Dr. Eric Westman: It’s my great pleasure to have Dr. Philip Ovadia. Thank you for taking the time. How did you get into the low-carb or keto space?

Dr. Philip Ovadia: I’ve been a cardiac, heart, surgeon for over 20 years, and for much of that time I was a very unhealthy heart surgeon. I was morbidly obese, I was pre-diabetic. I recognized that I was going to end up on my own operating table. I was traveling down that same pathway that so many of my patients have followed and so many of your patients have followed. I recognized that the advice I had been taught to give them – eat less, move more, eat a low-fat diet, follow the food pyramid – wasn’t working for me, and it wasn’t working for them. Thankfully, I got introduced to some different concepts.

My journey started with hearing Gary Taubes give a lecture at a Society of Thoracic Surgeons meeting. There were a couple of thousand heart surgeons in that room and Gary’s the lecturer. Gary had just written The Case Against Sugar. Before that, he had written Good Calories, Bad Calories and Why We Get Fat. Hearing Gary talk about the types of food that we eat are more important than the amount of food we eat, and the influences there and, mentioning things like insulin and insulin resistance, I had probably heard superficially during medical school but never really paid much attention to.

I read Gary’s books and cut out sugar, went on a low-carb diet, and ultimately lost 100 pounds and reversed my pre-diabetes. Along the way, I came to recognize that what I had been taught about heart disease, the disease that I had dedicated my career to fighting, was not the whole story, there was a lot more than just cholesterol, which is the primary focus of the healthcare system when it comes to heart disease. That’s led me down a different pathway. I’m still an active heart surgeon.

Dr. Ovadia’s training

Dr. Eric Westman: Before we go down the new pathway – you’re trained to do heart bypass surgeries?

Dr. Philip Ovadia: Yes, I do open-heart bypass surgery and coronary artery bypass. It’s the most common surgery I do.

Dr. Eric Westman: That is an awesome thing. I’m thoroughly in awe of that whole process, and having seen it a few times it’s hard work. It’s life and death, and you’re working on these arteries that are clogged. Most people who have come to this, even seeing the damaged heart say, “Well, there’s cholesterol in there, in the artery, then it’s cholesterol in the food.” It’s the thing that people say, then look at you blankly.

Let’s step back to the training you received. You weren’t trained as a preventive heart person. Is it more reactive? You go in and you repair things after the fact. Is that right?

Dr. Philip Ovadia: That’s definitely the case. I see patients at the later stages of their heart disease journey. By the time patients come to me their heart disease has become advanced. Many of the patients never knew that. They show up at the hospital having chest pains, having a heart attack. They might be on my operating room table right away or within a couple of days. Others, have known that they’ve had heart disease, and they’ve been seeing their cardiologists and their family doctors who have been trying to manage this disease with them, yet it still has progressed to the point that it’s advanced, and they’re coming to me for open-heart surgery.

Identifying the cause of heart disease

Dr. Eric Westman: This is downstream from the initial process of getting started. How would you know how to prevent it? You would be listening to what all the other cardiology, or other preventive people, would be saying. What woke you up, other than your own experience? You didn’t have heart disease yet, you didn’t say. How would you be able to say that there’s something other than cholesterol? That’s the paradigm of today.

Dr. Philip Ovadia: That’s been one of the most interesting things about this journey. It’s not what I was expecting. It’s not what I was planning, but the evidence revealed itself to me. Looking at insulin resistance, and coming to understand that the vast majority of what I do as a surgeon is preventable and should be prevented. I’ll even go that further step to say that I now view what I do, as a heart surgeon, is that just about every patient that has ended up on my operating table has been failed by our healthcare system.

We have evidence to show us that, more than 90%, 95%, maybe even as high as 99% of patients that end up needing coronary artery bypass surgery could have been prevented with a proper focus on – we’ll just say for now – the risk factors. I think it’s a failure of our medical system that we don’t do a good job of preventing this.

How did we get to only looking at cholesterol?

Dr. Eric Westman: My patients come in with PAs, nurse practitioners, and doctors, following guidelines that say, “Your cholesterol is elevated. You need to be on a drug for this.” They don’t even know if the person has a history or is going to get atherosclerosis. They’ve dumbed it down to a cholesterol number. How did we get into this situation? What’s your perspective?

