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The Neuro Experience
How Women Can Strengthen Their Hearts After Menopause | Dr. Jeremy London
00:21:38
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- [00:00]
A
I'm Louise Nicola and this is the Neuro experience. Why specifically do women's risk almost triple after menopause?
- [00:10]
B
Well, first to zoom out just a little bit. I think it's a shame that we're just getting to a point that we're recognizing these changes in risk for women in particular. But if you look historically, women have not been included in many of these cardiovascular studies till the early 90s, which is unbelievable to me.
- [00:30]
A
We can blame the Women's Health Initiative for that.
- [00:33]
B
Partly, yes. And I think a lot of the mindset was based on a male perspective, unfortunately. And as a result, women, I think, have suffered from lack of evidence because, yes, we're the same species, but clearly there are differences that occur at various touch points in our life, specifically perimenopause and menopause, which we all know is a change in the estrogen level. So let's look at what estrogen does specifically when it's low and how that affects cardiovascular disease. Well, at the outset, estrogen is a natural anti inflammatory. And as the estrogen levels start to drop, full body inflammation begins to go up, which we know is a driver for many chronic diseases, cardiovascular disease in particular. In addition to. If you talk to most women in perimenopause and menopause, weight control and maintaining a healthy weight is very difficult as the estrogen levels drop, particularly abdominal or visceral fat, which again we know is an engine for inflammation and chronic disease states and a direct risk factor for cardiovascular disease. We know that because measuring a waist to hip or a waist to height ratio, which gives you kind of a good indicator of where you are from a visceral fat standpoint, is a risk factor for cardiovascular disease. And finally, as you mentioned, cholesterol, which there's been a lot of discussion about cholesterol truly being important for cardiovascular disease or not. I would like to clarify, in my opinion, the burden of evidence that cholesterol, particularly LDL and some of the more granular things, and we can talk about that, are absolutely risk factors for cardiovascular disease, heart attack and stroke. And we know that as estrogen levels drop, cholesterol levels rise in perimenopause and menopause. So it's almost like a perfect storm. You know, we've got a direct regulator of inflammation in the body. We're now having more difficulty maintaining a healthy weight, which is also driving that, also putting us at risk for metabolic syndrome and poor glucose control. And all of these things that we know are risk factors for cardiovascular disease. And I think that the Women's Health Initiative really did a huge disservice because the information regarding hormone replacement therapy derailed many of these conversations. And so when we look at all of these negative impacts that perimenopause and menopause have, yes, there are plenty of lifestyle changes that you can make, but it's hard. And for some women, assuming that they're open to it and it's appropriate for them, hormone replacement therapy can make a dramatic difference in all of those areas, and it really help mitigate the risk of overall cardiovascular disease.
- [03:44]
A
Yeah. This is actually the same with Alzheimer's disease. 2 out of 3 Alzheimer's disease patients are female, and that's usually because women have estrogen receptors all over their heart and their brain. And when I describe receptors and hormones like a key and lock. Right. So when that lock has nothing to attach to, it becomes scary. And it's also neuroprotective, that hormone as well. So so many things, you know, I don't know. It's just so hard being a woman sometimes.
- [04:16]
B
Well, I think it's a perfect example that nothing happens in a vacuum in our bodies. You know, when we're talking about cardiovascular disease and general inflammatory response. We have blood vessels in our heart, we have blood vessels in our brain. Everything is impacted.
- [04:31]
A
Oh, yeah, yeah. In similar fashion, correct me if I'm wrong. Currently, worldwide, the number one cause of death is cardiovascular disease. And your mission is to make it the second leading cause of death. Right.
- [04:41]
B
Any impact that we can have if we can move the needle significantly like that, when we have 20 million deaths a year attributed to cardiovascular disease, if it's one patient that sends us an email, thank you. I didn't realize I was having these problems. I got a stent and got a second golden ring. We consider that a win. Right. And you're right. I think there's even a misconception that it's actually the number one killer. If you ask most people, they think it's cancer, women in particular, because breast cancer has been in the forefront, as it should be. But I think that, unfortunately, the light needs to be shifted back to cardiovascular disease just from an actuarial standpoint, you.
