#405: Heart Attacks Aren't What You Think | The Plaque LIE That Changes Everything (Cardiology 2.0) With Dr. Sanjay Bhojraj

Welcome to Longevity. I'm your host, Natalie Nidom. I'm a nutritionist, a human potential and epigenetic coach, and I created this podcast to bring you the latest ways to take control of your health and longevity. We cover it all from new technology and ancestral health practices, to personalized interventions, and a very special interest of mine, peptides and bio-regulators. Enjoy the show. Hi, I'm Natalie Nidom, your host, and we are back with a fabulous guest today. Today's conversation is with Dr. Sanjay Bojraj, who calls himself a curious cardiologist. And trust me, he means it. After decades, treating emergencies, he now focuses on prevention, root cause, cardiology, and building long-term health rather than chasing short-term crises. In this episode, he shares why most heart attacks don't come from the big scary blockages you think they do, why stress can be just as dangerous as cholesterol, and how modern imaging, like the clearly scan, gives us a new, far more accurate window into plaque. We even get into hormone shifts. Women's cardiovascular risk and why cardiologists should probably take Perry Manipaz way more seriously than they currently do. This is going to be epic. Next, I'll just thank a couple's sponsors, and then we are diving in. If a supplement claims longevity benefits, here's the real question. Can you actually feel it? Can it be measured? Well, here's a supplement that's answers yes to both of those questions. Regenribe is built around a clinically validated ingredient called Longaferra, featuring a novel Ash X4 complex derived from Ashwagandha root. But this isn't just about stress relief alone. 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I keep them on my desk and usually reach for them when I'm craving something sweet. That way I get my two gummies a day, and I feel like my internal battery actually shows up fully charged. They're the first-ever uralithane gummies that help new your mitochondria so that everything feels steady or stronger and clearer throughout the day. They are the only clinically proven uralithane gummies, their vegan, sugar-free NSF certified, and they support a key home-marketing mitochondrial decline. Do not let another year go by feeling less than your best. You can get 35% off your one-month subscription at timeline.com forward slash NAT 2026. That's timeline.com forward slash NAT 2026 while the offer is in place. So don't delay. Dr. Sanjay, welcome to the podcast. It's who knew a few months ago that we'd be sitting here. All right, thank you so much for having me. And boy, it feels like I've known you forever, even though it's only been just a handful of months, right? So we must be doing something right. I know. I know. And all we did was like, you know, share a meal with eight other people at a very hot table. Oh, yeah. Just remember it was super hot under the blazing sun. Yeah, in Scottsdale. It's funny. Like that you say that it feels like we've known for each other forever because you do establish connection with people very quickly sometime. And when it's the right fit in person, which I think is it's the beauty of getting of the world being back to an in-person world. There's there's nothing really replaces human connection in three dimensions, so much better than two dimensions for sure. 100 percent. But we'll make do with two dimensions because that's what we've got. We're going to talk heart. I mean, I've been wanting to do an episode on with a cardiologist like you forever. So I'm so, you know, if that was far through me, I'm like, oh, you would do what? Oh, yeah. No, no, we need to talk. There's not a lot of functional integrative cardiologists on this planet. So, and I think it's one of the sub-specialties within medicine that needs it the most because by and large for the most part, cardiovascular diseases, I feel are avoidable with the proper diet lifestyle mindset, you know, mental emotional spiritual interventions. But there's just, you know, I think number one, the average cardiologist is just so busy that they don't have time to think outside the box. But number two is that it really takes a leap of faith as with anyone really in this field to be able to break out and say, you know what, I think there's something more. And that's in my career as an interventional cardiologist. That was the epiphany that I had was I can kind of just jump into my origin story here. Yeah, that was going to be the next question. So, so I'm, you know, so I'm in it, I'm by training and what's called an interventional cardiologist. So we are the best type of cardiologist, which are the ones that do cardiac procedures. So I was the heart attack doctor essentially. And so I was the person that you'd meet it to in the morning, you know, chest pain, heaviness, health, and my chest, all those symptoms get knee KG. We'd whisk you away to the cath lab. I'd go in through the artery in your wrist and take a catheter, take pictures of your heart arteries. If there's a blockage, get it opened up. And I was very good at that for for a long time. And then one day, I remember one particular weekend I was on call and when you're on call, at least in my old practice, you were on from Friday morning to Monday morning. So Friday morning, 8 o' 1 a.m. to Monday morning, 7.59 a.m. And on that particular Saturday, I had eight patients come in with back to back to back to back to back to back to back to back to back heart attacks. And, you know, you're just running on adrenaline, go, go, go. And I had two realizations. Number one was that, you know, I don't think physically I can do this much longer because of the toll. It took on me. I mean, you're literally life or death, you know, you're measured by seconds. You have to get in. You have to open up. People anything can happen. So you're just mentally physically exhausted. But then, you know, as I mentioned, if diet and lifestyle plays such a huge role in cardiovascular diseases, where are the thousand left turns where this person, or right turns where this person went left or left when they went right? And, and why aren't we focusing on that, you know, in that vein of an ounce of prevention is worth a pound of cure. And that, in a weird way, led me into functional medicine. And now I run a diet and lifestyle program to help people avoid really cardiovascular risk. And it's, it's not just, you know, statins and beta blockers and medicines. But it's, you know, are you connected to community? Do you feel a sense of purpose? You know, are you managing your heart? Let's do deep breathing exercises and look at heart rate variability and manage stress and eat the right foods and healthy foods may be different than healing foods. And just a completely different approach. And in the front half of my career, as I say, I spent, you know, 15, 20 years getting medication lists longer and longer. And now my goal is to make them shorter and shorter, you know, and get people off meds and get people back on the life. So it's really, are really different paradigm shift. And why did I do this? I don't know. Like I sometimes feel stupid and I wish I could go back into the matrix and be happy as I was. But, you know, now that I've seen the outcomes that I've got, you know, there's no way that I can go back, right? Like, yeah, I mean, there's no way that I could go back because it's just so powerful. And this is really, I think what cardiovascular medicine and medicine in general really needs to do is not just look at numbers, but look at whole people, right? And it sounds like, sounds like the most obvious thing in the world. But when you're in the trenches as a conventional trained physician or when you're in there and you've got, you know, 7.3 minutes to have a patient encounter and, you know, the average patient is interrupted 7.3 seconds into the visit. You know, it's just, it's just not designed for that. So, you know, I'm thankful to be able to step out of the system and actually spend the time with patients and take care of people the way that I think people should be taking care of. So there's your, there's a long answer to a question you never asked. How do you like that? Yeah, I know, but I was going to ask it anyway. I mean, do you ever think about how many people like would you have, if there was two of you and one of you who stayed in interventional medicine and the other one who stepped off the merry go round like you did, do you think you would have put you out of business? Meaning the, the, the, what the, what the integrative Sanjay put, put the interventional Sanjay out of business? No, I don't think so. I mean, I think to a, to a certain extent, you know, the denominator is just so big, right? That, that, you know, unless I, unless I can scale myself completely to be able to address everything, but I think there will always be a role, honestly, for, for both. And I think there needs to be, you know, because, you know, if you have an acute heart attack, I'm not going to tell you to do a 478 breathing exercise, right? That would be nonsense. Like go in, no, I don't get your, get your heart reperfused, right? No, but, but my point being is that we need both sides of the equation, right? And I think of this like in, in chemistry, there's such a thing as a dynamic equilibrium. If you remember, a chemical reaction with an arrow that points both ways, I think sometimes you need to be on the more conventional side, sometimes you need to be on the more integrative side. But I think that the integrative functional side has really not been pursued, right? And so, and so, you know, I don't think that, you know, everyone's worried about AI and will AI take out cardiologists and will, well, integrative medicine take out cardiology and regal medicine? No, I don't think so. But I think that it is a necessary complement because if you are a healer, right? Which is different than a doctor, I think, but a healer really interested in healing your patients, healing the people that you take care of, then you have to step out of that conventional models where you're just treating people, right? And really, as we talk about root cause, and I'm going to talk a little bit later today on reactive oxygen species in the cardiovascular disease pathology spectrum. And it's just amazing because all of these very basic science principles don't really get thought about in the conventional world, right? And so, and so we can affect huge change with diet and lifestyle. You know, but I think there will always, you know, and we've always, you know, we've seen this where you have someone who you think is perfectly healthy that ends up having a heart attack, right? So the more, at least I see it, you know, I call myself the curious cardiologist because, you know, the more I learn, the more I realize I don't know, right? I mean, it's really fascinating. And so, so I think they're, you know, I would love to try and get the integrative Sanjay to put the interventional Sanjay out of business, but I think there's room for both of us. Well, I think that the integrative Sanjay would need to get, I guess I didn't ask my question properly, but I think a better question would be, and it makes a big assumption, right? It makes the assumption that the patient is willing to do the work, right? To change their course, right? To, as you said earlier, where did they go left when they might maybe should have gone right and where did they go right where they should have gone left? And so, if, and this will lead to a second question, actually. So if people followed the program, cleaned up the diet, cleaned up the lifestyle, got it, didn't the right amount of exercise, not too much, not too little, the right kind. I mean, there's a lot of companies that manage the stress. What percentage of people do you think could avoid heart disease? Yeah, I mean, I don't know that I have a significant, like a number that I can point out to, but I will say this and we can look at the data from COVID, right? So, when we look at COVID and we look at that initial period of the lockdown, presumably people work as stressed, they're working from home, all these things, we saw a significant decline. I'd say a 30% decline, at least in my hospital, in our heart attack census, in our stroke census, even in our acute append, appendicitis census, like people going for, for acute apis into the ORD, they all dropped about 30% or so. And I thought