CholesterolQuestion
0 (0 Likes / 0 Dislikes)
(rhythmic music)
- I was maybe a couple
blocks from my house
and all of a sudden I felt
something that was stopping
me from pedaling.
I was just grabbed.
- I lost all of power in my body.
The next feeling that came over me
was the feeling of impending death.
- I felt like the walls were
closing in a little bit.
At the time, I wasn't
thinking heart attack.
Although that was exactly
what was happening.
- [Narrator] Heart attacks strikes once
every 34 seconds in North America.
And the numbers are rising.
For decades, doctors have
pointed to a prime suspect
in the heart attack
crime wave, cholesterol.
- The higher your cholesterol level,
the higher cardio vascular risk.
- And so I go into the doctor
and he just says, you have
really high cholesterol.
And you have to start
medication right away.
And if you don't, you're gonna
be dead before you're 40.
- [Narrator] But there
are nagging questions.
- 50% of the people who have
a heart attack or a stroke
actually have normal cholesterol levels.
The question is, what
else is going on here?
- If it really is a big deal,
then I'm a ticking time bomb.
- [Narrator] This case is
far from open and shut.
What role does cholesterol really play
in these matters of the heart?
This is a detective story.
A hunt for the causes of
one of our biggest killers.
Heart attack.
It's a hunt that's gone on for decades.
But we have followed some false leads
and overlooked crucial clues.
It's time to take a fresh look
at the heart attack investigation board.
Compile more evidence,
identify new suspects,
and interview the witnesses.
Like Aaron Holm, whose personal
connection to this story
began 20 years ago with an urgent call
from his family doctor.
- They said, it's a big problem
with your blood results.
You have to come in as
soon as you possibly can.
So I'm like, oh wow, okay.
You know, what am I HIV positive?
Like what's the issue?
And so I go into the doctor
and it's a very somber,
serious conversation, he says,
you have really high cholesterol.
If you don't change your
lifestyle or whatever,
you're gonna be dead before you're 40.
And I'm like 21 or 22 years old.
I'm super healthy.
And not quite sure what
any of this stuff means.
- [Narrator] What it meant was
familial hypercholesterolemia.
A genetic tendency for
high levels of cholesterol
in his blood stream.
- I don't have the gene where
my body's able to understand
that it has produced enough cholesterol
and it doesn't need to make more.
And so as a result, it
just keeps making it.
Keeps making all this cholesterol.
I have never met anybody
who has cholesterol levels
as high as I do.
- [Narrator] Aaron went
to a number of specialists
who all said the same thing.
Medicate.
- If you take the medication,
who knows what the long term affects are.
Who knows what the impact on your liver is
over the years, and your
kidneys over the years.
Who knows?
I don't know.
I just did everything else
to manage the situation
except for taking medication.
There's a duality to
the cholesterol issue.
Because you don't feel any problems.
You don't feel sick.
Yet there's a lot of
pressure and fear around it
that make you think that
you really have to keep an eye on things.
- [Narrator] This pressure
and fear is because
most doctors say the higher
the cholesterol numbers,
the higher the risk for a heart attack.
- I really don't know
what's going on inside.
It's like all I know is that
there's this abstract number
which is supposed to have some
kind of meaning and value.
And if it really is a big deal,
then I'm a ticking time bomb.
- [Narrator] If Aaron has questions,
he might find answers here.
This is where everything we
now believe about cholesterol
and heart disease got started.
Like many good detective stories,
this one begins in a
small New England town.
Framingham, Massachusetts.
- Around 1940, 1950,
very little was known about the causes
of cardiovascular diseases
or how to treat it.
So the government wanted
to try to figure out
what were the things
that caused heart attacks
and better predict who would
develop cardiovascular disease.
- [Narrator] The study began
with over 5000 volunteers
who were monitored and
tested every two years.
And the numbers grew.
For Ray Reva, it's been a family affair.
- my father was one of the originals
and over the years, expanded the program
and now my sons are in it.
And hopefully someday my
grandchildren will be in it too.
- [Narrator] A decade
after the study started,
data began to appear on the participants
who were experiencing heart problems.
There were certain things
they had in common.
- Cigarette smoking, high blood pressure,
obesity, so these are things
that we take for granted now.
But before the initiation in Framingham,
it wasn't really known.
