[Bassam Shakhashiri, Professor, Department of Chemistry, University of Wisconsin-Madison]

Now, I’d like to move to the part of the presentation with our guest speaker, and that is Professor Patrick McBride from the U.W. School of Medicine and Public Health. And – and the title of his talk is Taking Care of Your Heart –

[slide with the title screen for the lecture – Taking Care of Your Heart: Chemistry and Heart Disease, Patrick McBride, MD, MPH, Professor, U.W. School of Medicine and Public Health]

– Chemistry and Heart Disease. So, please join me in welcoming Professor McBride.

[applause]

[Bassam Shakhashiri, on-camera]

Gotta get your slides here.

[Patrick McBride, Professor, Cardiovascular Medicine, U.W. School of Medicine and Public Health]

Yeah, we’re all set.

Well, thank you all very much for welcoming me here. And I’d like to welcome my good colleague and friend. What an honor to be here because he is part of the Wisconsin Idea, and my work has been the Wisconsin Idea as well, one of the great ideas that this state has ever had. So, thank you all very much. And he mentioned Galileo and Copernicus, who are some of my heroes. The greatest course that I ever took on this campus was The History of Science. And the great scientists that have come before us are always in my mind. And when I took that course, I was astounded to think that people could use things like a magnifying glass or a microscope to figure out that the world wasn’t flat, that it was round and that they could be headed for such a discovery like that because people didn’t want to believe that the Earth wasn’t the center of the universe, but the Sun was the center of the universe. So, I thank him for bringing up those kinds of things.

In my work, I work in the School of Medicine and Public Health. I work with people with heart disease, and I work with people who are trying to prevent heart disease. My goal has been trying to reduce heart disease and other diseases in the state of Wisconsin and in the country. So, I have worked in the last 30 years to try to reduce diseases like heart disease, diabetes, and obesity. And I’m going to talk to you about how prevention involves chemistry. So, the work I do involves biochemistry, and I’m going to talk to you about that in plain things, in plain language rather than medical terms, as much as I can. So, I hope you’ll keep me honest about that.

So, I’m going to focus on just two areas. There are a lot of different risks associated with that, but I’m going to focus on cholesterol –

[slide titled – Metabolism is life! – featuring the following bulleted list – Review the role of cholesterol and obesity in heart disease; Discuss the role of nutrition and activity in prevention; Discuss common clinical and public health problems with cholesterol, metabolism, and obesity]

– and how cholesterol is really chemistry. And I’m going to talk also about obesity. And I’m going to talk about the chemistry of obesity and how that’s changed in our world, in our country, and it’s really becoming a problem in the developing world. And I’ll use this example that Dr. Shakhashiri has mentioned together, and I’ll talk about how chemistry is really a big part of nutrition. He talked about malnutrition, and, you know, we have a big problem in this world with both undernutrition and overnutrition and how it would be better if we had a balance of that in our world. And I’m going to discuss common problems with cholesterol and how chemistry is really metabolism, about how our health is really about metabolism –

[new slide titled – Heart Disease – with the following list – Heart Disease risk factors – Men and Women at similar risk long term; Lifestyle Change Works!; Take Your Medicine – The internet – Friend or Foe?]

– and talk about how that’s really chemistry. So, I’m going to talk about the risk factors associated with heart disease, particularly cholesterol and obesity, and how some of those are associated. And I’m going to focus primarily on lifestyle, but I’m also going to talk about medicine because one of the most striking changes in the last 10 years in my career has been the development of the Internet. And one of the most interesting things about the Internet is that it’s a great source of knowledge, but it’s also a great source of misknowledge, you know, there’s a tremendous amount of misinformation.

I had the incredible experience this past weekend of sharing a stage with a guy named Akira Endo.

[Patrick McBride, on-camera]

And Akira Endo is a Japanese researcher who discovered the metabolism of cholesterol, and he discovered statins. And this man is responsible for saving millions and millions, perhaps billions, of lives with the discovery of statins. And I actually got kind of emotional when I first saw him. This was the first time I ever saw him. And he did this by working with fungus. And he studied over 6000 different fungi and realized that fungi metabolized cholesterol. And through that discovered these statins. And he never made a penny off that discovery and the pharmaceutical companies made billions and billions of dollars. He didn’t get one penny. But statins will have saved billions of lives and they’re incredible medicines, and yet the Internet has really confused people about those. They’re some of the best and safest medicines that have ever been produced, so, I’m gonna talk about that tonight.

But first of all, I want you to focus – this is an important slide that talks about two of the most important problems that we face in healthcare. And I want to point out tonight how both heart disease and cancer really have the same risks. And heart disease and cancer –

[slide featuring a graph titled – Leading Causes of Death in the United States, CDC/NCHS and NIH Statistics – featuring a bar graph that has three sets of data on the x-axis (All Ages, Younger than 85 Years, and 85 Years and older) and the number of deaths on the y-axis for the following death causing diseases – Alzheimers, COPD, Cancer, Other Cardiovascular Disease, Stroke, and Heart Disease. For All Ages the largest number of deaths come from combined Heart Disease, Stroke or other Cardiovascular Diseases followed by Cancer which has about half as many deaths. For people younger than 85 years-old the number of deaths from combined Heart Disease, Stroke and other Cardiovascular Disease and Cancer are almost tied with the former just slightly more than the latter. And for Over 85 years-old the combined Heart Disease, Stroke and other Cardiovascular Diseases towers above the others]

– as you can see, are the leading causes of death and disability that we face in medicine. So, heart disease at all ages is the most common source of problems that we face. And cancer is pretty close behind. And part of the issue is that we’ve been able to reduce heart disease so much over the last three decades in this country and other countries, and so cancer’s kind of catching up. Less than 85 years, both heart disease and cancer are pretty close, and when you add up stroke and heart disease together, that’s where they are. And you can see lung disease, COPD, which is the same as emphysema, is pretty far behind. And then over there at greater than 85 years, you can see that heart disease even far out – outstrips Alzheimer’s and dementia. So, we worry a lot about dementia and Alzheimer’s. Most of dementia is actually caused by small vessel blockages, which are actually very attributable to the same risk factors as heart disease and stroke. So, some of the same risk factors that we deal –

[new slide titled – Good News! A Significant Decrease in Heart Disease and Stroke – with the information that in the last 30 years – Stroke decrease by 70%; Heart Attack decrease by 50%; Decrease in heart disease and stroke has led to over 4 years of prolongation in life expectancy; Total increase in life expectancy is 6 years; Improvement = 2/3 lifestyle and 1/3 medicine]

– with with cancer and heart disease are the same risk factors that we deal with dementia.

So, the good news is that we’ve seen dramatic changes in heart disease and stroke over the last 30 years, and that’s due to the discovery of a number of the risk factors that have been associated with this, some dramatic changes in tobacco. So, when the Surgeon General’s report came out in the 60s and it said that tobacco was associated with heart disease and stroke, we’ve seen heart attacks decrease by 50%. You know, when Franklin Roosevelt died in 1945 at the end of World War II, he died because he didn’t have any treatment –

[Patrick McBride, on-camera]

– for high blood pressure. If he’d had medicine for high blood pressure, we wouldn’t have given away Eastern Europe, for example. And so, in the 50s we developed all these great medicines for high blood pressure, and so now we have over 300 medicines for high blood pressure. And so, that’s been very important to our reduction in stroke, for example. And now we’re seeing major decreases in heart attacks due to these important –

[return to the previous slide, described above]

– medicines and these important approaches we’re taking in nutrition for reducing cholesterol.

So, we’ve seen these important changes. And we’re starting to see life expectancy increased because of our important advances in medicine and our important attention. And we estimate that about two-thirds of the changes that we see are the changes that we see in lifestyle. And about a third of this has been attributed –

[new slide titled – Scope of the Problem, U.S. Heart Disease – featuring a line graph with the year from 1970 to projected 2050 on the x-axis and the number of Patients (in Millions) on the y-axis and showing that in the year 2000 there were 12.4 Heart Disease patients and that in 2050 the number of these patients is expected to rise to 24.6 million or almost double]

– to these important medicines.

But something really important is changing. So, the great changes that we’ve seen in the reductions in stroke and heart attacks are start – starting to take a sudden change for the worse. Now some of this is because of the changes in aging in our populations, but a big part of this is because of the epidemic in obesity and diabetes that we’re seeing, not just in this country but all over the developing world.

So, because of the great advances that we’ve seen in productions of food, productions in sugar, high fructose corn syrup, we’re seeing major increases in diabetes and obesity. And it’s projected that over the next several decades –

[Patrick McBride, on-camera]

– we’re gonna see a marked increase in heart disease and stroke again. And I’m hoping we’re able to reverse this curve.

