Live Long and Well with Dr. Bobby
Let's explore how you can Live Long and Well with six evidence based pillars: exercise, good sleep, proper nutrition, mind-body activities, exposure to heat/cold, and social relationships. I am a physician scientist, Ironman Triathlete, and have a passion for helping others achieve their best self.
Live Long and Well with Dr. Bobby
#37: We can reduce our risk of heart disease
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In this episode of Live Long and Well, I'm joined by Dr. Anthony Pearson, a board-certified cardiologist known for his evidence-based yet refreshingly skeptical take on mainstream cardiac care. Together, we explore the nuanced science behind heart health and how you can make smarter decisions to protect your cardiovascular system—starting today.
We open by recognizing that heart disease remains the leading cause of death for both men and women. While many of the six pillars of longevity—from exercise to stress reduction—play protective roles, today’s episode zooms in on two powerful, sometimes polarizing topics: the role of diet in heart health and the value of coronary artery calcium (CAC) scans.
Dr. Pearson shares how a personal brunch conversation with his wife challenged decades of low-fat dietary dogma, prompting his transformation into the "Skeptical Cardiologist." Here is a summary showing that dairy won't increase risk of cardiovascular disease. He recounts the
We dive into the broader saturated fat debate, highlighting how different fat sources have varied effects on cholesterol and cardiovascular risk. While dairy fats may be benign or even beneficial, others—particularly those consumed in excess on paleo or keto diets—can raise LDL cholesterol substantially. Dr. Pearson discusses the Keto-CAD Study, which found that even lean, low-risk keto followers may build up arterial plaque if their LDL levels skyrocket.
The conversation then shifts to the calcium heart or CAC scan, a non-invasive $100 screening test that quantifies calcified coronary artery plaque via CT imaging. While traditional risk calculators like the pooled cohort equations often fall short, CAC scoring offers a personalized look at actual plaque burden—critical since many heart attacks occur in people not flagged as high-risk. As Dr. Pearson explains, a high score doesn’t mean you will need surgery. Instead, it’s typically a cue for lifestyle and medication adjustments, not invasive procedures. He references the ISCHEMIA Trial, which found no benefit from stenting stable, asymptomatic patients over optimized medical therapy.
We close with practical advice: talk to your doctor, especially if you have a family history or fall in that “borderline risk” zone where a CAC score might influence your care plan. And yes, it should be okay to keep enjoying that butter—as long as you’re informed and mindful and don't overdue it.
Takeaways: Full-fat dairy is not the enemy—it may even be heart-protective. If your LDL skyrockets on keto, that’s a red flag worth addressing. CAC scans can personalize your prevention plan and offer peace of mind or a critical nudge toward action. Want more clarity on your own heart health journey? Talk with your doctor about whether a calcium scan makes sense for you and explore Dr. Pearson’s writings on The Skeptical Cardiologist and MedPage Today.
the bad news Heart disease is the number one killer of both men and women. The good news there's a lot we can do to lower that risk. Should we change our diet or get a calcium scan of our heart? Let's see where the evidence takes us. Hi, I'm Dr Bobby DuBois and welcome to Live Long and Well, a podcast where we will talk about what you can do to live as long as possible and with as much energy and figure that you wish. Together, we will explore what practical and evidence-supported steps you can take. Come join me on this very important journey and I hope that you feel empowered along the way. I'm a physician, ironman, triathlete and have published several hundred scientific studies. I'm honored to be your guide. Welcome listeners to episode number 37. We can reduce our risk of heart disease.
Speaker 1:Well, heart disease, cardiovascular disease, is the number one killer of men and women and we've talked in prior episodes about the six pillars which can each help reduce that risk, whether it's exercise, getting good sleep, sauna and cold plunge, nutrition, social relationships, mind-body harmony. We've also talked in another episode about doing screening tests like a total body MRI or large panels of blood studies, and I express my concern that when you do these large number of studies, you might get a false positive, sending you down a path of more tests, potential complications and really a lot of uncertainty. Today we're going to dive a bit deeper into cardiovascular disease and we're going to try to figure out a couple of things. What do we know about what we should eat? What do we think about a calcium heart scan? Are these things that we should consider and talk to our doctor about? Well, I could share my opinion and of course, I probably will and the evidence that I've run across.