Dr. Philip Ovadia: I graduated from medical school in 1998. I do not remember hearing one word when it came to heart disease, besides cholesterol was the cause of heart disease and the way that we should prevent heart disease is with the use of medications and low-fat diets. The diets were an afterthought. If you look at the guidelines carefully, they’re in there but like you said, it’s “Look at this number on the blood test, the cholesterol level, the LDL cholesterol level specifically, and if it’s high, you treat them with medication to lower their cholesterol, and that’s the way to prevent heart disease.” That was well established when I graduated medical school in 1998, and it became well established in the early 1990s when statins came to prominence. Here we are 30-plus years later, and heart disease is still the number one killer in the United States and worldwide.

That was one of the things that I woke up to. It was always right in front of me, but I never thought about it or paid attention to it. If all these patients are on these medications, why aren’t we making more of an impact when it comes to heart disease? That’s the sad reality. We can talk about how much effect these medications might have, but ultimately we have to acknowledge that they must not be having the effects that we expect them to have because here we are 30, 40 years later, they’re the most widely used medications and heart disease remains far and away the number one killer.

Insulin resistance and metabolic syndrome

Dr. Eric Westman: Getting back to Gary Taubes, his book, Good Calories, Bad Calories is a must-read if someone’s still questioning how could the whole medical system be focused on something so insignificant. The first half of that book is brilliant in bringing all the science together in a way that I haven’t seen anyone else do. It’s been helpful for me to understand how the old paradigm was built. You hear now and then the residual risk or, there’s this acknowledgment that maybe there’s something else, what about this insulin resistance, metabolic syndrome? It’s been there for a while too.

Dr. Philip Ovadia: We can go back to the work of Gerald Reaven and Joseph Kraft in the 1970s and 1980s. Even before that, we have data showing how important insulin resistance is in this, yet we don’t act upon it. You mentioned residual risk. This is a term that comes a lot in the cardiology world. To unpack it a little bit for people, it’s the concept that we’ve controlled the patient’s cholesterol level, yet they still develop heart disease. Why is that? It’s this nebulous term, residual risk, and you’ll talk about other risk factors. There are things like smoking, high blood pressure, and controlling those.

When I think back through my medical school, my training and my career as a heart surgeon, I struggle to remember if I ever heard the term insulin resistance before reading Gary’s books and hearing Gary talk. A lot came after that. I’m a heart surgeon, I was trained to be a heart surgeon. I wasn’t really trained to prevent heart disease. You still would think that this term would come up just understanding the disease that we were treating. I certainly was educated about what heart disease is. We went through all of the basic science that led up to it. I would struggle to say that I ever heard the term insulin resistance during all of that time.

Inflammation

Dr. Eric Westman: How about the term inflammation?

Dr. Philip Ovadia: Inflammation would be brought up, but not as important. That term, residual risk, implies that all of these other factors are less important than the main risk, cholesterol, as told to us. When you look at the studies and, you look at the statistics, LDL cholesterol is the residual risk factor. It’s a minor risk factor. Inflammation and insulin resistance are much greater magnitude risk factors when it comes to heart disease, yet our approach in medicine is the other way around. People ask why that is. The only reason I’ve been able to come up with is we have pharmaceuticals that modify cholesterol levels, but we don’t have medications that modify insulin resistance in the same way.

Dr. Eric Westman: Doctors don’t know lifestyle change. We’ve trained a generation or two of doctors who just give prescriptions for medicines. The CME, continuing medical education, is done by companies that sell drugs. I have to agree that doctors have plenty to do.

You were quite busy repairing diseased arteries. How did you have extra time to go out and learn on your own? This is quite hard to keep up with in the field of cardiothoracic surgery. How did you come up with that great slide that I saw at a recent presentation that you gave? Virchow talking about inflammation in the arteries, 150 years ago?

Dr. Philip Ovadia: In an 1858 lecture he talked about how inflammation proceeded, what at that time he called the “fatty metamorphosis”, now atheroma formation. I became so passionate about it because of my journey. Then, understanding that the majority of the patients that end up on my operating table shouldn’t need to be there. Ultimately, our role as physicians is to do what we can to best improve the health of our patients. One of the things that I now understand is, no matter how good a surgeon I might be, no matter how good all the heart surgeons out there are, you’re never as good after you’ve had heart surgery as you would have been if you didn’t need the heart surgery in the first place. That’s become my passion and my calling.

