Transcript for:
Cholesterol and Metabolic Health Insights

when you measure your triglyceride in the fasting state you're actually looking at how your liver handles the carbohydrate and in particular the sugar in your diet because those vldls those triglycerides they are what your liver does with sugar it turns sugar into fat and it turns it into fat and packages it as vldl and then those vldls offload elsewhere and become the small dense ldl and if the goal is to get rid of the small dense ldl that means you got to get rid of the sugar because that's what made it so by understanding what each of these species are and how one goes to the other then you can look at a lab slip and understand the evolution of those species you know in a photograph and so you can basically figure out what happened where which process is going on and therefore what you need to do about it now do you think your doctor's doing that unfortunately no [Music] hello friends i am so excited to welcome level's advisor dr robert lustig to a whole new level if you are in the levels ecosystem you know this brilliant human being for his books fat chance hacking the american mind and metabolical dr lustig is a pediatric endocrinologist and professor emeritus at ucsf and i think it's fair to say he's the most influential global global thought leader on metabolic health um we are going to be calling him rob today in this episode because that is his preference and today we are going to be talking about how to interpret your cholesterol panel and other basic lab tests to get so much more out of them so you can really grasp where you are on the metabolic health spectrum because i know that's something that everyone listening cares a lot about so welcome rob thanks for being here thank you casey it's always a pleasure as you know well let's just start by giving a quick overview of the four main elements of a cholesterol panel what's in it and what do each of these tests mean and represent all right the first is the total cholesterol throw it in the garbage just throw it in the garbage it means absolutely nothing anyone who tells you my cholesterol level is high tell them you don't know what you're talking about because a total cholesterol is useless you need to know what kind of cholesterol you're talking about so that is the first piece the second piece is called ldl now ldl has a checkered history to say the least there is no doubt absolutely no doubt that ldl levels correlate with heart disease risk in large populations that is true i don't argue that and yes you do need to know your ldl but the medical profession places way too much significance on this test and they do it because we had a drug for it okay the very first statin lovastatin came out in 1987 and so we put all our eggs in that one basket and said ldl matters the most turns out the hazard risk ratio for high ldl and heart disease is 1.3 in other words if you have a high ldl you have a 30 more likely risk of developing a heart attack in your lifetime now that's not nothing that's real that's reportable that's public health you know uh intervenable i don't argue that so you do need to know but there's something that's much more concerning which we'll talk about in a moment now here's the problem with ldl in 10 words or less there's not one there's two and when you measure your ldl you're measuring both at the same time it turns out only one of the two matters for heart disease the other one is actually completely cardiovascularly neutral but the met the measurement picks up both at the same time so the question to you is how do you know which one's which how do you know whether or not if you have a high ldl whether it's the kind that matters or the kind that doesn't and that's what your doctor does not know so he's going to say to you well you have an ldl level of 150 and that's high and hey you need a statin well maybe you do and maybe you don't but you don't need that l you don't need that statin based on an ldl of 150 that's for sure what you need to know is which of the two predominate in your lab test how do you figure that out that's where things get a little complicated you need to know another piece of information that's in that lipid panel and it's called your triglyceride level now triglyceride also has a checkered history and the reason it has a checkered history is because a lot of times when people say they're getting their fasting labs done they're not fasting okay they had their bagel and cream cheese that morning and they're getting their blood drawn at one in the afternoon okay and that's not fasting and so fasting triglycerides can be all over the map but if they're really fasting they actually tell you quite a bit now it turns out triglycerides are much much more indicative of a risk for heart attack than the ldl is triglyceride hazard risk ratio is 1.8 in other words if you have a high triglyceride you are eighty percent uh increased risk for having a heart attack thirty percent eighty percent but which one is more important but we don't worry about that because number one they're all over the map because not everyone's fasting when they get their blood drawn and number two as it turns out we didn't have a drug for high triglycerides until very recently and even that drug has some side effects so a lot of primary care doctors are a little loath to use it so that's sort of the the nidus of the conflict is understanding that you actually have to understand both of these uh pieces of information and you have to understand their relationship to each other so that brings us to hdl um which is the fourth part of the cholesterol panel and uh what should people a lot of people hear this is the good cholesterol how does this factor in right so hdl is quote the good cholesterol it is