Prescribed Listening
Prescribed Listening is a podcast from The University of Toledo Medical Center in Toledo, Ohio. Medical providers from UTMC provide insight into their medical specialties.
Prescribed Listening
Does Cholesterol Really Count/How to Lower Blood Pressure?
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Two of the top Googled Health Questions from the last few years are: "does cholesterol really count " and "how to lower blood pressure?"
Our host Chrissy Billau asks Primary Care Physician, Dr. Kevin Phelps, what can you do to change your blood pressure and cholesterol numbers, what are the risks if your numbers are high, and how lifestyle medicine can change your life.
You can schedule an appointment with Dr. Kevin Phelps at 419.383.5555.
Chrissy Billau:
Welcome to Prescribed Listening from the University of Toledo Medical Center. On this podcast, we interview our experts to get the answers you need and can trust. I'm your host, Chrissy Billau and today we are diving into some of the top Googled health questions with UTMC primary care doctor, Dr. Kevin Phelps. Dr. Phelps, thank you for joining us.
Dr. Kevin Phelps:
You're welcome. Nice to be here.
Chrissy Billau:
Should you really care about your cholesterol levels and what kind of control do you have when it comes to lowering your blood pressure? Let's ask the expert. Dr. Phelps, what is cholesterol and does it really count?
Dr. Kevin Phelps:
It counts big time. If you had asked me this question a year ago, my answer would've been much different. But yeah, cholesterol is probably the most significant risk factor for the development of cardiovascular disease, which is the number one killer in this country is heart attack and stroke and you have an amazing degree of control over your numbers and over what happens to your future.
Chrissy Billau:
What is cholesterol?
Dr. Kevin Phelps:
It is a compound that is produced in our bodies, primarily in the liver. We also consume it and we need very little cholesterol, if any, in our diet. But it's very important in cell membranes in hormones and so we need it, it's essential for life. But too much of it can clog our arteries and wreak havoc.
Chrissy Billau:
You always hear about good cholesterol and bad cholesterol. What's the difference and I guess is cholesterol just bad for you?
Dr. Kevin Phelps:
So there's good cholesterol, some people refer to as LDL, low density lipoprotein. And that's the type of cholesterol that's smaller particles that can go into the artery wall and create inflammation and then laying down a fatty streaks and ultimately plaque. And then the HDL or high density lipoprotein are bigger particles. They're scavengers. They're going to go around and basically gobble up all of the bad cholesterol in arteries. Take it back to the liver for reprocessing. And it's that balance of good and bad, hopefully you have a lot more good than bad in your bloodstream to prevent atherosclerosis.
Chrissy Billau:
When someone goes to their primary care doctor for a checkup, what are you looking for when it comes to cholesterol?
Dr. Kevin Phelps:
So it depends on their age in terms of when we start screening for cholesterol, we're going to take a good history. What is their family history like? What is their health history like? If they've got other medical problems that would make it more of a high risk condition, where we be thinking more about screening and monitoring their cholesterol levels. So, it's individualized and it really significantly depends on their family history. So we'll even screen kids if they've got a significant family history of coronary disease and high cholesterol.
Chrissy Billau:
So if my mom or dad has it, is it pretty much a guarantee I'll have an issue?
Dr. Kevin Phelps:
It's not a guarantee, but it's likely.
Chrissy Billau:
How can you tell if someone has high or low cholesterol? Is that something you can feel like, is there a physical symptom?
Dr. Kevin Phelps:
No. So that's something we need to do a blood test on, typically a fasting cholesterol panel to screen best for cholesterol issues.
Chrissy Billau:
What should someone be concerned about if you have high or low cholesterol? Like at what point do you need more or less, or when does it lead to a heart attack or stroke?
Dr. Kevin Phelps:
Yeah, so I think most of us nowadays are using risk calculators, which you're going to put in things like age, gender, blood pressure, good cholesterol, bad cholesterol, those types of things. And that puts out a number. It's a 10 year risk of having a cardiovascular event in the next 10 years and that risk stratifies patients and helps you decide on therapy. Whether it's lifestyle, whether we're talking about medications, but it's always going to start with lifestyle change.
Chrissy Billau:
Is this calculator something that has to be done in a doctor's office or are people Googling it and putting it in?
