Yeah. I think that’s right. And I think the lifestyle stuff is so huge. And you talked about the Pioppi diet, I talk about the Pegan diet. It’s essentially focusing on quality. So whatever you’re eating, the key concept is it should be high quality, meaning nutrient dense, unprocessed, whole real food. And you can kind of go up the chain, eating a filet steak is better than eating, for example, a bunch of bread, right? But it’s not as good as eating wild elk or eating a grass fed steak. So you can keep going deeper in the quality chain. The second is to really understand that food is medicine and that everything you’re eating is regulating your biology in real time. And three, it’s personal. Everybody’s biologically different and some people may be more carbohydrate tolerant than others. Some people may be more fat intolerant than others, and there are ways to figure that out, which is really important.

Losing some weight, if you’re overweight, can also help. If your cholesterol is not coming down enough, your doctor may prescribe the drug ezetimibe for you as well as your statin to further lower your cholesterol. This helps to prevent your intestine from absorbing cholesterol. As well as taking a statin, it’s important to keep active, eat well and if you smoke, stop. The son of two GPs, from the age of eleven he knew he wanted to be a heart specialist – fittingly, a desire inspired by love. His older brother, Amit, was born with Down’s Syndrome. Aged 13, he developed myocarditis after a stomach bug and died within days. Yeah. Yeah. It’s true. I mean, I think that the mechanisms are interesting. When you look at stress, what it does is a number of things. One, as you mentioned, increase inflammation. Two, it increases cortisol, which is a hormone that your body makes that actually causes your blood sugar to go up, your blood pressure to go up, causes your lipids to get worse. If you look at race car drivers, before and after a race, their cholesterol goes up a hundred points just from the stress. And not only that, but it actually causes your fat cells to store more fat. So if you eat under stress, there’s nerve endings that innovate your fat cells and the stress response communicates through your nerves and your autonomic nervous system to your fat cells and tells them to store the fat. So it’s kind of a big deal. And I agree with you. I think we are under such a barrage of stressors in our lives, whether it’s work, family stresses, financial stresses, COVID stresses, climate change. One in five people taking the drug have pain muscles and they stop it, right? 75% don’t take it after a year.

I’m on 80mg of atorvastatin but my cholesterol still isn’t low enough. What else can I do?

Malhotra clearly feels his duty is to his patients – to “reduce suffering”. He’s forthright, and long been unafraid of ruffling feathers. Most people get a total cholesterol HDL, LDL, triglycerides, but it turns out that LDL isn’t even that good of a predictor of heart disease. If you look at the average increase in life expectancy from taking statins from industry sponsored data, so we take that with a pinch of salt because industry sponsored studies, which are most of the statin studies in general are designed and the results are geared to kind of exaggerate the benefits and minimize the harms. But if we take that at face value, okay? Even- Ultimately, whether you choose to take statins or not, Dr Malhotra says, "Please, please, please do not neglect the lifestyle aspect, because eighty percent of heart disease is environmental and lifestyle related." He hopes people will read his book, consult their open-minded medical experts, and make informed decisions. Medical prescriptions are free in Northern Ireland, Scotland and Wales. They are also free for people in England who meet certain criteria, including people who are:

I mean, the behavior change factor is a huge thing. That’s a separate topic, which we could spend hours on. I’ve had BJ Fogg talking about behavior change and I talked [inaudible 00:59:49] behavior change. So the power of community and the power of group support or medical group appointments or shared medical appointments can be very, very effective. And we’ve seen this at even getting people to change their lifestyle is and the outcomes are almost three times better using groups than actually one on one doctor visits. We’ve done that at Cleveland Clinic. It’s really quite interesting data to see. One last question before we wrap up. I want to talk about, it’s a hypothetical patient because for me, let’s just say my cholesterol would be a little high and I do a coronary calcium score, which is a way of measuring calcium deposits around the heart and the arteries, which by the way, calcium is the body’s bandaid. Where there’s inflammation, calcium goes. Dr. Malhotra and I talk about the real factors behind heart disease, how to protect your own metabolic health, and so much more in this episode.Malhotra clearly feels his duty is to his patients – to "reduce suffering". He’s forthright, and long been unafraid of ruffling feathers. A Statin-Free Life contextualises his arguments. For example, he notes that cholesterol – a fatty substance made in the liver and present in all our cells – has important functions, and that LDL cholesterol plays a crucial protective role in our immune system. These are very powerful drugs and in the early days of statins, understandably, some people were concerned about potential undiscovered risks associated with them. They’re now one of the most investigated drugs, and we have lots of reliable data – some of which originated from work that’s been funded by the BHF – that show they are very safe and effective to take. How will taking a statin help me? As long as I’m on statin, they continue to gain weight. And there was one study in JAMA Internal Medicine a few years ago that showed if you followed people of similar risk profiles who were on statins and ones that weren’t on statins, over a 10 year period, the ones on statins gained more weight. And the reason for that probably is to some degree the illusion of protection. So again, this is about educating and informing patients-

Yeah. And Matt, so I caveat in that. What’s interesting is these are also most likely the patients that tolerated the statin and didn’t get side effects because those people are somehow weeded out of the trials. Often we have something called the pre-randomization running period before a randomized control trial starts where patients who don’t tolerate the drug or are non-compliant, they use this word, non-compliant, okay? Which doesn’t make sense to me to because if you’re enrolling in a trial and you volunteered, you are likely to be somebody who’s enthusiastic about taking a drug, right? So that doesn’t make sense to me, but very likely the people with side effects are weeded out within the first few weeks of a trial and then you then report on the results on the people who tolerate the drug, okay? So this is still a bias. So I talk to [inaudible 00:16:11], well, it’s more like those one and 83, one in 39 figures are people that tolerated the drug and were able to take it for five years.

Which in American [crosstalk 00:24:54] like, how would you translate that to American units [crosstalk 00:24:57]. Dr Aseem Malhotra FRCP is an NHS-trained consultant cardiologist and visiting Professor of Evidence Based Medicine, Bahiana School of Medicine and Public Health, Salvador, Brazil. He is a founding member of Action on Sugar. In 2015 he became the youngest member to be appointed to the board of trustees of UK health charity The King's Fund.