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Decoding the Risk: What New Cholesterol Guidelines Mean for Women with Dr. Harpreet Tsui · Clearly Hormonal

• 0:01
  Dr. Komal Patil-Sisodia: Welcome to Clearly Hormonal, the podcast where we stop googling our symptoms at midnight and actually start understanding what's going on in our bodies.
• 0:09
  Dr. Komal Patil-Sisodia: I'm Dr.
• 0:10
  Dr. Komal Patil-Sisodia: Komal Patil-Sisodia, an endocrinologist, internist, obesity medicine specialist, and a Menopause Society certified practitioner, which is really just a whole lot of words to say hormones are kind of my jam.
• 0:21
  Dr. Komal Patil-Sisodia: I've spent 17 years watching women try to navigate their hormonal health without ever having been taught the language for what's happening in their own bodies, and then meeting clinicians who want nothing more than to help them figure it out, but are up against 10-minute appointments and a system that just wasn't built for it.
• 0:37
  Dr. Komal Patil-Sisodia: This podcast is my answer to that gap.
• 0:40
  Dr. Komal Patil-Sisodia: We'll cover menopause, metabolism, hormones, and everything in between with real evidence, not trends, and without the overwhelm.
• 0:48
  Dr. Komal Patil-Sisodia: A quick disclaimer.
• 0:49
  Dr. Komal Patil-Sisodia: I'm a physician, but this is education, not personalized medical advice.
• 0:53
  Dr. Komal Patil-Sisodia: Take what resonates and discuss it with your own healthcare team.
• 0:56
  Dr. Komal Patil-Sisodia: Now, let's get into it and talk about what's clearly hormonal and what's not.
• 1:03
  Dr. Komal Patil-Sisodia: Hi, everyone.
• 1:03
  Dr. Komal Patil-Sisodia: Welcome back to the podcast.
• 1:05
  Dr. Komal Patil-Sisodia: Today, we are going to talk about the new American Heart Association cholesterol guidelines, and I'm so excited to have Dr.
• 1:14
  Dr. Komal Patil-Sisodia: Harpreet Tsui here with me.
• 1:15
  Dr. Komal Patil-Sisodia: She is an internist, obesity medicine specialist, and the founder of Coronado Health, which is a direct primary care in Nevada.
• 1:21
  Dr. Komal Patil-Sisodia: And I've had her on the podcast before, Dr.
• 1:25
  Dr. Komal Patil-Sisodia: Tsui and I share a background of both being Southeast Asian.
• 1:29
  Dr. Komal Patil-Sisodia: We've had a life story that just is really in parallel, even though we grew up on different sides of the country.
• 1:34
  Dr. Komal Patil-Sisodia: We wanted to come together and discuss this, especially both being Southeast Asian women who have a significant history of heart disease in our families.
• 1:42
  Dr. Komal Patil-Sisodia: We wanted to make sure that we were bringing you all of the new information from these new guidelines and what it means for you.
• 1:49
  Dr. Komal Patil-Sisodia: So welcome, Dr.
• 1:50
  Dr. Komal Patil-Sisodia: Tsui.
• 1:50
  Dr. Komal Patil-Sisodia: Thank you so much for being here.
• 1:51
  Dr. Harpreet Tsui: Thank you so much for having me.
• 1:54
  Dr. Komal Patil-Sisodia: It's always fun when I get to talk to you and compare all of these thoughts that we have about Southeast Asian heart health, about women's heart health, and, you and I both know that women's The number-one cause of death in women is still heart disease, We talk a lot about menopause and midlife changes, but what people don't realize is that this is really where your cardiovascular risk starts to go up.
• 2:17
  Dr. Komal Patil-Sisodia: I saw it in my mom.
• 2:18
  Dr. Komal Patil-Sisodia: I'm seeing it in me.
• 2:19
  Dr. Komal Patil-Sisodia: I think you've had a similar experience as well.
• 2:22
  Dr. Komal Patil-Sisodia: Absolutely.
• 2:22
  Dr. Komal Patil-Sisodia: Saw it in my
• 2:23
  Dr. Harpreet Tsui: mom
• 2:23
  Dr. Komal Patil-Sisodia: We're gonna talk through why the old,"Your numbers look fine," doesn't cut it anymore.
• 2:29
  Dr. Komal Patil-Sisodia: We're gonna go through the different updates, and we're gonna talk about what women need to talk to their doctors about, because they're still not having those conversations.
• 2:36
  Dr. Komal Patil-Sisodia: And what happened to my mom happened in the late'90s, and here we are almost 30 years later and really not much has changed.
• 2:43
  Dr. Komal Patil-Sisodia: So before we get started, Dr.
• 2:45
  Dr. Komal Patil-Sisodia: Tsui, I'm gonna call you Harpreet because you're gonna call me- Please Komal, and that's just much easier.
• 2:48
  Dr. Komal Patil-Sisodia: Tell us about your practice and how you got into direct primary care, internal medicine, and obesity medicine.
• 2:55
  Dr. Harpreet Tsui: Yeah.
• 2:55
  Dr. Harpreet Tsui: So I opened my office four years ago, and part of the reason was because I had so many female patients who felt like they didn't have enough time.
• 3:03
  Dr. Harpreet Tsui: 15 minutes is not enough time to discuss all of the issues.
• 3:06
  Dr. Harpreet Tsui: I loved internal medicine from when I was, like, in medical school really,'cause internal medicine's one of those things that's very detective work-y, it's oh, someone comes in with a problem, figure it out.
• 3:15
  Dr. Harpreet Tsui: Nancy Drew
• 3:16
  Dr. Komal Patil-Sisodia: it.
• 3:16
  Dr. Komal Patil-Sisodia: CSI, Yeah.
• 3:17
  Dr. Harpreet Tsui: I love doing that.
• 3:18
  Dr. Harpreet Tsui: And so for me, in the last four years, I feel like as we are getting older, we're seeing our mothers get older, we're seeing our patients get older.
• 3:27
  Dr. Harpreet Tsui: You and I are in specialties where we have probably had patients our entire career, and so now we've got these women who are young and are midlife to older.
• 3:35
  Dr. Harpreet Tsui: And I started to say"Okay, you know what?
• 3:37
  Dr. Harpreet Tsui: I need to take my primary care practice and build it out into women's health and obesity medicine." And as someone who struggled with obesity myself, and I have my own weight loss journey I understand what that's as a patient and also as a doctor.
• 3:49
  Dr. Harpreet Tsui: And so I have built this practice where it's, women's health, primary care, obesity medicine, but as it's kind of everything.
• 3:55
  Dr. Harpreet Tsui: It's all together.
• 3:56
  Dr. Komal Patil-Sisodia: Yeah.
• 3:57
  Dr. Harpreet Tsui: Yeah.
• 3:57
  Dr. Harpreet Tsui: We've just been able to build a practice where I can continue to enjoy practicing medicine, and I have fun every single day.
• 4:04
  Dr. Komal Patil-Sisodia: I love that, and your patients are so lucky to have you.
• 4:07
  Dr. Komal Patil-Sisodia: And like I said before, you and I have very similar stories.
• 4:10
  Dr. Komal Patil-Sisodia: I have my own weight loss journey.
• 4:12
  Dr. Komal Patil-Sisodia: I have my own heart health journey with both my mom and me, and what I'm trying to tell my sisters they're at risk for, whether they wanna listen to me or not.
• 4:19
  Dr. Komal Patil-Sisodia: This is me calling you out, girls.
• 4:21
  Dr. Komal Patil-Sisodia: Go get your stuff checked.
• 4:22
  Dr. Harpreet Tsui: If my sister's listening, she knows.
• 4:24
  Dr. Komal Patil-Sisodia: Yeah.
• 4:24
  Dr. Harpreet Tsui: I did call her out on it.
• 4:26
  Dr. Harpreet Tsui: See?
• 4:26
  Dr. Harpreet Tsui: And I took her to our labs after everything went by...
• 4:28
  Dr. Harpreet Tsui: that happened to my mom.
• 4:30
  Dr. Komal Patil-Sisodia: Yeah.
• 4:31
  Dr. Harpreet Tsui: I was like,"Hey girl, when's the last time you did labs?" She's"I don't know, four years ago." I'm like nope, gotta do'em now."
• 4:36
  Dr. Komal Patil-Sisodia: yep.
• 4:36
  Dr. Komal Patil-Sisodia: Now is your sister in medicine?
• 4:38
  Dr. Harpreet Tsui: She's a pharmacist.
• 4:38
  Dr. Komal Patil-Sisodia: My sisters are in healthcare too.
• 4:40
  Dr. Komal Patil-Sisodia: One's a therapist and one is a dentist.
• 4:42
  Dr. Komal Patil-Sisodia: So let's dive into it, when you and I were residents, we had the set of guidelines that were there, and they actually had pretty clear targets, so I knew, felt like we knew what we were doing, and then all of a sudden the guidelines changed and it was, like, so nebulous.
• 4:56
  Dr. Komal Patil-Sisodia: It was like, treat to, you don't have to treat to this target, but we want to see this type of a change.
• 5:02
  Dr. Komal Patil-Sisodia: And I was like,"Can you just give me something a little-" Yes.
• 5:06
  Dr. Komal Patil-Sisodia: So I know that you had some frustration with that as well.
• 5:09
  Dr. Komal Patil-Sisodia: I think all physicians really.
• 5:11
  Dr. Komal Patil-Sisodia: And so what's really nice, in my opinion, about these guidelines is they've gotten much more clear, correct?
• 5:17
  Dr. Harpreet Tsui: I think the issue is when we were in training, we would look at patients coming in with a stroke or a heart attack and then realize their LDL was not necessarily that high, But then in residency, the guideline was 100 for the LDL, okay, let's do aggressive.
• 5:32
  Dr. Harpreet Tsui: And then, yeah, when we were practicing in early practice, it was like, yeah, just bring it down if you feel like bringing it down.
• 5:39
  Dr. Harpreet Tsui: I'm like, I don't know what that means.
• 5:42
  Dr. Harpreet Tsui: And you and I were also in our earlier careers fighting the misinformation about statins.
• 5:47
  Dr. Harpreet Tsui: Correct.
• 5:48
  Dr. Harpreet Tsui: So then it just made it really hard.
• 5:50
  Dr. Komal Patil-Sisodia: And there's a lot of people who are, very anti-statin, and I have a hard time with that because they have data showing that they reduce the risk of heart disease and stroke, And in some of the studies with high enough doses of the right statin, we've actually even seen some plaque regression.
• 6:05
  Dr. Komal Patil-Sisodia: So yeah, and that's the part that I think people don't understand because they're like I want to do it naturally." And one of my biggest gripes is that, yes, we can do things naturally up to a point, but we can't out-natural our genetics, You can't out-exercise, out-lifestyle, out-hormone what your genetics are going to be.
• 6:23
  Dr. Komal Patil-Sisodia: And so at some point, that's why all of the science and medicine exists, so that we can give you options to get over that.
• 6:29
  Dr. Harpreet Tsui: And one thing I always like to remind patients is I say, the statins lower your cholesterol, and they also prevent secondary- heart attacks and strokes, but they are also anti-inflammatory.