So, I want to talk to you about what we’re really treating when I talk about treating heart disease and stroke. We’re talking about a problem called –

[slide titled – What Are We Treating? – and the answer – Atherosclerosis (Blockages or plaques)]

– atherosclerosis. And that’s what some people call blockages or plaques. And I’m gonna describe that in more detail for you and I’m gonna talk about the chemistry of heart disease.

[new slide titled – Evolution of Heart/Blood Vessel Blockages – featuring an illustrated image of a typical artery that progresses from normal to blocked. In the illustrations are six cross-sections of the artery showing the progression from normal to fully blocked with the first cross-section free of any cholesterol plaques and wholly open and the last cross-section showing the artery blocked by cholesterol plaques to the point where blood flow appears to be hampered by at least 75%]

So, this is a picture of the inside of an artery. It’s like you sliced an artery right across it. And then this is a lifetime of a person’s arteries and the development of arteries. And it’s why we’ve developed guidelines going all the way back to the health of children. So, I was on a panel both in 1992 and in 2010 where we talked about the health of children in this country because of the incredible epidemic of overweight and obesity in our children and because most of the kids that start smoking, start smoking before the age of 18. So, we really wanted to address how this process starts in childhood.

But what we see is inside the blood vessel, the arteries, we see the accumulation of cholesterol. And it’s developed in a process that starts with inflammation. There’s irritation and inflammation of the artery, the artery gets irritated. And then through the process of cholesterol entering into the artery, these blockages and plaques slowly build up over a lifetime. That happens through two processes. One is environmental, what we do to ourselves. The other is what we inherit, genetic. So, we can inherit genetic issues –

[Patrick McBride, on-camera]

– like, some of us inherit high blood pressure. Thanks to my parents, I’ve inherited high blood pressure. Many of you might have inherited cholesterol problems because they are quite common. And people can also acquire these in a lifetime through poor lifestyle habits: poor nutrition, poor exercise or activity habits. We – we like to joke that America’s favorite activity is watching other people exercise.

[laughter]

And so, you can inherit these both genetically or –

[return to the – Evolution of Heart/Blood Vessel Blockages – slide, described above]

– through the environment.

[new slide still under the same title as above now showing an actual cross-section of an artery that has a large build-up of cholesterol plaque and a rupture in the vessel]

And over the process of a lifetime, that may result in a heart attack or stroke. Now this is a blood vessel cut the other way, across the blood vessel. And this is from an autopsy of somebody that’s had a heart attack, and that artery has ruptured. That’s a plaque or a blockage that cracked open. And when the body has that blood vessel crack open, the body tries to repair it by putting a blood clot on it. So, that might have been a blockage that was 30% or 40%. And a lot of times somebody says to me, Well, my brother had a stress test two weeks ago and it was normal, and then two weeks later he had a heart attack. So, your stress test wasn’t very good. Well, it’s because it was a 30% blockage, and those didn’t get picked up. But under some form of stress –

[Patrick McBride, on-camera]

– that cracked open, and the body tried to put a blood clot on top of it. So, it went from 30% to 100% in a matter of seconds or a minute and completely blocked off that artery and may have caused a heart attack if that artery was in the heart, or a stroke if that artery was in the brain. And that could have caused a sudden cardiac arrest or a stroke and caused a death. And that’s why we have this autopsy picture.

And that’s one of the reasons we use blood thinners like aspirin or Warfarin, which was discovered on this campus, as a blood thinner for people that are at risk of heart attack or strokes.

So, the question is –

[slide that poses the question – Is This Reversible?]

– is this process reversible? And the answer is Yes. And we’ve done a lot of that research here on this campus and a lot of places. And we’ve done a lot of that research ourselves. And it’s reversible through two different ways: through changing lifestyle and through medication, if necessary –

[new slide titled – Heart and Stroke Risk Factors – with the following bulleted list – Age; High Cholesterol; Low HDL cholesterol; High blood pressure; Lack of physical activity; Tobacco; Diabetes; Obesity (especially Central); Stress (including loss); Family History of heart disease or stroke; Genetics; Other? High cholesterol, Low HDL cholesterol, obesity, and genetics are all highlighted in yellow]

– if a person has enough risk.

So, here’s the risk factors for heart disease and stroke, which many of you are aware of, and as I mentioned, I’m going to focus on the ones that I’ve highlighted in yellow tonight because they’re the chemistry, if you will. So, high blood pressure and physical activity, tobacco, diabetes, stress, family history, these are really important.

Family history, by the way, is expressed through these other risk factors like blood pressure, cholesterol factors.

[Patrick McBride, on-camera]

Inflammation, a lot of times, is a genetic factor, for example.

One of the things that’s difficult to do anything about is age because our arteries harden through age, but one of the ways we can reverse that is through regular physical activity. There’s no fountain of youth, but I like to tell people the closest thing we have to the fountain of youth is trying to remain physically active. If you want to speed the aging process, sit around. Sit on the couch and watch the “boob tube, as my dad used to call it. If you want to reverse the aging process, get active. Get out there and get moving.

But I’m going to focus on high cholesterol –

[return to the Heart and Stroke Risk Factors slide, described above]

– low/good cholesterol, it’s called HDL, and I’m going to focus on obesity and how it’s related to –

[new slide titled – How Do I Know My Risk? – with a bullet labelled – Risk assessment tool – www.healthdecision.org and noting that this website gives 10 year and longer heart risk and handouts to reduce risk. Another website – www.heart.org is also listed]

– genetics tonight.

Now there is one way that you can measure your risk, and there’s some good risk assessment tools, and I’ve listed a couple of those tonight right on this slide,
and one is called healthdecision, that’s one word, healthdecision.org. And there is a lot of really good tools at that site. That’s a site we developed here at the University of Wisconsin, healthdecision.org. Great site, where you can graphically look at your risk for the next 10 years or over the lifetime, both for heart disease and stroke.

And the other way that you can look that up is at heart.org. Heart.org is a great website. It’s the American Heart Association’s website. And so, I always tell people there are good internet resources and terrible internet resources. This is a great internet resource: heart.org.

[Patrick McBride, on-camera]

The American Heart Association is a non-profit source that has great sources of good information, new information on heart, good hand-outs, a lot of professional information. It’s where our guidelines are. It’s where I’d like you to read about nutrition because there’s a lot of misinformation about nutrition. So, our guidelines on cholesterol and nutrition and stroke are all published there, heart.org.

Now I want to point out that the same risk factors that we have for heart disease are the same risk factors for cancer. One of the things I like to joke about is that when I come through the cafeteria line at the hospital, everybody checks my tray to see what I’m eating.

[laughter]

And I go, Hey, go check the oncologist, you know. Because tobacco, big risk factor for heart disease –

[slide titled – Cancer risk factors – containing the following bulleted list – Tobacco use/smoking; High fat intake; Low intake of vegetables and fruits; Physical inactivity; Lack of appropriate screening]

– is a primary risk factor for cancer. Genetics is a big risk factor for cancer. High fat intake, major risk factor for prostate cancer, breast cancer, and even lung cancer, bladder cancer. Low intake of vegetables and fruits. I can tell you that on food records every patient that comes to our clinic we ask to do a three-day food record. The one thing that we see consistently over and over again is a low intake of fruits and vegetables, and that is a huge issue for cancer and heart disease. Low levels of physical activity. 80% of Americans do not even come close to meeting recommended levels for regular activity. And then lack of appropriate screening. That’s true for all Americans around heart disease and cancer. Same risk factors for heart disease, same for cancer. So, when people say, Oh, ya gotta die of something. That’s my favorite answer –

[Patrick McBride, on-camera]

– that I get, you know, when people say, you know, What about heart disease? Oh, ya gotta die … Yeah, well, you know what? If you want to prevent cancer and you want to prevent a stroke and you want to prevent a heart – a premature heart attack or premature surgery, live a healthy lifestyle. Go to your doctor for regular physical checkups, take your medicine.