that was super interesting at the time, because to me, that was almost like, okay, if we don't have to drive and be laid and do our meetings and not have to deal with coworkers and all this stuff, maybe that's the downshift that we see. Now, you mentioned patients doing all the work, and I think that that's where we kind of, our mindset needs to shift a little bit, because obviously conventional systems aren't working, right? But I think this is where, number one, returning agency back to patients and reconnecting them with the outcomes of their efforts becomes an issue, right? And so it's difficult to reconnect somebody, if you eat healthy for the next 10 years, you won't have a heart attack, right? It's hard to connect to a negative outcome. People can barely, it's difficult thing to do. But if you can say, you know what, as you eat healthy, watch your blood pressure decline, watch your energy level improve, watch the number of naps that you take improve, right? That will then reconnect them. And I think this is where really kind of the roles of a healthcare team need to evolve a little bit to involve health coaching, which I think is absolutely fascinating, because now they are that bridge that link oftentimes between kind of the goal that the doctor has, or the healthcare provider has for the patient or client, and the the effort that a patient or client can put in, right? And how do you match those two? And you know, I always talked about this, my father-in-law, wonderful guy. You know, I've been married now for 22 years. He's like a second dad to me. And he had a heart bypass 21 years ago, in fact, the year after we got married. And he is now becoming diabetic. And the great advice that he got from his physician was, well, eat less and exercise more, right? And it's just, and it's, I mean, and it's just pervasive out there, you know, but talk about completely just not connecting with a patient, right? Eating less. So does that mean that if I eat, you know, one pizza a day, and that's all I eat, is that, you know, less than I would normally eat. But is that, you know, like, do I exercise until I put myself into a heart? Like, what does that mean, right? So we need to, I think, change the mindset and realize that it's not just putting the onus on the patient, but it's creating a better team, right? And creating, creating a better team to reconnect, you know, shorter, shorter outcomes. I mean, I remember a few years ago, I lost my mind and ran a marathon, right? And it was not, and I'm not a runner, by the way, I hate running and every mile I say was worse than the mile before. So it was just the worst experience in my life. But I did it. I'm not sure I believe you. Even crazier, that was in the marathon was a training for a half Ironman race that I was running that year. But the point, my point was was that I didn't think of I met mile 20, you know, mile marker one, I've got 25 more to go. I've got a marker to 24 more to go. But I was like, let me get to that tree. Let me get to that crack in the street. Let me get to that fan holding that crazy sign. So what I did, right? And this is like an atomic habit is just make these kind of small changes, these small goals. And then you string them together as a victory and say, hey, wow, before you know what, I'm at mile 13, I can do this, right? Or, or, you know, hey, you know what? Like I have gone a week, like in my metabolic program, I give people a form to fill out, like, at the end of the week and say, what was your win for this week? And someone just said, you know what? I didn't have cravings, right? And that's a small win, right? But it's a win. And you string enough of these together and you get that momentum moving, right? And so I think that that rather than, you know, I think what we do all the time is blaming the patient, you know, oh, you must be doing something wrong. You must be having dietary discretion. You need to exercise more is creating a team that can foster success, right? And I think that involves much more kind of hands-on than then you get seeing a doctor once every six months. And so, you know, that's, that's where I see help. I think you know how to, right? It's it's walking with them instead of, I mean, you know, on the upside that cardiologist that told your father-in-law to eat less and move more, at least acknowledge that there was something to be done because not not a lot of cardiologists, I mean, there are plenty of cardiologists that there who wouldn't even have gone that far on the conversation. I mean, that to say he wasn't right, but, but, but he didn't have him. But, but, but, you need to give people tactical things, right? That's like, you know, like my daughters were in high school and if I said, oh, get a perfect score in the SAT. But I didn't give them like a book to read or a framework or study schedule, right? Like, like, so we need to chunk it up for patients in the smaller bits and pieces and, you know, there's an old line, how do you eat an elephant one bite at a time, right? And so that's, that's, that's what we need to do. Yeah, poor elephants, but, and don't eat an elephant because it's just not nice. But, but, but the point being is that, you know, I think we need to shift our, our mindset and healthcare. And that's where I think that the integrative model makes so much more sense because we have the time we have, we build the teams, we have the framework. And, but we're also dealing with things outside of just numbers, blood pressure, blood, it goes cholesterol, right? Like in the cardiovascular world, to, to say, hey, you know what? Like, one of the best interventions I had on a patient, she came in with palpitations. This is when I was in a conventional model, but training in the functional world. And she came in with palpitations. And I said, you know, she was, when do you get them? And are they related to your cycle and this had the other? And finally out of nowhere, I just asked a question, do you feel safe? Right? Like, why would a cardiologist have that? And turns out she was not safe. She was in a abusive relationship and all these things. And that was precipitating her palpitations and her stress and all that stuff. And I certainly didn't have the resources to, to put her, but I connected her to people that had the resources. And luckily she got better, right? And, and so that's the easiest easiest thing to me would have been just to prescribe a beta blocker, which is I think the most cardiologist would have done. But, but this is where, you know, the difference would be to bring being a treater and being a healer comes into play, right? And, and so, and so I think we just need to have, you know, like a kinder gentler approach to patient care and, and be able to give them time and, and, and really practice, you know, this precision and of one medicine where, you know, like the person in front of me at 10 o'clock is very different than the person in front of me at 1030, right? And, and so we have to give, like, understand the context of where people are coming from, understand, you know, what their exposures are, what their mindset were. And, and, you know, I'm not saying that I have all the tools for this, but at least I've knit together a network of other professionals that I can send to and say, Hey, you know what? It sounds like you're dealing with a ton of little tea trauma, you know, why don't we get you to a trauma specialist that I know so that, that you can do that, because until you're emotionally healed, you're not going to be physically healed, right? And, and so, it's just, you know, I think it's so important the work that that people like us do, because we're really in the business of improving lives, right? Not just improving numbers. Yeah. Well, helping people to, to have agency, like you said at the beginning. So when you made this transition and even to this day, and we're going to get into the nitty-grime, just guys hang in with me because we're going to go into the clearly scan, we're going to go into CIMT, we're going to talk about blood lipids and LP LP, all the things. But before we go there, how, how did your colleagues react? Are they sending you people now or do they, they walked you off as saying, Dr. Sanjay? Oh, yeah, he fell off the edge. Yeah, they, they tend to think I'm a little bit crazy, you know, and, and I guess maybe they've given up on me because before at least once a month, I'd get a, I'd get a text from one of my old partners and say, Hey, when are you coming back, right? Like what's going on? And, and I think it was just because they didn't want to, they wanted somebody back in the call rotation. They didn't want to be on Q4 call or whatever it was. But, but, you know, I think that, yeah, when I, when I talk to cardiologists, it's, it's kind of like a, Oh, bless your heart. Good, good for you, but I'm never going to do that, right? And, and, and, yeah, exactly. And, and that's cute. And there's always maybe an undercurrent of, you're going to wake up one day and realize that you've wasted a few years of your life. And, and then you're going to come back. And hopefully, and, and this was something my, my, the, the, the administrators at my job, when I, when I turned into my resignation, said, Oh, you're going to be begging us for a job in two years. And I'm not sure if there's going to be availability. And I was like, so the admin told me and I said, Okay, maybe this is what I said, I literally said, maybe, you know, but at least I know that I'm on my right path, right? And, I'm doing what I want to do. And so, and for me, just like I was saying, you know, like, like that one, you know, I'm going to run to that crack or that tree or whatever. As I start to accumulate outcomes and clients and patients of mine, you know, that's where I'm like, Okay, you know what, I think I'm on the right path here. God is instructing me the universe, the algorithm, whatever you want to call it is, is moving me in the right direction because I know that I've gotten, so, you know, hundreds of people off of blood pressure medicines. And we have a much more intelligent discussion about the necessity of statin drugs. And I've gotten, you know, hormone balancing and neuroinflammation and all these things that people honestly would have just pinballed around medical specialists for, like we can just, you know, with a with a lifestyle and diet kind of approach, I think now I completely believe that about 80% to 90% of the medical things that people present to me with can improve and can improve significantly. Then the 10 to 20% of the time I have to put my thinking head on and do some advanced testing and things. But, you know, so, so yeah, it's definitely been an evolution. I'd lie if I say there weren't days where I'm just like, oh, I wish I could just go back life was so much simpler, right? And, but honestly, I feel like I'm on the right path. And, and it's, it's, it's almost one of these inevitabilities where you just feel like you're moved by a higher power. You know, I think of it like one of those people movers at the airport, you know, what I mean, where you're walking in the platform is moving or whatever is it? That's where I feel I'm at right now is that even on my worst days when when I'm like, oh my gosh, self-doubt and, and the devil on one side of the angel on one side, you know, the devil is louder than you. But, but I just I still feel like as I as I see people do better as I as I help people avoid heart attack and and avoid, you know, going back to the cath lab, you know, I the cardiac procedure suite, like I just feel like, you know, this is the right thing. And there's a thousand interventional cardiologists out there practicing interventional cardiology. But there's like three interventional cardiologists practicing integrative medicine, right? And this is really the power behind what we should be doing. So yeah, it's been an interesting journey for me for sure. I'll bet. Well, it's kind of like when you know, you know, and you can't and see what you've seen, like all of those, all of those clichés apply here, like, you know, to go back to being an interventional cardiologist right now, I think it would be a struggle. And it was, I mean, towards the end of when I was staying on because it wasn't like I, you know, leapt, jumped headfirst without, you know, trying to create soft landings, but it was a struggle for a while. And I think, you know, that led to burnout, you know, in psychology, they talk about the ought