2 cardiologists discuss how to avoid a heart attack

0:00 Hello everybody.

0:01 Today I'm doing something slightly different for the channel.

0:04 Now, I've often joked that the videos I make are clinically useless.

0:08 Maybe there's some interesting trivia.

0:10 There's probably some lousy jokes,

0:12 but actionable advice, I'm not always so sure.

0:15 So, when a very clever friend of mine uh fairly unexpectedly

0:19 actually told me that he's written a book about heart health,

0:22 and I knew I'd be meeting him at a conference fairly soon,

0:24 I thought it would be the perfect opportunity to record an interview.

0:28 And I think this conversation will be of interest to anyone uh

0:32 keen on knowing how to maintain a healthy heart and cardiovascular system.

0:36 But it's probably of most interest to those in their 30s, 40s and above.

0:41 Uh specifically focusing on midlife as a crucial time

0:46 in your life to invest in your future health.

0:48 And while good habits are important at any age,

0:51 it's really around 40 that the risk starts to more significantly edge up.

0:56 a landmark that I passed a few years ago.

0:59 It's not a naval gazing 4-hour discussion

1:02 about some unproven and niche or expensive

1:06 product or supplement which will at best

1:08 give you a tiny minuscule return on investment.

1:12 No, this is simple stuff, straightforward advice based on the best

1:16 available data with the highest yield outcomes.

1:21 So, who is the friend I'm talking to?

1:23 Well, Dr.

1:23 Hi Bulock is a fellow interventional cardiologist like me.

1:26 But unfortunately for me that's where our resume similarities

1:30 end because Hiraj is a bit of a genius.

1:33 He's originally from the beautiful island of Maitius in the Indian Ocean which

1:39 had uh I don't believe had a established medical school when he finished school.

1:43 So he won a scholarship to learn medicine in Beijing.

1:46 Now something you may not know about people from Maitius

1:48 is they pretty much all speak about four languages.

1:52 French, English, Creole, Bhjpuri.

1:54 So, learning Mandarin in a year was clearly just a walk in the park for Hiaj.

1:59 And by the way, he subsequently went on to learn

2:01 Italian to woo his wife and Spanish because, you know, why the hell not.

2:06 Now, I replaced HiJ as a PhD

2:09 fellow researching heart attacks using MRI scanning.

2:13 And not a day goes by without me

2:15 sympathizing with our poor PhD supervisor who must have

2:18 had the worst case of whiplash in history

2:22 when the quality of fellow deteriorated so sharply overnight.

2:26 Apologies.

2:27 Um he works at the second busiest cardiac center

2:30 in the UK where he is head of interventional research.

2:34 It's widely published in in the field.

2:35 So I won't keep you much longer uh from our conversation

2:39 which I hope you will find uh interesting and useful.

2:42 It was recorded in my hotel room at the London Hilton Metropole.

2:46 This video is not sponsored, but and if anybody from Hilton is watching,

2:49 I'm very willing to accept a free hotel stay, preferably somewhere tropical.

2:56 And um I have to apologize as well because it is me.

3:00 So even though uh in spite of being on YouTube for something like seven years,

3:05 I am still a complete amateur.

3:07 Somehow the camera on me failed for part of the recording.

3:12 So, I'll use some very high-end AIdriven

3:15 CGI to digitally replace my face where necessary.

3:18 You probably won't even notice because, you know,

3:21 truly amazing the stuff AI can achieve these days.

3:24 But the camera on Hirage, uh, which is the main one, worked throughout.

3:27 Or if you're listening to this as a podcast,

3:30 as all new midlife crisis videos are now available simultaneously as podcasts,

3:34 at least the long ones, then well, this whole paragraph is irrelevant and you're

3:38 probably feeling quite proud of yourself, aren't you?

3:40 All right, here is my chat with Dr.

3:43 Hiroj Bulock on his book Heart Reset 40.

3:47 Hi, thanks so much for joining me.

3:48 We're busy with a annual conference of cardiologists.

3:52 I thought this was a great opportunity to have a bit of a chat.

3:55 So my friend Hiroj has written this book and um it's called Heart Reset 40.

4:02 So what does that mean?

4:03 Yeah, thanks Roin.

4:04 Thanks for organizing this.

4:05 It's a pleasure to have a chat with you about the book.

4:08 What does it mean?

4:08 So probably the idea is um myself being my 40s and having

4:14 treated heart attacks for a few years now like you you

4:18 would agree with me that we are seeing more and more patients

4:20 presenting younger and some of us younger than us myself being 47.

4:25 So we try very hard to treat them in the lab

4:29 and then advise them all the strict things afterwards.

4:31 But then it started to feel a bit wrong

4:34 like swimming against the tide when disease has already formed.

4:38 So that made me think I should optimize my heart health.

4:41 And along the way I thought actually there's nothing out

4:43 there that put everything in one place that's practical and hence

4:48 that's the idea to put it in a book and share

4:51 it with my peers and with everybody else out there.

4:55 And there's a bit of personal background here

4:57 that that kind of motivated you as well.

5:00 Yeah.

5:00 Yeah.

5:00 That's correct.

5:01 So I lost my father when he was in his 30s at the time.

5:05 We don't know the exact cause but that's also

5:07 at the back of my mind for me to be

5:09 more aware of you know our heart health what's

5:12 going on inside even if you don't have symptoms

5:15 and that's also part of the motivation.

5:18 So this is for general public this for anybody to to pick

5:21 up this book or is it aimed at sort of a specific demographic?

5:25 Yes that's a good question.

5:26 So it's called heart reset 40.

5:29 But the idea is it's for anyone in the mid30s,

5:32 40s, 50s and beyond who are in their midlife.

5:37 They feel fine overall but something is not quite right.

5:41 Probably the energy levels is dipping, their sleep is a bit lighter,

5:45 stress levels are a bit more and probably the parameters in terms of blood test,

5:50 blood pressure or borderline.

5:52 So this is aimed at them when they don't have a lot of symptoms.

5:55 they feel fine but actually deep diving into the book make them being aware

6:00 of what can be done now to change things from happening in the future.

6:06 And the reset in the title this is a framework that you've coined

6:11 before we dive into each topic and and sort of explore the nitty-gritty.

6:16 What what what is the the reset?

6:19 Yeah.

6:19 So I think the idea was not to make it

6:21 as a rigid program that you had to abide by religiously.

6:26 So it's more a framework um that's flexible okay

6:30 you know to to stick to a program you need

6:33 ideal conditions but life is not always ideal you

6:36 know you get busy you get ill um you drop

6:39 off the program and whereas reset the framework is

6:43 more about you can jump it at any time small

6:47 habits that compounds and probably we'll dive in what it

6:50 al it's as you know the R is for routines

6:54 eating sleeping All the stress could be included in that as well.

6:58 Exercise and then eventually tracking.

7:00 So the idea is it's a framework that you can use to guide you

7:04 but not to religiously abide by and you can jump in and out anytime you want.

7:09 Yeah, that's what I I I liked a lot that, you know,

7:12 in contrast to a lot of very prescriptive stuff,

7:16 as I'm sure um anyone who's who's seen my stuff before would know,

7:21 I I get very frustrated with a lot of the influencers

7:24 out there and a lot of the advice that's very highprofile,

7:28 which is often extremely not only prescriptive, but sort of spuriously detailed,

7:35 like you need to have 0.6% 6% of the you

7:38 know all these very very exact numbers and it feels rigid

7:42 and what I liked about this is you said you're not

7:45 following a program it's it's more just sort of a a guide

7:50 framework to to make these changes and and uh try

7:53 and avoid developing cardiovascular disease and what why should anyone

7:58 be in interested in cardiovascular disease in particular why not

8:02 why aren't we talking about cancer and and things like that

8:05 yeah that's a good So probably first of all

8:08 the the biggest killer worldwide is cardiovascular disease.