actually a um method for lipid transport away from adipocytes and toward the liver as opposed to from the liver toward adipocytes and it um is mostly protein rather than lipid and so that's why it's h high density it sinks and it has been shown in many studies that the higher your hdl is the better your recycling capability is and the lower your risk for heart disease is and it turns out that there are a few variants of hdl which are even better like hdl milano if you're italian you know the people's actually tried to give you know hdl milano to people you know to see if it would improve things it didn't but the point is that hdl does seem to confer some protective benefit so you would like your hdl to be high now as it turns out um this was work done by jerry reeve and back in the 1980s when he first conglomerated all of this information into one overriding concept called metabolic syndrome he called it syndromax but we call it metabolic syndrome what he realized was that the triglyceride when it offloaded its lipids into different tissues those triglycerides became the the the bad kind of ldl the small dense ldl and what he realized was the hdl was protective against that and so what he realized was that the triglyceride to hdl ratio was perhaps the single most important risk factor for determining heart disease and that is true the triglyceride to hdl ratio is what you really want to know and the reason is because you're looking at the bad guy the triglyceride and you're looking at the good guy the hdl and you're looking at them in comparison to each other with the ratios you actually have to do a computation some some most labs will give you that uh that uh computation on the on the lab slip and if you have a triglyceride to hdl ratio of about 1.5 or less you'll probably live forever if you have an uh triglyceride to hdl ratio of 2.5 or greater you got a problem also the thing to know is that these are race specific so if you're uh an african american your triglyceride to hdl ratio should actually be closer to 1.5 you know and or below so there are some um you know racial differences in this so i don't want to make a you know you know blanket statement on all of these the point is the point is that these different molecules that we've been talking about are evolutions of each other in terms of how they get made how they get processed by the liver how they end up at the fat cell what gets offloaded and what recirculates back and you are when you get a lab a fasting lifted profile you're getting basically a snapshot of where those are in relation to each other at any given moment so what you have to be able to do then is you have to be able to fold that into a narrative of what your lipids are doing at that moment and of course that's not what your doctor does all your doctor does is look at the lab slip and look at the high or the low next uh you know the number greener red check marks that's right that's right and so if your ldl is high oh you need a statin you know if your hdl is high you know he says oh don't worry about it and it doesn't even tell you about the rest of it so you know there's a lot to be learned from those uh numbers but you can't compare them to any stan any standard alongside it what you have to do is you have to look at the interrelationships between each of them and that's something likely your doctor does not know how to do because they were never taught to do it so you have touched on this concept of small density ldl briefly and i think that's such a crux of the conversation we should drill into that a little bit more because um i think one of the takeaways we've learned so far is that just ldl lumber ldl number alone is not sufficient to give you a lot of information about where you actually stand in terms of heart disease risk you have to know what goes what what did that what the sub-fractionated sort of particles are so can you talk a little bit about what those different particles are and also how some of these other ratios like triglyceride to hdl ratio can actually tell us about uh whether we have more of the good or bad cholesterol ldl cholesterol right something i should we should have actually started with casey is you can only interpret a lipid profile if you know you're not sick if you have acute disease if you have an acute infection so if your white count is high or for that matter if your white count is low when you've got a viral syndrome that is not the time to be looking at your lipid levels okay so you actually should look at your white blood count very you know as the first thing and say can i even trust any of these other numbers because they will go up or down based on how sick you are that's the first thing the other number that you need to know in order to be sure that your lipid levels actually mean something is your thyroid hormone level uh free t4 okay because if you are hypothyroid your triglycerides will be sky high and your doctor will think there's something wrong with you and all he has to do is put you on some synthroid and your triglyceride levels will come right back down well probably also worth mentioning too that right now you know the leading cause of hypothyroid in the united states is hashimoto's thyroiditis which is an autoimmune disease of the thyroid and there's there's some also aside from synthroid there's some incredible um sort of more holistic i think approaches that people can do for autoimmune disease um and and so just just gonna put a plug in for that that it's it's interesting that it's just it you know like with most autoimmune diseases we're seeing a rise especially in women and this baby partially died in lifestyle mediated right yes and i think that some autoimmune diseases can be mitigated by um appropriate nutrition and i actually talk