- [Narrator] There was one
new suspect in this gang
of villains that was a
complete mystery to most of us.
Cholesterol.
It's normally a good guy.
Our bodies manufacture it
and it's in every cell,
essential for making sex
hormones and vitamin D.
But Framinghamers with heart disease
tended to have a lot
in their blood stream.
And plaque deposits in their
arteries were loaded with it.
One theory said these deposits
might be clogging things up
and causing heart attacks.
So was this good guy really
a dangerous serial killer?
And where was all this
cholesterol coming from
in the first place?
For a long time, we
believed it only came from
places like this.
- Welcome to the Heart Attack Grill.
The most fattening place on earth.
- [Narrator] The Heart
Attack Grill in Las Vegas
says their food is to die for.
- It's bad for you.
But it's fun trying it.
- [Narrator] Patrons wear hospital gowns.
And the wait staff dress as nurses.
- You're not gonna see any salads
because we don't have any lettuce.
- [Narrator] Anyone who
weighs over 350 pounds
eats for free.
And for anyone leaving
food on their plate,
there are consequences.
But what about the consequences of downing
all the cholesterol in their
famous quadruple bypass burger?
Is it really heading
straight to the heart?
Researchers have long been suspicious
about a connection between
diet and heart disease.
In the early 1900s, a Russian scientist
fed eggs to rabbits.
And he discovered that their arteries
quickly built up plaque
deposits full of cholesterol.
In the 1950s, American
scientist Ancel Keys
heard that people in
Italy lived long lives
and had low rates of heart disease.
He wanted to find out why.
He launched a study comparing
the diets of people in Europe,
Asia, and North America
that revealed a suspicious connection
between heart disease
rates and dinner plates.
His conclusion, some diets were harboring
dangerous fugitives.
Countries with higher
rates of heart disease
not only had higher blood cholesterol,
but also a higher consumption
of dietary cholesterol
and saturated fat.
In the decades after Keys' study,
ads like these started to appear.
- What would you recommend?
- Something delicious, light,
and low in cholesterol.
- [Narrator] Slender
actors living the good life
creating the impression
that removing cholesterol
could make our favorite foods
healthy again.
According to this man,
the case files held
some surprising secrets.
- It's a huge disconnect that
most people don't understand
between the cholesterol in your diet
and the cholesterol in your blood.
Girls, who wants chicken scratch?
- [Narrator] When Dr. Christopher Gardner
is not looking after the
diet of his chickens,
he's investigating the influence of diet
on human health.
- It seems like you eat
cholesterol in your diet,
it ends up in your blood,
there's plaques full of cholesterol
impeding the flow of blood.
It must be a direction connection.
But they've done studies with eggs
and they gave people an egg a day,
three eggs a day, six eggs a day,
and they measured their blood cholesterol
throughout the study, never changed.
And eggs are full of cholesterol.
And they've been trashed
for years and vilified
because of all the cholesterol in the egg.
The other big sources are shellfish.
But in fact, your body adapts quite easily
to the cholesterol that
you get in your diet
from something like an egg or a shellfish.
- [Narrator] But look
for cholesterol in food,
and another familiar
villain is rarely far away.
- Here's what happens.
Cholesterol is only in animal foods.
And animal products typically come
with saturated fat in them.
And saturated fat has also
been vilified for years.
And so there was a public health movement
to get cholesterol and saturated fat
out of our diets.
- [Narrator] Saturated fat raises LDL.
The so called bad cholesterol
that can collect in our arteries
and cause heart disease.
But it also increases HDL,
the good cholesterol that
helps clear out the bad.
Ultimately, the war on
fat was undiscriminating
and had unintended consequences.
- It also led to an obesity epidemic
and you can't pin the obesity epidemic
on any one thing.
But there's certainly a
lot of us that believe
that it was the interpretation
of the food pyramid
that led to a trend of more calories.
- [Narrator] The food
pyramid was a campaign
launched in the 90s to
promote healthy diet choices.
The base was grains.
Then fruit and vegetables.
Then dairy, then meat and fish.
And then sugar.
And virtually no fat.
- And what we really got out of it
was a lot of bread.
A lot of processed refined bread.
Because grains were low in fat.
And so that has confounded everything that
the original investigators had intended.
Because vegetables are low fat.
Beans and legumes are low fat.
Fruits are low fat.
And that's not what people were picking.
