November 19, 2025 • 47 mins
Cardiologist Dr. Michael Koren is joined by a 35-year-old patient "Tucker" to walk through his cardiovascular numbers and explain what it all means. The doctor explores a lipid profile and an advanced lipid profile from top to bottom, explaining everything from how LDL is calculated to what hs-CRP measures. Along the way, they discuss how diet, exercise, supplements, and medications can affect these numbers, how the numbers relate to your risk of a cardiovascular event (like a heart attack or stroke) and what, if any, interventions should be taken. This real-world-example shows how complex the world of cardiology and lipids is and gives helpful, actionable information based on the numbers you might see.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Announcement (00:00):
Welcome to MedEvidence, where we help you
navigate the truth behindmedical research with unbiased,
evidence-proven facts, hosted bycardiologist and top medical
researcher, Dr.
Michael Koren.
Michael Koren, MD (00:11):
Hello, I'm Dr.
Michael Koren, the executiveeditor of MedEvidence! And we're
going to do something a littlebit different today.
And this came out of a meeting,actually a business meeting,
with my friend and colleaguehere, Tucker, who just started
running his cholesterol resultsby me.
It was funny.
It has nothing to do withmedicine, but he knew that I was
(00:31):
a cardiologist and he knew thatI'm very active in the lipid
field.
And he started asking mequestions about his personal
circumstances.
And it got me thinking, youknow, an intelligent guy like
Tucker, who's truly interestedin his health and doing the best
for himself and his family, hadthese questions, and it brought
up some misconceptions thatpeople have, and also the fact
(00:53):
that there's a lot ofinformation out there that
sometimes is tricky to discern.
So, Tucker, welcome toMedEvidence and tell everybody a
little bit about yourself andwhy you got a series of
cholesterol and other tests thatmay be of interest to
everybody.
Tucker (01:08):
Yeah, absolutely.
And thanks for having me here,Dr.
Koren, and and uh happy just tohave this conversation and and
really educate myself and othersthat are in the same shoes as I
that you know really care abouttheir health but want to go
next the next step or go alittle further in in their
journey and and making sure thatthey're doing the best they can
for not just themselves buttheir family.
Um, you know, I have a uniquefamily story.
(01:29):
I lost my father uh to a strokeheart attack, and and uh, you
know, it it really put inperspective-
How old was he when when hepassed?
He was 56, I want to say.
The stroke happened, and then, you know, progressively got worse over time. Umso you know, it was in 2008
that he had had a stroke, and umit really just opened up my
(01:51):
eyes for my health journey andand now being a father of three
kids, three boys, and and uh youknow, wanting to be a
grandfather one day and and andsee them live out their lives as
well.
Michael Koren, MD (02:02):
How old are your kids now?
Tucker (02:03):
So I have a six-year-old, a four-year-old,
and a one-year-old.
Michael Koren, MD (02:06):
It's a busy household, my friends.
Tucker (02:08):
It is, it is indeed.
It is.
Hearts are full and hands arefull for sure.
Michael Koren, MD (02:12):
Absolutely.
So you mentioned about yourdad.
Any other members of yourfamily die of a heart attack or
stroke, say before the age of60?
Tucker (02:19):
No.
Michael Koren, MD (02:19):
Okay.
No.
My my mother's mom had passedaway from cancer, but not of any
heart issues.
And are you having any specific symptoms
that make you worry about aheart attack or a stroke?
Tucker (02:31):
No, honestly, no, nothing in particular.
Just wanting to be moreeducated.
Michael Koren, MD (02:35):
Great.
And I'm just gonna ask you somebasic questions that a
cardiologist would ask apatient.
Uh, if any of these are notunderstandable or or you ask me
why I'm asking them, that'sfine.
Please ask me.
But uh we usually ask peopleabout a series of cardiovascular
risk factors because we'retrying to get a sense for what
your actual risk is and whetheror not your history is more or
(02:59):
less likely to reproduce yourfather's history in terms of
having a major cardiovascularevent at a relatively young age.
So with that in mind, uh thethings we'd ask is one, do you
smoke?
Tucker (03:11):
No.
Never smoked.
No smoke.
Uh I I've smoked a cigarette before, but not
consistently smoked, right?
Michael Koren, MD (03:16):
Yeah, gotcha.
Yeah, the uh it's funny.
The definition of somebody thatmay have smoked is a hundred
cigarettes in your life.
Although, quite frankly, uhmost people in college will get
to that number, just go going tobars on the weekends.
Right, exactly.
But uh but you never smokedhabitually on a regular basis.
Tucker (03:34):
No.
Michael Koren, MD (03:34):
Uh any history of diabetes?
Tucker (03:36):
No.
Michael Koren, MD (03:37):
Okay.
Um do you have high bloodpressure or are you being
treated for high blood pressure?
Tucker (03:42):
I have high blood pressure.
I'm not being treated for it.
Um, it's not to the point whereI feel it you know needed to be
treated for.
Um, but yes, I'd say I have thewhite coat syndrome, you know.
Every time I get it tested,there is-
Give us a range for what thatblood pressure is when it's at
its high and when it's at itslow.
(04:03):
I have no idea.
To be completely honest withyou, because it's, you know,
they'll come back and take itand they'll be like, you're
fine.
Michael Koren, MD (04:08):
So has anybody told you your your top
number, your systolic bloodpressure is more than 160?
Tucker (04:13):
No.
Michael Koren, MD (04:14):
Okay.
Has anybody told you that yourbottom number, your diastolic
blood pressure, is more than 90?
Tucker (04:19):
No.
Michael Koren, MD (04:19):
Okay.
Um, have you been told thatyour blood pressure actually
did, in fact, normalize whenyou're outside of the doctor
setting? Yes.
Okay.
So so what you know about yourblood pressure is that when
you're stressed, it may go up alittle bit, but other times it's
normal, which by the way is anormal thing.
Tucker (04:36):
Right.
Michael Koren, MD (04:36):
Blood pressure naturally goes up when
you're exercising, etc.
So getting back to thecardiovascular risk factors, uh,
I understand you do exerciseregularly.
You look very fit.
Tucker (04:45):
I Try, yes.
Tell us, tell us about yourexercise routine.
Yeah, so I typically four to five times a week, more
on the five times.
Um, and it's a mixture of, youknow, weightlifting to higher
heart rate cardio hit stuff.
Um so you know, a goodcombination of weight lifting
and high heart rate.
Michael Koren, MD (05:03):
Nice.
And never get any kind ofcardiovascular symptoms like
chest pain or tightness orbreathing issues while you're
doing your exercise.
Tucker (05:09):
No, no.
Michael Koren, MD (05:10):
Fabulous.
Now there's some cardiovascularrisk factors that are obvious.
Uh being a male puts you athigher risk than a female.
You're a male.
And your age, you want to stateyour age for everybody?
35.
Okay, so you're you're a youngman, so that actually puts you
in a lower risk group.
And by the way, age of all thestandard cardiovascular risk
factors is the one mostpredictive of who's gonna have
(05:31):
trouble.
So even if everything isperfect at age 80 in terms of
your cholesterol and your bloodpressure and your sugar status,
your risk is still higher thansomebody at 35 that has a lot of
problems with these numbers.
So I always like to bring thatinto perspective that age is the
most predictive thing that wehave, which is actually sobering
for doctors, is that um quitefrankly, if you know somebody's
(05:53):
age, you're gonna know moreabout their prognosis over the
next 10 years than anythingelse.
But that's a little bitdifferent than what you're here
for.
You're here to maximize thelikelihood of a good outcome for
yourself over the next 10years.
And then when you're 45, you'regonna come back and say, I want
to maximize that likelihood forthe next 10 years, et cetera.
So while age is the most potentcardiovascular risk factor,
(06:15):
there's a relative concept here,is that you want to reduce your
relative risk at your age.
Is that a fair statement?
Tucker (06:22):
That is very accurate.
Okay.
Yes.
Michael Koren, MD (06:24):
All right.
So now we're we're gonna jumpinto a little bit more.
Um, you know, you mentionedthat you did go online because
of your concerns about yourfamily history, and that you got
some extensive lab testing.
So just tell us a little bitabout that story.
Tucker (06:37):
Yeah, it's always something that, you know, like
you had said, given familyhistory that I've I've wanted to
do, and and uh, you know, thiswas very user-friendly.
Um, the platform that I used togather all this data and um,
you know, went to my wife andshe wanted to do it as well.
And uh, you know, the numberswere that-
and we'll go through some ofthe numbers, right?
(06:59):
But you got a you got a lot ofdata.
Did you feel like youunderstood everything or did it
uh tell me a little bit aboutthat?
No, I and and that's you know one of the conversations
or the what what led me to youuh in in our business meeting
and and saying, Dr.
Koren, can you can you pleaselook at this and break this down
for me?
Because you know, I have it, Idon't know what to do with it.
Got it.
And that's why that's why we'rehere today.
Michael Koren, MD (07:19):
Sounds great.
Okay.
Well, if it's okay with you,we're gonna just kind of jump
right into stuff.
Tucker (07:23):
Absolutely.
And you and I can look at thenumbers and people in the
audience, either the viewers orlisteners, can get this
information.
You give us permission to showthis online.
Yes, sir.
You okay with that?
Oh, yeah.
That's why we're here.
Okay.
Well, we'll cross out your nameso they can't see that other
than other than Tucker.
But just this is the old HIPAAthing.
We want to make sure that yourprivacy is protected.
Obviously, coming on thisprogram shows that you you're
(07:46):
okay being out there a littlebit, but we still want to
protect your privacy as much asmuch as possible.
My goal is to help others.
Michael Koren, MD (07:52):
Terrific.
So starting with yourcholesterol profile, we call
this lipid profile quotestandard, which literally
millions and millions andmillions of people get every
year.
And I I have family members andfriends, et cetera, that are
constantly calling me and youknow, what does this all mean?
And typically in this lipidpanel, you see total
cholesterol, HDL cholesterol,triglycerides, and LDL
(08:17):
cholesterol.
And then below that you havethe ratio, which is the
proportion of things, uhcholesterol to the HDL, and the
non-HDL cholesterol um totalnumber.
So does that make sense to you?
When you look at this, do youhave a do you have an intrinsic
a sense of I know what's goingon or not so much?
Tucker (08:37):
I know I have some things out of range and and you
know, some things I need to workon, but aside from that, my my
knowledge is very, very smalllow about this.
Yeah.
Michael Koren, MD (08:47):
So just let's just start with uh a basic
concept, which is the differencebetween total cholesterol and
LDL.
Cholesterol is a lipid, it's afat molecule.
Cholesterol is actually areally, really important
molecule in our bodies.
Every cell in our body needscholesterol to function.
And because cholesterol is soimportant to cellular function,
(09:10):
every cell in our body makescholesterol from basic
materials.
So our cells make cholesterol.
This is the thing that mostpeople don't understand, which
is that because the cells aremaking cholesterol and pushing
it out when there's extra, byand large, what we measure in
the bloodstream is the extrastuff our body's trying to get
(09:31):
rid of.
So there's a big misconception,even among some physicians,
that somehow we need dietarysources of cholesterol to
function and have normal lives.
Well, cholesterol is actually aproduct of animal cells.
So if you're a vegetarian,you're not gonna eat a lot of
cholesterol in your diet.
But that's okay because yourbody makes it.
(09:52):
Right.
But vegetarians can still have a
high level of cholesterol intheir circulation because of
genetic factors.
So again, think aboutcholesterol as something that
all your cells need, all yourcells can make, and the stuff
that you're measuring in thebloodstream is the extra stuff.
But as I mentioned, cholesterolis also a fat, and your blood
is mostly aqueous orwater-based.
(10:14):
Do fats and waters mix?
You ever put uh fats in a cupof water?
Tucker (10:19):
It's like oil and water.
Michael Koren, MD (10:20):
Exactly.
They don't mix.
Right.
So, how do you get this to movein your circulation and
eventually get out of yourbloodstream?
Well, the way you do that is byforming lipoproteins.
Your body forms lipoproteins,and we'll show a picture of
that.
But lipoproteins are these muchlarger molecules, typically
shown as spherical molecules,that have a combination of fat
(10:41):
and protein, which can besoluble in the blood and then
eventually get delivered todifferent places, most commonly
the liver, to get rid of them.
Interesting.
So HDL and LDL are two quote lipoproteins,
high density lipoprotein and lowdensity lipoprotein.
Tucker (11:01):
Understood.
Michael Koren, MD (11:02):
High density lipoprotein is epidemiologically
linked with better outcomes,meaning that if you have higher
levels of HDL, you're lesslikely to have cardiovascular
disease.
LDL is the opposite.