I also recognize that being able to deal with the patient in this holistic way, and the patient that shows up needing that heart surgery, I’m able to offer them that heart surgery that may extend their life or save their life but now I can give them the added dimension of helping them to understand why they got here in the first place, and what they can be doing so that they don’t end up back on the operating table. The sad reality is, that the majority of patients who have bypass surgery have stents, they live longer because of these treatments, but they still die of heart disease. That’s something that I think we can change as well.

Doctors are fixated on LDL

Dr. Eric Westman: Thank you for making the change. There’s something different between cardiologists and cardiothoracic surgeons. The training is very different. The cardiologists are dealing with the problem earlier on, and although many cardiologists aren’t into prevention, most aren’t, they’re procedure-oriented as well. There are preventive cardiologists though. At Duke, where I practice, the cardiothoracic surgeons are open to this. They send me their patients who are too heavy to get a transplant. Imagine my surprise when the first LVAD (left ventricular assist device), patient showed up in my office.

I never had LVAD patients in the 1980s when I was in training. I’m checking for a pulse, and he’s pulseless. The heart has failed so much that there’s a little pump put inside the chest to push the blood around. The cardiothoracic surgeons started sending me patients because they were already so sick, and all I did was change the food. I don’t even add new drugs to the mix. The cardiologists have a different view and it is hard for them to talk of anything other than LDL. Is that your experience too, that most cardiologists have been trained in this, steeped in this old paradigm, and it’s hard for them to see outside it?

Dr. Philip Ovadia: Very much so. I think it may be changing a little bit. I think it may be changing because the cardiologists are starting to recognize the futility of what they do. It’s not working. I just finished Sarah Hallberg’s book. I know you knew her well and mentioned in the book the frustration she expressed at not seeing progress in the patients she was taking care of at the beginning of her career. Many other internists and family physicians have expressed this as well. A lot of cardiologists are starting to see that as well because they’re treating these patients with these medications, they’re lowering their LDL cholesterol, yet they’re still developing heart disease. It seems to be that endless never-ending supply of these patients and we’re not making progress. We’re losing the war against heart disease. Even the cardiologists, not in large numbers, are coming to recognize that we need to do better for our patients.

Role of drugs in insulin resistance prevention

Dr. Eric Westman: I would generalize even within all of internal medicine, cardiology rules the lipid world, so most internists like me follow the cardiology LDL focus. They’re not into the triglycerides and HDL, the metabolic syndrome components in the blood. I try to teach that as much as I can to my patients. I go to the statin decision aid tool that the Mayo Clinic has online to help people understand if they do use medicines the amount of absolute risk reduction might be pretty small. Thinking about prevention, primary prevention or secondary prevention and lifestyle, is there a role for drugs, and how do you put things together? How is your transformation and what do you do today?

Dr. Philip Ovadia: I think at the center of it is insulin resistance. First of all, is the patient insulin-resistant or not? Studies are showing that when you’re looking at heart disease patients, the answer is almost always yes. Studies going back to the 1960s and 1970s demonstrate that 95% of the patients that show up with heart disease, or a heart attack, are insulin resistant – if you look for it in the right way, and do the right test for it.

The first part of it is to ignore the LDL, it’s just acknowledging that LDL isn’t the whole story, then let’s look at these other things. It would be akin to the same cardiology patient walking in, and we know that they’re a smoker, and we know that they have high LDL, and we say, let’s treat the LDL, but we’re going to ignore the smoking part of it. That’s not something we would do. Insulin resistance, it turns out, is an even bigger risk factor than smoking for cardiovascular disease, and yet we ignore it. The first thing I try to accomplish with patients, and my colleagues, if I’m working on educating them is, let’s acknowledge insulin resistance exists and it is a major risk factor for heart disease. Let’s test for it and then let’s talk about how we can mitigate that risk factor.

Testing for insulin resistance

Dr. Eric Westman: How would you test for it? What should the doctor do to figure this out?

Dr. Philip Ovadia: The easy things we can do are, measure a fasting insulin level, look at the triglyceride to HDL ratio, and sometimes that’s all we’re limited to for various reasons. At least if we get that we can start to get a sense of whether they are insulin-resistant. Ideally, I like to go beyond that.