- [Narrator] What people were
picking were highly processed
foods and refined carbohydrates.
Which actually lower HDL,
the good cholesterol.
They also led to obesity, diabetes,
and high blood pressure.
All heart risk factors.
The low fact diet
experiment had big problems.
And Gardner argues we could be missing
an even bigger picture.
- There's 20 other things
that affect heart disease.
But at the end of the day,
there's a lot of people
with high LDL cholesterol
who don't get heart attack.
And there are plenty of people
who have low LDL cholesterol
who get a heart attack.
There seems to be a misunderstanding
about the proportion of
risk that's attributable
just to LDL cholesterol.
It's really been exaggerated.
I think it's partly driven by the fact
there's a lot of money there.
- [Narrator] Money.
In any investigation, you
always follow the money.
In this case, Gardner's
referring to the billions
spent annually on statins.
First introduced in 1987,
statins currently lower
LDL cholesterol numbers
in the blood more effectively
than diet or any other method.
They have become the biggest selling
and most popular prescription
drugs of all time.
And the sales continue to rise.
- After the most recent
statin guidelines came out
from the American Heart Association,
it was estimated that if these
guidelines were followed,
about a billion people worldwide
would be prescribed statins.
- [Narrator] Could a
billion users be wrong?
Are statins the answer to
the cholesterol question?
The prime suspect in the
heart disease crime wave
continues to be cholesterol.
Aaron Holm's doctor told him
his cholesterol numbers
were dangerously high.
He was in his 20s then.
And he's been on the run ever since.
The doctor told me at one point,
if you don't take medication,
if you don't get your
cholesterol level down,
you're gonna be dead before you're 40.
And so I never allowed myself
to think beyond that age.
And as that age became closer,
and as I had kids,
I started to realize that
actually I really wanted
to be around.
And I really wanted them to have a father.
And when I turned 40, it
was like the epic moment
where the sun comes out
and the choir sings.
And you're like, holy cow, I didn't die.
And so all of a sudden
the future was this thing that opened up
and I'd never thought about it.
I might develop a relationship
with a doctor now.
And just be candid and say look,
I don't wanna take medication.
And I'd like it if you
were to come up with some
alternate ideas around how it is
that I can manage this,
if it is in fact a problem.
I just don't know how
many doctors are able
to have that conversation.
'Cause most of them can't seem to get past
the notion of medicating.
- [Narrator] The medication
Aaron wants to avoid
is a group of drugs called statins.
A tall order because statins are the most
widely prescribed drugs in the world.
He's come to see Dr. Beth Abramson,
the author of Heart Health for Canadians.
- And in terms of risk
for future heart disease,
we're just gonna go over a few of these.
You've never been told you
have high blood pressure?
- [Aaron] Nope.
- No history of diabetes?
- No.
- You a smoker?
- No.
- Shake your hand.
- [Aaron] Thank you.
- All right, so you're feeling well.
But you're a young dad and wanna make sure
your future risk is okay, is that right?
Okay.
Well, I'm gonna have a listen
to your heart and lungs.
When we calculate someone's
future risk for heart disease,
cholesterol is an important aspect.
It's not the only aspect.
A patient is not just a cholesterol value.
So if you have diabetes, you're smoking,
your blood pressure is high,
your risk is going to be even higher.
So every one of my patients that I see
who's come into the hospital
with a heart attack,
or who's been diagnosed
with coronary heart disease,
or who's had a stroke,
I know their chances of dying
or having a recurrent
heart attack are lower
on the classic cholesterol
pills called statins.
- [Narrator] There are
a number of statins.
- Getting the goal is important.
Especially if you have high cholesterol.
Plus any of these risk factors.
- [Narrator] Many of us have seen the ads.
Some aimed at our deep
fear of heart attacks.
Or playing into our
desire for easy solutions
by equating a pill with a
vigorous swim or bike ride.
Statins all work by inhibiting
cholesterol production
in the liver.
In randomized trials,
they are the only cholesterol medications
that have been shown to reduce risk
in people with known heart disease.
But debate has been raging.
Have they been over prescribed?
Dr. Barbara Roberts is the author of
the Truth About Statins.
- Almost without exception,
these trials have been paid
for by the pharmaceutical
company that makes the
statin being studied.
And we know that industry sponsored trials
are four times more likely to
be report a positive result
than non industry sponsored trials.
