our risk increases as we age and, if you could [00:11:20] touch on a little bit about how hormones, how post menopause affects us differently, like statistically, what is the difference in the risk, [00:11:28] pre menopause versus post menopause and then attached to that question.
What can we be doing as women and let's say our twenties, [00:11:36] thirties, forties before menopause to really help ourselves post menopause after you talk about the difference in risk [00:11:44] factors.
Kelly Ratheal: Okay I'm going to take a little broader approach and kind of land on hormones and perimenopause. So we talked about what would be [00:11:52] contained in a risk assessment and during that talk, we're also going to discuss, how important our [00:12:00] lifestyle is, right?
So this is our biggest tool for preventing these risk factors from creating disease. And so I always tell [00:12:08] patients, it's important to understand that sleep and emotional health really things that we want to have in order and [00:12:16] have occurring in a healthy way. So those.
Contribute quite a bit to preventing chronic disease. If we're not sleeping well, or we're always [00:12:24] super emotionally stressed, then that changes our metabolic health. It changes how our body processes, blood sugar, blood pressure, [00:12:32] deposits, fat builds muscle. So when we're stressed, we're stressed.
Because we're not sleeping or because of emotional stress, then those things are different and they're not generally [00:12:40] better. And so those things have to be addressed and then metabolic health. You're going to hear me mention that probably several times, but, that includes [00:12:48] how are we processing blood sugar?
What is our body composition like? So, do we have adequate muscle? Are we having excess? fat or adiposity. [00:12:56] Is it under the skin or is it around our organs? The latter of which is more dangerous. And so those are the [00:13:04] areas that we can impact a lot from very early in life. So we have control of those things.
forever. And if we learn really [00:13:12] early, let's say when we're teenagers, before we go to college, we recognize the importance of healthy diet, regular exercise, good [00:13:20] sleep. And we carry those things through our twenties. Cause a lot of us spend time in our twenties doing whatever it doesn't matter.
And it does matter. So, [00:13:28] if we learn those habits early, then keeping a good metabolic health is gonna help reduce the likelihood of chronic disease. And [00:13:36] so I'll refer back to those things because as we enter our childbearing years, we talked about, we [00:13:44] want to know what's happened in pregnancy so we can have adverse pregnancy outcomes that do, they're red flags or signals that we might be more [00:13:52] likely to have cardiovascular disease present.
clinically in the future. So things like if we start our [00:14:00] period really early or really late, that makes a difference. If we have PCOS if the age at which we have our first child if [00:14:08] it's very early versus very late, those all have effects on our risk. Adverse pregnancy outcomes are often things like [00:14:16] hypertensive pregnancy diseases.
So whether it's chronic high blood pressure, gestational high blood pressure or hypertension preeclampsia, eclampsia, [00:14:24] most females are familiar with these terms. But if we experience any of those things during pregnancy, then those are signs that our cardiovascular system [00:14:32] is not as healthy as we might've hoped.
And that we are more prone to having. Cardiovascular disease as we age. If we have premature [00:14:40] menopause, and I'd have to double check the age definition, but it's like 40. it's very early. If it's that early, if it's late 40s, [00:14:48] not quite 50, then we don't particularly fall in that category. But if we're just not having periods anymore, spontaneously at the age of 40.[00:14:56]
Or if it's iatrogenic, meaning it's it, we did it because we needed to take my uterus out for some reason. I almost bled to death during a high risk [00:15:04] delivery or I had awful fibroids or had uterine cancer. God forbid, we take the uterus out for those reasons. And most women would say, [00:15:12] yeah, it saved my life.
So, but now they oftentimes ovaries are taken with that so that sometimes comes together. [00:15:20] And then that's what creates menopause. And so if it happens for a medical reason, it's still a risk factor. And as we [00:15:28] age, so, did we use hormone replacement therapy or not? Right.
