Episode 7: Heart Disease Prevention for Women with Dr. Mark Menolascino

Evelyne: So happy to have you to hear. Today we’re going to be talking about heart disease, but specifically in women because heart disease is the leading cause of death for women in the United States. Dr. Mark Menolascino is the medical director of the Meno Clinic Center for Functional Medicine, located in Jackson Hole, Wyoming. He’s board certified as an internal medicine specialist, integrative holistic medicine, advanced hormone management and anti-aging medicine, and is a certified functional medicine practitioner. He additionally has a master’s degree in pharmacology and immunology, assisting with heart mood and dementia clinical trials, and was part of the heart disease reversal team with Dr. Dean Ornish. He’s also on the DFH Scientific Advisory Board. Thank you so much for being here today.

Dr. Mark Menolascino: Always a pleasure, Evelyn. Happy to help.

Evelyne: So like I said, heart disease is the leading cause of death for women in the US and I know I’ve read this before, but it still shocks me. I feel like we usually think of that as the number one killer in men. First of all, why did you decide to specialize in women’s cardiovascular health? And can you also talk about some of the key differences between men and women when it comes to our cardiovascular system and cardiovascular health?

Dr. Mark Menolascino: It’s such a great question and because it is the number one killer of both men and women. The men are worried about prostate cancer, the women are worried about breast cancer. We’re all worried about diabetes and other illnesses, but it’s heart disease that gets us, and we just haven’t done a great job protecting women from heart disease. Women are not just pretty men. Their anatomy is different. The way they respond to medications are different. Many of the clinical trials were designed only for men and we extrapolated that information to women’s health. So I just feel like we could have done a better job of women’s heart health. When I was during my training of residency, I had a woman come in with vague abdominal pain and they thought it was her gallbladder, even though her imaging was normal. They held her in the hospital for three days before I came on rounds and I ordered an EKG and she’d had a heart attack, was having ongoing ischemia.

So women just present differently. It can be a feeling of indigestion, of discomfort, of fatigue. It’s not the classic elephant on the chest going down the left arm into the neck type pain that many men get. So women, their anatomy is different, their chemistry is different. The hormonal milieu of young women versus perimenopause versus post menopause, it’s just different. So we have to really look at them as unique individuality, and that’s where I think in general, we miss cardiac health. We do great studies on huge populations and apply this end of 20,000 in the evidence-based way to you, Evelyne, and that’s just a mistake. And that’s where integrative and functional medicine really thrive. It’s a personalized precision approach to your health. Based on the data that we’ve accumulated.

Evelyne: And with clinical trials, it seems like most of them are done on men and a lot of clinical trials are done on young men, right?

Dr. Mark Menolascino: Young, healthy men.

Evelyne: Especially when it comes to medications. What are some physical signs that a practitioner can look for when assessing a patient, whether they’re seeing them for a regular workup or even if they’re not work like you are as an MD in a clinical practice actually seeing people, but even say a chiropractor who’s seeing people. But what are some abnormalities that you can notice without even doing a full physical exam? Like the crease in both your lobes is one that I’ve read about that could indicate cardiovascular problems.

Dr. Mark Menolascino: Well, we know that heart disease is inflammation. It’s not a plumbing problem where the cholesterol just fills up the pipe and we stop the blood flow. It’s a plaque rupture problem. It’s an inflammation problem. And when we look at the ancillary providers, the naturopaths, the chiropractors, the Chinese practitioners, for me, it doesn’t matter whether you have MDD, OND, RN, we’re all on the same team and getting healthy as a team sport. So they’ve known in those practices that the body tells the story. You mentioned the ear crease. It’s been known in Chinese medicine for 3,000 years that it’s an oxidative stress marker. And the pathologists in the early 1900s found that men that died of sudden death that were cardiac in nature tended to have this 45 degree angle in the ear lobe. So it’s more of a sign of inflammation, oxidative stress, but it’s been linked.

And when I see that in a man or a woman, my first thing to do is let’s assess their cardiac risk. The other big red flag is a symptom or physical sign called arcus senilis, and it’s a little blue ring around the colored part of your eye called your iris. It’s a thin blue circle that encompasses the colored part of your eye, and that’s a sign that you’re having elevated cholesterol. You can have little skin tags on your eyes or on your back, those are signs of elevated cholesterol. So there’s no one lab test, there’s no one symptom history, there’s no one sign on the body. It’s taking it all together and looking at the person as unique, individual personalized approach. And then we start to see these physical signs that tell us what’s really going on.

Evelyne: So let’s talk about that cardiac risk assessment. For you, what are the most important tests that you use basically for heart attack prevention?

Dr. Mark Menolascino: Well, that’s really why I wrote the book for women is that the data that we’re using, we’re using the total cholesterol. We divide it by the good cholesterol to get a ratio. And a lot of women are told that their health is fine because the HDL is so good, they have a safe ratio. This is all from the Framingham study in the 1970s. We’re still making decisions in 2023 based on 1970s data. Your total cholesterol divided by your good one gives you your ratio. And a ratio under five is predictive of low risk. That’s completely not true. And we’ve just published this spring in the medical journals that an HDL over 60 really is no different than an HDL of 60. So the higher your HDL doesn’t give you more and more benefit.

And this goes back to that same analogy. We’re doing population based studies to predict your risk as an individual. The LDL is the bad cholesterol. Well, guess what? There’s four subtypes of that LDL. We have to fractionate it out and define those people who have the lipoprotein A that’s a small sticky LDL with a nasty inflammatory tail on it. It’s hereditary, it’s statin resistant. So you can have a high cholesterol, high LDL, take a statin drug and get no benefit. I’m not antis statins, and we’ll talk about that data in a moment. But we have to find, again, for each unique individual, it’s really about inflammation. It’s not a plumbing problem where you fill up the pipe and then we stop the flow of oxygen. It’s a plaque rupture. That plaque rupture recruits platelets to fill that little cut. They overreact and fill the entire pipe.