• 6:39
  Dr. Harpreet Tsui: And so if I can decrease the inflammation in the arteries- then we're going to decrease the amount of all the inflammatory markers that are gonna make up a plaque,'cause a plaque isn't just cholesterol just sitting there hanging out.
• 6:50
  Dr. Harpreet Tsui: And a lot of patients don't know that, and I go like there's not a plant sterol in the world or like a large amount of omega-3 that's going to give you that anti-inflammatory effect.
• 7:00
  Dr. Komal Patil-Sisodia: Yeah.
• 7:01
  Dr. Komal Patil-Sisodia: I agree, and I think, unfortunately statins have gotten a bad rap.
• 7:04
  Dr. Komal Patil-Sisodia: I think there's just a lot of mistrust in medicine in general, Yes.
• 7:07
  Dr. Harpreet Tsui: Yes.
• 7:08
  Dr. Komal Patil-Sisodia: Because of what happened decades prior
• 7:10
  Dr. Harpreet Tsui: yes, and I will also start this by saying I prescribed a statin, and I literally stared at it for two weeks.
• 7:16
  Dr. Harpreet Tsui: I got the bottle And I put it on my nightstand, and every night I would look at it, and I'd be like,"Tonight's the night." And I'd be like,"Nah, tomorrow night's the night." Even as doctors we-
• 7:26
  Dr. Komal Patil-Sisodia: I've heard that
• 7:26
  Dr. Harpreet Tsui: we also sometimes are scared of taking medications based off of things that we have heard that we know are not true.
• 7:33
  Dr. Komal Patil-Sisodia: And it's very easy to be susceptible to all of those things and go down those rabbit holes.
• 7:38
  Dr. Komal Patil-Sisodia: So I have psoriatic arthritis, and, I had started a probiotic.
• 7:42
  Dr. Komal Patil-Sisodia: A lot of people will tell you probiotics, they won't do anything, this, that, and the other.
• 7:46
  Dr. Komal Patil-Sisodia: But I actually did feel an improvement in my joint inflammation, But I was taking the one from Costco, Align.
• 7:52
  Dr. Komal Patil-Sisodia: Great.
• 7:52
  Dr. Komal Patil-Sisodia: It's the one my GI friends recommend.
• 7:54
  Dr. Komal Patil-Sisodia: That one or Florastor.
• 7:56
  Dr. Komal Patil-Sisodia: But then you start seeing all of these new ones that are coming out that claim they're gonna help you with your glucose metabolism, or they have some proprietary blend and blah, blah, blah, blah, blah.
• 8:04
  Dr. Komal Patil-Sisodia: And so I went down that train, and I ended up on one that made my psoriasis worse.
• 8:10
  Dr. Komal Patil-Sisodia: Everything flared, my joints hurt, and I was like what happened?
• 8:13
  Dr. Komal Patil-Sisodia: And you don't understand the impact that these things can have.
• 8:16
  Dr. Komal Patil-Sisodia: And even as a physician, sometimes you are susceptible to those things, Yes.
• 8:19
  Dr. Komal Patil-Sisodia: So I don't want anybody listening to this podcast to think that we're sitting here telling people,"Oh my gosh,""You can't do this, you can't do that, listen to me because, I know best and I've never gone down a rabbit hole." That's bullshit.
• 8:31
  Dr. Komal Patil-Sisodia: We've all go down rabbit holes, We all have these very human reactions to learning that there's something happening in our bodies that we feel blame, shame, guilt over, even though it's just our genetics and It wasn't ever gonna be our fault.
• 8:45
  Dr. Harpreet Tsui: And do you feel like it is even more rampant in South Asian culture?
• 8:49
  Dr. Harpreet Tsui: Because from a young age, we have our dadis and our nanis are like,"I'm not gonna take anything." My masi's I don't need anything." And in fact, even my own mother, even though on her side of the family, we all have elevated HDLs.
• 9:02
  Dr. Harpreet Tsui: Doctors were like,"Yeah, it doesn't matter that your LDL's slightly high and you're diabetic.
• 9:06
  Dr. Harpreet Tsui: Your HDL's in the 90s we don't actually know what to do with that.
• 9:09
  Dr. Harpreet Tsui: Fine." And my mom would just be like no.
• 9:11
  Dr. Harpreet Tsui: I'm not gonna take anything." And culturally, I feel like that plays a giant role- 100% on the way that we think, even though we're doctors.
• 9:18
  Dr. Komal Patil-Sisodia: I think a lot of it in immigrant families comes from the fact that everybody worked so hard to survive when they got here.
• 9:25
  Dr. Komal Patil-Sisodia: And,"I can do it on my own.
• 9:26
  Dr. Komal Patil-Sisodia: I can do it without help.
• 9:27
  Dr. Komal Patil-Sisodia: I'm gonna push through.
• 9:28
  Dr. Komal Patil-Sisodia: I don't wanna be a burden to anybody.
• 9:30
  Dr. Komal Patil-Sisodia: I don't want to admit that I need help." And that invades every part of your life really.
• 9:35
  Dr. Komal Patil-Sisodia: And so I think you and I both being Southeast Asian daughters who are leading families we grew up with this culture around us where it was like,"No, you have to show up perfectly for all of these things, and asking for help is a sign of weakness," and I have had that moment where I'm, sitting there looking at my arthritis medication and being like if I just out-lifestyled it, it could be better." And then I sit back and I'm like,"What would you tell your patient?" Look in the mirror and pretend you're a patient and say what you would tell your patient, and then, put on your big girl pants and take the pills,
• 10:06
  Dr. Harpreet Tsui: that is my life when it came to bariatric surgery, when it came to GLPs.
• 10:09
  Dr. Harpreet Tsui: I would be like I don't really need it anymore," and I'm like,"What am I sitting there telling my patient to do?"
• 10:15
  Dr. Komal Patil-Sisodia: And it was the same thing for a GLP-1 for me.
• 10:17
  Dr. Komal Patil-Sisodia: I did all these lifestyle things.
• 10:19
  Dr. Komal Patil-Sisodia: Everything looked great, and despite losing weight on my own, My genetics kicked in.
• 10:24
  Dr. Komal Patil-Sisodia: Both my parents have diabetes.
• 10:26
  Dr. Komal Patil-Sisodia: And when you lose 40 pounds and then your A1C starts to go up, you're like,"Wait, what the hell?
• 10:31
  Dr. Komal Patil-Sisodia: What did I do all of that for?"
• 10:35
  Dr. Harpreet Tsui: You become very menopausal and your LDL goes up 100 points overnight.
• 10:39
  Dr. Harpreet Tsui: You're like- does that happen?
• 10:41
  Dr. Harpreet Tsui: I've lost 100 pounds and my LDL is like,'No, we're not doing this anymore.'"
• 10:45
  Dr. Komal Patil-Sisodia: Yeah.
• 10:46
  Dr. Komal Patil-Sisodia: Exactly right.
• 10:47
  Dr. Harpreet Tsui: Why I texted you and said we have to have this conversation.
• 10:50
  Dr. Komal Patil-Sisodia: Because we've both lived it, and I think a lot of times people will look at their doctors and say,"Oh they must have it all together," i've had patients say to me, and this is really interesting, Because I'm pretty open about this stuff with my patients, because I feel like it's important for them to see that we are not infallible, that we are humans just like them.
• 11:08
  Dr. Komal Patil-Sisodia: We have the same genetic and health issues that could pop up.
• 11:11
  Dr. Komal Patil-Sisodia: So I'm very open about talking about how when my husband had his heart attack, I went to therapy, because that's another thing that gets stigmatized in our culture.
• 11:19
  Dr. Komal Patil-Sisodia: Is"Oh my gosh, you must be crazy if you need therapy," right?
• 11:22
  Dr. Komal Patil-Sisodia: But no, I needed coping mechanisms to get over the stress.
• 11:25
  Dr. Komal Patil-Sisodia: Or if I'm seeing my A1C go up and it's not in a diabetic range, what am I gonna do to prevent it instead of Getting diagnosed with diabetes.
• 11:33
  Dr. Komal Patil-Sisodia: Yes.
• 11:33
  Dr. Komal Patil-Sisodia: And so these are all conversations that we have to have, and we have to help people understand that, your genetics are the hand of cards that you're dealt.
• 11:42
  Dr. Komal Patil-Sisodia: You could have a shitty hand, and unfortunately, sometimes that requires medication.
• 11:46
  Dr. Komal Patil-Sisodia: It always requires lifestyle and foundational stuff, but how do we make people feel like it's not their fault?
• 11:52
  Dr. Komal Patil-Sisodia: That is the part that I still struggle with on a day-to-day basis.
• 11:56
  Dr. Harpreet Tsui: Yeah, and I do think it comes down to genetics, and I think one of the things that I really liked about the new lipid guidelines is that they made it so concrete-
• 12:03
  Dr. Komal Patil-Sisodia: Yes
• 12:04
  Dr. Harpreet Tsui: so we can now tell our patients"Yeah, both of your parents have high cholesterol.
• 12:07
  Dr. Harpreet Tsui: Your grandparents had heart attacks.
• 12:09
  Dr. Harpreet Tsui: You've got all of this ASCVD risk in your family." This is not your fault.
• 12:13
  Dr. Komal Patil-Sisodia: Yes.
• 12:14
  Dr. Komal Patil-Sisodia: So let's go through what the key updates are.
• 12:16
  Dr. Komal Patil-Sisodia: The first one is that risk-based treatment replaces how we used to chase numbers.
• 12:21
  Dr. Komal Patil-Sisodia: So let's talk a little bit about that.
• 12:23
  Dr. Harpreet Tsui: Okay.
• 12:23
  Dr. Harpreet Tsui: So when we look at it, it was just always here's your LDL, and then I'm only gonna look at the LDL when we were in training, so your LDL's 140.
• 12:31
  Dr. Harpreet Tsui: Here's a statin.
• 12:32
  Dr. Harpreet Tsui: Have a nice day.
• 12:34
  Dr. Harpreet Tsui: But now I feel like we've built in the calculators, like the new PREVENT ASCVD calculator, plus/minus HDL, plus/minus triglycerides, plus/minus family history, ethnicity.
• 12:44
  Dr. Harpreet Tsui: The PREVENT ASCVD calculator even looks at your ZIP code, which I thought was really interesting as well.
• 12:50
  Dr. Komal Patil-Sisodia: Thought that was fascinating, but it makes sense, because it's their attempt to put social determinants of health in there.
• 12:55
  Dr. Harpreet Tsui: Yeah.
• 12:56
  Dr. Harpreet Tsui: And I feel like now we're getting just such a round picture, which is what we were trying to do when patients were coming into our office.
• 13:02
  Dr. Harpreet Tsui: If I sent a patient to you and I was like,"Oh, Komal, LDL's 285, and now I don't know what to do," or I get the hospital follow-up patient who had a stent placed, and now they're looking at that.
• 13:14
  Dr. Harpreet Tsui: Now we can look at more than just oh, the LDL is high.
