May 6, 2025 • 32 mins
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In this episode of Live Long and Well, I'm joined by Dr. Anthony Pearson, a board-certified cardiologist known for his evidence-based yet refreshingly skeptical take on mainstream cardiac care. Together, we explore the nuanced science behind heart health and how you can make smarter decisions to protect your cardiovascular system—starting today.
We open by recognizing that heart disease remains the leading cause of death for both men and women. While many of the six pillars of longevity—from exercise to stress reduction—play protective roles, today’s episode zooms in on two powerful, sometimes polarizing topics: the role of diet in heart health and the value of coronary artery calcium (CAC) scans.
Dr. Pearson shares how a personal brunch conversation with his wife challenged decades of low-fat dietary dogma, prompting his transformation into the "Skeptical Cardiologist." Here is a summary showing that dairy won't increase risk of cardiovascular disease. He recounts the
We dive into the broader saturated fat debate, highlighting how different fat sources have varied effects on cholesterol and cardiovascular risk. While dairy fats may be benign or even beneficial, others—particularly those consumed in excess on paleo or keto diets—can raise LDL cholesterol substantially. Dr. Pearson discusses the Keto-CAD Study, which found that even lean, low-risk keto followers may build up arterial plaque if their LDL levels skyrocket.
The conversation then shifts to the calcium heart or CAC scan, a non-invasive $100 screening test that quantifies calcified coronary artery plaque via CT imaging. While traditional risk calculators like the pooled cohort equations often fall short, CAC scoring offers a personalized look at actual plaque burden—critical since many heart attacks occur in people not flagged as high-risk. As Dr. Pearson explains, a high score doesn’t mean you will need surgery. Instead, it’s typically a cue for lifestyle and medication adjustments, not invasive procedures. He references the ISCHEMIA Trial, which found no benefit from stenting stable, asymptomatic patients over optimized medical therapy.
We close with practical advice: talk to your doctor, especially if you have a family history or fall in that “borderline risk” zone where a CAC score might influence your care plan. And yes, it should be okay to keep enjoying that butter—as long as you’re informed and mindful and don't overdue it.
Takeaways: Full-fat dairy is not the enemy—it may even be heart-protective. If your LDL skyrockets on keto, that’s a red flag worth addressing. CAC scans can personalize your prevention plan and offer peace of mind or a critical nudge toward action. Want more clarity on your own heart health journey? Talk with your doctor about whether a calcium scan makes sense for you and explore Dr. Pearson’s writings on The Skeptical Cardiologist and MedPage Today.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:02):
the bad news Heart disease is the number one killer
of both men and women.
The good news there's a lot wecan do to lower that risk.
Should we change our diet orget a calcium scan of our heart?
Let's see where the evidencetakes us.
Hi, I'm Dr Bobby DuBois andwelcome to Live Long and Well, a
(00:35):
podcast where we will talkabout what you can do to live as
long as possible and with asmuch energy and figure that you
wish.
Together, we will explore whatpractical and evidence-supported
steps you can take.
Come join me on this veryimportant journey and I hope
that you feel empowered alongthe way.
(00:56):
I'm a physician, ironman,triathlete and have published
several hundred scientificstudies.
I'm honored to be your guide.
Welcome listeners to episodenumber 37.
We can reduce our risk of heartdisease.
(01:19):
Well, heart disease,cardiovascular disease, is the
number one killer of men andwomen and we've talked in prior
episodes about the six pillarswhich can each help reduce that
risk, whether it's exercise,getting good sleep, sauna and
cold plunge, nutrition, socialrelationships, mind-body harmony
(01:41):
.
We've also talked in anotherepisode about doing screening
tests like a total body MRI orlarge panels of blood studies,
and I express my concern thatwhen you do these large number
of studies, you might get afalse positive, sending you down
a path of more tests, potentialcomplications and really a lot
(02:04):
of uncertainty.
Today we're going to dive a bitdeeper into cardiovascular
disease and we're going to tryto figure out a couple of things
.
What do we know about what weshould eat?
What do we think about acalcium heart scan?
Are these things that we shouldconsider and talk to our doctor
(02:24):
about?
Well, I could share my opinionand of course, I probably will
and the evidence that I've runacross.
But, more importantly, we have aguest today, dr Anthony Pearson
, and I am thrilled to have DrPearson join us today.
He's a board-certifiedcardiologist.
He was on faculty at severalacademic medical centers,
(02:46):
published over 100 peer-reviewedpapers, and he's also been in
private practice for about 20years, so he has both the
academic and the patient careexperience.
His focus is on preventivemedicine, ways to reduce the
risk of heart disease, and hehas a very broad holistic view
incorporating diet, lifestyle,exercise and, of course,
(03:09):
medications.
And most importantly, and why Ithink he's an ideal person here
today, is that he's also aneducator.
Very broadly stated, he's acolumnist for MedPage today.
Very broadly stated, he's acolumnist for MedPage Today and
for the last decade he has beenwriting the Skeptical
(03:30):
Cardiologist a blog on itswebsite, and now, as a sub-stack
, and some of the article titlesthat I think you'll find of
interest Butter Good or Bad?
Should we Take Antioxidants?
Should we Take Blood PressureMedicines in the morning or at
night?
How to stave off dementia,walnuts and cognition in the
dangers of unnecessary cardiacprocedures and I will have links
(03:55):
to his locations if you wouldlike to read and follow him.
I do and it's been wonderful.
So, dr Pearson, welcome to LiveLong and Well.
Speaker 2 (04:09):
Thank you, Bobby, it's my pleasure.
I'm a big fan of your podcastand I'm happy to be here.