Here’s –

[slide titled – Physical Activity and Breast Cancer – featuring a bar graph with three factors of Leisure time activity on the x-axis (Sedentary, Moderate, Regular) and Relative Risk of Breast Cancer on the y-axis from 0 to 1 in tenths and showing a Sedentary Leisure time activity leading to 100% (1.0) risk of breast cancer, with a moderate leisure time activity leading to a 98% (.98) risk of breast cancer, while a regular exercise leisure time activity leading to only a 67% (.67) risk of breast cancer]

– there’s a lot of good research on this, but here’s a good example. When women are regularly physically active, there’s a lower risk of breast cancer. So, you see that women in the regular physical activity group are one-third less likely to have breast cancer than the women that are inactive. And this is true in many –

[new slide titled – Reducing Risk of heart disease and stroke – with the following bulleted list – Activity daily; Healthy eating; Avoiding tobacco; Maintain optimal weight; Aspirin if your clinician recommends; Control of blood pressure and cholesterol; and highlighted yellow – Take your medicine!]

– many studies.

So, reducing risk of heart disease and stroke, it’s the same list that you’d expect to see – regular physical activity, healthy eating, avoiding tobacco, maintaining optimal weight, aspirin, if your doctor recommends it. So, some people do this on their own. You shouldn’t do that unless you talk to your regular clinician, and they recommended it for you. Generally, it’s men over 50, women over the age of 65. But you need to make sure it doesn’t interfere with other medication you’re on or other medical problems that you have. So, you need to talk to your clinician first. And then take your medicine. There’s so many patients that we recommend a medication for, they get on the internet, I can’t tell you how many patients say, Well, I talked to my neighbor and they said,
Well, you know, I heard this about a medicine, and I heard that. So, six months later they come to see me –

[Patrick McBride, on-camera]

– and they say, I’ve been off my medicine for six months. And I go, Has your neighbor got a degree?

[laughter]

Has your neighbor been in practice for 30 years? You know, this is the area that I work in. This is the area that I do my research, you know. So, please talk to your clinician before changing medicines and things like that. These medicines can be life-saving. They’re really, really important. There’s a lot of research that goes into them. So, reading somebody on the internet that has no connection to medical care or science or talking to a neighbor over the fence is not the way to do medical care. Find somebody you trust.

So, let’s talk about the chemistry of heart disease and – and about prevention.

[slide titled – Cholesterol – with two lists – the first is Bad (only if high in our blood) – LDL – cholesterol – Triglycerides and the second is Good cholesterol – HDL – cholesterol]

So, I want to focus on these three main areas of cholesterol: LDL cholesterol, triglycerides, and HDL cholesterol.

LDL cholesterol is the primary cholesterol, the lipoprotein that travels through the bloodstream, that accumulates in blood vessels, the one that forms that plaque. Triglycerides are another type of blood fat that accumulates because of what we eat and sometimes because of genetics, that also can irritate arteries, damage arteries, and sometimes accumulate in arteries. Those are the two that we call bad cholesterol. Now I put it in quotation marks because they’re not necessarily bad. A small amount are necessary for normal functioning. So, people always say, Well, how much? We’re going to talk about that. So, we – we need a modest amount for normal daily functioning, but the average American has many times more what we really need for our normal daily activity. So, one excuse people make for not changing their lifestyles, they say I heard it’s good for your brain.

[Patrick McBride, on-camera]

Well, not at the levels most Americans have it. We don’t need very much.

The good cholesterol, HDL, actually cleans out the system. It travels –

[return to the – Cholesterol – slide, described above]

– through the bloodstream and actually removes cholesterol from the blood vessel and from other tissues and it takes it back to the liver. So, it’s actually our cleanup crew. It actually removes cholesterol that we don’t need and takes it away. So, the more of that, generally, the better, and some people are born with very low amounts of that. They inherit low amounts of that. And we can raise HDL cholesterol through regular physical activity and losing weight. So, HDL cholesterol –

[new slide titled – Cholesterol Management – Normal Levels – with the following information – LDL-C less than 130 mg/dL (lower if we have heart disease or stroke); Triglycerides – less than 150 mg/dL; HDL-C greater than 40 mg/dL (greater than 50 mg/dL for females)]

– is very important to us.

Now these are what we consider normal levels of these cholesterols in our bloodstream when we get a blood test. LDL cholesterol, the one that accumulates in the blood vessels, should be less than 130 when we get the measurement, unless someone’s had heart disease diagnosed or a prior stroke, then generally much lower than that. Usually less than 100. Triglycerides should be at least below 150, the lower the better. And then good cholesterol, HDL, the higher the better because it’s a good cholesterol, it’s a cleanup cholesterol. So, for men at least above 40, and for women higher than 50 because it’s a – a very important predictor in women. In fact, HDL cholesterol, the higher it is –

[Patrick McBride, on-camera]

– the lower the risk of breast cancer in women. It’s associated with breast cancer, so HDL cholesterol is an important predictor in – in females. So, it’s important that we have a high HDL cholesterol.

Now, what we do when we try to lower it with both lifestyle and medicine is we –

[slide titled – Cholesterol Guidelines – with the following bulleted list – HDL greater than 40 for women over 50; Triglycerides less than 150; LDL cholesterol depends on condition – LDL 30-40% reduction if no heart disease; LDL 50% or more reduction if heart disease/stroke/diabetes; Lifestyle is the cornerstone of therapy. Cholesterol guidelines at www.heart.org ]

– determine the amount of reduction based on the person’s risk. So, if somebody has a high LDL cholesterol but they haven’t had a diagnosis of heart disease yet, then we generally shoot for about a 30 to 40% reduction. If somebody’s already had a diagnosis of heart disease, they’ve already got blockages, those plaques that I showed you, then we really try to reduce it, because we’re trying to reverse those plaques. So, it’s been shown that if you get more than a 50% reduction in LDL cholesterol, you can actually start shrinking the size of those plaques and flatten them out. And I’ll show you some pictures of that. So, we go for more than a 50% reduction if somebody’s had a prior heart attack or they’ve had a prior stroke or bypass surgery or they have a history of diabetes, because it’s been shown in people with diabetes that more than a 50% reduction in LDL cholesterol reduces the risk of heart attacks.

And it’s always important to do lifestyle. So, one of the things that’s been shown in studies is that when people take a medicine to lower cholesterol, they think, Well, great! Now that I’m taking a medicine, I can eat whatever I want. That’s not true. The medicine’s less effective if a person is eating a high-fat diet. So, it’s important to both eat healthy food and take their medication. That’s really important. I was in Washington, D.C. one time, visiting my brother.

[Patrick McBride, on-camera]

And we were sitting at a table, and he’s an attorney, and a plate of fettuccine alfredo showed up at the guy next to us. And the guy – guy that he was with said, Well, wait a minute. Aren’t you on a cholesterol medication? He said, Yeah, so I can eat whatever I want. And my brother, who’s the attorney, said, Are you going to say something to him? I said, I’m not licensed in this state, so I’m gonna -

[laughter]

- on my own, I’m not gonna say anything.

So, let’s talk about it. Now, this is the way cholesterol works –

[slide titled Net Cholesterol Balance in Humans – featuring a three part interconnected illustration with a tube representing the Intestines on the far left, an illustrated Liver in the middle, and a green rectangle labelled Extrahepatic tissues on the right. Under the Intestines illustration is the label – Dietary cholesterol (300mg/d) which has an arrow that flows down to Fecal sterols at the bottom with 1100 mg/d. In the middle of the Intestine illustration are two arrows – one pointing to the Liver labelled Absorbed Cholesterol and one coming from the Live to the Intestines labelled Excreted cholesterol. At the Liver is a circular group of arrows with Cholesterol absorbed into the Liver leading to the creation of LDL-C cholesterol and VLDL-C cholesterol. Some of the LDL-C cholesterol flows to the Extrahepatic tissues where that cholesterol is returned to the Liver as HDL-C cholesterol. Under the Liver and the Extrahepatic tissues is the label – Synthesized cholesterol (800 mg/d)]

– in the body. There are two really primary sources of cholesterol. As I mentioned, one source is what we put into our body, you know, the type of fats that we consume, cholesterol that we assume. And the other source is our own body, you know. So, what our own tissues produce, and that’s the genetic source. So, the liver is the primary factory for this whole process.

So, on the left I show the intestine, and the fats and cholesterol are important. Now you may have read that recently the dietary guidelines said, Well, we can lighten up on cholesterol. What people heard was, Maybe that means we can eat whatever we want. That’s not what they said. What they meant on that was dietary cholesterol. The average American consumes about 200 milligrams of cholesterol. Dr. Shakhashiri was talking about understanding in chemistry amounts. 200 milligrams of cholesterol is roughly about the amount in one egg yolk, one egg yolk. That’s the average that a person consumes, and that’s about the amount recommended per day. One egg yolk.