My preferred way of assessing insulin resistance today is what’s called the LPIR score, the lipoprotein insulin resistance score. This is a score that’s based on what we call the advanced lipid panel or the NMR panel. When people get their cholesterol measured, what we’re looking at is the amount of cholesterol, or more correctly, the cholesterol-carrying particles in the bloodstream. What the NMR, the advanced panel, starts to do is, look at the quality of those cholesterol particles, specifically looking at the size of the particles. When it comes to LDL-carrying cholesterol particles, the smaller the particles are the more problematic they are.

Again, one of the failings we have in this LDL-centric world is that we look at LDL too broadly. It turns out that not all LDL particles in our bloodstream are the same. Part of the reason why I think LDL management is so ineffective and inexact is that we’re looking at LDL too broadly. We really should be zooming in on the quality of these cholesterol particles, that testing gets a little bit more complicated. Ultimately, LPIR, the lipoprotein insulin resistance score, is a score that looks at the size of your cholesterol-carrying particles and uses that to determine if you are insulin resistant or not.

Lifestyle change

Dr. Eric Westman: Interestingly you went right to blood. I would have said for insulin resistance I’d want to know, the abdominal circumference, blood pressure, blood sugar, then blood lipids, all of that constellation. In some cases, I don’t even measure blood if it doesn’t change what I do. That’s my general training in the VA, the Veterans Affairs Hospital System. We were trained in the ’80s and ’90s. If you weren’t going to change what you did, why measure it? Having a baseline and seeing change is important for adherence. What kind of lifestyle changes do you recommend these days?

Dr. Philip Ovadia: You’re exactly right. Sometimes it’s obvious that the patient is insulin resistant. You don’t need that testing. We have the five basic measures that you mentioned: waist circumference, blood pressure, fasting blood glucose, triglycerides, and HDL. Oftentimes that is enough. You have to pay attention to it and manage it.

For me, when we do determine that the patient is insulin resistant, the evidence at this point is overwhelmingly obvious that therapeutic carbohydrate restriction is the best way to deal with that. That is my preferred approach. From a practical standpoint, we can get into all the different forms that this can take. That isn’t just one diet, but therapeutic carbohydrate restriction is the overarching principle that can help you to personalize that diet to the patient in front of you.

Keto research

Dr. Eric Westman: If anyone has any doubt that there’s research, I show the Ketogenic textbook published in 2023 and then side by side I have the Osler textbook of medicine from 1923. It’s the same diet for diabetes. We didn’t have to come up with a ketogenic book. No one has shown that it’s bad. There aren’t any prospective clinical trials that show our restriction is bad. But the power position was that they were bad, everyone knew it. There was a taboo on high-fat diets.

I flipped around. At a meeting, I asked Jeff Volek if I should tell my patients to stop carb-restricted diets. He said no, there’s no evidence there’s anything bad about a carb-restricted diet if you do it right. We didn’t have to do all that research except for the fact that it was the wrong time or, there was a paradigm, a time, where everyone thought eating fat was bad. The industry that pushes sugar has got a free pass. Even today, is there a study that shows eating sugar causes diabetes? I don’t think that exists. It’s so obvious that it comes out in observational studies. The argument that Gary Taubes taught me is that science will eventually find the truth unless you’re not able to do the science that needs to be done.

Dr. Philip Ovadia: Very much so. When we look at it in the context of the low-fat diet, it’s ironic and problematic that we’re in this situation. As you mentioned, you can go back to Osler, you can go back even further to William Banting in the late 1800s. Talking about carbohydrate restriction, in the look that I’ve done, no one’s ever shown me a low-fat diet suggested that far back. It only became suggested in the 1970s and 1980s. We’ve been running that experiment for 40 years. The results are quite frankly disastrous. They’re all around us, yet we are still in a situation where we have to somehow prove that carbohydrate restriction is safe, while that (the low-fat diet) is accepted as safe, even though it clearly isn’t, and has no evidence behind it. We have plenty of evidence showing the benefits of carbohydrate-restrictive diets. I am yet to see any evidence of the benefits of low-fat diets.

Evaluating the patient

Dr. Eric Westman: The big study that was government-funded didn’t show a difference. If you only believe in one thing, that’s all you’re going to see.