• 13:17
  Dr. Harpreet Tsui: I'm not gonna chase that number.
• 13:18
  Dr. Harpreet Tsui: I gotta look at everything.
• 13:19
  Dr. Harpreet Tsui: Exactly.
• 13:20
  Dr. Harpreet Tsui: Which is similar to what we do for ourselves.
• 13:22
  Dr. Komal Patil-Sisodia: Oh, 100%.
• 13:23
  Dr. Komal Patil-Sisodia: It's what we try and do for our patients, for ourselves, and make sure that we're, looking at the whole picture, and I think there's a lot of desire for that out in the community, And some of these phrases are interesting to me, like, when people are like,"I just wanna get to the root cause," or,"I want to a holistic picture." I think, in theory, we're all saying the same thing.
• 13:42
  Dr. Komal Patil-Sisodia: Yeah.
• 13:42
  Dr. Komal Patil-Sisodia: But the way that we are going about it is a little bit different, and I think the distrust towards medicine is oh, medicine is not trying to get to the root cause.
• 13:51
  Dr. Komal Patil-Sisodia: What do you do when the root cause is your genetics?
• 13:54
  Dr. Harpreet Tsui: Yeah.
• 13:55
  Dr. Harpreet Tsui: You really have to sit down and have a serious conversation.
• 13:57
  Dr. Harpreet Tsui: I had to have such a serious conversation with myself.
• 14:01
  Dr. Harpreet Tsui: And I was quick to tell my husband he needed cholesterol meds when he needed it, because- Yeah that's my husband, yeah.
• 14:06
  Dr. Harpreet Tsui: I'm treating him like a patient.
• 14:08
  Dr. Harpreet Tsui: But when it came to me, I was like,"Ooh, wow." Yeah.
• 14:12
  Dr. Harpreet Tsui: "You need to have a real serious conversation about what's happening in your body." And look at myself as a whole picture.
• 14:18
  Dr. Komal Patil-Sisodia: Do as I say, not as I do.
• 14:20
  Dr. Komal Patil-Sisodia: It's so much easier to do that, so yes, it is It's definitely a challenge, and definitely something that we wanna do, but I do the fact that we are not number chasing at this point, and I think we've recognized that when we look at the risk that people are going through with their heart health picture, we want to look, based on what you're saying, this PREVENT ASCVD calculator is looking at how your risk is in a time period closer to now, and then 30 years down the line, so it's 10-year and 30-year risk of what is going to potentially happen to you, and based on that, you also pick when you treat and when you intervene and when you just watch and try and do lifestyle stuff, which is different, because before it was just based on a single point in time.
• 15:04
  Dr. Harpreet Tsui: Yeah, and let me ask you, as an endocrinologist who sees adults who are, like, 18 up are you seeing more elevated LDLs in your patients in their 20s or early 30s?
• 15:14
  Dr. Komal Patil-Sisodia: My perspective's a little skewed, because I see diabetes, and with diabetes, people who are struggling with diabetes have already metabolic disease that's happening, so they're gonna be more predisposed to having higher LDLs, especially if their diabetes is not controlled.
• 15:28
  Dr. Komal Patil-Sisodia: So I feel like my conversation's a little bit different, but I am seeing more overweight and obesity in the general population.
• 15:35
  Dr. Komal Patil-Sisodia: We know that from that perspective.
• 15:37
  Dr. Komal Patil-Sisodia: And obesity and overweight are linked to more cardiometabolic dysfunction, so I think as a result of that, I see more elevated LDLs.
• 15:46
  Dr. Komal Patil-Sisodia: I also think that the food in our country is not the healthiest, we have a lot of packaged, processed foods that people lean on rather than...
• 15:54
  Dr. Komal Patil-Sisodia: And this is not a organic, non-organic, GMO, non-GMO conversation.
• 15:59
  Dr. Komal Patil-Sisodia: This is just purely processed versus cooking regularly at home, doesn't have to be all the expensive grocery store stuff, but just the difference in the food quality like that, I think really contributes to our risk to some degree.
• 16:11
  Dr. Komal Patil-Sisodia: Now we are looking at that lifetime risk, 10 years.
• 16:14
  Dr. Komal Patil-Sisodia: How do you think that this is impacting your younger midlife women, this is something that I'm just starting to pay attention to, and I see women who in their 20s and 30s have totally normal cholesterol panels, And this happened to me.
• 16:28
  Dr. Komal Patil-Sisodia: My estrogen levels started declining in perimenopause, and my lipoprotein little a, which runs in my family because that's what caused my mom's heart disease, totally normal before, is now elevated, and I didn't do anything different.
• 16:40
  Dr. Komal Patil-Sisodia: If anything, my lifestyle and my foundational habits got better.
• 16:44
  Dr. Komal Patil-Sisodia: How are you talking to your patients about that?
• 16:46
  Dr. Harpreet Tsui: I just share my story with patients.
• 16:49
  Dr. Harpreet Tsui: I was very shocked to find out that the women on my mom's side of the family started perimenopause symptoms in 43, 44.
• 16:55
  Dr. Harpreet Tsui: And so for me, I had been walking around literally with my mom's lipid panel.
• 16:59
  Dr. Harpreet Tsui: Low LDL and I would joke with my husband.
• 17:02
  Dr. Harpreet Tsui: I'd be like,"Oh, my LDL's 82.
• 17:03
  Dr. Harpreet Tsui: It's so good." And not that it...
• 17:05
  Dr. Harpreet Tsui: it could've been better, but a high HDL, low LDL, lipoprotein little totally nor- And then I go through peri- start perimenopause.
• 17:13
  Dr. Harpreet Tsui: My estrogen starts to drop.
• 17:14
  Dr. Harpreet Tsui: My LDL literally went from 77 to 177.
• 17:18
  Dr. Harpreet Tsui: My HDL still stayed high.
• 17:20
  Dr. Harpreet Tsui: My apoprotein B was elevated.
• 17:22
  Dr. Harpreet Tsui: My LP little a was fine, but my dad had heart disease in his 50s, so all the women on their side of that family.
• 17:28
  Dr. Harpreet Tsui: And then my mom, who recently just passed from a heart attack, had this, we're starting to find out that in their 70s, her older sisters also had heart disease, which we thought was weight-related so similar to you, where I was like,"Wait a minute.
• 17:41
  Dr. Harpreet Tsui: I've done all the things." My diet is cleaner today than it was five years ago, and now I've got this elevated LDL.
• 17:47
  Dr. Harpreet Tsui: And so I have the conversation with my patients, especially my midlife women.
• 17:52
  Dr. Harpreet Tsui: I say,"If I'm gonna do hormone testing on you, if I'm gonna do full labs on you, let me do an advanced cardiac lipid panel." And I know that the guidelines have now changed that we should do LP little a, at least once in their life.
• 18:04
  Dr. Harpreet Tsui: I have always been an LP little a once a year kind of girl.
• 18:07
  Dr. Harpreet Tsui: I'll be like,"I don't wanna just go all these years and be like it's fine forever.'" And I find that I am having the conversation about cholesterol-lowering, lipid-lowering medications in the adjunctive space of perimenopause and menopause.
• 18:22
  Dr. Komal Patil-Sisodia: Yes.
• 18:23
  Dr. Komal Patil-Sisodia: Same.
• 18:24
  Dr. Harpreet Tsui: Because it is all going together.
• 18:26
  Dr. Komal Patil-Sisodia: And it's interesting because I also think based on our genetics, we're very different in certain ways, like different ethnicities.
• 18:34
  Dr. Komal Patil-Sisodia: I have a patient of mine, Caucasian female, who came in and her cholesterol more than doubled when she hit perimenopause, she was like,"I don't know how I feel about statins yet." And I was like,"We have to consider it at some point.
• 18:45
  Dr. Komal Patil-Sisodia: Your triglycerides are in a range where it's still safe for me to start you on hormone therapy, but we're gonna repeat your lipids in a month, and if everything is still high, then we're gonna have to talk about doing a statin," and it was interesting, her lipids came down almost like they were maybe 20 points above her baseline compared to before.
• 19:06
  Dr. Komal Patil-Sisodia: But then in Southeast Asian women when I do that, I don't see that same drop, so there's some-
• 19:12
  Dr. Harpreet Tsui: I
• 19:12
  Dr. Komal Patil-Sisodia: didn't get that drop Yeah, n- neither did I.
• 19:14
  Dr. Komal Patil-Sisodia: I did initially slightly, and then it went away.
• 19:16
  Dr. Komal Patil-Sisodia: So yeah, I was like,"Oh look, it dropped a little." And then I was like,"Wait, no.
• 19:21
  Dr. Komal Patil-Sisodia: It's not doing what I want it to do.
• 19:23
  Dr. Komal Patil-Sisodia: Damn it."
• 19:23
  Dr. Harpreet Tsui: Crush up the Crestor straight into my coronary arteries.
• 19:26
  Dr. Harpreet Tsui: Let's just do that.
• 19:27
  Dr. Komal Patil-Sisodia: Honestly, if that's what's gonna prevent my potential heart attack down the line, yes please, I think it's important to understand that.
• 19:35
  Dr. Komal Patil-Sisodia: And yes, while we want things to work, they don't always work the way that we want them to, yeah.
• 19:39
  Dr. Komal Patil-Sisodia: And then at that point you have to consider something else, so I told this patient whose lipids almost came down to normal, I was like,"We're gonna check again in three months and just make sure they're not rebounding," because there are studies that show when you start women on hormone therapy, you'll see an initial decrease in all of the cholesterol markers, but then six months, some people rebound, and it goes-
• 20:01
  Dr. Harpreet Tsui: we know why
• 20:02
  Dr. Komal Patil-Sisodia: And it's interesting because the transdermal estradiol doesn't work as well as the oral estradiol for lowering the cholesterol numbers.
• 20:09
  Dr. Komal Patil-Sisodia: But people are scared to take the oral estradiol even though it's a really good drug because of that slightly increased clot risk, and obviously, if you have a BMI over 30 and you are concerned about blood clot risk- Transdermal estradiol is safer, but if you can't tolerate it, oral estradiol is fine, and you just have to be very careful about monitoring, and so I think what we have to do is really talk people through what their options are, but then also really push for this continued monitoring, like you're saying.
• 20:38
  Dr. Komal Patil-Sisodia: And, I'd had the lipoprotein little A done once, and I hit 44, and I told my primary, I was like,"I just have a bad feeling." And she's"But it was fine." And I was like,"I just have a bad feeling.
• 20:48
  Dr. Komal Patil-Sisodia: Can you please check it?" And she was so great.
• 20:50
  Dr. Komal Patil-Sisodia: She was like,"Sure." And then it came back, and she's"Oh, holy crap.""What do we do now?" And this was, like, three years ago, so yes, before these guidelines came out.
• 20:59
  Dr. Komal Patil-Sisodia: So I'm very happy to see lipoprotein little A and apolipoprotein B get called out as separate independent cardiac risk factors.