If you have high levels of LDL,you're more likely to have bad
cardiovascular outcomes.
Now, because of thisepidemiological association, we
(11:25):
talk about HDL as the goodcholesterol, quote unquote, even
though it's more than justcholesterol.
And we talk about LDL as thebad cholesterol, even though
it's more than just badcholesterol.
And more recently, there'sanother particle that's become
something we talk a lot about,which is called lipoprotein(a),
which we like to say here,at MedEvidence, is the really,
really, really, really badcholesterol four really bads.
(11:46):
And the reason for that, andwe'll show it structurally, is
it has an extra little uhcomponent to it called an
apolipoprotein that makes thatparticular particle more
difficult to get rid of, to getout of your bloodstream.
And because of that, there's amuch stronger epidemiological
link between high LPA and badcardiovascular outcomes.
(12:09):
And I mentioned this becauseyou may have a little bit of an
LPA problem here.
Right.
Tucker (12:12):
We'll get to that.
And that's something I cancontrol or not control?
Michael Koren, MD (12:17):
Well, we'll get to that.
Tucker (12:18):
Okay.
Michael Koren, MD (12:20):
We'll getting into that.
But I just want to giveeverybody the basics because
even simple things like this, Ifind most people don't really
understand exactly what theyare.
Tucker (12:27):
Right.
Michael Koren, MD (12:28):
But that does it all make sense so far.
Tucker (12:29):
It does.
Yeah.
No, it helps a lot.
Michael Koren, MD (12:31):
And then uh finally, you have another type
of blood fat calledtriglycerides, which is really
about energy.
Triglycerides are one of theenergy stores for your body, and
it's actually needed forenergy.
But it's different thancholesterol, which is also
structural.
So cholesterol is thefoundation of hormones,
cholesterol is the foundation ofcellular walls of the cells.
But uh triglycerides is reallyan energy store.
Tucker (12:53):
Okay.
Michael Koren, MD (12:54):
Okay.
So we have all those thingshere, and I'm gonna you'll be
able to see it from the audiencethat Tucker's total cholesterol
is 261, which is a little bithigh.
And it's listed as thereference range is less than 200
milligrams per deciliter.
But again, we're gonna talkabout the fact that if that
cholesterol is in HDL, it's notas bad as if it's in LDL.
(13:15):
And moving down, your HDL is67, which is actually pretty
good.
Um they're saying the referencerange is above 40.
Above 60 is even better.
So that's a that's a positive.
You have a high HDL, probablyin part due to the fact that um
you you're physically active.
Physical activity in exercise,particularly intense exercise,
will raise your HDL.
Another thing that can raiseHDL, I didn't ask you about this
(13:37):
yet, is alcohol use.
What's your typical alcoholuse?
Tucker (13:40):
Yeah, I would say weekly, I guess you could base
it off of, you know, probablyfour cocktails a week.
Michael Koren, MD (13:47):
Okay.
Tucker (13:47):
Or four alcoholic beverages.
Michael Koren, MD (13:49):
You don't drink every night.
Tucker (13:50):
No.
Michael Koren, MD (13:50):
Okay.
So you go out for dinner on theweekend and a glass of wine,
okay.
So four alcoholic beverages umper week.
So that's not a big driver, butum, that's certainly not
something that I would considerunhealthy from a heart
standpoint.
There's some debate aboutwhether or not um alcohol use at
moderate to low levels may havesome negative effects on your
GI tract and GI systems, butfrom a cardiovascular
(14:12):
standpoint, I'm perfectly okaywith that.
Tucker (14:14):
Yeah.
And and you know, there was atime that it was a lot higher
than that.
I'll preface the audience withthat, you know, and and since
doing you know these panels andreally dialing in, you know,
where I want to be, it, youknow, I've been cognizant of
intake.
Michael Koren, MD (14:26):
Yeah, and the other thing, by the way, is
when you drink a lot of alcohol,your triglycerides may go up.
That's one of the things thatcan drive higher triglyceride
levels.
And yours turn out to be verynormal, 73.
Uh, they say that for thereference range that it should
be less than 150, but in fact, Ilove seeing them less than 100.
So you get you get a fist pumpfor that.
Tucker (14:42):
Love it.
Michael Koren, MD (14:42):
So your triglycerides, you're you're
kicking butt onto thetriglycerides.
Tucker (14:45):
Good.
Michael Koren, MD (14:46):
But this is a little concerning.
Your LDL is 177.
Right.
Okay.
And they don't even give areference range from that.
And they also put somethinginteresting in it that says
calculated, which I like to makesure people understand, is that
LDL for most of the assays thatare done is not directly
measured, but is actuallycalculated based on your total
(15:08):
cholesterol, HDL, andtriglycerides.
And for somebody like you thathas numbers kind of in
mid-range, that's not a bigproblem.
It's usually pretty accuratecalculation.
But if you have particularlyhigh triglycerides or a low LDL
that you're trying to get reallylow, for example, patients of
mine that have very badcardiovascular disease, that
(15:29):
calculated measurement may notbe as accurate as a direct
measurement.
Tucker (15:33):
And you can get a direct measurement.
Michael Koren, MD (15:34):
You can get a direct measurement.
It's a little more expensive,and doctors have to ask for it
specifically, but it isobtainable.
I'm not going to go into allthe different ways of
calculating LDL, but I assumethis is the what we call the
Friedelwald equation, which isthe most commonly used way of
calculating your LDL.
Tucker (15:53):
You're exactly right.
It says, yep.
Michael Koren, MD (15:54):
And that would typically be the total
cholesterol minus the HDL minusthe triglycerides divided by
five.
So you can check to see iftheir math is correct now that I
gave you the formulas.
Tucker (16:08):
Thank you.
I will.
Michael Koren, MD (16:10):
All right.
And then moving down, you haveyour cholesterol to HDL ratio at
3.9.
They say less than five is iswhat you want to see.
And that's in part because youhave a nice HDL cholesterol.
And then your non-HDLcholesterol, which is all the
stuff other than HDL, is 194,which again is high.
So just looking at this, wewould say that this lipid
(16:33):
profile is not exactly where wewould want it.
And the first question thatcomes up is what's going on with
your diet?
Um, are you eating a lot ofmeat?
Are you eating a lot of uhsaturated fats?
As I mentioned, your body canmake cholesterol, but your
dietary sources of fats andcholesterol also drive this.
And remember, it's not justcholesterol when you're
(16:56):
consuming, but fats.
In fact, saturated fats aremore likely to drive higher
cholesterol than ingestingcholesterol itself.
Tucker (17:02):
Right.
Michael Koren, MD (17:03):
So tell us a little bit about that part of
your life.
Tucker (17:06):
Yeah, you know, I I do eat a lot of red meat and and
you know, meat in general, Iguess you could say, as far as
you know, chicken, and you know,I try to stay away from pork.
Um my fish intake is is lowerthan what it probably should be,
uh, in my opinion.
Um so you know, primarily everymeal it's either chicken or
(17:27):
steak.
Um now that you know I'vegotten these results, I've kind
of gone more to chicken, butyes, this and then dairy too,
right?
You know, and and cheeses andyou know eggs and and different
things like that.
But um pretty bland for themost part.
I do have some some rice mixedin or some grains mixed in, but
um that is something I try to becognizant of and then work in
(17:49):
some fasting as well just to toyou know help cellular repair.
Michael Koren, MD (17:53):
Would you say that you eat meat during every
meal during your day?
Tucker (17:57):
I wouldn't say every, I would say you know, one to two
times a day.
Okay.
So leave out breakfast and justyou know have the dairy as far
as you know, or or you know,eggs and and then probably lunch
and dinner.
Yeah, that's a fair assessment.
Michael Koren, MD (18:10):
Yeah.
So obviously bringing that meatconsumption and dairy
consumption and egg yolkconsumption, obviously the
whites of the egg don't havecholesterol in it, but the yolk
does, that would help drive downyour LDL.
But the truth is, is that as Imentioned, because so much of
cholesterol may come from yourbody itself, it's very variable
(18:32):
how much reduction in LDLcholesterol you get when you
change your diet.
And I've had people that havechanged to vegetarian diets or
even vegan diets, and they havea dramatic lowering, but other
people that do it and they arevery disappointed that they
don't have more of a lowering.
And that tells me that theirbodies are intrinsically making
cholesterol that's being putinto the circulation.
But the truth is it's very hardto know that without having a
(18:55):
patient try it.
So often we'll take somebodylike you and say, okay, well,
you're a young guy, you're nothaving any symptoms, you have a
cholesterol profile that's amixed bag, good HDL, but not
great LDL.
And maybe you should go on amuch stricter diet where maybe
you eat red meat once a week.
Maybe you eat fish uh five orseven times a week, which I tend
(19:18):
to do.
Um my main protein in my dietwould be fish.
Okay.
Uh and try to cut back on thecheese and maybe instead of
doing regular omelets, do eggwhite omelets and put these
things into your diet and thenrecheck in a few months and see
if you put a dent in that.
Tucker (19:35):
I was gonna say, how long is it typically that you
would have to do that trial, soto speak, to see results?
Michael Koren, MD (19:41):
Typically you want to see about two or three
months.
Okay.
Um that's usually what what youwant to see for triglycerides,
by the way.
If you have high triglyceridesand you change your diet,
that'll change very quickly.
Tucker (19:51):
Okay.
Michael Koren, MD (19:51):
But the LDL may take a little bit longer
before you're gonna have animpact on it.
And again, nutritional elementsof this are a whole podcast in
of itself, because there's alot, a lot of nuance in in all
these things.
But as I mentioned, saturatedfats and the ingestion,
ingestion of cholesterol willdrive this, uh, will drive your
LDL levels up.
(20:12):
But saturated fat's even morethan cholesterol.
And the reason I bring thatpiece up is that shellfish often
becomes a discussion.
Shellfish is high incholesterol, but very low in
saturated fat.
So that's not a bad place to goif you need to replace certain
things.
Tucker (20:28):
So shrimp aren't bad.
Michael Koren, MD (20:29):
They're not as bad as um really fatty meats
or eating the skin of chicken,even.
But um uh I personally will eatshellfish, and I consider that
part of my diet that pulls outfrom the meats and the fats and
is using a lower fat, butsomething that's not super low
in cholesterol.
Good to know.
Okay, so hopefully that makessense.
(20:51):
So getting back to um uh thesetypes of interventions, the
other thing is that there arecertain foods like oatmeal, for
example, that make it moredifficult for your gut to absorb
cholesterol.
And if that's not in your diet,you may want to think about
things like that.
So grains and other things thatuh we often eat in the
(21:11):
mornings, but not necessarily,are important.
And also bananas, um, otherthings that have roughage, et
cetera, are good things for usto consider in terms of diet.
And again, this is not anextensive podcast on that.
Right.
And but there's lists onlinewhere you can see how all these
different foods can actuallyaffect cholesterol absorption
and and their glycemic index,which is a whole other
(21:33):
conversation.
Tucker (21:35):
Is there a way it, you know, let's say you do go
through with a meal plan forthree to six months.
Do you notice any difference inyour body as far as if your
cholesterol levels change, asfar as energy or anything like
that, or is that strictly feltoff of or captured off of a
blood test only?
Michael Koren, MD (21:49):
Well, it's interesting.
Uh it it is different fordifferent people, but there's no
doubt that the type of food youeat does affect your mood.
It affects uh neurohormonesthat affect your brain, it
affects your appetite.
So there's a lot of factorsthat go in, and everybody's not
exactly the same.
So, in general, um, when youeat high protein things, people
(22:11):
feel a little bit brighter.
Um, when you eat some thingsthat are high in sugar,
sometimes that raises certainhormonal levels that make you
feel sluggish.
Although other people have animmediate rush when they have
sugar.
So, again, these are competinghormonal levels.
I'll tell you for myself, if Ihave something that's very, very
sweet, I want to take a nap in15 minutes.
Whereas other people kind ofget that sugar rush from but
(22:34):
these are how different hormonesare balanced in your
bloodstream and how they affectyou.
So there's no doubt that foodsaffect your mood and affect your
function, but it's it's veryindividual.
And uh we'll definitely look atthat for a future podcast about
some of these details.
But do you have anyobservations for yourself when
you eat high protein versus lowprotein?
Tucker (22:53):
No, honestly not.
Um I mean, I do it's more thefasting versus not fasting for
me, really.
You know, I notice energylevels and whatnot when I
haven't eaten and I've done amoderate to severe workout
versus when I've eaten beforeand done a
Michael Koren, MD (23:10):
you feel more energetic with fasting or less
energetic with fasting?
I would say less.
Okay.
Um just you know, given thetype of workout dependent upon
what I'm doing.
Sure.
