What You Need to Know About Heart Disease! | Dr Aseem Malhotra!

welcome to the plant-free md podcast with dr anthony chafee where we discuss diet and nutrition and how this affects health and chronic disease and show you how you can use this to optimize your health and happiness both mentally and physically hey guys just want to take a second to thank our sponsor at carnivore bar i don't promote many products because honestly all you need to be healthy is to just eat meat for those times that you're out hiking road tripping or stuck at work and you want nutritious snack that is just meat fat and salt if you want it the carnivore bar is a great option so i like this product not because it's just pure meat but also because i want the carnivore market to thrive as well and the more we support meat only products the more meat only products that will be available in the mainstream so if this sounds like something you'd like to get behind check it out using my discount code anthony to get 10 off which also applies to subscriptions giving you 25 off total all right thanks guys hello everyone this is uh dr chafee and i have a very special guest today dr haseem malhortra who i met first when we did the actin cholesterol debate a few months ago with dr ross walker asim is a british cardiologist public health campaigner author of several books um such as a statin-free life and uh the poippy diet i'm not probably not pronouncing that right that's much that's much more italian and uh and uh 21 day immunity plan he's been involved in many organizations uh uh activating for better nutrition and better health across the uk and the world such as action on sugar and now the public health uh collaboration or phc and was named uh the sunday times one of the 500 most influential people uh in the world and uh thank you so much for joining us i really appreciate you coming on how are you i'm great thank you for having me anthony um so obviously you know apart from the bio um if people don't know sort of what you work what are you working on now what's your a bit of your background tell us you know who you are yeah sure so i uh i qualified in 2001 edinburgh medical school in scotland i grew up in manchester uh both my parents are with gps so i came from a kind of medical family if you like and quite early on i decided i want to pursue a career in cardiology even as young as the age of 11 and part of it was motivated by the death of my older brother who died of what was probably viral myocarditis actually when he was 13. so that obviously was a very traumatic experience for the whole family um and then once i went to medical school you know my interest in cardiology only increased then i was like well this is what i want to do and then i sub specialized in interventional cardiology and which you you'll know is to do with putting in heart stents and treating heart attacks and um which i was you know i really loved and i was good at it um but then i kind of my career took a little bit of a different path from the conventional route um not longer after i became a consultant i um in fact i started before then but essentially i became also a campaigner and activist um using various platforms including medical journals mainstream media social media to try and initiate change that ultimately will improve public health and and i got to that position having had clarity that a lot of what was driving people's health decisions and was based upon misinformation um rooted in commercial interests essentially whether it's to do with the food industry or whether it's through the pharmaceutical industry and from my perspective i've sort of been the two key areas i've heavily campaigned on are improving the food environment and nutrition education and in that journey one of the roles i had was being science direction of action sugar and really i suppose being the first person in this country to get mainstream media awareness as certainly as a doctor on the harms of excess sugar and then that translated into advising politicians and policy changes and we then got a sugary drinks tax introduced here in the uk um a few years ago so that was one of the big roles or one of the big achievements i would say that i've been involved in um and then simultaneously for the last sort of ten years inspired by the bmj's too much medicine campaign i've been very proactive in um highlighting the problems with medical research uh in terms of quality of data commercial interests and then and then downstream ultimately lack of informed consent that takes place um when in terms of discussions with doctors and patients about many drugs of course we've discussed statins and we could talk about that as well i'm sure um but the you know for me what my my main motivating factor in all of this work um anthony is one how can i be the best possible doctor i can be for my patient but for the primary person purpose of improving their outcomes which specifically means in general terms or in broad terms relieving their suffering managing risks and treating illness so everything i do in terms of my work is motivated by that well that's great yeah the you know i'm right there with you with the uh the special interests you know manipulating and influencing people for decades uh and pushing us in the wrong direction and then um you know you know people people say there's like you know they feed us the wrong thing and then they give us some medicine to treat you know the bad outcomes and whether or not that's coordinated it certainly does seem to be the case that we're going down the wrong path we're eating the wrong things we're getting sick we're getting unhealthy and then we have an entire medical establishment uh that that profits on that that unwell um that that that sort of poor behavior and poor health and unfortunately everyone thinks that this is the right thing to do that they're eating healthy and that this is just a normal way of aging and that you know these medicines are actually providing uh you know benefit when they don't necessarily uh in in all cases especially when you're sort of treating something that doesn't need to exist in the first place um can you tell me a bit about what you what you're doing with uh with with phc and what you guys are or are trying to get going in the uk yeah i'm glad you've asked me that question so i'm uh my role now is i'm the president of the collaboration and public health collaboration really is uh made up of a group of doctors other allied healthcare professionals including dietitians nutritionist pharmacists nurses members of the public and patients and that's why it's a collaboration it's slightly different what separates us from other charities is that collaboration and also being removed from commercial interests a lot of charities unfortunately with the best intentions are funded by industries that see them as a useful branding opportunity for their products for example so we are funded by the public for the public interest and what we're trying to do is inform people to make healthy decisions but also simultaneously understand that a lot of the drivers behind disease processes um in the population and in individuals anthony are structural drivers so we you know we talk about the social determinants of health um another way of a better way of kind of um for help a better way to help people understand what that means is to talk about the biopsychosocial model so really the conditions in which we um are born which we grow which we live in which we work and age those conditions themselves have a role to play in driving our behaviors but also very much rooted in often psychosocial stress so for example if you are in a high demand low pay low control job that's uh in in effect i would say that is a death sentence so we know there's very good data showing that you know that through probably through psychosocial stress mechanisms will increase cardiovascular disease risk over time so i think it's important for us to understand that most of our choices when it comes to health behaviors are us are driven beyond by um situations that are beyond our immediate control and therefore although it's really important to educate individual patients and that's what we do we have to simultaneously appreciate that unless we sort out the environment in which those unhealthy behaviors are being fueled we're not going to have a real big impact that we want in terms of population health and this is a population health crisis when you look at think about obesity and therefore a population it needs a population intervention you know doing stuff that the grassroots is very important let's not underestimate that as individuals we can help so many people individually of course but how do we translate what you and i know for example when it comes to eating real food or avoiding ultra