• 21:08
  Dr. Komal Patil-Sisodia: Because your lipid panel, which is your total cholesterol, your low-density lipoprotein, your high-density lipoprotein, which are the LDL and HDL- Yeah bad and good cholesterol, and then your triglycerides, those can all look stone-cold normal, and you can still have elevations in either ApoB or lipoprotein little A that are gonna increase your risk for heart disease, so now that it's actually there in the guidelines, it makes me so happy because we can actually do right by patients.
• 21:36
  Dr. Harpreet Tsui: Yeah, and you know the thing that I find quite interesting,'cause we do have, both of us have quite a lot of diabetic patients, is I have seen LDL-Cs that are normal and then elevated ApoBs.
• 21:45
  Dr. Harpreet Tsui: Yep.
• 21:46
  Dr. Harpreet Tsui: But you're not...
• 21:48
  Dr. Harpreet Tsui: I think I started checking ApoB in the last year or so, and only, again, because you do the research and you do the reading, and I was like if I'm doing LP little A let me do ApoB."
• 21:56
  Dr. Komal Patil-Sisodia: Why would we not do both,
• 21:58
  Dr. Harpreet Tsui: imagine how many patients are not getting that tested, and they're diabetic, and they have an increased risk, and now they're also perimenopausal, and they're women.
• 22:07
  Dr. Harpreet Tsui: It's like this trifecta of insulin resistance, and your LDL's normal, and how, I feel like what we ended up doing and you and I probably around the same time, you before I did, is, you started checking insulin levels in your patients, and we'd be like,"I don't know.
• 22:21
  Dr. Harpreet Tsui: Let's just check it." It's high.
• 22:22
  Dr. Harpreet Tsui: Now I'm like, now it's time to do ApoB, so I was really happy that they talk about ApoB in the new guidelines.
• 22:27
  Dr. Komal Patil-Sisodia: Yes, and-
• 22:28
  Dr. Harpreet Tsui: Because mine was high, and I was very surprised.
• 22:31
  Dr. Komal Patil-Sisodia: Yes.
• 22:32
  Dr. Komal Patil-Sisodia: And these are the things that we don't know about.
• 22:34
  Dr. Komal Patil-Sisodia: So for the listeners, apolipoprotein B and lipoprotein little A are genetic cholesterol particles that when they're elevated, they will increase your risk of heart disease, and each one increases risk individually, so that's what we wanna pull together is the traditional panel is not always gonna tell you everything, and you should be having these other levels checked.
• 22:54
  Dr. Komal Patil-Sisodia: And it's interesting the guidelines call out lipoprotein little A for at least once in your lifetime.
• 23:01
  Dr. Komal Patil-Sisodia: I will go as far as to say for women, if you had it checked prior to perimenopause, you need to do it again when you're perimenopausal and when you're post-menopausal, if not on a more regular cadence with your doctor, because I am living proof that it was normal and then it wasn't, yeah.
• 23:16
  Dr. Komal Patil-Sisodia: And a lot of times people will tell you,"Oh y- you only need it that once," and then I don't believe that, and I have proof- in my patients- That it changes.
• 23:24
  Dr. Komal Patil-Sisodia: So it's definitely an interesting piece of the puzzle that's there.
• 23:28
  Dr. Komal Patil-Sisodia: I think the other thing that was really interesting for me were, like the calling out of the specific female risk factors because- the lack of data in women pisses me off, and I know it pisses you off, but just to see that section was like, it was so satisfying.
• 23:45
  Dr. Harpreet Tsui: So satisfying.
• 23:46
  Dr. Harpreet Tsui: I loved it.
• 23:47
  Dr. Komal Patil-Sisodia: Freaking finally, and then I looked at it and I was like,"Oh, shit, I have some of these things."
• 23:52
  Dr. Harpreet Tsui: A slap in the face in a good way.
• 23:55
  Dr. Harpreet Tsui: I was like,"Oh, yes.
• 23:57
  Dr. Harpreet Tsui: Time to look at my diet." Can I clean things up?"
• 23:59
  Dr. Komal Patil-Sisodia: Yeah.
• 23:59
  Dr. Komal Patil-Sisodia: Be a little more
• 24:00
  Dr. Harpreet Tsui: active.
• 24:01
  Dr. Harpreet Tsui: And
• 24:01
  Dr. Komal Patil-Sisodia: And I think we are seeing also in...
• 24:04
  Dr. Komal Patil-Sisodia: one, I think we do a crappy job of diagnosing women with PCOS, I think we are very scared to label young women who are in their teens as having PCOS because we don't want it to- taint the rest of their lives.
• 24:19
  Dr. Komal Patil-Sisodia: And PCOS, for those of you who are listening and don't know, is polycystic ovarian syndrome.
• 24:24
  Dr. Komal Patil-Sisodia: But what PCOS does is it increases your lifetime risk for diabetes, for heart disease, for stroke, for metabolic syndrome, high blood pressure, high cholesterol.
• 24:33
  Dr. Komal Patil-Sisodia: So if you already have that when you're a kid, we have to watch you more closely, and a lot of times women were just told that it only had reproductive implications, meaning it's gonna be harder for you to get pregnant.
• 24:46
  Dr. Komal Patil-Sisodia: But nobody talks about the other pieces that happen after, and I think it becomes very relevant, especially in perimenopause.
• 24:53
  Dr. Komal Patil-Sisodia: So I was happy to see that one called out.
• 24:55
  Dr. Harpreet Tsui: Yes.
• 24:56
  Dr. Komal Patil-Sisodia: You also see a lot of women with diabetes now who had gestational diabetes, and that was another call-out that I really appreciated.
• 25:03
  Dr. Harpreet Tsui: That was another one, which is great because you have that conversation, and I think that something about gestational diabetes has changed, where women are like I had gestational diabetes, but I'm not diabetic now."
• 25:12
  Dr. Komal Patil-Sisodia: Yeah.
• 25:14
  Dr. Harpreet Tsui: Yeah, but you have a risk of developing diabetes.
• 25:16
  Dr. Harpreet Tsui: Have we checked your insulin.
• 25:18
  Dr. Harpreet Tsui: They're a year postpartum.
• 25:19
  Dr. Harpreet Tsui: I'm like,"Oh, still high.
• 25:20
  Dr. Harpreet Tsui: Yes, your A1C dropped and then you're not technically diabetic, but you're walking around again with this insulin resistance." And I love that they finally called that out because it is so important.
• 25:30
  Dr. Komal Patil-Sisodia: It really is, and one of the biggest gaps we see in my clinic and in other spaces is that, women have babies and then they're so busy taking care of their families, they don't have time for self-care.
• 25:43
  Dr. Komal Patil-Sisodia: And the number of women who miss their three-month postpartum glucose tolerance test or testing to see whether they still have insulin resistance, pre-diabetes, diabetes, it's a pretty big number, that is a public health issue.
• 25:57
  Dr. Komal Patil-Sisodia: We are missing the boat on catching women there and then counseling them so that they can be healthy later on.
• 26:03
  Dr. Komal Patil-Sisodia: So I love that this calls that out.
• 26:04
  Dr. Komal Patil-Sisodia: They also called out preeclampsia and gestational hypertension- which I really appreciated.
• 26:09
  Dr. Komal Patil-Sisodia: I had high blood pressure at the end of my pregnancy, so I saw that and I was like,"Blah."
• 26:15
  Dr. Harpreet Tsui: The things that we don't talk about with women when they're pregnant, just like maternal mortality, like post-
• 26:23
  Dr. Komal Patil-Sisodia: postpartum
• 26:24
  Dr. Harpreet Tsui: health.
• 26:24
  Dr. Harpreet Tsui: Your life changes so much.
• 26:25
  Dr. Harpreet Tsui: You have this baby and everyone's"Go home with this baby.
• 26:27
  Dr. Harpreet Tsui: You're gonna be fine." And you're like,"Are you sure?
• 26:30
  Dr. Harpreet Tsui: Okay, fine."
• 26:31
  Dr. Komal Patil-Sisodia: Cause I don't feel like I'm gonna be fine.
• 26:33
  Dr. Harpreet Tsui: And I really feel like it's always a shock to the patient with preeclampsia who comes in years later who's"Wait, now I'm still on blood pressure meds, and you're telling me that my cholesterol is high?" And you're just like,"Yes." And then you start to talk to them about the family history, which is another thing that I don't think is discussed enough.
• 26:48
  Dr. Harpreet Tsui: And then they're like,"Oh yes, the women in my family all developed X, Y, Z at this point in time." And I think also because Komal, I feel like a lot of us will say the women in our family didn't get any of this until they were peri or post-menopausal, until they were older."
• 27:02
  Dr. Komal Patil-Sisodia: It's because they didn't get diagnosed before.
• 27:05
  Dr. Komal Patil-Sisodia: It's called avoidance, friends.
• 27:07
  Dr. Harpreet Tsui: You know what?
• 27:08
  Dr. Harpreet Tsui: I think that we're all sitting around having this happen.
• 27:11
  Dr. Harpreet Tsui: We're having our children later in life, so a lot of us are having- Yes, that is a
• 27:15
  Dr. Komal Patil-Sisodia: big part of it too, I think
• 27:16
  Dr. Harpreet Tsui: yes, in our 30s.
• 27:18
  Dr. Harpreet Tsui: Now we're in our 40s, now we're all learning about perimenopause, and I feel like a lot of us are sitting back going,"Oh, no.
• 27:24
  Dr. Harpreet Tsui: No, mom.
• 27:25
  Dr. Harpreet Tsui: Nope, that was...
• 27:25
  Dr. Harpreet Tsui: You were just not diagnosed'cause you just never went to the doctor."
• 27:29
  Dr. Komal Patil-Sisodia: Correct.
• 27:30
  Dr. Harpreet Tsui: Yeah.
• 27:30
  Dr. Komal Patil-Sisodia: Correct.
• 27:31
  Dr. Komal Patil-Sisodia: So yeah, so it's definitely an interesting shift that we're seeing in these guidelines, and I really hope that it makes women more aware of their bodies.
• 27:40
  Dr. Komal Patil-Sisodia: One of the things that I counsel my patients on is there's no stagnant point for women in our lifetime, if you think about it, from a hormonal perspective, we go from childhood, like that finger painting in kindergarten.
• 27:50
  Dr. Komal Patil-Sisodia: It's probably the most stable I ever was in my life, I don't know about you.
• 27:54
  Dr. Harpreet Tsui: Made a little popsicle house, and that was, like, the best part of my
• 27:58
  Dr. Komal Patil-Sisodia: Life was great, and then you hit puberty, and hormones are changing, and they're changing on a monthly cadence because you have to have menstrual cycles in order to reproduce, and then you hit your reproductive years, and then you hit perimenopause and post-menopause, and all of these things.
• 28:14
  Dr. Komal Patil-Sisodia: It's a constant change, so I recorded an episode with a good friend of mine, Dr.
• 28:20
  Dr. Komal Patil-Sisodia: Sonja Wright.
• 28:20
  Dr. Komal Patil-Sisodia: She is a midlife sex coach.
• 28:22
  Dr. Komal Patil-Sisodia: She's phenomenal.