Speaker 1:But, more importantly, we have a guest today, dr Anthony Pearson, and I am thrilled to have Dr Pearson join us today. He's a board-certified cardiologist. He was on faculty at several academic medical centers, published over 100 peer-reviewed papers, and he's also been in private practice for about 20 years, so he has both the academic and the patient care experience. His focus is on preventive medicine, ways to reduce the risk of heart disease, and he has a very broad holistic view incorporating diet, lifestyle, exercise and, of course, medications. And most importantly, and why I think he's an ideal person here today, is that he's also an educator. Very broadly stated, he's a columnist for MedPage today. Very broadly stated, he's a columnist for MedPage Today and for the last decade he has been writing the Skeptical Cardiologist a blog on its website, and now, as a sub-stack, and some of the article titles that I think you'll find of interest Butter Good or Bad?
Speaker 1:Should we Take Antioxidants? Should we Take Blood Pressure Medicines in the morning or at night? How to stave off dementia, walnuts and cognition in the dangers of unnecessary cardiac procedures and I will have links to his locations if you would like to read and follow him. I do and it's been wonderful. So, dr Pearson, welcome to Live Long and Well.
Speaker 2:Thank you, Bobby, it's my pleasure. I'm a big fan of your podcast and I'm happy to be here.
Speaker 1:Well, wonderful, I know, when we chatted a week or so ago and you were telling me a bit about how did you get into certainly not necessarily how you got into the cardiology business that is, of course, its own story but how did you get into the education and writing approach, and you mentioned something about having croissants and butter with your dear wife and I thought what a great place to begin. So maybe tell all of us a little bit about how did that start out?
Speaker 2:Sure, I, for the first 20 years or so of my career, followed the guidelines and the dogma that had been presented to me in the dietary world and that had started in 1977 with some dietary guidelines to Americans that said we should all be cutting down fat and increasing carbs, and I was following that and I would battle with my wife over my first wife, over whether we had skin milk or full fat milk in the refrigerator. I wanted my kids drinking skin milk and she wanted full fat. We eventually ended up at 2% percent but by after, after following these guidelines, which I assumed were solidly based in science, I was, he drinking skim milk, eating low or nonfat yogurt and I avoided butter like the plague and I egg white omelet. But I met my second wife and while she was still what I used to call on my blog the eternal fiancé. We were having a brunch outside at a very nice restaurant in St Louis and I found myself lecturing her on her decision to consume a croissant slathered with butter.
Speaker 1:And the best way to eat them, of course.
Speaker 2:Yes, according to her, and I was just astonished and she challenged my viewpoint on this that she felt like she was healthy and thin and could eat croissants lathered with butter.
Speaker 2:And so when she challenged that, I went on a quest to discover the scientific sources underpinning my recommendations, and I found that in this particular area they were very lacking, and it kind of led me to become the skeptical cardiologist at that point.
Speaker 2:A lot of my early writings in 2013 were about the kind of dietary myths that we had all accepted without substantial evidence, and so now I can consume full fat milk, yogurt and cheese as much as I desire, and my omelets are made from full eggs, including egg yolks.
Speaker 2:And I think when I first started this journey, I came across a study that was done in Wales where I was actually born in Wales and came to the United States when I was five by Peter Elwood, and he had studied some Welsh men and found that those who consumed the most milk had a 13% lower risk of dying than those who consumed milk, which went against the grain of the recommendation to consume low-fat milk, because at this time, everybody was consuming high-fat milk. And I communicated with him and he revealed to me that he had done a meta-analysis of all the studies which he published in 2010 in the European Journal of Clinical Nutrition, and it also showed that consuming dairy products of all kinds actually lowered cardiometabolic risk and lowered the risk of dying from cardiovascular disease. So that was the beginning of my journey as a skeptical cardiologist.
Speaker 1:And have subsequent studies borne out that the dairy, the saturated fat in dairy, is not problematic?
Speaker 2:It has. There have been lots of publications in this area. There are lots of meta-analysis and they have kind of been some have shown no effect. Most have shown a slight benefit from consuming dairy on cardiometabolic risk factors and on reducing the risk of stroke, and the most recent one was published in 2024. And I can give you a link to that. It is in the journal, the journal nutrition, and it confirms that and and shows that there is really no evidence that low-fat dairy is better for you than full fat, and the evidence is quite strong that full fat and fermented dairy products actually lower the risk of cardiometabolic disease, measured by things like metabolic syndrome, which includes hypertension, diabetes, metabolic syndrome, which includes hypertension, diabetes and obesity. And so I think that this is more and more. This is being recognized.