about that in this book over here but the fact the matter is um if you're hypothyroid you need to fix your thyroid levels before you can interpret your lipid tests that's that's all yes okay so large buoyant small dense ldl that's where we are these two species that we were that i mentioned earlier turns out large buoyant is 80 of your ldl it is cardiovascularly neutral it's not good it's not bad it's there so if it's high does it matter not really okay and 80 of your ldl is large buoyant it's large it doesn't get under the surface of the in endothelial cells in your arterial system to start the plaque formation process it's buoyant it floats okay so it gets carried along with laminar flow through the um uh through the arteries and through the arterioles and so it doesn't make pit stops along the way and so it basically is like little balloons they're like little balloons of fat running through your arteries but they're not stopping okay they're just along for the ride they're like little balloons in a wind tunnel now this other one is called small dents small dents is a different animal entirely yes you measure it in the ldl but it has a completely different set of properties it's small it gets under the surface of the endothelial cells to start the plaque formation process it's dense it sinks it doesn't float it sinks and so with laminar flow it may actually precipitate and not follow you know the wind tunnel and may end up finding a nook or a cranny inside um a blood vessel to lodge itself in and start the plaque formation process in addition the outside of that small dense ldl is much more inflammatory than the large buoyant so it's that small dense ldl particle that we have to be mindful of and it's only 20 of your total ldl level so when you measure your ldl what are you measuring you don't know and so that's why all these doctors who just read across and say oh yeah it's high you need your stat you know they're missing the book they don't understand what it is they're looking at well if they don't know what they're looking at then how do they how do you expect them to be able to take care of you properly so how do you figure it out that's the question how do you figure it out and the answer is you look at the triglyceride if your triglyceride is high that means that those ldl particles are small dense and the reason is because that's what those ldl those vldl those triglyceride particles are evolutionary going to become they're going to become those small dense lvl all right after the liver offloads and after the adipocyte offloads those vldls will become those small dense ldls so that's telling you what's happening in your vascular because you're looking basically at two points at in the same photograph and you're able to connect point a to point b people might be confused about vldl just might be helpful to tell them the relationship between triglyceride and vldl yeah so triglyceride is vldl in the fasting state all right so that's a yeah another thing we need to explain to people very low density lipoproteins are made by the liver they are made by the liver not in response to fat they are made in the liver in response to sugar sugar sugar is the driver of the ldl and the vldl is what you measure in the serum triglyceride fasting now if you're not fasting there's another species called chylomicrons and carbon microns are what your intestine does to fat and they're huge they're enormous they're they're you know they're they're like you know mr potato head they're just like enormous globs of fat that have to ultimately be cleared by the liver and your liver does it pretty routinely and efficiently unless you have a disease called type 5 hyper lipoproteinemia which only 1 in 10 000 people have so we're going to ignore it for today so if you're fasting and if you don't have type 5 hyperlipoprogenemia that means that your triglyceride equals your vldl and your vldl equals your sugar consumption but when you measure your triglyceride in the fasting state you are actually looking at how your liver handles the carbohydrate and in particular the sugar in your diet because those vldls those triglycerides they are what your liver does with sugar it turns sugar into fat and it turns it into fat and packages it as vldl and then those vldls offload elsewhere and become the small dense ldl and if the goal is to get rid of the small dense ldl that means you got to get rid of the sugar because that's what made it so by understanding what each of these species are and how one goes to the other then you can look at a lab slip and understand the evolution of those species in you know you know in a photograph and so you can basically figure out what happened where which process is going on and therefore what you need to do about it now do you think your doctor's doing that unfortunately no and i think i've you know i've seen so many patients or even family members who show me their cholesterol slip and say oh my gosh my doctor said everything was normal and i just take a quick two second glance at it and i'm i'm it's so obvious that this person is on the road to diabetes or heart disease or whatever because their ldl is right at the top of high normal their ldl is right at the lowest possible low their triglycerides are suit like right before they get elevated so it everything looks like it's in the green but if you start thinking about how these things are relating to each other it's clear that that things need to be optimized so i think that's happening all the time where people are essentially missing a potential opportunity or rewarding signs and an opportunity to get on top of this early um because they technically meet normal for each of these tests because we're not looking at them all together in a big picture we just totally