You know, if I'm going on arun, then you know, fasting, I
seem to feel a little bit betterthan you know, if I'm going to
lift weight.
Yeah, it's interesting.
Uh again, in my vast experiencewith people like yourself and
(23:31):
asking these questions, I'm notsure there's anything that's a
formula for any individual.
It's just a little bit trialand error what works best for
you.
Tucker (23:39):
Gotcha.
Michael Koren, MD (23:40):
So let's move on to the rest of these
numbers.
And some of these are lessrelated to vascular disease.
I'm going to kind of skip overthose.
But the one the next one onyour page is actually
homocysteine, which is one ofthese super interesting uh
concepts that people talk about.
And homocysteine is an aminoacid, it's it's in the protein
class.
And we know that people thathad higher levels of
(24:02):
homocysteine have a relationshipwith higher incidence of
cardiovascular disease.
But there's not that much talkabout homocysteine uh for the
reason that we don't have asmuch data that intervening makes
a difference.
So the reason we talk so muchabout LDL cholesterol is that
the association with higher LDLcholesterol and bad
(24:23):
cardiovascular outcomes is isstrong, but not super strong.
There are a lot of people thathave high LDLs that live
completely normal lives don'tget atherosclerosis, and other
people that have lower LDLs thathave tons of atherosclerosis.
So there's a correlation, butnot a perfect one.
But what we do know is thatlowering LDL with treatment
(24:44):
makes a huge difference.
And time and time and timeagain in studies, we show that
lowering LDL makes a difference,particularly when you're at
high risk.
But something like homocysteinethat also has that relationship
with bad outcomes when it getshigher, has never been shown to
be the same in terms of thelowering it.
Plus, the neat thing abouthomocysteine is that it's
(25:06):
something that reflects Bvitamin metabolism.
And there's a relatively easyway to treat high levels of
homocysteine, which is with Bcomplex vitamins.
Tucker (25:15):
Okay.
Michael Koren, MD (25:15):
And a lot of people take multivitamins or B
complex vitamins, and that willhave the maximal effect on
lowering homocysteine.
So outside of using B complexvitamins, there's not a whole
lot out there to show us thatlowering homocysteine is going
to make a difference, even forsomebody like you with a family
history.
Okay.
But that covers that.
And then you have some of thesethings.
These are things that anendocrinologist might look at.
(25:38):
Uh you have the zinc level,which is kind of interesting.
So the the general sense isthat zinc is protective.
Some people call it anantioxidant.
And your levels are 105, whichis completely normal.
But this comes up a lot.
And there's also somethingcalled the zinc-copper ratio.
You want your zinc-copper ratioto be higher rather than lower.
(26:00):
Uh, copper is complex in termsof how it's correlated with
cardiovascular disease.
Both low levels and high levelsare not good.
But there's a general sensethat your zinc-copper ratio
should be favorable.
And uh one of the interestingplaces where that was looked at
was actually in the country ofFinland.
Finland historically had a veryhigh rate of cardiovascular
(26:22):
disease.
And it turned out in particularthat there were areas in
Finland where there was morecopper versus zinc in the
drinking water that had thehighest rates of cardiovascular
disease.
So some of the epidemiologicalinsights came from that
particular study looking at acountry and how different parts
of the country were affected interms of epidemiological rates
(26:44):
of cardiovascular disease.
Now, again, um, do yourecommend zinc supplements?
No, unless you have profoundlylow levels.
And nor would I recommendcopper supplements.
But um it's something that ifyou're really out of whack one
way or another, you want to talkto a physician about, probably
an endocrinologist.
Tucker (27:00):
Are you getting those already in your multivitamin
that you know?
Michael Koren, MD (27:04):
Yeah, I honestly I don't I personally do
not routinely check this in mypatients.
Okay.
But it it is uh it it it's aneat interesting thing from an
epidemiological standpoint.
And if you have a good diet andyou take uh multivitamin once a
day, you're probably doing whatyou need to do for if you're
dealing with these issues.
And then um I'll skip some ofthese others because they're a
(27:24):
little esoteric.
And um, but I'll just mentionfor interest's sake is that they
measured your leptin.
Are you familiar with withthat?
Tucker (27:33):
Not at all.
Michael Koren, MD (27:34):
Okay.
So leptin is actually somethingthat suppresses your appetite.
Tucker (27:39):
Oh wow.
Michael Koren, MD (27:39):
And there's a lot of research going right now
with the GLP1 agonists abouthow it affects leptin levels and
other things.
And there's a belief, and weare actually doing a lot of
research on this particulararea, that maybe we can use
changes in leptin levels toreduce somebody's appetite.
So they did check that yours iswithin a reasonable normal
(28:01):
range for what you expect for a35-year-old man.
So nothing to worry aboutthere.
But uh it's just interestingthat that was checked.
Then you had some tests of whatwe call inflammation.
Your rheumatoid factor wasnegative, your antinuclear
antibody screen was positive,though.
And um this is a nonspecifictest that can be associated with
(28:24):
some immune diseases likelupus.
And generally, this issomething your physician should
follow up on and do some furthertesting to see if you have
other elements of inflammation.
Now, some of that testing wasdone, but not all of it as we go
into subsequent things.
But that's uh something that'sreasonable to follow up because
we know, for example, thatpatients who have lupus have
(28:47):
higher rates of cardiovasculardisease.
And maybe that's the threat inyour family history.
Maybe that's what um wassomething that affected your
dad.
And so I would definitelyfollow up on the positive
antinuclear antibody test, andwe'd get other types of testing
to see if you have the diagnosisof lupus.
Although you haven't mentionedany symptoms, that would make me
think of
Right, I was going to say, whatwould be a-
arthritic type simple symptomsare typical, rashes are typical,
(29:11):
and there's other things.
But um, again, that's a littlethread, but it's also a very
nonspecific test.
So just because it was quotepositive doesn't mean that you
have any illness related to it.
Tucker (29:21):
Got it.
Michael Koren, MD (29:21):
But it they did order that and it it is of
interest.
And uh I'm gonna skip some ofthese other things um in the
interest of time, but um I wantto get to um one other thing
that I noticed that was superinteresting, which was your
Lp(a) level.
And let's see if I can findthat here.
(29:42):
So, yeah, here we go.
So you have what's called anadvanced lipid profile.
So the first thing we talkedabout was the standard lipid
profile.
But there are a lot of otherways you can look at your your
lipids, your lipoproteins, toget insights.
So, one of the things that uhwe do in the advanced lipids.
Profile is actually look at thenumber of particles.
(30:03):
So when you measure somethinglike uh LDL, low density
lipoprotein, you can look at itin two ways.
You can look at it based on themass or the weight, or you can
look at it at the number ofparticles, which we call
concentration.
And so when you think about it,if you have fewer particles
that are of heavier weight,that's going to be a little bit
different profile than peoplethat have more particles of a
(30:25):
lighter weight.
So in the extremes, people thathave more particles with a
lighter weight may have the sameoverall lipid levels as
somebody that have fewerparticles at a heavier weight,
but their prognosis isdifferent.
So if you have more particlesthat are small particles, that's
actually worse than somebodythat has fewer particles that
are big, more buoyant particles.
(30:47):
And you do, in fact, have anexcess number of LDL particles.
So that's something we don'tlike to see.
And you have above what youwould want to see in terms of
small LDL and medium LDL.
So I would point out the factthat when you look at this
statistically, that's anothersmall reason why you would want
(31:09):
to consider getting that LDLlevel down, or maybe even
ultimately using a statin drug,which we'll talk about in a
second.
Okay.
So I think that's a uhsomething that's important.
And then um they looked at youromega-check, they called it,
which was uh looking at a panelof your omega-3 fatty acids, and
(31:29):
that came in a little bit low.
Um, I I think this this is aproprietary uh assay, and we'll
show this on the screen.
But it goes into all uhmultiple different omega-3 fatty
acids, which are very importantin terms of number of cellular
functions.
But the thing about the omega-3fatty acids that's tricky and
(31:49):
and even difficult forphysicians is that the
interventional studies for someof these things have been a
little bit all over the place,quite frankly.
So, what we know is that whenyou supplement with omega-3
fatty acids, you may have somebenefits.
Uh, there's some information,for example, that it may help
mood disorders, it may helppeople with depression.
(32:10):
But when we've used it to lookat reducing cardiovascular
disease or particularlycardiovascular outcomes, it's
been a little bit of a mixedbag.
Some studies have shownpositive results, other studies
have shown not great results.
And so, because of that, wedon't necessarily focus on that.
But it's interesting that's apart of your panel.
The flip side is that this isanother one of those things that
(32:33):
may be relatively easy to takecare of.
So, in somebody like you, wetalked about the fact that you
don't eat that much fish, whichis rich in omega-3 fatty acids.
Right.
And you may want to considerthat.
So, an easy intervention wouldbe for you to just eat more fish
and replace some of the otherproteins with that.
And I imagine that that wouldhelp your omega-3s go up.
But there are supplements outthere.
Tucker (32:55):
So Yeah, I've started to supplement with salmon oil and
and cod liver oil.
Okay.
Um there you go.
Michael Koren, MD (33:01):
We'll rerun these numbers in six months and
see.
Yeah, and you and you'll you'llprobably see them higher.
But again, this is one of thosereflections of uh your du how
you get your your diet canchange the numbers.
But you have to be a little bitcareful because I can't really
tell you the diet's gonna changeyour outcomes.
Tucker (33:16):
Right.
Michael Koren, MD (33:16):
But nonetheless, and there's no
downside, especially if you likefish, right?
Right.
Or if it's no big deal to take a fish oil
capsule a day, then there'sreally not any significant risk
to that.
Sometimes people talk about themercury risk of of some of
these things.
Tucker (33:29):
Which they test for already, and that was fine,
right?
Michael Koren, MD (33:31):
So exactly.
And there are products outthere that are refined products
that don't have mercury in it.
But um, quite frankly, a fishoil capsule a day, a thousand
milligrams or one gram, I don'tthink is gonna hurt you from a
mercury standpoint.
But uh interesting that theydid that.
So I want to touch on yourlipoprotein(a).
We we alluded to that earlier,and that's that really, really,
really, really bad cholesterol,as I mentioned.
(33:53):
And your level here is 151.
That's the concentration, it'sin nanomoles per liter.
And that's high.
And that's super interestingbecause high Lp(a) levels run in
families.
Okay.
And maybe that's what put butthat's what affected your dad.
Tucker (34:09):
Right.
Triggered this.
Michael Koren, MD (34:10):
Yeah.
And you mentioned you didn'thave any other family members,
but have you had other familymembers have their Lp(a)
checked?
By do you know of?
Tucker (34:16):
I I I'm sure they have.
Michael Koren, MD (34:18):
Brothers, sisters, or your mom, or or- I'm
sure my mother has.
Um, you know, my wife has, butI don't I haven't asked about
it.
Or anybody on your dad's sideof the family, um uh aunts or
uncles on his side of thefamily?
Tucker (34:30):
Yeah, not that I've asked.
Michael Koren, MD (34:32):
The reason I asked that is because there's a
genetic inheritance pattern foruh lipoprotein(a).
It's it's called what we callautosomal dominant.
And that number is reallydetermined by your genes.
Tucker (34:44):
Okay.
Michael Koren, MD (34:45):
So your overall LDL, as I mentioned, is
a combination of your geneticpredisposition and your diet.
But Lp(a) is almost allgenetics.
And it's interesting forsomebody like you that has an
Lp(a) level that's elevated tosee what their genetics are, and
you can kind of figure it outbecause you got one or both
genes from your parents, andit's discernible once you can
(35:05):
figure that out.
Obviously, your father'sdeceased, so we can't get that
now.
But by looking at other of hisfamily members, you may be able
to figure that out.
Tucker (35:13):
Or just his history.
If my mom doesn't have it, thenhe would have had to have it.
Michael Koren, MD (35:16):
Exactly.
That's right.
So exactly.
So the deduction, right?
Deductive reasoning,
Tucker (35:20):
right
Michael Koren, MD (35:20):
That's right.
Tucker (35:21):
And and I guess to that point, you know, for my kids'
sake, um, you know, since I haveit, and if my wife had it, they
all by trait will have it.
Is that a safe assumption?
Michael Koren, MD (35:32):
Probably so, but not necessarily.
Because remember, uh anautosomal dominant gene is
something that hides recessivegene.
So let's say that they both gotrecessive genes that don't code
for LPA at high levels, thenthey would have normal Lp(a)s.
I probably confuse you withthat.
Tucker (35:49):
But No, I I mean I I I can understand.
Michael Koren, MD (35:52):
Just like two brown-eyed people can have a
blue-eyed baby.
