“I think good and bad cholesterol is often confused, and when you have your cholesterol measured…”
Today, we will discuss the nordic diet and its effectiveness in managing cholesterol and diabetes with Dr. Robert Eckel, Professor of Medicine Emeritus with appointments in the Division of Endocrinology, Metabolism, Diabetes, and Cardiology at the University of Cincinnati College of Medicine. He is also a member of the Scientific Advisory Council of the National Institute of Diabetes, Digestive, and Kidney Diseases at the National Institutes of Health.
Shireen: Podcasting from Dallas, Texas. I am Shireen, and this is a Yumlish podcast. Yumlish is working to empower you to take charge of your health through diet and exercise and reduce the risk of chronic conditions like type 2 diabetes and heart disease. We hope to share a unique perspective and a culturally relevant approach to managing these chronic conditions.
Shireen: In today’s episode, we will be talking with Dr. Robert Ecel and we will be discussing cardiometabolic diseases like heart disease and diabetes, lifestyle changes, statins, and valuing[ the] quality of diet over quantity. Stay tuned.
Shireen: Dr. Robert H. Eckel is the former Charles A. Becher endowed chair in atherosclerosis in the Department of Medicine at the University of Colorado and shoots medical campus in Aurora, Colorado. Dr. Eckel is the past president of the American Heart Association, American Diabetes Association, medicine and Science, the Obesity Society, and the Association of Patient-Oriented Research and has published nearly 400 articles and editorials in peer review journals. Welcome, Dr. Eckel.
Dr. Eckel: Oh, thank you very much, Shireen. Good to be with you today.
Shireen: Well, diving right in. Dr. Eckel, tell us a little bit more about your background and what, really led you to understand cardiometabolic diseases, and what was your interest into it?
Dr. Eckel: Well, I was trained as an endocrinologist at the University of Washington, and I went to that institution to get further training because they had a broad program that related not only to metabolic disorders that fall within the endocrine space such as; obesity, diabetes, metabolic syndrome had yet to be defied, but ultimately would be a very important part of this relationship and cardiovascular disease. So my training really related to this overlap between metabolic diseases and cardiovascular disease. And then in the late eighties, mid-nineties, we all know that we talk about the Covid 19 pandemic, but the obesity pandemic has really hit us, not only in the United States but around the world. So this ultimately opened the understanding more so, as to what people ultimately with obesity have consequences of obesity, and many of them developed diabetes and ultimately developed cardiovascular disease, and that’s where the metabolic syndrome was described as an entity that related metabolic diseases to cardiovascular disease, risk, and risk for diabetes by the way. The initial criteria did not necessarily include diabetes as a feature of the metabolic syndrome.
So I got very active in this interaction between the two areas and with a joint appointment in cardiology at the University of Colorado Hospital. I ultimately had my clinic in cardiology, even though I’m an endocrinologist by training. So this led to the presidencies of all these organizations. I was really privileged to serve in a wide variety of ways, and I think that really represents cardiometabolic medicine as we currently understand it
Shireen: I wanna start getting into a little bit more about some of these different disease types. Let’s start, with just understanding cholesterol, right? We hear quite a bit around, get your cholesterol under control. Can you help us understand what the difference is between good and bad cholesterol and the types of food, uh, foods that may increase the bad cholesterol?
Dr. Eckel: Well, that’s a good question. Shireen. I think good and bad cholesterol is often confused, and when you have your cholesterol measured, unless you’ve had the components of the total cholesterol, we really don’t understand people’s risk for cardiovascular disease. So the good cholesterols and HDL, that’s really something higher in women than men may have something to do with the protection from atherosclerosis and coronary heart disease, and other forms of hardening of the arteries, and the bad cholesterols the LDL cholesterol, which is ultimately the type of cholesterol that gets into the artery, forms the plaque and results in heart attacks and strokes and death from cardiovascular disease. So when you measure your total cholesterol, you gotta break it down into good and bad cholesterol. Now we wanna focus on the bad cholesterol. That’s where the clinical trials have proven very effective in showing that reduction of the bad cholesterol is beneficial in reducing the risk of heart attack and stroke and other vascular outcomes.
So what about diet? Well, the dietary intake of cholesterol is not as important as the dietary intake of saturated fats. Those are the hard fats. And now since we have food labeling, everybody can know how much, saturated fat they’re eating, at least in foods that have food labels on them. So restricting your saturated fat is the best thing you can do in terms of nutrition and reducing your levels of bad cholesterol. Yes, dietary cholesterol, which is really rich in egg yolks and other foods that mostly come from animal products that have some benefit in lowering LDL or bad cholesterol, but ultimately saturated fats and trans fats. By the way, the food labels also show now almost zero trans fat and all foods that we eat. Those are the bad fats in terms of the bad cholesterol.