So that's part of our discussion. And Krista's question was [00:15:36] what should we be doing Around perimenopause and menopause that can help improve our risk. And so [00:15:44] this expert consensus I would say, has been consistent for a number of years, but guidelines are lagging behind, which [00:15:52] is usually the case.
The experts in the area are looking at data constantly and what the new studies show and we might even be reviewing old studies with [00:16:00] kind of a different question or viewpoint. And the hormone replacement therapy pendulum has swung all the way to one side with Premarin and [00:16:08] everybody should take Premarin and this is good for us and more recently in the 90s onward.
We want the smallest dose [00:16:16] for the shortest amount of time, right? This is like hormones will increase your risk of stroke and breast cancer and heart attack. And now the pendulum has swung more [00:16:24] towards the middle. I am by no means a hormone expert. And so I don't think I can give you accurate statistics for if we use it versus if we don't, how does our [00:16:32] cardiovascular risk change?
There's a lot that goes into it. How are we replacing with what formulation? At what age are [00:16:40] we starting? Do we already have existing visible coronary calcification? That's going to change those stats. But what we [00:16:48] understand about the physiology of hormone replacement therapy is that in patients who do not already have clinical coronary disease or [00:16:56] cardiovascular disease it seems that.
Estrogen specifically, but if you have a uterus progesterone has to go with it, right? So those two go [00:17:04] together. If you still have a uterus that estrogen is cardio protective. Okay. So this makes sense because for our whole lives live with estrogen, right? [00:17:12] And we don't tend to see clinical coronary disease in females until 10 to 15 years after menopause.
Generally, [00:17:20] so if you have a heart attack before the age of 65 as a female, we say this is early. This shouldn't be happening. Right? but in men, it's if you have a heart [00:17:28] attack before 55, and so there is a difference in we think that we have a little bit of protection from estrogen and after that estrogen goes [00:17:36] away.
There's a decade or decade and a half when we accumulate disease at a faster rate. Okay. Then we were doing [00:17:44] previously. And so my impression of the data and expert opinions currently is that we've come back to the middle. And with this [00:17:52] understanding that in patients who are. low or medium risk, and they don't have clinical disease.
It's certainly acceptable, if not prudent, to use hormone [00:18:00] replacement therapy surrounding menopause and continue it through life because we live half of our lives after menopause now. I'm [00:18:08] close to it. And So we have technology to help us not accrue chronic disease as quickly as we might otherwise simply [00:18:16] because of a biologic mechanism.
We haven't figured out how to change menopause yet, but maybe that will happen one day. We're doing our [00:18:24] best
Christa: with bioidenticals.
Kelly Ratheal: Yeah, so if it's so if we're going to go through menopause but we can supplement the thing that now we've lost and we think that in [00:18:32] general it's good for our health then it's a reasonable topic to discuss with your OB GYN, your endocrinologist, some primary care providers are comfortable with [00:18:40] it, but know that that arena is changing and the guidelines are changing, recommendations are changing.
There are patients who are at high risk for [00:18:48] hormone replacement therapy for menopause. Bad outcomes with hormone replacement. And so, that's why you need to have the discussion understanding your [00:18:56] cardiovascular risk first. Plays a role in whether or not we think we should use hormones and in what form or fashion, right?
Does [00:19:04] that answer the question?
Christa: Yeah, no, I think it's great. I think that hormone replacement is definitely a thing. I think also just, for women to [00:19:12] understand. And I think you touched on that metabolic health is really important. Meaning diet, exercise, stress, smoking, [00:19:20] sleeping, all of those things are super important prior to menopause.
to help prevent some of that, how can we take control? We can't take control of our [00:19:28] hormones dropping after menopause, outside of replacing it, but there's certainly so much we can do prior lifestyle wise.
Kelly Ratheal: Maintaining a healthy lifestyle [00:19:36] and specifically metabolic health and regular exercise can help lessen symptoms of menopause as well, so in our patients who [00:19:44] are metabolically healthy and physically active, oftentimes they don't have quite as severe vasomotor symptoms with menopause as they might otherwise.