Tucker (35:55):
Right.
Michael Koren, MD (35:56):
Makes sense.
Tucker (35:56):
Right.
Michael Koren, MD (35:57):
So, anyhow, um, but your lipoprotein(a) is
is high.
And so that is something thatwould be a risk factor.
And as I mentioned, that'sactually a stronger risk factor
than LDL itself.
So, because of that, um, uh youwould be somebody that I would
want to explore a little bitmore where you stand in terms of
(36:18):
atherosclerosis.
Okay, and I'll get to that in asecond.
The flip side is that you alsogot what's called an hs-CRP,
which is a look at your vascularinflammation, and that was
beautiful at point two.
Tucker (36:31):
Great.
Michael Koren, MD (36:32):
Okay.
So uh generally we want that tobe less than one, and yours is
optimal at less than one.
And there's some data that'sshowing of all these markers, we
call these biomarkers.
Of all these biomarkers, thehs-CRP may be the one that's
most highly correlated with badcardiovascular outcomes in the
future.
There's some debate whether ornot Lp(a) or uh hs-CRP are
(36:54):
better.
My personal opinion is that uhLp(a) identifies certain
subgroups that are particularlyhigh risk.
Tucker (37:00):
Okay.
Michael Koren, MD (37:01):
And hs-CRP is more of a general sense of
vascular inflammation.
But nonetheless, uh it's goodnews that your CRP is low.
And that's becoming more andmore studied in terms of how
inflammation and theidentification of inflammation
leads to bad cardiovascularoutcomes.
And we've had some podcasts onthat.
So I'd uh if you like thisdiscussion, I invite you to look
(37:21):
at some of the other podcastswe do in particular.
I did a podcast with myclassmate, Dr.
Paul Ridker, is considered theinternational guru on CRP and
inflammation, and and you'lllearn a lot more about this.
Tucker (37:32):
Love it.
Michael Koren, MD (37:33):
But yours is good, so that's good.
Tucker (37:35):
Great.
Michael Koren, MD (37:35):
All right, so we cover a lot of ground here.
Any questions before I get intomaybe some recommendations?
Tucker (37:42):
Yeah, I guess you know, one thing that I I've done
within the last two years, justbefore getting all of this done,
and curious to see what yourthoughts are.
You mentioned Finland earlierin the podcast, and and uh I
have a sauna in my backyard
OK
And uh, you know, uh in thefitness side of things, it's
obviously very common to do andand becoming more and more
(38:02):
common nowadays um or or moreaccessible.
And uh just curious to get yourintake on you know sauna usage
and and higher temperatures foran extended period of time.
Michael Koren, MD (38:14):
So there's a lot of these things we just
don't know the answer to.
So the when we when we do lookat things scientifically, we
have to do a randomized trial.
And a randomized trial meansthat we randomly choose you to
one thing or another.
So a randomized trial of saunause would be to randomly put
people in saunas or to dosomething else and and compare
(38:36):
the results over a period oftime or based on a biomarker or
based on something.
So we just don't have thosekind of studies for sauna.
But if it makes you feel good,there's not a whole lot of
downside.
Just be careful because it canlower your blood pressure, and
if you get out too quickly, youcan hit your head and do some
damage that way.
Yeah.
But um, I certainly you know,there's some things in life that
you should just enjoy, and uhsauna is one of those things.
(38:58):
But to have to do itcompulsively for your health, I
don't necessarily would don'tneed to recommend that.
Tucker (39:04):
Okay.
Michael Koren, MD (39:05):
But I don't see anything wrong with it
either.
Good to know.
So this gets into some of umthe things that what we uh we
would do is uh if you're in apatient setting with me, what we
do in terms of our plan, whathow we're gonna move forward
with all this information.
We've got a ton of information,we cover a lot of stuff.
So what do you do next?
Well, obviously you're veryconcerned with your risk, and
you have some factors here thatwill need to be followed up,
(39:27):
like your ANA, and we talkedabout your LDL and your Lp(a).
But what do you do to look atyour risk?
And one of the things that Iwould recommend for you is what
we call a coronary arterycalcium score or CAC score.
And what we're learning is thatCAC score gives you good
insight into whether or notyou're prone to atherosclerosis.
And if you remember, uh, wefirst uh became more aware that
(39:50):
young people can have pretty badatherosclerosis based on
autopsy autopsy studies thatwere done during the Vietnam
War.
And these were young men, youknow, 18 to 24-year-old men that
were killed in battle,unfortunately.
And during their autopsies, itshowed that some of them were
already developingatherosclerosis on their aorta.
And uh as technology hasprogressed, we can now uh uh
(40:11):
determine whether or not youhave atherosclerosis without
doing an autopsy, fortunately.
And the easiest way of doingthat, and uh it's a cheap,
effective way, is looking at theamount of calcium in your
coronary arteries.
Tucker (40:21):
Okay.
Michael Koren, MD (40:22):
And calcium is the way our bodies heal
atherosclerosis.
So if you have someatherosclerosis that develops,
your body's gonna try to healthat, and it'll typically
calcify that plaque, and that'llshow up in a CAT scan.
CAT scanning is a very good wayof looking at calcium.
And so, somebody like you atage 35, you would hopefully have
(40:43):
a zero CAC score.
You wouldn't have any calcium.
So if you had a zero CAC score,I'd feel a lot better about
using diet and exercise to tryto continue to work on that LDL.
But if you had a CAC score thatwas above zero, any number
above zero, I would say, hmm, atyour age, Tucker, um, this
means that your body is startingto already develop some
(41:03):
atherosclerosis.
And I would actually recommenda statin for you.
Now, the reason I wouldn'trecommend it without the CAC
score is that we probablywouldn't make a difference in
the next 10 years if you had azero CAC score.
But if you had any positive CACscore, then I think the statin
would.
And statins are one of thesedrugs that um unfortunately have
a mixed reputation, even thoughthey should be like the
(41:26):
mother's milk of cardiology andtreating people.
Because unlike some of theseother things I mentioned, every
time we study statins, we get apositive outcome.
So lowering the LDL withstatins has uniformly led to
better outcomes.
But of course, that's dependentupon your risk.
So if you're 35 years old andyou have virtually no risk of
(41:46):
having an event for the next 10years, will statins make a
difference?
No, they won't make adifference because there's
nothing to prevent.
On the other hand, if you're 60and you have the same profile,
then they're much more likely toactually make a difference.
So if if I saw this, thesenumbers in somebody age 60 with
everybody else the same, I'dabsolutely put them on a statin.
Tucker (42:07):
And what's the what's the scaling range for CAC
scores, I guess?
Michael Koren, MD (42:11):
Is it uh zero to over thousands.
Tucker (42:14):
Okay.
Yeah.
Michael Koren, MD (42:15):
So again, and it's very age dependent.
Tucker (42:17):
I was gonna say, so you know, a person in their sixties
probably definitely has a somethat they're not at zero.
Michael Koren, MD (42:23):
That's right.
Most people, it's it's would berelatively unusual for somebody
in their 60s to have zero, butsome do.
Tucker (42:29):
Wow.
Michael Koren, MD (42:30):
And some people in their 70s have zero.
So I've had actually patients,many patients, that come to me
freaking out about their Lp(a).
And they'll have the same Lp(a)as you, they'll be 72 years
old.
I'll do a CAC score and it'szero.
And I have the great pleasureto tell me to tell them, well,
you know, nothing's perfect inin medicine, but your risk is
(42:50):
really super low.
So I wouldn't worry too muchabout your Lp(a).
Thank God there's somethingthat's protecting you.
And we may not even understandwhat's protecting you.
Hopefully in the future wewill.
But despite the fact that yourLp(a) is high, I wouldn't freak
out about it.
On the other hand, we havepeople who are in a similar
situation that are zealots anddiet and exercise, and they have
CAC score in the thousands.
(43:12):
They'll say, Doc, I'm doingeverything.
I I eat a vegetarian diet, um,I run 50 miles a week.
Why do I have a CAC score of athousand?
Well, as we know from a numberof very high profile people that
have died despite theirfitness, um, there's stuff that
can happen that we can'tcontrol.
Tucker (43:30):
Right.
Michael Koren, MD (43:30):
And that's where you need medicine.
Tucker (43:31):
Right.
Michael Koren, MD (43:32):
So yeah, the CAC score is something I would
recommend in you.
Tucker (43:35):
Okay.
Michael Koren, MD (43:35):
And uh then we look at that and we see okay,
are you somebody that cancontinue doing diet and exercise
to treat these issues, oryou're somebody that I would
start a statin on?
And I would look at that as adetermining factor in somebody
like you.
Tucker (43:47):
Good to know.
Yep.
Excellent.
Michael Koren, MD (43:49):
And then um the other thing that came up is
uh we kind of covered italready.
Uh, should you take somesupplements?
Doesn't hurt to take some fishoils, but you would accomplish
pretty much the same thing byeating more fish.
Tucker (44:00):
Right.
Michael Koren, MD (44:01):
But again, nothing wrong with insurance
policy as long as you don't mindburping up fish every once in a
while.
Tucker (44:06):
Yeah.
The secret there is yeah, keepthe keep the capsules in the
freezer and they they tend toslide down better.
Good to know.
Michael Koren, MD (44:11):
Yeah.
All right.
And um they they they tend to,in my experience, cause less
burping and um you know you knowsometimes it could be a little
embarrassing in a meeting if youif you smell like salmon.
Tucker (44:21):
Yeah, yeah, yeah, yeah.
Yeah.
That's you're the last personin the office that that anybody
wants to be around.
Michael Koren, MD (44:26):
But I you know I I don't I don't see any
harm in that.
And a multivitamin, especiallymultivitamin with vitamin B
complex vitamins in it iscertainly something that uh I
seem to do little harm.
Tucker (44:35):
Okay.
Michael Koren, MD (44:36):
But then some of these other things that are
out there, I would talk to adoctor before you do them
because you know I have a lot ofpatients come in and there are
on a list of 15 supplements thatthey were told were quote good
for them,
Tucker (44:48):
Right
Michael Koren, MD (44:48):
But they don't necessarily have a good
reason for them.
Tucker (44:50):
Right.
Michael Koren, MD (44:51):
And unfortunately, supplements can
do bad things, especially if youtake too much of them.
So I'll give you a personalexample.
You know, when I finished mycardiology training over 30
years ago, I recommended vitaminE based on epidemiological data
showing that there seemed to bea correlation with vitamin E
and its antioxidant effects andbetter outcomes.
(45:11):
But then there wereinterventional studies were done
where you actually randomizedpeople to vitamin E or not.
And three major interventionalstudies were done, and two of
the three actually showed atendency towards harm of vitamin
E supplements.
Tucker (45:23):
Wow.
So you never know until you dothe testing what these things
are going to look like.
And because of the fact thatsupplements are not supported by
pharmaceutical companies andthey're just sort of considered
part of your diet, they're nottested to the same degree as
things that are pharmaceuticals,which go through incredible
testing.
You know, the scrutiny aroundthose pharmaceuticals is
(45:46):
intense.
And as consumers, people canbenefit from that knowledge by
either participating in clinicaltrials or by reading the
results.
Right.
Michael Koren, MD (45:54):
So in your case, certainly I see no harm in
a fish oil supplement.
I would wouldn't necessarilyrecommend more than a thousand
milligrams a day and amultivitamin with B complex in
it.
But other than that, I'm notsure there's anything else that
would jump to the fore.
Tucker (46:07):
Cool.
Yeah, we'll keep we'll keep theregular regularly scheduled
program with uh, and you know,my kids don't eat fish, right?
You know, you can make it putin front of them, they won't
touch it.
So that's you know more or lesswhy I we can disguise tuna in
different ways.
Michael Koren, MD (46:21):
Right.
That's a good point.
Tucker (46:22):
They will eat raw tuna, but you know, any salmon or
anything like that, it's adifferent story.
Michael Koren, MD (46:26):
If it looks like a fish, they won't eat it.
Tucker (46:28):
Right.
Exactly.
Exactly right.
No.
Michael Koren, MD (46:30):
Well, in any event, um, do you have any other
questions?
Tucker (46:34):
Um no, obviously a lot to unpack, and I appreciate you
know you taking the time toreview this and and um you know
have a follow-up in anothercouple months just to see where
I am now.
I'd love to get the CAC and andyou know really see where I am
in that.
Michael Koren, MD (46:48):
Let's do that for our audience.
Okay.
So we'll we'll get your CACscore.
Yeah, and we'll have you comeback after some of maybe these
dietary interventions and evenyour sauna, and you can tell us
how you do with that.
Yeah, and we'll see uh how thenumbers look.
Tucker (47:00):
Yeah, I would love that.
I would love that.