miss sort of the writing on the wall and the part that really kills me is that some of these numbers are so dynamic and or they're so easy to adjust i've seen several patients in my own practice drop their triglycerides 100 points 80 to 100 points in a month just by cutting out refined sugar and to think that that over the course of a lifetime is is is so impactful like um so that's why i think this conversation is so important is because hopefully people can pick up some of these subtle cues um that we just like you said or not are not taught to interpret in medical school exactly we basically throw people out of residency and have not given them a course in lipidology and today because chronic disease is so prevalent it is so much more prevalent than acute disease uh covet 19 notwithstanding um the fact is that we have not equipped our primary care physicians to be able to manage these problems what we've done is we've said oh high triglyceride here's a fibrate high ldl here's a statin we haven't explained to them what any of this means i know because i'm a medical school professor for all these years you know that's not what's happening so you know we have to do a whole lot better in terms of medical education but in order to be able to do that we also have to debunk the basic precept that all of the mythology was built on and that is that it's about calories and it's about obesity because you can be obese and have a very very good looking lipid profile and you can be thin and have a very very horrible looking profile and they have nothing to do with each other in fact if you're obese what that's telling you is that your lipids are actually delivering the energy where they belong the subcutaneous fat where they are essentially inert the thing that makes these various bad particles such a problem is not the subcutaneous fat it is the visceral or the liver fat and that liver fat is being made by the excess sugar in any given person's diet so that can happen whether you're obese or whether you're thin so the fact it's not the fat you can see it's the fat you can't and that vldl is contributing to the fat you can't something that you mentioned was that okay so someone has their ldl and let's say it's a little bit high um we need to know more that's one takeaway i think we have so far is like we need to know what what is actually making up that total ldl between the ratio of small density and high density ldl um so you said okay if you're tr then you look at your triglycerides and can you give people some specific guidance on let's so you go from ldl and then you immediately go look at triglyceride and maybe triglyceride hdl ratio you talked about for each triglyceride to hdl ratio you want it to be generally speaking less than 1.5 that's like a good sign that you're doing well what about for triglycerides that could say just alone um like glancing at it okay this is this means i'm probably okay in terms of my small density ldl versus not i would say triglyceride level of a hundred or less and you're fine you know that's a good those are good numbers if they're higher than 100 then you need to take a little bit longer and take you know they'll do a little bit more work the question is what is that high triglyceride telling you well remember you have to compare it to your hdl because that those are basically the different species because the triglyceride goes to small dense ldl and the l and the ldl goes to the hdl okay after it's been offloaded um so they're telling you you know so you're looking at the good versus the bad and you're looking at them in a way that they're uh they're they're they're comparable so it turns out that triglyceride to hdl ratio as jerry reeve reaven demonstrated is the poor man's marker for insulin resistance insulin resistance now let's talk about insulin and its role in all this insulin is not the diabetes hormone yes diabetics take shots of insulin that's true yes diet you know insulin lowers your blood glucose that's true the american diabetes association will tell you insulin is the diabetes hormone that's not true it is a blood glucose lower but it does so much more really what you need to think of insulin adds is it's your energy storage hormone insulin takes whatever is not whatever's in your blood that you're not burning right now and puts it into fat for storage now it can put it into subcutaneous fat which is kind of benign fat i mean it will grow your you know dress size but it doesn't necessarily mean it's uh dangerous or it can put it into visceral fat in which case you know you'll grow your belt size and that is very dangerous or it can put it in your liver fat in which case you won't even see it in your dress size or your belt size and it's extremely dangerous so where that fat goes has everything to do with how dangerous it is but insulin is the way it gets there and insulin resistance is the phenomenon of insulin not working right because of the fat usually in your liver so when your liver starts storing fat your pancreas has to make more insulin to make the liver do its job so let me ask you a question casey all right you're a surgeon you had to take anatomy right why does the pet pancreatic vein drain into the portal vein why doesn't the pancreatic vein drain into the inferior vena cava well i'm assuming it's because the portal veins gonna take it directly to the liver to signal there and it you don't really if it went to the inferior vena cava would go back to the heart and then circulate systemically but really it's a signal to tell the liver how to package energy exactly and the reason is because the liver is the primary target of insulin action and so the pancreas drains directly into the liver in order to tell the liver what to do that is so interesting i actually didn't