processed food how do we make sure that's translated that that becomes the default for everybody yeah yeah really public health collaboration is focusing at the moment primarily on issues around the diet situation and moving forward of course we want to promote uh more ethical medical practice through informed consent and shared decision making with pills which as you know is very much tied to um uh if we if you know those those lifestyle interventions so for example if we are helping patients send their type 2 diabetes into remission simultaneously they're going to come off some of their pills which is great but that conversation involves helping patients understand that actually the pills themselves may only have a very marginal effect on their health mostly don't improve quality of life and can and can come with side effects so once that conversation starts it does help i think motivate those patients more to actually be in a situation where they're very happy often more often i'm sure you know this answer me to come off the pills people by and large if they can avoid it once they're given the full information don't really want to be taking pills if they can avoid it and therefore of course the lifestyle is another alternative for them and often an additional tool for them if they want to carry on with the pills of course to improve their quality of life yeah and how did you um decide to make that transition from from working as an interventional cardiologist to then you know think that you're going to make more of an impact in this way what sort of drove you to to take that turn yeah i think it was incremental anthony um from a personal level a lot of my um a lot of what i do is informed by my own patient contact so over a period of say 10 years from 2001 when i qualified as a junior doctor to getting over to sort of 2010 on a visceral level on a clinical experience level i was seeing more and more patients that were coming in with lifestyle-related diseases more polypharmacy so patients on multiple medications and i could see that their outcomes weren't improving in the way that they should be and that obviously was associated with them you know being more affecting them mentally too in a negative way and then of course you match that with what's going on in terms of population data and understanding in the uk for example we had you know we've had this problem with overweight uh people being overweight or obese which is 60 of that um for almost two decades now and we haven't really made much inroads into tackling that so it was matching those two things and then actually looking then and seeing well hold on what's the root cause of this problem for me also what was because i'm a cardiologist i was specifically interested in cardiovascular disease and it was fascinating for me to learn uh that the biggest impact on reduction in death rates from heart attacks in the last three or four decades has been um curbing tobacco control it hasn't come from some magic pill i'm not saying that pills and emergency care don't have a really important role of course they do but when you look at the biggest impact at least 50 of that impact on reduction death rates from heart disease happen from tobacco control so specifically taxing cigarettes public health health education campaigns um but also smoke free buildings public smoking bans that kind of thing um and then it was interesting when i looked at obviously i'm also uh by nature um like a lot of people are foodie you know i grew up in a household where we valued uh home-cooked food i learned to cook when i was 16 by my dad i cooked through most of my university career um most days of the week and so i still cook you know i love cooking and i love um i appreciate the importance of nutritious healthy home-cooked food and then once i looked into the data you know data that was appearing on the impact of how diet can have probably similar if not stronger effects on a larger scale as as quitting tobacco in terms of improving once or reducing one's risk of heart disease very quickly i then felt that i needed to be an advocate for that movement to promote dietary changes that are going to reduce cardiovascular morbidity and mortality and i published paper in bmj open heart specifically on that i think it was 2014 if i'm not wrong uh so you know that was one of the things that motivated me as well is actually um the fact that dietary changes can very rapidly within a few weeks massively improved cardiovascular risk factors in in you know in selected patients are at high risk and that that's a really powerful message and it wasn't infiltrating itself into clinical practice most doctors as you know don't get any training in nutrition i had to learn all of this on on my own if you like and and obviously looking at other research that's done by other people and then really what i do is put the jigsaw together and try and translate it in something that's going to have meaningful impact for the population for patients in a way that's understandable for most people so i think that's probably my role as a clinician as an academic clinician yeah oh very good and um you know i think that that is absolutely absolutely one of the most important things you know obviously like you said you know we can do things as a grassroots uh movement and talk to people one-on-one and that's certainly you know something that i've done for a number of years but you really do have to start you know branching out and getting getting a bigger impact and like you say uh you need to address the root cause i think that's the most important thing in medicine is to identify what is actually causing this and to try and target that whereas right now we're just sort of papering over things and just and there's some sort of disease management and symptomatology and we're just sort of putting band-aids on things while you know everything's just falling apart around us and we're not and we're just ignoring the fact that these that the rates of these illnesses and diseases have increased dramatically in recent years and and not many people are asking well why the hell is that you know like obviously something's happening we're changing something in our environment our genetics aren't going to change that quickly and so something is happening in our environment you know what is it and um you know i think obviously you know smoking's huge and i think that that uh you know diet is such a major major player as well uh so it's great to see you know people like yourself uh really you know you know fighting that fight and trying to take this to higher levels as well to make this much more uh aware by the by the medical population as well and then disseminate that out uh to the uh population at large um in your estimation you've been working in this field for you know a decade or more um what what needs to be done at this point the stage that we're at now to you know get this as a mainstream idea that that nutrition actually makes very very big impact on our health and uh and you'll get this out to clinicians and to to people at large and maybe get policy changes you know to reflect these sorts of things as well what what's what needs to be done at this stage yeah it's a great question um anthony so just before i answer that i think one of the things that would help your listeners understand a little bit more of my role on all of this as a cardiologist is actually looking back the obesity epidemic seemed to take off from the 1980s and there's a very clear correlation of course correlation doesn't necessarily imply causation between changing dietary guidelines globally uh where we went for this low-fat food movement if you like and that was driven by heart disease concerns which had increased massively from the 1920s peaking in the 1960s um and of course scientists trying to figure out what was the cause of it and that was before they fully appreciated the impact of smoking and of course diet was part of that flawed understanding if you like and then everything got focused on low and cholesterol and as a result of this focus on learning cholesterol we then the food industry then obviously adopted to those guidelines um and produce a lot of low-fat ultra-processed cheap refined carbohydrate foods which now certainly might in my opinion and i'm sure many other people agree with this are certainly a big driver if not the main driver behind metabolic dysfunction and obesity so once i kind of figured that out i then wrote a very provocative article on the bmg in 2013 called saturated fats not a major issue and i put all the evidence together but actually in 800 words i really called out two big industries both the food industry and pharma uh with the over prescription of statins and the fact that low carbs you know the evidence of that stage just at low