- [Narrator] As for statin's role
in preventing heart disease.
- If you're giving statins to healthy
but high risk people,
healthy people who haven't
had a heart attack,
the absolute risk reduction
in three of the biggest
primary prevention trials,
in men, is on the order of 1.5%.
Even the most fervent statin apologist
has to admit that anywhere from 60 to 80%
of cardiac events are
not prevented by statins.
So if you had a vaccine, for example,
that didn't prevent 60 to
80% of the cases of flu,
how many people do you think
would use that vaccine?
Very few.
- Take a deep breath in.
- [Narrator] Dr. Abramson
believes that statins
do have a role in primary prevention.
Along with other therapies.
- In patients who have
not yet had a problem,
there is a role for
cholesterol lowering pills.
It doesn't mean we put
in the drinking water.
And it doesn't mean that we use the statin
for a substitute for
making lifestyle changes.
- [Narrator] But would there be any harm
in taking statins just in case?
- This gets us to the whole area
which gets me upset.
And that is that the benefits
have been vastly exaggerated
and the dangers have
been vastly underplayed.
The only group where we
know there is some benefit
is middle aged men who've
had a heart attack.
In fact, in the older age group,
higher levels of cholesterol
correlate with better survival.
Elevations in cholesterol
are only a risk factor
until about middle age.
- [Narrator] Dr. Roberts
says there are also questions
about benefits for women.
- I think that the reason
that women have less benefit
from statins if they
have any benefit at all,
which is questionable,
is because LDL is not a
significant risk factor in women.
The other thing is that women are more apt
to have side effects to statins.
We know that women are more
apt to have muscle pain.
And muscle damage.
Women are more apt to develop diabetes
as a result of statins.
There are multiple side effects
and I really worry about the long term
effect on the nervous system
of treating people and getting
their cholesterols down
to very low levels.
- [Narrator] Most doctors argue
the benefits of reducing risk
outweigh the potential side
effects in both men and women.
- There are a small
percentage of my patients
who will have a side effect on
a statin or cholesterol pill.
That often will manifest as
either an ache in the muscles
or an abnormality in the blood test.
Either the liver function
or the muscle enzyme.
The good news is is that
this is usually reversible.
This can be reversed by
stopping the medication.
Initially, when these drugs were tested,
they were tested mainly men.
There was less data in
women over the years.
But we have in this day and age
conclusive and good
clinical trial evidence
that statins save lives in women.
- [Narrator] In a surprise move,
the American Heart
Association recently abandoned
the cholesterol targets
that help doctors decide who
should get a prescription.
What's even more surprising
is the effect this could
have on statin use.
- After the most recent
statin guidelines came out
from the American Heart Association,
it was estimated that if these
guidelines were followed,
about a billion people worldwide
would be prescribed statins.
- What the American
guidelines have said is
we've tried lifestyle, it hasn't worked.
So we're gonna move ahead in society
and use a drug that's effective.
It is true that statins will save lives
if I prescribe them to more Canadians.
I still wanna use the art of medicine,
take a history, make sure your risk
really is high enough to be on the statin.
And make sure you're making
the right lifestyle changes as well.
- [Narrator] While statins
remain the drug of choice
for lowering cholesterol
and reducing risk,
there is still something puzzling
about a significant number
of heart attack victims.
- What's interesting is
that 50% of people who have
a heart attack or a stroke
actually have normal cholesterol levels.
- [Narrator] Cardiologist Paul Ridker
has a tennis partner who
fits this description.
A few months ago, the
man nearly dropped dead
from a heart attack while jogging.
He was fit, healthy, and
had lower than average
cholesterol levels.
- [Paul] The question has been,
what in addition to cholesterol
is driving this process?
- [Narrator] In the 1990s
Ridker and his colleagues began to follow
a trail of clues that
began at the site of the
heart attack itself.
It's where scientists had
noticed signs of inflammation.
- Inflammation broadly is the mechanism
by which our bodies fight
off foreign substances,
fight off infection, help
us to deal with cancer,
you can't live without inflammation.
The problem is, for some of us,
that inflammation can be overactive.
And we ask the question, is it possible
that in currently healthy individuals,
was there a measure of
inflammation in the blood
that we could get a grasp on
that would tell us five,
10, 15 years down the road,
a-ha, this person is at high risk
because they have a
pro-inflammatory response.
