Cardiovascular Disease Risk Markers & Ketogenic Diets for Heart Health | Dr. Ethan Weiss

Live Longer World Podcast #20

Live Longer World Podcast Episode #20 has been released!

My guest today is Dr. Ethan Weiss. He is a cardiologist and his special interests include preventive cardiology, genetics of coronary disease, risk assessment, and heart disease in the young.

In today’s conversation we spoke about misconceptions people have on heart disease, genetic factors involved in heart disease, how to understand cholesterol and triglycerides in the context of heart disease, ketogenic diets for preventative cardiology and so much more. 

If you want to understand how to think about your risk assessment for cardiovascular disease and how to prevent it, this conversation is for you. I hope you enjoy the episode!

[If you are a premium subscriber, you can also read the transcript of the episode below]

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Time Stamps:

0:00 Welcome to Live Longer World

0:44 Misconceptions of heart disease / young people with heart disease

4:01 Predictors of heart disease

6:59 LDL vs HDL; Triglycerides

12:51 Small-dense LDL vs. Large fluffy LDL

16:09 Dietary Carbohydrates & heart disease risk

25:50 Inflammation & Cardiovascular risk

26:43 Lipoproteins, ApoB, Lp(a)

31:31 Statins, PCSK9 inhibitors

32:45 ApoB as gold standard risk marker

36:50 Triglycerides & Insulin resistance

40:00 Saturated Fat

42:42 Variation in Cholesterol measurement

46:03 Body composition as marker for heart disease risk

51:23 Ketogenic diets & heart health

56:43 Keyto breath sensor

1:01:46 Stress & heart disease

1:04:44 Growth hormone & heart disease

1:07:46 On the shortness of life

1:10:52 Support & Connect with Live Longer World

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Premium Subscriber Transcript:

Aastha: As I started looking into understanding how disease risk better and some of the markers around, say, cholesterol and lipids, I realized there's just so much information that's floated around on the web, whereas understanding some of these are a lot more nuanced than what's common knowledge. I'm quite excited to learn from you.

I want to begin by talking about three misconceptions that you've mentioned before, that people have around heart disease. The first one being that people think that heart disease only occurs in those who are overweight or smoke. Second one being that people think if the take good care of themselves, they cannot have heart disease. Then lastly, people think heart disease cannot occur in young people.

I want to talk more specifically maybe about the last two misconceptions. Also, because I know you got fascinated by this field when you saw a lot of, say, people in their 30s or early 40s who were getting heart disease, but they had no obvious risk for it. I'm sure it also varies by person and a lot of is genetic, but what is happening in these young people who have no obvious risk for heart disease or a living healthy lifestyles?

Dr. Ethan Weiss: It's an amazing question. The short answer is there's no answer. I think there are some predictors that I think are demonstrated that confer risk. When you do see this disease show up in young people, and when, to me, especially now, but even normally, young to me is anything less than 40, right?

Aastha: Yes.

Dr. Weiss: No one less than 40 should be having coronary artery disease. When that does show up, I think there's some common things you'd look for. The most obvious of those is some significant lipid abnormality, so elevations in some cholesterol. There are people who have disease at a young age like that and have normal-looking cholesterol, and every other risk factor looks normal. That's still a big puzzle, we don't have an answer to why that is.

Aastha: Are most of those cases genetic?

Dr. Weiss: That's the assumption that people's make. It's actually ironic how I got involved in cardiovascular research in the first place and how I ended up deciding to be a cardiologist was, I got involved with a study. The study design was very simple, it took people like the young people who showed up with a heart attack or something like a heart attack at a young age. Then went and very carefully tried to analyze their siblings, their first degree, their siblings.

It was a study not of the program of the people with the disease, but a study of the people related to people who had early disease to see if anything could pop up. That was called the sibling study. I think it's still ongoing. It was an interesting effort to try and understand some of this connection. We always just fall back on genetics being the cause and likely is a major cause, but probably also not all of it.

Aastha: Do you have a hypothesis that maybe there are other risk factors that we should be testing that we don't test for, that are not the obvious ones for heart disease, but perhaps they could be telling in or predictors of heart disease in some of these people?

Dr. Weiss: Well, I guess, to answer your question, there are different factors that we measure today than we did when I started medical school 30 years ago. Well, the traditional risk factors that came out of the Framingham Study were the things that we all know, so cholesterol. I think at the time even then they were making a different distinction between the different fractions of cholesterol, HDL and LDL, the presence or absence of diabetes, presence or absence of smoking cigarettes. Let's see what else is on that one, as you think I know these by heart. Obviously, presence or absence of a history of disease in the vasculature. I'm drawing a blank on what else, what is in there? Those are the basic ones.

Since then, we've evolved now to get a little bit more sophisticated and look at lipids themselves. Not just, say, total cholesterol, but we'll look at the fractions and now not just the LDL, but we'll look at ApoB or non-HDL cholesterol, which seems to be more predictive. I think we have a better understanding of HDL cholesterol and its role in disease. We've got a appreciation of this other related molecule called Lp (a), lipoprotein little a, which I think is something that certainly not anything we'd looked at back then. Then the other thing that happened in the past 20-25 years is the role of inflammation. We measure inflammatory biomarkers, I think, that are also predictive of future risk.

Aastha: Okay, fantastic. I definitely want to dive into all those nuances. Before that, I had one question then. What sort of genetic screens or checks should a person get to test for their genetic risk for heart disease?