carb is a very effective intervention for reversing metabolic syndrome which is you know the biggest cluster of risk factors for heart attacks um so that's really where you know where where it uh it uh i suppose got me a lot more um uh you know i managed to get that into the mainstream media i mean that wasn't that was a bmj storage they press released and something that was world news and i think the fact that a cardiologist was saying that you can eat butter and it's not something to worry about obviously at that stage it was considered very controversial but something that they felt needed an airing or a discussion um but in terms of what we do i think there's a number of things that need to do i think certainly we haven't in the uk and i suspect in many parts of the world still got the nutrition education sorted in medical schools both undergraduate postgraduate chaining specifically in relation to the impact of diet and chronic disease because our big um you know the big issue the major issue around the world now is the fact that non-communicable diseases is causing the biggest strain on health care systems and diets within that is within the lifestyle hierarchy probably is the most important certainly one analysis in the lancet global disease the disease reports suggest poor diets is responsible for more disease and death than physical inactivity smoking and alcohol combined now um so i think that has to be a big focus um and then i think what we need to be doing as scientists as clinicians and of course science evolves and no study is perfect every study has elements of uncertainty to it that's the beauty of of medical sciences appreciating their uncertainty so we can keep evolving and developing more research to be more precise in our understanding of what works and what doesn't is dissociation from commercial interests because it hasn't worked it's had a really detrimental effect i mean you know if you look for example at um the pharmaceutical industry certainly last two decades in general without naming any companies i've spoken about at lectures and we've got data from all around the world if you look at most of the drugs that have been approved at least half to 75 percent of them depending on which countries you're looking looking at the drugs that have been approved by regulators have been shown to be just essentially copies of old ones so there's huge waste because they patent these drugs the taxpayer often then pays for it governments pay for it right so there's a huge waste there and of course that this in a in a healthcare system with finite resources you know one doctor's waste is another patient's delay so that's a big problem and then you look at the innovations they're very very small in percentage terms of all the new drugs certainly over a 10-year period and different analyses maybe 10 or 11 percent of those new drugs are thought to have an extra therapeutic clinical benefit over previous drugs so there's a lot of waste and therefore if you look at the whole picture of it um anthony one could very easily argue that the net effect of the drug industry in the last two decades on population on society has been a negative one um that's also understanding as well busting some myths amongst even doctors and patients sir modern medicine has only had a marginal role to play in increasing our life expectancy um and that most of that role has been through acute care so whether it's aspirin for treating heart attacks coronary care units being developed um you know insulin for type 1 diabetes you know you're going to die if you don't get insulin if you're a type 1 diabetic having ketoacidosis hemodialysis for kidney failure you know uh these are sort of the big hitters i've added about three and a half to five years to our increase in life expectancy of about 40 years since two since 1850 with most of those increases in life expectancy coming because of public health intervention safe drinking water seat belts in cars smoke-free buildings safer working environments so there's a few myths that need to be busted there as well so i think that's what really needs to be done but ultimately the reason why people have a lot of these false perceptions which drive behavior and even policies anthony is because of commercial interests because you have these big corporations with a lot of unchecked power they can determine the the the narrative they control the knowledge environment now most studies now um uh drug industries uh most um uh drug studies are sponsored by industry who then hold on to the data and then it's not made publicly available and independent analysis isn't done so what what does that mean well in essence the the the benefits of drugs are grossly exaggerated and the harms are underplayed which interferes with clinical decision-making um and uh and then ultimately the patient suffers and we can see all of that going on society right now so you know one of the uh best ways for people to kind of understand that in um uh in a um very clear and concrete way is a quote that came from the former editor of the new england medicine martial angel when i interviewed her for a guardian article and she said the real battle in healthcare that we have is one of truth versus money yeah yeah that's um i was going to say too there was a there was a reasonable account i really wish i remember what it was but anyway they they were talking about the conflicts of interest of the harvard uh professors at harvard medical school and how they were all tied up with with big pharma that had a number of of sponsors and they they had sort of like an f grade on their uh on their um being tied up and not disclosing a lot of their um a lot of their ties to big pharma and of course they're they're pitching out to all the new medical students hey these are the drugs you got to do there's nothing wrong with them they're really really good uh one medical student she was a first year there just asking okay what are the the side effects of some of these statins you know what do those do and the professor actually ridiculed her in class and actually made uh you know mocking uh you know remarks about her for daring to to question the the uh efficacy and safety of these statins and it turns out that this guy was was uh you know on on the board for some of these places and so there's a lot of um i don't know it's muddy water anyway you know in the medical community and even in medical education unfortunately um and you were saying you know with like you know treating metabolic disease with a keto diet you know that's something you look back in the literature has been used since the late 1800s to treat diabetics type 1 and type 2 to help you know really stabilize their blood sugar and and you know that that's something that's that was so well established for so long and then you know in 1977 when the usda you know decreed on high that cholesterol causes heart disease uh it's just just everything just shut down and we just forgot you know an entire body of of medical literature and knowledge i go back to you know jama and and different publications you know back in the 50s and 60s there's just a hot heated debate about cholesterol and people were just like this is garbage this is based on really bad studies really bad science you know we should not be listening to this and it was very interesting to look back and actually see what the discourse was like back then and then understand just how much of an impact that had that we've just completely ignored everything that happened before the 1980s uh to do with with our medical literature uh it is very surprising when i started going down this rabbit hole um you know several years ago i was i was very very surprised and uh interested in that fact it was just it was a different world pre-1980 and and now it's it's very different a lot of people say well we were probably still having all of those problems we just you know didn't notice it you know because you know anyone before born before 1986 is just an idiot and just can't can't see what's in front of them you know these are devastating diseases and they and they destroy lives and then take them very early so you know anyone to just assume that these just wouldn't be noticed is is a bit foolish i don't think they're really thinking uh that far ahead yeah i know you're right i think um you know it needs people to be critical thinkers but it also needs people to be courageous you know one of the things i talk about in my recent lectures is to lead the good and happy life you also need to act virtuously um and if you have knowledge and you don't act on it then it's vanity action without knowledge is insanity but wisdom without having courage to speak up for your convictions is fruitless and actually what we need is more people just to think to the going back to