• 28:23
  Dr. Komal Patil-Sisodia: But I had given a talk, gosh, I wanna say a year and a half ago, maybe two years ago now, And I was pissed about perimenopause, so I called it Mother Nature is Not a Feminist.
• 28:32
  Dr. Komal Patil-Sisodia: I went through all these different changes during perimenopause I think I was still angry about them, so it came through.
• 28:37
  Dr. Komal Patil-Sisodia: And, she's"That was a great talk." She's"But I disagree with you.
• 28:39
  Dr. Komal Patil-Sisodia: I think Mother Nature is the biggest feminist of them all." And I was like,"How do you mean?" And she's we become resilient with all that change, that's our superpower.
• 28:48
  Dr. Komal Patil-Sisodia: We know how to adapt, we know how to change, we know how to do all of those things because we have to go through all of these changes in our lives." And I just thought that was, like, such a beautiful reframe, and honestly, it made me less ragey.
• 28:59
  Dr. Komal Patil-Sisodia: So I was like,"Thank you for changing my life,"'cause I was gonna be really angry for the next however many years over this.
• 29:05
  Dr. Komal Patil-Sisodia: Sometimes you just need wisdom from a woman who's already gone through it to be like no.
• 29:09
  Dr. Komal Patil-Sisodia: It's okay," yeah.
• 29:10
  Dr. Komal Patil-Sisodia: Such a beautiful statement.
• 29:11
  Dr. Komal Patil-Sisodia: So yeah, so we have talked about, okay, so now we're not chasing numbers on the cholesterol panel.
• 29:17
  Dr. Komal Patil-Sisodia: We're looking at your risk overall at 10 years and at 30 years out.
• 29:21
  Dr. Komal Patil-Sisodia: We are recognizing female-specific risk factors like menopause, PCOS, preeclampsia, gestational diabetes.
• 29:29
  Dr. Komal Patil-Sisodia: We are looking at genetic cholesterol particles.
• 29:32
  Dr. Komal Patil-Sisodia: Now, the interesting thing is, and this is where the numbers come in, we're looking at lower LDL targets for higher risk patients.
• 29:39
  Dr. Komal Patil-Sisodia: We should talk about that.
• 29:40
  Dr. Komal Patil-Sisodia: What are your thoughts on that?
• 29:41
  Dr. Harpreet Tsui: I'm here for it because of a couple of things, and I really do have to say I'm here for it from my lived experience, growing up in a South Asian household, I don't know one South Asian person, male or female, in our age group who did not have somebody who had a massive MI, a stroke.
• 29:56
  Dr. Harpreet Tsui: And, like we would joke in our house we would have weddings and, big Punjabi family.
• 30:01
  Dr. Harpreet Tsui: And like my- uncle would, dial up his Novolog.
• 30:04
  Dr. Harpreet Tsui: He'd be like,"I'm gonna have two extra ladoos.
• 30:06
  Dr. Harpreet Tsui: There's paratha in the morning.
• 30:08
  Dr. Harpreet Tsui: I'm just gonna give myself a touch of insulin.
• 30:09
  Dr. Harpreet Tsui: Just so I'll be fine."
• 30:11
  Dr. Komal Patil-Sisodia: Oh, the extra ladoos.
• 30:12
  Dr. Harpreet Tsui: I actually think that the updated guidelines for LDL targets makes it so that if we can decrease LDLs and decrease inflammation, if you're high risk- your LDLs should be below 50, we should target these.
• 30:22
  Dr. Harpreet Tsui: And I went to a lecture pre-pandemic.
• 30:25
  Dr. Harpreet Tsui: At a lecture with a bunch of cardiologists and their partners who did veins, and these vascular doctors were literally saying LDL should be 50 or lower because so many, the population in the US, so many of us will end up with peripheral vascular disease and not just coronary artery disease based off of lipids and LDLs that are 100 or higher.
• 30:47
  Dr. Komal Patil-Sisodia: Yeah.
• 30:47
  Dr. Harpreet Tsui: And I was like when I got out of residency, the target was 100, and 70- if you were being aggressive."
• 30:52
  Dr. Komal Patil-Sisodia: Right.
• 30:52
  Dr. Komal Patil-Sisodia: 70 was the secondary target.
• 30:54
  Dr. Harpreet Tsui: And now we're like, actually, if you clinically have an ASCVD score and like it's not very high risk, that you should be 70, and if you have a high risk, we really need to drop you down to 55.
• 31:05
  Dr. Harpreet Tsui: So I really love that.
• 31:06
  Dr. Harpreet Tsui: What are your thoughts?
• 31:07
  Dr. Komal Patil-Sisodia: I feel the same way that you do, I think that we do need to be more aggressive with it.
• 31:12
  Dr. Komal Patil-Sisodia: I think that I also liked that they called out that there are treatments other than statins if you can't tolerate the statins, that's where I think a lot of people don't know, and they were expensive for a while, but our PCSK9 inhibitors, which are injectable treatments and people tolerate better than statins, can really make a huge difference on cholesterol levels, so it's not just one way to be aggressive, and it has to be statins.
• 31:37
  Dr. Komal Patil-Sisodia: If you truly don't tolerate them, they're causing muscle pain or even just degradation of your muscles, myositis then we can...
• 31:45
  Dr. Komal Patil-Sisodia: We have other options which we didn't before, and there's also drugs that are in the pipeline for lowering lipoprotein little A, which I think is interesting, and these other two medications we know lower apolipoprotein B, so there's so much we can do to reduce risk for all patients, and then, yes, I am a big fan of trying to push it lower.
• 32:06
  Dr. Komal Patil-Sisodia: Trying to get people on board with that when the recommendations keep changing is hard, because I think a lot of people are like but you told me this five years ago." And it's no, the science has changed now.
• 32:17
  Dr. Harpreet Tsui: I think that's the key though.
• 32:18
  Dr. Harpreet Tsui: I think the key is that we, especially us as medicine, especially-
• 32:21
  Dr. Komal Patil-Sisodia: Yeah
• 32:22
  Dr. Harpreet Tsui: it's very important that we let our patients know science changes, medicine changes, and in three years when those phase three drugs come to us for the Lpdrugs, then things will be changing then.
• 32:33
  Dr. Harpreet Tsui: The way that I look at it is I don't really have a lot of patients on simvastatin, but when I got out of residency, I had a lot of people on simvastatin, but rosuvastatin came out, and the studies were there, i've got patients who tolerate ezetimibe really well.
• 32:43
  Dr. Harpreet Tsui: And I think the important thing is to remind our patients, like, when it comes to cardiovascular health and heart health, the science is there, and it's coming down the pipeline every single day.
• 32:51
  Dr. Harpreet Tsui: And so these guidelines are really similar to diabetes guidelines of A1Cs.
• 32:59
  Dr. Komal Patil-Sisodia: Correct.
• 33:00
  Dr. Harpreet Tsui: Very similar that way.
• 33:01
  Dr. Komal Patil-Sisodia: Yeah.
• 33:01
  Dr. Komal Patil-Sisodia: We used to say, it was a higher A1C that we were okay with, then we tried to push everybody as low as we could go, and then we realized putting them too low kills them.
• 33:09
  Dr. Komal Patil-Sisodia: It's just-- it's-- we have to-- we settle somewhere in the middle.
• 33:13
  Dr. Komal Patil-Sisodia: My husband is in PR and marketing and digital, social, and we always kinda laugh about how- The pandemic was advertised.
• 33:22
  Dr. Komal Patil-Sisodia: We call it the biggest PR gaffe of our generation because it was the whole flatten the curve and then COVID will go away was the public understanding, that's what my husband told me he thought it was, he's why didn't it go away after two weeks?" And I told him flatten the curve doesn't mean that." He said what does it mean?" I said flatten the curve.
• 33:38
  Dr. Komal Patil-Sisodia: So you have a curve, and under the curve are the number of patients who are gonna get sick during this pandemic.
• 33:44
  Dr. Komal Patil-Sisodia: When you flatten the curve, the number of patients doesn't change, it just stretches out for a longer period of time." And he was like, why didn't we just say that?" And he's"And why would we do that?" I said,"So we didn't overwhelm the healthcare system and collapse it because everybody got sick at the same time and we couldn't save anybody." And he was like,"We should have just said that." And I said,"I know, but unfortunately the way that it was communicated out was like everybody, isolate for two weeks, we'll flatten the curve, and then it will go away was the presumption." Yes.
• 34:13
  Dr. Komal Patil-Sisodia: I don't think we actually ever said that.
• 34:15
  Dr. Komal Patil-Sisodia: But it's the same thing with any health guideline that comes out, our data, one, we have to do a good job of representing it to the people who are out there so that they understand why we're making these recommendations.
• 34:25
  Dr. Komal Patil-Sisodia: And then second, we have to talk about why our guidelines are gonna change because we're gonna learn new things.
• 34:31
  Dr. Komal Patil-Sisodia: I don't know if I ever told you this, Harpreet, but my hospital in Washington where I was working at the start of the pandemic was the first COVID deaths in the country.
• 34:40
  Dr. Komal Patil-Sisodia: It was a crazy time because we were situated between five nursing homes, and that's where it started,
• 34:46
  Dr. Harpreet Tsui: no.
• 34:46
  Dr. Komal Patil-Sisodia: And so all of the cases were coming to us as a small community hospital.
• 34:50
  Dr. Komal Patil-Sisodia: So the CDC shows up at our hospital and I was on the leadership team.
• 34:54
  Dr. Komal Patil-Sisodia: And I remember we all came in on a Saturday when we found out those two cases were positive and we were having these meetings.
• 35:01
  Dr. Komal Patil-Sisodia: And we laugh at the photos now'cause everybody's in the room without a mask touching their face.
• 35:05
  Dr. Komal Patil-Sisodia: But then the following Monday the CDC shows up, and we're like,"Oh, thank God.
• 35:09
  Dr. Komal Patil-Sisodia: They're here.
• 35:10
  Dr. Komal Patil-Sisodia: They're gonna tell us what to do." gonna be okay, and they're like, silently observing, and we're like,"You gonna tell us what to do?" And they're like we're here to learn from you." It's nobody knows right now because it is so fresh and so new.
• 35:25
  Dr. Komal Patil-Sisodia: And it was such a surreal experience, to be in that moment where you realize something is happening.
• 35:32
  Dr. Komal Patil-Sisodia: We don't have all the science we need to communicate it effectively to people, and it just sowed a lot of mistrust, because people thought that we were intentionally lying to them, and I feel like anytime a new guideline comes out or a recommendation changes, that mistrust is always there.
• 35:48
  Dr. Komal Patil-Sisodia: "Oh my gosh, you guys are lying to us." And we're not.
• 35:51
  Dr. Komal Patil-Sisodia: We're trying to adapt to changing science.
• 35:54
  Dr. Komal Patil-Sisodia: And I don't know, I always preface it like that when I'm talking to my patients.
• 35:57
  Dr. Komal Patil-Sisodia: I'm sure you do something similar.
• 35:59
  Dr. Harpreet Tsui: Yes.
• 36:00
  Dr. Harpreet Tsui: Especially in our perimenopausal and menopausal, like our midlife women, because I often say to them,"Listen, I'm going through it, too."