What we consume in dietary fat are grams. That’s 100 times what we consume in milligrams. So, it’s important that you understand that the guidelines are about dietary cholesterol, not fat. So, we’re still supposed to monitor the types of fat and how much –

[Patrick McBride, on-camera]

– fat we eat on a daily basis. And I’ll talk about that. So, we are still supposed to know how much fat we put into our guts, into our mouth, and into our stomachs, and our intestines –

[return to the – Net Cholesterol Balance in Humans – slide, described above]

– because that’s a primary source of cholesterol in our system, and the one that we really can control unless we take a medication. So, if we really want to reduce our serum cholesterol through our lifestyles, it’s how much we consume and how much we burn through physical activity. And then what happens in our body is really determined primarily by our livers, unless we burn it, because our muscles are a factory for burning cholesterol. So, if we exercise for 30 or 45 minutes a day, our muscles will burn away triglycerides and make more HDL cholesterol.

[new slide titled – Lipid Metabolism – Metabolic Pathway – featuring an illustrated diagram of the Lipid cycle starting with the Liver which clockwise produces VLDL cholesterol (represented by a circle with three smaller circles on it – labelled apo – B, apo E, and apo C) which in turn through Lipolysis produces LPL and HDL that produces IDL (represented by a circle with two smaller ovals in it) which through conversion produces HTGL and HDL catabolism that create LDL (represented by a circle with a smaller oval on top of it) that in turn goes back to the Liver and other sites and is labelled Clearance. Between the circle labelled IDL and the Liver is an arrow labelled Shunt Pathway]

So, this is also a diagram. It – its kind of a cartoon of these types of cholesterol. You know, you can’t put fat in water, or it will float up to the top. So, our body puts it in little particles, and these are the cholesterols. And so, when it’s produced in the liver, it first comes out as a particle called VLDL, which is high in triglycerides, and then the body converts it through a number of different conversions to this LDL cholesterol. And that’s what deposits in the body, and you can enhance this production and clearance by either eating less or burning more. And that’s really important to understand. You can put less in the system, or you can burn away more. That’s why we say, Eat better and do more physical activity. And your liver can only handle so much. You know, your liver has got its limits. And if the liver is overwhelmed, more and more will float through the bloodstream and it’s only got one place it can land and that’s your blood vessels. And that’s how it accumulates in your blood vessels.

[Patrick McBride, on-camera]

So, here are some key facts that you need to understand. Genetics and lifestyle are the key issues for the chemistry –

[slide titled – Key Facts – Cholesterol – featuring the following facts – Genetics and lifestyle play a significant role in our cholesterol pattern; Major influences for LDL-C are dietary saturated fat, trans-fats, and genetics; Major influences for VLDL (triglycerides) are dietary carbohydrates and fats (excess converted to triglycerides/VLDL and stored in adipose, alcohol intake, body weight/fat distribution, physical activity; HDL cholesterol reduces risk, removes cholesterol from blood vessel, is affected by genetics, exercise, weight, weight distribution, and alcohol]

– for cholesterol. And the major influence is on LDL cholesterol, the type that deposit in your blood vessels, are dietary saturated fats and trans-fats, which made the news this week, that I’m going to talk a little bit about and Sue Nitzke’s gonna talk a little bit about more in the course, and also genetics. So, LDL’s both affected by what we put in our body and also our genetics.

And the major influences for triglycerides, which travel around the body in this VLDL, are carbohydrates and fats. So, the carbohydrates we consume, which I’ll talk about, are very important to our triglycerides, and so is alcohol. So, carbohydrates are primarily affected by added sugars, the sugars that we consume, as well as how much alcohol we drink.

So, there has been a message around heart disease that, Hey, I heard alcohol is good for your heart. Well, in moderation. It’s all things in moderation. You know, one drink is –

[Patrick McBride, on-camera]

– one beer, one shot, or three ounces of wine. But what people have done is made, you know, glasses have gotten bigger and bigger, and so, if you say to an American Hey, I heard alcohol is good for your heart, that means a six-pack. Or, you know, 14 ounces, or a bottle of wine. They don’t understand it’s one drink, one drink a day.

So, a carb – triglycerides are also affected by our –

[return to the – Key Facts – Cholesterol – slide, described above]

– body weight and our fat distribution, which I’m gonna talk about. And they’re also affected by how much we burn. So, you can drop your triglycerides in minutes by how much activity you do. And our good cholesterol, as I mentioned, clears cholesterol from –

[new slide titled – Types of Dietary Fat – featuring the following list – Saturated, Trans-fats, Monounsaturated, and Polyunsaturated]

– the body.

Now the types of fat really fall into these categories. There are really only these fats in our body. Saturated fats are the ones that are fully saturated, and they’re – theyre the kinds of fats that we find in – in fatty meats, in – in whole dairy products. And I want to make one major disclaimer right now, because I’m from Wisconsin. Dairy products are good for you, but what you want to do is use low-fat dairy products, so skim milk, skim milk cheeses, yogurts, and things like that. So, we try to get the saturated fat lower in those products, because that’ll lower your cholesterol.

And then Trans-fats are the ones that have been altered. They’re not – theyre not natural fats. These are the ones that are altered, that the F.D.A. this week declared have to be completely removed from food by 2018. Now, most food manufacturers have already started to voluntarily take them out of chips, and crackers, and cookies, and things like that, because they’ve been shown to be associated not only with heart disease and cancer, but also dementia. And so, they’ve already been really –

[Patrick McBride, on-camera]

– removed, but if you look on a package and you see hydrogenated, that’s a Trans-fat. So, you don’t want to have Trans-fats. Saturated and Trans-fats are the ones that raise your LDL cholesterol.

Monounsaturated fats, the –

[return to the – Types of Dietary Fat – slide, described above]

– the ones that we think about most when we think about this, is olive oil or canola oil. These fats have been shown to lower LDL cholesterol and raise HDL cholesterol. So, these are the ones we try to encourage. That’s why we try to encourage the Mediterranean diet. And I’ll show you data that shows that the Mediterranean diet’s associated with lower heart disease, mortality, and overall better health.

And then, polyunsaturated fats are things like corn oil, and soybean oil, and things –

[Patrick McBride, on-camera]

– like that, and lower LDL, but are neutral on HDL cholesterol.

So, we tend to recommend to people substitute monounsaturated fats primarily or polyunsaturated fats for saturated fat in your diet, and you’ll lower your cholesterol. That’s what we’ve been saying for 30 years. People always say, Why do you keep changing the dietary recommendations? I got news for you: the American Heart Association has not changed the dietary recommendations in 30 years. They really haven’t changed. People around them have made changes, but they really haven’t changed substantially in 30 years.

So, as I mentioned, saturated –

[slide titled – Clinical Effects of Dietary Fats on Serum Lipids – with the following information – Saturated and Trans-fats increase LDL-C; Polyunsaturated fats decrease LDL-C; Monounsaturated fats (e.g., olive oil) decrease LDL and increase HDL; All may increase triglycerides if patient is susceptible, and all are caloric dense]

– and Trans-fats increase LDL. Polyunsaturates decrease LDL. Monos have the dual benefit of decreasing LDL and raising HDL cholesterol. That’s why olive oil is such a good fat to use in substitution for saturated fats.

Now all of these are fats, so remember they’re high in calories. So, they all have the same amount of calories, so you can’t just pour them on things. You know, people tend to do that. You know, if you substitute an oil for butter, it’s still the same amount of calories, so they’re still gonna increase weight. So, you still –

[new slide titled – Trans-Fatty Acids – containing the following bulleted list – Created when liquid oils are hydrogenated; very stable at room temperature; are monounsaturated fats, but act like saturated; may decrease HDL; Average U.S. intake is about 3% of total calories; Major sources – cookies, crackers, microwave popcorn, donuts, margarine, pie crust, fried foods. BANNED COMPLETELY IN 2018]

– have to be cautious in the amount of oil you use.

Now these Trans-fatty acids, as I mentioned, these are the hydrogenated. They use them because they are stable at room temperature. So, what I like to tell medical students and the P.A. students is Hey, when you go to the vending machine, the reason that those crackers, and cookies, and chips, and everything aren’t refrigerated is because they can leave them in that machine for a year without refrigerating them, because they have Trans-fats in them, ’cause they’re stable at room temperature. That’s why they don’t have to refrigerate them. That’s little scary to me, okay? So, that’s why they have Trans – Trans-fats. That’s why food makers developed them.

That’s not natural, okay?

So, they decrease HDL, they raise LDL, and fortunately they’re starting to come out of food, and as I mentioned, they’re completely –

[Patrick McBride, on-camera]

– gonna be banned.