Thanks for having me.
Michael Koren, MD (47:03):
Tucker, thank you for being part of
MedEvidence.
Announcement (47:05):
Appreciate it.
Thank you.
Thanks for joining theMedEvidence! Podcast.
To learn more, head over toMedEvidence.com or subscribe to
our podcast on your favoritepodcast platform.
Welcome to MedEvidence, where we help you
navigate the truth behindmedical research with unbiased,
evidence-proven facts, hosted bycardiologist and top medical
researcher, Dr.
Michael Koren.
Michael Koren, MD (00:11):
Hello, I'm Dr.
Michael Koren, the executiveeditor of MedEvidence! And we're
going to do something a littlebit different today.
And this came out of a meeting,actually a business meeting,
with my friend and colleaguehere, Tucker, who just started
running his cholesterol resultsby me.
It was funny.
It has nothing to do withmedicine, but he knew that I was
(00:31):
a cardiologist and he knew thatI'm very active in the lipid
field.
And he started asking mequestions about his personal
circumstances.
And it got me thinking, youknow, an intelligent guy like
Tucker, who's truly interestedin his health and doing the best
for himself and his family, hadthese questions, and it brought
up some misconceptions thatpeople have, and also the fact
(00:53):
that there's a lot ofinformation out there that
sometimes is tricky to discern.
So, Tucker, welcome toMedEvidence and tell everybody a
little bit about yourself andwhy you got a series of
cholesterol and other tests thatmay be of interest to
everybody.
Tucker (01:08):
Yeah, absolutely.
And thanks for having me here,Dr.
Koren, and and uh happy just tohave this conversation and and
really educate myself and othersthat are in the same shoes as I
that you know really care abouttheir health but want to go
next the next step or go alittle further in in their
journey and and making sure thatthey're doing the best they can
for not just themselves buttheir family.
Um, you know, I have a uniquefamily story.
(01:29):
I lost my father uh to a strokeheart attack, and and uh, you
know, it it really put inperspective-
How old was he when when hepassed?
He was 56, I want to say.
The stroke happened, and then, you know, progressively got worse over time. Umso you know, it was in 2008
that he had had a stroke, and umit really just opened up my
(01:51):
eyes for my health journey andand now being a father of three
kids, three boys, and and uh youknow, wanting to be a
grandfather one day and and andsee them live out their lives as
well.
Michael Koren, MD (02:02):
How old are your kids now?
Tucker (02:03):
So I have a six-year-old, a four-year-old,
and a one-year-old.
Michael Koren, MD (02:06):
It's a busy household, my friends.
Tucker (02:08):
It is, it is indeed.
It is.
Hearts are full and hands arefull for sure.
Michael Koren, MD (02:12):
Absolutely.
So you mentioned about yourdad.
Any other members of yourfamily die of a heart attack or
stroke, say before the age of60?
Tucker (02:19):
No.
Michael Koren, MD (02:19):
Okay.
No.
My my mother's mom had passedaway from cancer, but not of any
heart issues.
And are you having any specific symptoms
that make you worry about aheart attack or a stroke?
Tucker (02:31):
No, honestly, no, nothing in particular.
Just wanting to be moreeducated.
Michael Koren, MD (02:35):
Great.
And I'm just gonna ask you somebasic questions that a
cardiologist would ask apatient.
Uh, if any of these are notunderstandable or or you ask me
why I'm asking them, that'sfine.
Please ask me.
But uh we usually ask peopleabout a series of cardiovascular
risk factors because we'retrying to get a sense for what
your actual risk is and whetheror not your history is more or
(02:59):
less likely to reproduce yourfather's history in terms of
having a major cardiovascularevent at a relatively young age.
So with that in mind, uh thethings we'd ask is one, do you
smoke?
Tucker (03:11):
No.
Never smoked.
No smoke.
Uh I I've smoked a cigarette before, but not
consistently smoked, right?
Michael Koren, MD (03:16):
Yeah, gotcha.
Yeah, the uh it's funny.
The definition of somebody thatmay have smoked is a hundred
cigarettes in your life.
Although, quite frankly, uhmost people in college will get
to that number, just go going tobars on the weekends.
Right, exactly.
But uh but you never smokedhabitually on a regular basis.
Tucker (03:34):
No.
Michael Koren, MD (03:34):
Uh any history of diabetes?
Tucker (03:36):
No.
Michael Koren, MD (03:37):
Okay.
Um do you have high bloodpressure or are you being
treated for high blood pressure?
Tucker (03:42):
I have high blood pressure.
I'm not being treated for it.
Um, it's not to the point whereI feel it you know needed to be
treated for.
Um, but yes, I'd say I have thewhite coat syndrome, you know.
Every time I get it tested,there is-
Give us a range for what thatblood pressure is when it's at
its high and when it's at itslow.
(04:03):
I have no idea.
To be completely honest withyou, because it's, you know,
they'll come back and take itand they'll be like, you're
fine.
Michael Koren, MD (04:08):
So has anybody told you your your top
number, your systolic bloodpressure is more than 160?
Tucker (04:13):
No.
Michael Koren, MD (04:14):
Okay.
Has anybody told you that yourbottom number, your diastolic
blood pressure, is more than 90?
Tucker (04:19):
No.
Michael Koren, MD (04:19):
Okay.
Um, have you been told thatyour blood pressure actually
did, in fact, normalize whenyou're outside of the doctor
setting? Yes.
Okay.
So so what you know about yourblood pressure is that when
you're stressed, it may go up alittle bit, but other times it's
normal, which by the way is anormal thing.
Tucker (04:36):
Right.
Michael Koren, MD (04:36):
Blood pressure naturally goes up when
you're exercising, etc.
So getting back to thecardiovascular risk factors, uh,
I understand you do exerciseregularly.
You look very fit.
Tucker (04:45):
I Try, yes.
Tell us, tell us about yourexercise routine.
Yeah, so I typically four to five times a week, more
on the five times.
Um, and it's a mixture of, youknow, weightlifting to higher
heart rate cardio hit stuff.
Um so you know, a goodcombination of weight lifting
and high heart rate.
Michael Koren, MD (05:03):
Nice.
And never get any kind ofcardiovascular symptoms like
chest pain or tightness orbreathing issues while you're
doing your exercise.
Tucker (05:09):
No, no.
Michael Koren, MD (05:10):
Fabulous.
Now there's some cardiovascularrisk factors that are obvious.
Uh being a male puts you athigher risk than a female.
You're a male.
And your age, you want to stateyour age for everybody?
35.
Okay, so you're you're a youngman, so that actually puts you
in a lower risk group.
And by the way, age of all thestandard cardiovascular risk
factors is the one mostpredictive of who's gonna have
(05:31):
trouble.
So even if everything isperfect at age 80 in terms of
your cholesterol and your bloodpressure and your sugar status,
your risk is still higher thansomebody at 35 that has a lot of
problems with these numbers.
So I always like to bring thatinto perspective that age is the
most predictive thing that wehave, which is actually sobering
for doctors, is that um quitefrankly, if you know somebody's
(05:53):
age, you're gonna know moreabout their prognosis over the
next 10 years than anythingelse.
But that's a little bitdifferent than what you're here
for.
You're here to maximize thelikelihood of a good outcome for
yourself over the next 10years.
And then when you're 45, you'regonna come back and say, I want
to maximize that likelihood forthe next 10 years, et cetera.
So while age is the most potentcardiovascular risk factor,
(06:15):
there's a relative concept here,is that you want to reduce your
relative risk at your age.
Is that a fair statement?
Tucker (06:22):
That is very accurate.
Okay.
Yes.
Michael Koren, MD (06:24):
All right.
So now we're we're gonna jumpinto a little bit more.
Um, you know, you mentionedthat you did go online because
of your concerns about yourfamily history, and that you got
some extensive lab testing.
So just tell us a little bitabout that story.
Tucker (06:37):
Yeah, it's always something that, you know, like
you had said, given familyhistory that I've I've wanted to
do, and and uh, you know, thiswas very user-friendly.
Um, the platform that I used togather all this data and um,
you know, went to my wife andshe wanted to do it as well.
And uh, you know, the numberswere that-
and we'll go through some ofthe numbers, right?
(06:59):
But you got a you got a lot ofdata.
Did you feel like youunderstood everything or did it
uh tell me a little bit aboutthat?
No, I and and that's you know one of the conversations
or the what what led me to youuh in in our business meeting
and and saying, Dr.
Koren, can you can you pleaselook at this and break this down
for me?
Because you know, I have it, Idon't know what to do with it.
Got it.
And that's why that's why we'rehere today.
Michael Koren, MD (07:19):
Sounds great.
Okay.
Well, if it's okay with you,we're gonna just kind of jump
right into stuff.
Tucker (07:23):
Absolutely.
And you and I can look at thenumbers and people in the
audience, either the viewers orlisteners, can get this
information.
You give us permission to showthis online.
Yes, sir.
You okay with that?
Oh, yeah.
That's why we're here.
Okay.
Well, we'll cross out your nameso they can't see that other
than other than Tucker.
But just this is the old HIPAAthing.
We want to make sure that yourprivacy is protected.
Obviously, coming on thisprogram shows that you you're
(07:46):
okay being out there a littlebit, but we still want to
protect your privacy as much asmuch as possible.
My goal is to help others.
Michael Koren, MD (07:52):
Terrific.
So starting with yourcholesterol profile, we call
this lipid profile quotestandard, which literally
millions and millions andmillions of people get every
year.
And I I have family members andfriends, et cetera, that are
constantly calling me and youknow, what does this all mean?
And typically in this lipidpanel, you see total
cholesterol, HDL cholesterol,triglycerides, and LDL
(08:17):
cholesterol.
And then below that you havethe ratio, which is the
proportion of things, uhcholesterol to the HDL, and the
non-HDL cholesterol um totalnumber.
So does that make sense to you?
When you look at this, do youhave a do you have an intrinsic
a sense of I know what's goingon or not so much?
Tucker (08:37):
I know I have some things out of range and and you
know, some things I need to workon, but aside from that, my my
knowledge is very, very smalllow about this.
Yeah.
Michael Koren, MD (08:47):
So just let's just start with uh a basic
concept, which is the differencebetween total cholesterol and
LDL.
Cholesterol is a lipid, it's afat molecule.
Cholesterol is actually areally, really important
molecule in our bodies.
Every cell in our body needscholesterol to function.
And because cholesterol is soimportant to cellular function,
(09:10):
every cell in our body makescholesterol from basic
materials.
So our cells make cholesterol.
This is the thing that mostpeople don't understand, which
is that because the cells aremaking cholesterol and pushing
it out when there's extra, byand large, what we measure in
the bloodstream is the extrastuff our body's trying to get
(09:31):
rid of.
So there's a big misconception,even among some physicians,
that somehow we need dietarysources of cholesterol to
function and have normal lives.
Well, cholesterol is actually aproduct of animal cells.
So if you're a vegetarian,you're not gonna eat a lot of
cholesterol in your diet.
But that's okay because yourbody makes it.
(09:52):
Right.
But vegetarians can still have a
high level of cholesterol intheir circulation because of
genetic factors.
So again, think aboutcholesterol as something that
all your cells need, all yourcells can make, and the stuff
that you're measuring in thebloodstream is the extra stuff.
But as I mentioned, cholesterolis also a fat, and your blood
is mostly aqueous orwater-based.
(10:14):
Do fats and waters mix?
You ever put uh fats in a cupof water?
Tucker (10:19):
It's like oil and water.
Michael Koren, MD (10:20):
Exactly.
They don't mix.
Right.
So, how do you get this to movein your circulation and
eventually get out of yourbloodstream?
Well, the way you do that is byforming lipoproteins.
Your body forms lipoproteins,and we'll show a picture of
that.
But lipoproteins are these muchlarger molecules, typically
shown as spherical molecules,that have a combination of fat
(10:41):
and protein, which can besoluble in the blood and then
eventually get delivered todifferent places, most commonly
the liver, to get rid of them.
Interesting.
So HDL and LDL are two quote lipoproteins,
high density lipoprotein and lowdensity lipoprotein.
Tucker (11:01):
Understood.
Michael Koren, MD (11:02):
High density lipoprotein is epidemiologically
linked with better outcomes,meaning that if you have higher
levels of HDL, you're lesslikely to have cardiovascular
disease.
LDL is the opposite.
If you have high levels of LDL,you're more likely to have bad
cardiovascular outcomes.
Now, because of thisepidemiological association, we
(11:25):
talk about HDL as the goodcholesterol, quote unquote, even
though it's more than justcholesterol.
And we talk about LDL as thebad cholesterol, even though
it's more than just badcholesterol.