That’s what stops the blood flow, the oxygen feeding of the heart or brain tissue that gives you a heart attack or stroke. So it’s inflammation causing plaque rupture. There are three tests. The C-reactive protein or a high sensitive CRP, that’s been the inflammation marker we’ve used for over 10 years. It was actually linked in a statin study called the Jupiter Trial. And maybe the drugs are working in an inflammatory mechanism as well as a cholesterol mechanism. And if you have the lipoprotein A, they don’t benefit you at all. So we know that the inflammation and myeloperoxidase is the leader of that inflammatory cascade. When the CRP, the myeloperoxidase and the third member of the trifecta is the plaque two, those are the three that I check in every patient. We also look at ADMA for arginine, nitric oxide insight.

Nitric oxide helps your blood vessels dilate, and if they can’t dilate, they can’t handle that stress challenge, that physical challenge or that high fatty food content. I have a lot of my clients that will say, “Oh, I get chest pain after I have a high fat meal like a steak.” It’s because their blood vessels, their arteries cannot dilate. So yes, you want to know what your cholesterol status is, you want to know what your lipoprotein is, but it’s really those metabolic factors. So I look at inflammation first, cholesterol including lipoprotein a second. Then the third thing is you don’t want to sugarcoat your cells.

So we want to know not just your glucose and your four-month glucose A1C, we want to know your fasting insulin, your insulin resistance, your C peptide, what’s going on in your glucose mechanics. And again, it’s this bell-shaped curve of average. These linear, normal ranges are not acceptable for me, for my individual patients. So there are some ranges you want to be on the bottom end, some you want to be on the top end, but just because you’re in the range doesn’t mean you’re okay. Normal to American is overweight, pre-diabetic, and we don’t want to be normal. We want to be optimal for each individual.

Evelyne: I want to back up for a moment to the LDL cholesterol. So I know we’ve moved far beyond HDL is the good cholesterol, LDL is the bad cholesterol. You mentioned that the LDL is actually made up of four types. Can you explain these in a little more detail and talk about the small dense cholesterol versus the big fluffy cholesterol and the benefits of each of those? And then I want to dive more into LP(a) because everybody wants to know about that.

Dr. Mark Menolascino: Well, LP(a) really is a host of small particles, and it looks like there’s over 20 different sub genetic types of the LP(a) and they’re all being fractionated at this time. And we’re trying to figure out which one is the most difficult and most to be aware of. Right now all we have is a general lipoprotein A. It is hereditary. So if one member in the family has it, we check the others. It’s not linear. Some things in medicine, one is one, two is two, four is four. The risk of LP(a) is parabolic, where a slightly increase is the same if it’s a large increase. In my world, either you have the LP(a) or you don’t. And if you have it, the statins aren’t going to work as well. And we need to go beyond reducing that particle size because again, it’s a small sticky LDL with a little inflammatory tail on it.

It tends to work as you build this plaque up, you recruit white blood cells, they turn into foam cells inside the blood vessel, they get really inflammatory. They release their own inflammatory chemicals called cytokines. It’s its own unique immune system. We used to say the skin was the largest organ in the body. It’s not. It’s the endothelial blood vessel lining of the heart and the brain that are the largest organ in the body. And they have their own communication system, their own inflammatory system. And interestingly, the same inflammation of the heart is the inflammation of the brain. Your same risk factor, particularly for women postmenopausal with the hormone reduced. You have the same risk of heart disease risk as you do of dementia risk. And it’s the inflammation, the cholesterol, the blood sugar, sugar-coating. So the lipoprotein A, that fractionated cholesterol takes your LDL, your low density lipoprotein and breaks it down into four subtypes.

The two dangerous ones are lipoprotein A and a small dense LDL. In most advanced labs there’s multiple labs out there that people can use that will test these advanced particles, these advanced inflammatory markers and these advanced sugar products. So we look at this fractionated technology to see who’s got those more advanced risk. Again, the idea of taking your total, your good one, making a ratio and getting your LDL. It used to be an LDL less than 130. Now we want it under a hundred. But the clinical trials show that when an LDL in someone with known heart disease, you need to get it under 70. And that also is based on the Jupiter and several other trials. So I have a lot of people that come in that are either appropriately or inappropriately on a statin drug and their cholesterol is 110.

And I say, if you’re on the drug, let’s actually get it to a dose that works. And typically you have to do other things to get them to help tolerate that dose. In JAMA, they just published a data, said primary prevention with statins. The debate is intense, the data is weak. That’s the name of the article. It’s in JAMA, a not well-respected journal called JAMA. So this is in mainstream medicine, so it’s not a one size fits all. Again, I’m not anti-medication. I’m appropriate med for the right person. And we’ll talk about that for women too, and they’re less responsive and more at risk of side effects than the men are.

Evelyne: Yeah. And why is it that… Because we’ve had this advanced cardiovascular testing available for a long time. I feel like I took, what’s a lab that’s not around anymore, but I feel like I took that over 10 years ago. Why is it not being done in conventional cardiology yet?

Dr. Mark Menolascino: Yeah, that’s a good question. And I think there’s a lot of things that are done in medicine that are just done the way we used to do them and they’re not done the way that they should be done. And this is a great example of that with the cardiovascular health. What I see in the training is the people do what the people before them did, they’re unwilling to step out of line and do something unique. Whereas the physicians that we work with in functional medicine, integrative medicine, the natural paths, again, as a more personalized approach, they want more data to be able to empower the individual. Let’s provide people with information to empower them with knowledge to help them change your behaviors. Let’s not give them stories that scare them. “If you don’t stop smoking, your lungs are going to look like this.” Well, let’s give them information to empower them with knowledge to help them make changes. That’s really the relationship that most of us in our field are working with our clients.

Evelyne: And what is the testing that you most commonly use? I believe that Cleveland Heart Lab is now available through Quest. So I think a lot of people use that.

Dr. Mark Menolascino: There are multiple labs that you can use, and I tell every practitioner, “Go to a conference, get to know the lab people, find the people that you like that you connect with. They will teach you a lot of information, but also know that not any one lab has all the best things. So you’ve got to kind of create the package that you’re comfortable with, that you feel will benefit your patients the most. But the first thing you need to do is to educate yourself on what they’re looking at. Then find out who does the best.” I like the Cleveland Heart Lab. It just has always been a good panel for me. And the same tests they’re doing for the heart, they’re now doing for dementia prevention. So it’s the same markers, homocysteine, CoQ10, omega-3, fasting insulin, your A1C, your B-12, your folate, your MTHFR, your APOE, all of those that contribute to heart health also contribute to dementia reduction and prevention.