8:11 Um but although this focuses on heart health but it

8:15 by optimizing your heart health you're also optimizing your general health.

8:19 A lot of the the the tips and tricks not

8:22 only improve your heart health but overall health as well.

8:24 So you will have other additional benefits.

8:27 It's not although the focus is hard but you would

8:30 eventually benefit overall in terms of stroke prevention and overall health.

8:35 Yeah.

8:35 And it's all about preventing it,

8:36 but probably delaying things from happening as long as you can.

8:39 And

8:40 you know, you mentioned obviously 40 is is in the title.

8:43 You mentioned it's kind of 30s, 40s, 50s and beyond.

8:47 Why is midlife uh and I've got a vested interest here

8:51 as my channel is called midlife crisis and and I am in midlife myself.

8:55 Um why is that a important time?

8:59 So yeah, so midlife to me for some people

9:03 may feel like it's it's the decade of decline,

9:06 but actually I'm trying to position it as as the decade of opportunity.

9:11 So that's the time when you know there's shifts in hormones.

9:14 For example, in men, your testosterone gradually starts to dip.

9:17 In women, they start to have your estrogen start to dip.

9:21 So these hormonal changes start happen in in midlife

9:24 and that ends up leading to increased fat around your waist.

9:30 So increase in visceral fat,

9:32 increase in in insulin resistance and that leads to downstream

9:36 effects with your lipids and blood pressure and things.

9:39 So now it this decade probably is the decade of opportunity

9:44 because even small habits small changes which we will talk

9:49 later in this decade will reap the maximum potential benefit compared

9:53 to the same habit you do 10 or 20 years later.

9:57 So hence focusing on this particular decade the same thing you might be

10:00 doing in your 30s may not impact you as much as it does now.

10:03 When when does cardiovascular disease start?

10:05 Yeah.

10:05 So that's a a topic you know quite a hot topic.

10:08 So, we tend not to realize it,

10:10 but there's been studies out there looking at autopsies

10:13 of of young adults involving road traffic accidents.

10:16 And actually, surprisingly,

10:18 a lot of them in their 20s start having signs of fatty streaks in their vessel.

10:23 These are microscopic,

10:24 but they're the start of plaques starting to develop in your 20s,

10:28 and this gradually builds up in your 30s and 40s

10:32 without you realizing it because it doesn't give you any symptoms.

10:36 Yeah.

10:36 So that starts quite at a young age for most people.

10:39 So just tell us a little bit about that plaque

10:41 development because we we use the term lesions plaque and all

10:44 these things but I think to the general public they're

10:47 not familiar with these these phrases that we tend to use.

10:50 So you know I often find when I'm explaining to patients

10:53 some of the analogies we use are a little bit limited.

10:56 You know because we we talk about clogged pipes

10:58 and and things like that but actually it's not really that simple.

11:02 It's not a case of just 50% is double the risk of 0% and 80% is you know it's

11:09 not a linear progression like that and the characteristic

11:14 of these plaques these depositions um can affect the risk.

11:18 So so tell us a little bit about what you mean when you

11:20 say that we see development of fatty streaks or or plaques like that.

11:25 Yeah, that's that's a very interesting question and actually one

11:27 of your uh or a group of your subscribers asked the question,

11:30 can we unclog a clogged artery?

11:32 So probably that would answer that question as well.

11:34 So I think over time in our lifetimes as you said it's not a binary thing.

11:39 So gradually there are insults that causes damage

11:43 to the lining of our arteries of the inner lining.

11:46 So be it high blood pressure, glucose being high etc.

11:51 Or so what happens is these your your your fat particles

11:57 in which are the atherogenic one

11:59 the harmful ones which carries cholesterol predominantly

12:02 LDL which is the so those fat particles penetrate the lining

12:06 and some of them will come out but most of them get trapped.

12:09 So when they get trapped your immune system goes into action try to engulf

12:15 it and inflammation happens but eventually

12:18 those develop into what we call streak.

12:21 So there's small deposits of plaque within the lining of the artery.

12:25 So it becomes part of the your vessel lining.

12:27 It's not sludge inside the vessel.

12:30 So with time this plaque what we call plaque

12:33 this deposit of lipids will mature will expand you

12:39 will develop a fibrotic cap like a layer on top

12:42 and some of that can become hardened or calcified.

12:46 So so yeah it's a gradual process it happens over time there are different

12:51 stages and the issue is not about

12:55 delaying or or preventing or regressing plaque.

12:57 It's more about stabilizing it,

13:00 delay the progression and reduce the inflammation.

13:03 So it's a bit like in the book I mentioned,

13:05 it's a bit like a zit that gets inflamed and if it ruptures that's when

13:09 your body tries to repair it and then

13:11 that's when heart attack or stroke happens.

13:13 The idea is to pacify those those scars

13:16 or or layers of of of thickening that happens

13:19 with within the vessel to prevent inflammation and eventual

13:24 plaque rupture that leads to the cascade of events downstream.

13:28 So to kind of drill down on that question

13:31 that you highlighted which is um yeah a lot a lot

13:34 of people were were voting for that one but I'm

13:37 I'm frequently asked this question about can you unblock arteries.

13:41 So what you're saying is it's not so much about unblocking them,

13:45 it's about making them more quiescent, lower risk.

13:48 Yeah.

13:48 Although there has been some studies like more than 20 years ago now showing

13:52 if you do if you on a low-fat plant-based diet and strict lifestyle changes,

13:58 there might be a little bit of plaque regression, but overall the idea is yeah,

14:04 it's not too you can't really regress it

14:07 cause that's build up in in your artery.

14:10 Um it's about as you say make them pacify them

14:14 and stabilize them so that they don't cause downstream problems.

14:19 So let's do a little whistle stop tour of risk

14:23 factors and that's kind of how you structured the chapters.

14:26 Um and and this is very something very familiar to to all doctors

14:29 because there are sort of several questions

14:31 we ask to look at cardiovascular risk.

14:34 Um, so why don't we start with one I think that perhaps gets

14:37 a little bit overlooked in the in the popular media which is blood pressure.

14:41 I think we'll certainly talk about

14:43 cholesterol which which is absolutely something

14:45 that deserves attention but I see much

14:48 less discussion in online circles about BP.

14:52 So give us a little crash course in blood

14:56 pressure and and sort of how that affects health.

15:00 Yeah.

15:00 So probably in the book I mentioned blood

15:02 pressure refers to the pressure your artery feels.

15:04 So with each contraction it's the pressure your arteries

15:08 will feel and over time the constant pressure rising is

15:13 a bit like your arteries being hammered each time with each

15:16 heartbeat and it's as I call it a silent hammer.

15:20 So over time this silent hammer with your blood pressure creeping up it's not

15:25 a binary overall although we label it as hypertension borderline or not but it's

15:30 it's a linear uh direction so over time your artery will suffer some some

15:37 damage to the linings as we described and as I called it's a silent

15:43 killer so there is no symptoms there is your arteries have been put under

15:48 stress if it's been high over time without you realizing it and that would

15:52 lead to the to the downstream effect of you know your your um apo

15:58 B and your LDL cholesterol entering the linings

16:01 and causing hardening of the arteries etc.

16:04 So most of the time we don't have any

16:07 symptoms until it's it's quite advanced and and that's

16:11 why I mentioned in the book it's quite

16:14 important to know what is your blood pressure.

16:15 So you have the systolic blood pressure and the diastolic So the systolic

16:20 is the pressure when the heart contracts and exerts it in in the vessel.

16:24 Diastolic is more when the valve is closed.

16:27 The the the artery is under resting conditions

16:31 and the pressure that it exerts against the wall.