Speaker 1 (04:17):
Well, wonderful, I know, when we chatted a week or
so ago and you were telling me abit about how did you get into
certainly not necessarily howyou got into the cardiology
business that is, of course, itsown story but how did you get
into the education and writingapproach, and you mentioned
something about havingcroissants and butter with your
(04:40):
dear wife and I thought what agreat place to begin.
So maybe tell all of us alittle bit about how did that
start out?
Speaker 2 (04:50):
Sure, I, for the first 20 years or so of my
career, followed the guidelinesand the dogma that had been
presented to me in the dietaryworld and that had started in
1977 with some dietaryguidelines to Americans that
(05:12):
said we should all be cuttingdown fat and increasing carbs,
and I was following that and Iwould battle with my wife over
my first wife, over whether wehad skin milk or full fat milk
in the refrigerator.
(05:32):
I wanted my kids drinking skinmilk and she wanted full fat.
We eventually ended up at 2%percent but by after, after
following these guidelines,which I assumed were solidly
based in science, I was, hedrinking skim milk, eating low
(05:54):
or nonfat yogurt and I avoidedbutter like the plague and I egg
white omelet.
But I met my second wife andwhile she was still what I used
to call on my blog the eternalfiancé.
We were having a brunch outsideat a very nice restaurant in St
(06:18):
Louis and I found myselflecturing her on her decision to
consume a croissant slatheredwith butter.
Speaker 1 (06:28):
And the best way to eat them, of course.
Speaker 2 (06:31):
Yes, according to her , and I was just astonished and
she challenged my viewpoint onthis that she felt like she was
healthy and thin and could eatcroissants lathered with butter.
And so when she challenged that,I went on a quest to discover
(06:55):
the scientific sourcesunderpinning my recommendations,
and I found that in thisparticular area they were very
lacking, and it kind of led meto become the skeptical
cardiologist at that point.
A lot of my early writings in2013 were about the kind of
(07:15):
dietary myths that we had allaccepted without substantial
evidence, and so now I canconsume full fat milk, yogurt
and cheese as much as I desire,and my omelets are made from
full eggs, including egg yolks.
And I think when I first startedthis journey, I came across a
(07:42):
study that was done in Waleswhere I was actually born in
Wales and came to the UnitedStates when I was five by Peter
Elwood, and he had studied someWelsh men and found that those
who consumed the most milk had a13% lower risk of dying than
(08:05):
those who consumed milk, whichwent against the grain of the
recommendation to consumelow-fat milk, because at this
time, everybody was consuminghigh-fat milk.
And I communicated with him andhe revealed to me that he had
(08:28):
done a meta-analysis of all thestudies which he published in
2010 in the European Journal ofClinical Nutrition, and it also
showed that consuming dairyproducts of all kinds actually
lowered cardiometabolic risk andlowered the risk of dying from
(08:48):
cardiovascular disease.
So that was the beginning of myjourney as a skeptical
cardiologist.
Speaker 1 (08:55):
And have subsequent studies borne out that the dairy
, the saturated fat in dairy, isnot problematic?
Speaker 2 (09:05):
It has.
There have been lots ofpublications in this area.
There are lots of meta-analysisand they have kind of been some
have shown no effect.
Most have shown a slightbenefit from consuming dairy on
(09:30):
cardiometabolic risk factors andon reducing the risk of stroke,
and the most recent one waspublished in 2024.
And I can give you a link tothat.
It is in the journal, thejournal nutrition, and it
(09:55):
confirms that and and shows thatthere is really no evidence
that low-fat dairy is better foryou than full fat, and the
evidence is quite strong thatfull fat and fermented dairy
products actually lower the riskof cardiometabolic disease,
(10:19):
measured by things likemetabolic syndrome, which
includes hypertension, diabetes,metabolic syndrome, which
includes hypertension, diabetesand obesity.
And so I think that this ismore and more.
This is being recognized.
Speaker 1 (10:41):
Well, this is fascinating and also very
reassuring, since I of course,love to cook, and love to cook
with butter and cream and allthose wonderful things, and love
cheese.
So let me probe a little bit.
So what you're saying is, dairymay not be problematic.
Perhaps it is even protective.
Now we know that the full fatdairy is saturated fat or has a
fair bit of it.
Are you saying that saturatedfats in general are fine, or
(11:03):
there's something peculiar aboutthe dairy-saturated fats that
make dairy eating safer thanhaving a ribeye steak at three
meals a day?
Speaker 2 (11:19):
Yeah, I think that one of the reasons that dairy
continues, that full-fat dairycontinues to be not recommended
in most nutritional guidelinesis because of the saturated fat
issue.
Dairy contributes about aquarter of the saturated fat to
the diet of Americans and themainstream nutritional
(11:43):
guidelines want to promote asimple message that all
saturated fats are bad for you,so that the public doesn't get
confused.
But the actual fact is thatdairy fat is much different than
the fat that you get from redmeat, for example.
Speaker 1 (12:07):
Much different than the fat.
Speaker 2 (12:08):
That you get from red meat, for example.
Why might that be?
Because the saturated fats andthe fatty acids in general are a
broad family, ranging fromshort chain to medium chain to
long chain, and each one ofthose fatty acids has a slightly
(12:32):
different effect.
Some of them definitely raiseLDL and raise your blood
pressure.
Some of them don't do that.
Some of them might raise theLDL a little bit but also raise
the HDL, and the truth is thatwe don't consume these fatty
acids in and of themselves.
(12:53):
They're in a food matrix andthere is quite a bit of evidence
that the food matrix that dairyis in is protective and behaves
differently when we put it intoour bodies than if we were just
consuming the fatty acids as inan experiment where we can
purify it in some way.
(13:14):
So it's a big, heterogeneousfamily of compounds and it's a
mistake to consider them all asequally harmful to you?
Speaker 1 (13:24):
Okay, that's helpful.
Consider them all as equallyharmful to you?
Okay, that's helpful.