And that's [00:19:52] not a uniform blanket statement, but it does seem to help. So, it can help with the symptoms and not just the risk. [00:20:00]
Sheree: When you say metabolic health, because and we've talked about this a number of times on the podcast from a variety of different angles, but can you touch on what you mean specifically, just [00:20:08] so that our listeners are very aware of what you're referring to?
Kelly Ratheal: So, I would say, know your numbers is a good concept for [00:20:16] tracking metabolic health. The numbers that convey. The status of your metabolic health. The best are triglycerides, [00:20:24] HDL, your waist circumference your blood pressure and I put blood sugar and insulin in the same category.
[00:20:32] It depends on how we're evaluating those things. But a one C is a rough. a very rough indicator of that. But if you have any other [00:20:40] evidence that you're insulin resistant or not processing blood sugar normally, then that is a sign of abnormal metabolic health. Like we're moving towards unhealthy. Notice [00:20:48] I didn't say LDL, right?
That's a separate topic maybe for a different day. But I do also see patients with lipid disorders , [00:20:56] and those can be. Anywhere from, we're in bad shape because of poor lifestyle decisions to inherited and inherited [00:21:04] risk or genetic risk. So, that's my other hat, but they tend to overlap quite a bit.
And so often patients who have lipid disorders have [00:21:12] higher cardiovascular risk. And so they end up maybe we're needing to use the medication to treat some of those inherited disorders, but also they have to understand the [00:21:20] power of. What they can do with lifestyle, because I like the saying, I don't know whose it is, but that genetics loads the gun, [00:21:28] but lifestyle pulls the trigger so we may have the cart, the deck even stacked against us.
It might seem, but you still have a lot of input [00:21:36] and ability to manipulate your outcome with lifestyle regardless. So that's the number one thing to understand is. If [00:21:44] you come for risk assessment and walk away with like, I think your risk is pretty low, but learn, oh, I need to stay on top of just being healthy.
Right? [00:21:52] Then that's the most powerful thing you can do. So we're not really teaching that in elementary or junior high or high school. I think very [00:22:00] effectively, we're not feeding our kids good food. They're not exercising the way they should, and so, It's a little bit of an uphill battle, but if we can have it trickle [00:22:08] down through younger patients, because young moms are coming for cardiovascular risk evaluation, then they can teach those babies as they [00:22:16] grow up, what are healthy habits.
So, yeah,
Christa: yeah, I think it is interesting. It's I think we view cancer. Cardiovascular disease. We view those [00:22:24] diseases. As old people diseases, right? But the fact is those diseases started multiple decades prior and [00:22:32] prevention is a tough thing to sell because when you're in your 20s, you're just like, whatever.
It's fine. I remember being in my 20s. Just I wouldn't even think [00:22:40] about a heart attack of what that's like old people problems, but. It's I think it's just the education is necessary. I think [00:22:48] it's needed to say, but these things that you're doing now will affect you. We've seen, you know, generations upon generations.
[00:22:56] fall to the same problems. And yeah. Just learning. Yeah.
Kelly Ratheal: Something that most people don't know about atherosclerosis or putting plaque in your arteries [00:23:04] is that it starts before you're 10.
Sheree: What?
Kelly Ratheal: So if you think what you're doing when you're a teenager in your twenties doesn't matter, [00:23:12] think again.
We certainly can accelerate that risk with our lifestyle even really early in life. So, it's humans are good [00:23:20] at making plaque. Because we tend to now in our developed day and age have lots of risk factors for this, [00:23:28] things that, promote metabolic dysfunction or dyslipidemia or abnormal cholesterol panels.
And we have other pollutants and toxins and [00:23:36] stressors and, things that fit in that lifestyle column that aren't always really objectively. Or consistently able to [00:23:44] be manipulated on. So it's tricky. It's insidious and it happens. It's an accumulation or area under the curve, exposure to these risk [00:23:52] factors over lifetime.
