Welcome, my name is Dr Warrick Bishop. I'm a cardiologist, an author and a keynote speaker. I'm CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible. Heart disease is huge in Australia. Every 20 minutes someone suffers a heart attack. Most of these could probably have been avoided if only we knew what to do. This podcast is all about helping you understand blood pressure, weight, cholesterol for better health. If you enjoy this podcast, I would be honored for a five-star review. You can share it with your family and friends. It may well save someone you love. Hi, my name is Dr. Oreck Bishop and welcome to my podcast and videocast station. Today, I have the pleasure of... speaking with Tony, Dr. Tony Sangster and Dr. Karim Kostner. You've met both of them before through the podcasts done previously. Good afternoon, gentlemen. Good afternoon. Good afternoon, Warrick. Absolute pleasure to be with you from beautiful Austria at the moment, where I'm originally from. And Tony from beautiful Adelaide. Adelaide, that's right. Yep. So, look, thank you both of you for taking the time out. Today, I'm really keen to talk about reduction of carbohydrate plus or minus ketone type diets because people ask about this a lot and coronary artery disease and roll that onto saturated fatty acids and where we are with those when it comes to diet and cardiovascular risk. What I might do is invite you, Tony, to give us just a little bit of your own experience when it comes to... reduced carbohydrate or keto type diets, particularly with your own diabetic background and your medical background. Would you like to give us a bit of an entry into that? Thank you, Warrick, certainly. Perhaps to reiterate something in the last podcast, that I've been diabetic for 56 years, since the age of 13. And there's been a lot of emphasis on what's called HbA1c test, which gives an idea of what happens over three months with your blood sugars. And there's been talk about it has to be less than seven, preferably near a six, but not too low. And I'll jump in there quickly, Tony, for people listening who have never heard of the term HbA1c, it's a measure of free glucose getting attached to the hemoglobin molecule. And that can be measured quite accurately and gives a great indication of how much glucose is floating around in the body. If your HbA1c is really high, then there's been a lot of glucose floating around in the body. And if it's low, vice versa. So it's a nice. long-term evaluation of sugar control. Yeah. And it struck me that I could do better. And I was hearing of people that were doing better. They were getting their level of this HbA1c level down to a non-diabetic range. And I was hearing of people that were actually, they'd started to develop a complication in their diabetes, for example, to do with their eyesight, the blood vessels in their eye. And they were actually being able to reverse that problem. Of course, as long as it hadn't gone too far, others that had mild kidney problems due to their diabetes that were also reversing it. And it seemed to be that it was related to a low-carb diet. And this is what started me off on looking at this. And so it was three years ago that I started on this journey. And it was with a degree of trepidation because my endocrinologist was not very happy. He said that I would die young from heart problems, et cetera. And yet I felt I had to stick to my guns because I was seeing such good results. And there's a paper written in 2015 that describes that when you're talking about the amount of carbohydrate in these low-carb diets, you're looking at, for an adult, under 130 grams per day of carbohydrate. And the rest, of course, is made up of protein and fat. And as you lower that carbohydrate, it means you're having to have a bit more protein, but a lot more fat. And this is also a sticking point for my specialist because he was concerned that this would have caused heart problems, cholesterol problems. And I also had to be careful because when you're on insulin, as you lower the amount of carbohydrate you're eating, it means your blood sugar can get too low. So one has to moderate that back. And same if people are on. certain diabetes tablets with type 2 diabetes, the same problem can occur. And I weaned it down carefully because I thought it's better not to jump in too quickly. And that's an important point for everyone because these low-carbohydrate diets, there are different measures, a new normal in the way things happen and what you need to eat and so on. Sorry, Tony, finish off. But the end result after, say, two years was that I had an HbA1c, this one of 6.4, and that was on an insulin pump. So it was the very best I could do. And I got down to less than 5.5. So I got down to a non-diabetic range. And most importantly, I wasn't getting low blood sugars. in this which is always the thing that the doctors say if you get if this reading gets too low you'll have too many blood low blood sugars and that's bad news okay fantastic look there's nothing like hearing uh the proof in the pudding and you've walked the walk just for people who are listening Not all patients understand what a carbohydrate is. So if I can quickly explain the carbohydrate in its simplest term is a chemical structure that if it's broken down, it yields its most simple building block, which is sugar. So if you eat a carbohydrate, you're