So, the natural ways to lower cholesterol, and this is really important because most people in the United States could lower and make their cholesterol normal on their own, if they change their lifestyle. These are the ways you –

[slide titled – Natural Ways to Lower Cholesterol – featuring the following bulleted list – Low-saturated fat; High soluble fiber (oats, psyllium); Fish oils and flax; Nuts; Olive oil or canola oil (in place of saturated); Sterols; Soy; Exercise and weight loss. Guidelines care of www.heart.org ]

– could do it. Lower saturated fat in the diet. Increase the soluble fiber through things like oats, and flax, and psyllium. Fish oil, more omega-3s in the diet. Nuts are a very good way to lower cholesterol, especially almonds and walnuts. As I mentioned, the use of these monounsaturated oils. Soy, tofu, soy nuts, soy milk, and then exercise and weight loss –

[Patrick McBride, on-camera]

– and there’s a very good resource for that at the lifestyle guidelines at heart.org, as I mentioned.

And then, just to give you an example –

[slide titled – Dietary Adjuncts: Efficacy at Reducing LDL-C – featuring two photos – one of a gathering of corn, oats, rice and flax on a table and another with a glass milk next to a bowl of cereal. Above the photos is a three by four table with the columns being – Therapy, Dose and Effect and the rows being Dietary soluble fiber, Soy Protein, and Sterols. So, for Dietary Fiber at a dose of 2-8 grams/day leads to a reduction of LDL-C by 5-10%, Soy Protein at a dose of 20 to 30 grams/day leads to a reduction of LDL-C of 5-7%, and Sterols at a dose of 1.5 to 4 grams/day leads to a reduction of LDL-C by 10 to 15%]

– if people added soluble fiber, things like oats and oat bran, in – in their breakfast in the morning, you can drop your LDL cholesterol five or 10%. Using soy milk or tofu or soy nuts as a snack, for example, you could get another five to 7%. Using these sterols, they’re – theyre an added ingredient that people can use as a number of different ways of do it. They’re – theyre found in different margarines. That’s another 10 or –

[Patrick McBride, on-camera]

– 15%. Ways to naturally lower LDL cholesterol. So, there’s a lot of different ways to do that.

Let me say something about carbohydrates, because they’ve been massively misunderstood. Number one thing I want to tell you is carbohydrates are good for you, okay? Fruits and vegetables are good for you, okay? So, carbohydrates, don’t get this idea. Added sugars aren’t good for you, okay? That’s the carbohydrates that we’re talking about. Carbohydrates: carrots, celery, apples, bananas, straw (berries). Those are carbohydrates. Those are good for you. They’re necessary, they’re important. So don’t try to eliminate all carbohydrates. Complex grains, oats, flax, those are carbohydrates. They’re critical, they’re important, they’re good for you, okay? So, don’t get this idea all carbs are bad.

But here’s what we’ve done. We’ve added –

[slide titled – Simple Sugars in Foods- with the statement – U.S. Dietary Guidelines recommend no more than 10 teaspoons per day. The slide also includes the following list of products with added sugar and the amount – Cola, 12oz. = 10 teaspoons; Pancake syrup, cup = 10 teaspoons; Hostess Lemon Fruit Pie = 11 teaspoons; McDonalds Vanilla Shake = 12 teaspoons; Fruitopia, 20 oz. = 18 teaspoons; Dairy Queen Mr. Misty, 32 oz. = 28 teaspoons; Mountain Dew 44 oz. = 37 teaspoons]

– sugars to our – to our food. Like, here’s a 12-ounce soda. There’s 10 teaspoons of sugar in this. 10 teaspoons of sugar, okay? So, you look at these kinds of things that we do, you know, and these shakes and – So, if a kid is at a fast-food place, and they go and they get a – a big cup of soda, and they get 37 teaspoons of sugar and they go refill it, they get another 37 teaspoons of sugar. That’s enough to bake a cake and put frosting on it –

[laughter]

– okay? That’s what we’ve done to our kids –

[Patrick McBride, on-camera]

– okay?

And I’ll tell you one of the things that makes me the most angry is the fact that we have a children’s menu at restaurants. Starting at the age of two, children are supposed to be eating the same food at a meal that we eat. Theres not supposed to have little weenies and macaroni and cheese and PB and J – although I love PB and J – there’s not supposed to be meals without vegetables, and, you know, we have a kid’s menu and it’s horrible food. That’s inexcusable as a society. I talk to every manager at every restaurant where I see a children’s menu and say, This is inexcusable, okay? It’s – its – in – its inappropriate. Kids should be ordering from the same menu that we order from. We – this is what we’ve done to our children, is we’ve tripled obesity in adolescents in this country by doing this. That’s what happened. The two factors are soda and television, if you look at the data. And in the last two decades, we’ve not only just added television, we’ve added GameBoys and computers and video games. You know, 30% of three-year-olds have a television in their bedroom. So, if you say to a kid, Alright, you’ve been bad, go to your room, they turn on their television, alright? So, we’ve really got to change, alright?

So –

[slide titled – American Diabetes Association: Carbohydrate and Glycemic Effects of Foods – with the following information – Foods containing carbohydrates from whole grains, fruits, vegetables, and low-fat milk should be included; Total amount of carbohydrate is more important to the total glycemic effect than type of carbohydrate; The use of restrictive diets should not be a primary strategy in food/meal planning, but an overall strategy is needed to reduce diabetes complications]

– the American Diabetes Association recommends foods containing carbohydrates but from whole grains, fruits, vegetables, and low-fat milk. Carbohydrates are important to the diet. But the total amount of carbohydrates is what’s important and they should come from healthy sources. So, it’s added sugar that we’re really talking about. And restrictive diets are really only for special circumstances. You know, every week I hear about a new diet plan. Healthy eating is what we should be talking about. Not paleo or grapefruit or, you know –

[Patrick McBride, on-camera]

– healthy eating for a lifetime is what we should be talking about.

So, I want to talk about triglycerides cause this comes up a lot. And they’re really related to calories, alcohol. I saw two people in clinic today. It was about, you know, 15 to 25 drinks a week that was really the issue. You cut that out, their triglycerides would’ve been normal. Simple carbohydrates.

[slide titled – Triglyceride Disorders – with the following bulleted list – Highly diet responsive – fat, alcohol, simple carbohydrates, total calories; Very low-fat and low carbohydrates; Physical Activity and Weight Loss; Medications – Fibrates, Niacin, Fish Oils]

So, we try to work with people to do healthy eating, regular physical activity, and – and moderate alcohol –

[new slide titled – American Heart Association Dietary Guidelines – and the statement to include foods from each of the major food groups – 5 or more from fruits and vegetables per day; 6 or more grains per day, including whole grains]

– and we’re really okay. So, we want to make sure that people are doing this, and I can tell you this is a rarity on a food record, is that people are eating vegetables.

[the slide animates on the statement – to achieve and maintain healthy body weight – match energy intake to energy needs; participate in physical activity that achieves fitness and matches or exceeds energy intake]

And what we want to do is make sure that people are including foods from all the food groups and trying to match energy intake to energy output. And, if we could just get more people walking.

You know, I’m excited when I see Fitbits, and, you know, pedometers, and things like that. People don’t have to do high intensity. If I had a wish –

[Patrick McBride, on-camera]

– I would take away all the heart rate monitors off every machine. Just walk, walk the dog. You know, most people’s dogs are just staring at em, saying, Please take me out twice a day, you know. That’s all we need, you know. We really need that.

So, let me talk to you about healthy lifestyle and how it affects chemistry. You can reverse the blockages that people have in their arteries through changing lifestyle. Dean Ornish –

[slide titled – Multiple Lifestyle Trials Show Heart Disease is Reversable – featuring the following bulleted information – Lifestyle Health Study (Ornish) – 60% reduction in progression of heart disease and twofold increase in regression; STARS trial – healthy lifestyle reduced atherosclerosis progression by 85%; CLAS trial – atherosclerosis progression was related to higher consumption of total and saturated fat – increasing protein and lower saturated fat had lower progression]

– was one person that did it. He showed a 60% regression in these blockages with changes in lifestyle. It was done in a study called STARS. They found an 85% decrease in progression of these blockages. There was a study we did here at the University of Wisconsin with a professor in the University of Southern California. We were part of this study called CLAS. And we found that this lack of progression was related to a – a reduction in polyunsaturated fat and an improvement in healthy fats, and fruits and vegetables. So, if people increased activity –

[Patrick McBride, on-camera]

– and had a healthier lifestyle, guess what? They had an improved outcome in their arteries.