Now I know we had a briefchance to talk a little bit
about the paleo and keto diets,which have gotten a lot of
attention.
These are folks who feel likethey want to cut out
carbohydrates from their dietand when people are eating a lot
of fat and protein becausethat's really what's left you
get vegetables and fat andprotein.
(13:45):
Some of these folks, thecholesterol levels, specifically
the LDL cholesterol, can go wayup.
Is that a worrisome thing?
When somebody is trying one ofthese diets and the LDL goes way
high, do you just say, well,you're losing weight, that's a
wonderful thing.
So what?
The LDL is high.
Speaker 2 (14:06):
Or do you say, no, no , we should try to do something
about that well, I think it is aworrisome and it is a situation
where we really have to be verycareful that we're not
predisposing the patient to highrisk of building up
atherosclerotic plaque and heartattack and stroke as a result
(14:29):
of that.
And there is a study that wasjust published within the last
month which has gotten a lot ofattention on social media.
It is called the Keto CAD study.
The Keto CAD study CAD standingfor coronary artery disease and
(14:53):
these patients were these leanmass hyper responders which, in
the keto world, if you are notobese and if you don't have
diabetes, sometimes about maybe20% of individuals will develop
these very high LDL levels andapolipoprotein B, which is the
(15:14):
particle that gets the LDL intothe lining of the arteries and
triggers heart attack.
And the community there believesthat they are protected against
heart disease, against plaquebuildup.
And this study was an attemptto look at that plaque buildup
over a year in these individualsand what it showed to me is
(15:40):
that number one they havealready built up a significant
amount of plaque and within ayear that plaque progressed,
progress and plaque again is thefaster that plaque progresses,
the larger the burden of thatplaque, the higher the risk
those patients are of heartattack and stroke.
(16:01):
So there are ways to modify theketo diet to make it less
likely to raise the LDL and theAPOE, and that is to use avocado
oil, olive oil and notnecessarily consume massive
amounts of meat.
But the bottom line is if thatdiet is giving you an LDL over
(16:30):
180, you are at high risk andeither the diet should be
changed or you should be startedon medication to get that LDL
down.
Speaker 1 (16:44):
That's very helpful, thank you, and I think putting
the various types of fats incontext the dairy, the non-dairy
, and then sort of the extremecase of the paleo-keto, where
you're getting a tremendousamount of fat Wonderful.
Speaker 2 (17:00):
Let's switch.
And I would add that I am aketo-friendly cardiologist.
When I first started the blog,I went on a keto diet and I
researched it and I think it'sbeen very beneficial for many of
my patients in losingsubstantial amounts of weight.
But again, we have to monitorthese patients to make sure that
(17:26):
they are not harming themselvesin the long run.
Speaker 1 (17:30):
Well, like everything we do in medicine whether it's
a medication we're givingsomeone or it's lifestyle
changes there are always goingto be risks and benefits.
And obviously losing, losingweight, is critically important
for us to live long and well.
And if paleo helps you getthere, that's a wonderful thing,
and if it doesn't change yourldl, wonderful.
(17:51):
But if it does, then I thinkyou talk to your doctor and
maybe you get treated and thenyou can have really the best of
both worlds of being on a dietthat seems effective for you and
keeping that risk factor undercontrol.
Well, that's great, absolutely.
Let's switch gears, and this isa fascinating one.
(18:15):
Folks have probably heard aboutthe calcium heart scan.
It's something that getsadvertised on radio, tv, social
media.
It's a pretty inexpensivescreening test $100 or so and,
as my audience knows, I'mgenerally not that excited about
routine large screening things.
(18:38):
Now, of course, if it's amammogram or a colonoscopy or a
pap smear, these are veryimportant.
They're recommended by USPreventive Services Task Force
and the benefits have been shownto outweigh the harms.
To outweigh the harms.
But when you just do 100 or 200blood tests or you do a total
body MRI just looking for earlyforms of disease.
(18:58):
I think you can end up withsome difficulties and false
positives and anybody who'sinterested in listening more
about it.
By all means go to my priorepisode.
But when we chatted about thecalcium heart scans, you had a
very important way to thinkthrough it.
So maybe first tell folks whatare these calcium heart scans
(19:20):
and why might it be helpful forfolks?
Speaker 2 (19:26):
Sure.
The calcium scan coronaryartery calcium scan is what we
generally call it, anabbreviated CAC.
Cac is a kind of x-ray or CTscan.
It is non-invasive in thatthere are no needles, there are
(19:49):
no catheters placed into yourartery and it is done using a
CAT scan or CT scan and it isour best way of determining
whether there is any plaque inyour coronary arteries and how
(20:13):
much you have, compared to otherpeople, your age.
It is not covered by insurancebut in most of the places where
I've worked I've been able toget it for around $100 paid out
of the pocket and it is a verysafe and very, very accurate
(20:36):
test to measure the amount ofcalcium in your coronary
arteries.
Calcium builds up Plaques, startdeveloping very early in our
lives, possibly even inchildhood, and that
atherosclerotic plaque, overtime, as it heals and progresses
(20:59):
, calcium is deposited into itand when we look with this PT
scan, we're looking to determinehow much calcium you have
compared to normal to your age,compared to normal to your age.
Now, the risk of this test isthat you are getting a small
(21:21):
amount of radiation.
It's usually measured inmillifevers.
It's about one millifever onaverage, which compares to about
0.4 for a mammogram.
So it's about twice as much asa mammogram and each year, if
you're in the Midwest, you getabout 3 millisieverts of
(21:42):
radiation from backgroundsources.
So it's not considered to behigh or dangerous in terms of
increasing risk of cancer, andso I think it's a great tool to
assess in an individual fashionto kind of personalize the
(22:04):
patient that's in front of mehow much plaque they've built up
and, as a result of that plaque, what is their risk of heart
attack and stroke down the line.