Evelyne: Which just shows just how important it is to actually work on this work with the right person. I want to go back to the things to prevent heart attack in addition to the advanced testing. Actually, let’s go to that first and then I want to go back to LP(a). So you also are a fan of the functional stress test and also looking at calcium score. Can you talk more about those and also cover any other things that you look at when you’re assessing risk?

Dr. Mark Menolascino: So there’s a trifecta to prevent heart attack, and it’s the same for men and for women, it’s the right blood test. And 99% of people that walk in here have never heard of what we just talked about. The second thing is a calcium score. A calcium score is a low dose radiation that looks at your entire chest to find your heart. So you get a free lung cancer screen. Number one cause of death is what? Heart disease, what’s number two? It’s lung cancer, smoking and non-smoking. You kind of get a scout film with a lung to see if there’s anything bad there. It’s not a dedicated lung film, but you do get a good idea of what’s going on in those fields. But to find the heart, they don’t need a high dose radiation because the calcium lights up. You have two coronary arteries, they branch into two more. Those four pipes.

So when they do the calcium score, if you have zero calcium regardless of your cholesterol, you will not benefit from a statin drug. And that was published in JAMA just recently, and Annals of Internal Medicine just in the last year, 30 years of calcium data. What do we know? And that’s a paper probably everybody should read. So it’s a real low cost. Our hospital charges $200 to do it. It’s very low radiation, so it’s safe for both men and women, and it gives you an idea to risk stratify who may benefit from further therapy, who doesn’t need it, and you get a lung scan for free. The third part of the trifecta is a functional stress test. Now if you and I, you’re a fit woman, you run on the treadmill, you could pass it pretty easily you with a 95% blockage. But for women, we do the stress echo, which is an ultrasound of the heart at full exertion.

How well does the heart muscle squeeze together? Are the pipes feeding it oxygen, bringing enough oxygen to that muscle so that they operate optimally at full exertion? The other mistake I see in stress tests is they only need to get you to 85% of your maximum and they can all go to lunch. I tell my clients, “You’re in a cardiac stress lab, make them take you to 105% of your maximum. So in the lab, you’re safe. So when you go skiing or you go hiking with your grandkids, you’re fine.” So again, it’s the trifecta. The right blood tests, we just talked about them. Everybody should get those once. The calcium score is a great cheap, easy, low radiation risk stratification, then the stress echo for women, a stress thallium for men, that’s where they inject a dye into the vein that’s taken up as a sugar by the heart to look at the uptake of the sugar.

That’s a little bit more sensitive and specific for men, the stress echo is more sensitive and specific for women. I saw several men in my hospital ICU days that got pre-op stress tests that passed that had a heart attack during the surgery, because they only went to 85% during the stress test. And operation is a very, very stressful event on the body. So we’d have people that pass their stress test, have a heart attack during the surgery. That should never happen. If we do the trifecta right, no one should ever have a heart attack. We should be able to catch it and find all of these risk factors in a personalized way.

Evelyne: So what’s the age that women should, or men too should get these three tests? Is it something that you should repeat on a regular basis? And also I feel like a lot of practitioners are not necessarily treating cardiovascular health. They might refer out for that, but I think it’s still important to know and to ask the patient or client, when is the last time that you had this? Have you ever looked at this?

Dr. Mark Menolascino: That’s a great point. And I used to teach doctors how to do this. It’s not very hard. It’s get the right blood test. It’s do that three part trifecta, the blood test, the calcium score, the stress test, and you can find these problems. You don’t need to be a cardiologist because they’re all read by cardiologists and by radiologists. You just take this report and the summary of all the data for this individual in front of you. Then optimize all of those other issues like we already do. The leaky gut, the stress in their life, the optimal nutrition and the nutritional supplementation that they need. Find this individualized, personalized package for them. It’s really not hard to do. And I would encourage every single person listening to add this to your practice.

It’s an easy thing to do. It’s the number one cause of death in your patients. And women won’t have had anyone talk to him especially about this because we just don’t really worry about it. I’m a doctor that practices what he preaches. And if you have a doctor who’s overweight and smokes, fire them because that’s not who you should have as a doctor. And if you are a practitioner listening, you need to deal with your own stuff. You need to be healthy, you need to be active. Do some inside time, really work on yourself as a healthy person so you’re a better practitioner. I just turned 60, I think I’m 50 because 60 is a new 50. I did my first calcium score at 45. I welded for a trucking company to pay for medical school, high lung cancer risk. My father died of lung cancer. So I did my first scan really to look for lung cancer, not heart disease.

My calcium score was zero at 45. I did another one at 50, 55 and I’m doing another one this year at 60. I do my lab tests every six months. So do those things that you would do that you want your patients to do. But I think the calcium score every five years, if there’s a heavy calcium burden, we’ll repeat it in three years. And there are multiple tests and some of our listeners that know about these, there are better tests in the calcium score that look at these plaque in different ways. They’re just being explored… A CT angiogram is a much better test to look at the blood vessel, but you really want to know not what the plaque is, but what’s the risk of plaque rupture? And that’s where it all comes together for you.

20 year old kids already have plaque buildup. We all have some, but who’s the canary in the coal mine? And I feel like that trifecta is an easy low cost should be in all primary care. I mean, we shouldn’t go to cardiologists until you have a heart problem. Let’s prevent you from having a heart problem. Look at the lung cancer risk at the same time. We just knocked out the top one and two risk factors for both men and women.

Evelyne: So you said calcium score every five years, you do advanced cardiovascular testing every six months. Do you think everybody should?

Dr. Mark Menolascino: I typically do it every year. And when I do hormone management for women, if they’re on hormones, we do every six months. Same with men. If there is a risk that we’re following, typically we’ll look at that individual risk just to save our clients money. But the annual test every year is kind of the baseline in my practice because we look at everything. Your hormones, CoQ10, B-12, folate, omega-3’s, all your metabolic markers, all your hormones, all your thyroid. We get a full 360 degree look.

Evelyne: And then what about a stress test? Is that something that has to be repeated often?