But yeah, we've known this for a very long time. Kiddos who die for some reason and have [00:24:00] autopsies often have fatty streaks in their arteries. And this is. Not uncommonly seen, but so we know that this is a process that starts really early in life. And so [00:24:08] being on top of those risk factors certainly being aggressive about lipids.
That's something that, although it uses [00:24:16] drugs, we're talking about hormone replacement therapy and getting on it at menopause and continuing it forever. We can make lipids physiologically normal fairly [00:24:24] easily and continue it for life. And that really drops your exposure your area under the curve to atherogenic lipoproteins or [00:24:32] lipid molecules that can potentially put plaque in the arteries.
And it's a game of statistics, I can't. Tell one patient or another that they're going to be the one that has a [00:24:40] heart attack or stroke or dies from those things. Just looking at their lipid panel. But I can tell them that their risk is higher than someone [00:24:48] else's. And if the investment in taking a medication and consistently and objectively mitigating that risk.[00:24:56]
over decades is worth it to them, then the payout can be really large. It can be that I have a calcium score of zero [00:25:04] at 75, 80, it can happen. You do not have to have plaque in your arteries.
Christa: along the lines of statins, I would love your [00:25:12] input on. The risk versus benefit is always something that we talk about in medicine, so the risk I would say with, which has been in [00:25:20] my mind with, statins and things like that is, is it metabolically, is it mitochondrial poison? Is [00:25:28] it, it inhibits, CoQ10, it kind of disrupts that process of energy for the cell. What is your take on that?
Kelly Ratheal: So first I would say, [00:25:36] remember that what we see in bench science does not always translate to what we see in living creatures.
And so we [00:25:44] know mechanistically that there's some interference in mitochondrial function, perhaps by depletion of coq 10 with statin [00:25:52] use. And some patients don't tolerate statins because they have myalgia or muscle aches. And that may have something to do with that mechanism and in those patients, in [00:26:00] my patients, if that happens.
We don't use that drug. We use a different one. We use a different dose. We use something that doesn't give you those clinical symptoms. Because that's not [00:26:08] appropriate. There's no reason for you to take a pill every day that gives you side effects for something that I cannot guarantee you is going to change your outcome.
I'm betting on it, [00:26:16] but I wouldn't prescribe it, otherwise. But every person that uses a statin is not the person in which we prevent an event, right? [00:26:24] So, risk benefits should be. Addressed overall in patients who. meet criteria [00:26:32] or their risk is high enough that I recommend lipid lowering therapy of any kind.
It could be statins, it could be, we have a plethora of other [00:26:40] drugs now that are available that are effective. And so if I recommend any of them, it's going to be because I feel that taking that medicine for a [00:26:48] long term, the rest of their life potentially, right, outweighs the risk of the side effects that they would have with that medication.
We don't have a [00:26:56] good understanding that if, so we've looked at patients who've been on statins now for 30, 40 years, right? We have a lot of decades of exposure to statins [00:27:04] in even individual patients. You guys probably know, well, maybe your parents have been on a statin for 30 years, right?
What we see is that [00:27:12] our mortality from cardiovascular disease goes down. We're not seeing that and it goes down with cumulative [00:27:20] exposure over time because it's exactly the opposite of so if lipids are high for most of our life, we have a lot larger area [00:27:28] under the curve. And if I keep them lower for longer, which means more statin exposure over time and less atherogenic lipoprotein exposure over time, [00:27:36] my area under the curve to.
atherogenic lipid proteins is lower, my area under the curve to statins is higher, we [00:27:44] see less, fewer cardiovascular events. And so in patients whose risk warrants lipid lowering therapy, I [00:27:52] absolutely recommend lipid lowering therapy. I can't tell you that we have good evidence to say that we're having people live a shorter [00:28:00] amount of time because their mitochondria are dysfunctional.