And more recently, there'sanother particle that's become
something we talk a lot about,which is called lipoprotein(a),
which we like to say here,at MedEvidence, is the really,
really, really, really badcholesterol four really bads.
(11:46):
And the reason for that, andwe'll show it structurally, is
it has an extra little uhcomponent to it called an
apolipoprotein that makes thatparticular particle more
difficult to get rid of, to getout of your bloodstream.
And because of that, there's amuch stronger epidemiological
link between high LPA and badcardiovascular outcomes.
(12:09):
And I mentioned this becauseyou may have a little bit of an
LPA problem here.
Right.
Tucker (12:12):
We'll get to that.
And that's something I cancontrol or not control?
Michael Koren, MD (12:17):
Well, we'll get to that.
Tucker (12:18):
Okay.
Michael Koren, MD (12:20):
We'll getting into that.
But I just want to giveeverybody the basics because
even simple things like this, Ifind most people don't really
understand exactly what theyare.
Tucker (12:27):
Right.
Michael Koren, MD (12:28):
But that does it all make sense so far.
Tucker (12:29):
It does.
Yeah.
No, it helps a lot.
Michael Koren, MD (12:31):
And then uh finally, you have another type
of blood fat calledtriglycerides, which is really
about energy.
Triglycerides are one of theenergy stores for your body, and
it's actually needed forenergy.
But it's different thancholesterol, which is also
structural.
So cholesterol is thefoundation of hormones,
cholesterol is the foundation ofcellular walls of the cells.
But uh triglycerides is reallyan energy store.
Tucker (12:53):
Okay.
Michael Koren, MD (12:54):
Okay.
So we have all those thingshere, and I'm gonna you'll be
able to see it from the audiencethat Tucker's total cholesterol
is 261, which is a little bithigh.
And it's listed as thereference range is less than 200
milligrams per deciliter.
But again, we're gonna talkabout the fact that if that
cholesterol is in HDL, it's notas bad as if it's in LDL.
(13:15):
And moving down, your HDL is67, which is actually pretty
good.
Um they're saying the referencerange is above 40.
Above 60 is even better.
So that's a that's a positive.
You have a high HDL, probablyin part due to the fact that um
you you're physically active.
Physical activity in exercise,particularly intense exercise,
will raise your HDL.
Another thing that can raiseHDL, I didn't ask you about this
(13:37):
yet, is alcohol use.
What's your typical alcoholuse?
Tucker (13:40):
Yeah, I would say weekly, I guess you could base
it off of, you know, probablyfour cocktails a week.
Michael Koren, MD (13:47):
Okay.
Tucker (13:47):
Or four alcoholic beverages.
Michael Koren, MD (13:49):
You don't drink every night.
Tucker (13:50):
No.
Michael Koren, MD (13:50):
Okay.
So you go out for dinner on theweekend and a glass of wine,
okay.
So four alcoholic beverages umper week.
So that's not a big driver, butum, that's certainly not
something that I would considerunhealthy from a heart
standpoint.
There's some debate aboutwhether or not um alcohol use at
moderate to low levels may havesome negative effects on your
GI tract and GI systems, butfrom a cardiovascular
(14:12):
standpoint, I'm perfectly okaywith that.
Tucker (14:14):
Yeah.
And and you know, there was atime that it was a lot higher
than that.
I'll preface the audience withthat, you know, and and since
doing you know these panels andreally dialing in, you know,
where I want to be, it, youknow, I've been cognizant of
intake.
Michael Koren, MD (14:26):
Yeah, and the other thing, by the way, is
when you drink a lot of alcohol,your triglycerides may go up.
That's one of the things thatcan drive higher triglyceride
levels.
And yours turn out to be verynormal, 73.
Uh, they say that for thereference range that it should
be less than 150, but in fact, Ilove seeing them less than 100.
So you get you get a fist pumpfor that.
Tucker (14:42):
Love it.
Michael Koren, MD (14:42):
So your triglycerides, you're you're
kicking butt onto thetriglycerides.
Tucker (14:45):
Good.
Michael Koren, MD (14:46):
But this is a little concerning.
Your LDL is 177.
Right.
Okay.
And they don't even give areference range from that.
And they also put somethinginteresting in it that says
calculated, which I like to makesure people understand, is that
LDL for most of the assays thatare done is not directly
measured, but is actuallycalculated based on your total
(15:08):
cholesterol, HDL, andtriglycerides.
And for somebody like you thathas numbers kind of in
mid-range, that's not a bigproblem.
It's usually pretty accuratecalculation.
But if you have particularlyhigh triglycerides or a low LDL
that you're trying to get reallylow, for example, patients of
mine that have very badcardiovascular disease, that
(15:29):
calculated measurement may notbe as accurate as a direct
measurement.
Tucker (15:33):
And you can get a direct measurement.
Michael Koren, MD (15:34):
You can get a direct measurement.
It's a little more expensive,and doctors have to ask for it
specifically, but it isobtainable.
I'm not going to go into allthe different ways of
calculating LDL, but I assumethis is the what we call the
Friedelwald equation, which isthe most commonly used way of
calculating your LDL.
Tucker (15:53):
You're exactly right.
It says, yep.
Michael Koren, MD (15:54):
And that would typically be the total
cholesterol minus the HDL minusthe triglycerides divided by
five.
So you can check to see iftheir math is correct now that I
gave you the formulas.
Tucker (16:08):
Thank you.
I will.
Michael Koren, MD (16:10):
All right.
And then moving down, you haveyour cholesterol to HDL ratio at
3.9.
They say less than five is iswhat you want to see.
And that's in part because youhave a nice HDL cholesterol.
And then your non-HDLcholesterol, which is all the
stuff other than HDL, is 194,which again is high.
So just looking at this, wewould say that this lipid
(16:33):
profile is not exactly where wewould want it.
And the first question thatcomes up is what's going on with
your diet?
Um, are you eating a lot ofmeat?
Are you eating a lot of uhsaturated fats?
As I mentioned, your body canmake cholesterol, but your
dietary sources of fats andcholesterol also drive this.
And remember, it's not justcholesterol when you're
(16:56):
consuming, but fats.
In fact, saturated fats aremore likely to drive higher
cholesterol than ingestingcholesterol itself.
Tucker (17:02):
Right.
Michael Koren, MD (17:03):
So tell us a little bit about that part of
your life.
Tucker (17:06):
Yeah, you know, I I do eat a lot of red meat and and
you know, meat in general, Iguess you could say, as far as
you know, chicken, and you know,I try to stay away from pork.
Um my fish intake is is lowerthan what it probably should be,
uh, in my opinion.
Um so you know, primarily everymeal it's either chicken or
(17:27):
steak.
Um now that you know I'vegotten these results, I've kind
of gone more to chicken, butyes, this and then dairy too,
right?
You know, and and cheeses andyou know eggs and and different
things like that.
But um pretty bland for themost part.
I do have some some rice mixedin or some grains mixed in, but
um that is something I try to becognizant of and then work in
(17:49):
some fasting as well just to toyou know help cellular repair.
Michael Koren, MD (17:53):
Would you say that you eat meat during every
meal during your day?
Tucker (17:57):
I wouldn't say every, I would say you know, one to two
times a day.
Okay.
So leave out breakfast and justyou know have the dairy as far
as you know, or or you know,eggs and and then probably lunch
and dinner.
Yeah, that's a fair assessment.
Michael Koren, MD (18:10):
Yeah.
So obviously bringing that meatconsumption and dairy
consumption and egg yolkconsumption, obviously the
whites of the egg don't havecholesterol in it, but the yolk
does, that would help drive downyour LDL.
But the truth is, is that as Imentioned, because so much of
cholesterol may come from yourbody itself, it's very variable
(18:32):
how much reduction in LDLcholesterol you get when you
change your diet.
And I've had people that havechanged to vegetarian diets or
even vegan diets, and they havea dramatic lowering, but other
people that do it and they arevery disappointed that they
don't have more of a lowering.
And that tells me that theirbodies are intrinsically making
cholesterol that's being putinto the circulation.
But the truth is it's very hardto know that without having a
(18:55):
patient try it.
So often we'll take somebodylike you and say, okay, well,
you're a young guy, you're nothaving any symptoms, you have a
cholesterol profile that's amixed bag, good HDL, but not
great LDL.
And maybe you should go on amuch stricter diet where maybe
you eat red meat once a week.
Maybe you eat fish uh five orseven times a week, which I tend
(19:18):
to do.
Um my main protein in my dietwould be fish.
Okay.
Uh and try to cut back on thecheese and maybe instead of
doing regular omelets, do eggwhite omelets and put these
things into your diet and thenrecheck in a few months and see
if you put a dent in that.
Tucker (19:35):
I was gonna say, how long is it typically that you
would have to do that trial, soto speak, to see results?
Michael Koren, MD (19:41):
Typically you want to see about two or three
months.
Okay.
Um that's usually what what youwant to see for triglycerides,
by the way.
If you have high triglyceridesand you change your diet,
that'll change very quickly.
Tucker (19:51):
Okay.
Michael Koren, MD (19:51):
But the LDL may take a little bit longer
before you're gonna have animpact on it.
And again, nutritional elementsof this are a whole podcast in
of itself, because there's alot, a lot of nuance in in all
these things.
But as I mentioned, saturatedfats and the ingestion,
ingestion of cholesterol willdrive this, uh, will drive your
LDL levels up.
(20:12):
But saturated fat's even morethan cholesterol.
And the reason I bring thatpiece up is that shellfish often
becomes a discussion.
Shellfish is high incholesterol, but very low in
saturated fat.
So that's not a bad place to goif you need to replace certain
things.
Tucker (20:28):
So shrimp aren't bad.
Michael Koren, MD (20:29):
They're not as bad as um really fatty meats
or eating the skin of chicken,even.
But um uh I personally will eatshellfish, and I consider that
part of my diet that pulls outfrom the meats and the fats and
is using a lower fat, butsomething that's not super low
in cholesterol.
Good to know.
Okay, so hopefully that makessense.
(20:51):
So getting back to um uh thesetypes of interventions, the
other thing is that there arecertain foods like oatmeal, for
example, that make it moredifficult for your gut to absorb
cholesterol.
And if that's not in your diet,you may want to think about
things like that.
So grains and other things thatuh we often eat in the
(21:11):
mornings, but not necessarily,are important.
And also bananas, um, otherthings that have roughage, et
cetera, are good things for usto consider in terms of diet.
And again, this is not anextensive podcast on that.
Right.
And but there's lists onlinewhere you can see how all these
different foods can actuallyaffect cholesterol absorption
and and their glycemic index,which is a whole other
(21:33):
conversation.
Tucker (21:35):
Is there a way it, you know, let's say you do go
through with a meal plan forthree to six months.
Do you notice any difference inyour body as far as if your
cholesterol levels change, asfar as energy or anything like
that, or is that strictly feltoff of or captured off of a
blood test only?
Michael Koren, MD (21:49):
Well, it's interesting.
Uh it it is different fordifferent people, but there's no
doubt that the type of food youeat does affect your mood.
It affects uh neurohormonesthat affect your brain, it
affects your appetite.
So there's a lot of factorsthat go in, and everybody's not
exactly the same.
So, in general, um, when youeat high protein things, people
(22:11):
feel a little bit brighter.
Um, when you eat some thingsthat are high in sugar,
sometimes that raises certainhormonal levels that make you
feel sluggish.
Although other people have animmediate rush when they have
sugar.
So, again, these are competinghormonal levels.
I'll tell you for myself, if Ihave something that's very, very
sweet, I want to take a nap in15 minutes.
Whereas other people kind ofget that sugar rush from but
(22:34):
these are how different hormonesare balanced in your
bloodstream and how they affectyou.
So there's no doubt that foodsaffect your mood and affect your
function, but it's it's veryindividual.
And uh we'll definitely look atthat for a future podcast about
some of these details.
But do you have anyobservations for yourself when
you eat high protein versus lowprotein?
Tucker (22:53):
No, honestly not.
Um I mean, I do it's more thefasting versus not fasting for
me, really.
You know, I notice energylevels and whatnot when I
haven't eaten and I've done amoderate to severe workout
versus when I've eaten beforeand done a
Michael Koren, MD (23:10):
you feel more energetic with fasting or less
energetic with fasting?
I would say less.
Okay.
Um just you know, given thetype of workout dependent upon
what I'm doing.
Sure.
You know, if I'm going on arun, then you know, fasting, I
seem to feel a little bit betterthan you know, if I'm going to
lift weight.
Yeah, it's interesting.
Uh again, in my vast experiencewith people like yourself and
(23:31):
asking these questions, I'm notsure there's anything that's a
formula for any individual.
It's just a little bit trialand error what works best for
you.