basics about what does it mean to lead a good life and actually if more people were acting in a virtuous way with courage then i think we would um a lot of society's problems would be resolved very quickly but people are being misled and uh there's just too much power of these big corporations who are literally just profit making machines and in in their pursuit of profit accident and to human ways um you know the the uh the forensic psychologist that originally came up with the almost certainly part of the original definition of psychopath his name was dr robert hare in the documentary film and in the book the corporation he actually saves the big corporations as entities not the people within them because they're doing what they're supposed to do what they're legally obliged to do but the entity that is the corporation actually behaves in a psychopathic manner so if you think about this anthony the way i've been thinking about this people is if you've got a culture and a power you know if you've got say let's just say the the psychopathic entity has increasing increasing power that also influences culture that which is anti-human it's going to have a negative effect effects on us mentally and physically so i think we need to think about that and changing the narrative that actually the roots of a lot of these problems is what is the end result of a psychopathic entity that has a lot of power over institutions universities most of the funding for example comes from drug industry research uh comes from drug companies now from the prestigious institutions and then it creates a culture that feeds the psychopath yeah so what what's going to happen yeah yeah yeah and um that was something that reminds me of uh you know what like jordan peterson would say uh you know said if you want to change the world like clean your room and you know it sounds you know try it but it's just like no you need to take care you need to be able to take care of your own life you need to be able to to clean things up around you and get your own life in order and you getting your own life and lord will make the world a better place and how are you going to fix the world if you can't even fix your own your own your own your own life and and some people i think because their lives are in disorder and disarray and they say like well can't deal with this so i'm going to i'm going to go order this around it makes it maybe that makes them feel a bit more in control when they're trying to um you know do some sort of big grand grand project and uh and and helps them ignore the problems that they're in or in their life you know yeah and i think in relation jordan peterson i think um you know i'm uh um i admire a lot of uh his work you know i've listened to him a lot i've read his books and one of the things that really um caught my attention which made a lot of sense is that he said it's not safe to speak the truth but it's even less safe to not speak the truth because even if you're preventing some potential short-term risk you're actually pushing it down the line and it'll in fact become potentially greater and uh if not if it doesn't affect you then it's going to affect your kids and a society that moves away from the truth or increasingly is moving away from the truth combined with our um you know our capacity for being empathetic is going to have a very detrimental impact on the human condition on the human human beings on society so you know i think in broad terms what we need to do is to start moving more towards creating the conditions where certainly has better access to information and the truth but simultaneously realizing that we are we don't live in cocoons we are dependent on each other and therefore our you know collective survival or something that works well for society and its totality is going to benefit us individually and anything that has a negative impact on society is going to have a negative impact on us individually and i think the kovid pandemic in a way has drawn that out a little bit more that we are people have appreciated more and more that we're all dependent on each other yeah and if even if you are very wealthy you've got access to all the information you want and you are able to follow the healthiest diet you you can and you're going to be able to meditate and exercise if the world around you is burning you're not going to be happy unless you're unless of course you're a psychopath yeah that's going to say or a sociopath which most of us are not thankfully so that's just my way of sort of you know provoking people's thoughts a little bit more on this yeah yeah [Laughter] yeah definitely um i was going to say too um so being a cardiologist obviously you know heart disease is is your sort of your bread and butter um we had a you know i thought we i thought we had a great debate with uh you know the australian college of nutritional environmental medicine i don't think that um the other team really really appreciated us i know they got really pissed at me when i just basically argued that like this isn't even a story like it look this was all based on fraud this should never have been a you know thing in the first place they got really pissed at me but uh which i you know i think that that's that's a good sign you know if you uh are upsetting them but um people should watch that anyway and then they can get your short views on that but it was a very quick quick sort of debate it was only seven minutes uh each person you know can you tell us your views on cholesterol and statins as well you're in a whole book called you know statin-free life so obviously you have you have a different take than the mainstream and obviously i you know you would uh yeah like to hear what your your thoughts are on that yeah so i spent quite a lot of time um i've probably studied cholesterol and statins uh more than anything else i've studied actually certainly in the last decade in a lot of depth looking at research and trying to understand it better and unpick it all and pick all the data and really to summarize the issue certainly you know the framingham study that started in 1948 which was there to try and determine various risk factors for heart disease which followed up about 5 000 people in the town of framingham massachusetts from the late 40s you know for several decades it's still an ongoing study as far as i'm aware and from that various risk factors for heart disease emerged you know smoking lack of exercise to some degree diabetes hypertension and of course high cholesterol but when you look back at that framingham study what they found was that the prediction of heart heart disease a significant association of heart disease with cholesterol was actually when it was extremely high so um in australia you use millimoles do you in terms of uh with people's cholesterol yeah so i think over over 300 milligrams per deciliter released and over 10 millimeters where you'd see the big association with heart disease from framing them which we now know which we'll talk about in a minute is essentially mainly people with familial hyperlipidemia you know which is a genetic condition which gives people very very high cholesterol and affects about 100 people and at the other extreme people with genetically very low cholesterol less than five percent of the population didn't seem to develop heart disease although the lifespan wasn't changed from anybody else so they so the thinking at that time was at the extreme ends even but most people in the middle your class total cholesterol specifically and even ldl didn't predict whether or not you're going to get heart disease or not so the thinking was it was linear and therefore we should if we push people's cholesterol to be as low as possible we are going to prevent heart disease and in fact you know nobel prize winners who are involved in uh understanding the role of cholesterol in heart disease uh brown and goldstein in the late 90s even predicted that we may see the end of heart disease now because of statin drugs and cluster alone drugs that had come on the market and had shown from some randomized controlled trials that there was a benefit even though lots of other drugs that lowered cholesterol before statins even significantly didn't show any benefit and we know that dietary stuff lowering cholesterol doesn't so i had to unpick all of that and put it all together um and the upshot is this that first of all unless your cholesterol is very very high um an ldl of at least four point nine which is usually the cutoff for formula hyperlipidemia it's not very helpful at all in predicting whether you're gonna get heart disease or not but what is more predictive is your triglyceride to hdl ratio which comes into this metabolic syndrome or metabolic health situation and that's just part of the story so the upshot on the