actually eating lots of little bits of sugar all clumped together. And that includes things like bread. pasta, rice, potatoes, cereal, and fruit. So when you think about it, just as Tony reports, if you eat less carbohydrate, which is all made up of sugar, and you're trying to reduce the blood sugar level, it makes sense. If you're putting less into your body, you're probably putting less into the bloodstream. And that's exactly what occurred for you, Tony. The other thing I'll mention just by way of definition is that term keto or ketosis or ketone diet. We've sort of touched on it just to let people know. Normally, if you've consumed carbohydrate or have sugar in the bloodstream, the body preferentially uses sugar as its energy source. If you don't have sugar in the bloodstream and your sugar levels are low, the body switches over to burning fat primarily. And it does that through a breakdown process that liberates a chemical called ketones. And ketones then become the energy source of the body. So we literally flick from burning. um normal uh if you like unleaded petrol we then swap over to uh burning diesel so the body can do that and ketones is that other energy source so um karam i'm guessing you heard uh tony share his own story about reduction of carbohydrate what what have you seen clinically and where are your thoughts about a reduced carbohydrate or keto style diet The reason I'm interested in this, Warrick and Tony, is that I see more and more patients in my lipid clinic that are on these type of diets that are feeling better. Initially, the diabetes obviously gets controlled better if they lose weight, similar to weight reduction with other means, obviously. But I have seen some of the highest increases in LDL cholesterol in people on a ketogenic diet. Now, not on everyone. And I think they are the genetic types that are hyper absorbers of dietary cholesterol, maybe that metabolize saturated fat in a different way. But I've seen LDL increases to 10, 15 millimoles per liter in people on a ketogenic diet. Now, I don't believe that a short term increase in LDL increases your cardiovascular risk. Absolutely not. You know, so for several months, even a year, unless you already have coronary disease or a high plaque burden, But I'm concerned long term that those people with such a high increase in LDL cholesterol basically will have increased cardiovascular risk. And there is very little studies that look exactly at these people longitudinally. So what I do is, first of all, if their risk is high enough, I recommend medication to lower the LDL cholesterol. But I also try to adapt their diet to a less ketogenic diet where they still have protein but less saturated fat. And that's why I'm very interested in this discussion. So that's why I'm interested. It's a super complicated space. I think for anyone who listened, sorry, for anyone who missed the last podcast that the trio here did on LDL and coronary artery disease only turns out to have a zero calcium score or very minimal plaque. for someone who's had diabetes for 50 plus years, which puts you in a remarkable position, Tony. It means that whatever your cholesterol level is, for whatever reason, as we discussed in the last podcast, it's not ended up in your arteries. What Karam's talking about is a situation I've seen as well, Karam, which is a really difficult situation where people feel for the reasons that you talked about. better on a reduced carbohydrate eating guideline but they've got terrible plaque in their arteries and we need to do something about it how would you if you were confronted with that tiny what if you were in the situation where your arteries were uh a lot of plaque in them and and yet you how would you balance that reduced carbohydrate the saturated fat the the medications, where would your head be with that? Yeah, okay. Well, I suppose, first of all, in the past, I have been prescribed statins and I have been prescribed esitrol. And I had side effects to both. And they were significant enough for me to not continue with. So if you like, I've, and yes, there are now other alternatives, but back then there weren't. It's a tricky one. I mean, I've heard the term hyper-responder, and I presume that's what is being talked about where people's cholesterol goes up quite high on that diet. And I've seen mixed reports on whether this is harmful or not. And I guess, again, I would be saying, well, maybe to me, The sense is that if cholesterol is high enough, perhaps there are enough of the small, dense particles, which are the more troublesome ones, there just because there's a certain ratio that tends to be certain amounts of the small and the large LDL particles there. So I honestly don't have a good answer. To me, the low-carb helps keep my high-density cholesterol, which is supposed to be a good cholesterol to have lots of, and keeps my triglycerides low or lower than they have been. And they are both markers that I regard highly as being important. Explain the ketogenic diet briefly to bring into the conversation. We're talking about in the general term is where the person is taking less than 50 grams of carbohydrate per day and depends on how their body is functioning. They may have to get down to 20 grams before they start developing these byproducts of fat. And the thing is that... I have to be very careful as a type one