• 36:07
  Dr. Komal Patil-Sisodia: Yeah.
• 36:07
  Dr. Harpreet Tsui: The science of what I learned when I graduated residency a decade and a half ago is different than what we learned March 1st.
• 36:15
  Dr. Harpreet Tsui: Let's go through it together.
• 36:17
  Dr. Komal Patil-Sisodia: Yeah.
• 36:18
  Dr. Harpreet Tsui: Yeah.
• 36:18
  Dr. Komal Patil-Sisodia: And that's where I think this conversation is really important.
• 36:22
  Dr. Komal Patil-Sisodia: Unfortunately, we don't have a ton of time in the traditional healthcare system.
• 36:27
  Dr. Komal Patil-Sisodia: I know that's one of the reasons you opened your direct primary care so you get that time- to be able to educate patients.
• 36:32
  Dr. Komal Patil-Sisodia: For me, it's a similar thing.
• 36:33
  Dr. Komal Patil-Sisodia: I have a small direct care practice that I run on the side, and it is a different practice of medicine in which I get to spend more time with patients, and I really enjoy that, because I feel like we make reasonable changes, and people feel better when they are given information, and they understand what their health goals are.
• 36:51
  Dr. Harpreet Tsui: I also feel like we're really lucky to be practicing medicine in this time.
• 36:57
  Dr. Komal Patil-Sisodia: Yeah.
• 36:57
  Dr. Harpreet Tsui: We get frustrated, but the guidelines that are coming out will mean that every woman that is our age, and honestly, women in their 20s and 30s will live longer, healthier lives because of these guidelines, because of the fact that women like us and other women in medicine and women scientists and PhDs are out there being like,"Nope.
• 37:16
  Dr. Harpreet Tsui: Everyone stop.
• 37:17
  Dr. Harpreet Tsui: We're gonna talk about women and what the heck is actually going on in our bodies."
• 37:21
  Dr. Komal Patil-Sisodia: I look back at what happened to my mom when I was in high school with her heart disease and not being diagnosed for two years despite having symptoms because everybody was like,"Why is a 40-year-old woman short of breath?" Everybody thought it was her lungs, and it was not.
• 37:36
  Dr. Komal Patil-Sisodia: It was her heart.
• 37:37
  Dr. Komal Patil-Sisodia: And so by the time they found it, similar story, 80% blockage in her coronary artery.
• 37:42
  Dr. Komal Patil-Sisodia: At that point, stents weren't good, so she had to have an open heart surgery, it just was like the beginning of the, a health decline.
• 37:49
  Dr. Komal Patil-Sisodia: Yes.
• 37:49
  Dr. Komal Patil-Sisodia: But now we are empowered to believe, or at least you and I are, and several other physicians are pushing to believe women when they come into the doctor's office, yeah.
• 37:59
  Dr. Komal Patil-Sisodia: Unfortunately, years of being dismissed make it much harder for women to trust the system, but I agree with you.
• 38:06
  Dr. Komal Patil-Sisodia: I think this is an amazing time to practice.
• 38:08
  Dr. Komal Patil-Sisodia: I think we're going to be able to heal that distrust women have felt in the system- and make it better for the future generations.
• 38:15
  Dr. Komal Patil-Sisodia: I don't have a daughter, but I have nieces.
• 38:17
  Dr. Harpreet Tsui: Yes
• 38:18
  Dr. Komal Patil-Sisodia: yeah.
• 38:18
  Dr. Harpreet Tsui: you know what?
• 38:18
  Dr. Harpreet Tsui: We have baby sisters.
• 38:20
  Dr. Komal Patil-Sisodia: We do.
• 38:20
  Dr. Komal Patil-Sisodia: We have baby sisters.
• 38:21
  Dr. Komal Patil-Sisodia: Yeah
• 38:21
  Dr. Harpreet Tsui: we will be on their case forever.
• 38:23
  Dr. Komal Patil-Sisodia: Yeah.
• 38:24
  Dr. Komal Patil-Sisodia: If you girls are listening.
• 38:25
  Dr. Harpreet Tsui: If you girls are listening, we're coming
• 38:27
  Dr. Komal Patil-Sisodia: for you.
• 38:27
  Dr. Komal Patil-Sisodia: We won't call you out by name, but you know who you are
• 38:31
  Dr. Harpreet Tsui: Let me ask you a question now.
• 38:33
  Dr. Harpreet Tsui: As an endocrinologist and menopause specialist, how do you feel that these guidelines are affecting those of us in perimenopause?
• 38:41
  Dr. Harpreet Tsui: Where do you see that link?
• 38:42
  Dr. Komal Patil-Sisodia: I think that, my big frustration is we talk a lot about symptoms of menopause, but we don't talk about the fact that this is where your cardiometabolic risk starts increasing pretty significantly.
• 38:56
  Dr. Komal Patil-Sisodia: And I think that this is going to force that conversation because the number one killer of women is still heart disease, whether you are struggling with overweight and obesity or not, the number one killer of women is heart disease, period.
• 39:08
  Dr. Komal Patil-Sisodia: And we don't do anything about it until something is wrong, instead of watching it and seeing when it will change.
• 39:14
  Dr. Komal Patil-Sisodia: And I think a lot of us who are now caring for primarily women in our practices will be pushing that, when I started my direct practice a year ago, I was telling every woman who came in, I was doing a cardiometabolic screen on them and talking about their ancestry, their family history all of, anything in their past medical history that may have contributed.
• 39:35
  Dr. Komal Patil-Sisodia: And I would tell them,"I'm going to check these two other genetic cholesterol markers in you." And this was before the guidelines came out.
• 39:42
  Dr. Komal Patil-Sisodia: I feel very validated in seeing that.
• 39:45
  Dr. Komal Patil-Sisodia: I think it will encourage other people to do that, hopefully.
• 39:48
  Dr. Komal Patil-Sisodia: And hopefully it will empower women to say,"Okay, this is something that's happening to me, not something that's my fault- because, my hormones are changing, and so now I need to do something actively to manage it so I can have a great quality of life and good longevity after."
• 40:04
  Dr. Harpreet Tsui: Why is it that when your estrogen starts to drop, your LDL starts to go up?
• 40:09
  Dr. Komal Patil-Sisodia: So I think a lot of it comes down to our body composition changes that happen, when we lose our estrogen, we have a harder time holding onto muscle.
• 40:19
  Dr. Komal Patil-Sisodia: We see that we develop more fat tissue because fat tissue produces estrogen, so it's our body's messed up way of saving itself, unfortunately, a lot of that fat tissue that we gain in midlife tends to be right around our abdomen, and it's visceral fat.
• 40:33
  Dr. Komal Patil-Sisodia: And you and I know what visceral fat does.
• 40:35
  Dr. Komal Patil-Sisodia: It is going to create that environment of insulin resistance and of processing of your cholesterol in a way that those levels stay elevated because you're insulin resistant, and so I think it all comes down to that, and that's why I get so frustrated When women are like,"Oh my gosh, I'm gaining all this weight," but they don't want to understand the cardiometabolic piece of it, or nobody has bothered to explain it to them.
• 40:59
  Dr. Komal Patil-Sisodia: I don't think it's that they don't wanna understand it.
• 41:01
  Dr. Komal Patil-Sisodia: I think it's that people are not emphasizing how critically important it is going to be- to the quality of their life later on.
• 41:09
  Dr. Harpreet Tsui: Yes.
• 41:09
  Dr. Harpreet Tsui: And I will say while not hormone specific and probably more in the cardiometabolic piece of it- i've been checking HSCRPs for many years.
• 41:17
  Dr. Komal Patil-Sisodia: Yes.
• 41:17
  Dr. Harpreet Tsui: Cause I always tell women"Okay, we can have this and we can have that, and we do the apoprotein." And I was really surprised when my cardiologist checked my HSCRP and it was high.
• 41:29
  Dr. Harpreet Tsui: And I thought, I did a deep dive on HSCRP in South Asian women with the MASALA trial but-
• 41:35
  Dr. Komal Patil-Sisodia: Yeah
• 41:35
  Dr. Harpreet Tsui: I was really surprised that we don't put that kind of emphasis on an inflammatory marker when, as women, we're dealing with literally more inflammation due to adipose tissue, causing all visceral fat.
• 41:47
  Dr. Harpreet Tsui: Like, a vicious cycle.
• 41:48
  Dr. Komal Patil-Sisodia: Yeah.
• 41:49
  Dr. Komal Patil-Sisodia: And I think I'm a firm believer that we should check it, I was diagnosed with autoimmune arthritis right at the beginning of the pandemic.
• 41:56
  Dr. Komal Patil-Sisodia: We'll talk about that another day-
• 41:57
  Dr. Harpreet Tsui: part two.
• 41:58
  Dr. Komal Patil-Sisodia: Stay tuned, y'all.
• 41:59
  Dr. Komal Patil-Sisodia: But the interesting thing was when I was first diagnosed with autoimmune arthritis, I was not quite perimenopausal yet, and my HSCRP was totally normal.
• 42:07
  Dr. Komal Patil-Sisodia: The only abnormal inflammatory marker I had was a slightly elevated ESR.
• 42:12
  Dr. Komal Patil-Sisodia: And the reason I got diagnosed with autoimmune arthritis was that I had skin psoriasis, and then they saw joint changes on x-ray, but otherwise, my blood markers were totally normal, but then this last year, I checked an HSCRP and it was elevated for the first time, and I was like,"My arthritis is controlled." Make it make sense.
• 42:31
  Dr. Komal Patil-Sisodia: So it's like this is all midlife change,
• 42:33
  Dr. Harpreet Tsui: just me
• 42:33
  Dr. Komal Patil-Sisodia: wanting
• 42:34
  Dr. Harpreet Tsui: And so- it's the hormones.
• 42:35
  Dr. Harpreet Tsui: Give me the hormones It's- I need the hormones
• 42:38
  Dr. Komal Patil-Sisodia: I...
• 42:38
  Dr. Komal Patil-Sisodia: No, at this point, girl, I need a statin.
• 42:40
  Dr. Komal Patil-Sisodia: Sign me up,
• 42:41
  Dr. Harpreet Tsui: I have a bunch at my house if you want some.
• 42:43
  Dr. Komal Patil-Sisodia: I have a primary care appointment coming up, so we will definitely chat about that, but this is where we have tools that help women, I have also seen, in women who struggle with overweight and obesity when they get started on GLP-1s or the GLP-1/GIP combination, there's an improvement in their cholesterol as well, so there are different things that we can do.
• 43:03
  Dr. Komal Patil-Sisodia: There's an improvement in the inflammation.
• 43:05
  Dr. Komal Patil-Sisodia: I think there's new studies coming out in the rheumatology space that show some of the GLP-1s are really good i- for autoimmune conditions as well, there are so many things that we can potentially do to improve somebody's metabolic status I think we just have to keep talking about it.
• 43:20
  Dr. Komal Patil-Sisodia: But again, women have never had the opportunity to be educated about these things in midlife.