Dr. Kevin Phelps:
I've never been asked that question. I think most of the time it's going to be done by your doctor. I'm crunching these numbers right in front of the patient when they come in the office because I've got their numbers in front of me, their current blood pressure and their lipid panel numbers or cholesterol panel numbers. And oftentimes I'll email a copy of that report to them.
Chrissy Billau:
What's a range you want to be in?
Dr. Kevin Phelps:
Lower the better. Your LDL should be as low as possible. And you are looking at that ratio of good over bad, even though the bad may not be terrible if your good is low, that ratio of bad over good can still be significant.
Chrissy Billau:
Okay. Is there a number to it? Like, don't go over this.
Dr. Kevin Phelps:
So the old number was a total cholesterol of 200, but again, that has been a moving target over the years. If you don't have diabetes or coronary artery disease risks, then an LDL of less than 130. If you've got diabetes, you want it less than 70. So it really depends on your health.
Chrissy Billau:
How old do we need to be to start checking our cholesterol?
Dr. Kevin Phelps:
Again, that depends on family history. If you're healthy and no comorbid illnesses and insurance factors in on this too, that's changed significantly over the last few years. A lot of insurance companies are not paying for screening cholesterol panels. It used to be those types of things we could easily get covered. Now it falls on the patients about whether they want to have a screening cholesterol panel or not. But if they've got risk factors or they've got a history of an elevated cholesterol, typically we're starting screening 35.
Chrissy Billau:
35.
Dr. Kevin Phelps:
Age 35.
Chrissy Billau:
So unless you're under 35 it's not going to be something they check at your annual appointment?
Dr. Kevin Phelps:
Typically not.
Chrissy Billau:
Okay. What's the danger of having high cholesterol when we're, I don't want to say youngish, but not finding out until you're in your 50s.
Dr. Kevin Phelps:
Yeah. That's a great question because there's studies that have shown that you're seeing evidence of atherosclerosis in a very young age, 20s and 30s, fatty streaks and things like that. It doesn't become evidence or manifests itself until 40s, 50s, 60s. But all of that is happening at a much early age.
Chrissy Billau:
And so I guess, why is it not being screened? It's blood work, right?
Dr. Kevin Phelps:
Right.
Chrissy Billau:
What changed? Something in the healthcare world of cholesterol is not the bigger issue, it would be other things?
Dr. Kevin Phelps:
It's the country and the world that we live in right now. Is it okay if I talk a little bit about Blue Zones? So I think that really puts us into context because those are areas of the world where you pretty much do not see things like hardening of the arteries, heart disease, cancer, obesity, diabetes. They don't see them in those areas of the world. And there are things like Central Africa, Okinawa Japan, even Loma Linda California, places like that, where they eat mostly plants. They're very active physically. They take time to de-stress. They're very community oriented, oftentimes with a spiritual or religious theme. They push themselves away from the table when they're about 80% full. Their smallest meal of the day is late afternoon, early evening. They don't have hardening of the arteries in those communities. And that was a real like epiphany for me when I started learning about these things, because we have just become accustomed to having hardening of the arteries in this country, and we don't have to.
Chrissy Billau:
It's a lifestyle.
Dr. Kevin Phelps:
It's a lifestyle.
Chrissy Billau:
Now talking more about lifestyle stuff and things you can do to control your cholesterol. If anyone has ever seen a Cheerios commercial, you know it's been drilled into our heads that it helps lower cholesterol. What can we do to change our cholesterol levels? Is there a natural way? Foods we should be eating? More Cheerios? What do we do?
Dr. Kevin Phelps:
Yeah. So there's good evidence to support advising your patients that they should be eating mostly plants. Whole grain breads and whole grains, things like that. The thing in the Cheerios, which makes it healthy is that it's got whole grain, whole wheat in it and that's going to bind cholesterol on the gut and lower your cholesterol level, reducing your risk for hardening of the arteries. So dietary changes are significant, but regular physical activity, all those things is going to be protective for you.
Chrissy Billau:
So for bad cholesterol, that's meat?
Dr. Kevin Phelps:
It is.
Chrissy Billau:
Anything else?
Dr. Kevin Phelps:
Mostly you're talking about meat. Whether it's red meat, chicken, even fish. There is some like evidence in the Mediterranean diet, that's a significant component of the Mediterranean diet is fish, but there's evidence that even fish can be harmful.
Chrissy Billau:
We talk about in a couple of these episodes of Prescribed Listening this season the one thing I've learned and I've heard most about no matter what we're talking about is fiber. So, when you're talking about mostly plants, fiber plays a good role for your cholesterol levels?
