Jaime Lewis (Host): Here to share insights about preventative cardiology and whole heart wellness Is Dr. Charles Russo, board-certified cardiologist and cholesterol expert at Holy Cross Health in Fort Lauderdale.

This is Thrive with Holy Cross Health, a production of Holy Cross Health in Fort Lauderdale. I'm Jamie Lewis. Dr. Russo, thank you for being here.

Charles Russo, MD: Thank you for inviting me.

Host: Of course. Well, this is an important topic. So, let's talk a little bit about preventative cardiology. Why is that important for both patients and healthcare professionals to understand its principles?

Charles Russo, MD: I think that it's fairly apparent to almost everybody these days, certainly in this country, that the great majority of atherosclerosis, clogged arteries, whether it's in the head or the heart, which is the number one killer in the country, is preventable. It's preventable by things that are very simple and very hard to do: diet, exercise, weight control primarily, eating the right foods, eating the right amount of foods, and keeping yourself in better shape.

Unfortunately, our generation has really, because of technology, become more sedentary. And it's happening to our children too. And the problem is that now we have an obesity epidemic as you know, probably about two-thirds of the country are either overweight or obese, and it's really spread to our children, which is a problem because we may have the first group of children that may not outlive their parents, which is very, very sad.

Host: Wow, that is a hard statistic to swallow. How does cholesterol management play a role in that? And what are the most effective ways to lower-- I know we all know what LDL cholesterol is-- what's the best way to lower that?

Charles Russo, MD: So ,cholesterol is a complicated subject. It's not just what your cholesterol is, it's what your body does with it, okay? There are certain genetics involved, probably about 21 different genes, and we don't have any great genetic testing. While there are known defects of one or two or three genes that cause sky high cholesterols, for the majority of patients that have atherosclerosis, it's really a metabolic problem that occurs where they eat too much. They become a little chubby or stocky. Their bodies become insulin resistant. As a result of not really responding well to insulin, certain parts of the blood fats go up, the triglycerides may go up; the good cholesterol, the HDL, may go down; the LDL may stay the same or may go up. And there are certain subvariance of the LDL bad cholesterol that are even worse. You may have been reading a lot about this so-called LPa that attaches itself to the LDL cholesterol and is a particularly malignant form of LDL. It's not just the LDL that's a problem. Let's say up front, we need cholesterol in every cell in our body. All the membranes of all our cells have cholesterol in it. So, it is a very needed nutrient for our body. And it's only when it's in excess and our body can't handle it, that it's sort of like if you have too much garbage, what are you going to do with it? Well, the body starts packing it everywhere, but mostly in the blood vessels and it creates blockages.

So, there are complicated genetics associated with the majority of clogged artery syndromes. Even though there's just one or two variants that may be pinpointed by genetics, we are getting better for that. And there may be formal genetics screening in the future. Family history, of course, is very important, pointing at the genetics. And then, it's your lifestyle predominantly. I mean, we've shown that if you stay in shape, if you eat a good diet if you stay thin, if you stay active, you can inhibit the great majority of atherosclerosis that we see. And it's sad because I see people, unfortunately after decades of this problem, and now we're trying to reverse it. And we have very good drugs and they're all getting better to slow down and reverse atherosclerosis. But why take a drug if you don't have to?

Host: Yes. And thanks for that distinction between cholesterol being just purely bad and actually being necessary, but going in excess of that. I think it's a good thing for people to understand. I have a long family history of heart disease and actually managed to get a coronary calcium scoring scan. And so, I was going to ask you about that. Can you explain the significance of that procedure in assessing heart disease risk, and who should consider getting that test done?

Charles Russo, MD: Absolutely. As you know, we do measure cholesterol in young adults and try and fractionate out what's the good, what's the bad, what's the ratio, who's at risk, depending on their family history. So for people with a high family history of coronary artery disease or diabetes per se, that they've had since childhood, you can look inside their body with a coronary calcium score. And it's a pretty simple test. It probably takes less than 90 seconds to do. There's no dye injected in the body or anything like that. The radiation dose has now been ramped down to the point where it's just above background radiation. So, it's not even considered anything that puts a patient at risk.