self, you feel you ought to be in who you are, right? And so as that, as that split kind of widens that that fueled my burnout quite a bit. Until finally, I was like, you know what, this is the path that that has been chosen for me in Hindus. And we call that your, your Dharma, right? Your purpose in life, like your purpose in life is to find and share your purpose in life. It's kind of a crazy thing, right? And I'm like, you know what? This is chapter three or chapter four or chapter five of my book. And you know, the worst plan B.I. have, I can go back to being a cardiologist one day, but this is really what needs to happen for my continued evolution as a human. So I just kind of, you know, gave myself to the ocean and we'll see what happens. Love it. Okay. So let's get into some technical stuff here. Let's go. Let's do it. Let's talk about scanning, right? Let's talk about the CIMT, which is the cardio-intimum video. Carotid intimumumidial thickness. Yeah, that. And the clearly scan, which is the CAC, right? Well, clearly is a specialized type of a CT angiogram, which is different than a coronary calcium score. So let's just start. Let's talk about our three. Let's go through all of them. And I'll start with the carotid intimumumidial thickness. So CIMT, carotid intimumidial thickness, is looking at one particular layer of the blood vessel. So when we look at a blood vessel, there's got three layers. There's what's called the intimum, which is the interlining, the media, which is the middle and the adventisha, which is on the outside. The adventisha, easiest. It's mostly the connective tissue. It's the stuff that makes vessels rubbery and being able to kind of expand and contract when you feel your pulse pulsing. That pulses as a result of the strength of that. We want that. We want, yeah, you definitely want pulses. You definitely want that. No, I mean, if you want, you want the flinch. You want sponginess, right? That's what stiffens with age. Yeah, well, stiffening. We can talk about stiffening, I think, but, but yeah, because there's a neurohermonal part of stiffening and then there's a mechanical part of stiffening both. So on the outside is, let's just say the elastic component. On the middle, that's really kind of the meat potatoes. That's where you have a lot of the cells circulating, vascular smooth muscle cells and dendritic cells and immune cells and modulators and that's where foam cells come in and form a thrish process. And there's the intimum, which is kind of the barrier. It's kind of like the skin of the blood vessel that's layered on top by something called endothelium, which is a single cell layer of thick group of cells. And I kind of think of it like old shag carpeting on the inside. Anyway, a lot of detail. Good shag carpeting. Yeah, it's like that fun stuff that that I had in my house growing up. So when we talk about crotted intimumedial thickness, as I mentioned, the media is kind of like I consider it like the workhorse of the blood vessel in terms of the active biology where it happens. And so that's where you can get thickening, plaque formation, star, it's all of these things. So when we look at a crotted intimumedial thickness, we're doing an ultrasound of the crotted artery. The crotted artery sits in the neck whenever you watch a detective show and they check if they push on someone's neck to check if they're alive, right? That's that's the crotted. Just as a quick safety public service announcement, never measure, never measure both crotted at the same time. You'll pass yourself pack pass out, right? So one at a time, just I always put that out there. And you'll use your thumb because you'll use your you'll measure your own yeah, well, when you're measuring on somebody else, yeah, because you have a pretty significant vestuature in your thumb. So anyway, so C-A-M-T is looking with ultrasound at the crotted artery and getting a measure of the thickness thickness, then assessing as a surrogate of plaque because you can't tell the difference, but there are associations with an increased C-I-M-T and atherosclerosis. And remember that process of plaque formation, what we call atherosclerosis, is non-pregnist. It happens everywhere, right? There was an old I think it was a WC field sign. I'm not precious. I hate everybody the same, right? So that's what I say about atherosclerosis is that if it's happening in one territory, it's very likely it's happening in others. And in fact, the literature shows it's about a 1.6 to threefold increase in coronary risk if you have a C-I-M-T. So they're not a 100% correlated, but but it stands to reason if you have plaque in your carotids, you're probably going to have something building in your heart. So how much plaque is significant? So when we talk about significance in the interventional world, we talk what we're really worried about is flow disruption. So I've got three daughters who have long Indian hair and so I say there's always some amount of hair in their shower drain, but when it gets to a certain critical mass, then the water starts to back up and I have to go snake the drain out, right? So for in the arteries, that flow limitation happens around 70, 70%. That's when you start to see kind of a reduction of flow and a pressure drop, which is what we'd look for across the vascular. So that is what's considered quote unquote significant when we look at coronary arteries for stenting or whatever, like peripheral vascular renal arteries wherever I used to put stents in, 70 is kind of that benchmark, that metric. But what gets hidden behind that is that when we look at the blockages from 20 to 50%, these are less mature. So they're not they have what's called a thin fibrous cap. These are the ones that are likely to rupture. These are the ones that really just metabolically angry on the inside and they have a lot of inflammation in them. So those are the ones that will cause acute cardiac events. And so this is where a lot of times we see some discrepancy in testing and we'll get back to calcium scores and all this stuff. I promise in a moment, but I think it's a good point. Yeah, you know, we've heard of, you know, like, oh, did you hear about, you know, Bob, right? I hate, I'm sorry, if anybody out there's named Bob, right? I hate to put that out there. But, but, you know, Bob went to the normal stress test on Monday and then had a heart attack on Tuesday, right? And so heart attacks must be caused by stress test, right? We we try to find these correlations. No, but what happened was Bob probably had a 30% or 40% plaque that was not flow limiting. Error go therefore you wouldn't see it on a stress test because stress tests are really only geared towards finding those flow limiting tests. But because it's the 20, 30, 40%, 50% lesions that are less moisture and rupture, the hemodynamic stress, the shear stress on that cap probably unroofed it and that led to his heart attack, right? So, okay, question before you keep going. So if Bob is an athlete, yeah. Is he more likely to have an event? Well, so, you know, that's in an acute setting generally of like a couch potato type person that like like like the weekend warriors where you see this a lot, you know, I always I live in Southern California and I'm always nervous about the first gorgeous socal weekend because that means that people and it's like when I trained in Michigan and and you know, we always worry about the first snowfall because you have people who are not doing anything for a long time. They're going out and shoveling snow, which is a very physically demanding thing here and socal. It have people go surfing or do endurance cycling that they weren't accustomed to doing and that was a huge hemodynamic stress on their cardiovascular system that led to then this event happening, right? So chronic athletes are a little bit different. So endurance athletes and I used to see a fair number of endurance athletes in my triathlon days. So, so we have this but there are adaptive changes that can happen. So your body gets more accustomed to these these forces of nature, these hemodynamic things that happen. Interestingly though, they are not immortal. Is that you see you can see premature coronary calcification and endurance athletes. You can see left atrial, left atrial stretch. So increasing in size of the of the chambers as a result of what we call the cardiovascular universe excessive endurance training and a lot of EET is called and in a lot of the literature that's described as running more than 25 miles per week. Now if you're a runner or an athlete, 25 miles is I mean for me right now, not something I would do, but it's not that much. And of course, different sports are different, right? Cycling is a different human and hemic stress load than running or swimming just to put it in the triathlon days. So, so we're learning a lot about these these athletic events and athletic endeavors rather and how they may differ. But you know, just because you're long-term athlete, you may be subject to other stresses that a couch potato wouldn't be right. So so nobody is safe, but that's why everybody needs to know their risk and that's why everybody needs to know their numbers and know their anatomy. Okay, another question for you is I have heard and because I'm just gonna go because I have a lot of people in a in a community. So, all these questions are bouncing around and I don't have the answers and I'm like I'm interviewing a guy. I'm getting the answers. So, if somebody has a CIMT score, let's say it's 23 or 24 or 25% or 30%, does that necessarily represent plaque or could the thickening of the wall be due to something else? I mean, generally, it's going to be some sort of athletic process most of the time. I mean, you can't have, you know, medial hyperplasia from from other like trauma can cause it. I had one one guy who was a surfer that took a surfboard to the neck and that caused a huge inflammatory response. You know, so but generally speaking when we're looking at CMT, yeah, I would say, you know, it's plaque and if it's bilateral, it's going to be plaque. And if it's, yeah, I mean, if it's bilateral, generally, you know, and you know, nature loves symmetry, right? And so generally, you're going to see it on one side of the other. That being said, the aorta, the way the vessels come off the aorta are not symmetrical. So, generally speaking, on the right side, you've got what's called the break is a fountain trunk that then splits into the crotted in the left and the right subplavian on the right side. Each has a different or on the left side rather. They have a different take off each one. So the crotted has a it's own origin and the left subplavian has its own origin. And that is to say that when we see vascular disruption or plaque, it generally is at what we call a bifurcation point or fork in the road because that's where the currents of blood flow get a little bit more chaotic and you've got pressure drops and things like that. So it's generally going to be at a bifurcation or split in flow that that will see these these plaques and things develop. But yeah, if it's if it's bilateral, generally, that's going to be arthroscarotic. And you know, that's not to say it has to be pretty significant trauma to see kind of a vascular response. It's not just like wearing a tie to work, you know, for 40 years, right? That's right. It's like, you know, if you took a seat belt, you know, and like a seat belt in a car accident or something, that's the sort of stuff we're talking about. Yeah, just to hop back though to complete our discussion. So CIMT ultrasound based, I think the strength of that is that it's non-ionizing radiation, right? So it's ultrasound. And so we're able to see, thankfully, the crotted is an easy enough vascular distribution to access that it gives us a good proxy. And I think that's why it's been pretty, you know, pretty established as a potential screening tool. And I know there are a lot of people in their offices who have CIMT measurements. And there's automated scans that can be done. So there's that. Then there's coronary calcium scores. So so when you have a plaque in your artery that heals, I kind of think of this like, you've got this angry mass of plaque. And the body says, you know what, I recognize something is going on. I don't want this angry hot mess to digest through the artery, which is essentially what's happening is that you're secreting and the these inflammation gone bad cells of arse secreting enzyme