totally know that about that insulin drains into the directly in the liver yeah so there are two portal systems in your body now for the our audience who don't know what that means okay everywhere in your body blood goes like this heart aorta artery organ vein vena cava heart that passes through one organ on the way back to the heart a portal system goes like this heart aorta artery organ one vein organ two vein inferior vena cava heart passes through two organs to get back to the heart and there's a reason is because there's signaling that goes on at organ one to tell organ two what to do and there are only two portal systems in the body here's one hypothalamus pituitary which i'm an expert in as a neuroendocrinologist and the other is pancreas liver the pancreas is telling the liver what to do and when the liver is not doing what it's supposed to the pancreas has to work harder to tell the liver what to do so when you get liver fat and it turns out 45 of americans now have liver fat when they never had it before when you get liver fat your liver is not working right when your liver is not working right that's going to raise insulin levels all over the body because the pancreas has to tell the liver what to do it has to make more insulin to make the liver do the right thing well that extra insulin all over the body is what's going to cause all of the chronic metabolic diseases that we know because insulin is not just the diabetes hormone it's not just lowering blood glucose it's also causing cell proliferation in places it shouldn't like your coronary arteries or in your breast tissue or in your prostate or in your brain okay and so in fact high insulin levels have been associated with virtually all chronic diseases and cancer and dementia so insulin is good when it lowers your blood glucose and your diabetic and it's bad for everything else insulin is a good news bad news deal and so you want your insulin to be as low as possible and still do the job well the way to get your insulin to be as low as possible and still do the job is to have a liver that works and if your liver doesn't work you're screwed so what makes your liver not work in the liver that liver fat is the baddest guy in all of medicine right and the question is how did that fat accumulate in the liver to cause this problem answer sugar and how does that manifest in the lipid profile with small dense ldl and where do you find that you find that in your triglyceride to hdl ratio even though the triglyceride to hdl ratio isn't even measuring ldl so this is why this is so complicated because in fact to determine what your ldl is you have to look at the other species and the dot and most doctors don't understand this oh my gosh this is so good i i that was those beautiful description of of the pathways and the liver and um i have so many so many follow-up questions i want to ask i think the first the first question i have is another way to measure insulin sensitivity is to look at our basically a ratio of insulin fasting insulin to our glucose levels and to kind of generate and you can literally go on the computer and search for this for md calc for homa ir which is a way of testing our insulin sensitivity um by doing a ratio of fasting insulin to glucose and that's one way to kind of look at insulin sensitivity and you're saying that another good way to look at insulin sensitivity is to look at our triglyceride to hdl ratio or you could directly measure small density ldl in a in an advanced lipid testing test which most doctors don't offer but really the triglyceride adhd the reason that it offers because insurance companies don't pay for it they would offer it if insurance companies paid for it but it's about 500 bucks and the insurance companies don't want to spend 500 bucks on every you know patient in america because they they would go broke but i think a really hopeful thing that people can can take away from this conversation is that you know if your doctor's not willing to order that that's okay you can look at your triglyceride hdl ratio and get a sense of what your small density ldl is but how so how does if if triglyceride hdl ratio is sort of a proxy of insulin sensitivity how does that relate to uh fasting insulin and glucose and getting and doing a formal homa ir which is kind of like our way we look at insulin sensitivity in the research right i always drew homa ir i i always drew fasting insulin fasting glucose in my clinic on any on all of our obese patients to try to figure out are they sick with their obesity or are they not sick with their obesity are they metabolically healthy obese or do i actually have to worry about metabolic syndrome in order to do that you need a fasting glucose well that one's easy everyone does that now and you need a fasting insulin so you have to draw a fasting insulin is a fasting insulin on your standard chem panel no no your doctor has to draw it it has to be drawn separately now here's the problem the american diabetes association by the way they're the ones who don't know the difference between small dense and large buoyant ldl the american diabetes association specifically tells doctors don't draw fasting insult oh my gosh straw fasting insulin which feels to me like probably one of the worst decisions ever made by like a governing body in medicine given where we're at right now with chronic disease yeah without doubt so the question is why would they do that why would they say don't draw a fasting insulin there are two reasons and they're both garbage they're both total trash they're both complete bunk they're both by the way what they say is true but it's like true true and unrelated they have nothing to do with the problem all right so i'll tell you what they say and i'll tell you why what they say is true