Hi Everyone,

I hope you enjoy this week’s newsletter. I really appreciate feedback, so please reply to this email if you have any comments, critiques or questions you’d like addressed in a subsequent issue.

Happy Holidays,

Steve

Newsletter 13 Contents

• What does middle school have to do with heart disease?
• Treating upper respiratory infections
• Preventing and treating aphthous ulcers

What does middle school have to do with heart disease?

Most people I know found their middle school years to be a strange and awkward time. Our bodies grow rapidly and not always in proportion, and we become much more self-aware and self-conscious of our outward appearance. I was no exception. I was vertically challenged but precocious in my ability to grow facial hair. I had rosy cheeks and a widow’s peak. I completed my look with a gold chain, gel in my hair, and Tommy Hilfiger cologne that I got from a friend. What I didn’t know at the time is that, in addition to all of these amusing changes in appearance, something more insidious happens inside our bodies at that time.

We begin to accumulate lipid and cholesterol in the walls of our coronary arteries.

Actually, this process begins at birth, but it doesn’t progress in earnest until our teen years.

By the time we’re thirty years old, nearly all of us have advanced plaque in our coronary arteries.

It looks like this:

Source

That is a cross section of a coronary artery containing a cholesterol laden plaque.

It’s not nice to look at or think about, but it’s very likely that if you’re reading this, you have something like this inside your arteries — as do I. As we age, this process progresses. To a degree, the process of lipid deposition within the arterial wall is physiologic, which means, a little bit of this can be normal and unproblematic. But, by the time we’re in our thirties, we develop pathologic lesions that can be problematic.

For one in eight Americans every year, one of these plaques will rupture. If the rupture occludes a large coronary artery, the victim may die a sudden and unexpected death.

Here’s the big question - what is driving this process and how do we stop it?

In my two most recent articles “No Time to Die From an MI” and “What is LDL-Cholesterol?” – I explain how lipids including fatty-acids and cholesterol are trafficked in the blood within lipoproteins.

Cholesterol gets into the wall of an artery as a passenger in a lipoprotein.

It’s thought that the most common lipoprotein that brings cholesterol into the artery wall is low-density lipoprotein (LDL).

This is why your doctor cares so much about your LDL-cholesterol levels.

But, there’s a somewhat counter-intuitive fact about this whole situation: it’s not always the LDL-cholesterol level that matters most.

What do you think is more important: the total amount of LDL-cholesterol in your blood stream, or the number of LDL particles in your blood stream?

You probably see where I’m headed. It’s the particle number that matters most. The particle number is more predictive of coronary artery disease and MI than is the LDL-cholesterol alone.

You can think of this in terms of traffic on the highway. What matters more: the number of people on the highway, or the number of vehicles?

You could imagine a few hundred people driving a stretch of road, but they’re all in just a few buses. What are the chances that a few buses will cause a traffic jam or crash into one another? It’s low.

Consider the alternative - everyone is driving in their own car. The more cars you have, the greater the chance of an accident. This may not be a perfect analogy on the biochemical or pathophysiologic level, but it gives you a way of visualizing the concept I’m trying to explain.

In any event, the only reason we care about this distinction between LDL-cholesterol (LDL-C) and LDL-particles (LDL-P) is that for a significant number of people, these are discordant.

You can’t always count on the idea that a low LDL-C means low LDL-P.

It’s possible to have low LDL-cholesterol but a high number of LDL particles. This is called discordance. In fact, this is the most dangerous situation. People with discordant LDL-C and LDL-P are likely to have atherogenic dyslipidemia and are likely to be under-diagnosed and under-treated. Furthermore, one of the most common causes of discordant LDL-C and LDL-P is metabolic dysregulation (e.g., type 2 diabetes, metabolic syndrome, obesity, etc.) which poses additional risks for developing atherosclerosis.

The way to detect such discordance is to order a lipid panel and an ApoB.

You’re going to get a standard lipid panel from your doctor each year, and this will reveal your LDL-cholesterol concentration (it should be a direct LDL-cholesterol, if it’s calculated, you can’t count on its accuracy). But, most doctors still don’t order a test to count your LDL particles. Blame who you’d like; they’re just following guidelines.

In addition to a standard lipid panel, it’s possible to measure an LDL-particle count in a few different ways. Probably the simplest and best in most scenarios is to measure ApoB. This is a regular blood test that can be done for $5-10. My patients currently pay $5.30.

What is ApoB?

Each LDL-particle has a single ApoB protein on its surface. We can measure ApoB concentration in the blood and therefore we can count the number of LDL particles — they exist in a 1:1 ratio. There’s one ApoB per LDL-particle.