foam cells and macrophages are just inflamed angry heated messes. And you have to build a wall around the prisoners, so to speak. And so that's a healing response. It's called endotheptia epithelial to mesenchymal transformation EMT, where these circulating stem cells inside the the media of the blood vessel actually transform from stem cells into similar cells to the ones that create bone to osteoblasts. And so and so now they kind of build the shell of calcium in three dimensional space around that angry plaque. And that's actually healing. That's that you know, that's considered plaque healing. Just like stabilizing the. It's stabilizing the unstable area. And so when we do a crotted artery, sorry, a coronary calcium score, you're you're measuring. There's there's a unit called an Agustin unit. So you're measuring in how many units of calcium you have in the arteries. And that was a great tool back in the 1980s and 90s to be used to establish, you know, at a low level of radiation. So it is a CT scan. So there's x-ray involved, but it's a lower level than most scans. You know, in your arteries, this is what we see. And so the power of that is I can say, you know, again, let's go back to Bob, you know, Bob in your artery, the the the widow maker, you know, has plaque in it and the left artery has this and the right artery has this. So, you know, you can use that. We're talking about agency and motivation and patience. You can say, so this is what your heart looks like, dude, we need to be aggressive about fixing things and this, that, the other, right? And we need to be aggressive about getting on meds and and diet and lifestyle and all these things. And so it was a really great scan. And and I say and I say it was a great scan, because I think at the time that it came out as pretty revolutionary papers were written about it, you know, scanners popped up all over the universe. But now it's almost like a black and white television relative to the next generation of scanning that we have, which are these coronary CT scans. Now, a coronary CT is a dedicated cat scan of the arteries that allows us to image the heart arteries themselves. And so now we're not just saying you have calcium, but we say, but we can say, oh, you've got a narrowing here of 30% or 20% or 50% or whatever in a traditional CT angiogram, which is, which is what became very popular. And and and the cool thing about that is now that gives us insight not into what's just called the lumen, which is the opening of the blood vessel, where the water flows in the pipe, so to speak. But we can actually, which is what we see on a conventional angiogram, which is the test where I go in and take pictures of the arteries. But now we can get an assessment of the vessel itself. And if there's thickening of the vessel, which is not something that you can see on a calcium score, nor can you really see that on a conventional angiogram. And now we've taken that one step further with with this AI technology called clearly CLERLY, which is I think the the one test that as cardiologists, we've needed or not just as humans, right? That we've needed forever. Because now not only we're seeing the calcified plaque, which is important. But in the mind of an interventional cardiologist, a little bit less important because it's less likely to rupture. But what we can do is quantify the soft plaque. And we can actually see how much plaque do you have? Where is it located? It is all in one spot. And I think of it like a balloon where you can almost look at the wall tension of the balloon and eventually a rupture, right? Well, you can look at plaque size and you can look at lesion size and you can look at calcification, where it is in the spectrum. And you can assess how significant it is. And this is what a lot of people don't understand about calcium scores. You can have a zero calcium score and still have a ton of plaque, right? Because the plaque could just be non-calcified. It could be what we call a quote unquote soft plaque. So, so, you know, now with a scan like clearly, you're not only getting an assessment of calcium, which again, I would, I would posit is less important. But more importantly, we're able to quantify the amount of soft plaque, get an idea of vascular health, and now engage in either, you know, conventional medical approaches or diet lifestyle approaches. And we can actually regression of the soft plaque, which is I think is the important actionable part, right? Is that that through diet, aggressive diet and lifestyle interventions through, you know, for people who need them and not everybody needs them, but for people who need them, cholesterol, amount of high medications, you can actually see an improvement. And this is where, when we talk about cardiovascular medicine and longevity medicine, you know, I say cardiologist are like the OG longevity medicine docs, because most people die of heart, heart events, right? Of cardiac events. So, if you are stopping cardiac events, by definition, you're going to improve longevity, right? And so now we then can talk about, once you've talked about longevity, then you can talk about health span and making days better and kind of all this stuff, right? So, so this is I think a revolution in testing that I love. Now the downside to it is that, you know, you do need to have what's called IV contrast infused. So you have to get an IV and they have to put an iodinated contrast in you. And so for some people, you can have a reaction to that. For some people, if you have kind of poor kidney function, that can affect you. And there is a lot more x-ray. There's a lot more radiation, right? So this is in the test that you're going to want to have once a year, right? I mean, I think that there are guidelines on this, depending on, you know, the amount of plaque that you have in the distribution, when to repeat a study. But I definitely think as an initial scan, you know, the the bark is worth a bite here is that, you know, the just to be able to get a better insight is so much better. And I had a patient. So I recently implemented this, I well, I recently started a telehealth practice. And so I've got patients. And so I recently had a patient who on the outside, you know, he was, he's probably about 150 to 200 pounds overweight, was telling me, you know, symptoms when I walk up a flight of stairs, I get really short of breath. And, and you know, I'm having a hard time, you know, with breathing and activity and all these things. And in my mind, I'm prepping for the heart bypass talk. And a lot of patients might not realize that it's very emotionally disturbing for a cardiologist to have to have, or at least for me to have that talk. It's, it's an up people for me, right? Like because I become friends with my patients and I just, I don't want anything bad to happen. And so to have that talk is quite, is quite emotionally draining. And so I said, all right, but you know, let's, let's call him Fred. His name's not Fred, but we got Bob and Fred. So Fred, let's get clearly test for you. And so I can better define the anatomy. And again, this is a guy who on the outside, you know, looks like the poster child for cardiovascular disease. And we did the scan and lo and behold on the inside, he had like a 14% lesion in one of his arteries. And everything else looked okay. And I was like, wow, that's amazing. Now I can just focus on your blood pressure and focus on your cardiometabolic and plug you into the diet lifestyle program and really see some change. But you know, it really gave me such like the opposite insight that I thought I thought I'd learn how bad his heart was. But instead I learned how good his heart was. And that was very optimistic for him, right, kind of changed his mindset. So he's like, wow, now I don't need to be so scared. You know, I mean, that's not to say I don't need to change. But you know, that fear of God kind of left him. Now he's like, he became motivated and positive to say, hey, you know what? This was, you know, this scared me. This was my, this was my awakening. Now I can really work on diet lifestyle with you, Dr. B and get things moving. And he's done great, right? So, so, you know, you don't judge a book by a cover similarly, like with with cardiovascular disease, I've been humbled so many times by stories like this where I think, oh, someone's actually going to be okay. And they have needing bypass or I think someone's going to need bypass or standing and they don't. So it's just it's another great tool to not just look at your risk today, but also then to stratify what your risk looks like five, 10 years down the line. So that we can do appropriate diet diet lifestyle interventions that are based in science and have some credence of, you know, not some crazy nonsense trend or fatter. Whatever the new Instagram TikTok reel is, right? But do things that can actually have have effect and make a difference. So you would said earlier that the CIMT bears some relationship to what's happening in the heart, but it's not a direct relationship. Conversely, for someone like that who had a pretty clear, clearly scan, yeah, you would be able to extrapolate that to carotid arteries or would you also be doing a CIMT at that? Yeah, I mean, I mean, I need to look at the reason for the outcome, right? If he was having neurologic symptoms, then I, you know, like I would have probably just gone straight to carotid, but really we're we're looking through cardiovascular. And again, I mean, he's got a 14% lesion, right? And so he has he doesn't have nothing. He just doesn't have like eyes popping over my head like in the cartoons findings, right? So, you know, I think that, that, you know, because he presented with cardiovascular symptoms, that's why I went straight to a cardiac test because really like I said to the outside, listening to the story, I was worried about, you know, bypassing. In fact, I almost I wanted him to get an angiogram, but he insisted on the clearly. So I said, okay, it's just because I was able to schedule him quickly. But, you know, if someone comes in like what we call a primary prevention patient, you know, my, my dad had a heart attack at 52. I'm 48. I just want to make sure I'm okay. I run, I exercise, I, you know, I go to temple, I read the blind kids, I do everything good in life, you know, and I just want to get a sense of what's going on. Then, you know, then I might start with a less invasive test, you know, I tend to not want to irradiate people and particularly women because you're irradiating the chest area and breast tissue as sensitive. So I really use x-ray sparingly, but that's where I'm saying sometimes the bark is worth a bite, right? Or the bite is worth a bar or whatever. That's sometimes you just kind of push through the risks because you know that you're going to need, you're going to get such important information for him, for Fred, it was such a great example of, you know, going to the having the right technology for the right test, so that I could connect him with the best plan to move forward. Is there an age you think that like I, in many different things, different aspects of health, it can be helpful to have a baseline from when you're healthy, not wait till you have symptoms or you're sick. Is there an age where you think that probably for most people, it would be a good idea to get that clearly scanned on to get a baseline and then leave it along. Like if it's clean, then shelve it for a while. So yeah, I mean, I think that when we look at longevity, right, in the longevity space, there's two ages that kind of pop out in the literature, 44 and 60, right? These are two years where we just see kind of big shifts. And so I think right around then and and you know, if you think about the average life expecting scene in the United States, I think I looked it up a few days ago, is 79.2 years. So yeah, so middle age is like 39. That's kind of so, sorry for the listeners, but that's just numbers, right? That's the math is mathing here. So, so I think, you know, maybe not necessarily a scan, but certainly a clinical evaluation around 45. I think it's a great 45th birthday. In fact, that was the first time I went to see a doctor for me. And when I kind of made my own life changes was I kind of felt like 45 was the official birthdays of more birthday of more yesterday's than tomorrow. Tomorrow's right? So I said, you know, I need to kind of take my health serious now. And for a lot of people right in the world, that's