Let’s shift gears. Imagine we’re in the clinic and someone doesn’t know if they have heart disease or not. Their doctor has told them they need medication treatment for high cholesterol. How would you go about evaluating this patient other than looking for insulin resistance? Say there is insulin resistance, how would you counsel and then gauge measurements?

Dr. Philip Ovadia: This is another very important concept for people to understand. Again, our evaluation of heart disease is typically based on blood cholesterol levels. The reality is that blood cholesterol levels tell you absolutely zero about whether or not you have heart disease. Maybe there’s some correlation, maybe there isn’t. If we want to know a view of heart disease, the best way for us to do that these days is with a coronary artery calcium scan. It’s a fairly simple, non-invasive, relatively inexpensive test that can show you whether or not you have calcified plaque in the arteries of your heart.

I understand that it’s not a perfect test, it doesn’t show us all the plaque, for that you need a more advanced test called the CT angiogram. The CAC scan, the coronary artery calcium scan, is the best initial screening test that we have. I am a strong advocate for this test. It can also be used as a marker of the progression of the disease. We can get a CAC scan today, we can get a CAC scan a few years from now, and we can see, do you have disease and is it getting worse or not. We don’t utilize this test as we should in medicine. It is very underutilized. We rely on this blood marker that has nothing to do with whether or not you have heart disease.

Using ultrasounds

Dr. Eric Westman: In our area, there’s a company that will do the ultrasounds of your carotid artery and aorta for a small fee. I recommend that my patients do that to get more data on their bodies. Do you recommend those at all?

Dr. Philip Ovadia: Those can be another screening task, but they’re indirect. We’re not looking at where we’re actually interested, so I prefer the CAC scan. In cases where it’s not available, looking at the carotid artery or the aorta for evidence of atherosclerosis can be helpful as well.

It’s so interesting because you look at all these other diseases that we take more of a preventative, or at least an early diagnostic, approach. Look at something like cancer – breast cancer, women know to get their mammograms. The reason we want to get the mammogram is that it’s better to diagnose breast cancer when it’s a microscopic, or very small tumor, than when it becomes clinically apparent, which can be in the very late stages of the disease. Yet with heart disease, we don’t take that approach. I view coronary artery calcium scans as the mammogram of the heart. We can see this disease process at its early stages, yet we don’t utilize the test. It doesn’t make sense to me. CAC scans are safe, they’re low radiation, and they’re very inexpensive. You can get them done for $100 or less, and they’re noninvasive. I don’t know why they’re not utilized more.

How to use a coronary score of zero

Dr. Eric Westman: In our area, people have to pay out of pocket if it’s not covered. There’s a false expectation that your doctor’s going to know all the preventive things to do. A lot of patients in my area don’t want to pay anything out of pocket. The monopoly, or ownership of different machines, is part of it. You have radiologists, cardiologists, nuclear radiologists, everyone jockeys for positions. I love your metaphor, “the mammogram of the heart.” When a patient comes in and the coronary score is zero, what does that tell you?

Dr. Philip Ovadia: It’s going to depend on the age of the patient. The younger you are, the more likely you have a zero score and the less predictive that zero score is. Ultimately, it tells us that you do not have any significant coronary plaque. I always understand the criticism that there could be a non-calcified plaque there, but that’s probably not going to be to a significant degree.

Dr. Eric Westman: The risk isn’t zero but it’s very low that you would have a heart attack in the next 10 years.

Dr. Philip Ovadia: Exactly. If you’re 50 years old, a man 50 years old, and you have a CAC score of zero, your risk of having a heart attack in the next 10 years is less than 1%. No test we have in medicine is perfect.

We know, at least in people in their 50s and 60s and beyond, with a CAC score of zero, there is no benefit to cholesterol-lowering medications. This has been demonstrated in many studies. You can say that if it’s a younger patient, maybe you can’t make those same conclusions. I think that’s valid but what I tell young patients is if you’re 40, maybe even 30, and you have particular risk concerns, go get that first CAC scan. The zero score may not mean a whole lot, but the non-zero score in those patients is very meaningful. It tells us we have a major problem. You’ve already started accumulating plaque at this young age. This makes it even more imperative to address things like insulin resistance. I have yet to see a young patient, with a positive CAC score of more than zero, who is not insulin resistant. Maybe heavy smokers, but honestly, I haven’t seen it. If you’re 30 and have a non-zero CAC score, you’re insulin-resistant. We need to address it pronto before it becomes a big problem.