Now the Mediterranean diet is what we really tend to talk about. We want to talk about healthy eating, but this Mediterranean approach, I generally not a fan of the word diet, I like healthy eating, but –

[slide titled – Mediterranean Diet – featuring an illustrated food pyramid on the left with four stages – at the top of the pyramid is Monthly consumption which has Meat in it; the next three rungs down are labelled Weekly and contains – Sweets, Eggs, Poultry, and Fish; the next four rungs are labelled Daily and contains – Cheese and Yogurt, Olive Oil, Fruits, Beans, legumes and nuts, vegetables – with the bottom food rung being Bread, pasta, rice, couscous, polenta, other whole grains, and potatoes; the base of the food pyramid is Daily Physical Activity. Also noted is wine in moderation. Next to the pyramid is this bulleted list – Complex carbohydrates; Nuts and legumes; Daily fruit and vegetables; Fish; Less red meat (use poultry); Olive Oil; Two studies show decrease in heart disease by 50%]

– this really focuses actually on complex carbohydrates, nuts, fruits and vegetables, omega-3s, lean meats, olive oil. And two large studies, I mean very large studies, population-based, have shown a reduction in heart disease by 50%. So, this is, to me, I look at that and I go, Man, that sounds pretty good to me, I could eat that, you know. Everything that you want to eats on that list. If you’re a vegetarian or vegan, you can work around that as well. So –

[new slide titled – The Use of Mediterranean Diet and Olive Oil – featuring two graphs – both have Years on the x-axis from 1 to 6 and the top graph has Incidence of Composite Cardiovascular End Point on the y-axis and the bottom graph has Total Mortality on the y-axis for three diets – a control diet, a Mediterranean diet with nuts, and a Mediterranean diet with extra virgin olive oil. Both graphs have smaller sub-graphs within them showing more detailed data from the larger graphs. Both graphs show lower incidences of End Points and Mortality for the Mediterranean Diet with Extra Virgin Olive Oil than the Control Diet by a wide margin and a Mediterranean Diet with Nuts by a smaller margin]

– you can do pretty well with that. This slide doesn’t show very well, except if you look at a couple of things. Just look at the lines and notice the separation. And what this shows is a decrease in mortality in people that went on the Mediterranean diet versus a usual diet in this study. And there’s a drop in mortality. And if they added extra virgin olive oil to the diet, they get even a greater drop in the mortality. So, Mediterranean diet is a really healthy –

[new slide titled – DASH Diet – Dietary Approach to Stop Hypertension – featuring the following bulleted list – High intake of vegetables and fruits; Low salt (sodium); Modest alcohol intake; High intakes of low-fat dairy products (calcium and vitamin D); Appropriate calorie intake to improve body weight; Can drop Blood Pressure by 12 points systolic and 8 points diastolic]

– way to go. And there’s other studies that show this. There’s a study in Lyon where they took patients with heart attacks, and they showed a marked reduction in heart attacks in patients with heart disease.

This is another variant of it. The U.S. News & World Report, and other groups have called the DASH diet approach, which is very similar to the Mediterranean diet. Fruits and vegetables, low sodium, modest alcohol, low-fat dairy products, very important, because they contain calcium and vitamin D, very important to Wisconsin, appropriate calorie intake for bodyweight. You can drop your blood pressure 12/8. That’s as good as any blood pressure medicine we have –

[Patrick McBride, on-camera]

– by using this dietary approach, okay? So, lifestyle can really make a difference.

So, the practical approach to eating, just to say this – you know, a lot of times people want to say, Oh, this food is good for you, this food is, – there are no bad foods or good foods.

[slide titled – Practical Approach – featuring the following list – There are no good or bad foods, just good or bad meal plans; Use the 3 by 3 approach – at least three meals per day and at least three food groups at each meal; Liquid calories can be trouble; Vegetables every day – the more the better; Live life in balance]

There’s just healthy eating, okay? And so we say eat three meals a day because I can’t tell you how many people skip breakfast, and have almost nothing for lunch, and then have a big meal at night, then hit the easy chair and watch their favorite show, and [makes snoring sound]. And then it accumulates right here, okay? So, spread the food out. Watch out for liquid calories because we have a lot of people who say, I don’t eat much at all, and then they have the mocha-Frappuccino-latte-cappuccino-blah-blah, and then just, and soda, soda, soda, beer, beer, beer, and boom, boom, boom, okay? So, liquid calories can be a real big problem. And – and eat your vegetables.

You know, the seven things your mother told you? Don’t do drugs. Get plenty of sleep. Eat your vegetables. You know, Stay out of bars.

[Patrick McBride, on-camera]

Know who your friends are. Well, she – [looks up at the ceiling] she was right, so –

[laughter]

– hate to tell you, but anyway.

Now, I want to talk about medicines, because so many of the medicines people misunderstand. You know, we have the safest, most effective medicines in the history of the planet, and people think there’s some big conspiracy or something. There is not a conspiracy. Most of our medicines came from plants. Statins came from a fungus. I mean this great researcher in Japan spent years figuring this out. And these – these medicines are safer than aspirin. There’s 5% of people they get muscle aches. There’s one in 1000 people that their blood sugar goes up, and that is it, that is it. And theyve saved millions and millions of lives. And they cost $4 a month. They are incredible –

[slide titled – Statins and other cholesterol Medicines – with the following bulleted information – Safe! Effective! Low side effects; Reductions in heart disease and stroke of 30 – 45%; Highest effect in highest risk]

– and people get on the internet and read all kinds of crazy baloney. These are incredible. I have patients that would have been dead 30 years ago, if they weren’t on these things.

I mean, when I met Akira Endo, this researcher this weekend, I almost cried because of this guy’s discovery. He has won so many awards, and he should win the Nobel Prize. And they are so safe, and they are so effective, and they reduce heart attack, strokes, and death by 30 to 45%. So, if your doctor –

[Patrick McBride, on-camera]

– recommends that you should take ’em, you should take ’em, okay?

So, don’t talk to your neighbor, unless they’ve got an M.D., okay? And they haven’t read your chart, okay? They’re really incredible. The greater the risk, the greater the benefit.

So, please –

[slide titled – Can Artery Blockages Reverse? The Effects of Cholesterol Treatment – featuring an illustration of a mostly blocked blood vessel on the left-hand side and two illustrations on the right at the end of two arrows. The first arrow is labelled No Statin Therapy – plaque progression, micro-calcification with lipid pools and leading to an illustration of a 75% blocked blood vessel, The second arrow is labelled High-intensity Statin Therapy – plaque regression, delipidation, vascular smooth muscle cell calcification and leading to an illustration of a blood vessel that is mostly unblocked]

– because this is what they do. So, this is a picture of what I was talking about. Again, the artery cut this way. And this was published two weeks ago. A researcher at the Cleveland Clinic summarized eight studies of this regression, we call it. These arteries blockages shrinking. Patients not on statins, the arteries progressed, the blockages got bigger. Patients on high-intensity statins, the arteries not only the blockages not only got smaller, but they actually got firmer and less likely to crack open. They actually sort of scarred, so that they couldn’t crack open, and the data is quite clear. There are over 50 studies that have shown this, and we’ve done three of them here. So, it’s very clear that you can reverse these blockages with aggressive statin therapy. And you can reduce deaths –

[Patrick McBride, on-camera]

– strokes, and heart attacks. Take your medicine, if your doctor tells you to take your medicine.

This is a study in children that have a genetic form of very high LDL cholesterol –

[slide titled – the JAMA Network – Efficacy and Safety of Statin Therapy in Children with Familial Hypercholesterolemia: A Randomized Controlled Trial – and featuring a bar graph with these four blood vessels on the x-axis – Common carotid artery, Carotid Bulb, Internal Carotid Artery and Mean Combined Carotid IMT, on the y-axis is the Mean IMT Change in mm. The graph shows that those children on Pravastatin had their plaques reduced greatly compared to the children on the Placebo for all four vessels]

– where they measured the early blockage formation in children in their carotid arteries. And the dots above the line are showing blockages progressing in two years in children. The black dots below the line show that you can actually reverse blockages in children in three years by use of statins in children. So, we start children at age 10 with genetic cholesterol disorder. I’ve been using statins in children for 25 years and have yet to see a child with a side effect from ’em.

[Patrick McBride, on-camera]

So, they’re very important medicines.

So, here’s a summary of those. Can you reverse these blockages?