- [05:21]
A
Know, and when we say cardiovascular disease, we're talking about diseases of the heart.
- [05:26]
B
And that's a great question, because when we talk about death from heart disease, what does that mean to people? And we can really put it into three buckets. The first is coronary disease, which simply means blockages in the arteries to the heart, where nutrients and oxygen are brought to the heart. Muscle. The heart's just a pump and it requires energy to work. That's the leading cause. Heart attacks. That is a leading cause. The second bucket is valvular disease. In other words, the valves that keep the blood moving in a forward direction in the heart. And that can come in many forms, either blockages of those valves or leakages of those valves. And then the third bucket is electrical abnormalities. Most people are familiar with things like atrial fibrillation. That's one of the most common diagnosis in Medicare in this country. And so those are the three common buckets. Then there's others that fall pretty far behind. Congenital heart disease. In other words, things you're born with, cancer of the heart, which is very, very rare, and infections and things of that nature. But when we're talking about heart disease, really what we're talking about is heart attacks taking people's lives.
- [06:34]
A
Yeah. And those blockages can occur from cholesterol buildup in the.
- [06:40]
B
Absolutely.
- [06:40]
A
Okay, absolutely. So let's talk about that. You go to the doctor, you get your cholesterol tested, something will come up as total cholesterol. So, so that means the amount of. What are we talking about? The amount of fat?
- [06:51]
B
So no, they're talking about the combination of two things. High density lipoproteins and LDLs, or the bad cholesterol, low density lipoproteins. And those two things together is the total cholesterol level. And then the third thing that most people get on that standard panel is triglycerides, which is separate from the total number, but also a risk factor for sure. And so it is important to know then what that breakdown is, because HDLS are typically not what we refer to as atherogenic or causing the blockages in the arteries, whereas the LDLs have been given the moniker of the bad cholesterol. And triglycerides are almost the forgotten stepchild, but they tend to be a very common risk factor for people when they're actually checked. So the breakdown of that is important.
- [07:44]
A
Cholesterol and lipids tell a story.
- [07:46]
B
Yes.
- [07:46]
A
And they tell a very big story. And it's not about who takes your blood. And you and I know that to become a phlebotomist, it's a two day course. Anyone can take your blood. It's about who's interpreting it and who understands the ratios and the trends. That's what you want to look at. Like, are you trending upwards?
- [08:03]
B
Absolutely.
- [08:04]
A
And so when you're looking at these three values, you also want to look at something called apob, which I think is more of a direct indicator.
- [08:13]
B
The way I look at apob, and I'd be interested to know your opinion of this as well is I look at, look at it as like a 25,000 foot view of all of the cholesterol subgroups and total to determine how much dangerous cholesterol do you have?
- [08:31]
A
Yeah.
- [08:32]
B
And I think that's how APOB is valuable because if you have one elevated number and a low apob, you, yes, you may have to work on that one number with lifestyle changes or whatever it may be. But if your overall APOB is low, you definitely fall in a lower risk because you've got less cholesterol particles that can actually cause damage to that inner lining of the blood vessel. So I think APOB is very important because as you said, the panel kind of paints the broad brush strokes. Now we want to look at, at what those numbers truly mean.
- [09:11]
A
And so what ends up happening? Let's just say you've got elevated APOB and LDL and your cholesterol's all over the place. You tend to end up getting plaque along the walls of the arteries, right?
- [09:23]
B
Yes. And it's more likely to get plaque. It's not a death sentence. And it doesn't mean that it's absolutely going to happen. It's a red flag.
- [09:33]
A
Yes.
- [09:34]
B
And the other thing to remember is this doesn't happen at one point in time. This happens over the course of our lives. The important thing is to check.
- [09:46]
A
Yes.
- [09:46]
B
So that you can intervene at the earliest point possible.
- [09:49]
A
What are some of the things we can do that are free to us, that are going to minimize coming to see you? And I will start with exercise now. I don't know. Are you familiar with Dr. Ben Levine?