Dr. Mark Menolascino: It depends. Again, everybody’s individual, if you pass the first one and two, typically you don’t need a stress test. We save that for people who really need them. My friend Joel Kohn in Detroit, a cardiologist that used to do CAS, he likes the CIMT test, particularly for women. It’s a carotid intermedia thickness that looks at the thickness of that endothelial lining. It’s a really great non-invasive, it’s about 500 bucks. A non radiation way to look at your blood vessel health. Again, seems to be a little more sensitive and specific for women than for men, but it can help you find those early problems. And that’s what we’re all trying to detect. How do we find someone in the early stages so we can shift that trajectory and reverse the heart disease program as Dean Ornish prove that we can. Just like with Hashimoto’s, you can reverse that fairly easily. Diabetes, you can reverse it if it’s type two pretty easily. These are all lifestyle programs that we in our space of integrative, nutritional, functional medicine are really good at doing.

Evelyne: And at what age should we get these tests for the first time?

Dr. Mark Menolascino: A lot of it does depend. Family history used to be such a big part of this, and I’m not a huge fan of family history because there’s now epigenetics. You can turn on good genes and turn off bad genes and the powers at your fork and your feet. So your lifestyle choices-

Evelyne: I love that.

Dr. Mark Menolascino: … and that’s a very great thing for people to hear. That you’re not doomed to be your parents. You can change the trajectory. And when someone says, “Oh yeah, my dad had a heart attack at 55, but he ate Burger King every day and he smoked like a fiend and drank heavy and had a stressful job and wasn’t happy.” All of those types of things versus someone who is more empowered and taking good care of their health. So again, I like this epigenetic message. Let’s empower people to change their behavior based on their belief systems. And if you don’t want to be your dad had a heart attack, then don’t. And you have the power to do that. We’re going to watch and make sure that what we’re doing is right.

Now, if someone tells me they had a brother at 42, a sister at 43 and a dad at 45, they all died of heart attacks. That’s a different story. But mostly these family histories really aren’t that helpful because you’re not your parents or your grandparents and you’re not doomed to live this life of being in fear. So it’s really about providing information to empower people’s knowledge.

Evelyne: So if somebody does not have a family history, like close family history, did they start at 40, 45, 50, younger?

Dr. Mark Menolascino: I typically start 50 for men. And again, it depends when a woman hits menopause. So five years post menopause, she has the same risk as a man does. Estrogen is a double-edged sword medicine. We think we knew all about it when we did the women’s health initiative, the WHI study. Well, we got it wrong. We now know women that miss this hormone window or have early hysterectomies with their ovaries removed, have a 10 to 15 times higher dementia risk. So estrogen is both protective and can be provocative. It’s each individual. I like the 45 starting point. These are not expensive tests. We’re not talking thousands and thousands of dollars. You can get the blood test for $500. You can do the calcium score for 200 and at 45 you’re done, at 50 you repeat those. So I like the blood test every year, the calcium score every five years.

And if you need a stress test, then we go right to it. Stress cycle echo for women, stress thallium for men and this new CIMT, I’ll probably have one in my clinic eventually, but that’s a nice easy way. A lot of people had their carotid arteries, doppler or ultrasound and the way the radiology report comes back is less than 10%, 10 to 90% or over 90%, not very helpful. It’s nice to know what that endothelial lining is doing. Do you have a endothelial lining 10 years older than your stated age or 10 years younger? And these are those all predictive values. Unfortunately, there’s no one thing that will tell you all the risk. It’s a combination of all of them. And really I encourage all practitioners to learn how to do this. Do it on yourself first. Figure it out. Look at some of the talks, go to some of the conferences, listen to some of the experts. It’s pretty easy to do and you’ll make a huge impact on your clients.

Evelyne: And when you’re looking at some of these scans like CIMT for example, are you then able to see there if it’s the kind of plaque that’ll rupture or you just see what the plaque is?

Dr. Mark Menolascino: It’s a great question and when you have an angiogram, you don’t really know if that’s a hard or soft plaque. Some of the advanced imaging will give you a little bit better idea. But again, 20 year olds already have plaque. And it’s not just the calcium, it’s the entire story. An angiogram is not a benign procedure. One in 200 to 250 people will pop their coronaries and need immediate bypass surgery. I saw 10 of those in my residency, five of them passed away, never made it to surgery. So every test has a risk/benefit and you got to be careful with the risk for the benefit you’re getting. That’s why this program that I’ve mentioned, the trifecta catches probably 99% of those people. There is no perfect test and there is no perfect plan. We just do our best for each individual and then we watch them like a hawk and I’d rather be a little overconservative.

The problem with testing is we accept a P 0.05 statistical error rate, correct. So one in 20, you’re going to be wrong. You have to be careful to shotgun tests and take everything you see. You have to take it in light of the person sitting in front of you. It’s a whole person approach. The data is helpful. It’s not that expensive. It’s not that hard to interpret. And if you need help, then you find help. That’s the beauty of our tribe is that as an internist training in ICU medicine, people would tell me, “Yeah, that’s what I did. I’m not going to tell you how I did it.” In our field people would say, “Yeah, this is what I did. Here’s what I used. Here’s the program I did. Here’s my cell phone. Call me if it doesn’t work, I’ll email you my program.”

So it’s just a different community of people. And I think this tribe, which is why you’re doing what you’re doing today, we’re trying to share what works for us and also be humble that we don’t know everything and it’s really trying to individualize it. And the more you get to that space, the better your outcomes are.

Evelyne: Yeah. I want to get back to the hormones and the endothelium, but first let’s go back to LP(a) because it’s so popular. So you said that you “treat it” if it’s present regardless of the amount. So I feel like that’s one of the top questions that I get is how to actually treat it because statins don’t have an impact on it. So in terms of diet, does that help? Does exercise help? Does nutritional supplementation help? Something else I often hear when it comes to nutritional supplementation, whether it’s for LP(a) or just for cholesterol in general, is that, “Oh, I need to use more than one intervention.” Can you talk about that as well?

Dr. Mark Menolascino: Well, I think everything that we do, there’s a synergy. It’s not one plus one plus one equals three. It can equal 30 if you pick the right ones. So what we’re really looking for is in each individual, what is going to give us the one or two things that give us 90% of the benefit? Then what are the things that can synergy for us? You can eat badly, have high stress, you don’t manage and take the same supplements as someone with the same numbers that manages those things. You’re not going to have the same outcome. So it’s a whole person approach. Lipoprotein A is not well understood, and I think you will see another billion dollar drug coming out of it. What was interesting when I was doing my immune work, we realized that people with autoimmune conditions tend to have higher rates of heart attacks, particularly women.