[slide titled – Can Blockages (Plaques) in Arteries Reverse? Atherosclerosis Regression, Vascular Remodeling, and Plaque Stabilization – with the following bulleted information – Significant change in plaques are noted by 2 years with statin treatment – also with aggressive lifestyle change and treatment of blood pressure with ACE/Calcium Blockers; Placebo groups in statin trial show plaque progression; Statins diminish the lipid pool plaques- the fibrous portion of the plaque remains; Plaques become far more stable and less likely to rupture = fewer heart attacks and strokes; Plaques most likely to rupture – those with the most fat and most inflammatory cells – are most positively affected by lifestyle and statins]

Yes, significant change in plaques are noted within two years of using these medicines, also with aggressive lifestyle treatment. So, the combination is really powerful. The placebos groups in these studies show progression in these blockages. So, if you want the blockages to progress, put ’em, don’t take medicine. And they diminish the pool of the – of the cholesterol, and they make the fibrous portion, the scar, much more firm. And they are much less likely to rupture. So, the way to prevent future heart attacks is –

[Patrick McBride, on-camera]

– take your medicine.

Now I want to talk about the chemistry of obesity and overweight briefly to finish up. So, this is the most recent map –

[slide titled – Obesity Among U.S. Adults 2013 – showing a color-coded map of U.S. States and their incidences of obesity and showing that most of the Ohio River Valley States as well as Tennessee, Alabama, Georgia, and South Carolina have highly obese (30-35% of population) adults as well as the States to the west of the Mississippi River Valley (Iowa, Missouri, Arkansas, Louisiana, Texas, Oklahoma, Kansas). The highest rates of obesity are the States of West Virginia and Mississippi with over 35% of adults being obese. Wisconsin is in the moderate category with 25-30% of the population obese]

– from the C.D.C. showing how common overweight and obesity are in the United States. So, sadly, in the states in the U.S. that have the highest rates of poverty, and the highest socio-economic issues, the Southeast, have the highest rates of overweight and obesity. So, Wisconsin used to be number one, but fortunately we’re not there, but no – no state has anything to brag about. Most of the states are above 25 to 30% rates of – of obesity. All states in the country are above two-thirds of the population being overweight.

[new slide titled – Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults Aged 18 Years or Older – featuring six color-coded maps of the United States for the years 1994, 2000, and 2010. The top three maps map the increase in obesity over these years for each state and the bottom three maps map the increase in Diabetes for each state over the same three-year period. Both maps show a huge increase in Obesity and Diabetes over the three-year period]

Now what’s important is this trend has happened very, very rapidly. So, first thing I want to say is, I teach our medical students and our P.A. students, 40% of overweight and obesity is genetic. 40% is genetic. So, a lot of this is it’s really difficult for a lot of people to control. But unfortunately, in the last three decades we’ve seen a huge increase, and a lot of that has to be related to the environmental changes. This change in high fructose corn syrup and inactivity, the Internet, computers, videos, Netflix, and Game of Thrones, and God knows what else. So, you look at this trend of how rapidly overweight and obesity has changed in three decades. It’s striking and makes the HIV epidemic look tiny. It’s – its unbelievable, and diabetes has followed right along behind it. And, what’s going to follow right along –

[Patrick McBride, on-camera]

– behind it is stroke, and – and a rise back again in heart disease. And, sadly, I teach our medical students this is going to dominate everything they do, whether they’re a surgeon, or an anesthesiologist, or a pediatrician, this will dominate their entire practice. And, as a country we really have to think about this. Health care costs are going to spiral out of control unless we do something about it. We put more and more people on medicine when the treatment could be healthy eating and regular physical activity. We have taken physical education out of schools, which is a tragedy. It’s not about gym class, it’s about health education. That’s what – thats what those classes were. It’s a tragedy because overweight and obesity is directly –

[slide titled – Obesity and CHD Risk in Women – Nurses Health Study – 8-year Follow-up – featuring a bar graph with five different Body Mass Indices on the x-axis and Relative Risk Adjusted for Age and Smoking on the y-axis and showing that the higher ones Body Mass Index the higher the risk for heart disease. A person with a B.M.I. over 29 is 3.3 times more likely to develop heart disease]

– associated with heart disease risk.

So, if a female or male has a body mass index above 29, which 1/3 of our country does, their risk is three times someone else –

[new slide titled – The Increase in Diabetes Is Epidemic – noting a 33% increase from 1990-1998 and an increase of 76% in patients 30-39 years of age. Also noted on the slide – Obesity/weight gain are major risk factors; 2 pounds of weight gain translated to a 9% increase of developing diabetes; Higher rates of obesity will lead to more diabetes]

– their same age. So, we’ve seen diabetes increase by 33% since the 90s, and in patients 30 to 39 years of age it’s gone up 76%. So, the youth are really dramatically affected, and obesity and weight gain are – are it. This is not type I diabetes this is type II diabetes. That’s 95% of all –

[Patrick McBride, on-camera]

– diabetes.

Two pounds of weight gain translate to a 9% increase risk of developing diabetes. Two pounds. You know how easy that is for all of us to – to gain? And I do that in a day, you know. So, it’s so easy to do that, and so we’re really at risk here.

So, diabetes leads, of course, to blockages in all kinds –

[slide titled – Diabetes and Vascular Disease – with two headings – Blockages in legs and Stroke that each have their own bulleted list. Under Blockages in legs is – 2-4 times higher with Diabetes; Leg pain 4-8 times higher with Diabetes; Leading cause of leg amputation. Under the heading Strokes is – Stroke risk 1.5-4 times more with Diabetes; Strokes outcomes worse; Even elevated blood sugar a risk!]

– of places, you know, in our neck. Risk of stroke, risk of heart attack. Blockages particularly in the legs which lead to amputations and sores and – and all those kinds of things. And when I see people losing toes and feet and, you know, it’s just a tragedy, you know. And it’s in my clinic all the time. And so, I am always, you know – and when a person goes from a blood sugar of 118 to a blood sugar of 130, five medicines. ‘Cause they need two medicines for their blood pressure, two for their diabetes, and they need to go on a statin. Just like that.

[Patrick McBride, on-camera]

And I – I battle it. We have a diabetes prevention program that I started at our clinic. It’s really successful, so when we see people’s blood sugar go up, we refer them to this clinic, start working with their nutrition and their activity to try to prevent it. It’s really successful, but it’s a battle ’cause I don’t want to put them on all those medicines, but those medicines are life-saving if they need them. So, it’s really important. And I’ll tell you what it is: it’s the weight gain in the middle.

[slide titled – Metabolic Syndrome – noting that it is – Weight gain in middle and the following list of Causes – Increased blood sugar and diabetes risk; High-blood pressure; Abnormal cholesterol levels (Low HDL, high triglycerides, small LDL); Inflammation in arteries; increases risk of heart disease and stroke]

So, it’s what my dad used to call the middle age spread. You know, and we can prevent this if we really do it. But we’re genetically determined to put it on here because it’s a – a thing that we used to do as – as cavemen 2,000 years ago, you know. We used to go out and hunt the animal and kill it and we’d put the fat on here because we would sleep for a day. And then somebody would poke us with a spear and say, Go get another one. Oh, okay. You know, wed get up and go hunt for another animal. But now the animal is in a grocery store in plastic –

[Patrick McBride, on-camera]

– you know. And we eat it three times a day. So, people think that’s a paleo diet, but we don’t go paleo through the woods, okay? This paleo thing is ridiculous because that’s not the way we do it anymore. People aren’t getting nuts and berries and scavenging for it. They drive to their car and go get the paleo. It’s ridiculous, alright?

So, here’s what happens.

[return to the – Metabolic Syndrome – slide, described above]

When you get weight gain in the middle, you increase your blood sugar and your diabetes risk. All these chemicals, the inflammation chemicals that cause blood pressure and cholesterol go up and you get the chemicals that cause inflammation in the arteries. And this whole process of –

[new slide titled – Measuring waist circumference – featuring an illustration of a woman, a skeleton, and a man shown in profile within a circle and an arrow pointing to the Iliac crest which is the area of the stomach. The slide also includes the following steps – Locate upper hip bone and top of right iliac crest; Place measuring tape horizontally around abdomen at the level of the iliac crest; Tape should be snug without causing compression. For women the measurement should be equal to or less than 35 inches, for men the measurement should be equal to or less than 40 inches]

– these blockages start. So, when you get this weight gain around the middle, and the measurement at the middle is at your hips, it’s the hipbone, not your pants, ’cause I get guys that sag, okay, please don’t sag, okay? I get guys that sag. It’s the measurement at your belly button. So, you take a tape measure, and you exhale. It’s not the holiday picture where you hold it in to look good in the picture. You exhale and you take a tape measure, and you make a measurement at your belly button at the top of the hip bone. If women are over 35 inches or men are over 40 inches, again, this is not your waist that you wear your belt at, this is up here, okay? So that it’s where your belly is.