where you're like mid career, you're maxing out your earning potential. You've got your family, you've got your kids, you know, you're you're doing all these things. So that's also kind of a time where you stand to have the most to lose, right? If something bad were to happen. So for me, I loved getting the patient in in their mid 40s as a cardiologist that says, you know what? I nothing is wrong, but I want to keep things moving, right? And I want to keep things going. And that's where you can do things like, like, you know, you don't necessarily have to jump to a scan. I think Acarodid is a great, but great test in that sort of a population. But doing things like, you know, I don't even call them advanced lipids anymore, but comprehensive lipids, doing a cardiometabolic analysis, looking at L.P. Little A, looking at markers of vascular inflammation. You know, I think that's where that kind of well exam kind of comes into play because if you can make those little one or two percent lifestyle changes at 45, then 65 is going to look a whole lot different for for for you than it would otherwise if you stayed on the path that you were on, right? So so I I like those mid 40s patients to come in and say, you know what? I just I want to live forever. I mean, not live forever, right? But I want to live like really well. What do I need to do? And I think that's a great time. And then, you know, with those patients, I might see them once every other year, once every three years, you know, but but keeping them on that straight narrow path. Because I think that's one of the main differences between the conventional model and the and the functional model, right? Is the conventional model says, you know, we're not going to see you until you're broken, right? Yeah. No, 100%. We're going to we're going to just be a 100% crisis management. And and that was, you know, when I saw a lot of patients come into their 50s with heart attack and and mostly guys and I'd say when was the last time you saw your doctor and they'd be like, oh, when I got my high school football physical field out, right? I mean, there's like a long time in between. So so I loved getting those kind of patients and and you might not do a lot of interventions in the sense of balloons and stents and things, but you can keep people on the proper path and integrative cardio Sunjay can put put, you know, interventional Sunjay out of business that way. But that is just that's just the smarter way to approach this. As we head into the new year, I'm thinking less about drastic resolutions and more about choosing better daily inputs and protein, of course, is one of them. Like many women, I'm working hard to hit my protein goals for muscle metabolism, bone strength. But I've also learned my lesson with proteins. You really have to dig for the truth about their ingredients. I've read that two thirds of protein powders tested had more lead in a serving than California safety limits. Not exactly the morning ritual I had in mind. Now, this is why I switched to puri PW1. I used the bourbon vanilla made with real vanilla seeds from Madagascar and it is so smooth and naturally sweet that adding it to my yogurt bowl or shake actually feels like a treat. Plus, for every scoop, I know I'm getting clean, high quality way that supports my strength goals. Puri doesn't just say they're clean, they prove it. PW1 is third party tested for more than 200 contaminants. And puri was the only brand that earned the clean label project transparency certificate. All you've got to do to get it for yourself is go to puripuorri.com forward slash net and use code net for 32% off your first subscription or 20% off anything on the site. And I promise you, everything on that site is just as clean and just as tested as the protein powder. What about women? Because when women go through menopause, things start to shift. All of a sudden, we get a lot closer to being small men and premenopause. Yeah. Like cardiovascular disease risk goes up. And are you making a distinction? Because you mentioned hormones earlier, would you make a distinction between a woman who is and we don't need to argue the benefits or, you know, whether people should or shouldn't do hormone replacement. But there, I would imagine there's a distinction between the woman who's on hormone replacement and the woman who isn't. Oh, for sure. I think we, would we add maybe another goalpost for women postmenopause to see where they're at? Because things can shift pretty fast. Well, and I think postmenopause is even a little bit later than I'd like. And premenopause, or purimenopause, which is a very difficult time to define. Unless you're a cardiologist, because we see this all the time, right? You get your labs done and your LDL, which was the 80 forever, bounces up to 100, right? Yeah. And the primary care doc, or if you're seeing a cardiologist, says, oh, you must be doing something differently. You must be having some dietary indiscretion, or you must be exercising more. But really, when you see that jump to go from 80 to 100 is a 25% increase, right? If my math is right. And really what we're seeing there is not the only thing you're doing is not forming enough estrogen. So you get that, I mean, that's, that you get this, I know, how do you, right? How do you? And so when you see that initial estrogen drop that is part of the premenopause, you see this LDL bump. And as I look back in time, you know, you always face palm about, oh my gosh, all the things I wish I knew then that I didn't know now. But that's, I think, one of the earliest signs of purimenopause, premenopause is that LDL bump that we see, it's almost never enough to elicit therapy. Like it's never enough where I would say conventional sun j would say, oh, you know what, you need to go on a statin for this. But it's enough that you see a percentage jump. And so that's the time when, and this is where cardiologist, conventional cardiologist probably there might be one on earth that would do this need to have the discussion with with these pyramid opposal premenopausal women about, you know, now might be the time to start doing comprehensive hormone panels and potentially adding in estrogen because as I see it, and I've had several, you know, talks with hormone people is that estrogen is as important for, you know, hot flashes and all that crap. Yeah, there's some benefit to that. But when you look at bone health or cardiovascular health, right, it becomes hugely important. Astrogen is protective against cardiovascular events. And so that's why, as you mentioned, as you see that drop off an estrogen woman become little men, you know, meaning that their, their cardiovascular risk jumps up precipitously because they don't want to longer have that protective effect of estrogen. And so we are, you know, right at the front line of seeing this, and I just didn't know how to read the tea leaves correctly there was, you know, right, when that happens, you're like, okay, you know what, let's, let's, you know, either meet with an OBGYN or someone who's like a, a B-H-R-T specialist or something who can start to have that discussion. And, and you're going to see so much improvement, not just in cardiovascular outcomes, hypertension, lipids, atherosclerosis, all of these things. But, you know, bone health and longevity and brain health, I mean, every receptor in the body has, every cell in the body has sex hormone receptors, right, essentially, with the exception of maybe red blood cells. But, but, you know, these are important things for longevity, but also for health span as well. And so, you know, I think cardiologists have been front line, unknowingly, at that, at that, you know, that, that transition without realizing that we, it was within our power to interpret this and act on it. Yeah, well, you wouldn't hope that somewhere, someone is listening who runs a school like the cardiology program and saying, holy shit, we need another module. Yeah, I mean, it's for women, you know, for your women patients who are coming up, but, but this is the thing, if you weren't taught it in school, you don't know, we're victims of our, we're all victims of our training, right? And, and when you look at historically in the cardiovascular literature, I mean, there's just famously, I think it's so, so funny, is that probably about a year and a half two years ago now in the Journal of the American College of Cardiology, they had a review article about the differential effect of stress in women. And it was like the first time that they acknowledged that women are different than men, you know, in, in cardiology. And now you're looking at cardiovascular trials, they're including more women and all these things. But when you look at all the data, all the science that our current fund of knowledge in the conventional world is based on, those trials were like 80% if not more men, right? And, and I mean, I hate to say it this way, but women aren't just men without penises, right? Or whatever, like, like, it's a completely different physiology. And so, you know, this whole realm of, and if you talk to old crash-d cardiologists, they will still do this day say, oh, why do we need women's, you know, women's cardiologists, you know, women are the same as men. I'm like, no, they're not. Like, like, they're so different, dude, like, come on, are you serious? Like, the reason why women were excluded from research is because they're so different from men. Otherwise, they wouldn't have been excluded. Yeah, you have four different women a month. And it's, it's so complex, right? And if you talk about the life cycle of a woman, you know, there's pre-pubrital, pubertal, fertility age, pre-menopausal, period menopausal, menopausal post-menopausal, I mean, it's a, it's a wild ride to be a woman, right? But I mean, I like, you know, we know that you know, because you're surrounded by, I've got three daughters in my wife. So I, I have a front line to this all the time. But, you know, we, we need to, I think, look at hormones a little bit differently. And I think of it like vitamin D, right? Like vitamin D, you have a low level. So we supplement it for the potential health benefits, bone health and hormone health, and all of these things. Similarly, with estrogen, I think there's still this WHI, women's health initiative cloud that hangs over that says, you know, unless you're having really bad symptoms of hot flashes or, or whatever, there's no reason for hormone replacement. But in fact, with vitamin D, you're, you're treating a number for all these other benefits, right? So if you're, if your estrogen is low, and you're already seeing an LDL bump, well, the easiest way to treat that LDL bump is to give back some estrogen, right? And there's all these other health benefits, brain health, bone health, and you can probably talk my ear off about all of these things, right? And so we have to frame that conversation differently, frame the mindset of cardiologists differently, and realize that again, we are front line to a battle that we didn't even realize we were at the front lines of. But we also have such a powerful ability to heal. And you know, and that's why, you know, I'm working with some other cardiologists to create like a functional cardiology curriculum and training pathway, because, you know, we see these things and we need them. And I think of all the, of course, you know, to hammer all the words, looks like nails, so to a cardiologist, I'm saying, boy, the single specialty that I think would really move the needle the most for humanity if we had a more functional mindset is cardiovascular disease, right? Is cardiology. So anyway, that's, I love it. That might just be me justifying my own existence. I don't know. No, I think it's, it's, I mean, I was hoping you were going to say at some point that you were going to be spreading this, oh, yeah, other people in the field. So let's talk about another topic that is wildly controversial. I mean, there's so many of them, right? Let's talk about cholesterol. Yeah. All right. So the cholesterol is bad versus the, you not only do you need cholesterol, but there's no high cholesterol numbers that are bad enough that you should ever do that you should ever need a statin for. And like there's these, you know, the world is just. Yeah, it's polarizing, you know, like, like, you know, air is good, air is bad, fire is good, fire is bad, right? Like, so number one, right? Cholesterol is a necessary molecule for existence hormone