cholesterol hypothesis um uh anthony is that certainly lowering cholesterol in populations through diet or drugs and we published a systematic review i co-authored it with two cardiologists in bmj and space medicine a couple of years ago people can look it up look it up it's called hit or miss um on the new cholesterol targets um are they based on evidence and what we found was just looking at uh drug treatment not not dietary treatment because drug treatment has a big effect on lowering ldl and total cholesterol there was no correlation um clear correlation with lowering ldl and preventing heart attacks so that's very interesting um so the question then is well okay okay does statins have any effect well they do the date the lit over literature does show an effect in preventing heart attacks stroke and death but then it has to be individualized and it has to be broken down in a way that's understandable for patients so if you take people at low risk of heart disease let's say that people who have a less than 20 risk of having a heart cycle stroke in the next 10 years the statin data doesn't show any mortality benefits so they're not going to live any longer but there is around about 1 reduction in heart attacks or strokes over over a 5 year period and then if you take people at high risk essentially people who've had a heart attack already or have severe coronary artery disease the benefits are probably one in 39 in preventing a non-fatal heart attack over a five-year period and one in 83 in in saving one's life or preventing death now why that's information is important is that we should be having conversations with patients around this for informed decision making and that's something the who put out in the news bulletin in 2009 something that the medical oncologist in this country said 2015 in a paper i co-authored in the bmj um so that's something that's been established but again it hasn't infiltrated into clinical practice but to just to answer the question that many people may be asking saying hold on if lowering cholesterol cholesterol is not a big issue how does statins have the effect well there is good evidence to show that statins have an independent effect of low in cholesterol which is anti-inflammatory and anti-thrombotic and my view and i've written about in this in the book i think that's probably the most likely mechanism of of that small benefit of statins but then if we're just focusing on low in cholesterol and people then think they can eat what they like and they're having a high starch high carbohydrate diet and they're increasing the risk of metabolic syndrome that's really ultimately that scenario anthony in my view is actually having a negative impact on the patient and one of the problems is there has been there have been cardiologists eminent cardiologists who've written in fact one wrote and i talk about this my in my paper and try and go through the points this cardiologist made i think his name was um william roberts and he wrote the american journal of cardiology in 2011 and it was entitled it's the cholesterol stupid and he makes lots of claims in this paper which i try and counter in my book but one of the most interesting claims is this he says you can be an obese diabetic smoking sedentary individual but as long as your cholesterol is low enough you won't develop heart disease so i had to take issue with that because we know even from clinical practice that's completely false and data that's there but if you imagine an influential person like that and the impact he would have in other cardiologists and they then have that as a mantra and it is indoctrinated and i can tell you that it has been indoctrinated because i've worked in cardiology and been to conferences and spoken to many cardiologists and colleagues over the years and it's false then we've got a problem because if people uh you know are prescribed cardiologists are behaving or acting in a way based upon that also without understanding the absolute benefits of statins and certainly not having conversations with the patients around it and then simultaneously not having the knowledge around the lifestyle interventions it's not a good situation for us to be in is it um uh in terms of uh medical management of heart disease yeah and so and so anyway is there a time when people would benefit from standards you're saying there's like an anti-inflammatory anti-thrombotic effect i mean this is is this anything more than we're getting from aspirin really well i think with all of these things anthony we have to think that you know just because something has a plausible biological mechanism that isn't enough so in you know in medicine today's truth maybe tomorrow will be often tomorrow's folly and uh you know just to give people an idea and a better understanding of that medicine itself is not even an exact science like chemistry or physics yeah it's an applied science where we use the patient and the individual patient but also look at um it's an arts in many ways using probabilities from studies that evolve and change over time and one of the quotes that i always start with in one of my in my medical lectures and even teach my medical students this is that half of what you learn in medical school will turn out to be either outdated or dead wrong within five years of your graduation the trouble is nobody can tell you which half you have to learn to learn on your own and because of the system this isn't pointing fingers at doctors i mean doctors work very very hard you know that but many of us for unintentional reasons may be climbing up the wrong wall in terms of our management of conditions based on outdated evidence and then don't have the time to update ourselves with the evidence or even the critical skills to be able to uh understand the reliability of medical evidence because we're not taught that in medical school so all of these things contribute to this medical misinformation mess and population health deteriorates because of it so and to answer your question um beyond biological mechanism the best thing the best instrument we have to use to understand the benefits of intervention is uh the randomized control trial you know and that in terms of the hierarchy of evidence is the best data we have but even the randomized control trial can be rigged and manipulated by industry through the design and the interpretation of the results and holding on to data and all that kind of stuff so that there are ways and this is a longer discussion for another time of how we can improve that but one of the things certainly is we have to at least start by dissociating you know one of the things i would say is and i'm i'm actually just quoting cochrane researchers who said that all in after they reanalyzed data from a drug called tamiflu an antiviral that was supposed to be used for flu management and we found ultimately when the data was released independently when it was originally marketed and we thought and it was approved as being safe and effective actually wasn't very effective and had some significant harms the conclusions of these cochrane researchers that reanalyzed the data on tamiflu when the raw data was released is that all industry sponsored studies should be seen as marketing until proven otherwise so what i would say is moving forward what do we need to do well if we want to be good scientists the ideal scenario what you will be striving for is one never allowing a single study to be approved unless it's a very huge effects effect size and even then it should be you know the discussion with the patient saying listen this is an industry sponsored study which is what i say to my patients so there's uncertainty about whether it's absolutely true or not and it hasn't been replicated independently so moving forward the ideal scenarios is we get you know industry-produced products we need them to produce drugs or whatever they should be tested independently and then we can be more confident in the reliability of the results but even then you want replication of those results as well so i would say at least two studies independent of industry randomized controlled trials and then what do those results indicate in terms of absolute benefit then use that information now some people might think this is pie in the sky and it's impossible but no i think every you know i think we're the situation has become so dire in terms of the net effect of of drugs on society you know one of the other figures the third most common cause of death after heart disease and the cancer according to peter gosher co-founder of cocco corporation is prescribed medications what your doctor prescribes for you and he says that most of these side effects these deaths are preventable with better information so if you think about that to start with you realize this is a major