and why we don't care okay why why they're just completely off base you know and and so we need to basically not listen to them all right reason number one insulin levels across the country are not standardized that's true so what all right now it is true that if your insulin assays are not standardized that makes it very hard to conglomerate information you know from all different providers and make header tailors of it in terms of um universal policy so they're correct on that so what is what i say all right here's the problem the insulin assay that a cheap insulin assay i should say they're expensive insulin assays they're cheap insulin assets cheap insulin assays will pick up another species not just insulin it will pick up something called pro-insulin pro-insulin is the precursor molecule to insulin and cheap assays will not be able to distinguish the precursor from the product now in order for pro insulin to become insulin the beta cell in the pancreas has to cleave a piece of peptide called c-peptide out of the pro-insulin molecule to make the mature insulin and the mature insulin has about 20 times more insulin lowering capacity than the pro-insulin so the pro insulin is a precursor hormone it's not very potent the insulin molecule is the product hormone it is very potent so when your pancreas is stressed when you are sick when you are that insulin resistant your pancreas is trying to put out insulin as fast as it can to try to lower the blood glucose and so sometimes it doesn't have time to wait for that enzyme called prohermum convertase1 pc1 to be able to cleave that c-peptide out and so it's basically trying to just dump everything it's got into the bloodstream it to get to the liver to make the liver do its job and so what it's doing is it's dumping less effective hormone because it's dumping pro-insulin true that pro-insulin will get measured in the insulin assay and so it will factitiously raise the serum insulin level and so the american diabetes association is saying well we don't want to measure that well that's true we don't but like so what because if it's high that's telling you something that's telling you you got a problem irrespective of whether it's insulin or pro-insulin it's a problem and the patient needs to know that so yes you should still measure fasting insulin even if it's a cheap assay and even if it picks up pro insulin instead so what so that's the first problem with the ada now the second problem the second reason why they say don't draw fast against them insulin levels do not correlate with obesity that's true they don't insulin levels don't correlate with obesity and the reason is because we have metabolically healthy obese people and we have unhealthy metabolically of these people right and it turns out the fasting insulin in the healthy metabolically obese people will be low and the fasting insulin and the unhealthy metabolically obese people will be high right but insulin doesn't correlate with obesity that's right it correlates with metabolic health because there are plenty of you know fat healthy people and they need to know that they're fat and healthy and there are plenty of thin sick people and they need to know they're thin and sick and the fasting insulin is a way to tell so who cares that fasting insulin does not correlate with obesity it correlates with metabolic health which is actually more important so the reason they say not to do it is exactly the reason you should do it so in both instances in both cases what the american diabetes association says to do is based on an incorrect assessment of what it is they're trying to fix and so i have been railing against this for the last 15 years i am doing my best but it's tough well we are trying to do our part by offering fasting insulin as part of the levels metabolic health panel so that people can actually have access to it um but uh in your in your practice what are you looking to shoot for for a fasting insulin level well the lower the better obviously it can't be zero right zero then you have diabetic kidney since type one yeah and well that that's not so good how close to zero can you get actually this is a question that comes up a lot you can get pretty low i mean basically the fat the the insulin assay is you know sort of the lower limit of sensitivity is two so if it's under two and you're still you know uh vertical um you're you're terrific you know and marathoners will have you know fasting insulins less than two um really if you're fasting insulin is anywhere under six seven you're in fine shape yeah if it's under 10 you're still in good shape once you get above 10 you're starting to it's starting to be a question if you get to 15 you've got some insulin resistance and i think it's like given what you were saying earlier about the liver and the portal vein it's like it makes it so much more clear like if the body is producing more of this insulin it's likely in response to the liver kind of not responding to it well so as it's getting higher it's a sign of dysfunction happening in an organization that is critically important for all aspects of our health so the fasting insulin isn't just telling you about the pancreas it's actually telling you more about the liver yeah how do you um this is probably out of the scope of this conversation but i think um since liver liver is so liver is like not an organ i think the average person is thinking about and yet we should all be thinking about it literally nonstop and it is our detoxification and when it's not working then toxins run rampant that's how you have to think about it i have found that especially in in residency and and just in training people often kind of just like gloss over the liver function tests like asta alt billy rubin et cetera obviously if billy