not to have too many ketones. And if I'm sick and I develop too many ketones, I get very sick. Easier if you don't have to take insulin, you're producing yourself. But these ketone bodies do have an anti-inflammatory action on the body. And the same part of the... cells which have a genetic code, a code which tells the cell what to do and make certain things, that the ketone bodies can actually reduce the amount of inflammation in that cell. And that's regarded as a positive. I think it's going to be having, as Karim was saying, long-term studies to look at what happens to... people with their plaque score, whether it's the calcium score or whether they have the more intricate one to look at soft plaque, as to what effects or benefits. the diet has. There's also the fact that we know that saturated fat intake increase will increase the amount of LDL. And there's a particular mechanism that may apply there, which I'll answer later if you wish. Look, I'll speak to that briefly and then pass it over to you, Karim, if that's okay. Certainly my own practice is to reduce carbs and I do a bit of fasting as well. And I think there are real benefits. which are metabolic and separate to that raised LDL cholesterol. You're exactly right. We know there is a link between saturated fatty acid and cholesterol levels, and that's exactly what Karen was talking about before. But my own experience, and I think the experience of people who go sort of keto, and I go keto because I've been fasting, is reduced inflammation, weight control. improved insulin resistance. These are things that are to the good of coronary artery disease, probably better blood pressure control if you're keeping the weight under control. So there are certainly positives that I think we don't want to ignore because I think they're part of that healthy journey and we do achieve them through these sort of diets. But that LDL cholesterol is a sticking point for those people who have plaque in their arteries. Carol, any other thoughts on your approach? The only important thing I would like to say is that we have to distinguish between healthy people who don't have coronary disease and people who have diabetes. There's a lot of people who don't have diabetes who are on this diet. And again, that's a completely different scenario, you know, where I don't prescribe medication as early as I would in diabetics or people who do have coronary disease. I think we also have to recognize that most experts, endocrinologists, cardiologists, GPs as well. would say that if you have diabetes, and especially if you have coronary disease and diabetes, your LDL needs to be lowered. With statins, there's a troll in other means. And 95% of people tolerate this medication very, very well. Statin side effects are not common. You know, some people get them like you, but they're not common. And I think once you've got diabetes, once you've got coronary disease, your LDL needs to be low. If you don't have diabetes, if you don't have diabetes and you don't have coronary disease. That's a different scenario. And I think we'll talk about both of these scenarios probably. If I may, one of the things that strikes me is that... to try and if we know someone's got coronary artery disease then i think we are pretty well obliged to try and lower their cholesterols within the guidelines that we understand for the large population are going to be beneficial i think it would be remiss of us not to try and at least have those conversations with people and and i do that the um the challenge obviously is trying to get those levels down now some of those people as you said have remarkably elevated levels of ldl cholesterol when they eat their saturated fatty acids they're the hyper responders are those same hyper responders hyper responders to the therapy as for example azetamide which is a gut blocking um cholesterol lowering agent there may be people who respond such that They go very high, but on therapy, they come very low. Have you got a comment on that? Yes, I do. And some of it is correct. You know, those people that increase their LDL very significantly with a very high saturated fat diet are the ones where LDL goes down very quickly if they reverse that diet or adopt it to a more Mediterranean type diet or less saturated fat diet. All of those respond very well to medication. But the thing that I struggle with, they're often young people that don't, in my opinion, need medication yet. And that's where imaging guides us. And that's where, as Tony also said, we need more research. So if your LDL goes up to 5, 6, 7 in a healthy 35-year-old who doesn't have diabetes, who doesn't have coronary disease, I'm not convinced that we need statins and azitrol. But I think that's where we need more research. How long does your LDL have to be up in that setting? Which types of LDL? Does the LP layer play a role, et cetera? So I think that's a very interesting topic because more and more people are interested in these diets and they feel much better on these diets. That's what I can tell already. You know, also with epilepsy, also with other conditions that you're very well aware of with certain bowel conditions. And it's a fine line between telling them they have to change that diet and they feel worse. And we're not 100% sure that it ends up in the arteries. and not doing that. So I think it's a very