16:33 So knowing those numbers ideally nowadays we say we

16:36 should a optimal is less than 120 over 80

16:40 and knowing that number you know at home

16:44 getting a blood pressure cuff is a good investment.

16:46 Yeah.

16:46 I mean they're pretty pretty cheap these days.

16:48 you can you can buy them quite easily.

16:50 So when should people start checking the blood pressure?

16:53 So probably in midlife I would say.

16:56 So uh I don't think we should get overly um obsessed with the numbers

17:02 in in our 20s or 30s unless there's

17:04 a strong family history or ethnicity and things like that.

17:07 So I would say in your in your 40s a good time in the NHS as you know

17:13 we have a health check at some point in men in in the 40s, women in the 50s.

17:17 So you would have an idea then but also it's a good

17:19 time to buy a blood pressure cuff and check it at home probably

17:23 to start with once a month but if it is more than the number

17:26 I mentioned 120 or 80 maybe it's worth checking it twice a day

17:30 for a week get an average if it's normal range then you just

17:34 once once every six months or you don't need to be too too strict

17:38 about it or obsessed about it but getting an idea what's happening and when

17:42 life circumstances change or more stressed

17:45 it's worthwhile checking what's happening as well.

17:48 And I mean I I I don't want to say this for each of the risk factors we

17:53 go through cuz the advice is pretty much the same

17:55 like the things that address each of these is

17:58 the same but um perhaps if we start now and we and we just kind of refer back

18:03 to it but what are the things aside obviously

18:06 from pharmacological intervention that can bring your blood pressure down?

18:10 Probably one of the underrated activity is walking.

18:14 So you know you know walking bris walking specifically

18:17 for if you walk bris walk for 20 minutes a day

18:20 that's a very good activity even part of your you

18:24 know we call it the nonex exercise activity thermogenesis.

18:28 So even taking the stairs or parking a bit

18:30 further away at the supermarket or at work.

18:33 So walking moving every day even if it's just walking and if you can do bris

18:38 walking even better that has a big impact

18:40 on blood pressure especially if you start early.

18:43 Yeah.

18:43 And and then there are things about in in terms of what we eat

18:47 being cautious about ultrarocessed food which is

18:50 rich in in salt or sodium contents.

18:53 So being mindful of what's going on our plate and how much sodium

18:58 we're having or or salt overall because probably at home most of the salt

19:02 we eat is a minority of what enters our diet compared to the processed

19:07 food we have which is the bulk of the the source of sodium.

19:10 So that would be the second thing.

19:12 The third thing would be make sure we sleep adequately.

19:15 So a minimum of seven hours uh and also good quality sleep.

19:20 So especially in our midlife weight starts to creep up.

19:23 Some people starts to snore.

19:25 If they develop you know sleep apnnea as we call it you know

19:28 they have times overnight when your breathing

19:30 is affected your oxygen level dips.

19:32 That's a a cause of hypertension as well.

19:34 So that's something to be mindful.

19:37 Um and lastly is managing your stress.

19:40 So um we don't really realize it

19:42 but probably stress we can't really eliminate stress

19:44 from our life probably but we can find ways to to cope with it better

19:49 for our body to respond to it better in terms of bre doing breathing exercises

19:54 you know mindfulness going for walks helps and sleep as well you know would help

20:00 yeah so I mean we'll refer back

20:02 to these these kind of core pillars um but moving

20:06 next on to cholesterol or lipids And this is

20:10 something again I think that that a lot of people ask about and and you know get

20:16 conflicting advice and I don't want to drag you

20:19 into the murky world I inhabit of um social

20:22 media uh well one you just referred to salt.

20:26 I don't know if you've heard about the the salt truthers

20:28 and people who claim that salt is is actually not harmful at all.

20:32 Um this has become a popular trope.

20:34 I don't know if you've these are very influential public figures who

20:38 say that actually you know salt is is uh not not the problem

20:42 we've been led to believe and um they even promote salt supplements

20:48 um to uh you know not just exercise related electrolytes but I

20:54 think um there's unfortunately some conflicting

20:56 evidence there but certainly when it

20:58 comes to cholesterol that's a bit more um prevalent in that a lot

21:03 of people who maybe uh have embied some of the propaganda around

21:10 um the carnivore diet and things like that which are very meat heavy.

21:15 Obviously carnivore is meat heavy but there are other diets which which are not

21:19 as strict but still involve a lot of meat and people are being told

21:23 and publishing you know some people I

21:24 see putting their lipid profile online which

21:28 you or I would kind of be a ghast and they say this is fine

21:31 this is this is not a problem so let's have a bit of a general

21:36 discussion about when again when when's a good time are you going to say

21:40 midlife again to start checking uh cholesterol

21:43 I mean should should a 25year-old y old

21:45 who doesn't have a adverse family history

21:47 should they be worried about checking their cholesterol

21:50 probably not in your 20s or 30s those time

21:53 of our life your body adapts very well

21:57 and copes very well to changes so as you

21:59 said if you don't have a strong family history

22:02 uh I wouldn't recommend checking it at that time

22:05 it's more when our biology start to shifts

22:08 you know in our 40s and onwards that would be a good time to to get a baseline

22:13 lipid panel and what are the numbers that people should be remembering.

22:18 So the main one would be LDL.

22:21 So the way I remember it, although it's not technically lousy,

22:24 but LDL is considered the bad cholesterol.

22:28 HDL is the healthy cholesterol.

22:30 So LDL would be a number to pay attention to.

22:33 The total cholesterol doesn't really give you what's

22:36 happening because when you get your blood result,

22:37 you have total cholesterol, LDL, and the calculated the LDL and the HDL.

22:43 So the number important number would be LDL.

22:46 Ideally the optimal number should be less than 2.6 in the UK units.

22:51 So mill per liter.

22:52 Ideally if you can get it to 2.6 or lower that would be optimal.

22:56 But anything 3.4 to 2.6 would be you know near optimal.

23:01 Anything higher than that probably you need to try hard to to

23:04 with your lifestyle measures and and exercise

23:06 and things to try to bring bring that down.

23:08 Then there's the triglyceride as well which also plays a role

23:12 and indirectly gives you an idea of your insulin resistance.

23:16 There's some people use there's a ratio of your HDL

23:19 to triglyceride indirectly gives you an idea how you know

23:23 insulin resistance is happening in your body whether there is

23:26 so that would be the two things LDL and probably triglyceride

23:30 and how about some of the the the newer

23:32 tests which are not always routinely available liver

23:36 protein APO B people have heard these terms are

23:40 these also things that they should be worried about

23:43 probably to start with I think we don't routinely best for it.

23:46 But to start with, I wouldn't say you

23:48 have to definitely get an idea what's your APO.

23:50 So going back, Apo B as I put in the in the book,

23:54 um if you imagine APOB are the protein particles.

23:58 They're the delivery trucks in your in your vessel.

24:01 Your cholesterol particles are fat and and blood is watery.

24:05 So they don't carry very well.

24:07 So the the cholesterol the fat particles needs to tag on the trucks

24:12 to be able to be transported where they need to go.

24:14 So the apo B carries LDL.

24:16 So they're the delivery trucks.

24:19 Um the more delivery trucks you have the more you

24:22 will have in so having high apo B is harmful.

24:26 But indirectly if you know your LDL level

24:28 and your triglycerides which is also being transported by part

24:33 of the we call it VLDL without being too technical

24:36 but by your by your harmful um atherogenic particles the apo.

24:41 If you get an idea of LDL and and triglyceride indirectly,

24:44 you will have an idea what's your APOE B is, but it's not perfect.

24:50 I don't think you need to be very strict to look for it.

24:52 If we have it, it's a bonus because we do

24:54 have some patients we've seen the LDL numbers are perfect,

24:57 but they still present with with issues with heart attacks.