• 43:26
  Dr. Harpreet Tsui: No, and I have to say just to share my own story- Yeah when I was 44 and I started having what I felt like my brain was falling out of my head.
• 43:35
  Dr. Harpreet Tsui: Yeah.
• 43:35
  Dr. Harpreet Tsui: And I was having so much brain fog.
• 43:37
  Dr. Harpreet Tsui: I'd be in front of a patient and not know a word, and I started on my hormones.
• 43:40
  Dr. Harpreet Tsui: You could take my transdermal estrogen out of my cold hands, okay?
• 43:45
  Dr. Komal Patil-Sisodia: Yes.
• 43:45
  Dr. Harpreet Tsui: Love it.
• 43:46
  Dr. Harpreet Tsui: It's been such a life-changer, but I still needed a statin with an elevated LDL, an elevated HSCRP, I ended up getting a CTA coronary scan with some really great heart flow studies.
• 43:58
  Dr. Harpreet Tsui: I see a cardiologist in San Diego, and now I'm on a plan.
• 44:01
  Dr. Harpreet Tsui: And now I just did my labs, and my LDL's back down to under 70.
• 44:05
  Dr. Harpreet Tsui: My HSCRP- is down normal.
• 44:07
  Dr. Harpreet Tsui: And it's also because I added back in my GLP GIP because I had lost so much weight and I've kept the weight off, but the food waste had come back.
• 44:17
  Dr. Harpreet Tsui: Have bilateral family history of di- both sides family just-
• 44:20
  Dr. Komal Patil-Sisodia: right to me.
• 44:21
  Dr. Komal Patil-Sisodia: Yeah.
• 44:21
  Dr. Harpreet Tsui: Type 2 diabetes.
• 44:22
  Dr. Harpreet Tsui: Everyone in my family is diabetic on both sides, so I feel like that combination really has unlocked the plan that works for me.
• 44:31
  Dr. Komal Patil-Sisodia: And everybody is so genetically diverse, and that was why I gave those examples of those two patients, like my Southeast Asian one and my one who's white, and it's very different what I saw in them.
• 44:41
  Dr. Komal Patil-Sisodia: And I will continue to monitor both of them in the same way and suggest interventions based on how their trends change.
• 44:47
  Dr. Komal Patil-Sisodia: But we can't not have those conversations with women, and so that's why I am really pushing to figure out how we can emphasize the importance of that, how we can empower women to be able to get information to have conversations with their doctors about how we can make sure our colleagues are stepping up to the plate as well, and I think everybody wants to.
• 45:10
  Dr. Komal Patil-Sisodia: It's just the current healthcare system is interesting.
• 45:13
  Dr. Harpreet Tsui: Yes, to say the least.
• 45:16
  Dr. Komal Patil-Sisodia: Doesn't leave a lot of time for shared decision-making visits, no.
• 45:18
  Dr. Komal Patil-Sisodia: And that's really hard because I think every person deserves that time.
• 45:22
  Dr. Komal Patil-Sisodia: So let's switch gears a little bit and, we talked about statins a little bit, but what I'd love to hear from your perspective is when you counsel your patients these are clearly indicated, or when you can give it a little bit of time and see whether, their lifestyles will work.
• 45:42
  Dr. Harpreet Tsui: So I do feel like lifestyle is important, and that is a whole piece in and of itself.
• 45:46
  Dr. Harpreet Tsui: So one thing that I do in my office-
• 45:48
  Dr. Komal Patil-Sisodia: when
• 45:48
  Dr. Harpreet Tsui: patients are coming in, regardless of gender, regardless of age, I really sit down at that first visit and I have a deep dive about what they eat.
• 45:55
  Dr. Harpreet Tsui: And I say to them,"Give me just a typical day.
• 45:58
  Dr. Harpreet Tsui: I just wanna know what time and what it is you're eating, what your schedule is like." Are you managing multiple jobs?
• 46:03
  Dr. Harpreet Tsui: I'm in Las Vegas.
• 46:04
  Dr. Harpreet Tsui: Are you a shift worker?
• 46:05
  Dr. Harpreet Tsui: We got a lot of people that work swing shift, graveyards, are you in healthcare?
• 46:09
  Dr. Harpreet Tsui: Do you have children?
• 46:10
  Dr. Komal Patil-Sisodia: Yeah.
• 46:11
  Dr. Harpreet Tsui: It is very important to be like,"How did you eat and how do you eat now?" Because when I pull some of these labs, I take that into account, so I'm looking at almost, like, how the prevent AHA guidelines have changed.
• 46:23
  Dr. Harpreet Tsui: The calculator's different, i'm looking at all of that.
• 46:25
  Dr. Harpreet Tsui: And I, living in a city where I live you have to also take into account food prices, They're grocery shopping, all of those things.
• 46:32
  Dr. Harpreet Tsui: So if I feel like someone's BMI is high and their LDL is likely elevated along with triglycerides due to poor diet, I will go with that first, and I will give that three months.
• 46:42
  Dr. Harpreet Tsui: And for me, it's do, would they benefit from a GLP or a GLPGIP?
• 46:47
  Dr. Harpreet Tsui: Will they benefit from some nutrition counseling?
• 46:49
  Dr. Harpreet Tsui: I do a body composition on all of my patients on their first visit if we're doing cardiometabolic, hormonal health, and we look at fat-to-muscle ratio and all of those things.
• 46:58
  Dr. Harpreet Tsui: And so sometimes with my older patients, especially, can we take a walk?
• 47:02
  Dr. Harpreet Tsui: What can we do?
• 47:03
  Dr. Harpreet Tsui: Where can we make changes?
• 47:04
  Dr. Harpreet Tsui: Can we do a meal delivery service?
• 47:05
  Dr. Harpreet Tsui: Oh, is that too expensive?
• 47:06
  Dr. Harpreet Tsui: Okay.
• 47:06
  Dr. Harpreet Tsui: Let- here are some easy recipes.
• 47:08
  Dr. Harpreet Tsui: And then if at the three-month mark the triglycerides have come down to normal, but the LDL is still high, okay.
• 47:13
  Dr. Harpreet Tsui: Look, the calculator has changed this much.
• 47:16
  Dr. Harpreet Tsui: These are your past medical history.
• 47:18
  Dr. Harpreet Tsui: I really think you would benefit from taking a statin.
• 47:20
  Dr. Harpreet Tsui: When it comes to the misinformation piece you counsel them about all the stuff that's been debunked.
• 47:25
  Dr. Harpreet Tsui: And then a lot of times the patient says,"We're gonna do this for three months."
• 47:28
  Dr. Komal Patil-Sisodia: Yeah.
• 47:28
  Dr. Harpreet Tsui: And then we're gonna- reassess and we're gonna go from there.
• 47:30
  Dr. Harpreet Tsui: And sometimes it's adding ezetimibe.
• 47:32
  Dr. Harpreet Tsui: Sometimes you're seeing okay, I did that, plus you had high triglycerides, so we put you on an omega-3.
• 47:38
  Dr. Harpreet Tsui: It's working, but it's not working, or you have myositis or you have, back pain or you're having leg cramps.
• 47:43
  Dr. Harpreet Tsui: Let's try a PSK9 inhibitor.
• 47:45
  Dr. Harpreet Tsui: Let's just try it and see what happens.
• 47:47
  Dr. Harpreet Tsui: And the other thing I like to add in, I think from a cardiometabo- metabolic standpoint is a calcium score.
• 47:53
  Dr. Harpreet Tsui: Like a coronary calcium scan.
• 47:54
  Dr. Harpreet Tsui: Because again, you can have a score of zero and that's great, or you could be like me who had a perfect LDL and an elevated HDL and a score of 214.
• 48:04
  Dr. Harpreet Tsui: Yeah, at 43.
• 48:05
  Dr. Harpreet Tsui: And can I be honest with your listeners and your viewers?
• 48:09
  Dr. Harpreet Tsui: I literally just did the coronary calcium score'cause I was in a competition with my husband, and I was gonna prove to him that my heart was healthier than his, and he still hasn't done his, so I'm calling him out.
• 48:18
  Dr. Harpreet Tsui: It's been three years, and he hasn't done
• 48:21
  Dr. Komal Patil-Sisodia: his.
• 48:21
  Dr. Komal Patil-Sisodia: The talk.
• 48:21
  Dr. Harpreet Tsui: Yeah.
• 48:22
  Dr. Harpreet Tsui: But that led me to be like,"Oh-" Yeah"what we know about HDL is probably..."
• 48:29
  Dr. Komal Patil-Sisodia: Not true
• 48:29
  Dr. Harpreet Tsui: not true.
• 48:30
  Dr. Komal Patil-Sisodia: Yeah.
• 48:31
  Dr. Harpreet Tsui: I- Likely an independent biomarker for atherosclerosis.
• 48:34
  Dr. Komal Patil-Sisodia: And it's interesting because I interviewed a cardiologist, Dr.
• 48:38
  Dr. Komal Patil-Sisodia: Ambreen Mohamed, and I'm excited for that episode to come out, but we talk about that.
• 48:42
  Dr. Komal Patil-Sisodia: We talk about CT coronary angiogram and the role of that, and there is so much heart disease that we don't know about that's just lying there in wait for us.
• 48:54
  Dr. Komal Patil-Sisodia: And I'm glad you had this competition with your husband, and tick-tock, he needs to get on it.
• 48:59
  Dr. Harpreet Tsui: Yeah, come on.
• 49:00
  Dr. Harpreet Tsui: He's gotta get on it.
• 49:01
  Dr. Harpreet Tsui: That, and his colonoscopy.
• 49:03
  Dr. Harpreet Tsui: But you know what?
• 49:03
  Dr. Harpreet Tsui: We're gonna get it all done.
• 49:04
  Dr. Harpreet Tsui: It's happening.
• 49:05
  Dr. Komal Patil-Sisodia: Yes.
• 49:06
  Dr. Komal Patil-Sisodia: But, I mean- Yeah, step by step,
• 49:07
  Dr. Harpreet Tsui: yeah, and I think that the interesting thing is when we were in training, coronary calcium scores weren't a thing.
• 49:12
  Dr. Harpreet Tsui: And even then when we were in practice- Yeah, they're- coronary calcium score was not a thing, it's- It,
• 49:18
  Dr. Komal Patil-Sisodia: it's a pretty recent thing, but it's interesting because our cardiology colleagues, they've been doing this for a long time,
• 49:24
  Dr. Harpreet Tsui: long time
• 49:24
  Dr. Komal Patil-Sisodia: I remember when my lipoprotein little A popped up, like I texted one of my colleagues in cardiology and he was like,"Oh yeah, do an ApoB, get a coronary artery calcium score.
• 49:35
  Dr. Komal Patil-Sisodia: Come in, we'll do a treadmill te- he just had a whole thing laid out for me, and I was like,"How often do I gotta do that?" He's"Like every three years if it's all negative." And I was like,"Oh, okay.
• 49:45
  Dr. Komal Patil-Sisodia: That's good to know.
• 49:46
  Dr. Komal Patil-Sisodia: Where's that written down?"
• 49:47
  Dr. Harpreet Tsui: Yeah, nobody wrote it down anywhere.