major public health problem and therefore we need to actually implement something a different model in the system [Music] to improve that clinical decision making so sorry to come back and answer your question even if you've got a plausible biological mechanism this is great and we want that we have to be able to match that with the trial data that gives you an absolute benefit on what a drug is doing because even if it has some anti-inflammatory and anti-thrombotic benefits what else is it doing is it having a negative impact on mitochondria for example we know that statins have an effect on certainly reducing exercise tolerance in people who are doing you know moderate to vigorous physical activity so what's the downside so all of these things need to be taken into consideration and that but the randomized control trial that's designed well is the best way or the best tool that we have to determine the actual benefits and harms of any intervention we do any drugs so you know i'm paraphrasing um the director of the center owners-based medicine oxford uh carl hennigan who's brilliant he's a g practicing gp you know a very smart guy very high scientific integrity and he says this and i i think this is a great line he says for every intervention you do as a doctor you've got to ask yourself two questions how much difference does it make and how do i know this yeah that's a good question to ask yeah um i was gonna say two you know i mean thinking it's like well you need you know at least two studies and that might be um you know high hopes but you know study is only as good as this reproducibility you know you do something you make a you make a statement and you make a theory and then you try to you know show that and it's like okay you do that okay now do it again like that's the entire point i mean that's the entire scientific method is is the reproduction absolutely of that yeah so i agree like and that's not been happening anthony for so long it doesn't happen as well as it should do and that's because of that really there's too much power unregulated activity of industry and therefore you know it's interesting i said earlier that most of what's increased our life expenses have been public health interventions which really have been changes regulations and law changes and nothing has changed now if you look back at the root cause of these problems affecting society in a negative way it's unjust unethical and undemocratic laws that are perpetuating this problem and therefore we need to get to the root and change the laws yeah for the problem to resolve itself yeah um sort of that note you i know you've done a lot of work with uh dr robert lustig out of ucsf and i know you you just spoke in my hometown of santa barbara uh at the is the metabolic convention there or what was that yeah metabolic health summit yeah absolutely yeah in santa barbara which i love is by the way it's a great place beautiful place yeah absolutely yeah that's why i grew up my family um saw there my grandmother was in in montecito which is a little area there and my aunts and i have a few aunts and uncles and cousins there still and i always love going back it's such a such a gorgeous place um i've followed dr lestig's work since he first started publishing uh his work on fructose in 2009 i was a first year medical student and just happened to come across it actually my dad came across it he just said hey you know you might be interested in this and i was very interested in it and i've sort of followed it since then um you've done some work with him as well obviously you're very out you you're very much aware of the fact that you know sugar is uh just toxic you know in my view um can you tell me some of your work with uh with sugar and with lustig and what sort of i think you co-authored a paper as well together yes yeah i've done i've done a lot of work with rob in fact we've co-authored as far as i remember at least two papers together and uh rob i'll be honest with you rob has been my kind of guru on sugar i mean he really got me looking at sugar in detail and you talk about replication certainly the stuff he was writing and one of his seminal papers was in nature uh you know uh on sugar and i think it was two 2012 if i'm not wrong and you come out saying sugar is a major issue and then i started doing my own research into it but then i i connected with rob as well because i wanted to ask him a lot more questions understand where the uncertainties were um have a more definitive understanding of the science of sugar and fructose so you know pretty much everything i learned about sugar um primarily came from rob you know and he deserves full credit for that because i think he's an amazing scientist and an advocate and again he's not afraid to speak truth to power you know and uh and when i uh with people i interact with as well and i'm sure we all do this i often um start with uh and this maybe is a human trait of ours or you know a characteristic of us in terms of the way we connect with people but for me i also try and understand the human is this person someone with integrity because i think that does make a difference uh in terms of the stuff that they're doing it doesn't mean they can't we don't get things wrong but we need to start from a position of understanding the character what really motivates them and are they somebody that's acting with scientific integrity and rob is definitely ticks all those boxes um and then for me i think the first publication i wrote about sugar i'm glad you've asked me this question it's quite interesting because it was my own investigation in fact it was my first publication the bmj may 2013 and it was called the dietary advice on sugar isn't in need of emergency surgery and what i discovered first of all is once i was aware of the science of sugar being harmful and from a cardiovascular disease perspective rob co-authored a paper which was published by the american heart association in 2009 and what i found really interesting is in that paper according to the up-to-date evidence at that point and these and the people who are co-authors have no links to industry so it was as independent as you can get um you know it was in those guidance in the american heart association paper 2009 it said that for the average american citizen they shouldn't be consuming more than nine teaspoons of sugar a day if they're a male six teaspoons if they're a female and if you are a child aged between four and eight the american department of agriculture has said no more than three teaspoons now what's really interesting is at that point when i looked at that and i thought hold on a minute what what are people consuming and i figured out in europe and the figures were not december in the u.s probably a bit worse in the us that we were being told in the european union through labeling on products in the supermarket that we should be consuming as part of our guideline daily amount 22 and a half teaspoons of sugar a day anthony should be and i thought hold on a minute how how there's a disconnect here between what's being published and what's and then i went in my own investigation trying to figure out well why is this science not matching the policy and i basically didn't take long for me to figure out that companies such as coca-cola and the sugar industry were controlling a lot of that information through funding scientists and institutions and therefore i exposed this in this paper and said and called on the world on the scientific advisory committee and nutrition the uk but all subsequently the world health organization as well and call them out and saying hold on a minute this is a big problem with sugar and then the bmj press released that paper and became bbc news on bbc breakfast it was picked up a few newspapers and then i'd already started writing a few articles about sugar anyway in newspapers like the observer which is a very high impact in this country so the awareness was increasing and then we took it further and after i wrote that paper i was contacted by a number of scientists in cardiovascular disease research and uh you know quite well-known eminent powerful people and they saw they read my article and said listen this is really good can you come and educate us on sugar so i remember going as i was specialist registrar on cardiology time i wasn't even consulted i remember going and i was a little bit like overwhelmed thinking wow so we sat around the table and i already learned everything i needed to know about sugar and fructose by that time by robert lustig and i told them this is what what's the issue and didn't they want to to say listen we need to form an organization called action on sugar and that i was made their science director and then we um i wrote another piece in the bmj saturated fat is not the major issue in 