25:00 Very likely their APOB levels are still not optimal.

25:04 But to start with, I would say stick with LDL triglyceride.

25:07 If you have access in the future, APOB would be useful.

25:12 And then we have the LPA.

25:13 You may have heard LPA is so is another component of the APOB.

25:19 So when you have APOB with LDL and then

25:23 there is another particle uh APO A attached to it, it become more sticky.

25:27 So that would be your LPA, it's a bit more sticky LDL.

25:31 And usually this is decided genetically from birth at the moment.

25:36 So 80 to 90% of them is genetically uh predetermined.

25:40 So you just need to check it once.

25:42 But that's something still as a research tool.

25:44 There's currently no therapies although there's lots

25:46 of trials going on to try to reduce it.

25:48 That's another number which people talk about and might be useful to know

25:53 but not not essential I would say.

25:55 Now, I'm so slow editing and uploading my videos

25:58 that actually since recording this, the American College of Cardiology

26:01 and the American Heart Association have released their updated

26:04 guidelines for the management of lipids in March of 2026,

26:08 which does include now testing for liver protein little A and apoin B.

26:14 And I'm sure other health systems like the UK will follow suit soon.

26:18 And apo B, I think certainly is

26:21 a useful test which adds some additional information.

26:24 liver protein little A is slightly more

26:27 controversial because some people advocate that it shouldn't

26:29 really be tested for it because at the moment

26:31 there's no treatment for an abnormal result.

26:34 However, I think it can be regarded as an additional genetic risk factor

26:39 because the thing with liposin little A is it's essentially a oneandone test.

26:44 It's something that you only really need to check once

26:46 at some point in your life because it doesn't really change.

26:50 And if you look at it like that, then it can, you know, further inform.

26:56 Although it, you know,

26:57 I I wonder if I've actually been victim

26:59 to false reassurance because I got the lip protein little

27:02 a tested some years ago and it was kind

27:04 of new on the scene and it was through the floor.

27:07 It was incredibly low result and it made me go out and have a burger and chips.

27:12 And that's why I invite much more

27:15 sensible cardiologists like Hero to listen to him.

27:17 Don't don't listen to me is I think the moral of this story.

27:20 This is probably too big a topic for us to go

27:23 into now because there's a lot of um extreme opinions regarding statins.

27:30 And so I I think we're not going to be able

27:34 to to deal with the the huge variation in opinions regarding statins.

27:38 But I I made a a video about statins years

27:42 ago and I I would say easily that is the one

27:44 I'm emailed about and get messages about most and I

27:47 I was it was a pretty kind of agnostic video.

27:52 I wasn't trying to be too prescriptive or anything but just

27:54 trying to um deliver a a summary of of kind

27:59 of the evidence for statins and say ultimately it's it's

28:04 you know the patient's choice but they should be fully informed.

28:07 try not to believe, you know, everything you you read online.

28:10 And and and that goes for, you know,

28:12 you know, whichever kind of extreme somebody someone's adopting.

28:16 So if a patient says to you, look, doc, I'm, you know,

28:21 say they've got a LDL over five and they have tried

28:28 lifestyle measures and it's it's not really budged and they say,

28:32 "Look, I'm I'm not too keen on statins.

28:35 I've heard a lot of bad press about them.

28:38 What's the kind of how do you address sort of um approach that conversation?

28:43 What what's your general way of talking to patients who who say that to you?

28:47 Yeah, it's it's an interesting hot topic as you

28:50 know and with lots of conflicting evidence out there.

28:52 So probably the way I would answer

28:54 that to the patient is the bulk of the evidence

28:58 um points towards benefit in the long term

29:02 and there are some d you know some studies showing

29:05 you're more likely to have diabetes and things

29:07 like that but probably sometimes a bit confounded people

29:10 on statin tends to live longer and if you

29:12 live longer probably you're more likely to have diabetes.

29:14 Um on the other hand people are worried about side effects you know liver

29:19 toxicity and things but there has been

29:20 some studies where they blinded the patients

29:23 to to statin or a placebo and then in fact when they don't know

29:27 what they're taking even those having

29:29 the placebo had those muscle aches and pains.

29:32 So part of it is is is a placebo effect.

29:36 Um um but if if the symptoms are real,

29:39 they've got derange liver function test which we monitor anyway

29:43 then by all means there are other options out there

29:44 but to start with I would usually recommend to go first

29:49 line with statin and there are various groups we can try.

29:53 Yeah.

29:54 Um so one of our mutual friends uh Uni Krishnan um g did a a talk

30:01 once which I I've I've often refer back to where he looked at all

30:05 the different lipid modifying therapies and as you

30:08 say that there are different options

30:10 now and I think a lot of people have the attitude that they're all comparable

30:13 but actually you get the most bang for your buck so to speak with statins

30:17 and then these other things can be

30:19 incremental or if someone is truly intolerant you

30:22 can consider them but they they don't have the same kind of evidence base

30:26 and so just maybe briefly to mention some

30:29 of the other lipid modifying therapies out there.

30:32 What are the ones in in common use these days?

30:35 Yeah, so there are the injectables like PCSK9

30:37 inhibitors as we call them or pmpid you have

30:41 in glyceride injections twice a year you could use

30:43 and then you have pmpedic acid is another option.

30:46 So these are the ones that might help with LDL

30:50 if you can't tolerate a statin or as an add-on.

30:52 But before that they they have the Satetimi

30:54 as you've heard which works well sometimes with with statin

30:57 and again you know sort of modifying

31:00 these with lifestyle prior to starting medication.

31:04 Are we just talking the same the same advice?

31:07 The lifestyle changes would modify your environment

31:11 definitely that would help but then sometimes medication would help to modify

31:15 biology sometimes just despite lifestyle changes if

31:18 you're still not hitting this target then there's no it's not a failure

31:22 to go on medications so I would say lifestyle first as we talked about

31:26 you know exercise it's more about what you put

31:28 on your plate rather than what you don't so

31:31 there's a chapter on things like you know um more like the Mediterranean

31:35 style pattern of food for like lots of fresh fruits and vegetables,

31:39 berries, lentils and legumes,

31:42 oily fish at least two portions a week, olive oil, avocados.

31:46 So these are things if you add on your plates

31:49 and then naturally you you you reduce the the processed

31:53 foods and those have helped benefit in terms of optimizing

31:56 your lipid profile together with exercise and making and the other

32:00 things we mentioned as you said sleep and and stress management.

32:03 So I don't want to get deep into a dietary

32:06 discussion because I think it's a kind of topic where

32:10 everybody seems to have an opinion and I like

32:14 to defer to those who are genuine experts in the field,

32:16 nutrition scientists, dieticians, you know,

32:19 people people who spend their whole lives doing this and and uh

32:22 hopefully I'll have conversations with some of those people in future.

32:26 But and I'm a I'm a simple guy.

32:29 We we we're interventional cardiologists.

32:31 We're we're plumbers.

32:32 We're simple guys.

32:33 we we like to make um you know boil things down to the simple advice.

32:39 So when it comes to dietary advice from a cardiologist perspective and you

32:45 mentioned already a kind of Mediterranean style diet um lots of fresh fruit,

32:51 vegetables, legumes, lentils, uh oily fish.

32:56 um why are these things sort of why do we as as heart doctors

33:02 why do we tend to to talk about this stuff what what's the background here

33:05 I do talk about median style diet in the book but probably eventually the diet

33:11 people need to stick to is the one they they can maintain long term

33:17 and probably your body or your arteries doesn't matter what

33:21 dietary hacks you you do as long as it's balanced

33:24 it's rich in fibers because you know it's giving you

33:27 all the nutrients you need and protein is a major part.