Well women are 11 times more likely to have an autoimmune disease. If women have one, they’re four times more likely to have a second one. And we know that the inflammation of autoimmune disease drives both heart disease and dementia. So that’s why we develop these drugs to put autoimmune disease into remission. And when we use those biologics to put autoimmune disease in remission, the heart attack rate went down. So now we have biologic drugs that treat cholesterol, and in the Jupiter trial for the statin, they use Crestor, which Crestor is an interesting statin. Let me back up and we’ll come forward again. Crestor has almost a two day half life, and if you take your cholesterol meds at night, when you make cholesterol, you get twice the benefit. So why would you not take a low dose every other night to get the same benefit as a high dose every morning and get the same benefit with a 10th of the side effect risk?

Evelyne: Interesting.

Dr. Mark Menolascino: So that’s what when I do use the drug for those unique people that benefit from it, then that’s how I use it. And I like the Crestor at five milligrams every other night, and we seem to get the same results as Lipitor 20 milligrams every morning. Most cardiologists don’t know that, and most pharmacists don’t know that. But that’s an easy way to just change the statin to evening and try a longer half-life, one that you can get more benefit from. Many people are intolerant of these statin drugs because they were started at a very high dose. I see people come out of the hospital with 80 milligrams, which is banned in Europe by the way. It’s also exponential. The higher your dose 20 milligrams versus sordid isn’t two times the side effects. It’s 20 times the side effects. So it’s again, it’s a parabolic curve.

The lipoprotein A, I think we’re just in our infancy of understanding and I think we’ll find many more particles. There’s a Danish dessert called a crinkle, crinkle that’s got a little circular and that’s what the lipoprotein A is. It’s this little sticky LDL particle with this little circular tail on it. And there are some supplements called kinases, kinases, Latin for Cleve, and it cuts off that inflammatory tail. There’s somebody in molecular chemistry that’ll tell me, I don’t know what I’m saying and I probably don’t, but this is my easy way to think about it and my easy way to explain it to people. These kinases cut off that tail to reduce the inflammation potential to burrow into the endothelial plaque to make it inflammatory to rupture. That’s why it reduces these inflammatory markers. Your lipoprotein A value may not go down, but your neutralization of it does.

The two kinases are nattokinase, which is essentially what they use in many parts of Asia instead of Aspirin. They realize Aspirin isn’t a completely benign chemical, but they use nattokinase as a way to cleave and they use it as heart disease prevention. Where did they come up with a statin drug? Well, they heard about the Chinese heart tonic, which was red yeast rice extract, and they put a carbon on the corner, patented it, and that’s where we got Lipitor. The problem is many red yeast rice in the market and consumer reports, I believe is the one that did the test. They looked at 10 big box store vendors of red yeast rice, nine of them had Lipitor in it. The 10th one was radish powder. So you got to be very careful with low level quality supplements. So when we talk about nattokinase, not all nattokinase are the same.

There are specific brands that are higher level. Lumbrokinase, which is from an earthworm, tends to work better than does nattokinase. I know some of my colleagues use niacin and niacin works for some people, doesn’t work for other people. A postmenopausal woman having hot flashes probably won’t tolerate niacin in any form. The no flush is also equated with no benefit. Now, the cardiologists don’t like niacin because they published a study, I think it was the All Hat study where they came out and said, “Finally, niacin’s dead. It doesn’t work.” Well, they took people with a high cholesterol, gave them Crestor, lowered the cholesterol, then added niacin, and it didn’t make much of a difference. So they said it didn’t work. So you have to understand these studies. You have to read them and know what the number needed to treat and the weaknesses of the studies.

Going back full circle, I typically use a lumbrokinase for my patients with LP(a). It works well. Many things tell you to take three or four a day. Usually one does it for most people. There is a neutralization assay that can be done and you’ll find at some conferences, there’s companies that perform this, they’ll show you in your blood. And there’s always a concern when people are already on a blood thinner like Eliquis or Coumadin or even Aspirin. Should you be adding these? I’ve not seen a problem with it. I’m going to tell everybody to have caution with it. The new class of blood thinners, we don’t really understand that well, but you just have to be careful with the interactions. And again, it goes back to the uniqueness of the individual. Not everybody with a LP(a) of 75 should take this supplement or take two of them or three of them. It’s personalizing it. And that’s where the expertise of the different practitioners comes in board and where your wisdom born over years of experience. But use your colleagues, reach out to them, you’ll find them very helpful to help share this with you.

Evelyne: Yeah, it’s very nuanced too. And when you’re treating with supplementation or even statins. When you’re actually lowering cholesterol or lowering some of these other markers, because sure, the drugs or even the supplements, they can lower cholesterol. But what is the impact of that? Is it actually affecting or reducing risk of heart attack?

Dr. Mark Menolascino: That’s a great question. I’m not sure that’s totally been answered. So there’s a big difference between primary prevention and secondary prevention. I’ve never had a heart attack, so the current cardiology plan to reduce my cholesterol doesn’t seem to reduce my heart attack or death risk. In people that have had a heart attack introducing the cholesterol meds does seem to have a small benefit, not much in women. I believe the studies from England showed you need to treat 5,000 women for five years if they’re under 50 to reduce the risk of one death. That’s a lot of exposure to medications and side effects. So when you see the commercials of the people dancing the flowers and they say, “oh, it’s three times better or cuts the risk in half or 80% lower risk,” those are bogus statistics. You can’t trust that you’re looking for the number needed to treat, the number needed to harm.

That’s how you figure out a drug and you’ll never see that said on TV. The number needed to treat for women under 50 based on the British studies, which are really good because it’s the national health service data, 5,000 women to prevent one death in five years. That’s a lot of medication exposure. For primary prevention of men, even JAMA just published editorial saying, we’ve got a lot of data. The debate doesn’t show there’s a benefit. So not everybody gets a primary benefit. Not everybody gets a secondary benefit. Most of the people that are the time bombs, and these are people with high inflammation, high calcium score burden, maybe you have failed to stress test. And when I was training stents just came out, they coated them to prevent the re-sent stenosis. That’s a big plague of stents. They plug up. If there’s a piece of metal in your artery, it’s a place for the jet to a pool and cause a clot or a plaque to build up.