I don't have clinical evidence of that and because what we're seeing is that people [00:28:08] are, that mortality is reduced. So potentially living longer, but dying less frequently of this disease, morbidity is [00:28:16] a separate question, and that's harder to study, I would say, but if your patient is on an appropriately dose statin with no [00:28:24] clinical side effects, and they use it for several decades, I would also venture to say that their morbidity is improved because they don't suffer a heart attack or a stroke that [00:28:32] doesn't kill them.
Christa: Right. Would you recommend then, ubiquinol, like CoQ10 in the form of ubiquinol, something like that to fill in the [00:28:40] gaps of where maybe we are, because we are blocking that, that pathway.
Kelly Ratheal: Yeah. So I tell patients if they let's say they're in a [00:28:48] pickle and they have a statin that they can tolerate like pretty well, but they have some symptoms with it, but we can't get one of the newer drugs and they don't [00:28:56] tolerate some of the other older, cheaper ones.
And like, this is the best we can do. Okay. If CoQ10 helps improve those symptoms or resolve them, [00:29:04] absolutely. Is it going to hurt you? We don't have any evidence that it will hurt you. If you are on an appropriately dosed statin and lipids are a goal [00:29:12] and you have no side effects from this that we can tell clinically do I recommend that you take it just because it might be impeding mitochondrial function?
No, [00:29:20] because it adds to pill burden. I would recommend that you increase your aerobic exercise and improve your capillary density, which improves [00:29:28] mitochondrial function. So I think I would rather do that through exercise and lifestyle than supplementing CoQ10, but not everybody's going to do that. [00:29:36] And if they want to take CoQ10 because they want to perfect the pathway, we're back to bench science, right?
We don't have any clinical evidence that [00:29:44] this is changing our outcomes. Okay. I don't think it's going to hurt you. But I also can't track it objectively, and I can't tell you that it's harming you or changing your [00:29:52] outcomes, so that's hard to, I kind of leave it to the patient, specifically with CoQ10.
Sheree: it's so interesting, like, I'm still processing the fact that [00:30:00] you said that. The plaque and stuff can start developing from the age of 10. It
Sheree: but brain is just exploding right now. And you've mentioned so [00:30:08] many times these lifestyle factors. And so I'm wondering, All of that is going to impact those risk factors.
Can you share with us a little bit more [00:30:16] what some of those lifestyle factors are? You just mentioned the aerobic exercise, which is really important. Does sugar play a role in this, like in developing the plaque? Where [00:30:24] does food and nutrition come in and how do you support in that way too?
Kelly Ratheal: So the way that I usually describe [00:30:32] atherosclerosis or plaque formation patients is that we have kind of two areas to focus on. We've spent a little time recently on lipids. [00:30:40] Okay. And so that separated out because you can have the best metabolic health in the world and you can have familial hypercholesterolemia and you might die [00:30:48] in your twenties of coronary disease.
Wow. Okay. So it's its own thing. Sometimes it tracks and improves with metabolic improvement, [00:30:56] but to some extent in most people, it, we can always improve our lipid panel in terms of when I'm saying LDL. Okay. And ApoB those tend [00:31:04] to square up a little bit when we improve metabolic health, but it's not usually your workhorse.
And so if you tend to Float higher with your lipid panel, and [00:31:12] that's your genetic input there. Then we'll talk about that separately. Okay. Do we need drugs? Do we not? Is this acceptable based on your risk? The other key component to [00:31:20] forming plaque. is inflammation or damage to the arteries over time.
And so that's that list of you name it. It's [00:31:28] there in the inflammatory category. So it can be environmental toxins. It can be lack of sleep. It can be emotional stress. It can be blood [00:31:36] pressure. People think like, Oh, I don't feel my blood pressure being high. So it must be fine. Blood pressure hypertension is called the silent killer.
Like this [00:31:44] is, we should be paying attention to our blood pressure. Remember it's in those of the five, know your numbers. It's in there, right? Okay. It [00:31:52] could be diet and exercise. It could be, I mean, the list goes on autoimmune disease. Okay. So that fits in that risk enhancing category that we talked about.