back bone cell membranes, all of these things. So, so yeah, brain, you know, all these things. Number two, the majority of yourselves have the ability to synthesize their own cholesterol when needed, right? So circulating cholesterol and cellular health, I think are two different things, right? Okay. Three, and this is what I think a lot of cardiologists don't realize, or they don't see things correctly is when we look at the dietary, the contribution of dietary cholesterol, meaning if I eat a thousand eggs, right? How high does my cholesterol bump? It's actually not that much. And in fact, it's in the, in the evidence, right? In the literature, now they're saying it's not a big contributor. So I say, okay, if diet, which we took as the major reason for why cholesterol was elevated, right? If diet has taken out of the equation, why do we have high cholesterol at all? Mm-hmm. Right? Like, if people are eating low cholesterol diets and things are, or, I mean, even if they're not eating low cholesterol diets, if we are literally saying to people, it doesn't matter what you eat for your cholesterol, why is LDL elevating? Right? And this is where I think the conventional world is right for the wrong reasons. I think that, I think that LDL, so to be clear, cholesterol is a sterile molecule. It's not soluble in water, so it would be like a little oil bubble floating on top of a glass, right? Of oil and water. So what do you need? You need particles, like school buses, to shuttle them around. And that's really what LDL is, low density lipoprotein. And on the, on the vehicle, you have these little receptors, and one is called APOB, which a lot of people are, or people are getting more familiar with. And that's like the sticker on the car that says Ford or Toyota or whatever it tells you that this is an atherogenic particle, a particle that can cause cholesterol synthesis, right? Or cholesterol platformation. And so you have APOB receptors and LDL receptors on various cells. And the reason that that cholesterol gets transported around is that the cholesterol is generally supposed to be incorporated into the cell membranes. But you have so much cholesterol, right, that it gets taken in. And then, and then you have, it gets damaged by reactive oxygen species and becomes oxidized and then forms plaque and all this stuff, right? So, so in my mind, you know, I think that there is little doubt that elevated LDL is associated with cardiovascular disease, right? That's just, that's just there. Now, I'm going to stop you right there. Yeah, because before you go on, there's another conversation about VLDL and oxidized VLDL. And there's big fluffy LDL and little BDLDL just because before you keep going, I know, yeah. So there's types of LDL. And this is where, so this is where advanced lipid or I call it just comprehensive lipopanels can be helpful. Because we get a sense of LDL particle size. And so I call them big and bounties and small and stickies. So you can have big bouncy LDL's large point LDL particles that are less atherogenic. And then you can have small dense LDL, which I am blessed to have myself. I've got the smallest LDL particles I've ever seen. And, and those are the ones that are more atherogenic. And the answer, the, the question is then why? And this is again, where cardiology is right for the wrong reasons is that, you know, when we look at particle size, when you get these small dense LDL's, that tends to happen in people that have cardiometabolic dysfunction, people who are insulin resistant, all these things, you get these small particles that are more easily oxidized. Oxidized is rusted basically, or damaged. And what does your body do with damaged cells? Well, it tries to get them out of circulation, right? So it pulls them out of a blood into the cell. And when, unfortunately, when it happens in the arteries into the media, where it forms a foam cell and plaque and all these things. So oxidized LDL is, I think, a very important metric to kind of look at, not just for, for the state of, of what your cholesterol is, but also the state of your reactive oxygen species, and, and what the, the redox status is, and what the imbalance looks like there, right? So you're, you're damaging these LDL particles. You're turning them into dams, right? Damage associated molecular patterns, and you're activating the immune system. And atherosclerosis is an immune mediated process, right? So, so we have these now advanced metrics that you can check oxidized LDL, oxidized phospholipids, even oxidized L.P. the L. is something that I've seen described now in the literature. And, and what that does is it takes a bad thing and makes it really, really bad, right? And LDL, why do we focus so much on LDL? Because in the 80s, that's what we could calculate, right? But, but there are total cholesterol particles, they're what are called HDL high-density lipoproteas, the cruel, good cholesterol, they're like the cholesterol scavengers. And then you have this entire population of LDL, you know, which is low density, you have the LDL, very low-density, ideal, intermediate density, lipoproteins. And all of these are atherogenic, we just in the 80s didn't know that they existed. And so they didn't become part of the standard panel, standard panel, the total cholesterol, HDL, LDL, and, and triglycerides. So then there is this metric now of non-HDL cholesterol that that was assessed. And essentially that's in my mind kind of very congruent to what we think of APOB cholesterol. APOB, as I mentioned, is like a cell surface protein, it's like a marker that sits, because you can't just look into a microscope and it says LDL and HDL on there, right? You have to look at the tags that it has on the cell surface. So when you have an APOB particle, that means that it is one of these atherogenic particles. And so it kind of more completely describes the entire pool of LDL particles, sorry, lipid particles, lipid transport particles, that can be linked to atherosclerosis. And some people, if you have familial issues or genetic types of hyperlipidemia, you can actually have low LDL and high IDL in the way that the biochemistry works. So, so an LDL is an imperfect assessment. So you really want to look at either non-HDL, which most commercial labs will run, or APOB, which is a test that you can run cost about maybe 10 or 15 bucks, to get a sense of what's going on. Right? Was that that we exhaust the LDL talk? So in this day and age, if you're sitting with your cardiologist, you want to kind of push them a little bit and say, but can we look beyond just the LDL number, or is the LDL number enough? No, I know, no, I think that it is. It's not like on the LDL, the way we do on the oxidized. Exactly. And so I think that, you know, looking at the LDL particle size becomes important. I've had people that have familial hyperlipidemia, so they had familial genetic polymorphisms that led to their LDL cholesterol being an excess of 200. And they had very large buoyant LDL particles. And with those patients, I always scan them. I do it clearly, or a CT angio to take a look at their arteries controversial. But for me, I'm trying to keep people alive for as long as possible. So I get that baseline scan for them. And lo and behold, they'd be in their 40s with these large buoyant LDL particles, like in an ungodly high number. And their arteries would be okay. They didn't have that much soft plaque because they had buoyant LDL particles, right? I've had other patients with kind of small to normal size familial LDL hyperlipidemias with LDL. And I've had to send them to bypass it. The youngest was 31 years old, needed a five vessel heart bypass. So I think that looking at LDL alone is not, you know, at least in 2025, when we're recording, is part of the equation, but it's not the end of the story. Right? It's like when you're like my kids, I mentioned I have daughters, they say, oh, I'm going out. Right? That would never be a sufficient statement, right? Who are you going out with? Where are you going? Are there guns and drugs in this involved? You know, does the person driving you have a criminal record? Right? There's a ton of follow-up questions that need to be asked, right? So similarly, like with the LDL particle, with a regular lipid panel, I think there's so much more now knowledge that we have and so much more testing that's more available for us to get a more complete picture of what's going on with our patients and our clients. And so looking at APOB, LPLL, all of these then kind of added into the tapestry and the mosaic of that person is an individual for me to be able to say, okay, you know what, your LDL is low, which is good, but your LPLL is high. So we still need to do this, right? Or the other or, you know, or, you know, getting back to if diet isn't the source of cholesterol, where is all this cholesterol coming from? Well, LDL can be in a cute phase reacted, right? So, you know, maybe there's a ton of inflammation happening somewhere. There's, you know, bascon from maybe there's glycocalyx injury, maybe there's toxin exposure that you don't realize, right? Maybe there's chronic mold, maybe there's some ongoing smoldering chronic bacterial infection or viral infection that's at play here, right? I mean, we have to look beyond the, if I lower LDL, people get better, which is what the conventional model kind of thinks. And again, I think we're right for the wrong reasons, but we're not getting to the why, right? Why is cholesterol high? What's beyond? If diet isn't the cause, then, then what's the, what's the deal? So that's where the body making it. Yeah, exactly. That's where that's where the cardiovascular metabolic comes into play insulin resistance and looking at all these other metrics, because once you start to improve that, then kind of these energy blocks get unstuck and then the body works the way it should, right? So, you know, I can't say that happens in everybody, but I certainly know in me as my end of one, as I started to improve my body composition, lift more weights, eat fewer processed foods and all that stuff. I mean, I'm not saying I got back to normal because genetically I'm cursed, but I was able to go on a much lower dose of stat, and yes, I'm on a stat, as a cardiologist, I feel that it's important for me. It's a personal decision, but, I know that I'm doing what I can do to look at my numbers, look at my risk and reduce things as much as possible. Yeah, well, I mean, so you bring up the next hot topic. So, first of all, just to recap, a little bit, when it comes to cholesterol numbers, what you're looking at, it's the details, the devil's in the details on the cholesterol numbers. You've mentioned LP L.A. a couple of times, maybe explain to the audience who are not familiar with LP L.A. what it is and what it means, and then we're going to dovetail into the dreaded statin discussion because it's another, you know what I mean? It's emotionally charged. So, LP L.A., yeah, we can hit that one pretty quickly. So, as I mentioned, on the surface of these LDL particles, we have a ton of cell surface proteins, their receptor ligands for LDL receptor and APOB and all these things. And one of them can be this lipoprotein little A, it's called. And essentially what that is, it's a structural protein, so I mean, imagine this is just a blob of jelly floating around. So, you have to have proteins to give these cells structure. So, it's a structural protein, but it significantly increases the atherogenic risk of that particle. So, it's like taking something bad and making it worse, right? So, it's like, what is it like, you know, riding on a motorcycle and then tearing off the sleeves of your leather jacket, right? All of a sudden you look more like a badass, right? So, it's kind of like that for these LDL particles and it's something that's been around in the literature for a while, it's probably been known about for 20 years or so, but just now we have these commercial assays available. And the remarkable thing is that it's a genetic mark of cardiovascular risks. So, you can have somebody with a low LDL but has an high LPLL A and they're still at risk famously that that personal trainer on the biggest loser, I can't remember his name, but he had a heart attack. This is someone in the prime and working out and all this stuff, but he ended up having a high LPLL A knowingly, right? So, now we're seeing about 20% of people in a general population will have an elevated LPLL A in African American