interesting topic. It certainly is. And I'll swing back to one of the things you spoke about in the last LDL or bad cholesterol and coronary artery disease podcast, Karam, and that's that all LDL may be problematic. And I'll speak to this because I recently went to a presentation on some cardiac. death or sudden cardiac arrest at cardiac society and what absolutely struck me was that for all the genetic and all the potential issues that can give rise to sudden cardiac death the single most significant one was still coronary artery disease when they took adults up to 35 years of age and that I think represents holus bolus the FH or familial hypercholesterol communities and these These people at up to 35 years of age, they would have been a bit well healthy and almost negligible, small, dense lipoprotein particles, almost completely large, fluffy particles, but it still ended up in their arteries just by sheer numbers. And I think that's a very hard concern to dismiss. But a lot of them will actually have elevated LDL without wanting to do something about it. And I can tell you, last night, two people in our friend circle here, One of them, a 53-year-old trauma surgeon married to a GP who we had dinner with last night, died in his sleep. All times he showed extensive coronary disease, you know, only had an LDL in the range of about four millimole per liter, never wanted to do anything about it. Second patient, well, not patient, friend, the husband of a good friend of mine here in Austria, very healthy skier, never had any sort of medical problems apart from an elevated LDL and a family history. died chopping wood in front of his son a couple of weeks ago. And his only risk factor was elevated LDL and a positive family history. So a lot of these people do have the wrong LDL, but a lot of people have high LDL without wanting to do something about it, without wanting to do imaging, et cetera. So I think it's important to mention that as well. Look, it's super complicated, but let me put this. We're talking about saturated. fatty acids so these are the fats that would come off um well the fat off your lamb chop basically or the fat on a piece of steak and left uh left in the fridge overnight it goes solid the the question i've got is in this process of and very importantly for those listening we're particularly interested in um saturated fatty acids because there's a direct uh sequence of events that drives LDL or the so-called bad cholesterol up with saturated fatty acid question i've got for either of you gentlemen is what if we substituted that saturated fatty acid with monounsaturate or polyunsaturate what i'm suspecting that would lower LDL but what what impact do you think it might have on risk monounsaturates like olive oil avocado oil may certainly from our understanding on the Mediterranean diet, be beneficial. These polyunsaturated, the sort of seed oils, not so much, but I'd be delighted for either of you to speak to that. Okay. Well, may I? Yeah. Certainly on my diet, I eat the fat, I eat the butter, you know, and I, am very particular about not having seed oils. Several points here. One is Krauss' work back in say 2000 to 2006. He did some experiments where he got people and put them on a high saturated fat diet. And what happened was, yes, their LDL went up, but it was all the big fluffy LDLs. He then put people on a progressive increase in their carbohydrate, their sugars in their diet. And he found that you got more small LDL and of course the triglycerides went up. The other point that Krauss made too was that these small dense LDL particles actually don't carry a lot of cholesterol. And that, whereas, you know, the large buoyant ones carry a lot of cholesterol, but of course, LDL, of course, they can get back to the liver to deliver it back to the liver. Whereas the small, dense ones, even though they're not carrying as much cholesterol, can't get back to the liver. So they can't offload things. So there may be something in that. So, you know, Krauss was showing that the saturated fat intake was associated with your pattern A, not the pattern B. The other thing, though, is that when you think about if you have, say, lots of ice cream and things like that, you're getting a combination of fat, some of it saturated, and carbohydrate. If you get both together, which is the common food industry, highly processed food. What happens is that the saturated fat doesn't clear from the bloodstream. On a low-carbohydrate, high-fat diet, the saturated fat clears from the bloodstream quite quickly. So, yes, there's a combination of saturated fat with high sugar content that can cause problems. So this is why the... All the studies on saturated fat have been where they're taking particular note of the amount of sugar in them. And there are now four Cochrane reviews showing that saturated fat is not associated with cardiovascular disease. Therefore, there's no causation. You can't prove that saturated fat intake per se, not with loads of carbohydrate, but you cannot. prove in his causation between the two. So that's a little bit off the question I was asking. Sorry. That's okay. We'll come back. But you've raised a really important one, and that's did you want to speak to that Cochrane Review remark? Karam, because although there may be a review that says that saturated fats are not linked to cardiovascular disease, that