Speaker 1 (22:17):
So, as we've talked about in our last call, I tried
to play devil's advocate alittle bit.
It's like okay, so we know iftheir blood pressure is elevated
, we should do something aboutit.
We know if their cholesterol iselevated, they should try to do
something about it If they havediabetes or they're overweight.
So how would this add to theequation?
(22:39):
And really are you suggestingthat pretty much everybody in
their 50s or so get one of thesethings?
Is it going to change what youdo by getting these results?
Obviously, they could benegative or they could be
positive, and if they'renegative you can be very happy
about that If it's positive, butyou're already treating their
(23:02):
blood pressure and theircholesterol and their weight and
such.
How will this help us?
Speaker 2 (23:09):
Yeah, I think this is a common question and it is one
of the reasons that it's notbeing universally applied,
although I would say that anypreventive cardiologist that
I've talked to or listened to isan advocate of using these and
(23:30):
using these in a lot of people,using these and using these in a
lot of people and that isbecause progress in sudden
cardiac arrest death fromatherosclerotic cardiovascular
disease has slowed down in thelast 20 years, and that is the
(23:53):
problem with atheroscleroticdisease, with coronary artery
disease, heart disease, theinitial symptom is often not
chest pain or angina that occurswith exertion due to a tightly
blocked artery.
The initial symptom can just bea heart attack coming out of
the blue and then resulting inan abnormal rhythm that drops
(24:13):
you dead and causes cardiacarrest.
So we don't always get warningsand the plaque can build up to
very dangerously high levelswithout having anything, without
knowing that anything is goingon.
So what the calcium does, whatcoronary calcium does, is give
(24:35):
us an idea of how much plaque isbuilt up and what is your true
risk.
Now, what's the current waythat primary care physicians are
told to assess this is by kindof estimating the risk in an
individual in front of them,based on the standard risk
(24:58):
factors such as blood pressure,diabetes, cigarette, smoking and
the lipid levels, thecholesterol levels level.
But these are not, theseso-called pooled cohort
(25:18):
equations that estimate risks,are not applicable to young
adults and older adults.
They come from studies decadesago.
They overestimate the risk inthe general population and one
out of every three persons whopresent with a heart attack
would have been considered lowto moderate risk.
They would not have beentreated.
So these are kind of notadequate if we want to be very
(25:42):
proactive, if we want to be veryaggressive about reducing this
risk of heart attack and suddendeath.
I would also point out thatthere are no trials supporting
the use of these pool cohortequations.
Basically, what they do is kindof try to estimate your 10-year
(26:03):
risk of heart attack and stroke.
Low risk is considered lessthan 5%, high risk greater than
20%.
But there's a large number ofpeople that are in the
borderline risk or theintermediate risk, and that is
the population that mostbenefits from getting their risk
(26:24):
better personalized.
Speaker 1 (26:27):
Now many people have heard a story like this oh, my
brother-in-law had a heartattack and died and so I decided
to get the cardiac calcium scanand thank God I did, because it
showed a high number.
And then they showed that myblood vessels were, excuse me,
(26:50):
very narrowed.
I got an angioplasty and Ithink I'm now cured, or at least
I'm in so much better of aplace.
And I think what we need totell our listeners is that the
purpose of the calcium scan it'snot a plumbing diagram You're
not inevitably going to get apositive test and say, oh, you
need bypass surgery or you needthose vessels opened, that in
(27:14):
fact the studies don't supportthat for people who are in a
stable asymptomatic condition,but rather that these people
just need medications orlifestyle changes.
So maybe sort of walk thelisteners from a positive study
to does that inevitably meansurgery?
Speaker 2 (27:36):
Yeah, that's a great point, Bobby, and one that needs
to be emphasized, and it's ahard point to get across to
patients that we can identifythat you're at high risk.
With a calcium score, you canhave a very high score for your
age that indicates that you havea lot of plaque filled up.
(27:58):
But if you are free of symptoms, if you are not having a heart
attack, a sense is not going tolower that risk at all, and
neither will a bypass operation.
If you're free of symptoms andyou're active and you have built
up a lot of plaque, what youneed is very aggressive
(28:19):
lifestyle and drug therapy tolower that risk.
Um, you don't need a stent andtherefore you don't necessarily
need to have more testing atthis point address all their
other risk factors and kind ofoptimize the therapy for them
(28:40):
short of having to put a devicein like a stent.
And the problem is that somecardiologists feel that this is
(29:06):
an indication for downstreamtesting with, say, a stress test
.
Stress tests are problematicbecause they have a lot of false
positives and even if they'renormal, they don't necessarily
mean that you're not at superhigh risk.
And the best study I think inthis area.
(29:29):
I think you and I discussed theCOURAGE study, but the best
study in this area came outabout five years ago.
It's called the ISCHEMIA trialI-S-C-H-E-M-I-A, and it took
patients who had evidence forsignificantly blocked arteries
and who had abnormal stresstests showing that there was
(29:53):
poor blood flow to their heartmuscle, which is called ischemia
, and randomized them to eithergetting an invasive approach
with a catheterization andpossible stenting, versus just
managing them with lifestyle anddrug therapy, and there was no
difference in outcome.
(30:15):
This was an amazing study thathelped us understand that we can
treat patients just withmedications.
We don't have to rush to doingthese procedures, and the scent
that that person's friend gotdidn't necessarily save their
lives.
Speaker 1 (30:36):
That's an important study and an important set of
findings.
Well, I think we're going tobring this discussion to a close
.
Always when we talk aboutmedical issues, we need to
remind you talk to your doctor.
But now I think you're armedwith some questions to ask about
your diet and whether dairy isfine for you, and a
(30:57):
consideration of the calciumscan and whether that might be
beneficial to help fine-tunewhat you do.