Just like they might be at risk
if they had a high cholesterol level.
- [Narrator] So Ridker tested blood
from heart attack victims.
He was looking for
markers of inflammation.
If he found one of these markers,
he would have evidence that
inflammation was at the scene.
- It turned out something
called C-reactive protein
or CRP was a very powerful
predictor of your risk
of having a future heart attack.
Even if your cholesterol levels were low.
And it was light bulb going off for us.
- [Narrator] But could
stopping inflammation
actually help stop heart attacks?
Ridker looked for answers by
investigating another mystery.
An unexpected statin side effect.
- Investigators around
the world had noticed
that the statin drugs, these
cholesterol lowering drugs,
also lower the risk of stroke.
And that's a little bit unusual
because stroke is not really driven by
high levels of LDL cholesterol.
But it is driven by inflammation.
And we already knew the statins
lower the risk of stroke.
And so we said, why would that be?
- [Narrator] Ridker looked closer
and discovered that
statins also lowered CRP.
So he asked a provocative question.
Could statins stop heart
attacks in seemingly
healthy people with low cholesterol,
but with signs of inflammation
in the form of CRP?
- We randomized almost 18,000
patients around the globe.
Their cholesterol levels
were very low or baseline.
But they all had high levels of CRP
and we therefore, they
were all at high risk
for having a future
heart attack or stroke.
Well, fast forward several years later,
there's a 50% reduction in heart attacks,
50% reduction in stroke.
And about a 20% reduction
in all cause mortality
by giving a cholesterol lowering drug
that we know lowers inflammation.
To people who don't have high cholesterol.
That was a real breakthrough.
Statin drugs, the drugs that we think of
as cholesterol lowering drugs,
are sort of twofers.
They both lower cholesterol
and they lower inflammation.
And many of us now think of the reason
is these drugs are so effective
is because they have beneficial effects
on both of these systems
which seem to interact with each other
to really deal with
aggressive heart disease.
- [Narrator] The study was
funded by the same company
that makes the statin, Crestor.
And the results and methods
were not without controversy.
So Ridker is going one step
further to prove his theory.
He's testing an anti-inflammatory drug
that's been used for years to treat
another ailment entirely, arthritis.
- And it was noticed many years ago
that people who took
this drug for arthritis
seemed to have lower
rates of heart disease.
We're giving the drug to patients
who had a prior heart attack.
They don't have arthritis.
And we're asking the question,
if we lower the inflammation,
will we in turn get fewer heart
attacks and fewer strokes?
It's a very exciting study.
And it's up and running right
now in the US and Canada.
- [Narrator] Billions have
been spent in research labs
around the world to try
to stop the heart attack
crime wave.
But meanwhile in a tiny
isolated village in Italy,
a medical mystery, a
mutation that not only stops
but reverse heart disease.
- I thought it was a
one in a million chance.
And I was absolutely
stunned when it worked.
- [Narrator] HDL, Italian style.
Italy is in the top 10
when it comes to longevity.
The mediterranean diet has
been given much of the credit.
But here in the north,
in the tiny resort town
of Limone Sul Garda,
there is another secret that
has been extending lives.
It's a secret that was
discovered by Dr. Cesare Sirtori.
When he encountered a patient
who broke all the rules.
A man with high LDL or bad cholesterol,
and virtually no HDL,
the good cholesterol.
- Usually, males have a
HDL cholesterol about 40.
He had seven.
So it is something a little
bit weird scientifically.
Something unexpected.
- [Narrator] Put simply,
he should've been dead,
yet his arteries were clear.
Just what was keeping him healthy?
Dr. Sirtori and his team
spent years looking for an
answer until another clue.
There's a protein component in HDL
that helps it do its job
clearing out bad cholesterol.
Tests on the man and his family
revealed that it had
been genetically mutated.
On a hunch, Sirtori went
searching for more clues
in the patient's home town.
Limone.
- So in Limone in 1981,
we screened the whole population.
And my major concern, I say,
suppose I go there and draw
a 1000 samples of blood,
I don't find anyone.
Miss Elive
is a historical figure for me.
Because she was the first diagnosed
gene carrier in Limone.
And after 30 so years,
every time I see her,
it's sort of shock for me.
- [Narrator] Dr. Sirtori
screened 1000 people
and found 40 with the
same genetic mutation.