rubin is high there's certain biliary problems that people think about but often like ast and alt are just like oh okay if they're normal they're fine like do should we be caring a little bit more about our liver function testing i know you talk about this in the book but i think you know that's just tests that i think the average person just never think about and i i feel like there should be like a renaissance of us thinking a little bit more about our these levels and as a sign of of liver health so what are your thoughts on those without doubt without that um liver function tests are extraordinarily important and you can interpret them they they're very interpretable uh and uh i teach people in the book you know as to what they actually mean the test that's probably the most abused is the alt which stands for alanine amino transferase back 45 years ago when i entered medical school it had a different name it was called sgpt but it's it's the same test it's done the same way right alt is just a little easier off the tongue all right and what it tells you about is liver fat tells you about the amount of liver fat now the problem with this test is the normal range so the normal range currently if you got yourself a chem profile and you looked at alt and you looked at more orange it would say less than 40. so if you have an alt of 39 it's telling you you're fine because you're within the normal range garbage wait 39 is way too high yes way too high now why is the alt less than 40 why is that the the cutoff when i went to medical school 45 years ago the upper limit for alt was 25. it is now 40. what happened how come 45 years ago it was a whole lot less is it because you're trying to create business for the liver transplant industry something like that but the reason is because the entire normal curve has shifted to the right because how do you get a normal range anyway where does it come from well you go to a laboratory and they do thousands and thousands of tests on ostensibly and i put this in air quotes you know healthy people because most people don't know if they have liver fat right it's one of those silent killers like hypertension they don't know that they have a problem and so they get their blood drawn and it turns out that over the last 45 years this thing called fatty liver disease has overtaken america 45 of americans now have fat in their liver when they didn't before and so they have a higher alt than they did 45 years ago and so the gaussian distribution has now all been shifted to the right and so you end up drawing you know you look at the mean and then you do two standard deviations from the mean and that's where you draw your line for what's normal and so it used to be less than 25 and now it's less than 40. so the question is is less than 40 normal well it's within two standard deviations of the current mean what makes that normal because the current mean is that we all have chronic illness that's right yeah or not all but like 88 of american adults have metabolic dysfunction so the genius yeah right so like why would you use that number so that's the that's the problem so the problem is not the test the problem is the reference range yeah the problem is the interpretation of the test so if your doctor knows how to interpret that test and i explain that in the book as to why this is okay then they would understand that any alt above 25 and if you're african american any alt above 20 is cause for concern yeah and it's that's liver fat until proven otherwise then you have to say okay why in the world would you have liver fat and what are we going to do about it because the goal is clear the fat out of the liver to make the liver work right so the pancreas can basically rest and do its job properly lower levels of insulin all over the body and prevent chronic metabolic disease um okay so since we're coming up on time i feel like we could literally go on for three more hours about all this stuff it's this is so helpful i really hope that what people are realizing is that all these tests need to be looked at in the context of each other and they're not all separate things these are not like little separate liver silo insulin silo glucose silo cholesterol silo it's all this beautiful picture and we actually all no matter whether you've not gone to medical school whatever have the power to understand these in context of each other and really get a sense of our holistic metabolic health so these are the take home like points that i think we've talked about that i'll run through and then if there's anything that you know you think we should clarify we should um one get don't worry like don't think about the total cholesterol number kind of throw out that number total cholesterol is fairly meaningless it's uh completely meaningless if you're if your hdl is a hundred your total cholesterol it's going to be high and like and you're going to live you know to be 180 you know so like why do you care about your total cholesterol so that's exactly that's the thing that has to go i the fact that they even reported out i think is uh specious right and my total my hdl cholesterol is a hundred and so my total cholesterol i don't i don't think it's in the elevated range because my ldl and triglycerides are pretty low but it's like that's being that that total number is being made up of the good thing you know and we don't we don't in any way show that to people so so throw out the total cholesterol number then look at your ldl um and ldl alone not very useful and if it's elevated that does not necessarily mean you immediately should jump on a statin first thing to do is to look at your triglycerides and your hdl um triglyceride to hdl ratio which you can calculate on your iphone calculator um generally speaking if this is