It's [00:32:00] not in the traditional list. It's in the risk enhancer list. Okay. So things that affect our artery health are the things that really fall in the lifestyle category. [00:32:08] And so generally. When I talk to patients about food and exercise, because those are our, aside from sleep, I go back to [00:32:16] sleep.
I don't forget sleep. Right? Those are big effectors of our metabolic health. And so food matters, [00:32:24] but I think in the largest way, it matters that we don't have an excess of energy input, right? We have to [00:32:32] be an energy balance, meaning. So lately patients have done well with this. When I explain it this way there's a concept called the personal fat [00:32:40] threshold.
That some diabetes and metabolic specialists have begun explaining some great resources for you guys if you want to listen, but there's [00:32:48] some podcast resources, but evolutionarily, we have. The ability to store fat under the skin. This is good, [00:32:56] right? Because if you can't catch a gazelle for a week and you're starving, you don't die.
When we have excess energy available as we do in our day and age we [00:33:04] have. more calories than we need in probably most days. And otherwise we don't think about it if we're maintaining a healthy body weight and we're like, okay, I [00:33:12] wanted to eat the cookie. But we have energy imbalance in the positive direction, then eventually we can.
Surpass this capacity for [00:33:20] putting fat under the skin, and we start depositing in the organs, namely, that's the liver and the muscles. That's when we see metabolic dysfunction [00:33:28] occur. And it usually starts in the form of insulin resistance, and that doesn't mean your a1c will be abnormal. Okay, so it means that [00:33:36] you're.
Insulin levels, maybe not even your fasting insulin, but your insulin level sometime during the day is elevated because it's chasing this spike in blood sugar to bring [00:33:44] it back down. And that's insulin resistance. We shouldn't need so much insulin to maintain our blood sugar at a normal level.
And when those needs start [00:33:52] rising, it's because we're becoming insulin resistant. This is the premise. for metabolic dysfunction. Okay, so people [00:34:00] argue about how insulin resistance develops mechanistically. Does it start in the muscles? Does it start in the liver? Does it, but once it is present, this is [00:34:08] what drives arterial damage over time.
It's a big driver. It first in our microvasculature, so it affects our eyes, our kidneys, our [00:34:16] Peripheral vessels and we end up with peripheral neuropathy, right? Like I'm describing a long term diabetic patient, right? And it can also take a toll on [00:34:24] our larger vessels as well. So we, it promotes plaque formation in the heart arteries and in the aorta.
And, so, we want to [00:34:32] maintain normal blood sugar metabolism, but it takes more investigating than what [00:34:40] insurance will currently pay for easily. So looking at fasting insulin levels and looking at even continuous glucose monitors are great tools, [00:34:48] but so I digress. We were talking about food and how that contributes to metabolic health.
So, energy imbalance is a problem [00:34:56] and when it leads to visceral adiposity and insulin resistance, then we're already in that disease state [00:35:04] exercise. Is one of your most powerful tools for maintaining metabolic health. Okay. So both aerobic and resistance training. [00:35:12] They each have their own benefits.
In general patients who just want to be healthy. They're not training for a specific event. Or [00:35:20] some lift or run or sporting activity. if we're just training to be healthy, then we want [00:35:28] most of our aerobic or cardio training to be in a zone that is what we call zone two. We need more [00:35:36] episodes of, this goes down into its own thing.
And then maybe once a week, some higher intensity cardiovascular training, and those give two different benefits. [00:35:44] So zone two training is improve our mitochondrial density. So back to the CoQ10 question. And then VO2 max training or [00:35:52] high intensity intervals is going to improve our VO2 max, which is our absolute efficiency of delivering oxygen to our body, [00:36:00] right?
So how efficient is the pump and how efficient are the mitochondria and your tissues at uptaking that oxygen so that we can do [00:36:08] the activity that we're wanting to do. The higher our VO2 max stays throughout life, Just like the higher our muscle mass stays throughout life, the [00:36:16] slower that decline, if we can level off that trajectory a little bit, then we age better.