[new slide titled – How Common is the Metabolic Syndrome – with the following bulleted list – Adults over 20 years of age; 24% all adults, 42% over age 60; Similar for Men and Women; Mexican Americans = 32%; African American women greater than men; 47 million adults in the U.S.]

If you’re greater than that, you have this syndrome. Now it’s really common, its at least 25% of adults and climbing. And it’s much more common in lower socio-economic groups and certain genetic groups. It’s very common in Mexican-Americans, African-Americans, Native Americans. At least 50 million –

[Patrick McBride, on-camera]

– adults. There’s certain people that in families, you gain it here if you’re gonna gain it. You’ll see people that have no rear end. They – their jeans are falling down, and their bellies are here. That’s the people that have this syndrome. High blood sugar, high blood pressure, bad cholesterol levels. That’s what it is and it’s because the fat right here, turns out, it’s a gland. These fat cells are producing chemicals –

[slide titled – Adipose Tissue – Adverse Endocrine Effects – featuring an illustration of 7 olive-like cells that are bunched together labelled – Enlarged Adipose Cells – and surrounded by upward facing arrows for the following body processes (clockwise) – increased Resistin (insulin resistance/glucose); increased Leptin (appetite); increased Fatty Acids (atherosclerosis); increased Inflammatory Mediators (TNF, IL-6,CRP); increased Angiotensin (hypertension); increased Sympathetic Nervous System (hypertension)]

– that tell the body where our hormones are supposed to be.

So, these fat cells we used to just think were just fat, they’re not. They – they determine our appetite. They’re releasing a chemical called leptin that increases our appetite. They release these fats into our bloodstream that cause the blockages. They release chemicals that cause inflammation in the arteries. They release chemicals that raise our blood pressure. And they increase chemicals that cause release of adrenaline and things like that that lead to high blood pressure. So, these fat cells are not inert. They’re controlling all kinds of changes. So, they raise our blood pressure, they raise our blood sugar, and they raise our cholesterol.

[Patrick McBride, on-camera]

And they lower our good cholesterol, and they cause it. So, when we gain five and 10 pounds here, boom, the system goes haywire. And that’s why we gotta fight the battle of the bulge, okay? That’s really important.

Here’s what it does when you lose weight –

[slide titled – Does Weight Loss Work? – and featuring the following list – 200 pounds times 5% = 10 pounds; Total cholesterol down 15%; Triglycerides down 20%; HDL up 15%; Systolic Blood Pressure/Diastolic Blood Pressure down 12/9 mmHg; Improved blood glucose – Diabetes down 60-70% with weight loss of 5%; Improved life expectancy]

– if you lose 10 pounds, the cholesterol goes down 15%, the triglycerides 20%, HDL goes up 15%, blood pressure 12/9, as good as a medicine. The blood glucose goes down, with a weight loss of 5%.

So, I get a lot of patients and they go, I want to lose 50 pounds. I go, Why don’t you start with 10? Let’s just go with 10, ’cause that’s what you’ll get, okay?

[Patrick McBride, on-camera]

And that will improve your life expectancy and keep you off medicine, okay? That’s what this will do. 10 pounds, okay? 10 pounds.

What – what does a pound equal? 10 potato chips, 20 corn chips –

[slide titled – 1-Pound Equals = – noting that it is 3500 calories a day for one week or 100 calories per day for one month. The slide also notes a list of foods that equal 100 calories – 10 potato chips; 20 corn chips; cup ice cream; cup pudding; cup frozen yogurt. It also notes that one gum drop per day for one year = 1 pound]

– a quarter-cup of ice cream, a quarter-cup of pudding, half a cup of frozen yogurt. One extra gumdrop a day is a pound in a year. Do you know how easy it is to do that? I have a sweet tooth if it’s – if its at home I’ll eat it. So, last night I was feeling sorry for myself. I’m saying to my wife –

[Patrick McBride, on-camera]

– Where’s the chips?, you know. She goes, I’m not letting you eat em. Where are the chips?, you know.

[laughter]

You know, when you get home and you’re tired and you’re feeling – you know, I was on call and, so fortunately, she protected me, you know. She gave me a glass of ice water and an apple, sliced apple, you know.

[laughter]

Thank – Thank you, Kim. You know.

[laughter]

Otherwise, I was going to – you know – you know, when you feel sorry for yourself you – right? But that’s how easy it is, right there. That’s how easy.

[new slide titled – UW Active Living and Learning Program – with the following bulleted list – Goal – 7% weight loss through lifestyle change; Group program, multidisciplinary professionals; Data show 5-7% weight loss at 3 months; Waist circumference decreased 3 inches; Fasting glucose decreased form 131 to 119; Average exercise time increased from less than 40 minutes per week to over 120 minutes per week; over 90% adherence to the program at 11 months; covered by insurers, behaviorally based]

So, what we do in our diabetes prevention program, when we see somebody’s blood sugar go 101, 105, 110, so we can keep them off the medicines, hopefully, is we put them in this program. And our goal is 7% weight loss ’cause it leads to all those changes. And this is what happens. Our data shows people can get this. The average waist loss is three inches. That’s – thats changing clothes, I mean. I did this, I went into the first group and that’s what I got. So, I went from a size 36 waist to 34. I had to put all of my pants in the closet. I still got them in there, thinking, in case I ever go back, you know. I couldn’t get rid of them, you know. But I was – I went down, I lost 30 pounds, you know, cause I did it with the group. Fasting glucose from 131 to 119, diabetes to no diabetes. They increase their exercise to 120 minutes per week. 90% of people showed up for the class. That’s what we found. We’ve had this program for 11 years, those –

[Patrick McBride, on-camera]

– numbers have hung right in there.

So, it’s really important.

So, that’s what – you know, people are always looking, right?

[slide featuring a photo from the perspective of a man looking at his feet on a scale and instead of a number for his weight the scale reads – GO RUN]

Move, doesn’t matter what you do. If you like square dancing, if you like jump-roping, if you like walking the dog, I don’t care. People always say, What’s the best form of exercise? I don’t care, just do it. Forget the heart rate, doesn’t matter. 30 to 45 minutes. It doesn’t matter if it’s three times 15, four times 10. It does not matter.

[Patrick McBride, on-camera]

Intensity’s not the difference in this. It’s the amount of time you spent, okay? That’s what – thats what it shows.

So, what are the benefits? Here’s all the benefits of exercise: you improve your bones –

[slide titled – Health Benefits of Exercise – with the following bulleted list – Reduce Cardiovascular Disease; Reduce Cancer (breast, colon, bladder); Reduce diabetes mellitus; improve/prevent osteoporosis; Reduce weight; Improve blood lipoproteins; Reduce systolic/diastolic Blood Pressure; Psychological well-being; Reduce total and cardiac mortality]

– improve your heart, improve your brain, you reduce dementia. That’s even more – bigger effect than heart disease. You improve your cholesterol and your blood sugar, and you improve your psychological well-being. One of the best treatments for depression and anxiety is exercise. That’s research from this campus, a lot of research on that from this campus. And there’s good guidelines on this.

[new slide titled – Guidelines for Exercise Prescription – with the acronym F.I.T.T. – Frequency – most days (3-6 days per week); Intensity – Just Do it; Time – 30-60 minutes total; Type – Aerobic/Resistance]

So, what is the best prescription? Three to six days a week. It’s best if you do this, but six days a week with one day of rest. Just do it. 30 to 60 minutes and mix in both endurance and some strength because –

[Patrick McBride, on-camera]

– you not only have to have some flexibility and strength, but you also have to have some endurance. All three to be fit. And it doesn’t matter.

If you’re trying to win a 10K or a marathon, then you should worry about intensity. I am not trying to win a 10K, so if you are, good for you, but otherwise don’t worry about your intensity.

So, in summary –

[slide titled – Summary – with the following bulleted list – Regular physical activity; Healthy eating; Weight reduction as appropriate; Take your medicines as recommended by a doctor you trust; Metabolism is life!]

– I talked about some of the chemistry of heart disease and stroke and diabetes. And the best ways to do this are through good nutrition, healthy eating, variety. Variety is the spice of life. Take care of yourself. And regular physical activity. And if you need medicine, and a lot of us do, take your medicine, you know. These medicines are fantastic, and they are safe, so please take your medicine if your doctor recommends it to you. And remember, metabolism is life. Our bodies are –

[Patrick McBride, on-camera]

– chemicals and they’re – theyre really important. They all interact, so take care of your bodies. Thank you very much for your attention.

[applause]