And no heart disease.
Even though they had very low HDL.
- This is a very peculiar exception.
Of course, one could ask
questions, say why here?
Why here?
It was never found anywhere else.
- [Narrator] Sirtori
suspected that the largely
Mediterranean diet eaten
in this isolated community
was not enough to answer his question.
A search through the church records
traced the mutation back to
a couple who married in 1750.
And their descendants were long lived.
- So it's a single mating couple.
This part of the lake was isolated.
There was no involve from
Milan or other towns nearby.
Which meant this community is inbred.
People married to each
other, cousins and so forth.
And this is why the
mutation was saved so well
over the centuries.
- Salute.
- [Narrator] Could the
mysterious HDL these people
have preserved for generations
help unlock the secrets
of the good cholesterol?
When it comes to heart health,
the more HDL, the better.
But these people were
healthy and astonishingly,
they had almost no HDL in their systems.
Sirotri had a theory.
Somehow the mutated gene
had supercharged the HDL.
Making it work more efficiently.
Human trials with a synthetic
version of the mutant HDL
were conducted at the Cleveland Clinic
by Dr. Steve Nissen, who
was skeptical at first.
- I thought it was really interesting.
But you know, good scientists
are always skeptical.
And so you know, we
don't drink the Kool-aid.
And I must tell you, I thought the chances
that this confusion in
six weeks is all we did
was treat these people for six weeks.
And they could reverse
the build up of plaque
that had taken place over many decades.
I thought it was a one
in a million chance.
And I was absolutely
stunned when it worked.
- [Narrator] The results were so promising
that pharmaceutical giant Pfizer
bought the rights to develop the treatment
for a reported 1.3 billion dollars.
They did more research.
But ultimately, never released a drug.
A number of companies are now
working on the Limone story
in hopes of cracking the code.
But treatments won't be on
the shelves any time soon.
- The problem was, we had
no way to make this stuff.
And we still are struggling to find a way
to make enough of it
to turn it into a drug
that can be used for
large numbers of people.
- [Narrator] The story is further evidence
that the heart disease crime wave
is more than a cholesterol numbers game.
Genetic abnormalities can
give heart protection to some.
While causing a cholesterol
crisis in others.
Our fear of cholesterol in the diet
is not all it's cracked up to be.
Some people on statins
continue to have heart attacks.
And many heart attack victims
have normal cholesterol levels.
Back at the Cleveland Clinic.
Dr. Stanley Hazen has
been searching for answers
beyond cholesterol.
- We can treat a person's
cholesterol level
down to a level of what they
were when they were a baby.
And we still know that
there's a significant
additional residual risk.
So what are the other
pathways that are involved
beyond cholesterol?
- [Narrator] Hazen's
search beyond cholesterol
led to a study of blood collected
from heart disease victims.
- We began with studies
of thousands of subjects
and said, what can we measure
in the blood of humans
that tracks with cardiac risk?
- [Narrator] They did find
a compound called TMAO.
But where it came from was a mystery.
- At finding that there was a hint
that it may have come from bacteria,
it really was a kind of eureka
moment and very exciting.
- [Narrator] What excited
Hazen was that it seemed
to show up first in the gut.
When gut bacteria feed on what we eat,
waste byproducts are excreted
that show up in the blood stream.
Hazen thought this explained
where the TMAO was coming from.
But it took some testing
to figure out what we ate
to make it.
The answer was carnitine.
It's found in the same stuff they serve
back at the Heart Attack Grill.
Red meat.
It's long been associated
with heart disease.
But researchers suspected
that cholesterol and fat
couldn't fully explain the connection.
Sensing new answers, Hazen investigated.
- [Stanley] We had a feeding
study that involved literally
making steaks.
And so we bought a George Foreman grill.
And started making small steaks
and then would do timed
feeding studies to look at
following ingestion of a steak,
which is a rich source of carnitine,
did certain metabolites
appear in the blood stream.
- [Narrator] That certain
metabolite did indeed appear.
High levels of TMAO.
- That was the really exciting moment
where we saw that bacteria
are having a huge impact
on things that appear in our blood stream.
That compound will
accelerate heart disease.
It both enhances cholesterol
that get deposited
into cells of the artery wall,
and it also inhibits the
removal of cholesterol.
So the net effect is more build up.