Dr Pearson, thank you.
Thank you for being on thepodcast, thank you for allowing
me to continue to love my butterand my cream and for helping
listeners understand the calciumscans and where they may fit in
(31:19):
for them, and I look forward tohaving your wisdom join us on
future episodes.
So thank you so much.
Speaker 2 (31:28):
You bet, bobby, it's my pleasure.
Speaker 1 (31:31):
Well, let's just close by saying I want everyone
to live long and well and have ahappy heart.
If you are able to go to thelink in the show notes and go to
a brief couple of questions togive me feedback on my podcast,
that would be helpful and I'm,as always, interested in topics
that everyone might want to hearabout.
(31:54):
Well, with that, look forwardto future dialogues.
Thanks so much for listening toLive Long and Well with Dr
Bobby.
If you liked this episode,please provide a review on Apple
or Spotify or wherever youlisten.
If you liked this episode,please provide a review on Apple
or Spotify or wherever youlisten.
If you want to continue thisjourney or want to receive my
(32:16):
newsletter on practical andscientific ways to improve your
health and longevity, pleasevisit me at
drbobbylivelongandwellcom.
That's, doctor, as in D-RBobbyLiveLongAndWellcom.
the bad news Heart disease is the number one killer
of both men and women.
The good news there's a lot wecan do to lower that risk.
Should we change our diet orget a calcium scan of our heart?
Let's see where the evidencetakes us.
Hi, I'm Dr Bobby DuBois andwelcome to Live Long and Well, a
(00:35):
podcast where we will talkabout what you can do to live as
long as possible and with asmuch energy and figure that you
wish.
Together, we will explore whatpractical and evidence-supported
steps you can take.
Come join me on this veryimportant journey and I hope
that you feel empowered alongthe way.
(00:56):
I'm a physician, ironman,triathlete and have published
several hundred scientificstudies.
I'm honored to be your guide.
Welcome listeners to episodenumber 37.
We can reduce our risk of heartdisease.
(01:19):
Well, heart disease,cardiovascular disease, is the
number one killer of men andwomen and we've talked in prior
episodes about the six pillarswhich can each help reduce that
risk, whether it's exercise,getting good sleep, sauna and
cold plunge, nutrition, socialrelationships, mind-body harmony
(01:41):
.
We've also talked in anotherepisode about doing screening
tests like a total body MRI orlarge panels of blood studies,
and I express my concern thatwhen you do these large number
of studies, you might get afalse positive, sending you down
a path of more tests, potentialcomplications and really a lot
(02:04):
of uncertainty.
Today we're going to dive a bitdeeper into cardiovascular
disease and we're going to tryto figure out a couple of things
.
What do we know about what weshould eat?
What do we think about acalcium heart scan?
Are these things that we shouldconsider and talk to our doctor
(02:24):
about?
Well, I could share my opinionand of course, I probably will
and the evidence that I've runacross.
But, more importantly, we have aguest today, dr Anthony Pearson
, and I am thrilled to have DrPearson join us today.
He's a board-certifiedcardiologist.
He was on faculty at severalacademic medical centers,
(02:46):
published over 100 peer-reviewedpapers, and he's also been in
private practice for about 20years, so he has both the
academic and the patient careexperience.
His focus is on preventivemedicine, ways to reduce the
risk of heart disease, and hehas a very broad holistic view
incorporating diet, lifestyle,exercise and, of course,
(03:09):
medications.
And most importantly, and why Ithink he's an ideal person here
today, is that he's also aneducator.
Very broadly stated, he's acolumnist for MedPage today.
Very broadly stated, he's acolumnist for MedPage Today and
for the last decade he has beenwriting the Skeptical
(03:30):
Cardiologist a blog on itswebsite, and now, as a sub-stack
, and some of the article titlesthat I think you'll find of
interest Butter Good or Bad?
Should we Take Antioxidants?
Should we Take Blood PressureMedicines in the morning or at
night?
How to stave off dementia,walnuts and cognition in the
dangers of unnecessary cardiacprocedures and I will have links
(03:55):
to his locations if you wouldlike to read and follow him.
I do and it's been wonderful.
So, dr Pearson, welcome to LiveLong and Well.
Speaker 2 (04:09):
Thank you, Bobby, it's my pleasure.
I'm a big fan of your podcastand I'm happy to be here.
Speaker 1 (04:17):
Well, wonderful, I know, when we chatted a week or
so ago and you were telling me abit about how did you get into
certainly not necessarily howyou got into the cardiology
business that is, of course, itsown story but how did you get
into the education and writingapproach, and you mentioned
something about havingcroissants and butter with your
(04:40):
dear wife and I thought what agreat place to begin.
So maybe tell all of us alittle bit about how did that
start out?
Speaker 2 (04:50):
Sure, I, for the first 20 years or so of my
career, followed the guidelinesand the dogma that had been
presented to me in the dietaryworld and that had started in
1977 with some dietaryguidelines to Americans that
(05:12):
said we should all be cuttingdown fat and increasing carbs,
and I was following that and Iwould battle with my wife over
my first wife, over whether wehad skin milk or full fat milk
in the refrigerator.
(05:32):
I wanted my kids drinking skinmilk and she wanted full fat.
We eventually ended up at 2%percent but by after, after
following these guidelines,which I assumed were solidly
based in science, I was, hedrinking skim milk, eating low
(05:54):
or nonfat yogurt and I avoidedbutter like the plague and I egg
white omelet.
But I met my second wife andwhile she was still what I used
to call on my blog the eternalfiancé.
We were having a brunch outsideat a very nice restaurant in St
(06:18):
Louis and I found myselflecturing her on her decision to
consume a croissant slatheredwith butter.
Speaker 1 (06:28):
And the best way to eat them, of course.