How to read coronary scores

Dr. Eric Westman: The studies we’re talking about don’t treat insulin resistance for those patients. They’re getting the typical American approach, which is to eat whatever you want and we’ll give you pills. My hope and hunch is that people who start changing their lifestyle won’t have that high a risk as time goes on. Let’s say a patient comes in and the coronary score is 100. What’s the range? I’ve seen different ranges. I am not an expert on it. It depends on when the study is done but 100 is pretty high.

Dr. Philip Ovadia: 100 is what I would consider moderately elevated. I have seen these scores in the multiple thousands. I’ve seen 6,000, 7,000. I think the highest score I’ve ever seen is 9,000. They go pretty high. 100 is usually a threshold where we start to think this patient may have significant disease. For the patient that’s now in front of you with their CAC score of 100, there are really two questions that you need to ask. Number one is, do they have significant disease today that we might need to do an intervention on, a stent, bypass, something like that? Are they at imminent risk of a heart attack? If they’re not, what are we going to do to stop this from getting worse?

One of the other very interesting things about CAC scans, that most doctors don’t know, is that the progression over time of your CAC score is very predictive of your risk of heart disease. Let’s say you walk in with a score of 1,000. We do whatever testing and we determine you’re not at imminent risk. If we rescan you a year, or two years later, and your score is still at 1,000, that puts you back into a low-risk category, as opposed to if your score progresses. An average progression is about 15 to 20% per year. If we scan you again in two years and your score is 1,200, 1,300, 1,400, you’re at high risk. If your score is still at 1,000 that puts you back into a low-risk category. That’s another way that the CAC scan becomes so powerful for us.

Calcium in the arteries

Dr. Eric Westman: Is calcium a sign of healing? If you have more calcium going up, it means you’ve had more disease and more healing going on.

Dr. Philip Ovadia: This is a controversial topic. What do we know? We know that more calcium equals a higher risk of disease, that’s been shown consistently. There’s been this inconvenient truth that has been uncovered, as we do more CAC scans. For patients who are on statins, specifically, they seem to have a faster progression of coronary calcification. In an attempt to explain this away, this theory has come up that it’s a good thing because what has happened in that patient is the soft plaque that you’re not seeing on the CAC scan has now turned to calcified plaque, which means that the plaque is more stable, unlikely to break off, unlikely to cause a heart attack.

The evidence to support that hypothesis is not there, but that’s what’s been pushed forward. I go back to the fact that every study that I’ve looked at says higher coronary calcium, higher risk of disease. For us to think that if you have high calcium because you’re on a cholesterol-lowering medication, it’s okay, but if you have high calcium when you’re not, it’s problematic, that does not make sense to me. This is probably getting a little deeper into the woods than we want. The whole theory that the atherosclerotic process starts with a soft plaque, what we call an atheroma, becomes a calcified plaque that stabilizes it, has not been definitively proven.

The role of the CT angiogram

Dr. Eric Westman: What’s the role of that CT angiogram? The calcium score doesn’t tell you directly about narrowing. If you get a CT angiogram with dye put in, then the CT, you can have the artery itself shown with the amount of narrowing. How do you use that test?

Dr. Philip Ovadia: The CT angiogram gives us more detail but it is a more involved test. You have to give the patient dye, you’re exposing them to a greater radiation dose. It’s a more detailed imaging, but it gives us additional information as it shows us both the calcified and the non-calcified plaque. We can now actually quantify the degree of narrowing of that blood vessel.

I use this test in several ways. The first would be a patient with a very high CAC scan that isn’t having symptoms, and we’re concerned about whether or not they have enough blood flow, a blood vessel might be narrowed enough to require intervention, that’s a good situation for a CT angiogram.

For patients who have already had stents, maybe the CAC scan is not as applicable because that stented area is going to show up as calcified plaque. CT angiograms can be useful if we’re trying to follow patients after they’ve had a stent rather than the more invasive cardiac catheterization test. These are becoming better and better options. The technology behind them has advanced in the past 5 to 10 years. We’re getting very high-fidelity images. We’re even able to reduce the dose of radiation, which makes them more and more useful. I admit that I would love to be able to just do the CT angiogram as the screening test on everyone, but the reality is the radiation, the expense, and the IV dye are all barriers to that. That’s why I say the CAC scan is the better screening test.