- [Narrator] Carnitine is
found naturally in most meats.
Amounts are low in
chicken, higher in lamb.
And kangaroo meat has 50 times
more carnitine than beef.
But carnitine has become a
popular body building supplement
and can even be found in energy drinks.
- We're very concerned
about the very widespread
use of carnitine as a supplement.
That's because carnitine is
carnitine to the bacteria,
it doesn't really matter
whether it comes in an
energy drink or a piece of steak.
And we've now measured this in thousands
and thousands of patients.
If you ingest excess carnitine, long term,
you might be at increased risk
for developing heart disease.
Decreasing the amount
of red meat in the diet
is probably a healthy thing to do.
A lot of epidemiology data
had already argued for this.
This is just reinforcing it now
with some data that
explain yet another reason
to cut the red meat from the diet.
So I don't eat red meat on a
daily basis like I used to.
I now eat it less frequently.
But I haven't eliminated it.
- [Narrator] Aaron Holm
doesn't eat a lot of red meat
or drink energy supplements.
So he is likely safe from TMAO.
He's fit, at least on the outside.
But his cholesterol levels have
always been off the charts.
- From a population perspective,
your cholesterol is higher than
the majority of the population,
I'd say over 90% of the population.
- [Narrator] Aaron's about to find out
what shape he's in on the inside.
When Aaron was diagnosed with
high cholesterol in his 20s,
doctors warned him, he could
be dead by the age of 40
if he didn't take statins.
He decided not to.
Betting that a healthy lifestyle
would trump the high cholesterol.
Now that he's 40, he's come
to see Dr. Beth Abramson
to find out if his bet paid off.
- When we first sent you to the lab,
your bad cholesterol or
LDL cholesterol was so high
we couldn't calculate it.
So we went back and remeasured it.
And your LDL cholesterol is 8.44.
It's actually quite high.
So your total cholesterol is 12.32.
So from a population perspective,
it's higher than the
majority of the population.
I'd say over 90% of the population.
If I saw junk in your arteries,
a build of atherosclerosis
or plaque already,
I'd say you're on the road to potentially
having a stroke or heart attack.
But the good news is,
I did this measurement
of your carotid arteries,
and we don't see plaque.
So that's good.
We are seeing a thickening.
And let's talk about what that means.
In Aaron's particular case,
we saw a thickening in one
of the parts of the arteries
that we think is a
measurement for future risk.
It tells us that his
arteries have been affected
and damaged to some degree.
Likely from high
cholesterol over the years.
- The lady at the restaurant
yelled, 200 pizzas,
are you crazy?
- If Aaron goes on a
cholesterol medication,
on a statin, which I'm hoping he will.
His thickness in his
arteries may not go down.
It might.
But we don't have a lot
of clinical trial data
to look at that.
But being put on the
medication will reduce his risk
whether or not that
measure changes or not.
So your body has been
exposed to high cholesterol
for 20 years now.
That's different than
someone who just started off
with a borderline elevation
in cholesterol at 45 or 46.
My personal and professional
opinion would be
that I would favor
medical therapy for you.
- What would the medical therapy be?
- [Beth] I'd put you on a statin.
I'd start you on a low dose
'cause you're not keen on
the constant of medication.
Commonest side effect is no side effect.
- But if you haven't had a heart attack,
they're not really able
to say with certainty
that they reduce the risk.
- I think there may be
a benefit risk ratio
where the benefit
outweighs any risk for you.
So I don't prescribe
cholesterol medications to all
patients walking in this office.
But there are certain patients
who've not yet had a heart attack
that we think are at higher risk.
And the idea is to try and prevent that.
Now the catch 22 is, we never
see what we're preventing.
- [Narrator] Aaron has always known
his cholesterol numbers are high.
But his thickening arteries
is new information.
And a new additional risk factor.
- I was asking myself on the way in.
I was like, what if they
find that inside my body,
it's having an impact?
What'll I do?
And I said the only thing
they can really recommend
is statin.
They don't have any other
tools in the chest, really.
There's not much else that they can do.
So if they recommend it, what'll I do?
So I thought about it a lot,
and I thought, well, if
there is something going on
in my body that's an
indication that the cholesterol
is having a negative impact,
I'll probably go on the meds.
And then monitor and see how low
a dosage I can maintain
have the result that I want.