2013 october which is all about saturated fat but also said we should focus on sugar that became a big news story so i think that was gaining momentum and getting this information into the mainstream and then we lost action on sugar that became massive you know it's front page of the daily mail sugars new tobacco you know i was involved in coordinating all of that and it became a world news story by that stage so that's really the the how it all started for me with sugar and then you know there's lots of stories but ultimately involved me as science director of action sugar with action sugar going and meeting the secretary for health jeremy hunt uh in 2000 2014 and uh and basically uh we gave him a child obesity plan and one of those recommendations which interestingly was a repeat of a recommendation i was involved with the medical or colleges that represent every doctor in the uk on their obesity strategy plan in 2000 and uh at the beginning of 2013 which was uh a plan to tackle obesity we we call for a sugary drinks tax so we pushed jeremy hunt and then i was pleasantly surprised not long after that um you know within a year or so a couple of years the um the chance of the extracted george osborne at that time came out and in between i was invited to attend downing street to meet the prime minister you know in events that were you know i was being recognized for my role in as an obesity campaigner um they came out and said we're going to introduce a sugary drinks tax and this was from what we call a conservative or what can be considered a relatively right-wing government which is amazing because you know part of that ideology on on the right has traditionally been this is all about personal responsibility this is nothing to do with industry industry are great we create jobs blah blah blah so it was interesting to see that a relatively so that really was a measure of the impact we'd had as action as action on sugar and of course then i was probably you know considered one of the lead if not the lead campaigner that made that happen so it's quite satisfying obviously a lot more work to do and for me things have evolved from sugar which is still a major issue to link to sugar is ultra processed food and i think the policy focus now should be on ultra processed food and to some degree in education campaign on low-quality carbohydrates yeah yeah yeah i think that's answered your question yeah no yeah and um yeah rob was part of action sugar rob was one of the international advisors so we got we got international people involved and obviously rob was in my view the the sort of the um the scientist with the the greatest amount of research and understanding of sugar and its effects and of course it was imperative to have him involved in that in the organization yeah no he really broke the case open on fructose and just so very conclusively you know but with hard biochemical you know like you said you know like medicine is is more art than science certainly uh or a soft science there's a lot of junk science as well in the publications that we put out there unfortunately and um but this is this is a as hard as it's hard science to get this actual pure biochemistry it's like this molecule does this in your body that's it you know and so yeah i think it's one of the one of the one of the best pieces of nutritional science that we have our you know our or his work on on fructose because it's just it's biochemistry now you know it's just the actual pure biochemistry which is awesome um you know i'm very much in the the camp of you know let people you know sort of uh live their own life and make their own decisions but at the same time i think that uh things like sugar i honestly should be at least age restricted you know i think that that lustig showed very clearly that that fructose is a drug it's addictive in the same way as cocaine heroin and meth kills the same areas of your brain as meth to the same extent as meth you see those on mri studies that he's uh spoken about in a number of his talks and um you know we we we restrict other things that are addictive and damaging of this nature especially for your your development as a child i mean this is a major major issue and you're addicting children i mean the sugar's just in everything and then they promote it like oh look how great this is and you know just walking around the hospital here i'm sure you can feel my pain here it was just every every patient is you know served just the sugary carb filled core you know garbage and and i look at that i'm like the reason you're here is because you eat that you know it's like we're feeding people the thing that's perpetuating their illness in the first place um especially like cancer patients and heart disease they're feeding them sugar and carbs you know i literally just get just did a consult uh for a cardiology patient who had a stemi a few days ago and they were worried about his legs thought he might have like you know spinal cord impingement and so i went to go see him and on his on his table was bread with jam and juice what are you doing yeah you're giving someone who's just had a heart attack the fuel for another heart attack and um yeah so i think that that sugar i you know i suggest you start in your own backyard as well that's one thing when i first started campaigning one of the major issues i took on board was you know we should ban the sale of junk food and hospitals and we need to set exams and uh you know and um and that still hasn't happened really to any significant degree we've got statements we've got policy statements from various organizations in terms of you know the medical establishment but the implementation hasn't happened yet and uh until it happens you know when that needs to start there you know if we can't we can't win hospitals we can't win anywhere else right in improving the food environment so yeah and you know people i think also just people just don't realize just how how bad it is i think it's just something nice and sweet it's a treat oh you're sick let's get you some chocolates make you feel better not realizing that this is actually you know a harmful harmful substance of your weight right yeah yeah the independent way it's harmful negative impacts on your health yeah yeah exactly and you're giving it to kids and like oh well you know the kids like it they really enjoy it and it's like you know they they enjoy cocaine too you know like you don't give it to them you know there was a um there was a young child i think he was in in the in indonesia this kid was you know we made he was an internet sensation because he smoked like 60 cigarettes a day and he would do like tricks with them and like flip it around his fingers like blow smoke rings and and and now he's just this little chubby kid smoking cigarettes all day and they did a news story on him that went viral and they asked him i was like well you know you should be letting him smoke he's like well you know he gets really upset when when we don't give him his cigarettes you know he gets he gets really really uh angry and you know and he seems healthy and he's fine so he's you know might as well just let him do that i'm like okay for now he's he's fine for now that's not gonna last and of course he gets upset it's a drug he's missing his drug and that's the same with sugar you know the kids are freaking out throwing tantrums we've been using the vernacular for decades uh you know it's a sugar high yeah yeah well it's because it's a drug it it actually is you know that there's more accurate than people realize but you know we recognize this intuitively that this was a sugar high that they're coming down off sugar and they want their sugar fixed and these things i i heard these these uh phrases you know bandied around when i was a child um so these aren't these aren't new terms and it's and now with lustig's work and your work which is showing very conclusively that this stuff is an actual drug and actually should be be uh at least age restricted i would think i don't know if you've uh in the same camp on that one no 100 um it doesn't have any nutritional value right and you know there is emerging evidence certainly to suggest for for many people it's addictive and addiction is the opposite of free will and particularly to protect kids i think you're right that's where there needs to be bigger restrictions it doesn't mean listen we all like the occasional treat but it's just infiltrated itself um into in into people's meals in some way shape or form three times a day as opposed to you know a couple of times a week or whatever and that's the problem yeah um is there just a sort of uh sort of jump to a tangent uh uh or maybe basically to the to the left um and maybe we'll sort of sort of wrap up after this um is there is there you know obviously we talked