Dr. Kevin Phelps:
Yes. Yep. Yeah. It's huge. And as we learn about this, it's going to affect a lot more than just hardening of the arteries. The gut microbiome is dramatically affected by the types of foods that we eat, specifically fiber. So you can select out healthy populations of bacteria in our gut and there's some evidence that it's even protective against COVID, and it helps control of diabetes. Eating fiber produces healthy, short chain, fatty acids in our blood, which is protective in keeping our blood sugar down and it's kind of antioxidant. So, cellular damage, oxidative stress, all those things that create inflammation in our body is made better with fiber.
Chrissy Billau:
And exercise too.
Dr. Kevin Phelps:
And exercise.
Chrissy Billau:
Now, can cholesterol be managed by diet and exercise alone, or is medicine like statins necessary?
Dr. Kevin Phelps:
So if you look at the National Cholesterol Education Program, these guidelines that we have known about for decades, the baseline recommendations like the foundational recommendations, and there's pages and pages and pages of them, all have to do with lifestyle. And the healthcare providers know about this and yes, we do talk to our patients about this, but it's so much easier to prescribe a medication than it is to help people change behavior. To really help them understand the influence they have over their health. I think most patients really don't understand or appreciate how much control they have over their health.
Dr. Kevin Phelps:
They think it is going to require a prescription. I would argue that it's completely the opposite of that. Looking at lifestyle as the main source of treatment, not secondary but the main source of treatment, and then if you need a medication, that's going to be an add-on.
Chrissy Billau:
So let's see if you can stop, don't have macaroni and cheese all the time, get up a half hour earlier and work out for 20 minutes before you start getting ready for your day. Those habits, try and make those stick before you try medicine.
Dr. Kevin Phelps:
Absolutely.
Chrissy Billau:
So we talked about Mediterranean diet, which brings up the question do you have any diet recommendations or any diet changes we can make? Because you always see there's a new fad diet out there, but what can we realistically do that you believe would be most effective?
Dr. Kevin Phelps:
Yeah, I really don't like the word diet. What I'm learning is to help patients change behavior you need to be very specific. There's something called a SMART goal and SMART is an acronym for specific, measurable, achievable, realistic, and time based. So you're going to set a goal with the patient at the time of the visit helping them with behavior change and it's going to be them picking what the goal is going to be. Is it going to be a dietary goal? Is it going to be a physical activity goal? Is it going to be a sleep goal or a stress management goal? And then you can just build on that over time.
Dr. Kevin Phelps:
But I would say, if you're looking at making some changes with your eating habits, I like the term flexitarian because it's a progressive dynamic kind of thing. The flexitarian you could look at that as basically to traditional American diet on one side and vegan on the other. And then in between is eating more plants, more and more plants and less and less animal protein on your way over to the vegan. The vegan diet is a challenging diet. There's no doubt about it. But moving towards more vegetables and fruits and whole grains and less animal protein, you're going to help yourself significantly. And these changes are dose dependent. The more changes that you make, the more benefits you're going to get.
Chrissy Billau:
See, I like that more than we're going to be on whatever the latest fad diet is and you can only do this and this much each day. And that seems more reasonable and something I can easily do. It's less daunting, I think.
Dr. Kevin Phelps:
When I talk to patients about health behavior change, I like the term relentless incrementalism, which is basically baby steps over time. And you're going to have missteps and you're going to fall backwards, get back at it, learn from your mistakes and just continue to make these small steps over time. It's going to help in the long run.
Chrissy Billau:
Switching gears let's talk about blood pressure. But before we get to the top Googled question, just as a baseline, what is blood pressure?
Dr. Kevin Phelps:
Blood pressure is the pressure inside of our heart and cardiovascular system arteries. That's produced by the heart contracting, which is the top number and relaxing, which is the bottom number of a blood pressure measurement.
Chrissy Billau:
Why is that so important for our body?
Dr. Kevin Phelps:
Well, we need blood pressure to live, obviously, but when the blood pressure gets too low, then we don't feel good, we're tired and we can pass out and fall and hurt ourselves. If the blood pressure is too high, then it's going to damage arteries and capillaries in our hearts, in our brains and our kidneys and all over our bodies.
Chrissy Billau:
More often it's people have the high blood pressure though?