So they coded them with a magic chemical to reduce that. Well, they just published several, it’s been five years now. Medical management, optimal medical management is equal to a stent for your outcome with chronic heart disease. So the $50,000 stent is the same as doing optimal medical management. So maybe we’ll see in the future a drug like a statin at a very low dose with these advanced markers looked at, with the sugarcoating balance, with the stress managed, get some of the additives out of the foods. It’s a whole story picture and you can’t take one supplement or one drug and not do the lifestyle.

When I was in residency, one of my mentors was creating a super drug. It was Aspirin, a statin drug, a blood pressure drug, and one other, I can’t remember the fourth part of it. It was a miracle, quadruple drug in one pill, and that was supposed to be the answer. So you get in McDonald’s when you go to the drive-thru so that you can eat. And I have a lot of people that think, “Well, I’m on the medicine now. I can eat whatever I want.” Well, it doesn’t really work like that. So medicine for some people some of the time, but you’ll find most of what we do in the lifestyle medicine far out trumps what you’re going to do for medication anyway.

Evelyne: Yeah. I want to talk about diet and also nutritional supplementation in general for cardiovascular health. You mentioned the nattokinase and the lumbrokinase and niacin. What are some of the other nutraceuticals that you’re a fan of using in your practice?

Dr. Mark Menolascino: Well, we were talking about that endothelial lining of the blood vessels being the biggest organ of the body. Well, now we’re finding there’s these little hairs on top of that endothelium called the endocalyx, and that may be the next frontier of where we’re addressing. And arterial salt is a sirtuin based chemical supplement that works at that. The more we can learn about the pathology of heart disease, particularly finding early interventions before there’s a problem, I think we’re going to see that. And there’s people that eat everything right and still have heart attacks because they’re missing something, and there’s people who take every supplement and still have them. It’s about uniquely finding what that person needs. Aspirin, I was hammered into me that everybody has to take a baby Aspirin to prevent heart attacks. Well, last year they published there’s more people, particularly men dying of ulcers from bleeding ulcers, from taking Aspirin than are preventing from heart attack and stroke death.

So what we thought we knew isn’t always what… That’s what Mark Twain said, “It’s not what you know, it’s what you think is true that isn’t so.” You’ve got to really take all this data with it. CoQ10 I think is the big misleader. When they developed the drug Lipitor, I spoke to one of the physicians on the advisory company’s committee who said, “The pharmacist told us it depletes CoQ10 out of the mitochondria.” And they were going to put it in with the pill it was 3 cents more per pill. They decided not to do it due to financial reasons. Many cardiologists don’t know that the statins damage the CoQ10 reserves in the mitochondria to prevent free radical oxidative stress. And really, this goes back to all of our diseases. Oxidative stresses is at the root of all evil, dementia, heart disease, depression, mood disorders are really an inflammatory disease as much as they are a serotonin dysfunction.

So the omega-3’s, most of your natural sources of omega-3’s are now tainted with heavy metals. You got to be careful. You got to get a high quality. One of my race car driver patients came to me and said, “Mark, I can’t take those fish oil pills because my girlfriend tastes it when I take them.” And I said, “Well, where do you get it?” “Oh, I go to that Costco and get the big economy bottle because it’s on sale.” He brought them in and they were rancid. And I said, “Geez, you’re buying rancid spoiled fish oil and you make $20 million a year.” So I gave him good high quality omega-3’s. He called me a month later and said, “My girlfriend doesn’t even know I’m taking it. She can’t taste it.” So again, it’s not just what you take. It’s the quality you take and designs for health.

The leader in the industry, I feel at quality. It’s checked before it’s made. It’s batched tested after it’s made. It’s made in a facility that’s equal if not better than a pharmaceutical company. I’ve been to two of the manufacturing facilities. They’re amazingly world-class facilities. So this is not your grocery store supplements. This is such a high quality it’s on the pharmaceutical grade level, and that’s what I share with my patients. Let food be your medicine, kitchen your pharmacy, targeted supplements when you need them, but take the highest quality you can find. So the omega-3’s, the CoQ10. The big thing in women’s health is this methylation defect, MTHFR. Some women just can’t take folic acid and make what they need out of it. So we’re giving folic acid for pregnancy and 40% women don’t even use it. B-12 most B-12 is dysfunctional. You need a methyl B-12. You can also use too much. There’s always too much of a good thing.

So it’s trying to find the right balance for the individual. So the B vitamins that affects your homocysteine levels. Homocysteine is a not well understood protein that we check in all of our patients linked to heart disease, linked to cancer, linked to dementia. But to me it seems to be just a bad protein that irritates that inflammatory nature of the endothelium. We want to fall in love with our endothelium, the glycocalyx. We want that to be the healthiest part of our body from the inside out and what you’re doing, nutrition, lifestyle, stress management, avoiding the toxins, all of that works together to prevent this.

Evelyne: I know that you practice personalized precision medicine with your patients, and yet people want to know how much CoQ10 do you give, do you give a hundred milligrams? Do you give 200, 400? Omega-3’s, do you give one gram of EPA and DHA three grams? Do you have any general recommendations for most people?

Dr. Mark Menolascino: That’s a great point and I’m going to evade the question slightly by telling you I don’t always use what the bottle says. So a lot of times it’ll say take four, I tell them to take two. Now, if you’re 105 pound woman versus a 280 pound linebacker, you’re really going to take the same dose of CoQ10 or the same dose of fish oil. So a lot of times it’s weight based to me, and I’ll adjust the dose based on use an individual. I was going to say, if you’re an athlete, I consider all my patient’s athlete. Evelyne, you’re an athlete. I know how you take care of yourself, how you think about your health. You think about it like an athlete, and when your doctor says, “I’m going to think about you like an athlete,” you immediately want to get into that plan because that’s how you want to be taken care of. You’re going to be taken care of like Michael Jordan.