Speaker 2 (06:31):
Yes, according to her , and I was just astonished and
she challenged my viewpoint onthis that she felt like she was
healthy and thin and could eatcroissants lathered with butter.
And so when she challenged that,I went on a quest to discover
(06:55):
the scientific sourcesunderpinning my recommendations,
and I found that in thisparticular area they were very
lacking, and it kind of led meto become the skeptical
cardiologist at that point.
A lot of my early writings in2013 were about the kind of
(07:15):
dietary myths that we had allaccepted without substantial
evidence, and so now I canconsume full fat milk, yogurt
and cheese as much as I desire,and my omelets are made from
full eggs, including egg yolks.
And I think when I first startedthis journey, I came across a
(07:42):
study that was done in Waleswhere I was actually born in
Wales and came to the UnitedStates when I was five by Peter
Elwood, and he had studied someWelsh men and found that those
who consumed the most milk had a13% lower risk of dying than
(08:05):
those who consumed milk, whichwent against the grain of the
recommendation to consumelow-fat milk, because at this
time, everybody was consuminghigh-fat milk.
And I communicated with him andhe revealed to me that he had
(08:28):
done a meta-analysis of all thestudies which he published in
2010 in the European Journal ofClinical Nutrition, and it also
showed that consuming dairyproducts of all kinds actually
lowered cardiometabolic risk andlowered the risk of dying from
(08:48):
cardiovascular disease.
So that was the beginning of myjourney as a skeptical
cardiologist.
Speaker 1 (08:55):
And have subsequent studies borne out that the dairy
, the saturated fat in dairy, isnot problematic?
Speaker 2 (09:05):
It has.
There have been lots ofpublications in this area.
There are lots of meta-analysisand they have kind of been some
have shown no effect.
Most have shown a slightbenefit from consuming dairy on
(09:30):
cardiometabolic risk factors andon reducing the risk of stroke,
and the most recent one waspublished in 2024.
And I can give you a link tothat.
It is in the journal, thejournal nutrition, and it
(09:55):
confirms that and and shows thatthere is really no evidence
that low-fat dairy is better foryou than full fat, and the
evidence is quite strong thatfull fat and fermented dairy
products actually lower the riskof cardiometabolic disease,
(10:19):
measured by things likemetabolic syndrome, which
includes hypertension, diabetes,metabolic syndrome, which
includes hypertension, diabetesand obesity.
And so I think that this ismore and more.
This is being recognized.
Speaker 1 (10:41):
Well, this is fascinating and also very
reassuring, since I of course,love to cook, and love to cook
with butter and cream and allthose wonderful things, and love
cheese.
So let me probe a little bit.
So what you're saying is, dairymay not be problematic.
Perhaps it is even protective.
Now we know that the full fatdairy is saturated fat or has a
fair bit of it.
Are you saying that saturatedfats in general are fine, or
(11:03):
there's something peculiar aboutthe dairy-saturated fats that
make dairy eating safer thanhaving a ribeye steak at three
meals a day?
Speaker 2 (11:19):
Yeah, I think that one of the reasons that dairy
continues, that full-fat dairycontinues to be not recommended
in most nutritional guidelinesis because of the saturated fat
issue.
Dairy contributes about aquarter of the saturated fat to
the diet of Americans and themainstream nutritional
(11:43):
guidelines want to promote asimple message that all
saturated fats are bad for you,so that the public doesn't get
confused.
But the actual fact is thatdairy fat is much different than
the fat that you get from redmeat, for example.
Speaker 1 (12:07):
Much different than the fat.
Speaker 2 (12:08):
That you get from red meat, for example.
Why might that be?
Because the saturated fats andthe fatty acids in general are a
broad family, ranging fromshort chain to medium chain to
long chain, and each one ofthose fatty acids has a slightly
(12:32):
different effect.
Some of them definitely raiseLDL and raise your blood
pressure.
Some of them don't do that.
Some of them might raise theLDL a little bit but also raise
the HDL, and the truth is thatwe don't consume these fatty
acids in and of themselves.
(12:53):
They're in a food matrix andthere is quite a bit of evidence
that the food matrix that dairyis in is protective and behaves
differently when we put it intoour bodies than if we were just
consuming the fatty acids as inan experiment where we can
purify it in some way.
(13:14):
So it's a big, heterogeneousfamily of compounds and it's a
mistake to consider them all asequally harmful to you?
Speaker 1 (13:24):
Okay, that's helpful.
Consider them all as equallyharmful to you?
Okay, that's helpful.
Now I know we had a briefchance to talk a little bit
about the paleo and keto diets,which have gotten a lot of
attention.
These are folks who feel likethey want to cut out
carbohydrates from their dietand when people are eating a lot
of fat and protein becausethat's really what's left you
get vegetables and fat andprotein.
(13:45):
Some of these folks, thecholesterol levels, specifically
the LDL cholesterol, can go wayup.
Is that a worrisome thing?
When somebody is trying one ofthese diets and the LDL goes way
high, do you just say, well,you're losing weight, that's a
wonderful thing.
So what?
The LDL is high.
Speaker 2 (14:06):
Or do you say, no, no , we should try to do something
about that well, I think it is aworrisome and it is a situation
where we really have to be verycareful that we're not
predisposing the patient to highrisk of building up
atherosclerotic plaque and heartattack and stroke as a result
(14:29):
of that.
And there is a study that wasjust published within the last
month which has gotten a lot ofattention on social media.
It is called the Keto CAD study.
The Keto CAD study CAD standingfor coronary artery disease and
(14:53):
these patients were these leanmass hyper responders which, in
the keto world, if you are notobese and if you don't have
diabetes, sometimes about maybe20% of individuals will develop
these very high LDL levels andapolipoprotein B, which is the
(15:14):
particle that gets the LDL intothe lining of the arteries and
triggers heart attack.