33:31 So probably the Mediterranean pattern diet ticks

33:35 all those boxes and there are several studies

33:38 or it's the most studied diet in the literature

33:41 showing it can optimize your lipid profile,

33:44 your blood pressure, reduce insulin resistance,

33:47 reduce your triglyceride and eventually it will that would

33:51 reduce your apo we talked about the atherogenic particle.

33:54 I want to talk about pre-diabetes.

33:56 And the focus I've got here is is I've been planning uh

34:01 having this idea for a video about the new definition of normal.

34:06 And what it is is in the era of wearables

34:11 like um heart rate tracking and you know potentially

34:14 in the future blood pressure um but even continuous glucose

34:18 monitors we are getting unprecedented data which we've never had before.

34:21 you know, looking at non-diabetic patients um who are

34:25 buying continuous glucose monitors and seeing glucose spikes after eating

34:30 and then interpreting this that they they've got to avoid

34:32 whatever the food is rather than understanding the physiology.

34:36 And um even with with heart rate, you know, we're we're just up till now,

34:43 say for example, something like atrial fibrillation,

34:44 which is a pathological irregular heart rate.

34:48 um in in the trials that have you know for decades we've

34:51 used ambulatory monitoring and we've had a sort of arbitrary cut off

34:54 as you know 30 seconds this is atroofibrillation and now we're seeing

34:59 24 year olds or something where may have 3 seconds of atroofibrillation so

35:03 where do we draw the lines and I think that's that's there

35:06 isn't necessarily an answer for a lot of these things but it's

35:08 a really fascinating development I think in medicine and when it comes

35:14 to people with uh impaired glucose ucose

35:18 uh in glucose tolerance or glucose processing.

35:21 Um again we've had arbitrary cut offs.

35:24 This is diabetes.

35:25 This is not diabetes.

35:28 And I think what you're what you get at in the book is

35:31 that again this you know you shouldn't think of this this kind of binary.

35:35 You know nothing in biology is really um binary like that.

35:39 Um, so what if somebody's been told that they're, you know,

35:45 glucose is a little bit abnormal, but you know, don't worry about it.

35:49 We we'll check it again in a couple of years.

35:51 You're pre-diabetic.

35:53 How should they react to that news?

35:56 Yeah.

35:56 So, that's a very interesting question.

35:58 And just touching on your the continuous glucose monitoring, the CGM,

36:02 I have to admit I've tried it myself more out of curiosity rather than,

36:06 you know, trying to see whether I have diabetes or not.

36:08 And it's interesting as you said after a depending on the meal

36:11 you have you have a certain spike but there's also a quick

36:14 uh drop in glucose or if I go for a run there

36:18 there is a spike to come to you know to to accomodate.

36:21 Great point.

36:21 Yeah.

36:21 Yeah.

36:21 So that's one thing.

36:23 Um so probably the HBA1C as we call it.

36:27 So that's a more accurate reflection of what's been

36:30 your average blood glucose over the the last three months.

36:35 It's the glucose attached to your hemoglobin.

36:37 We call it glyc glycated hemoglobin.

36:39 So probably that would be more accurate than a random blood sugar you do.

36:43 And as you mentioned in the book we go

36:46 I probably to mention that pre-diabetes isn't pre- anything.

36:49 It's already diabetes, early diabetes if not diabetes.

36:54 And sometimes, as you said, we may someone may be borderline,

36:58 they call it, in the pre-diabetic range, and they're told we'll keep an eye,

37:02 but actually now is the time to to be more uh to take

37:08 action quicker because that's the time

37:10 when you can actually reverse um pre-diabetes.

37:14 If you for there are studies showing if you reduce your weight by 5 to 7%.

37:20 That can reverse your pre-diabetes states as we call it.

37:24 So it's it is a continuum.

37:26 It's I would say it's early diabetes if

37:28 your your HBA1C is already in that range and taking

37:32 action now has the greatest in terms of what

37:35 we've discussed you know exercise what you eat and etc.

37:38 So that would have the biggest impact to to reverse biology and prevent

37:43 you know you having established diabetes

37:45 when you would need medication downstream.

37:47 So don't be reassured by someone saying this is

37:50 this is pre-diabetes you're not not diabetic yet.

37:53 Don't don't take sort of

37:55 yeah I think I would say that you should not be reassured.

37:59 It should be alarm bell saying your body is struggling.

38:02 There is insulin resistance already accumulated and now the glucose levels

38:07 are are are not being you know regulated as it should.

38:11 So it should be alarm bells and you should take action more now rather

38:15 than just say we'll keep an eye and recheck it in a few months time.

38:19 Now this question I I think I have to declare some um uh conflict

38:25 of interest here because um we as I said we're at our annual conference which

38:31 is ostensibly about learning cardiology but I

38:33 think it's generally regarded as a pissup

38:36 and um I'm feeling rather worse for wear

38:39 because I just can't handle alcohol particularly

38:42 these days and and and drink so rarely and I've noticed that the the messaging

38:48 on alcohol has changed recently that uh

38:52 people have become quite puritanical and saying

38:55 that even a single drink is is is bad for you and and and generally

39:01 there's a move to say zero alcohol is the only kind of healthy option.

39:07 And um for someone like me who really doesn't drink,

39:12 you know, for months at a stretch,

39:14 but then has a few drinks at a a social event like like this week,

39:18 um how does that compare?

39:20 Is that truly like is it true that even a single drink is bad or is

39:25 suggesting moderation is is that is that problematic

39:28 because people will will get the wrong message?

39:31 What do you what's your general approach to something like alcohol?

39:34 Interestingly, in the past,

39:35 we used to believe red wine is is good for your heart, right?

39:38 It's cardiorive, but actually those studies were confounded by people being

39:43 on on other cardrotective things like the Mediterranean style food we mentioned.

39:49 So, the latest evidence suggests alcohol

39:52 doesn't really have any cardoprotective evidence.

39:55 So, if we want to have it, I'm not saying you should not have alcohol at all,

39:59 but it shouldn't be for heart health.

40:01 It's more for pleasure.

40:02 And I think in the book I always talk about

40:05 80% of the time if you're cautious 20% of the time

40:08 you you know your body will accept every now

40:11 and then say have a glass of of wine or beer.

40:14 So it's not about avoiding it all together.

40:16 If you can if that's your lifestyle that's that would

40:19 be good but if like us every now and then

40:21 having a glass or two I don't think our body

40:24 can cope and and can you know um autoregulate that it Yeah.

40:28 Yeah.

40:29 So I think that's that's the message I take and obviously I

40:31 I had my own answer to the question where I asked is

40:34 that I think the whole point of looking after your health as much

40:38 as you can is so that you can still endure a bit

40:43 of st and you know obviously alcohol is a is a voluntary

40:45 thing but uh you and I are on on call rotors we

40:49 get called in the middle of the night we frequently have to go

40:52 into the hospital in the in the early hours of the morning

40:55 and that's not good for your health but I spend the rest

40:59 of my time trying to protect myself against that trying to to you

41:04 know put myself in the in the best starting point so that you

41:09 know that's that's a unusual example to be on an encore rotor

41:12 but being a parent for example is a very common um example

41:16 caring for a loved one who who may have um uh you know

41:22 needs that that mean that your sleep is affected and and I

41:25 think that's a key message from the book and and just In general,

41:29 sometimes when I listen to some of these longevity influencers

41:32 who say that they're meticulously in bed by 8 8:00 p.m.

41:35 every night and they have 12 hours of uninterrupted

41:37 perfect sleep and they take uh 200 supplements a day.

41:41 I'm I'm just like are are you living like what's the point

41:44 of doing this unless it is to to live an enjoyable life?

41:48 And yeah, I don't it's not really a question.

41:50 I'm just mouth spouting off here.

41:52 But I mean I guess that you know that's that's a message

41:56 that you you've kind of got in the book as well.