This is currently the best known measure for estimating your risk of cardiovascular disease with respect to blood cholesterol.

Experts believe, and I am convinced by my own appraisal of the evidence, that many people would benefit by minimizing ApoB through dietary and pharmacologic interventions as early in life as possible.

Of course, ApoB is not the only thing we should measure, and it’s not the only thing we should attend to, but it’s an essential component of accurate risk stratification that deserves detailed attention.

In my next article, I’ll share the evidence that supports the safety and efficacy of lowering ApoB to decelerate atherosclerosis.

One example that we’ll discuss comes from patients with an interesting condition called hypobetalipoproteinemia. This is a genetic condition in which the afflicted have a near zero rate of atherosclerosis. Due to genetic mutations, these people have only one-half or one-quarter of the ApoB concentration of an average person without the condition. These are fascinating cases that indicate the beneficial effects of lower ApoB.

Cold Protocol

Conflict of Interest Disclosure: If you use one of the Amazon Affiliate links below to make a purchase, there’s a chance I could get a tiny commission.

It’s the time of year when people are more prone to infections of the nose and throat. Most of these symptoms are caused by viruses - coronaviruses, rhinoviruses, respiratory syncytial virus (RSV), parainfluenza, adenovirus, and more. Most of the time, these viruses cause mild symptoms, but they can still be uncomfortable. Through a combination of reading the medical literature and personal experience, I’ve developed the following list of treatments that I’ve found very helpful to minimize the symptoms of viral upper respiratory infections and pharyngitis:

Decrease Duration of Symptoms

• Zinc Acetate Lozenges
• Use these as directed on the bottle at the first sign of any upper respiratory symptom.

For Pharyngitis (sore throat)

• Salt water gargle - 1 tsp. of salt to 8 oz. of water every hour
• Tea with lemon and Manuka Honey twice daily
• Benzocaine lozenges (e.g. Cepacol) as directed on the package to treat pain

For Rhinitis and Sinus Congestion

• Flonase - use as directed
• Proper nose blowing technique
• Sinus drainage technique
• Pseudoephedrine - The effective formulation is kept behind the counter at the pharmacy. You don’t need a prescription, but you have to ask the pharmacist to get it for you. It’s much more effective than the phenylephrine that you can find on the counter. It’s reasonably safe, but there are some considerations with this medication. Read my cold protocol article for more details on that. Use as directed on the package.

Aphthous Ulcers (Canker Sores)

I’ve battled with aphthous ulcers for a long time. I can go months without having one, but then sometimes I’ll have one after another. Once you’ve had these things for more than a week or two at a time, it gets pretty annoying. I’ve had some that were so severe that my lymph nodes were swollen and tender for days. In the grand scheme, not a big deal, but it’s a nice quality of life improvement to be able to prevent and treat these. I know I’m not alone, so I thought I’d share my protocol.

Prevention

If I bite my cheek or tongue, or feel any sort of sore area developing in my mouth, I make sure to double down on my dental hygiene. This means brushing and flossing thoroughly twice daily (which I try to do anyway) and also using an alcohol based mouth wash with menthol. I like regular Listerine.

I’ve recently switched to a “gum health” toothpaste that contains glycine. I don’t know if there’s any data to support this, but it seems to be helping. I’ve been using Coco Floss for about six months now and it’s a complete game changer.

Treatment

Once you’ve gotten an aphthous ulcer, the best treatment I’m aware of are these sore covers. They’re like tiny little gelatinous tabs that you can press over the sore. If you can get it to stick in place (which can be a trick), they make a seal over the sore. The pain is virtually eliminated and healing time is accelerated by days. In essence, it’s a cure. The only problem is that sometimes due to the location or size of the sore, you can’t get the covers to stay in place. Even when they don’t work perfectly, they’re still helpful.

To temporarily alleviate pain, a Kanka Brush is awesome. These contain benzocaine which is a topical anesthetic — you’ll get 20-30 minutes of complete relief. There are other brands that make topical benzocaine treatments as well, but I’ve personally tested this one and it works well.

Next, you can try using these glycine lozenges by OraSwift. I’ve used these a few times. They provide a 50% or so pain reduction and may decrease healing time.

Keep your mouth super clean and use mouth wash with menthol 2-3 times daily which seems to help with healing, halts progression, and diminishes the pain.

-Steve

Other articles that might interest you:

• No Time to Die From an MI
• What is LDL-Cholesterol?
• Case Report: The Metabolic Effects of Losing 30 Pounds
• Get the Blood Work You Want Without a Doctor’s Order
• Create a Helpful Food Environment