Dr. Kevin Phelps:
Correct.
Chrissy Billau:
How would you lower it?
Dr. Kevin Phelps:
Again, I'm going to start with lifestyle. If you look in those Blue Zones where we don't see much hypertension, hypertension is very uncommon. I think the statistics that I read recently was in those Blue Zones you may have 5% of the population having hypertension, as compared to this country we see 30% of the population with hypertension.
Chrissy Billau:
When you hear that number, 30% of our country's population has that, I mean, do you get angry?
Dr. Kevin Phelps:
It's more concern.
Chrissy Billau:
So how can a person tell if their blood pressure is up or down?
Dr. Kevin Phelps:
When I went to medical school we were taught that patients really can't tell if their blood pressure's up, but through experience there are some patients who experience headache and fatigue consistently when their blood pressure is elevated. So, I do think in certain instances, if patients are not feeling well or if they're tired or if they've got headaches and they don't normally get headaches that that may be an indicator that their blood pressure may be elevated.
Chrissy Billau:
What causes your blood pressure to go up?
Dr. Kevin Phelps:
So 90% or more of high blood pressure is what's called essential hypertension, which means we don't know what causes your blood pressure to be high. But again, going back to the lifestyle, it's probably we're eating too much salt and too much red meat and we're not exercising and all of those things that go along withed blood pressure.
Chrissy Billau:
So the same question is before with cholesterol, who needs to really watch and get their blood pressure checked and should everyone be thinking about this? Is there a screening for this? Or is this something that is regularly checked?
Dr. Kevin Phelps:
Because it's such an important risk factor for disease, specifically cardiovascular disease, it is a vital sign that we check every single time patients come in the office.
Chrissy Billau:
Is there a good range to be in, or does it depend on the person?
Dr. Kevin Phelps:
So there are many, many different guidelines for high blood pressure, but I think most doctors will go by the guideline of a blood pressure in the office of less than 140 over 90, and at home or out of the office your blood pressure should be lower. Most of us use a blood pressure of less than 130 over 80.
Chrissy Billau:
At what point does someone need to be on medication to control it?
Dr. Kevin Phelps:
So we make the diagnosis of high blood pressure when you've got more than two readings at or above 140 over 90. And then at that point, we are talking about lifestyle change and then give them time to make some of these changes. And then at some point you decide with a patient on when it's time to start treating their high blood pressure.
Chrissy Billau:
Like having high cholesterol, that is hereditary, you always look at family history. Is high blood pressure the same?
Dr. Kevin Phelps:
Yes. It seems to run in families.
Chrissy Billau:
I want to talk about some elements of your practice, what have you been working on lately and specifically based on where our conversation is gone. I'm eager to hear about lifestyle medicine and some changes you've made in how you perceive overall health.
Dr. Kevin Phelps:
Yeah. So I mentioned at the beginning that my answers to your questions today, would've been completely different a year ago. And that's because I had a non-medical friend ask me, almost two and a half years ago, if I ever watched the documentary, The Game Changers and I hadn't and my wife and I decided to watch it-
Chrissy Billau:
It's on Netflix.
Dr. Kevin Phelps:
It is on Netflix. My wife and I watched it and it literally was a game changer for both of us. Then I learned about a subspecialty in medicine called lifestyle medicine, which been around for about two decades. It's through the American Board of Medical Specialties. And as I started learning about it really drew me in to the point of getting board certified this past December in lifestyle medicine. We have decided as a family medicine residency program to bring the Lifestyle Medicine Residency Curriculum into our program. So residents who we elect to get trained in lifestyle medicine can be double boarded at the end of training.
Chrissy Billau:
Tell me about how this transformed you as a doctor. I mean, it was Game Changer. It was a show?
Dr. Kevin Phelps:
Yeah.
Chrissy Billau:
Where was the impact there?
Dr. Kevin Phelps:
Well, it's a little embarrassing to say but I really feel like I was deceived as a physician. And I think I got more nutritional education in my undergrad because I selected courses in nutrition and also, in my residency program, we had a nutritionist. But over time I think society and what's accepted by society can kind of wear you down so to speak. So you're believing what everybody else is believing, but we have a lot more influence over our health than we think we do. The pillars of lifestyle medicine include whole food plant based, eating regular physical activity, restorative sleep, stress management, avoidance of toxic substances specifically alcohol, tobacco, and positive social connections. When I talk about these pillars with patients, they light up and they immediately will identify a couple of them that they don't do well on.