And then, there's a simple program that the technician runs through that identifies hardening of the arteries. That's what we're looking at. We're looking at calcium in the arteries. Calcium in the arteries is actually old healed plaque. So if you see calcium in your arteries, you have atherosclerosis, you have plaque, that's what I try and tell people. The more fascinating story about coronary calcium was that Dr. Agatston, who did the South Beach Diet, had been experimenting with this technology 30 years ago, out on South Beach, down here in Miami.

And the score that we rate people with is called the Agatston score, actually. And zero means you don't have any plaque, any hard plaque. There's a distinction between hard plaque and soft plaque, which we can talk about too. One to 100 is mild plaquing, 101 to 300 is moderate plaquing, and over 300 is heavy plaquing. And I've seen patients anywhere from zero to 2,000, 3,000 or 4,000, okay?

Now, there's a distinction between plaquing and significant blockage too. What a positive calcium score tells you is that you have atherosclerosis. It doesn't tell you if that atherosclerosis is limiting flow in your arteries. And what do I mean by that? Well, it's been now known that you have to block more than 80% of the artery to limit flow. And years ago, 25, 35 years ago, we were probably doing way too many catheterizations, angiograms and placing way too many stents and doing way too many bypasses. And even nowadays, we'll get people in here and they'll have a catheterization for symptoms and you'll see that they have 60%, 70% blockages. And we just send them home with diet, exercise, and medication. And they'll say, why didn't you do anything while you were there? And the reason is because medicines work, diet and exercise works, and you don't need anything artificial in your body if you don't need anything artificial in your body.

So, nowadays, you can even take the calcium score to another extreme and do what's called a CT angiogram. That's a CAT scan angiogram. That does require more radiation in an injection of dye. And that tells you above what the hard plaque is, it can also see soft plaque in the arteries and the degree of obstruction you have 50%, 60%, 70%, 80%, et cetera. It's not as good as the catheterization. We will often get people who the emergency room doctor will be alarmed that they have a very bad-looking CT angiogram and we'll do a catheterization on them and find that really nothing, all the blockages are less than flow-limiting, and they don't need anything done. And my partners in the catheterization laboratory can put a little wire, it's about the size of a hair, a human hair, and they put it down the artery and they look at the pressure before and after the blockage. If there's no significant pressure drop, if the pressure isn't less after the blockage than before, then that's not a flow-limiting lesion, and you should leave it alone. And if it does have a drop in pressure, that's when you would put a stent in.

But I can't stress over and over and over again, we all know what we should be doing at this point. We should be eating no processed foods, no trans fats, plenty of fruits and vegetables and a Mediterranean diet style with beans and, salads. And yes, you can have a little rice and a little pasta, but they're also predominant carbohydrates, which certain people have a predisposition to not do well on. So, you need to watch those, the white rice, the potatoes, and the macaroni in particular, before you can figure that. And the white bread too, even if it's whole grain bread, you have to watch that. But chicken and turkey and fish predominantly is your meats. It's not that you can't ever have red meat, but it should be the leaner cuts. Game meat is great for you to eat because, as opposed to even a lean piece of filet mignon, which may have 20-30% saturated fat, game meat has 9% or 10% saturated fat. So, those are good to eat too. And nuts and so on, these are all good things to eat.

There's no one diet that I like in particular. I don't think you need to become a vegan. I don't think you need to become a vegetarian. I think the carnivore diet is a little excessive. Also, I think that the caveman diet is a likewise excessive. We've evolved beyond that. And there's an important-- we're learning more and more about the fact we used to think our genetics were fixed, and we know now that that's not the case in a lot of instances. Your body and your genetics respond to your environment, not only what you do and what kind of stress you're under, what you put in it, okay? And there are proteins that wrap around your DNA that open or close the DNA depending on what stresses are presented to it. So, you could clearly modify some of that.

The biggest example I have of that is not in actually atherosclerotic or coronary artery literature, but it's in prostate literature. They identified 11 genes that cause cancer, and they put these people on a vegetarian, not a vegan diet, but a vegetarian diet. And nine of the 11 genes that caused cancer were turned off. So, we can clearly influence our genetics to a certain extent, and to a very great extent when it comes to atherosclerosis In the future. Hopefully, it will be a disease that will go away.