41:58 Yeah.

41:58 Yeah.

41:58 Exactly.

41:59 Yeah.

41:59 So I think it's it's it's about doing

42:03 certain optimizing it our health most of the time

42:06 but allowing that buffer where you can still you know have a bit of flexibility

42:11 and you know small we're not talking about extreme changes small changes

42:15 now can have big impact and while still enjoying life as you mentioned

42:20 now stress is clearly something that is very easy

42:23 to say to someone oh you got to reduce

42:25 your stress and they're like uh thanks doctor you

42:28 know who who's going to look after my kids?

42:30 Who's going to work two jobs in in uh

42:33 an economy where so many people are struggling?

42:36 Um or all the stresses of modern life, sitting in an office all day,

42:41 sedentary lifestyles, processed food,

42:43 these these well that that's going back into the diet,

42:47 but just you know sources of stress um can

42:50 contribute to those poor dietary habits and and so on.

42:54 And is it more important to be trying to build in the micro

43:03 kind of habits and habitual movement during

43:07 the day rather than dedicated exercise periods, say the weekend warriors?

43:13 Um, which tends which do you think has a has

43:17 a higher yield or is that an artificial question?

43:19 Is it is it more important to be say an active person who's kind of moving

43:23 around much of the day but doesn't

43:25 necessarily take dedicated exercise or someone who's got

43:28 a 9 to5 where they're they're not doing a great deal but then they're they're

43:32 really cramming in some intense exercise at the weekend

43:35 is is one better than the other.

43:38 So actually probably the first scenario you mentioned is actually better.

43:41 So going back to stress probably yeah it's quite hard to eliminate

43:45 or avoid stress in our lives but it's how we manage it

43:49 and help our body not to have the biological effect and and part

43:53 of it as you say um going back to how we manage

43:57 stress it could be anything from box

43:59 breathing mindfulness or exercise and movement

44:03 probably the the first scenario you mentioned so if we suppose we

44:06 exercise one hour hard for in the morning and then six and sit

44:09 for six eight hours 68 hours during the day that doesn't negate

44:13 that doesn't you know doesn't compensate for that 1 hour exercise

44:18 in the book I mention every hour we sit ideally we should set

44:22 an alarm and walk for 2 minutes and all these you know micro

44:27 movements we do during the day will eventually compound and and there is

44:32 a word I think for not in the book but people refer

44:34 it to nonex exercise activity thermogenesis

44:37 so it's anything it's these for every

44:39 hour we sit if you walk for 2 it's or park a bit

44:42 further away or or take take the stairs in instead of the lifts.

44:46 All these will compound and actually help your overall

44:50 health and and probably help with stress management as well.

44:53 Something I hear these days in fact from a personal trainer

44:57 um who said this which was slightly concerning is that uh

45:01 weights are are cardio and there's been a very deserved

45:06 attention on resistance exercise in the in the last few years.

45:10 Um because I think you know generally people regarded exercise

45:14 for the heart up till now as you know it's it's called

45:19 cardio right it's sort of that that aerobic exercise and people

45:22 understanding that resistance exercise as part of an exercise program has

45:25 a lot of additional benefits um for other health measures as well

45:30 bone density and longevity and and maintaining strength and and things

45:34 like that but that seems to have shifted to almost

45:38 you don't need to do cardio because if you're doing weights,

45:43 you're getting your heart rate up a little bit and so that this personal

45:46 trainer was telling me that I don't do any cardio because weights are my cardio,

45:49 you know, if I do a weight session.

45:52 What do you think about that?

45:53 In my opinion, I don't think it's actually true.

45:56 So, cardio actually probably refers to uh a period

46:00 of persistent effort where your heart rate is,

46:03 you know, 70% at least of of your target heart rate, maximum target heart rate.

46:07 So cardio requires that sustained time not the intervals where it goes up

46:13 and down but sustained period where your heart is subjected to high heart rates.

46:19 We we can talk about zone 2 training but but anyway

46:21 once your heart rate is high for s a sustained period

46:26 that's when your micro mitochondrial function improve you know which eventually

46:31 leads to more cardiorespiratory fitness your V2 max we refer to.

46:35 So how efficient your cells are at at utilizing oxygen.

46:38 So cardio actually is a bit different to doing these gym

46:42 exercise where it's more like high intensity training probably more than cardio.

46:46 So I would say they complement each other.

46:48 It's not you probably need that those periods of doing at least

46:53 20 minutes of brisk walking or swimming or whatever you fancy but having

46:58 that sustained period of to start small 10 minutes but build it

47:02 to 20 minutes and there are some recommendation of you know doing 150 minutes

47:06 of moderate exercise which refers to getting your heart rate at least

47:10 to 70% of what's the maximum target heart rate or if we talk about

47:14 the zone 2 training which another way to look at it you it's

47:18 more easy way to to to look at it is if you're going jogging,

47:22 you should be able to talk to your partner next to you while you're jogging.

47:26 So that would be your zone two training.

47:27 You're not panting and able to talk.

47:30 If you're if you're panting, that's probably you're running too fast.

47:33 And zone 2 training has been shown to be

47:35 more efficient at burning fat and improve your cardiorespiratory fitness

47:40 rather than the the the anarobic the non-arobic exercise

47:45 which is when you do fast runs more for endurance.

47:48 So again, sort of trying to boil it down

47:50 to a simple advice for for exercise and and like diet,

47:55 this this is a topic that's frequently discussed and again, you know,

47:59 we're not exercise physiologists or anything, but as a overall benefit,

48:05 you're saying the message is a a combined exercise program

48:11 is going to offer sort of a wide range of benefits,

48:13 but in terms of really cardiovascular optimization,

48:18 you do need those kind of longer duration moderate uh exercise

48:24 with getting your heart rate sort of getting your heart rate up.

48:27 Yeah, I think a combination of both.

48:29 Probably two three times a week of cardio and a couple

48:32 of times a week of of weight is the right balance.

48:35 So cardio is a bit like um as you say it's good for longevity.

48:39 It's a bit like making sure your engine is welloiled for the long term.

48:42 And weight exercise is more about your metabolic

48:45 health and and to have a strong physique.

48:49 Uh so it's a combination of both that works well rather than one or the other.

48:55 Uh family history.

48:56 I think you've got a nice phrase which is

48:59 I think I encounter people that are a bit fatalistic.

49:02 They're like you know all the men in my family have

49:04 died in their in their 40s so I can't escape it.

49:08 So screw it.

49:09 I'm not going to try.

49:10 And I'm always really sad when when I hear that cuz we we

49:14 see these patients on our table who've come in with big heart attacks,

49:17 you know, often in their 30s or 40s and they've got

49:20 horrendous family history and yet they're they're smokers or, you know,

49:24 something equally counterproductive.

49:26 And and you know, I I chat to them and and they just kind of feel like,

49:30 well, this is my lot that I've been dealt.

49:33 My hand I'm mixing metaphors here.

49:35 My hand that I've been dealt.

49:37 Um, so I can't escape it.

49:40 And I think you referred to it it

49:42 as uh loading the gun but not pulling the trigger.

49:46 Yeah.

49:46 Yeah, that's correct.

49:47 So, so genes is a bit like genes will load the gun.

49:50 So, you're you're given a loaded gun,

49:53 but you decide whether you pull the trigger or not by the lifestyle you have.

49:57 So, yeah, some people may take like having a strong family history of, you know,

50:02 early heart disease as they're doomed.

50:05 There's nothing they can do about it.

50:06 So they they won't try hard.

50:07 But actually in the book we I kind of emphasized actually this is a good thing

50:12 that you know early on that you need

50:14 to be twice as cautious and start interventions

50:18 very early right compared to the normal you

50:20 know general population and the earlier we start

50:23 in these situations the more likely you're like

50:25 to bend the curve in the right direction.