- [Narrator] After years avoiding statins,
Aaron's decision to give them
a try is a bit of a surprise.
But while he's taking care of
all the risk factors he can,
you just can't run from your own genes.
Or can you?
- We have made tremendous progress
in our understanding of
cardiovascular disease.
And in fact, at the population level,
we do know that risk factors
such as high blood pressure
and high cholesterol can
explain up to 90% of the risk.
However, when it comes
to specific patients,
it's very difficult to predict
which patient will go
on to have the disease,
and which one won't.
- [Narrator] Dr. Guillaume
Pare and the team at the
population health research
institute in Hamilton
are on a hunt for genetic clues
to unlock the remaining
mysteries of heart disease.
They're using a forensic facility
that rivals any CSI lab.
Blood and DNA from hundreds
of thousands of people
around the world stored in a deep freeze
all managed by Dr. Matt McQueen.
- There are about three million samples.
They are from over 70 countries.
Five continents, and five major
ethnic groups in the world.
These aren't just samples being stored.
They are samples are well characterized
so we know all the
details, person's illness,
what the outcome of the study was.
What treatment they received.
A whole variety of other information.
- [Narrator] Investigators
can now reopen the oldest
case files of all.
Human DNA.
Genetic variations can have a major affect
on how we respond to risk
factors like cholesterol,
inflammation, and blood pressure.
They may also have answers
for a high risk group
that's increasing rapidly.
People with diabetes.
One in nine adults now have it.
And their heart risk is three times higher
than a person without the disease.
Specialist Dr. Hertzel
Gerstein is on the team.
- So there's no broad agreement on why
there is an increased risk
of cardiovascular disease
in people with diabetes.
But there are number of candidates.
And we at PHRI here are
trying to investigate
and better characterize
what these candidates are
and better understand and
hopefully solve the puzzle
of why people with
diabetes are at higher risk
for cardiovascular as well
other series health problems.
- [Narrator] They are
now running a DNA study
of 5500 diabetic patients.
Searching for genes involved
in their heart disease risk.
Once identified, the
genes will become targets
for new treatments.
It's a big job.
- One of the greatest challenge
we're facing right now
in human genetics is
really a big data problem.
Right now, we can
sequence all human genomes
in three days.
And generate a considerable
amount of data.
But what do we do with this data?
How do we identify these mutations
that could be important
to health and disease
within the tens of millions of mutations
that were identified?
It's a bit like trying to find
a needle in the hay stack.
We have identified about 50
genes involved in heart disease.
But we estimate that over
1000 genes are involved.
Once we have identified
all of these genes,
we will be in a great position to identify
individuals and families at risk
and perhaps to better treat them as well.
- [Narrator] Genes and aging
are heart disease risk factors
we can't control so far.
But there is one risk
factor we can work on
that will have a positive
affect on all the others.
- We know that for
people who exercise daily
throughout midlife and to later life,
these people very rarely get
heart attacks and strokes.
Our own research has shown
that diet and exercise
contribute to keeping inflammation down.
They contribute to keeping
blood pressure down.
They contribute to
keeping cholesterol down.
And all of these are contributing
in a very important way.
- [Narrator] Who hasn't
been told by their doctor
to get out and exercise?
But how many of us
actually take that advice?
- You think about how hard it is
to get people to be more active.
What could we do?
So we proposed a challenge
and in class, somebody came
up with a seven minute app
that has you do 12 30 second
workouts with 10 second breaks.
And it's got push ups,
and squats and lunges.
And triceps.
- [Woman] This is favorite, to do lunges.
- Let's make this the
social norm in the class.
That it is acceptable to get up and move
because honestly, as health professionals,
it should be unacceptable
to sit still for two hours
and listen to me rant on and on.
- It's not enough for us
to sit at our hospital
and talk about this.
We need to get into the community and say
the biology of this disease tells us
that if I can get people in
their teens and 20s and 30s
in to exercising regularly,
we just won't have as much diabetes.
We won't have as much heart disease.
We'll have fewer need for the
angioplasties in surgeries
that my cardiovascular colleagues
are so good at providing.
It's a win win if we do it right.
- [Narrator] The search
to catch new culprits
in the heart disease crime wave continues.
Cholesterol is implicated.
But there are other
suspects still at large.
Each one a menace on its own.
And together, this gang can be lethal.
Be on the look out.
(slow mysterious music)