So it’s not just a one size fits all, but in general, the two grams. Omega-3’s are interesting. Two grams for heart protection, four grams for joint health, six grams for mood benefit. That’s what the clinical studies show. I don’t know that I could take six grams and some people can tolerate fish oil, some people can’t. So the CoQ10’s a hundred milligrams. That’s what typically most people do. They say after age 40, most of the typical CoQ10’s don’t work. They don’t become bioavailable. You need to get to the ubiquinone ubiquinol subtypes. So again, it goes back to supplement quality. You’ve got to find the best stuff you can and be sure that it’s clean, it’s been batch tested and that it’s the right subtype of that supplement because not all CoQ10’s are similar.

The B-12, I use the liquid B-12 typically start a dropper a day for a month and then go to half a dropper. Most people can get by with 500 micrograms versus a thousand. So I usually personalize the dosing. We’ll start maybe a little high initially to get on top of it and then back it down to kind of a therapeutic maintenance dose. One just for patient convenience, two for cost and three for functional benefit. You don’t need max doses of everything all the time. It kind of goes back to when in flu season/COVID season, you bump up your zinc level, you bump up your vitamin C level, you do some of the more immune supplements. I personally take immune fizz. I take zinc lozenges. I do all of that in the winter. I boost my vitamin D up.

I grew up in Nebraska. My vitamin D was 12 when I tested the first time here in Jackson Hole, and every February it dips. So I take 10,000 in the winter, 5,000 in the summer to get my vitamin D level to 80. The lab says 30 to a hundred. And this is another pearl for our listeners. These lab ranges, vitamin D is 30 to a hundred. There’s all kinds of debate in the internal medicine journals about vitamin D. There’s no debate in this clinic. Vitamin D is helpful for most conditions. Mood, diabetes, heart disease, hypertension, immune system health, cancer prevention. Almost every single person I see that has cancer and has heart disease, has low vitamin D. Doesn’t mean it caused it, but there’s definitely a corollary there. So I like a vitamin D in the 70 to 80 range and we titrate it. You can get toxic in it because it’s fat soluble, A, D, E, and K.

But most people don’t supplement high doses of A, E and K. They do use high doses of D. And I do find people that are toxic once in a while. There’s been some case reports to toxicity, but I’ve never seen anyone even with vitamin D levels and the three or four hundreds that come from other practitioners that be in trouble. So again, you want to be cautious, and I tend to under supplement maybe and try to let food be your medicine because you can get your nutrition from food. I would much rather you do that than try to get it from a supplementation. But targeted supplements when are high quality make a huge difference.

Evelyne: So when it comes to diet, I mean I feel like there’s nothing more controversial like in a science than nutrition. It’s just crazy. People get so dogmatic about diets and I definitely believe in individuality within people. Are there any general principles when it comes to diets specifically for cardiovascular health? Do you even want to get into red meat?

Dr. Mark Menolascino: Sure. No, I’m happy to. So the Forks Over Knives documentary is probably worth everybody’s seeing. And I met Caldwell Esselstyn, he’s 6’5, I believe, 135 pounds. And I didn’t think a vegan diet you could survive on because I tried it in college and it didn’t work for me. The Dean Ornish nutrition plan is very rigorous. It’s difficult for many people to follow. So what’s the best diet? Should you go keto, paleo, Mediterranean, intermittent fasting. I don’t think there is any one size fits all. Now the Mediterranean has a best data by far, but that’s in a family-based setting at a big table with a family in Italy, Greece or Spain. And it might be the family connection that has more power for your health than does the food that you’re eating. So if you’re eating and sitting in your car or sitting at your desk, and Michael Poland, one of my favorite authors says, “Your desk is not a table.”

So it may be that socialization of how we eat is more important than the food that we eat. I tell my patients, forget about diets because the first three letters are what?

Evelyne: Die.

Dr. Mark Menolascino: D-I-E, die. I don’t believe in diets. I believe in personalized nutrition plan. So we like to do food sensitivity testing, and I tell many people, you can just shortcut it and avoid dairy and bread. If you avoid dairy, bread, corn and soy. Those are most of the inflammatory chemicals in our food supply. In Europe, there’s 11… There’s 11 food additives banned in the US. There’s 2,100 food additives banned in Europe. They just seem to be ahead of us all the time in this nutritional optimization. Go organic when you can, but there’s some things organic you spend a lot of money on, don’t get much benefit. Red meat is not red meat.

Now, if you’re eating wild game versus grass fed and non-hormone, non-antibiotic beef, that’s different than most grocery store red spray, painted hormone infused antibiotic laden meat. So they’re different… Red meat’s, not red meat. In my book, and I live in Jackson Hole where a lot of people eat venison and elk meat, and I used to do that with my kids. We’d grill up some elk burger that was purple and had no grease versus a 98% lean hamburger from the grocery store that had half a cup of grease, and they could just tell which one was better for them. So diet wise, the gluten issue in America is really obsessive, but correct. You talk to Tom O’Brien, he’s right about almost everything and the wheat in America, which means the bread in America tends to be trouble. I went to Italy, ate bread three times a day, my stomach was flat. I came home and had one bagel and had a Buddha belly. It is just different. And the gluten-free foods are hyper processed, super processed to be gluten-free.

So people think they’re doing the right thing and they get sabotaged. So I kind of have a doctor mark plate that I draw for my patients, and half your plates vegetables, the more color, the better for your anti-cancer benefit. You can have a piece of fruit. Fruit juice is a bad idea because it’s six apples for one glass high glycemic load. Then don’t eat anything white, the white rice, white potato, high glycemic load. Then the starches are what everybody struggles over is trying to figure them out. And I just tell people, minimize those breads. But you can do food sensitivity testing and really personalized nutrition and it gets a behavioral modification tool to help you to get people to behave.

So it can’t be hard, it can’t be draconian, and it’s got to fit their belief system. You can’t get an Italian like me not to eat Italian food. I won’t go on vegan, I won’t go on starvation. Intermittent fasting, that’s from Vaulter Longo, I believe at USC, looking at immune system and cancer patients, huge benefit, but it should be done intermittently. So I think diets in America have been completely taken over by commercialization, and I don’t think there’s any one diet that’s right for everybody. The Mediterranean is the easy thing to fall back, and I do think Caldwell Esselstyn in the vegan for people that do well, if you want to prevent heart disease, I don’t think there’s a nutrition plan out there that’s better. But it depends on where you’re getting your vegetables. So it’s a tough question.