50:28 Um, hence you know the the idea of although genes load the gun but it's

50:34 the lifestyle you adopt will pull decide whether you pull the trigger or not.

50:38 And is genes what's behind sort of high prevalence in in certain ethnicities

50:44 probably different ethnicities have

50:45 different predisposition to different things.

50:47 So probably as South Asians the literature would suggest they

50:51 they have higher incidence of insulin resistance or familial dysipidemia.

50:56 So that gen those genetic factors and insulin

51:00 resistance is not a good mix I guess.

51:02 So with um family history although they or genetic

51:07 predisposition to you know familial dysipidemia they alth

51:11 they're trying everything with lifestyle measures the body has

51:15 got this defect to unable to clear the LDL.

51:19 Hence these this patient very often needs medications

51:22 early on on a diet or life lifestyle changes alone would not lower their LDL

51:28 to the levels we would ideally want them to be.

51:30 There's a few hot topics.

51:32 I'm going to hit you with some

51:33 some quickfire quickfire um questions screening scans.

51:40 Um so asymptomatic patient as in they have no symptoms

51:45 of heart disease and uh they come to you and say

51:49 I want to have a CT scan of my of my heart

51:53 and we'll talk about the different types of CT scan.

51:55 Um what yes or no?

51:59 Yeah I think so the probably the the easy or safe answer is it depends right

52:04 and it probably depends where you are as well

52:06 if you're in the states or in Europe.

52:08 So I think first of all um if they're younger than

52:12 40s and they don't have a strong family history I think

52:16 usually there's potential for more harm than screening and which lead

52:20 to unnecessary tests and radiation exposure and things um if they're completely

52:24 asytomatic in the 40s and in the in in Europe

52:30 in the UK we use these curies for example in UK curis four

52:33 score so we use risk prediction scores to decide whether what's

52:37 their risk of a heart attack in the next next 10 years.

52:40 So I would probably use those to predict because doing a CT

52:44 scan to look at your arteries tells you what's happening now.

52:47 It doesn't predict what will happen in the future.

52:50 It's only those who have got the the inter the borderline risk.

52:53 So they are not they are not low risk,

52:55 they're not high risk for those groups you know

52:57 what to do is they are in in between.

53:00 Those are the ones if you're not sure whether to recommend a statin or not.

53:04 Although the evidence is not very strong and there's trials going on.

53:07 I think they're doing the Scott 2 which is coming which will

53:10 happen in a few years by the time we get the result

53:13 in those groups who are in the intermediate risk potentially there might be

53:17 a role but again um it will tell you what's happening now it doesn't

53:21 predict what will happen in the future and in the book I mentioned

53:24 something like if you want to know what's the weather like now would

53:28 you rather scroll and look at the the forecast or open the window

53:33 and look outside what's happening so that's that kind of the difference Hm.

53:37 Yes.

53:38 I think that's an important point that maybe isn't mentioned so much

53:41 that it can be falsely reassuring as well in that uh you

53:44 know you have a well we have we haven't talked about the different

53:47 types of CT scan but if the more detailed one which is

53:49 the CT coronary and which is actually imaging the the inside

53:52 of the coronary arteries using an injection of contrast um you say well

53:57 you know it looks fine you know this very minor disease

54:01 but that often you know doesn't uh tell you the the the 5 risk.

54:08 Um, as you say, it tells you what's going on now.

54:11 Um, so it it can actually, you know, give give a false reassurance as well.

54:18 So what are the there's coronary calcium scoring and and u CT corneagram.

54:25 What what are the differences between what when one should be used and

54:30 yeah so in the book I call the CAC you know the correct calcium score scan.

54:35 So that one just without contrast just looks at any hardened plaque.

54:40 So the bright spots we see and actually they can quantify that.

54:44 So that gives you an idea of PL burden many calcified PL burden.

54:48 Whereas when you give them contrast to do the coretic

54:51 corog it looks what's going on inside the lumen

54:54 as well and actually can highlight soft blocks which

54:57 can be missed with a with a C scan.

55:00 So they are different.

55:02 One is giving you PL burden.

55:03 One is trying to tell you whether there's an illumininal stenosis or not.

55:08 But that's always overestimated if there is any stenosis.

55:11 If especially they have a lot of calcium as you know with blooming artifact,

55:15 you can overestimate the degree of stenosis and it

55:19 can also highlight any soft or high risk plaques.

55:22 Yeah.

55:23 So the overestimating is is an important point because then it

55:26 can often lead to a subsequent test which is an invasive test

55:29 an angio in many cases and um which you know brings risks

55:34 and so I think that that's a message that I try and emphasize

55:39 as well is that uh it's very tempting to to see

55:42 these as oh you know what's wrong with getting additional information but it's

55:45 not as simple an an equation as that because you know

55:48 it can end up with with an invasive test and And often,

55:53 you know, the young patients with low risk seem to be the ones

55:58 that have catastrophic complications in in in um something like an angagram.

56:03 So, and then you're left asking should should we really have been doing this?

56:08 So, um okay, that's uh screening scans.

56:12 You you interestingly said that you've tried a continuous glucose monitor.

56:16 Now, you're obviously someone with with training

56:18 in the field and understanding of medical science.

56:21 What do you think of non-diabetic people using these now

56:27 um in general and how they're maybe misinterpreting what they're seeing?

56:34 Yeah, I think it can be dangerous in in in in hands of the general

56:38 public without any supervision

56:40 of the of the any medical profession uh professionals.

56:44 So probably it can help to inform how

56:48 our body reacts to what food we are eating.

56:50 probably different people may have different reactions to it.

56:54 I think for a short term for curiosity it's fine.

56:58 It kind of informs you, okay, if you eat this type of diet, you get a spike.

57:01 And and probably when we don't monitor it, recurrent long-term,

57:06 you know, frequent spikes, which is harmful, I guess.

57:10 But at the moment, this is still a field of research

57:13 where people are using more for research than informing the general public.

57:16 And if you're not diabetic healthy individual,

57:20 I I don't really think there's a role.

57:21 And I wouldn't recommend let's do it.

57:24 I I did it more out of curiosity to to to learn

57:27 about you know what happens to my body when I exercise for example

57:30 or for at some point I wasn't having breakfast for example and see what

57:34 happened but that's changed now I do have breakfast by the way so so

57:39 uh yeah to answer your question I don't think it's it's

57:42 a tool that we should put in the hands of the public

57:44 yet without any data to back it or any medical team

57:48 behind it to to advise them what to do with the information

57:52 yeah I think it's a very human reaction ction to to want information.

57:56 I totally get that.

57:57 But that's the key thing is that what are you doing with that information?

58:01 You know, we again coming back to wearables.

58:03 We're now in an era where people can get reams of data about their own body.

58:09 Uh and there's nothing wrong with data,

58:10 but it's it's it's not that we um don't want them to do it,

58:17 but it's that we genuinely don't actually know how

58:19 to interpret a lot of this this information yet.

58:21 So, it's important to do research, but maybe not ready for prime time quite yet.

58:27 Yes.

58:27 Talking about wearable,

58:28 you probably you will see I've got an orura aura ring smart watch nonsponsored.

58:34 Yeah.

58:34 Yeah.

58:35 So, I think you're you're right.

58:37 I think sometimes too much information can be dangerous

58:40 and it's it's more about what we do with that information.

58:43 We shouldn't let ourselves become, you know, slaves to these devices.

58:48 It's more about guidance.

58:50 So, for example, if you're driving a car,

58:51 you want to have a dashboard to see how much fuel you've got,

58:54 what speed you're going.

58:55 Otherwise, you're driving in the blind.

58:56 So, you know, awareness, as I mentioned,

58:59 is the first reset because you can't really change what you don't know.