Right? So we're less frail. We have less [00:36:24] fractures. We have less dementia. We have less diabetes. We have less cancer. We have less heart disease. And so exercise is a great way Tool that everybody [00:36:32] has at their disposal in some shape or form. And so resistance training offers maintenance and building a muscle mass.
And so [00:36:40] that contributes to long term health as well. And so we start losing our muscle mass. In our thirties as [00:36:48] females we peak around late twenties. I think you'd have to ask an expert or my exercise physiologist. But so it's the same with, bone [00:36:56] density tends to start declining in our thirties as well for females.
And those are intimately related. So if we're not putting stress on the bones by [00:37:04] doing resistance training and maintaining our muscle mass, then those things are going to decline more quickly. And it correlates with chronic disease. So, we should [00:37:12] be lifting heavy things, in our childbearing years, it's our children, sometimes a minor, a good exercise.
And after that though, we have to be a little bit more [00:37:20] intentional about how are we getting our resistance training. So. Yeah, you
Christa: mentioned too and weightlifting you know, some people are like, Oh, I want [00:37:28] to run a marathon on my forties.
Kelly Ratheal: Yeah.
Christa: What do you say about, the shearing effect on the arteries with long term, like long exercise, right?
Like [00:37:36] that's a stress on the endothelium.
Kelly Ratheal: There's recently been a little bit more talk because, we have a lot of. Calcium score data [00:37:44] now. So coronary artery calcium scores. And sometimes we see that in like, let's say lifelong marathon runners, they have super high [00:37:52] calcium scores. And we're surprised by that because we think, oh, you're so metabolically healthy.
Why do you have coronary disease? And it's a little [00:38:00] difficult to say that this is causative. It can. It could be that those people also have significant risk factors for cardiovascular disease that are [00:38:08] beyond their metabolic health or that their life was not always as metabolically healthy.
Sometimes those runners uptake that exercise [00:38:16] and in midlife. And when do we start forming plaque? Okay, so, you can't say that that's causative and it's possible that it's very [00:38:24] likely that their habits, whenever they began them, have been cardiovascularly protective. And so there's, a [00:38:32] general consensus that calcified plaque is often more stable than non calcified plaque.
And so the runners who are metabolically [00:38:40] healthy and have lots of calcified plaque, it might be that their ratio of calcified to non calcified is more heavily on the calcified side. And that's [00:38:48] why they are not dying of heart attack or stroke or vascular disease as often. Do we see runners drop dead during marathons?
Yes. Okay. That's a separate topic. [00:38:56] But if you look at all comers there are going to be marathon runners with significant coronary disease. And it may be that [00:39:04] they are as old as they are and as functional as they are because of their healthy habits. And that's a hard thing to look back and say, Oh, because I [00:39:12] took my statin for 30 years and I exercised every day.
And I did this. I didn't pull the trigger. I have these bad genetics and I have reasons to have [00:39:20] a calcium score of 800, but I'm not dead, and so it's hard to say that just because they have an elevated calcium score that they're running [00:39:28] is the cause. I think that that's a very crass conclusion.
We need to know more before we can say that we don't have evidence to say that. [00:39:36] And to. discount their healthy lifestyle as something that has gotten them to where they are now. So less [00:39:44] alarm about that, I think is appropriate. And if you are the marathon runner with a calcium score, that's very high, then talk to your doc,
Christa: [00:39:52] exactly.
When would you recommend getting your first calcium score?
Kelly Ratheal: So now we have built calcium scores into 10 year and lifetime risk [00:40:00] assessment calculators, right? We like calculators. So 40 is the age at which many of those calculators start. I do [00:40:08] calcium score people in their thirties if they have really significant risk factors or have reason to believe it might be positive.
But we also have other technology that can allow us to [00:40:16] look for non calcified plaque in those high risk patients that are younger than that age. So.