may be an observation, we still can't sidestep the reality that an increase in saturated fat through the diet will increase LDL cholesterol. And all the stuff we've talked about still raises LDL as a potential cloud over CBD risk and management for people who have known CBD risk. And in addition to that, I think we're learning more and more, as Tony says. I'm a little bit on the other spectrum. And the reason for that is that if you look at most guidelines around the world, whether it's cardiology guidelines, endocrinology guidelines, or GP guidelines, do not recommend a high saturated fat intake in itself. Even though we are learning more and more about that not being as bad as we thought previously, there is other problems associated with it. And one of them, obviously, is the high LDL cholesterol. While I think that in a healthy individual, having saturated fat in the forms that you mentioned over a short or medium term may not be a problem. For people with heart disease, for people with metabolic syndromes, I am not convinced that this is really a recommendable diet. And the guidelines seem to support that. There's no guideline around the world that recommends a very high saturated fat diet in people with... diabetes, with heart disease, et cetera. Correct me if I'm wrong, but I'm not aware of one. Let's come back to that question that I posed before. And that was, if we've got someone who's on a ketogenic diet, they're eating a lot of saturated fats. We do want to reduce their LDL cholesterol. Can we swap them over to mono or polyunsaturated fats? I'm happy to dismiss polyunsaturated fats, but changing over those. changing from saturated fat to poly or mono should lower their LDL cholesterol. What are people's thoughts on doing that? Look, I recommend that. And what I recommend is to stay on a higher protein diet in the form of leaner meats, cut out the butter, cut out the cream, because they're the two things that really increase cholesterol and incorporate monounsaturated fat. So I recommend them to have nuts, avocado, which has a high satiety index. And, you know, for me, that is a good way of counterbalancing some of these LDL increases, but Tony probably has a different view. Yeah, how would that work for you, Tony? Okay, yeah. Well, first, I can say something about the Mediterranean diet. A number of the studies done have concentrated more on the vegetable and olive oil, naturally, intake, whereas the people that have actually been over to the Mediterranean and... worked with the people is that that they have a lot of animal fat protein and fat so and an olive oil is uh for memory it's about 14 saturated fat i mean the the so we've got to remember that that most of the fats that we eat are a combination of different levels of fat so so you have you know less saturated fats in your olive oil and less saturated than meat. And same with the canola oil and sunflower oil, et cetera. But this is a thought put forward by a chap called Dr. Paul Mason, who has done a lot of work on ketogenic diets and sports medicine. And his view is that when you move to more, take in more saturated fat, you have less of the polyunsaturated fat and the thing about polyunsaturated fat is is that it contains a lot of what are called plant sterols so they're like a plant cholesterol and we know this in the form of margarines that people can buy which contain these plant sterols and the idea is that it sort of supplants the cholesterol we're getting in from other food but those particular margarines are banned in pregnant women and in growing children so which says something and so so the thing is if you you're there is a people's cholesterols are probably if they're taking lots of polyunsaturated fat if you'd like in a sense are artificially low because they're on the seed oils and yet we also know that these phytosteroils these plant cholesterols if you like actually increase the risk of heart disease I'm not convinced, to be honest. Look, I recommend plant sterols to almost all of my patients who don't want to take medication. I know the people that did that research, and my read of the literature is actually different. Plant sterols do not increase the risk of heart disease unless you have a genetic condition called cytosterolemia, where you have extremely high plant sterol levels, and they can actually end up in your plaque. And azotrol is the only drug that helps in that condition, by the way. So I'm of a different opinion here, I have to say. Because one of the few natural things, apart from fiber, soy, and other sort of artichokes, et cetera, that does reduce cholesterol by up to 10, 15% are plant sterols. And in my view, they're not banned in any state in Australia in pregnant women. In pregnancy, we don't lower cholesterol that much anyway, because that's a time where people can have higher cholesterol naturally. But I use quite a bit of plant sterols. quite effectively in people who don't want to take statins in primary prevention, not in secondary prevention. Let me sort of jump in there momentarily. Maybe we could agree that we're a bit neutral on plant sterols. Maybe there's a difference of opinion there and maybe an interpretation of the literature. I think we've probably agreed that polyunsaturates, we would probably... None of us would be advocating that. I think we'd all be agreeing perhaps that monounsaturates