Host: That's amazing and very hopeful. So of course, like you say, we all know the answers to these things: good diet, regular exercise. You've touched on what we eat, but talk a little bit about movement. How does regular exercise contribute to heart health? And what kinds of physical activity are the most beneficial for, let's say, longevity?

Charles Russo, MD: Okay. So, that's a super complicated question, and it really is somewhat individualized. But clearly, there's a dose response curve. What do I mean by that? Any exercise is good. Anything you do to get up and move is good, okay? You'll see, "Oh, you don't need to walk 10,000 steps. You only need to walk 7,500." Let me tell you something, the more you do, the better it is. Obviously, certain extremes are not necessary. Marathon runners, triathletes, they have their own issues and their own problems. But for Joe Q, public getting up at all, walking, doing yoga, there are some people that don't like to sweat. You don't have to sweat doing some of these things. You can do stretches. There's lots of things that you can do, but there's a dose response curve to that. And the more you do and the quicker that you do it and the higher you get your heart rate up, the less you have to do. What do I mean by that?

Well, now there are thresholds of about 150 minutes per week of aerobic activity that you should do, whether that's walking or like jogging or whatever. But there's a good dose response curve all the way up to 450 minutes per week. And if you decide to get on a treadmill and to maybe jog and then run rapidly for 15 or 20 minutes, you're going to gain benefit for that for hours, and probably do the equivalent of what you would do walking for an hour and a half. So, it depends on your time. It depends on how much effort you want to put into it. Swimming is good. It doesn't get your heart rate up as high, but swimming get all the muscles in shape.

Something that I've realized in my older age is that muscle mass does matter as you get older. So, doing some sort of weightbearing activity, whether it's just with your body weight in terms of pushups or squats, those things will work. Lightweights, multiple repetitions. You don't have to become Charles Atlas, although that's probably my generation. I don't know if this generation knows who Charlie is. I should say Arnold Schwarzenegger for this generation. You don't have to be  Arnold Schwarzenegger. But a combination of all of those things is the formula. Do a little bit of resistance activities, whether it's lightweights or just body resistance with sit-ups and pushups and squats and planks and stuff like that. Walking, jogging, running a little bit, also swimming, bicycling.

But you have to keep in mind what you're working against and what causes the stress on your body and builds the muscle or even decreases osteoporosis is working against gravity. So that, for instance, if you were going to do 30 minutes of jogging, that same 30 minutes, you'd have to do an hour and a half of riding a bicycle because of the negated gravity, and you'd have to do even longer swimming. So for people who are time-pressured, you have to choose what you want to do and how you want to do it. But when you think about it, 150 minutes a week, 200 minutes a week, it's not very much. What's that, a half hour, six days a week? So, all of this is within our reach if we want to do it, and it's a matter of incorporating it into your lifestyle.

I can talk about eating. It's not just what you eat, it's how much you eat. We know about that. It's also the time that you eat. There's a lot of data now that a time-restricted eating, let's put it that way, is probably better for you than, eating the three square meals a day that we were raised with, maybe too many calories and too much to eat. And really, there's probably a window of about eight hours a day when you should eat. It depends on what you want to do. It could be between 8:00 and 2:00 and 8:00 AM and 2:00 PM. It could be between 10:00 AM and 4:00 PM It could be between 12:00 and 8:00 at night, but probably time restricted eating is better for you. The more time you leave not eating, whether that's 12 or 14 or 16 hours, that's what creates your insulin sensitivity. It makes you more sensitive to insulin and less prone to obesity and insulin resistance. So, there's all of this data that's coming out. And yes, you can find arguments on one side of this and another, I'm just giving a general overview, a probably common sense approach to diet, exercise, and staying healthy.

Host: Well, it's something that I think we've heard a lot, but it's never bad to hear it again and to be re-encouraged to look at our diet, our exercise, to take care of our hearts, and especially I think about women because it's such a killer, heart disease. It's something that can be prevented. So, thank you so much for all of your insights, the valuable information, and we just really appreciate it.

Charles Russo, MD: Thank you very much for listening to me.

Host: That was Dr. Charles Russo, board-certified cardiologist and cholesterol expert at Holy Cross Health in Fort Lauderdale. To learn more about preventative cardiology and heart health services, visit holycrossheart.com. And thank you for listening.