- [10:00]
B
Yes.
- [10:01]
A
And so you know about his world famous study where he took a group of 50 year old patients and you know, imaged their heart and put them on a protocol over a two year period where he got them exercising at a very intense state. So that zone five, which is, you know, I call it the, the sting phase or the spew sessions. Right. Where you're going hard out efforts as hard as you can. And what he did over the course of two years was he turned from pure exercise, he turned these 50 year old hearts into 30 year old hearts. So literally reversing the signs of a declining heart by 20 years. When I read that study and I tore that study apart, I thought like, without a doubt, we all should be exercising at that maximum at least once a week.
- [10:49]
B
It's so crucial. And again, from A brain health standpoint as well. It's really the only lifestyle modification or intervention that we really have that impacts brain function statistics statistically across the board. And it's the same way from a health span and lifespan standpoint as well. I put exercise into two buckets, as I'm sure you are familiar with aerobic exercise, which you're referring to, and VO2 max, which is just a fancy way of delineating cardiovascular efficiency or how efficient your heart is at getting blood and nutrients to your end organs. Now, to do that, you do have to replicate that study a bit. Just walking at a reasonable pace, although a great form of exercise, and I have no problem with walking. There have to be at least one or two sessions a week where you are getting into that uncomfortable zone because that's how you really shift that curve. So when we look at VO2 max or cardiovascular efficiency, it's probably one of the single most important indicators of longevity that we have. The most powerful, I would say, when we're comparing individuals that exercise versus individuals that don't, it's magnitudes. The second, of course, is resistance training. Muscle mass is so important. After the age of 30, we lose 10% of, you know, of our muscle mass every, every decade. And it's really important that we work to prevent that from happening. How do you do that? It's with some sort of resistance training. You don't have to be in the gym moving heavy weights if that's not your thing. Simple body weight exercises on a regular basis will, will have a huge impact. And again, regular basis is the key. Consistency is the magic sauce here. Finding what works for you and what you like, that you're gonna be looking forward to doing is what is going to move the needle most effectively. Muscle mass is important not just from skeletal stability and avoiding falls, but as Gabrielle Lyon loves to say, muscle is the organ of longevity. Why is that? Because it's a glucose sink in our bodies. It's a for our bodies to really chew up any extra energy that is left in our bloodstream and not be stored as fat. Keeping our glucose well managed is again another indicator of our overall health. So exercise is crucial. Move every day, literally every day.
- [13:26]
A
And as I tell my parents, you know, the nomenclature actually has to change. The CDC guidelines state physical activity and I always, I'm trying to lobby against that and say exercise because then you've got my mother who tells me that she did the washing and she hung them on the line.
- [13:42]
B
Right, Right. Yeah. And look, there's going to be individuals that you're going to have to redirect, you know, and there's even individuals that think they're doing a really good job where they get up every morning and they go for a run and they work out really hard, and then they go to work and they sit for five or six hours during the day. And that still is a sedentary lifestyle. You have to make sure that you plan movement throughout the day in addition to that morning workout, because the sitting disease is a real thing. And leading a sedentary lifestyle is a cardiovascular risk factor.
- [14:20]
A
So that's the most important one. Right. And then if we.
- [14:23]
B
Well, it's an important one.
- [14:25]
A
That's not pharmacologically driven.
- [14:27]
B
Fair. Okay, I'll take that.
- [14:29]
A
Because we know that statins. And we could do it. I think you and I could do an entire podcast on statins, but we're not going to. Okay, now let's move into something else. What do you think the next one is?