Speaker 1:Well, this is fascinating and also very reassuring, since I of course, love to cook, and love to cook with butter and cream and all those wonderful things, and love cheese. So let me probe a little bit. So what you're saying is, dairy may not be problematic. Perhaps it is even protective. Now we know that the full fat dairy is saturated fat or has a fair bit of it. Are you saying that saturated fats in general are fine, or there's something peculiar about the dairy-saturated fats that make dairy eating safer than having a ribeye steak at three meals a day?
Speaker 2:Yeah, I think that one of the reasons that dairy continues, that full-fat dairy continues to be not recommended in most nutritional guidelines is because of the saturated fat issue. Dairy contributes about a quarter of the saturated fat to the diet of Americans and the mainstream nutritional guidelines want to promote a simple message that all saturated fats are bad for you, so that the public doesn't get confused. But the actual fact is that dairy fat is much different than the fat that you get from red meat, for example.
Speaker 1:Much different than the fat.
Speaker 2:That you get from red meat, for example. Why might that be? Because the saturated fats and the fatty acids in general are a broad family, ranging from short chain to medium chain to long chain, and each one of those fatty acids has a slightly different effect. Some of them definitely raise LDL and raise your blood pressure. Some of them don't do that. Some of them might raise the LDL a little bit but also raise the HDL, and the truth is that we don't consume these fatty acids in and of themselves. They're in a food matrix and there is quite a bit of evidence that the food matrix that dairy is in is protective and behaves differently when we put it into our bodies than if we were just consuming the fatty acids as in an experiment where we can purify it in some way. So it's a big, heterogeneous family of compounds and it's a mistake to consider them all as equally harmful to you?
Speaker 1:Okay, that's helpful. Consider them all as equally harmful to you? Okay, that's helpful. Now I know we had a brief chance to talk a little bit about the paleo and keto diets, which have gotten a lot of attention. These are folks who feel like they want to cut out carbohydrates from their diet and when people are eating a lot of fat and protein because that's really what's left you get vegetables and fat and protein. Some of these folks, the cholesterol levels, specifically the LDL cholesterol, can go way up. Is that a worrisome thing? When somebody is trying one of these diets and the LDL goes way high, do you just say, well, you're losing weight, that's a wonderful thing. So what? The LDL is high.
Speaker 2:Or do you say, no, no, we should try to do something about that well, I think it is a worrisome and it is a situation where we really have to be very careful that we're not predisposing the patient to high risk of building up atherosclerotic plaque and heart attack and stroke as a result of that.
Speaker 2:And there is a study that was just published within the last month which has gotten a lot of attention on social media.
Speaker 2:It is called the Keto CAD study.
Speaker 2:The Keto CAD study CAD standing for coronary artery disease and these patients were these lean mass hyper responders which, in the keto world, if you are not obese and if you don't have diabetes, sometimes about maybe 20% of individuals will develop these very high LDL levels and apolipoprotein B, which is the particle that gets the LDL into the lining of the arteries and triggers heart attack.
Speaker 2:And the community there believes that they are protected against heart disease, against plaque buildup. And this study was an attempt to look at that plaque buildup over a year in these individuals and what it showed to me is that number one they have already built up a significant amount of plaque and within a year that plaque progressed, progress and plaque again is the faster that plaque progresses, the larger the burden of that plaque, the higher the risk those patients are of heart attack and stroke. So there are ways to modify the keto diet to make it less likely to raise the LDL and the APOE, and that is to use avocado oil, olive oil and not necessarily consume massive amounts of meat. But the bottom line is if that diet is giving you an LDL over 180, you are at high risk and either the diet should be changed or you should be started on medication to get that LDL down.
Speaker 1:That's very helpful, thank you, and I think putting the various types of fats in context the dairy, the non-dairy, and then sort of the extreme case of the paleo-keto, where you're getting a tremendous amount of fat Wonderful.
Speaker 2:Let's switch. And I would add that I am a keto-friendly cardiologist. When I first started the blog, I went on a keto diet and I researched it and I think it's been very beneficial for many of my patients in losing substantial amounts of weight. But again, we have to monitor these patients to make sure that they are not harming themselves in the long run.