Tucker (23:39):
Gotcha.
Michael Koren, MD (23:40):
So let's move on to the rest of these
numbers.
And some of these are lessrelated to vascular disease.
I'm going to kind of skip overthose.
But the one the next one onyour page is actually
homocysteine, which is one ofthese super interesting uh
concepts that people talk about.
And homocysteine is an aminoacid, it's it's in the protein
class.
And we know that people thathad higher levels of
(24:02):
homocysteine have a relationshipwith higher incidence of
cardiovascular disease.
But there's not that much talkabout homocysteine uh for the
reason that we don't have asmuch data that intervening makes
a difference.
So the reason we talk so muchabout LDL cholesterol is that
the association with higher LDLcholesterol and bad
(24:23):
cardiovascular outcomes is isstrong, but not super strong.
There are a lot of people thathave high LDLs that live
completely normal lives don'tget atherosclerosis, and other
people that have lower LDLs thathave tons of atherosclerosis.
So there's a correlation, butnot a perfect one.
But what we do know is thatlowering LDL with treatment
(24:44):
makes a huge difference.
And time and time and timeagain in studies, we show that
lowering LDL makes a difference,particularly when you're at
high risk.
But something like homocysteinethat also has that relationship
with bad outcomes when it getshigher, has never been shown to
be the same in terms of thelowering it.
Plus, the neat thing abouthomocysteine is that it's
(25:06):
something that reflects Bvitamin metabolism.
And there's a relatively easyway to treat high levels of
homocysteine, which is with Bcomplex vitamins.
Tucker (25:15):
Okay.
Michael Koren, MD (25:15):
And a lot of people take multivitamins or B
complex vitamins, and that willhave the maximal effect on
lowering homocysteine.
So outside of using B complexvitamins, there's not a whole
lot out there to show us thatlowering homocysteine is going
to make a difference, even forsomebody like you with a family
history.
Okay.
But that covers that.
And then you have some of thesethings.
These are things that anendocrinologist might look at.
(25:38):
Uh you have the zinc level,which is kind of interesting.
So the the general sense isthat zinc is protective.
Some people call it anantioxidant.
And your levels are 105, whichis completely normal.
But this comes up a lot.
And there's also somethingcalled the zinc-copper ratio.
You want your zinc-copper ratioto be higher rather than lower.
(26:00):
Uh, copper is complex in termsof how it's correlated with
cardiovascular disease.
Both low levels and high levelsare not good.
But there's a general sensethat your zinc-copper ratio
should be favorable.
And uh one of the interestingplaces where that was looked at
was actually in the country ofFinland.
Finland historically had a veryhigh rate of cardiovascular
(26:22):
disease.
And it turned out in particularthat there were areas in
Finland where there was morecopper versus zinc in the
drinking water that had thehighest rates of cardiovascular
disease.
So some of the epidemiologicalinsights came from that
particular study looking at acountry and how different parts
of the country were affected interms of epidemiological rates
(26:44):
of cardiovascular disease.
Now, again, um, do yourecommend zinc supplements?
No, unless you have profoundlylow levels.
And nor would I recommendcopper supplements.
But um it's something that ifyou're really out of whack one
way or another, you want to talkto a physician about, probably
an endocrinologist.
Tucker (27:00):
Are you getting those already in your multivitamin
that you know?
Michael Koren, MD (27:04):
Yeah, I honestly I don't I personally do
not routinely check this in mypatients.
Okay.
But it it is uh it it it's aneat interesting thing from an
epidemiological standpoint.
And if you have a good diet andyou take uh multivitamin once a
day, you're probably doing whatyou need to do for if you're
dealing with these issues.
And then um I'll skip some ofthese others because they're a
(27:24):
little esoteric.
And um, but I'll just mentionfor interest's sake is that they
measured your leptin.
Are you familiar with withthat?
Tucker (27:33):
Not at all.
Michael Koren, MD (27:34):
Okay.
So leptin is actually somethingthat suppresses your appetite.
Tucker (27:39):
Oh wow.
Michael Koren, MD (27:39):
And there's a lot of research going right now
with the GLP1 agonists abouthow it affects leptin levels and
other things.
And there's a belief, and weare actually doing a lot of
research on this particulararea, that maybe we can use
changes in leptin levels toreduce somebody's appetite.
So they did check that yours iswithin a reasonable normal
(28:01):
range for what you expect for a35-year-old man.
So nothing to worry aboutthere.
But uh it's just interestingthat that was checked.
Then you had some tests of whatwe call inflammation.
Your rheumatoid factor wasnegative, your antinuclear
antibody screen was positive,though.
And um this is a nonspecifictest that can be associated with
(28:24):
some immune diseases likelupus.
And generally, this issomething your physician should
follow up on and do some furthertesting to see if you have
other elements of inflammation.
Now, some of that testing wasdone, but not all of it as we go
into subsequent things.
But that's uh something that'sreasonable to follow up because
we know, for example, thatpatients who have lupus have
(28:47):
higher rates of cardiovasculardisease.
And maybe that's the threat inyour family history.
Maybe that's what um wassomething that affected your
dad.
And so I would definitelyfollow up on the positive
antinuclear antibody test, andwe'd get other types of testing
to see if you have the diagnosisof lupus.
Although you haven't mentionedany symptoms, that would make me
think of
Right, I was going to say, whatwould be a-
arthritic type simple symptomsare typical, rashes are typical,
(29:11):
and there's other things.
But um, again, that's a littlethread, but it's also a very
nonspecific test.
So just because it was quotepositive doesn't mean that you
have any illness related to it.
Tucker (29:21):
Got it.
Michael Koren, MD (29:21):
But it they did order that and it it is of
interest.
And uh I'm gonna skip some ofthese other things um in the
interest of time, but um I wantto get to um one other thing
that I noticed that was superinteresting, which was your
Lp(a) level.
And let's see if I can findthat here.
(29:42):
So, yeah, here we go.
So you have what's called anadvanced lipid profile.
So the first thing we talkedabout was the standard lipid
profile.
But there are a lot of otherways you can look at your your
lipids, your lipoproteins, toget insights.
So, one of the things that uhwe do in the advanced lipids.
Profile is actually look at thenumber of particles.
(30:03):
So when you measure somethinglike uh LDL, low density
lipoprotein, you can look at itin two ways.
You can look at it based on themass or the weight, or you can
look at it at the number ofparticles, which we call
concentration.
And so when you think about it,if you have fewer particles
that are of heavier weight,that's going to be a little bit
different profile than peoplethat have more particles of a
(30:25):
lighter weight.
So in the extremes, people thathave more particles with a
lighter weight may have the sameoverall lipid levels as
somebody that have fewerparticles at a heavier weight,
but their prognosis isdifferent.
So if you have more particlesthat are small particles, that's
actually worse than somebodythat has fewer particles that
are big, more buoyant particles.
(30:47):
And you do, in fact, have anexcess number of LDL particles.
So that's something we don'tlike to see.
And you have above what youwould want to see in terms of
small LDL and medium LDL.
So I would point out the factthat when you look at this
statistically, that's anothersmall reason why you would want
(31:09):
to consider getting that LDLlevel down, or maybe even
ultimately using a statin drug,which we'll talk about in a
second.
Okay.
So I think that's a uhsomething that's important.
And then um they looked at youromega-check, they called it,
which was uh looking at a panelof your omega-3 fatty acids, and
(31:29):
that came in a little bit low.
Um, I I think this this is aproprietary uh assay, and we'll
show this on the screen.
But it goes into all uhmultiple different omega-3 fatty
acids, which are very importantin terms of number of cellular
functions.
But the thing about the omega-3fatty acids that's tricky and
(31:49):
and even difficult forphysicians is that the
interventional studies for someof these things have been a
little bit all over the place,quite frankly.
So, what we know is that whenyou supplement with omega-3
fatty acids, you may have somebenefits.
Uh, there's some information,for example, that it may help
mood disorders, it may helppeople with depression.
(32:10):
But when we've used it to lookat reducing cardiovascular
disease or particularlycardiovascular outcomes, it's
been a little bit of a mixedbag.
Some studies have shownpositive results, other studies
have shown not great results.
And so, because of that, wedon't necessarily focus on that.
But it's interesting that's apart of your panel.
The flip side is that this isanother one of those things that
(32:33):
may be relatively easy to takecare of.
So, in somebody like you, wetalked about the fact that you
don't eat that much fish, whichis rich in omega-3 fatty acids.
Right.
And you may want to considerthat.
So, an easy intervention wouldbe for you to just eat more fish
and replace some of the otherproteins with that.
And I imagine that that wouldhelp your omega-3s go up.
But there are supplements outthere.
Tucker (32:55):
So Yeah, I've started to supplement with salmon oil and
and cod liver oil.
Okay.
Um there you go.
Michael Koren, MD (33:01):
We'll rerun these numbers in six months and
see.
Yeah, and you and you'll you'llprobably see them higher.
But again, this is one of thosereflections of uh your du how
you get your your diet canchange the numbers.
But you have to be a little bitcareful because I can't really
tell you the diet's gonna changeyour outcomes.
Tucker (33:16):
Right.
Michael Koren, MD (33:16):
But nonetheless, and there's no
downside, especially if you likefish, right?
Right.
Or if it's no big deal to take a fish oil
capsule a day, then there'sreally not any significant risk
to that.
Sometimes people talk about themercury risk of of some of
these things.
Tucker (33:29):
Which they test for already, and that was fine,
right?
Michael Koren, MD (33:31):
So exactly.
And there are products outthere that are refined products
that don't have mercury in it.
But um, quite frankly, a fishoil capsule a day, a thousand
milligrams or one gram, I don'tthink is gonna hurt you from a
mercury standpoint.
But uh interesting that theydid that.
So I want to touch on yourlipoprotein(a).
We we alluded to that earlier,and that's that really, really,
really, really bad cholesterol,as I mentioned.
(33:53):
And your level here is 151.
That's the concentration, it'sin nanomoles per liter.
And that's high.
And that's super interestingbecause high Lp(a) levels run in
families.
Okay.
And maybe that's what put butthat's what affected your dad.
Tucker (34:09):
Right.
Triggered this.
Michael Koren, MD (34:10):
Yeah.
And you mentioned you didn'thave any other family members,
but have you had other familymembers have their Lp(a)
checked?
By do you know of?
Tucker (34:16):
I I I'm sure they have.
Michael Koren, MD (34:18):
Brothers, sisters, or your mom, or or- I'm
sure my mother has.
Um, you know, my wife has, butI don't I haven't asked about
it.
Or anybody on your dad's sideof the family, um uh aunts or
uncles on his side of thefamily?
Tucker (34:30):
Yeah, not that I've asked.
Michael Koren, MD (34:32):
The reason I asked that is because there's a
genetic inheritance pattern foruh lipoprotein(a).
It's it's called what we callautosomal dominant.
And that number is reallydetermined by your genes.
Tucker (34:44):
Okay.
Michael Koren, MD (34:45):
So your overall LDL, as I mentioned, is
a combination of your geneticpredisposition and your diet.
But Lp(a) is almost allgenetics.
And it's interesting forsomebody like you that has an
Lp(a) level that's elevated tosee what their genetics are, and
you can kind of figure it outbecause you got one or both
genes from your parents, andit's discernible once you can
(35:05):
figure that out.
Obviously, your father'sdeceased, so we can't get that
now.
But by looking at other of hisfamily members, you may be able
to figure that out.
Tucker (35:13):
Or just his history.
If my mom doesn't have it, thenhe would have had to have it.
Michael Koren, MD (35:16):
Exactly.
That's right.
So exactly.
So the deduction, right?
Deductive reasoning,
Tucker (35:20):
right
Michael Koren, MD (35:20):
That's right.
Tucker (35:21):
And and I guess to that point, you know, for my kids'
sake, um, you know, since I haveit, and if my wife had it, they
all by trait will have it.
Is that a safe assumption?
Michael Koren, MD (35:32):
Probably so, but not necessarily.
Because remember, uh anautosomal dominant gene is
something that hides recessivegene.
So let's say that they both gotrecessive genes that don't code
for LPA at high levels, thenthey would have normal Lp(a)s.
I probably confuse you withthat.
Tucker (35:49):
But No, I I mean I I I can understand.
Michael Koren, MD (35:52):
Just like two brown-eyed people can have a
blue-eyed baby.
Tucker (35:55):
Right.
Michael Koren, MD (35:56):
Makes sense.
Tucker (35:56):
Right.
Michael Koren, MD (35:57):
So, anyhow, um, but your lipoprotein(a) is
is high.
And so that is something thatwould be a risk factor.
And as I mentioned, that'sactually a stronger risk factor
than LDL itself.