about uh uh you know fructose being a problem as well um but there's also you know people talking around like in the different you know carnivore communities and keto communities that like you know things like seed oils are very damaging and detrimental to our health and particularly cardiovascular health um do you have any insights about about that sort of thing using these vegetable oils and cooking oils as well yeah i mean so i think that i still think there's a bit of uh debate about the issues on seed oils only in that and i've written about this as well the harmful effects seems to be most prominent when you cook in these oils absolutely so when you cook in these oils and common for common frying purposes seed oils they produce these compounds called aldehydes which are clearly linked to have some link to cancer and heart disease and therefore i would avoid and i advise my patients to avoid cooking in them whether they have that similar effect when they're used in a pure kind of form um in in cold pressed form for example i think it's difficult to to know for sure but what i would say is actually we've got better oils that we know are safe and probably healthy to cook in you know i always go for good quality extra virgin olive oil but of course you can also up you know coconut oil even butter lard that kind of thing but from a heart disease perspective the only real data we have um which seems to show benefit from from sort of oils if you like comes from extra virgin olive oil and there are lots of properties of that you know whether it improves hdl functions anti-inflammatory observational data some randomized control trials so i think at the moment i would say the default is from a heart disease perspective would be to go for good quality extra virgin olive oil which is a fruit oil but i do you know i do generally avoid i certainly avoid it and i know and i think we we need a bit more better data in terms of any kind of trial data on the sea door stuff but yeah i mean the direction of evidence suggests that it's probably harmful yeah absolutely yeah and then just just uh last last question uh promise um what are your views on on diet now you know it seems like like a low carb high fat sort of diet uh obviously i i you know promoted like a carnivore diet and and just argued that biologically that's uh you know where we came from and that's our biologically appropriate diet what is your thoughts on diet now what sort of diet do you follow really good question so um obviously the information is evolving and changing and i think the most important thing where hopefully everybody can get behind certainly whether you're a carnivore or kids though or real food they're both real food but is is minimizing the low quality carbs it's not eliminating them and eliminating entrepreneurs food so eating real food i think should be the main message and then tailor it for the individual um certainly i know patients that have done really well on carnivore they feel better physically they have reversed their metabolic syndrome for example there is anecdotal data on autoimmune conditions and i think this is fascinating and it needs a lot more research through funding to look at the carnivore diet in detail and i certainly haven't seen anything so far that suggests that it's particularly harmful if followed in the right way because of course it's very nutritious the question that we need to ask is where that there is some research and of course every bit of research can be um you know there are uncertainties attached to it is if you look from a heart disease perspective i wrote a paper in 2017 and created sports medicine to try and shift the paradigm of the understanding of heart disease that it's a chronic inflammatory condition that is exacerbated or influenced by insulin resistance risk factors um is that is there an anti-inflammatory components of food and this does seem to be anti-inflammatory components to things like um you know extra virgin olive oil nuts and seeds you know whole fruit vegetables for example uh oily fish omega-3 so i think we need a bit more definitive data on whether those types of foods are having an anti-inflammatory effect in relation to heart disease but i also know there is certainly some anecdotal evidence that suggests that um you know plants and certain vegetables can be pro-inflammatory now is this because of the way that they are produced in the modern day as opposed to you know what was being consumed 40 or 50 years ago or is there something else going on which is specific to certain individuals and we don't know the answer to that so there's a lot of uncertainties there but i would say for patients my default as a cardiologist is really to recommend a low-carb mediterranean-style diet and for certainly for my patients the metabolic syndrome that seems to be the best approach for reversing the metabolic syndrome and of course i also look at inflammatory markers high sensitive crp and that kind of stuff and that gets better um but uh it may not be for everybody and uh certainly with weight loss and people who really want to um who stall on their weight then you've got other options and i write about this my book i even i think mentioned carnivore but even going higher in the protein so ted neyman uh has done a lot of interesting uh advocacy on this and i think a lot of the stuff he says makes sense so for me personally uh i i'm still very much a mediterranean style diet low carb not moderate low carb used to be moderate low carb i'm lower than moderate low carb now i tend to eat my carbohydrates unprocessed carbohydrates uh through or whether it's even um uh you know some grains in the form of uh of oats around my workout but really after lunch time i don't you have anything starchy whatsoever um so it's pretty low carb but i'm because i work out i lift weights um i tend to be quite high in the protein and it's working quite well for me you know certainly all my metabolic risk factors are in the best place i haven't quite quite got a six-pack yet i'm working on that and that's that's not for any health reasons because you know i think that people can get too obsessed about six packs and that kind of thing but i'm just experimenting with myself a little bit because my genetics and my family history there's no one of the six back in my entire extended family and that little bit of subcutaneous fat around the belly i was like okay well how far can i push this can i actually get rid of that subcutaneous fat because my visceral fat index and everything is outstanding my metabolic health is perfect from those parameters but i'm just pushing myself a little bit just to see whether i can you know for myself just how far can i take it but it's not something i'd never necessarily in any way recommend that people do but you know people are vain and people want to push themselves to the limit and all that kind of stuff so i understand why people do it um so that's where i'm at at the moment so let's say work in progress i'll keep you posted on that nice go carnivore you'll get a six-pack two months i'll call it right now all right all right well i'm gonna try that next maybe probably want to kind of one next yeah awesome i've gotta go for sure yeah absolutely they should um well great well eseem thank you so much i i don't want to take all your time i really appreciate you taking the time out uh to speak to me today i think this is very beneficial i've obviously talked about um cardiology issues and cholesterol but it's like but i literally like quoted you know your study so it's really good to to have uh everything coming from the horses now and i think everyone will really appreciate it um where can we find you how can we how can people follow you and support your work sure thanks anthony so yeah i do um i'm on social media most of my activities on twitter as i see malhotra facebook and instagram as lifestyle medicine doctor um and yeah that's where people can confine and follow my work i also have a patreon um because i'm you know about 80 of my time i'm doing stuff that doesn't fund me in any way you know writing articles and doing media work doesn't give you but i'm an activist i get that so any help people can give me through that is obviously very much appreciated um but uh yeah all of my you know knowledge shouldn't be commodified so i share all the information uh freely people can get my books and um and read my articles yeah just by putting putting my name to google and putting anything they want sugar cholesterol statins it's all there lovely all right we'll put we'll put uh uh all those links up and and uh engage websites and everything like that as well and uh thank you very much really appreciate your time i hope you uh my pleasure on today's been great really enjoyed the conversation with you take care [Music]