- [14:38]
B
Sleep. So I would go with diet next. Wow. Yeah, I really would. And here's why. You know, we internalize 90% of the outside world through our mouths. Sure, we're bringing in air through our lungs and we absorb air and toxins and what have you through our skin as well. But 90% of the outside world is through our body. And we literally are made of what we eat. And I'll give you a great example, and this was actually told to me years ago, that if a farmer looks at his crops and all of the crops are sick, where is the first place that they look? In the soil. This is our soil. And I think that maintaining a solid whole foods diet, really trying to avoid or limit processed and ultra processed foods, limiting or removing alcohol, whatever works for you, makes a tremendous difference when we're talking about the development of chronic disease and things that we are doing to ourselves, even if it's subconsciously doing to ourselves again, to kind of drive this inflammatory engine and drive ourselves down this journey towards chronic illness. So I think that exercise without. Without being conscious of what you're putting in your mouth is not going to work as well, you know, And I've even told patients, before you get that fancy gym membership, before you pay for a trainer, like, let's look at your diet because we can change that today.
- [16:17]
A
And correct me if I'm wrong, there's actually supplements out there, right. That can, you know, that promise, which I don't think is the correct way, but they promise to eliminate plaque.
- [16:30]
B
But that's not possible, not with the current no. And there have been instances of plaque regression with certain of the statins and some other drugs, but there is no data to support that once you have formed plaque that we can actually somehow create a scenario or environment for regression or improvement of that. So the key is to get it before it starts.
- [16:56]
A
That's why everything you're speaking about is so important for 30 year olds. Because even like with Alzheimer's disease, it is non reversible. I actually, you know, Alzheimer's disease comes in four stages and I say if you are diagnosed with the disease, not, not mild cognitive impairment, but actually Alzheimer's disease, that is comparable to end stage cancer. There is no reversal of it and that's at the time where it's a very scary diagnosis. So. And there's no, you know, there's no stopping it, there's no medications for it. So it is very much all of the things that you're talking about is driven through lifestyle and we have to get onto it very fast in our 30s and our 40s to prevent coming to see you.
- [17:37]
B
You're not defined by your past that don't, don't allow yourself to fall into that deep dark hole. If you will decide on where you want to be and the person that you want to be and then decide on which of these levers you want to pull on first, which ones make the most sense and small steps because all of those small step compound to really get you where you want to be. So when we start talking about diet, that can be as emotional as a religious conversation with many people and it's about figuring out what works for you. And I'm cool with that as long as it's within certain parameters. People feel like it's hopeless. And it's never too late to start exercising. It's never too late to think, do I want to eat this? Should I really eat this? What are my other alternatives? Just be mindful. And then the last category is sleep, which is my personal Achilles heel and probably one of my risk factors, quite frankly. And sleep is just, it's not sexy and it's not cold plunging and saunas and all of these really fun things that people want to integrate in their lives. But we all have to do it. And true growth, whether it's our mental muscle or our physical muscle, occurs during sleep. You know, our true memory occurs during sleep. Our brains rejuvenate. They get the full washing of all of the toxic metabolites from the day. And the same occurs for the rest of our body. In addition to really stabilizing our hormonal swings during the day, which helps us with glucose management and all of these other pieces that go into this. Not to mention, you know, we feel better. Our mental state and emotional state is better. I'm certainly a.
- [19:36]
A
We look better at skin health.
- [19:37]
B
Absolutely.
- [19:38]
A
It's the secret to beauty.
- [19:40]
B
I know, and listening to many of your podcasts, just how pivotal this is for my overall health. I mean, I really worry just from an Alzheimer's standpoint and dementia standpoint, like, you know, can I work out and run enough to offset that? The answer is probably not. No, probably not. You have to pull all of these levers. And you made a comment earlier about exercise being the most important, and I'm really sensitive about delineating one as the most important, because if I tell you that exercise is the most important, you're like, okay, great. Check that box. I do this regularly.
- [20:18]
A
I don't have to sleep or eat.
- [20:19]
B
Well, exactly, because I've checked that box. What I like to tell people is, of these pillars of health, figure out which one you don't do well, because that's the one that's most important for you. And that's really where you need to focus your efforts, because you got the other ones dialed in pretty good. I mean, honestly, we can all do better with our diet at certain points in our lives. I think I certainly can. But if you identify where your weaknesses are, that's really where the opportunity for the most growth is and the most benefit, I feel like, exists.
- [20:55]
A
I couldn't agree more, Dr. London. What's good for the heart is good for the brain.