And the community there believesthat they are protected against
heart disease, against plaquebuildup.
And this study was an attemptto look at that plaque buildup
over a year in these individualsand what it showed to me is
(15:40):
that number one they havealready built up a significant
amount of plaque and within ayear that plaque progressed,
progress and plaque again is thefaster that plaque progresses,
the larger the burden of thatplaque, the higher the risk
those patients are of heartattack and stroke.
(16:01):
So there are ways to modify theketo diet to make it less
likely to raise the LDL and theAPOE, and that is to use avocado
oil, olive oil and notnecessarily consume massive
amounts of meat.
But the bottom line is if thatdiet is giving you an LDL over
(16:30):
180, you are at high risk andeither the diet should be
changed or you should be startedon medication to get that LDL
down.
Speaker 1 (16:44):
That's very helpful, thank you, and I think putting
the various types of fats incontext the dairy, the non-dairy
, and then sort of the extremecase of the paleo-keto, where
you're getting a tremendousamount of fat Wonderful.
Speaker 2 (17:00):
Let's switch.
And I would add that I am aketo-friendly cardiologist.
When I first started the blog,I went on a keto diet and I
researched it and I think it'sbeen very beneficial for many of
my patients in losingsubstantial amounts of weight.
But again, we have to monitorthese patients to make sure that
(17:26):
they are not harming themselvesin the long run.
Speaker 1 (17:30):
Well, like everything we do in medicine whether it's
a medication we're givingsomeone or it's lifestyle
changes there are always goingto be risks and benefits.
And obviously losing, losingweight, is critically important
for us to live long and well.
And if paleo helps you getthere, that's a wonderful thing,
and if it doesn't change yourldl, wonderful.
(17:51):
But if it does, then I thinkyou talk to your doctor and
maybe you get treated and thenyou can have really the best of
both worlds of being on a dietthat seems effective for you and
keeping that risk factor undercontrol.
Well, that's great, absolutely.
Let's switch gears, and this isa fascinating one.
(18:15):
Folks have probably heard aboutthe calcium heart scan.
It's something that getsadvertised on radio, tv, social
media.
It's a pretty inexpensivescreening test $100 or so and,
as my audience knows, I'mgenerally not that excited about
routine large screening things.
(18:38):
Now, of course, if it's amammogram or a colonoscopy or a
pap smear, these are veryimportant.
They're recommended by USPreventive Services Task Force
and the benefits have been shownto outweigh the harms.
To outweigh the harms.
But when you just do 100 or 200blood tests or you do a total
body MRI just looking for earlyforms of disease.
(18:58):
I think you can end up withsome difficulties and false
positives and anybody who'sinterested in listening more
about it.
By all means go to my priorepisode.
But when we chatted about thecalcium heart scans, you had a
very important way to thinkthrough it.
So maybe first tell folks whatare these calcium heart scans
(19:20):
and why might it be helpful forfolks?
Speaker 2 (19:26):
Sure.
The calcium scan coronaryartery calcium scan is what we
generally call it, anabbreviated CAC.
Cac is a kind of x-ray or CTscan.
It is non-invasive in thatthere are no needles, there are
(19:49):
no catheters placed into yourartery and it is done using a
CAT scan or CT scan and it isour best way of determining
whether there is any plaque inyour coronary arteries and how
(20:13):
much you have, compared to otherpeople, your age.
It is not covered by insurancebut in most of the places where
I've worked I've been able toget it for around $100 paid out
of the pocket and it is a verysafe and very, very accurate
(20:36):
test to measure the amount ofcalcium in your coronary
arteries.
Calcium builds up Plaques, startdeveloping very early in our
lives, possibly even inchildhood, and that
atherosclerotic plaque, overtime, as it heals and progresses
(20:59):
, calcium is deposited into itand when we look with this PT
scan, we're looking to determinehow much calcium you have
compared to normal to your age,compared to normal to your age.
Now, the risk of this test isthat you are getting a small
(21:21):
amount of radiation.
It's usually measured inmillifevers.
It's about one millifever onaverage, which compares to about
0.4 for a mammogram.
So it's about twice as much asa mammogram and each year, if
you're in the Midwest, you getabout 3 millisieverts of
(21:42):
radiation from backgroundsources.
So it's not considered to behigh or dangerous in terms of
increasing risk of cancer, andso I think it's a great tool to
assess in an individual fashionto kind of personalize the
(22:04):
patient that's in front of mehow much plaque they've built up
and, as a result of that plaque, what is their risk of heart
attack and stroke down the line.
Speaker 1 (22:17):
So, as we've talked about in our last call, I tried
to play devil's advocate alittle bit.
It's like okay, so we know iftheir blood pressure is elevated
, we should do something aboutit.
We know if their cholesterol iselevated, they should try to do
something about it If they havediabetes or they're overweight.
So how would this add to theequation?
(22:39):
And really are you suggestingthat pretty much everybody in
their 50s or so get one of thesethings?
Is it going to change what youdo by getting these results?
Obviously, they could benegative or they could be
positive, and if they'renegative you can be very happy
about that If it's positive, butyou're already treating their
(23:02):
blood pressure and theircholesterol and their weight and
such.
How will this help us?
Speaker 2 (23:09):
Yeah, I think this is a common question and it is one
of the reasons that it's notbeing universally applied,
although I would say that anypreventive cardiologist that
I've talked to or listened to isan advocate of using these and
(23:30):
using these in a lot of people,using these and using these in a
lot of people and that isbecause progress in sudden
cardiac arrest death fromatherosclerotic cardiovascular
disease has slowed down in thelast 20 years, and that is the
(23:53):
problem with atheroscleroticdisease, with coronary artery
disease, heart disease, theinitial symptom is often not
chest pain or angina that occurswith exertion due to a tightly
blocked artery.