are probably favored. And I haven't had a clear answer from anyone yet, but in that context of a ketogenic diet where someone's on a lot of... saturated fatty acids we've demonstrated they've had such bad coronary disease they've needed bypass grafting and they want to stay on a reduced carbohydrate eating guideline would we say look monounsaturates might be the way to keep that fat content up and reduce those saturated fats hoping that that would lower ldl cholesterol without necessarily an adverse cv risk have we got a comment on that look i haven't got a comment on that but the other thing i would like to say is that If you look traditionally, you know, people who are on a Mediterranean diet, if you look at Mediterranean countries, and there may be a paradox there, they live a fairly healthy life without much coronary disease. If you look at Japanese populations that eat a lot of fish, they are some of the oldest people in the world that we know. I'm yet to find a population that eats a lot of saturated fat. that leads a healthy and long life now that may exist you know but if you look at cavemen um they died in their 30s or 40s i mean they were probably eaten by sable tooth tigers and stuff but we have to be careful that there's not many populations around the world that have a very that have a ketogenic diet that live to an old age but maybe that's because nobody has tried it yet okay yeah i i would ask about the inuit yes fish may be part of that they have a lot of land mammals as well And the Maasai, who we know can get coronary calcification, but not necessarily due to cardiac disease or coronary artery disease. So both of those, they have animal fat. Maasai have milk. And yes, perhaps their exercise is a protective factor there. But the Inuit, they've got no vegetables. They've got no fibre as such. Some sour tasting berries maybe in springtime, but that's about it. Until the Western diet came along. And the other thing, the last thing I'll say on that topic is that if you talk to endocrinologists, there's very few endocrinologists that recommend these diets, even in diabetics. in an altered form maybe but i yet have to come across endocrinologists in australia europe and the united states that are in favor of this diet and it may be that they haven't done enough research yet but you know they're they deal a lot with diabetics and that that concerns me a little bit too too yeah yeah i think in the interest of time gentlemen we might just wrap this one up but i can tell it's absolutely fascinating For those who are listening, I hope this has kept you on the edge of your seat because it's kept me on the edge of my seat. If I can, we've spoken about reduction of carbs slash keto diets. There's no question they're good for things like reduced inflammation. They're good for sugar control. They're good for weight control and therefore good for blood pressure control. My own experience is I go a bit keto by fasting and it helps the arthritis in my thumbs. There's no question about that. And in people who don't have coronary artery disease, it seems we're all in agreement that we don't see any problem with that sort of lifestyle choice. I think we're all in agreement that it becomes a really complicated situation if someone's stuck on the idea of a reduced carb eating guideline with a lot of saturated fat. but they've got a lot of plaque in their arteries. And I think we are really in a space that it's a one-to-one conversation with that patient, sharing as best as possible where the literature is, looking how that person responds, because they may be a hyper-responder, not just to the saturated fat, but also to the therapy. What an amazingly interesting space. And you've had a world, you've had a national and international opinion on this from Austria and Adelaide. Have you got a last word you want to say, Karim? A last word on saturated fats and ketones before we end up? Not at all. We have to learn more, especially with the long-term effects of this type of diet. But it was an interesting discussion. I would agree with that. Thank you. Tony, did you want to wrap up with a couple of words? Perhaps to point out that people have, you know, the seven countries study. It's a cherry pick study. But somebody looked at the countries that were chosen and they found that the closer to the equator you were, the lower your cardiac risk. Well, there you go. So, you know, there may be other factors like vitamin D maybe that come into this as well. We've got a mixed picture here. But these are communities. Some have fish, some have fatty meat. There was a great variety in terms of their diets. I think the seven countries study is a conversation all of its own. But look, thank you so much for sharing today, Karen. And I'm far enough away from the equator that there should be plenty of work for me as a cardiologist. For everyone joining us and having a listen, I really hope you got as much out of this as I did. Thank you, Tony. Thank you, Carl. Thank you. Absolute pleasure. Thanks, sir. Did you know that coronary artery disease kills one in four people? So most of us. are likely to carry some risk or know someone who does. If you're interested in finding out more about how to evaluate that risk check out www.virtualheartcheck.com.au It will give you information about risk and what else can be done to be even more precise.