Speaker 1:Well, like everything we do in medicine whether it's a medication we're giving someone or it's lifestyle changes there are always going to be risks and benefits. And obviously losing, losing weight, is critically important for us to live long and well. And if paleo helps you get there, that's a wonderful thing, and if it doesn't change your ldl, wonderful. But if it does, then I think you talk to your doctor and maybe you get treated and then you can have really the best of both worlds of being on a diet that seems effective for you and keeping that risk factor under control. Well, that's great, absolutely. Let's switch gears, and this is a fascinating one.
Speaker 1:Folks have probably heard about the calcium heart scan. It's something that gets advertised on radio, tv, social media. It's a pretty inexpensive screening test $100 or so and, as my audience knows, I'm generally not that excited about routine large screening things. Now, of course, if it's a mammogram or a colonoscopy or a pap smear, these are very important. They're recommended by US Preventive Services Task Force and the benefits have been shown to outweigh the harms. To outweigh the harms. But when you just do 100 or 200 blood tests or you do a total body MRI just looking for early forms of disease. I think you can end up with some difficulties and false positives and anybody who's interested in listening more about it. By all means go to my prior episode. But when we chatted about the calcium heart scans, you had a very important way to think through it. So maybe first tell folks what are these calcium heart scans and why might it be helpful for folks?
Speaker 2:Sure. The calcium scan coronary artery calcium scan is what we generally call it, an abbreviated CAC. Cac is a kind of x-ray or CT scan. It is non-invasive in that there are no needles, there are no catheters placed into your artery and it is done using a CAT scan or CT scan and it is our best way of determining whether there is any plaque in your coronary arteries and how much you have, compared to other people, your age. It is not covered by insurance but in most of the places where I've worked I've been able to get it for around $100 paid out of the pocket and it is a very safe and very, very accurate test to measure the amount of calcium in your coronary arteries.
Speaker 2:Calcium builds up Plaques, start developing very early in our lives, possibly even in childhood, and that atherosclerotic plaque, over time, as it heals and progresses, calcium is deposited into it and when we look with this PT scan, we're looking to determine how much calcium you have compared to normal to your age, compared to normal to your age. Now, the risk of this test is that you are getting a small amount of radiation. It's usually measured in millifevers. It's about one millifever on average, which compares to about 0.4 for a mammogram. So it's about twice as much as a mammogram and each year, if you're in the Midwest, you get about 3 millisieverts of radiation from background sources. So it's not considered to be high or dangerous in terms of increasing risk of cancer, and so I think it's a great tool to assess in an individual fashion to kind of personalize the patient that's in front of me how much plaque they've built up and, as a result of that plaque, what is their risk of heart attack and stroke down the line.
Speaker 1:So, as we've talked about in our last call, I tried to play devil's advocate a little bit. It's like okay, so we know if their blood pressure is elevated, we should do something about it. We know if their cholesterol is elevated, they should try to do something about it If they have diabetes or they're overweight. So how would this add to the equation? And really are you suggesting that pretty much everybody in their 50s or so get one of these things? Is it going to change what you do by getting these results? Obviously, they could be negative or they could be positive, and if they're negative you can be very happy about that If it's positive, but you're already treating their blood pressure and their cholesterol and their weight and such. How will this help us?
Speaker 2:Yeah, I think this is a common question and it is one of the reasons that it's not being universally applied, although I would say that any preventive cardiologist that I've talked to or listened to is an advocate of using these and using these in a lot of people, using these and using these in a lot of people and that is because progress in sudden cardiac arrest death from atherosclerotic cardiovascular disease has slowed down in the last 20 years, and that is the problem with atherosclerotic disease, with coronary artery disease, heart disease, the initial symptom is often not chest pain or angina that occurs with exertion due to a tightly blocked artery. The initial symptom can just be a heart attack coming out of the blue and then resulting in an abnormal rhythm that drops you dead and causes cardiac arrest.
Speaker 2:So we don't always get warnings and the plaque can build up to very dangerously high levels without having anything, without knowing that anything is going on. So what the calcium does, what coronary calcium does, is give us an idea of how much plaque is built up and what is your true risk. Now, what's the current way that primary care physicians are told to assess this is by kind of estimating the risk in an individual in front of them, based on the standard risk factors such as blood pressure, diabetes, cigarette, smoking and the lipid levels, the cholesterol levels level. But these are not, these so-called pooled cohort equations that estimate risks, are not applicable to young adults and older adults. They come from studies decades ago.