Evelyne: Yeah. I want to switch gears to something that you said earlier, and I don’t want to not talk about this, but when it comes to hormones, especially in women. So we know with the Women’s Health Initiative, the women were given Premarin, the study was stopped prematurely, but you recommend prescribed bioidentical hormones. Do you think, and we could probably talk about this topic for a whole episode, but do you think that there’s a point where it’s too late to start on bioidentical hormones? What’s that optimal window and how does that relate to cardiovascular risk?

Dr. Mark Menolascino: Oh, that’s a great question. And when I first moved to Jackson Hole, I was climbing up Glory Bowl to go skiing. I got passed by this old gentleman, I was 30, and I said, “Excuse me, how old are you?” And he said, “I’m 71. Why?” I’m like, “Keep doing it.” He passed me hiking up the hill. So your age is just a number. And we were taught med school, get to 50, and then it’s a slow decline in the nursing home. No, we want our patients to be active, fit and vital in their eighties. So they’re active in skiing with their grandkids. So I don’t think there is a number for that. The WHI study again, Premarin pregnant horse, urine estrogen. It’s dried from pregnant female horses. We know when you take it orally, the liver makes things it’s never seen before and it should not ever be used.

Oral estrogen just does not make sense in our world. Why not use the same that’s biologically identical to women in small amounts. You can do topically that goes in without getting that metabolism through the gut in the liver. So bioidentical, whether it’s a patch and you can do a pharmaceutical patch that technically still is bioidentical, but I don’t think we really know the benefits from it. And it has to be done on an individual basis because there’s some people that are 52 and physiologically they’re 82. There’s some people 82, physiologically 52. So in my clinic age is not a barrier for anything. In my residency, I saw a 92-year-old get an aortic bypass. They did recraft on his aorta. You never do that 90 year olds, but he convinced the cardiac surgeon that he wasn’t your typical 92-year-old and he did great. And I believe he’s still alive.

So I think it’s not just what the number says. I do use hormones in women in their seventies, and a lot of them missed that window based on the WHI study. We really didn’t do well by a whole generation of women by avoiding those hormones because we are afraid of them. I think the study wasn’t helpful. Bioidentical hormones will probably never be studied, there’s no money in it. Most of my compounding pharmacist friends who are some of my favorite people on the planet besides naturopaths, they’ll tell you they don’t see cancer in their patients. And it may be that biologically similar identical hormones protect you from cancer because it occupies your estrogen receptors so that the xenoestrogens in the food supply and environment don’t. And that’s a theory that I like, that personally makes sense to me.

But the other thing, if you’re taking a supplement or you’re taking a biological bioidentical hormone, you might also be doing some morning meditation, you might also be doing some exercise. You might also be looking for more love in your life and coping with these stresses and finding other things that we know contribute. So it’s not just the drug, not just the supplement, not just the exercise, not just the nutrition. It’s the whole package. And that’s the beauty of what we get to do with people. We get to help them find what package works for them. And that’s really what this personalized medicine is all about.

Evelyne: I love that. Just three really rapid fire questions that we ask every guest on the show. So the first one, what is your personal favorite supplement? If you could pick one.

Dr. Mark Menolascino: Vitamin D by far.

Evelyne: Love it. What are your top health practices for your personal health and wellbeing?

Dr. Mark Menolascino: One of my favorites is, and maybe it’ll be this conversation, I wake up every morning and give a thought of intention based on an experience I had the day before. And it’s usually with a client or something really small, but I don’t go to my phone, I don’t do anything. I lay in bed, wake up, have a moment of gratitude and a moment of intention to start my day being thankful for what happened the day before. And when I do that, it seems like the day just goes well. So that’s one of my things. I try to move the body every day. I’m not a perfect eater, but I do a smoothie most days. That’s my kind of morning ritual. I just like the way I feel. I have dairy and gluten sensitivities, and I find when I do dairy and bread, I get bloated and I feel a little stiff, more stiff.

I’m an athlete. My body does hurt. So if I reduce the inflammation, inflammatory foods, I do well. But I also find if I don’t move the body for a couple of days, I get a little irritable and grumpy. So those are my three big things. Move the body. I’d also add drink water. We live in a dry environment even though there’s 10 feet of snow outside in the mountains, so I try to get a gallon of water a day. It’s hard as she drinks hers, but that’s one of the easiest things you can do. It’s half to three, four ounces of water per pound of body weight. I weigh 200 and so 150 ounces is a lot of water for me.

Evelyne: Yeah. I’ve been trying to drink two of these bad boys a day.

Dr. Mark Menolascino: That’s it. I start with… I have two pint glasses. I don’t drink beer out of them, I drink water. I start every morning by two big glasses of water. At least it starts me right.

Evelyne: And then finally, since you are a conventionally trained MD, but even at any time in the last couple of years, what’s something that you’ve changed your mind about through all the years that you’ve been in practice?

Dr. Mark Menolascino: That’s a great question. Statins might be one of them. And we’re all such anti-statin people, and we’re kind of anti-medication in general. Medications really are a poison that we figured out have a benefit. It’s a side effect that has a clinical usefulness, and that’s why we use it. I mean, Aspirin, willow bark, Foxglove, digoxin, Digitalis. So there’s a lot of things like that. I am not against medicines. I’m not anti-medicine, I’m pro Evelyne. So if you’re my client, I do what’s best for you. And I try to get my own biases and prejudices out of the way and listen to my patients. So sometimes the smartest person in the room when I’m seeing a female patient is her intuition and we have to trust it and it’s usually right.

Evelyne: I love that. Thank you so much.

Dr. Mark Menolascino: You’re welcome.

Evelyne: And Mark, thank you so much for all the insights and clinical pearls that you shared with us today, especially regarding all of the testing. I definitely learned a lot from you.

Dr. Mark Menolascino: You’re very welcome. And everyone out there, you’re welcome to borrow anything I said and use it in your clinic, and I hope you create success.

Evelyne: I love that. Thank you. Thank you for tuning in to Conversations for Health. Check out the show notes for any resources from our conversation today. Please share this podcast with your colleagues, follow, rate or leave a review wherever you listen. And thank you for designing a well world with us.

Voiceover: This is Conversations for Health with Evelyne Lambrecht, dedicated to engaging discussions with industry experts, exploring evidence-based, cutting edge research and practical tips.