populations, it's about 50, so specific to their group. So, you know, I think it's an important marker to assess. Generally speaking, it's a one and done, so you just check it once and it will be elevated. There are some medications now out. Well, probably phase three or phase four clinical trials. A couple were reported at the American Heart Association meeting last year that show a reduction in LPLL A, so therapeutic for it. They're like these antibody medications, like I can't remember the name off the top of my head. Not the SGL. SGL T2 is a different, different medication. Yeah, that's for diabetes and stuff. Or you may be thinking of the PCKS-9 inhibitors. Yeah, those are injectable. Those work to help prevent the degradation of the LDL receptor. So, you have more of these hungry, hungry hippos on your cells. That's a different mechanism than this. But the point of that being is that there are therapeutics. We don't know completely. We're not sure with the outcomes data where it would be, you know, okay, the first step of any cholesterol medications, like the PCKS-9, so it's number one, does it change the biomarker that you're looking for? So, does it drop your LDL for PCKS-9? Does it drop the LPLL for these medicines? And number two, does dropping that medication have the intente- or dropping that biomarker had the intente- of fact, right? Because we learned, I think it was in the 1990s or so, there's this APO-A Milano. It was this some Italian village outside of Milan, these people live forever. And so they learn that, oh, they've got this special protein. Let's just isolate it and give people a ton of it and see what happens. And turns out, you increase their APO-A Milano level, which is what you're looking for. But they also died faster, which that clinical trial will stop, right? So not good. So, you know, now the outcome trials will come out. So there may be some benefit. The PCKS-9 inhibitors, which are the genetic or the injectable cholesterol medications, do show a modest drop in LPLLL levels as well. So, the point of that being is that, you know, for most people, buy in large, you just check it once and you're done. If you do have some elevation, you want to optimize whatever else you can optimize, you know, and that may include being on a stat drug to reduce your stat. And I think diet and lifestyle is certainly a big part of that. And then, you know, wait to see what these new medications will show. Yeah. So, on the cholesterol, going back to the cholesterol thing, there's, you know, one of the big fights is there are people who just simply will not, but you know, there's, there was a study I read a long time ago that talked about, you know, in elderly populations where in cholesterol's were too low, which they seem to be getting driven down constant, like being driven down by the pharmacites. I mean, I don't know who, but let's just pharmacize. Keep dropping what the threshold should be. But in people over the age of, I can't remember if it was maybe 80, people with the lowest cholesterol rates had the higher rates of depression and maybe even cognitive decline. And so, based on that, you have a big population of biohackers who are like, we need to keep our cholesterol numbers high. And then you've got the other guys who are like, are you insane? You're going to die. We need to drop them down. So, where do you think the nuance? Yeah. And this is a classic case of, you know, cardiologists are from Mars and everybody else is on Venus because when we look at these LDL trials and, and, you know, and, you know, driving these rates down, we're looking at what's called MACE, major adverse cardiac events, right? So, we're looking at, you know, if I drop your cholesterol, the negative six, right, are you going to have a heart attack? And the answer is unsurprisingly. And again, like I said, I don't think there's a lot of discussion to be had about LDL and cardiovascular correlations, right? So, at least in my mind. So, you know, so these outcomes studies are looking at driving these LDL targets lower and lower and reducing cardiovascular events. And, and, you know, they're seeing it a reduction. And so, you know, that is what the guidelines and societies are putting forth. But what we're not looking at are other outcomes, right? Like the signal for insulin resistance and brain and, and kind of all these things. As you mentioned, the brain is like 80% cholesterol or some crazy, amount, right? Or, or looking at hormones. And, you know, if we, if you've got hormones, all have a cholesterol backbone. And now I'm dropping these, you know, the cholesterol particles super low, what's going to happen? Now, again, as I mentioned, most cells have the ability to synthesize cholesterol and are able to make the, the hormones that they need. So, it's not that big of a deal. But, but I will say as I think that cardiologists and, and the medical establishment in particular doesn't understand maybe not the, the, the, the, we have a good understanding of the major adverse cardiac events that happen. But we don't understand like the nuisance things that happen to patients, right? And, and, and the literature doesn't really point to that too much. So, there may be a concern about memory loss, right? And so, there was a database looking at, I think it was the all-hat patient database, looking at a hypertensive trial, but they looked at brain outcomes in these patients on, on statin drugs. And they saw, you know, no statistically significant difference, right? Is, is what they say. And so, therefore, there's no point, you know, it doesn't make sense that statins cause mental decline, but no statistically significant difference doesn't mean there's no difference, right? And, and this is what the nuance of statistics is that population-based statistics can't be applied to an individual, right? So, if having an LDL of 160 puts somebody at a 63, and I'm making that number up, 63% risk of a heart attack, that doesn't mean I have a 63% heart attack. I'm binary, right? I'm either 100% or zero from my cardiovascular outcome, right? And so, this is where we have to be kinder and gentler as we look at clinical trials is that is to say, okay, maybe an aggregate people do okay, but there's never been a 100% zero outcome of any clinical trial as far as I've known, meaning that if you don't do an intervention XYZ, 100% of people get it, and if you do do the intervention, 0% of people get it, right? So, now what we're doing is throwing the baby out with the bath water. We're taking people who are potentially seriously suffering from whatever outcome, back pain, shoulder pain, brain fog. I remember when I took a statin called Sympistatner Zokor, I got weird, trippy dreams, right? And so, we're not taking that into account for people and saying, okay, you know what, this is real, this can happen. And, you know, there's this famous trial that a study that was done that people put on the statin versus placebo, and the placebo arm was higher in terms of ad-reported adverse reactions than the statin arm was. And so, that was taken by most cardiologists to say, oh, people are just making this up. Come on, like a patient doesn't have something better to do than complain about something they're worried about. And if they are worried about something and it's not your drug, you still got to figure it out, dude, you can't just be like, go to hell. If you look, it's nonsense. Doesn't fit the narrative. Nonsense. Yeah, exactly. You don't fit my evaluate or my algorithm, what should happen, therefore, you're wrong. No, it doesn't make sense. And so, you know, so in this world of statins, yeah, there are camps of people who will have LDLs of 200 and say, I will never go on a statin. There are people who have LDLs of like 30 and say, I'm taking a statin every day. In fact, I'm just, you know, crushing up the tablet and storming lines of statin. I love it so much, right? So, yeah, these two camps, and I don't think, you know, and I mean, honestly, it's not a cop-outing answer, but, you know, I think what we have to do is take into account the belief system of the patients, right? Taking into account where they're coming from, why they're saying these things. Help them understand the science a little bit more. So, if someone is like a, I want to get my cholesterol down to negative 10. Okay, understand, you know, like you are an extremist in that standpoint. Let's talk about what this actually means. Or if you are a, you know, I sneeze in a blob of cholesterol comes out of my nose, but I still don't want to go on a, because my level is just so high, and I still don't want to go to statin. Okay, why are you coming at that? Help people understand the risk. I think either way you optimize diet lifestyle, right? Nobody can argue that. And then, and then, you know, see, you know, is it a block of being on a medication in general? Is there something about a statin? Because now we have several lovely statin alternative drugs injectable and oral and otherwise that can be used. So, is it just, you know, the depletion of coins on Q10 that you're worried about, the back pain, the muscle, you know, and I'm a power lifter. So, there is a study that shows that being on statins can lead to a 10 to 12 percent decrease in muscle function. So, for most, for most people, it's not a big deal, but when I'm squatting 400 pounds, that's a difference between 3,600 and 400, which is a huge deal, right? So, you know, is that what the block is? Like, where are we coming at this from? You know, and again, you know, you're never going to win a debate, right? You're never going to win when, when people are so zealous about whatever side they're on, there's very little that I can say that's going to change their mind, right? But you just, you have to kind of let them know, okay, you know, I see where you're coming from. This is where I'm coming from. Does it make sense to you? And I will say this, you know, people might think, oh, Sanjay's pro statin. I'm not pro statin. I'm just anti-stupid, really is what it is, right? Because on the flip side is that we use too much stat medication. Like, so in our universe, there's this in the statistical kind of approach to medicine and literature. There's this number that we calculate called the number needed to treat one of our absolute risk reduction, right? Basically, what that is is how many people do you need to treat to save one life? Very, you know, altruistic and great metric, right? And so when we look at heart failure and medications for heart failure, it's like one in 30 people. When we look at dialysis, which is the benchmark, I think it was one in 25, you do 25 patients on dialysis to save one, right? That was a Medicare benchmark. But when we look at primary prevention for stat medications, oftentimes that number, depending on the study and the population is anywhere from one in 90 to one in 200, which, you know, sounds less efficacious. But then when you flip that statistic and say, all right, so that means 89 out of 90 people who are on this medication will never get a benefit, right? That just means that we have to be smarter about our decision making, right? Or in, you know, like, and so, you know, I think that we have to look at this appropriately and say, okay, I get that you don't want to be in a statin as cardiologist and as vascular specialist and doctor be able to say, and you know what? I never, I didn't think that you would ever get a benefit from a statin, right? Or you may never get a benefit from a statin. But let's do a clearly scan. Let's see if you have soft plaque. Let's go to your cardiometabolic, so let's go to your insulin level. Let's pop you on a CGM. Let's look at your hemoglobin A1C. Let's look at your CPEPTI. Let's look at these other markers of metabolic and vascular information. Let's look at cholesterol degradation products and see, you know, are you an over absorber or are you an over producer and change things that way? You know, I mean, there's so much more that can be done. So, you know, I guess I'm, I am, like I said, I'm very much pro using all the tools that are disposal to have a much sharper indication for a cholesterol medication. And I will say that now, unless it's in a, what's called the secondary prevention setting where somebody's had a heart attack or had a stroke or had heart bypass, or I've had to fix their lower extremity arteries or something, I'm much more deliberate about that statin conversation. And in fact, there's a great tool put out