Sheree: I found this so [00:40:24] interesting because it's quite funny that you bring up the exercise because in my brain, especially when I was younger, I was like, I don't need to do cardio because [00:40:32] I don't have to worry about my heart until later. And so this has been a really empowering conversation. I love that you brought in the resistance training as well, because I.[00:40:40]
I don't hear enough people in your industry or people in the medical industry, even talking about the importance of resistance training for heart health. [00:40:48] Right. We hear all about doing the running and getting your VO2 max optimized and that sort of thing. And so also
Kelly Ratheal: the worst girls are like, I don't want to be look [00:40:56] like Arnold Schwarzenegger.
I'm like, first of all, you're not a male on testosterone. We just have so many need your conclusions and, preformed [00:41:04] conceptions about what's going to happen if you lift weights, and many other things in life, but yeah,
Sheree: but this has just been so great to have that [00:41:12] conversation because you are breaking a lot of the myths.
We are starting to have that preventative talk and I really do. I know for like me, I've learned a lot and I know a lot of [00:41:20] our listeners will be learning so much. And I would love to have you back on because I feel like we could just pick your brain for hours. Thank you so much for everything [00:41:28] you've shared.
Is there any like last comments or anything you want to share with our listeners before we wrap up or Chris, do you have any final [00:41:36] questions?
Christa: I would love to know if there's a 35 year old woman listening or man, but particularly women. And we don't want to
Kelly Ratheal: exclude men. A
Christa: [00:41:44] 35 year old, what is one thing that you would say, or maybe the two top two things you would [00:41:52] say, start now
or stop.
Kelly Ratheal: Yeah. Make sure that your sleep and emotional health is in order [00:42:00] and fix your metabolic health. Know your numbers. Yeah.
Christa: I love that.
Kelly Ratheal: And if any of those are abnormal, then you need to see somebody like me or Krista. [00:42:08]
Christa: Yeah. Or see us first so that we can even know if you have those issues.
Sometimes you don't know that they're up.
Kelly Ratheal: Yeah. Right. Yeah. It is not [00:42:16] ever too early to ask the question. What is my risk? Because the worst you're going to get is I say, I think it's pretty low, maybe you're doing pretty good right now. [00:42:24] Like, is that, I don't know, some people might say, well, I could have told you that, but sometimes a lot of times there are things that you don't [00:42:32] know.
And when we ask those questions and we walk through that. It takes an hour plus and labs and imaging. And, when [00:42:40] we get through that process, sometimes people go, Oh, I guess I should pay more attention to X, Y, or Z. Right. Or I didn't realize that was a risk [00:42:48] factor. Very common. Almost every human has at least one risk factor.
Okay. So there's something on the list. And it's [00:42:56] just the earlier you start with a mindset of, I want to optimize. Then if you have the mental bandwidth, financial [00:43:04] capacity time, is it absolutely necessary? I would say yes, but is it going to kill you if you don't do it in the next 10 years for a [00:43:12] lot of people?
No. But could it potentially give you a leg up and an advantage for the rest of your life? Yeah. Because you might find out something that you don't know. And if you [00:43:20] don't find out something that's new to you, then you've had a good evaluation and you're reassured that you're on the right trajectory.
We're doing healthy [00:43:28] things. We're treating our body well, so I think there's value both ways, but the majority of people come up with some risk that they weren't really [00:43:36] fully grasping or they learned more about it.
Christa: Yeah, I think in the world right now, or we're in the medical world anyway, and in the wellness world where we're really focusing on [00:43:44] lifespan health span, you can't start early enough to start working on that.
So, thank you so much [00:43:52] Kelly for being here. This was a wealth of information. hope our listeners, took something away from this because it is so important. I mean, Cardiovascular health is [00:44:00] health in general. You can't live without it. So thank you so much for being here. Thank you for having me.
If you love this episode, be sure to leave us a review, [00:44:08] download and subscribe. If you know someone that could also benefit from this conversation, please share. That's how we spread empowered health. We'll see you again for another [00:44:16] episode of the Wild and Well Collective.