Shireen: Now, why is it dangerous to have some of that high bad cholesterol?
Dr. Eckel: Well, we know the bad cholesterol can get outta the artery. It, it’s a fairly small particle that carries the bad cholesterol and it can get through the wall of the artery and get into the sub-arterial space and there that bad cholesterol can get chemically modified like oxidative metabolism. When that happens, that creates inflammation and the combination of having excess cholesterol in the artery wall, the reactive, compounds that modify the bad cholesterol. And then finally, ultimately, the inflammation that follows results in the atherosclerotic plaque. So that’s why the bad cholesterol is worthy of attention and very important to lower, it to reduce your risk of cardiovascular disease.
Shireen: I do want to switch to diabetes, real quick next, and help us understand, why does diabetes and high cholesterol are more importantly heart disease often occur together .And are there any other health complications that can result from managing both of these?
Dr.Eckel: Boy, that’s a loaded question. Shireen. I don’t think we still have a total understanding as to why diabetes confers in up to two, to threefold increased risk for cardiovascular disease outcomes. I think we can say it’s partly related to other aspects of diabetes mostly type 2 diabetes and that’s obesity. It’s having low levels of the good cholesterol. It’s having higher levels of triglycerides. It’s having higher levels of blood pressure. It’s maybe related to lifestyle in terms of the quality of the diet. It may relate to sedentary behavior or less physical active lifestyles. So there’s a lot of things that bleed into this relationship between diabetes and cardiovascular disease. And of course, controlling the blood glucose is relatively important. More so in type one diabetes, which occurs in only about 5% of patients with diabetes. But even in type 2 diabetes, there’s still some evidence that improving the blood glucose control results in less events. So it’s complicated, but I think, the understanding currently of that relationship is still not complete.
Shireen: Is there a role that genetics plays in the amount of cholesterol, even just the susceptibility to either diabetes or heart disease?
Dr. Eckel: Well, the genetics behind diabetes is clearly there from family studies, but when we look at genetic profiles, in other words, we’re living in the age of genomics where everybody’s DNA can be sequenced. The amount of genes that relate to the causation of type two diabetes doesn’t fit the family studies. In other words, if you’ve got a mother who has diabetes or a father who has diabetes, you’ve got an increased risk of having diabetes. Again, type 2 occurs mostly in adults. But also the genetic risk of having high levels of cholesterol is clear, clearly apparent. The high risk for atherosclerosis or hardening of the arteries independent of cholesterol and diabetes is there, but it goes beyond genetics, Shireen. It very much relates to lifestyle and how that impacts our genetic risks. So I think it’s a combination of both, and there’s a balance between the two, but both are important for sure.
Shireen: For some people who find it difficult to manage their cholesterol through diet, exercise, are there other ways to manage cholesterol outside of lifestyle choices?
Dr. Eckel: Well, I’m sure everybody in our audience has heard of statin drugs, and those were developed in the early eighties and ultimately proven to be safe and effective in the mid-eighties. And then clinical trials would show the benefit of using statins to reduce levels of the bad cholesterol. And those trials are numerous, perhaps over 30 trials now that have demonstrated the benefit of statins at various intensity levels. High-dose statins are better than moderate-dose statins and low-dose statins, but it relates to the amount of LDL lowering.
So the first step beyond lifestyle in reducing LDL or bad cholesterol is statin therapy. And now there are guidelines all over the world about how aggressive we should be as healthcare providers in lowering the LDL cholesterol with statins. But beyond statins, there are other drugs we also have available if the LDL cholesterol is not lowered sufficiently with the statin drugs or if people have side effects to the statins, and those are not uncommon in the patients I’ve treated over decades with statins.
Shireen: Can you speak to some of the side effects and also help us understand why statins are so controversial?
Dr.Eckel: Well, the side effects mostly relate to the muscular systems, and that is muscle aches and pains. This is by far the most common consequence. Now, many people who have these statin-related side effects can be improved by stopping the statins and restarting at lower doses are alternatively working through other disorders that can cause muscle symptoms that could be causative in addition, to or instead of the statin therapy.
So this is the art of medicine, so I’ve called it for years. The art of medicine is listening to your patient and then assuring that you’ve taken all steps necessary to evaluate the differential diagnosis of people who have myalgias, the so-called medical term for muscle aches and pains. But when a patient can’t tolerate statins through a variety of steps to work on reducing statin dose and or discontinuing the medication because of adverse effects, then we have other drugs to turn to. And we do list those patients as statin intolerant, which is a medical diagnosis that enters the medical record.
Shireen: Is it true that statins worsen or even cause diabetes?