Speaker 2:They overestimate the risk in the general population and one out of every three persons who present with a heart attack would have been considered low to moderate risk. They would not have been treated. So these are kind of not adequate if we want to be very proactive, if we want to be very aggressive about reducing this risk of heart attack and sudden death. I would also point out that there are no trials supporting the use of these pool cohort equations. Basically, what they do is kind of try to estimate your 10-year risk of heart attack and stroke. Low risk is considered less than 5%, high risk greater than 20%. But there's a large number of people that are in the borderline risk or the intermediate risk, and that is the population that most benefits from getting their risk better personalized.
Speaker 1:Now many people have heard a story like this oh, my brother-in-law had a heart attack and died and so I decided to get the cardiac calcium scan and thank God I did, because it showed a high number. And then they showed that my blood vessels were, excuse me, very narrowed. I got an angioplasty and I think I'm now cured, or at least I'm in so much better of a place. And I think what we need to tell our listeners is that the purpose of the calcium scan it's not a plumbing diagram You're not inevitably going to get a positive test and say, oh, you need bypass surgery or you need those vessels opened, that in fact the studies don't support that for people who are in a stable asymptomatic condition, but rather that these people just need medications or lifestyle changes. So maybe sort of walk the listeners from a positive study to does that inevitably mean surgery?
Speaker 2:Yeah, that's a great point, Bobby, and one that needs to be emphasized, and it's a hard point to get across to patients that we can identify that you're at high risk. With a calcium score, you can have a very high score for your age that indicates that you have a lot of plaque filled up. But if you are free of symptoms, if you are not having a heart attack, a sense is not going to lower that risk at all, and neither will a bypass operation. If you're free of symptoms and you're active and you have built up a lot of plaque, what you need is very aggressive lifestyle and drug therapy to lower that risk. Um, you don't need a stent and therefore you don't necessarily need to have more testing at this point address all their other risk factors and kind of optimize the therapy for them short of having to put a device in like a stent. And the problem is that some cardiologists feel that this is an indication for downstream testing with, say, a stress test. Stress tests are problematic because they have a lot of false positives and even if they're normal, they don't necessarily mean that you're not at super high risk.
Speaker 2:And the best study I think in this area. I think you and I discussed the COURAGE study, but the best study in this area came out about five years ago. It's called the ISCHEMIA trial I-S-C-H-E-M-I-A, and it took patients who had evidence for significantly blocked arteries and who had abnormal stress tests showing that there was poor blood flow to their heart muscle, which is called ischemia, and randomized them to either getting an invasive approach with a catheterization and possible stenting, versus just managing them with lifestyle and drug therapy, and there was no difference in outcome. This was an amazing study that helped us understand that we can treat patients just with medications. We don't have to rush to doing these procedures, and the scent that that person's friend got didn't necessarily save their lives.
Speaker 1:That's an important study and an important set of findings. Well, I think we're going to bring this discussion to a close. Always when we talk about medical issues, we need to remind you talk to your doctor. But now I think you're armed with some questions to ask about your diet and whether dairy is fine for you, and a consideration of the calcium scan and whether that might be beneficial to help fine-tune what you do. Dr Pearson, thank you. Thank you for being on the podcast, thank you for allowing me to continue to love my butter and my cream and for helping listeners understand the calcium scans and where they may fit in for them, and I look forward to having your wisdom join us on future episodes. So thank you so much.
Speaker 2:You bet, bobby, it's my pleasure.
Speaker 1:Well, let's just close by saying I want everyone to live long and well and have a happy heart. If you are able to go to the link in the show notes and go to a brief couple of questions to give me feedback on my podcast, that would be helpful and I'm, as always, interested in topics that everyone might want to hear about. Well, with that, look forward to future dialogues. Thanks so much for listening to Live Long and Well with Dr Bobby. If you liked this episode, please provide a review on Apple or Spotify or wherever you listen. If you liked this episode, please provide a review on Apple or Spotify or wherever you listen. If you want to continue this journey or want to receive my newsletter on practical and scientific ways to improve your health and longevity, please visit me at drbobbylivelongandwellcom. That's, doctor, as in D-R BobbyLiveLongAndWellcom.