So, because of that, um, uh youwould be somebody that I would
want to explore a little bitmore where you stand in terms of
(36:18):
atherosclerosis.
Okay, and I'll get to that in asecond.
The flip side is that you alsogot what's called an hs-CRP,
which is a look at your vascularinflammation, and that was
beautiful at point two.
Tucker (36:31):
Great.
Michael Koren, MD (36:32):
Okay.
So uh generally we want that tobe less than one, and yours is
optimal at less than one.
And there's some data that'sshowing of all these markers, we
call these biomarkers.
Of all these biomarkers, thehs-CRP may be the one that's
most highly correlated with badcardiovascular outcomes in the
future.
There's some debate whether ornot Lp(a) or uh hs-CRP are
(36:54):
better.
My personal opinion is that uhLp(a) identifies certain
subgroups that are particularlyhigh risk.
Tucker (37:00):
Okay.
Michael Koren, MD (37:01):
And hs-CRP is more of a general sense of
vascular inflammation.
But nonetheless, uh it's goodnews that your CRP is low.
And that's becoming more andmore studied in terms of how
inflammation and theidentification of inflammation
leads to bad cardiovascularoutcomes.
And we've had some podcasts onthat.
So I'd uh if you like thisdiscussion, I invite you to look
(37:21):
at some of the other podcastswe do in particular.
I did a podcast with myclassmate, Dr.
Paul Ridker, is considered theinternational guru on CRP and
inflammation, and and you'lllearn a lot more about this.
Tucker (37:32):
Love it.
Michael Koren, MD (37:33):
But yours is good, so that's good.
Tucker (37:35):
Great.
Michael Koren, MD (37:35):
All right, so we cover a lot of ground here.
Any questions before I get intomaybe some recommendations?
Tucker (37:42):
Yeah, I guess you know, one thing that I I've done
within the last two years, justbefore getting all of this done,
and curious to see what yourthoughts are.
You mentioned Finland earlierin the podcast, and and uh I
have a sauna in my backyard
OK
And uh, you know, uh in thefitness side of things, it's
obviously very common to do andand becoming more and more
(38:02):
common nowadays um or or moreaccessible.
And uh just curious to get yourintake on you know sauna usage
and and higher temperatures foran extended period of time.
Michael Koren, MD (38:14):
So there's a lot of these things we just
don't know the answer to.
So the when we when we do lookat things scientifically, we
have to do a randomized trial.
And a randomized trial meansthat we randomly choose you to
one thing or another.
So a randomized trial of saunause would be to randomly put
people in saunas or to dosomething else and and compare
(38:36):
the results over a period oftime or based on a biomarker or
based on something.
So we just don't have thosekind of studies for sauna.
But if it makes you feel good,there's not a whole lot of
downside.
Just be careful because it canlower your blood pressure, and
if you get out too quickly, youcan hit your head and do some
damage that way.
Yeah.
But um, I certainly you know,there's some things in life that
you should just enjoy, and uhsauna is one of those things.
(38:58):
But to have to do itcompulsively for your health, I
don't necessarily would don'tneed to recommend that.
Tucker (39:04):
Okay.
Michael Koren, MD (39:05):
But I don't see anything wrong with it
either.
Good to know.
So this gets into some of umthe things that what we uh we
would do is uh if you're in apatient setting with me, what we
do in terms of our plan, whathow we're gonna move forward
with all this information.
We've got a ton of information,we cover a lot of stuff.
So what do you do next?
Well, obviously you're veryconcerned with your risk, and
you have some factors here thatwill need to be followed up,
(39:27):
like your ANA, and we talkedabout your LDL and your Lp(a).
But what do you do to look atyour risk?
And one of the things that Iwould recommend for you is what
we call a coronary arterycalcium score or CAC score.
And what we're learning is thatCAC score gives you good
insight into whether or notyou're prone to atherosclerosis.
And if you remember, uh, wefirst uh became more aware that
(39:50):
young people can have pretty badatherosclerosis based on
autopsy autopsy studies thatwere done during the Vietnam
War.
And these were young men, youknow, 18 to 24-year-old men that
were killed in battle,unfortunately.
And during their autopsies, itshowed that some of them were
already developingatherosclerosis on their aorta.
And uh as technology hasprogressed, we can now uh uh
(40:11):
determine whether or not youhave atherosclerosis without
doing an autopsy, fortunately.
And the easiest way of doingthat, and uh it's a cheap,
effective way, is looking at theamount of calcium in your
coronary arteries.
Tucker (40:21):
Okay.
Michael Koren, MD (40:22):
And calcium is the way our bodies heal
atherosclerosis.
So if you have someatherosclerosis that develops,
your body's gonna try to healthat, and it'll typically
calcify that plaque, and that'llshow up in a CAT scan.
CAT scanning is a very good wayof looking at calcium.
And so, somebody like you atage 35, you would hopefully have
(40:43):
a zero CAC score.
You wouldn't have any calcium.
So if you had a zero CAC score,I'd feel a lot better about
using diet and exercise to tryto continue to work on that LDL.
But if you had a CAC score thatwas above zero, any number
above zero, I would say, hmm, atyour age, Tucker, um, this
means that your body is startingto already develop some
(41:03):
atherosclerosis.
And I would actually recommenda statin for you.
Now, the reason I wouldn'trecommend it without the CAC
score is that we probablywouldn't make a difference in
the next 10 years if you had azero CAC score.
But if you had any positive CACscore, then I think the statin
would.
And statins are one of thesedrugs that um unfortunately have
a mixed reputation, even thoughthey should be like the
(41:26):
mother's milk of cardiology andtreating people.
Because unlike some of theseother things I mentioned, every
time we study statins, we get apositive outcome.
So lowering the LDL withstatins has uniformly led to
better outcomes.
But of course, that's dependentupon your risk.
So if you're 35 years old andyou have virtually no risk of
(41:46):
having an event for the next 10years, will statins make a
difference?
No, they won't make adifference because there's
nothing to prevent.
On the other hand, if you're 60and you have the same profile,
then they're much more likely toactually make a difference.
So if if I saw this, thesenumbers in somebody age 60 with
everybody else the same, I'dabsolutely put them on a statin.
Tucker (42:07):
And what's the what's the scaling range for CAC
scores, I guess?
Michael Koren, MD (42:11):
Is it uh zero to over thousands.
Tucker (42:14):
Okay.
Yeah.
Michael Koren, MD (42:15):
So again, and it's very age dependent.
Tucker (42:17):
I was gonna say, so you know, a person in their sixties
probably definitely has a somethat they're not at zero.
Michael Koren, MD (42:23):
That's right.
Most people, it's it's would berelatively unusual for somebody
in their 60s to have zero, butsome do.
Tucker (42:29):
Wow.
Michael Koren, MD (42:30):
And some people in their 70s have zero.
So I've had actually patients,many patients, that come to me
freaking out about their Lp(a).
And they'll have the same Lp(a)as you, they'll be 72 years
old.
I'll do a CAC score and it'szero.
And I have the great pleasureto tell me to tell them, well,
you know, nothing's perfect inin medicine, but your risk is
(42:50):
really super low.
So I wouldn't worry too muchabout your Lp(a).
Thank God there's somethingthat's protecting you.
And we may not even understandwhat's protecting you.
Hopefully in the future wewill.
But despite the fact that yourLp(a) is high, I wouldn't freak
out about it.
On the other hand, we havepeople who are in a similar
situation that are zealots anddiet and exercise, and they have
CAC score in the thousands.
(43:12):
They'll say, Doc, I'm doingeverything.
I I eat a vegetarian diet, um,I run 50 miles a week.
Why do I have a CAC score of athousand?
Well, as we know from a numberof very high profile people that
have died despite theirfitness, um, there's stuff that
can happen that we can'tcontrol.
Tucker (43:30):
Right.
Michael Koren, MD (43:30):
And that's where you need medicine.
Tucker (43:31):
Right.
Michael Koren, MD (43:32):
So yeah, the CAC score is something I would
recommend in you.
Tucker (43:35):
Okay.
Michael Koren, MD (43:35):
And uh then we look at that and we see okay,
are you somebody that cancontinue doing diet and exercise
to treat these issues, oryou're somebody that I would
start a statin on?
And I would look at that as adetermining factor in somebody
like you.
Tucker (43:47):
Good to know.
Yep.
Excellent.
Michael Koren, MD (43:49):
And then um the other thing that came up is
uh we kind of covered italready.
Uh, should you take somesupplements?
Doesn't hurt to take some fishoils, but you would accomplish
pretty much the same thing byeating more fish.
Tucker (44:00):
Right.
Michael Koren, MD (44:01):
But again, nothing wrong with insurance
policy as long as you don't mindburping up fish every once in a
while.
Tucker (44:06):
Yeah.
The secret there is yeah, keepthe keep the capsules in the
freezer and they they tend toslide down better.
Good to know.
Michael Koren, MD (44:11):
Yeah.
All right.
And um they they they tend to,in my experience, cause less
burping and um you know you knowsometimes it could be a little
embarrassing in a meeting if youif you smell like salmon.
Tucker (44:21):
Yeah, yeah, yeah, yeah.
Yeah.
That's you're the last personin the office that that anybody
wants to be around.
Michael Koren, MD (44:26):
But I you know I I don't I don't see any
harm in that.
And a multivitamin, especiallymultivitamin with vitamin B
complex vitamins in it iscertainly something that uh I
seem to do little harm.
Tucker (44:35):
Okay.
Michael Koren, MD (44:36):
But then some of these other things that are
out there, I would talk to adoctor before you do them
because you know I have a lot ofpatients come in and there are
on a list of 15 supplements thatthey were told were quote good
for them,
Tucker (44:48):
Right
Michael Koren, MD (44:48):
But they don't necessarily have a good
reason for them.
Tucker (44:50):
Right.
Michael Koren, MD (44:51):
And unfortunately, supplements can
do bad things, especially if youtake too much of them.
So I'll give you a personalexample.
You know, when I finished mycardiology training over 30
years ago, I recommended vitaminE based on epidemiological data
showing that there seemed to bea correlation with vitamin E
and its antioxidant effects andbetter outcomes.
(45:11):
But then there wereinterventional studies were done
where you actually randomizedpeople to vitamin E or not.
And three major interventionalstudies were done, and two of
the three actually showed atendency towards harm of vitamin
E supplements.
Tucker (45:23):
Wow.
So you never know until you dothe testing what these things
are going to look like.
And because of the fact thatsupplements are not supported by
pharmaceutical companies andthey're just sort of considered
part of your diet, they're nottested to the same degree as
things that are pharmaceuticals,which go through incredible
testing.
You know, the scrutiny aroundthose pharmaceuticals is
(45:46):
intense.
And as consumers, people canbenefit from that knowledge by
either participating in clinicaltrials or by reading the
results.
Right.
Michael Koren, MD (45:54):
So in your case, certainly I see no harm in
a fish oil supplement.
I would wouldn't necessarilyrecommend more than a thousand
milligrams a day and amultivitamin with B complex in
it.
But other than that, I'm notsure there's anything else that
would jump to the fore.
Tucker (46:07):
Cool.
Yeah, we'll keep we'll keep theregular regularly scheduled
program with uh, and you know,my kids don't eat fish, right?
You know, you can make it putin front of them, they won't
touch it.
So that's you know more or lesswhy I we can disguise tuna in
different ways.
Michael Koren, MD (46:21):
Right.
That's a good point.
Tucker (46:22):
They will eat raw tuna, but you know, any salmon or
anything like that, it's adifferent story.
Michael Koren, MD (46:26):
If it looks like a fish, they won't eat it.
Tucker (46:28):
Right.
Exactly.
Exactly right.
No.
Michael Koren, MD (46:30):
Well, in any event, um, do you have any other
questions?
Tucker (46:34):
Um no, obviously a lot to unpack, and I appreciate you
know you taking the time toreview this and and um you know
have a follow-up in anothercouple months just to see where
I am now.
I'd love to get the CAC and andyou know really see where I am
in that.
Michael Koren, MD (46:48):
Let's do that for our audience.
Okay.
So we'll we'll get your CACscore.
Yeah, and we'll have you comeback after some of maybe these
dietary interventions and evenyour sauna, and you can tell us
how you do with that.
Yeah, and we'll see uh how thenumbers look.
Tucker (47:00):
Yeah, I would love that.
I would love that.
Thanks for having me.
Michael Koren, MD (47:03):
Tucker, thank you for being part of
MedEvidence.
Announcement (47:05):
Appreciate it.
Thank you.
Thanks for joining theMedEvidence! Podcast.
To learn more, head over toMedEvidence.com or subscribe to
our podcast on your favoritepodcast platform.
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