There is no one perfect test

Dr. Eric Westman: I did my cardiology internal medicine training in the ‘90s. There was always a role of the treadmill test, the functional test, and you would always look at an anatomic narrowing and not know if it’s flow limiting to the degree that you need to intervene. I was always a big proponent of the functional test. It’s always important to talk about what someone’s lifestyle is. I even had a marathon runner who couldn’t go up the hill as well, and he found this really little lesion in one of the tiniest coronary tributaries. You have to balance the decision for the patient, what is the narrowing, what is the person’s lifestyle. I find a lot of people are searching on the internet for the answer.

Dr. Philip Ovadia: It is important to understand that we don’t have one test that gives us all the information we need. You mentioned stress testing and functional testing. We also have what’s called FFR testing, Fractional Flow Reserve. Even when the patient is in the catheterization lab and the cardiologist has put the dye directly in the artery and we’re looking at it and we’re visually assessing, this looks like a 70% blockage or an 80% blockage, we don’t know, is that causing problems or not?

We now have what’s called FFR testing where we can actually measure the flow across that lesion and determine whether the flow is being reduced significantly. That’s really become the gold standard to decide if that blockage, that lesion, needs an intervention or not. These are all downstream tests that become possible. It starts with let’s look for the early stage of disease. If the patient shows up with chest pains, you’re not going to start with a coronary artery calcium scan. This is all context-dependent.

Dr. Eric Westman: You have chest pain in Durham, North Carolina, you’re going to end up in the Duke cath lab.

Dr. Philip Ovadia: Most likely. Sometimes in the ER, they’re now doing CT angiograms in patients if they think it might be chest pain for another reason. The CT angiogram can be a good test in that situation so that you don’t have to go to the cath lab. That is becoming increasingly common.

Dr. Eric Westman: What the practice patterns are will depend on the relative influence of the different sub-specialty. Probably within a certain hospital, if the powers that be have more radiology emphasis, they may go toward the scans rather than if the cardiologist rule, then they’d go more toward the cath lab. These behind-the-scenes things aren’t publicly discussed. I have had enough people who have lived all over the country, they have figured out that things are done in different ways.

How to approach and talk to your doctor or cardiologist

Dr. Eric Westman: Any tips on how to talk to the doctors, even cardiologists, about their heart disease risk? Any pearls that you found useful?

Dr. Philp Odavdia: I think this is probably the common scenario that comes up, you and I have run into many times where you’ve started the patient on therapeutic carbohydrate restriction, they’re getting great results, losing weight, feeling great, their insulin resistance has improved, maybe you’ve got them off a bunch of medications, then they go to the doctor and maybe their LDL cholesterol has gone up, and because of that, they’re discouraged from doing this.

In that situation, the discussion has to turn toward what is the quality of the LDL cholesterol. This is where we’re looking at the advanced panel and the particle sizes. Even without that, stepping back and saying, when you look at the LDL studies that have been done in insulin-sensitive patients, we’ve never demonstrated that same risk associated with LDL. When you take the insulin resistance out of the picture, it’s not clear that LDL in and of itself is problematic. There’s a lot more science being done around this to answer this question that has come up. This shouldn’t be a barrier because in the end, if you’ve reversed insulin resistance, reverse your diabetes, and come off blood pressure medications, even if we think there may be some increased risk with that elevated LDL, the net benefit is still clearly in favor of what you’ve done. That’s how I instruct patients to think about this and talk to their other clinicians about it.

Dr. Ovadia’s book, “Stay Off My Operating Table”

Dr. Eric Westman: I like that because it’s staying within their frame of reference of, worry about cholesterol rather than just saying don’t worry about it, the triglyceride HDL looks great. Most doctors don’t understand that even today, sadly.

I loved your book, Stay Off My Operating Table. It’s a myth-busting book. Tell me a little bit about the book.

Dr. Philip Ovadia: It gives patients the blueprint. It goes into all of these myths. The first section of the book is focused on myths when it comes to heart disease, then it gives patients, and people, the roadmap on how to avoid heart disease. It talks a lot about insulin resistance, metabolic health, what it is, how to improve it, and how to feel your best every day.

Find Dr. Ovadia at I Fix Hearts.

Watch the full video here.