Dr.Eckel: What’s interesting in type two diabetes, incidents, is we’re looking at patients who are treated with statins who may be at higher risk for type two diabetes, and that means they have a family history, as we mentioned earlier, or they have what’s so-called impaired glucose tolerance or pre-diabetes. And we define pre-diabetes as a range of the hemoglobin A1C, which is the test we now use to measure average blood sugar levels over a three-month interval when those A1C are closer to 6.5, which is the diagnostic threshold for the diagnosis of type 2 diabetes. Those patients, in addition to those who have a family history, are at higher risk for developing new-onset type 2 diabetes.
Now, the good news about that, it’s only occurring at about 5- 10% of people treated with moderate to high-intensity statins. But the good news is patients with diabetes, as we discussed, have a higher risk of cardiovascular disease, and being on a statin reduces that risk. So we don’t wanna cause diabetes with statins, but we know a risk for a major outcome from diabetes, which is unfavorable for sure, and that includes death from a cardiovascular disease event. We reduced that, magnitude, some 25 to 30% as if the patient did not have diabetes.
Shireen: Interesting. So if anything is, is helping reduce that. Gotcha.
Dr.Eckel: That’s correct. We do not give a patient a statin because they have a family history or have impaired fasting glucose or pre-diabetes. We give it to them and explain upfront that this may result in a transition to a slightly higher hemoglobin A1C to make the diagnosis of type two diabetes. We try to comfort them with their risk for a heart attack or stroke now is substantially reduced.
Shireen: So is it, is it safe then to assume, uh, on this then Dr.Eckel; Is that the best thing to do is make those lifestyle choices, make those lifestyle changes, excuse me, get those done early on if you wanna avoid statins, the side effects associated with that, try to focus on things that you can do, things that are in your day to day focus there but, if you’re not able to, for whatever reason, then statin would be sort of the second option from there.
Dr. Eckel: Right. And the American Heart Association has recently published what they call the Essential Eights, and let me list those in order for the audience. Number one is know your risk, and that includes how are you eating? What’s the quality of your diet? Number two, what about activity? Are you sedentary or minimally active? And can you become more active? The third is avoiding tobacco, all forms of tobacco. The fourth is ultimately managing your weight. And that can be a challenge for many people and remember, diabetes is almost always at least type 2 associated with excess body fat and being overweight or obese.
Now, the other things that we can do is we can manage our blood pressure. We can manage our glucose. We can manage our cholesterol and ultimately sleep is another issue. We need to consider having seven to eight hours of sleep a night. Those are all health-provoking eights that relate to the protection for cardiovascular disease and ultimately mortality from cardiovascular disease events.
Shireen: Thank you for sharing that. I do wanna double click on the diet in itself. You know, we hear a lot of the quality of the diet is more important than the quantity of the diet. Right? Can you tell us, can you explain to us why exactly and what should one consider, especially if someone has some form of heart disease or diabetes?
Dr. Eckel: Well, this could be recommended for people at high risk for cardiovascular disease or actually for normal individuals prevent to prevent that extra risk from developing. What we’re into nutritionally in terms of the benefit that relates to diabetes, cardiovascular disease, and ultimately even cancer, are dietary patterns. And those aren’t good foods and bad foods, and we can all name those if we want, but I don’t like that terminology. And I advise my patients always about dietary patterns. Now, what do I mean by a dietary pattern? A dietary pattern is either the Mediterranean-style dietary pattern or the so-called dash dietary pattern.
And the dash dietary pattern is very similar to the Medi Mediterranean style dietary pattern. These diets have lots of fruits and vegetables, lots of whole grains, legumes, lean poultry, and fish, and have a limited amount of simple sugar. And carbohydrate is mostly in complex form like starches and beyond. So we’re thinking about a diet where, in fact, when I address this with a patient, I ask them; how many servings of fruits and vegetables are you eating a day? And by the way, potatoes are a vegetable. So we ask how many servings of fruits and vegetables they have a day? How many are servings of whole grains?
We’re talking about grain cereals. We’re talking about grain breads, we’re talking about beans and legumes, and things that include a lot of fiber basically are where whole grains are at. I ask how many fish servings per week? I ask, do you read food labels in terms of saturated fat and sugar? And of course calories. Now we can’t dismiss the quantity of the diet too. But as a healthcare provider, my emphasis initially is always he’s been put on the quality of the diet, not the amount of calories eating. And once the quality is moving in the right direction, we think about weight reduction, which must result in a reduction of caloric intake.
Shireen: Is that what you normally recommend to your patients is to look at the diet, try to adapt a diet, kind of like the dash diet or the Mediterranean diet? Is that, is that normally the the stance on it?
Dr. Eckel: Right. I always start with quality before I go to quantity.
Shireen: Let’s get into fiber. To reduce blood cholesterol, levels and prevent coronary heart disease. Many diseases, many studies recommend reduced consumption of saturated fat, cholesterol, and an increased intake of carbohydrate foods, high in fiber, especially soluble fiber. Can you help us understand soluble versus insoluble fiber? And then how does that really help?