59:03 Um, that wasn't very quick fire.

59:04 That was my that's that's my fault.

59:06 So, let's do um another few quick questions.

59:11 Putting you on the spot,

59:12 what is the most important number that people should know for their health?

59:19 So well one answer here no hedging

59:23 I think from based from what we can access now it would be LDL I would say yeah

59:29 if we had Apo B levels that would have

59:31 been ideal but that's not routinely available so LDL would

59:34 be the one number but before that if you

59:37 want to really what we can do at home would

59:39 be your blood pressure what's your blood pressure doing

59:42 when you're at rest that would be one easy number

59:46 the second number would be LDL which requires you

59:48 go to to the GP to have a blood test.

59:51 Yeah, there there's clearly no right answer to this.

59:53 Other people, depending on what they're kind of focusing on, again,

59:57 I'm not saying right or wrong answer,

59:59 you have talk about V2 max and and things like that, but um yeah,

1:00:03 so that was that was uh just interesting to hear what you um had to say.

1:00:09 Are there any tests?

1:00:10 We've talked about lipids when you get to middle age, so 40 and above.

1:00:16 Um, typically blood pressure we've talked about.

1:00:19 Are there any other tests that everyone should be doing at some point?

1:00:22 You can and you can say which point in in so

1:00:25 obviously if people are developing symptoms

1:00:27 of something that's a different story.

1:00:28 They're going to go and they should get that investigated.

1:00:30 But if someone's feeling well, they're generally fine.

1:00:34 Um, what are there any other tests aside from blood pressure

1:00:39 and and and cholesterol that you would

1:00:41 recommend everyone should get at some point?

1:00:44 Um, probably not not much as a test,

1:00:48 but probably at home you could probably mon or track your waist circumference.

1:00:53 I think that's an an indirect marker of your visceral fat.

1:00:57 So the the more important than weight I would say.

1:01:00 Yeah, definitely.

1:01:01 I think your waist circumference tell you more

1:01:04 about your health than your BMI or weight.

1:01:07 So having keeping a track of what's your so in the book

1:01:11 there are different cut offs depending on ethnicities and gender.

1:01:15 So knowing what's your waistline is doing gives you an indirect

1:01:19 measure what's happening around your vital organs and those visceral

1:01:23 fats are considered to be active and and release you

1:01:27 know harmful chemicals and inflammatory

1:01:29 markers that leads to insulin resistance.

1:01:32 So that's one number it's worth knowing

1:01:34 and tracking and see if you can optimize that.

1:01:39 Is heart disease the same in men and women?

1:01:43 Um so probably eventually yes.

1:01:46 Although women tends to delay you know to develop

1:01:50 heart disease by almost 10 years after their menopause.

1:01:53 But after menopause the risk eventually catches

1:01:57 up or the risk profile eventually matches.

1:02:01 uh before that women are a bit protected around the menopause

1:02:04 or permenopause area or before menopause and and until they have it.

1:02:09 So men tends to develop it more gradually and early whereas women

1:02:13 once they develop menopause it it it tends to happen quite quickly.

1:02:17 So risk sort of rapidly increases

1:02:20 I would say so on once they lose the protection of estrogen and progesterone.

1:02:23 So we're going to finish with a few questions I asked subscribers on on YouTube.

1:02:27 We've kind of already touched on one

1:02:29 about reversing unclogging of of the arteries.

1:02:33 We've also kind of talked about another one which was uh a loweffort high impact

1:02:38 intervention and I think you were saying you

1:02:39 know regular building walking into your daily routine.

1:02:43 Any others that you'd say that?

1:02:45 So the question is a list of maybe

1:02:47 to-dos sorted by lowest effort and highest impact.

1:02:51 Yeah.

1:02:51 So yeah, I think walking bris walking for at least 20 minutes is an easy win.

1:02:56 Um try to have at least some protein in each of your meal.

1:03:00 That's probably another easy win with maximum benefit.

1:03:05 Avoid if if elim if not eliminate u um your your sugary drinks,

1:03:10 juices and and alcohol if you can.

1:03:13 So that would be you know you should avoid

1:03:16 drinking the the calories in with the sugary drinks.

1:03:19 That would be another easy win.

1:03:21 And lastly I would say sleep.

1:03:22 Make sure uh you optimize at least you have at least 7 hours of sleep.

1:03:29 I don't think I've done that since 1985 or something.

1:03:32 What is the most common mis misconception

1:03:35 about heart health that bothers you the most?

1:03:38 Probably I I would have to say it is when people say they

1:03:42 are fine and without knowing what's

1:03:45 happening with the numbers with the parameters.

1:03:48 So the illusion of fine in in midlife as as I mentioned in the book.

1:03:52 So that's probably the misconception is I don't have any symptoms.

1:03:56 I feel fine.

1:03:57 So therefore my heart health is fine.

1:04:00 So feeling fine doesn't equate to your heart being protected.

1:04:04 So that's one misconception is and that's why the book

1:04:08 is aiming to shift the conversation early when people are actually

1:04:12 feeling fine but actually we should be aware know our numbers

1:04:17 see what's going on and what can be done to change

1:04:20 the the trajectory of it's a bit like a fork

1:04:22 in the road right you can either choose to carry on what

1:04:24 you're doing and face the consequence later or optimize things now

1:04:29 and not only survive but you can thrive in years to come.

1:04:33 Going to the gym is boring.

1:04:35 What kind of activities are good exercise but also fun?

1:04:39 And if I've only got 10 or 15 minutes, what has the best impact?

1:04:43 I think we've talked about walking, but probably that's not very fun.

1:04:46 Bris walking with with a group of friends and family is easy and and probably

1:04:51 do like a minute of brisk walking and then slow a bit like HIT.

1:04:56 Hit overall if you do 10 10 minutes of HIT

1:04:58 is better than 30 minutes of running for example, right?

1:05:01 That's probably something mentioned in the book.

1:05:03 So, if you can do some sort of hit as a group with friends or family members,

1:05:09 make it fun.

1:05:09 Even if it's 10 minutes in front of the TV before a Netflix episode.

1:05:14 So, that that would be an easy and fun

1:05:17 exercise to do rather than going to the gym.

1:05:19 Yeah.

1:05:20 Yeah.

1:05:20 I think the key thing is anything can

1:05:23 be exercise that involves moving your body, dancing, whatever.

1:05:26 I think we've actually dealt with the the the top

1:05:29 questions already just just in the the conversation so far.

1:05:33 So all that um is left for me to say is thanks very much Hiroj.

1:05:37 Were you going to you were going to say

1:05:38 no no just probably a final line for or a closing remark would be

1:05:44 um midlife you know is not the beginning of decline as I mentioned already.

1:05:49 It's it's the decade of opportunity and it's never too late to start.

1:05:55 You even if you are in your 50s and 60s, it's never too late to start.

1:05:59 It's not about perfection.

1:06:01 It's about beginning and momentum which eventually compounds.

1:06:06 Great.

1:06:06 That's a that's a good positive closing message.

1:06:09 And you I think you can tell that the the method

1:06:12 works cuz you're looking in great shape for for 47.

1:06:16 So I was going to say what's your secret?

1:06:17 But here is the secret.

1:06:18 And and I'm not just saying that because uh Herod is an old friend,

1:06:22 but um it's a very easy to read

1:06:24 book and it's it's got lots of simple instructions.

1:06:28 Um so uh yeah, thanks very much for the chat and hopefully see you again soon.

1:06:33 Thanks very much, Roin.

1:06:34 It was a pleasure.

1:06:34 Thank you again.

1:06:36 Thanks, buddy.

1:06:38 Oh, thanks a lot.

1:06:38 I think it's a bit awkward being on camera.

1:06:43 you.