Chrissy Billau:
Are there times where you make these recommendations and they walk away and you're like, they did not hear me. Eventually they're going to want some medicine to go with this.
Dr. Kevin Phelps:
Yeah, that's a great question. I had a patient yesterday afternoon, my first patient in the afternoon, who I had seen three months ago and I may have seen her a half a dozen times. I really didn't felt like I made that much impact on my last visit with her but I head in my note that I did talk to her about the Game Changer documentary, because that's something I've been doing with most of my patients. When I entered the room, she immediately said, I watched the Game Changer's documentary and I am now vegan. And I looked at the vital signs and she's lost 30 pounds. She was on fire. She was so excited. She was telling her friends about it, who were watching the Game Changer documentary. She hasn't influenced her son and daughter and her husband yet but she is fully on board with these changes.
Chrissy Billau:
That's incredible. It's just going vegan?
Dr. Kevin Phelps:
Yes.
Chrissy Billau:
That's incredible. It's hard to do. You mentioned it's really hard to do, but the results are... Three months, that's fast. 30 pounds.
Dr. Kevin Phelps:
This lady actually had prediabetes. Her A1C was 6.3% and she said, I'd like another three months to continue on this journey and then when I see her again in three months from now, we're going to recheck an A1C at the point of care. I am certain it's going to be normal when I see her.
Chrissy Billau:
What is one thing you want to tell your patients? If you could tell all of them one thing.
Dr. Kevin Phelps:
Well, the thing that comes to mind, which I've already said a couple of times is that we have a lot more control over our health than we think we do. I think some people are resigned to their family history. They've got a family history of heart disease or diabetes or high blood pressure or cancer and they think that's just their lot in life, that's what's going to happen to them.
Dr. Kevin Phelps:
There's an emerging field called epigenetics. You've heard of genes and the DNA and things like that. But epigenetics is the study of non-DNA sequence components that influence genetic expression. So think of it as like switches or modulators on these genes that influence whether or not that gene is expressed or not. So whether it's the cancer gene or the diabetes gene or the heart disease gene. If you don't take good care of yourself and you're not eating well and you're not managing your stress well, and you're not active physically and you're not sleeping well or you're smoking and you're doing things like that, the likelihood of you turning on those bad genes is much higher than if you were taking good care of yourself and paying attention to those.
Chrissy Billau:
So you do have control?
Dr. Kevin Phelps:
You do. You have a lot more control than you think you do.
Chrissy Billau:
What's the most common question you get from your patients and what's your answer?
Dr. Kevin Phelps:
Most patients don't bring this up to me, this is a new concept, believe it or not because we live in a society where we just think that we got to take pharmacological medications. I learned in residency, my faculty taught me an external locus of control. Meaning, things are influencing me and that's just the way it's going to be. Rather than an internal locus of control, like I can influence what happens to me. You want to really help patients understand that they have a significant internal locus of control, that they don't need outside things to take care of them, that they can take care of themselves with help and guidance and advice.
Chrissy Billau:
So for someone who is listening right now, how can they schedule an appointment with you?
Dr. Kevin Phelps:
They can call our office at 419-383-5555. I've got many partners who take good holistic care of patients, patient-centered care. We give advice, you guys make decisions.
Chrissy Billau:
You as a doctor you're not in control, we are. It's always flipped around. I always look at a doctor and it's like, you're going to help me. You're going to help me figure this out. But it's really in my hands.
Dr. Kevin Phelps:
Right. We like to look at it as a therapeutic alliance, but the patient is in the center and we are your advisor and your colleague. And whatever we can do to help you with all of those domains of lifestyle, whether it's what you're eating, how you're managing your stress, how we can help you become more physically active. And we've really evolved into team based care. So in my practice five years ago, for many years I thought it was a doctor practicing on an island. Now we have embedded behavioral health at the point of care. We've got doctors of pharmacy in our practice that are helping our patients every single day. We've got RN care managers in our practice who take care of our patients who need the most help and touches in between visits. So, we have a lot of resources in our practice that can really take good care of patients.
Chrissy Billau:
Well, thank you, Dr. Phelps. That's all for this episode of Prescribed Listening from the University of Toledo Medical Center. Thank you for listening, and if you like this episode, subscribe to hear more on your favorite podcast platform.