Dr. Eckel: Well, the insoluble fiber doesn’t go through much digestive action or so soluble fiber can be acted upon by the gut bacteria. Fiber intake, when it’s increased, can lower bad cholesterol. But ultimately above, let’s say 25 grams a day, the more fiber you eat, the better LDL cholesterol lowering you get. But ultimately, the maximum amount of LDL cholesterol lowering you get with diets high in fiber is probably no more than around 10%. So often you need other steps in the dietary management of hypercholesterolemia or having high levels of bad cholesterol and reducing your LDL cholesterol. And that includes, of course, medications as we alluded to earlier.
* cut for time: More imformation about soluble and insoluble fibes from Dr. Eckel
“Dietary fiber is the part of the food this is not affected by the digestive process in the body. Only a small amount of fiber is metabolized in the stomach and intestines, the rest is passed through the gastrointestinal tract and makes up a part of the stool. There are two types of dietary fiber, soluble and insoluble. Soluble fiber retains water and turns to gel during digestion.It also slows digestion and nutrient absorption from the stomach and intestines. Soluble fiber is found in food such as oat bran, barley, nuts, seeds, beans, lentils, peas, and some fruits and vegetables. Insoluble fiber appears to speed the passage of foods through the stomach and intestines and adds bulk to the stool. It is found in foods such as wheat bran, vegetables, and whole grains. Fiber is very important to a healthy diet and can be a helpful aid in weight management. One of the best sources of fiber comes from legumes, the group of food containing dried peas and beans.”
Shireen: One of the key things that I also wanna talk about are, um, some of the things around, you know, people will say, well, I can’t, I can’t give up a food. I can’t my sugars. I can’t give up you know, I can’t give up my breads or certain types of foods. What do you, what do you say to someone like that? And on the other side to say, you know, it’s, how do you, I guess, how do you reconcile with someone to say, okay, this, this is something that you can give up, but, here is an alternate that you can do, or what do you, what do you even say to a, a patient like that?
Dr. Eckel: Well, first we need to get the equality of the diet history to understand what the current dietary intake patterns are. We try to modify that one step at a time. So if somebody’s eating only, two servings, a whole grains a day. The next visit, I’d like to see them eating three. So I have the dietician who’s very much on board with my approach to nutritional management to try to work for alternatives. And their cultural considerations are really very important. I mean, the Latino or Hispanic population, the Indian population, uh, even in the south of the country, ultimately dietary patterns can be very, very different than they are on the east coast or even on the west coast.
So we need to consider what people are used to eating and trying to modify it gradually, one step at a time by substituting more heart-healthy choices that are part of an optimal dietary path. It’s important to remind people that having a medium rare steak once in a while, or going to have fast food once a month is not something they need to confess. Ultimately, we can have some foods occasionally and not so much worry about that. It’s the overall dietary pattern we wanna stress, not an individual food or an individual meal.
Shireen: Thank you so much for sharing that, Dr. Eckel. So with that, we are toward the end of the episode. At this point, we would love for listeners to know how they can connect with you. Just learn more about your work, uh, your LinkedIn perhaps, or, um, how they can even look at some of the journal articles that you’ve written. Would you, um, guide us to that?
Dr.Eckel: Well, thank you very much, Shireen. I hope the audience has benefited from our time together today. Well, LinkedIn is one option, but I would prefer an email directly sent to me and that is Robert.email@example.com That’s my academic part.
Shireen: Lovely. Oh, I appreciate that. Before I let you go though, Dr. Eckel, will you list the eight essentials real quick? One more.
Dr. Eckel: So the eight essentials relate to, uh, ultimately your dietary quality, physical activity, sleep and avoiding tobacco, and then managing your blood pressure, your weight, your blood glucose, and your blood cholesterol.
Shireen: And so to our listeners out there, thank you so much for tuning into this episode. The question to you is have you checked your Essential Eights recently? And if you have, Dr. Eckel just listed it out for you. I hope you were listening and you were checking all of those boxes. If you have head over to our podcast episode on social media, so join us on Facebook on Instagram find this podcast post and comment below to tell us. Yep, I have checked my essential eight, so go over there comment. We will continue the conversation there. Again, Dr. Eel, thank you so very much for your time.
Shireen: And thank you everyone for tuning in. Thank you for listening to the Yumlish Podcast. Make sure to follow us on social media at Yumlish_ on Instagram and Twitter and at Yumlish on Facebook and LinkedIn for tips about managing your diabetes and other chronic conditions, and to chat and connect with us about your journey and perspective. You can also visit our website, yumlish.com for more recipes, and advice, and to get involved with all of the exciting opportunities Yumlish has to offer. If you like this week’s show, make sure to subscribe so you can hear more from us every time we post. Thank you again, and we’ll see you next time. Remember, your health always comes first. Stay well.