The initial symptom can just bea heart attack coming out of
the blue and then resulting inan abnormal rhythm that drops
(24:13):
you dead and causes cardiacarrest.
So we don't always get warningsand the plaque can build up to
very dangerously high levelswithout having anything, without
knowing that anything is goingon.
So what the calcium does, whatcoronary calcium does, is give
(24:35):
us an idea of how much plaque isbuilt up and what is your true
risk.
Now, what's the current waythat primary care physicians are
told to assess this is by kindof estimating the risk in an
individual in front of them,based on the standard risk
(24:58):
factors such as blood pressure,diabetes, cigarette, smoking and
the lipid levels, thecholesterol levels level.
But these are not, theseso-called pooled cohort
(25:18):
equations that estimate risks,are not applicable to young
adults and older adults.
They come from studies decadesago.
They overestimate the risk inthe general population and one
out of every three persons whopresent with a heart attack
would have been considered lowto moderate risk.
They would not have beentreated.
So these are kind of notadequate if we want to be very
(25:42):
proactive, if we want to be veryaggressive about reducing this
risk of heart attack and suddendeath.
I would also point out thatthere are no trials supporting
the use of these pool cohortequations.
Basically, what they do is kindof try to estimate your 10-year
(26:03):
risk of heart attack and stroke.
Low risk is considered lessthan 5%, high risk greater than
20%.
But there's a large number ofpeople that are in the
borderline risk or theintermediate risk, and that is
the population that mostbenefits from getting their risk
(26:24):
better personalized.
Speaker 1 (26:27):
Now many people have heard a story like this oh, my
brother-in-law had a heartattack and died and so I decided
to get the cardiac calcium scanand thank God I did, because it
showed a high number.
And then they showed that myblood vessels were, excuse me,
(26:50):
very narrowed.
I got an angioplasty and Ithink I'm now cured, or at least
I'm in so much better of aplace.
And I think what we need totell our listeners is that the
purpose of the calcium scan it'snot a plumbing diagram You're
not inevitably going to get apositive test and say, oh, you
need bypass surgery or you needthose vessels opened, that in
(27:14):
fact the studies don't supportthat for people who are in a
stable asymptomatic condition,but rather that these people
just need medications orlifestyle changes.
So maybe sort of walk thelisteners from a positive study
to does that inevitably meansurgery?
Speaker 2 (27:36):
Yeah, that's a great point, Bobby, and one that needs
to be emphasized, and it's ahard point to get across to
patients that we can identifythat you're at high risk.
With a calcium score, you canhave a very high score for your
age that indicates that you havea lot of plaque filled up.
(27:58):
But if you are free of symptoms, if you are not having a heart
attack, a sense is not going tolower that risk at all, and
neither will a bypass operation.
If you're free of symptoms andyou're active and you have built
up a lot of plaque, what youneed is very aggressive
(28:19):
lifestyle and drug therapy tolower that risk.
Um, you don't need a stent andtherefore you don't necessarily
need to have more testing atthis point address all their
other risk factors and kind ofoptimize the therapy for them
(28:40):
short of having to put a devicein like a stent.
And the problem is that somecardiologists feel that this is
(29:06):
an indication for downstreamtesting with, say, a stress test
.
Stress tests are problematicbecause they have a lot of false
positives and even if they'renormal, they don't necessarily
mean that you're not at superhigh risk.
And the best study I think inthis area.
(29:29):
I think you and I discussed theCOURAGE study, but the best
study in this area came outabout five years ago.
It's called the ISCHEMIA trialI-S-C-H-E-M-I-A, and it took
patients who had evidence forsignificantly blocked arteries
and who had abnormal stresstests showing that there was
(29:53):
poor blood flow to their heartmuscle, which is called ischemia
, and randomized them to eithergetting an invasive approach
with a catheterization andpossible stenting, versus just
managing them with lifestyle anddrug therapy, and there was no
difference in outcome.
(30:15):
This was an amazing study thathelped us understand that we can
treat patients just withmedications.
We don't have to rush to doingthese procedures, and the scent
that that person's friend gotdidn't necessarily save their
lives.
Speaker 1 (30:36):
That's an important study and an important set of
findings.
Well, I think we're going tobring this discussion to a close
.
Always when we talk aboutmedical issues, we need to
remind you talk to your doctor.
But now I think you're armedwith some questions to ask about
your diet and whether dairy isfine for you, and a
(30:57):
consideration of the calciumscan and whether that might be
beneficial to help fine-tunewhat you do.
Dr Pearson, thank you.
Thank you for being on thepodcast, thank you for allowing
me to continue to love my butterand my cream and for helping
listeners understand the calciumscans and where they may fit in
(31:19):
for them, and I look forward tohaving your wisdom join us on
future episodes.
So thank you so much.
Speaker 2 (31:28):
You bet, bobby, it's my pleasure.
Speaker 1 (31:31):
Well, let's just close by saying I want everyone
to live long and well and have ahappy heart.
If you are able to go to thelink in the show notes and go to
a brief couple of questions togive me feedback on my podcast,
that would be helpful and I'm,as always, interested in topics
that everyone might want to hearabout.
(31:54):
Well, with that, look forwardto future dialogues.
Thanks so much for listening toLive Long and Well with Dr
Bobby.
If you liked this episode,please provide a review on Apple
or Spotify or wherever youlisten.
If you liked this episode,please provide a review on Apple
or Spotify or wherever youlisten.
If you want to continue thisjourney or want to receive my
(32:16):
newsletter on practical andscientific ways to improve your
health and longevity, pleasevisit me at
drbobbylivelongandwellcom.
That's, doctor, as in D-RBobbyLiveLongAndWellcom.
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