by this really funky, you know, place you may never heard of called the Mayo Clinic. Yeah. That it's called the Mayo Clinic Statin Decision Tool or AID or something. Just Google it. And you can plug in your numbers and it'll say it'll show you a real pictograph of what your benefit would be and it'll, it'll say, I mean, most of the time when I plug it in, show it to patients, it'll say, given your age, your gender, your blood pressure, your cholesterol numbers, you know, four out of a hundred people may get a benefit out of this, you know, and so then it's up to that patient to decide, you know, or me to have that discussion with them. Do you think that you're one of those four people or one of those 25? What are the other things that we can look at? Let's get testing. Let's do a CIMT and see if there's something brewing, right? Exactly. Let's look at you start to dig. So then you dig deeper. And my favorite thing to do is, you know, I worked in a healthcare system where we had all their x-rays and cat scans available. I'd pull up an old scan that they may have already had and look up and down the vessels and say, hey, you know what, on the scan that you had two years ago, for your belly pain, which you probably didn't need to scan for your belly pain, but that's a whole other thing, is that I see evidence of, you know, calcification in your abdominal aorta, you know what, that puts you at a higher risk. So, you know, we don't need to use more testing. We can just use the testing that we've had to further risk stratify. Yeah, yeah, I know. I think that's so interesting. Okay, a couple of questions. I know you've got to go your presentation and there's 20 questions I want to ask you. Oh, no. Quickly, I'm not going to ask all 20. You mentioned that there are better statins. Do you want to just rattle off like the statins that people maybe should ask their doctor? Yeah, I think, I think the two that are probably the ones that should be used the most right now at Torva statin used to be brand-new blip ator and Rasuba statin brand name Crestor. Both of these are available as generic for people who are on a lot of medications or have had muscle aches and pains. Still around is something called pravastatin. It used to be called pravacol. It's metabolized a little bit differently more through the kidney. It's more water soluble. So tends to be that people get less of the aches and pains. Now, the tradeoff for that is that it's less potent. You'll need a higher dose to get the same effect, but it's still around. So I think those three are really the only three that should exist in my mind. Right. Because the pravastatin would that make it more appropriate for someone who, you know, your patient who's got LP little a very active kind of an athlete? Yeah, I mean, I don't want to compromise their athletic performance. Yeah, I mean, I would, if there's a dose response to the side effect, so I probably put people on like a low dose for Suva statin, you know, if that's what it comes to. But again, it would depend on the numbers and so many different factors. Okay. But, but there's options and different outcomes. There's options and there's non-statin options, as I mentioned as well. Okay. Oh, shoot, can plaque be reversed? Actually, yeah, with aggressive LDL control, some studies that it can. I think that part of that is diet and lifestyle interventions. So the the the funded, I'll say it this way is the funded clinical trials show that high dose of Rasuvastatin and some of these injectable PCKS9 inhibitors. So three or four papers on this can lead to reduction in plaque volume. So you can reverse it. I suspect that diet and lifestyle interventions reducing inflammation, you know, optimizing health, getting rid of insulin resistance can also do that. Nobody's paying for a clinical trial of broccoli versus placebo, but, but, you know, but, but I think mechanistically it makes sense. And in fact, that's what this next chapter of my career is based on. So I hope it works. I love it. All right. So if you could prescribe non medical habits for a healthy heart, what would be at the absolute top of the list? Sleep seven and a half hours at least of sleep a night. People don't realize that, right? So not so much movement, but sleep is huge for brain health, for maskier health, for cardiovascular, all the things. Yeah. And sleep quality, I would think, you know, because the other big caveat and sleep is the mouth breethers. And what when actually speaking which what are your thoughts on mouth breathing? Yeah. I mean, so you're reducing part of the benefit of nasal breathing is you're increasing nitric oxide, NO, NO is a potent vasodilator. You don't get that through the mouth. I actually suggest mouth taping to people quite a bit. So you take a piece of paper tape, go up and down when you sleep and people are surprised that their blood pressure responds to that as well. You know, it's a it can be a little bit, you know, if you're been a boxer and you have a hugely deviated septum or something, then you have to be worried about it. But as long as you have normal, normal nasal passages, people say my nose is plugged up all the time, but when you actually have to nose breath, it opens up. I famously, I when I was early on in my duck in my mouth taping experience, I did a peloton with duct tape across my mouth. I didn't realize that I wouldn't be able to drink water, but I made sure I breathe through my nose and my nasal passages were never more open than they were at that time, both of them. So don't use duct tape. Bad idea, particularly in a peloton, a 45 minute peloton, where I was dying for thirst, but it was just one of those mental things where I was like, you know, I just need to give this a go, you know, like a stupid, suffer fest nonsense. Not like our buddy that walked across Antarctica, but you know, a stupid little mini-suffer fest thing. But yeah, I think that nasal breathing is huge. And yeah, if you can do a mouth tape, you'll see blood pressure responses and all sorts of different things. Okay, a couple of quick fire questions, and I'm going to let you go. So we never got to the diet conversation, which I really wanted to get to. Well, we'll have to come back. We will absolutely have to come back and do a part two. But if there's a food to avoid, to avoid compromising hard health, and if there's a food to eat. Well, I think in terms of foods to avoid, I mean, I hate to be generic, but any ultra-processed. You know, so anything, I kind of think of it in arievedic terms, anything that doesn't have prana, anything that doesn't have a life force, right? So, so ultra-pros- anything that won't spoil, basically, it was, you know, is kind of like, you are adding to your life by taking on the life force of what you eat, right? It's kind of a weird way to think about what I eat every day, but it works for me. And so, you know, the ultra-process foods, our body doesn't know what to do. I mean, I would think, you know, anything that comes in a foil bag or a box is basically something. If we're looking at the worst things, Skittles have been shown, the candy Skittles, to have the highest glycemic impact and they're full of, you know, as of right now, they haven't taken out of the artificial dyes and things. So, I think that's probably the worst. I mean, deep fried foods. Yeah, I mean, deep fried foods, grilled meats, like all of that stuff, I think, you know, are horrible. Anything that you can get into county fair, probably is to be avoided, right? Like deep fried butter sticks and all sorts of craziness like that that people get at those fairs. You know, in terms of healthy things, I think it's stuff that your body is designed to eat, right? So, I go to straight to like broccoli and the cruciferous vegetables. I think they're not just healthy foods, but healing foods. So, if you're a fein, you know, eating five colors at every meal, right, getting the phytochemicals in, I don't think that extremes of diet, and this is something we can talk about maybe in our next, but like carnivore or vegan, I mean, I'm much more of a balanced person. We have, you know, all these different types of teeth. We have insiders and molars and all these things because our bodies were designed to eat different things. And so, you know, finding a happy medium, and that's what I preach in the program that I run is it's not all of this or all of that. It's some of this and some of that. And that's why I'm not super popular online because when you're moderate, nobody cares. You know, you have to, you have to know, you've got to eat all, you know, all fish eyes. You have to eat all, you know, liver, all this, all that. And our bodies were just not designed to do that, right? So, so yeah, so I think in terms of the single beneficial heart health thing would be, would be, you know, the cruciferous vegetables. I love those for a lot of different reasons. Beats are great. You have to be cautious about sugar, but they do have a lot of precursors for nitric oxide, which is another great thing. Hi magnesium containing foods. You know, all, basically it's like the stuff your grandma told you to eat, right? This is really kind of, you know, it's grandma wisdom I call it is really just going back to the natural stuff that your body was meant to eat. I love it. Thank you. But not excluding meat, fish, and chicken. So, no, I think that yeah, at least in my mind, yeah, is that while, you know, being plant forward is definitely good idea. You don't necessarily need to be planet exclusive, right? So, so I think that there's definite benefits to proteins and the right proteins don't see it here in you know, hot dog and tell me that meat is healthy, right? But, but you know, eating grass-fed, grass-finished, you know, not, you know, if you eat fish watching out for the high mercury fish, being cognizant of the mercury load, you know, even in chicken like antibiotic free and, and, you know, happy chickens and all that stuff, you know, it makes a difference because we are, we food, what are food eight? So, if you're eating in plain food, that's going to inflame you, right? I think that's where a lot of these meat-based clinical trials can go wrong, is that they're not not looking at the proper kind of the proper foods to be eaten. And so we're eating inflamed foods and we're getting signs of inflammation. Yeah, that just makes sense. You know what, if you eat a bad banana, you're going to get sick, right? Like that's just, it's just, it's just, I like I said, I'm anti-stupid, I guess. Yeah. You know, I love it. Well, Dr. Sanjay, there are, I have a whole other list of questions for you. So clearly, we're going to need a part two. Thank you so much for your time today. This has been really great and eye-opening. Why don't you let people know where they can find you? Yeah. And so, those who are interested, how they can learn more about your program? Absolutely. So you can follow me on Instagram, which is my primary social media route at Dr. Sanjay MD, so D-O-C-T-O-R-S-A-N-J-A-Y-M-D. In fact, it's right there down there. And if you want to learn more about working with me, you can go to www.legunamedicine.com. That's my practice. I run a health and wellness program online, so anywhere around the world, called Well12, a 12-week program that really kind of focuses on mental, emotional, spiritual, diet, sleep, stress, all of the 12 elements of wellness that that are outside of just lab tests. Or I'm taking on private patients as well. So if you want to work with me one-on-one in your state where I'm licensed, we can take that on again. All right, take that on as well. But it's, you know, it's just great. And really, my purpose in life, I tell people my midlife crisis is to try to heal at scale, right? And really kind of being doing diet, doing lifestyle intervention is so powerful. And, you know, if there is one takeaway I wish anybody had from our time today, it's just that you can change the narrative. It's never too late, and it doesn't have to be a pill, right? That's what I want people to know. Thank you. That's amazing. Thank you so much. This has been fantastic. Awesome. So great to be here. Hopefully I can come back soon. Absolutely. Hey, folks, just a quick reminder that all of the information presented in this podcast is for information purposes only. No medical advice, no diagnosing, no treatments suggested here. Before you try anything that you hear about or learn about here, make sure that you check with your medical provider.