over 2.5 to 1 in caucasians or over 1.5 to 1 in african americans that means there's a problem you want to keep it below those numbers and pretty much ideally for everyone i think generally speaking if it's less less than 1.5 to 1 that's a good thing but lower is better well lower is better i won't argue that the question is when is it high that you have to do something and that's where you know the art of medicine you know has to play in and that's what you know doctors are not you know they're not looking at that issue totally with ldl when you're looking at your triglycerides if it's less than 100 that's a good that's a good thing that's probably an indication that your you know your small density ldl is not through you know super high um so take a look at that number um with hdl we want it to be high um right now i think it says above 40 unlike most reference ranges it says like keep it above 40 for men and above 50 for women um it should be it should be way higher than 40 if you can help it i mean if you're down at the 40 level you're not doing that well right so we want that up in like the 80s 90s 60 and above if you can get it there but a lot of the problem with hdl is a lot of that is genetic yeah and so you know if you're if you've got a family with you know really good genetics my wife's got a an hdl of 98. she's probably related to you but yeah but basically if your dog if you're if yours is like 41 and your doctor's like oh great your hdl is normal like get it we need to get it that's not that's not that's not that normal next thing i'm hearing is sugar is driving the liver fat liver fat is what's making us insulin resistance insulin resistance is driving our dangerous small density ldl levels we need to figure out how to get the liver fat down that would be my next question after this um and then my last thing is liver function tests if you happen to have those which most people will if they're on their physical look at your alt if it's above 25 you really should be looking into that um is that is that fair in terms of absolutely fair and still all things your doctor doesn't know right oh i want every single one of my friends from residency to listen to this episode i think it's so important um and it also makes looking at labs way more fun like this is fun this is the fun part of medicine looking at the screen on epic and just seeing if there's any red check marks like that's not fun this is this is a puzzle this is this is how you know medicine used to be practiced right because we actually you know looked at the physiology this is the physiology right yeah oh and then last take-home point i think that we talked about is um ask your doctor to get a fasting insulin test ideally it should be less than six um and if you cannot get that um certainly look closely at your tracheal steroid hdl ratio um okay so wrapping up um in the last three minutes how do people get rid of their liver fat the easy answer get rid of all the sugar beverages in the house that's the easy answer okay sugar is the driver of liver fat without question oh by the way alcohol is the other driver yeah yeah well no people know that they don't know about the sugar so alcohol and sugar are metabolized the same way they get both both get turned into liver fat they both cause chronic metabolic disease that's why children now get the diseases of alcohol without alcohol because sugar doubles for alcohol uh that's the first way the second way is exercise because exercise will burn off some of that liver fat and the third way is intermittent fasting because that gives your liver a chance to burn off some of that liver fat so those are the three easiest ways metformin can help it's not perfect for that purpose but it can help um there will be other uh drugs down the coming down the pike for non-alcoholic fatty liver disease they're not ready yet they're not ready for prime time they all have side effects um you know we're not ready for that yet so get rid of the sugar start with that and i would just add um getting rid of the refined carbohydrates like anything made with white flour i i've definitely seen for my patients that just go they just make the commitment to like avoiding processed foods meaning you know no white flour no refined sugar like i said several patients who have dropped 80 to 100 points on their triglyceride in a month like and within the first week it can sometimes drop 30 40 point i mean it's it's it changes so fast when you get this crap out of the diet and so but for the average you know i think the liquid sugar that's like a super easy one to just like get rid of immediately exactly right those are the easy things to do because they're within everyone's purview yeah all right um you if if your doctor doesn't understand any of this okay we'll you know give them this book for christmas present and that's pointing to metabolical metabolical give them that as a christmas present and hopefully you know maybe they'll like read it everyone give i mean i think metabolical um is like the best possible gift you could give to a family member because it's a book of empowerment you know and it gets people to think for themselves it gets people to wake up it gets people to have actionable tools to do the things that are going to have the highest leverage impact on your health so this is amazing i am so excited for this episode to come out i think it's going to really really help people thank you so much rob um and i cannot wait for the follow-up conversations to this i think we probably have more episodes we could do on this topic we can probably do a year's worth of episodes but this is a great i think this is a really great overview for people so sit down with your cholesterol test your cholesterol panel and um and get to work [Music] you