• 49:49
  Dr. Komal Patil-Sisodia: Yeah, exactly.
• 49:50
  Dr. Komal Patil-Sisodia: I've been trying to learn from them because I think unfortunately with the way that m- medicine has become, as we get more specialized and as we gain more knowledge, we naturally get a little bit siloed.
• 50:00
  Dr. Komal Patil-Sisodia: And if we're not taking that accountability to learn from each other- We're not really dispensing information in the right way.
• 50:08
  Dr. Komal Patil-Sisodia: So I'm glad that he was, like, very open with sharing that with me.
• 50:12
  Dr. Komal Patil-Sisodia: How do you manage your s- patients when they start having the symptoms, the myopathy symptoms and things like that.
• 50:18
  Dr. Komal Patil-Sisodia: Do you feel like they're more resistant to trying a PCSK9 because they've had a bad side effect to the statin, or do you think that they're more open to it?
• 50:29
  Dr. Komal Patil-Sisodia: I don't know, I get a mixed bag.
• 50:30
  Dr. Harpreet Tsui: I get a mixed bag, too.
• 50:31
  Dr. Harpreet Tsui: I feel like one thing that I do with statins, and I did learn this from a cardiologist, is some of my older patients and For women, because we know that women metabolize statins differently than men do.
• 50:41
  Dr. Harpreet Tsui: So I will often guide them and say,"You may get muscle cramps.
• 50:44
  Dr. Harpreet Tsui: You may get leg cramps.
• 50:45
  Dr. Harpreet Tsui: But you know what?
• 50:45
  Dr. Harpreet Tsui: If that happens, you take it two nights in a row.
• 50:48
  Dr. Harpreet Tsui: Why don't you take it every other day for a week,""and then that'll help get you up there," or,"Why don't we start on a lower dose and move our way up to where we need to be," there's a lot of things we can do.
• 50:55
  Dr. Harpreet Tsui: I feel like the big thing with PCSK9s, price, if they're not all covered.
• 51:01
  Dr. Harpreet Tsui: Yeah, and do you mean I have to inject myself?" or,"What do you mean I have to go to an infusion center and get LEQVIO?" You're just like,"Yeah, I know." And so then I like to tell them,"But it's not all the time."
• 51:11
  Dr. Komal Patil-Sisodia: Yeah.
• 51:12
  Dr. Harpreet Tsui: And then it's like- Every
• 51:13
  Dr. Komal Patil-Sisodia: day,
• 51:14
  Dr. Harpreet Tsui: yeah and then they ask you.
• 51:15
  Dr. Harpreet Tsui: Like I know your patients do as well.
• 51:16
  Dr. Harpreet Tsui: They'll say,"Okay would you do it?" Yeah, 100%.
• 51:20
  Dr. Harpreet Tsui: I'm a young woman who has children and a business and a healthy life and a fabulous life, and I don't wanna die.
• 51:26
  Dr. Harpreet Tsui: And over something that could be prevented.
• 51:28
  Dr. Harpreet Tsui: And so I feel like having, again, that really open, honest conversation, I can get about 75% of my patients that if they need a PSK9 inhibitor to do it.
• 51:37
  Dr. Harpreet Tsui: I will say in Nevada, the difficulty is when I do prior authorizations, which is another topic for another day- a lot of these big insurance companies are asking me to have an endocrinologist, a lipidologist, or a cardiologist on board, and I'm like,"For what?"
• 51:50
  Dr. Komal Patil-Sisodia: like,"I have all
• 51:51
  Dr. Harpreet Tsui: that expertise." I can do it in the meantime.
• 51:52
  Dr. Komal Patil-Sisodia: Yeah.
• 51:52
  Dr. Komal Patil-Sisodia: That's crazy work.
• 51:53
  Dr. Harpreet Tsui: So then I'm like calling cardiologists, and they're like okay, I'll see the patient and do the test, but can you manage the PSK9?" I'm like,"That's the whole reason I'm...""This is what we're trying to do." I'm, like, fighting insurance 25% of the time.
• 52:07
  Dr. Komal Patil-Sisodia: Yeah.
• 52:07
  Dr. Komal Patil-Sisodia: It's really frustrating.
• 52:08
  Dr. Komal Patil-Sisodia: I agree.
• 52:09
  Dr. Komal Patil-Sisodia: And again, this is a topic for another day.
• 52:11
  Dr. Komal Patil-Sisodia: I spent a few years as the quality officer for a medical group.
• 52:15
  Dr. Komal Patil-Sisodia: Learned way more about insurance and Medicare than I ever wanna know, and I have a lot of thoughts.
• 52:19
  Dr. Komal Patil-Sisodia: So we'll do that on a different day because it really does cause patients to suffer and not get the care that they need when they are having difficulty navigating that system.
• 52:29
  Dr. Komal Patil-Sisodia: It's really unfortunate.
• 52:30
  Dr. Komal Patil-Sisodia: All right.
• 52:31
  Dr. Komal Patil-Sisodia: And then let's go through, what are your takeaways for, because we are in different geographic locations.
• 52:39
  Dr. Komal Patil-Sisodia: This podcast is going out to...
• 52:41
  Dr. Komal Patil-Sisodia: I was looking at the stats.
• 52:42
  Dr. Komal Patil-Sisodia: It's hit- Yeah 77 countries in the world.
• 52:45
  Dr. Komal Patil-Sisodia: For the people who are listening but don't, are not going to come see us, what do you recommend that they tell their doctor when they come in to talk about their cholesterol or their cardiometabolic risk?
• 52:55
  Dr. Harpreet Tsui: I think the biggest thing is having a really clear history from your family.
• 52:58
  Dr. Harpreet Tsui: Sit down with those who are around still, dig deep and find the data the family.
• 53:03
  Dr. Harpreet Tsui: When did Auntie Margaret have a heart attack, when did Uncle John stop smoking?
• 53:08
  Dr. Harpreet Tsui: Try to find all that out.
• 53:09
  Dr. Harpreet Tsui: Take it to your doctor and ask for the PREVENT ASCVD calculator.
• 53:14
  Dr. Harpreet Tsui: Say,"I want to have my cholesterol..." We have to advocate for ourselves as patients.
• 53:18
  Dr. Harpreet Tsui: Say,"I wanna have my cholesterol checked, cardiovascular health history in the family that I'm worried about.
• 53:24
  Dr. Harpreet Tsui: I'm worried about my age or where I'm at hormonally as well.
• 53:27
  Dr. Harpreet Tsui: Can we do an apoprotein B?
• 53:29
  Dr. Harpreet Tsui: Can I have an LP?
• 53:31
  Dr. Harpreet Tsui: Will you do the calculator for me?" Have that conversation because, again, I think the biggest takeaway you and I can take from the new guidelines is we cannot just use total cholesterol, HDL, triglycerides, and LDL, and non-HDL cholesterol.
• 53:44
  Dr. Harpreet Tsui: We can't.
• 53:45
  Dr. Harpreet Tsui: We have to use these genetic factors.
• 53:47
  Dr. Harpreet Tsui: And have the conversation, again and I say this as an obesity medicine doc, have the conversation about GLPs and GIPs.
• 53:53
  Dr. Harpreet Tsui: Yes.
• 53:54
  Dr. Harpreet Tsui: Please-
• 53:54
  Dr. Komal Patil-Sisodia: Yes
• 53:55
  Dr. Harpreet Tsui: have
• 53:55
  Dr. Komal Patil-Sisodia: that
• 53:56
  Dr. Harpreet Tsui: conversation.
• 53:57
  Dr. Harpreet Tsui: And if you have a doctor who's"I don't believe in that, I don't write in that," find another doctor.
• 54:04
  Dr. Komal Patil-Sisodia: Yes, because that person is not up to date on the science.
• 54:07
  Dr. Harpreet Tsui: Yes.
• 54:07
  Dr. Harpreet Tsui: Ask for your insulin level.
• 54:09
  Dr. Harpreet Tsui: Go in and ask.
• 54:10
  Dr. Harpreet Tsui: Again this is a whole other conversation you and I can have.
• 54:12
  Dr. Harpreet Tsui: But, menstruating women who are tired, why do we not check ferritin regularly?
• 54:17
  Dr. Komal Patil-Sisodia: Thank you.
• 54:18
  Dr. Harpreet Tsui: Why?
• 54:18
  Dr. Komal Patil-Sisodia: I do.
• 54:19
  Dr. Harpreet Tsui: I
• 54:19
  Dr. Komal Patil-Sisodia: do.
• 54:20
  Dr. Komal Patil-Sisodia: So
• 54:20
  Dr. Harpreet Tsui: Patients come into my office and they're like...
• 54:22
  Dr. Harpreet Tsui: I have a midlife Asian woman, came in yesterday, has spent bajillions of dollars on functional medicine doctors, seen every specialist, was told that doctors,"Oh, I don't think you need that.
• 54:32
  Dr. Harpreet Tsui: You're skinny.
• 54:32
  Dr. Harpreet Tsui: I don't think you need that." No, I'm sorry, she has medical problems and hormonal health that needs to be taken care of.
• 54:38
  Dr. Harpreet Tsui: And go to your doctor and say,"I want these things." And I think as a physician, if you're listening, it's really behooves you to check insulin levels in your insulin-resistant patients.
• 54:46
  Dr. Harpreet Tsui: Talk to your women about PCOS.
• 54:47
  Dr. Harpreet Tsui: Do this calculator regardless of ethnicity, but, know that certain ethnicities, like all of my Asian ethnicities, I talk to them about being skinny fat, because it is a legitimate thing.
• 54:57
  Dr. Harpreet Tsui: And to the people that are listening, a lot of things can be changed with diet, but don't be scared to start medication.
• 55:04
  Dr. Harpreet Tsui: And I think you and I can say that as doctors and as patients ourselves don't be afraid to start medication because there is sometimes no natural way to lower your...
• 55:13
  Dr. Harpreet Tsui: There's no natural way to lower your LP little A and your apolipoprotein B.
• 55:16
  Dr. Harpreet Tsui: It's just not gonna happen.
• 55:17
  Dr. Harpreet Tsui: There's not.
• 55:19
  Dr. Harpreet Tsui: And so also know that because I see a lot of families of adults know that you can start checking your children, but if you're going to your doctor and you have your child with you and they're 19 and they haven't had their cholesterol checked, let's start checking it now.
• 55:33
  Dr. Komal Patil-Sisodia: Yes.
• 55:34
  Dr. Komal Patil-Sisodia: it's important to do all of that.
• 55:36
  Dr. Komal Patil-Sisodia: I think we talked about this.
• 55:37
  Dr. Komal Patil-Sisodia: My husband had a heart attack in his late 30s, and I am so type A about...
• 55:43
  Dr. Komal Patil-Sisodia: I think I was almost pushing our pediatrician.
• 55:45
  Dr. Komal Patil-Sisodia: She's"How about we wait till he's..."'Cause my son was, like, almost four.
• 55:48
  Dr. Komal Patil-Sisodia: He hit eight and I was like,"When do we check his cholesterol?" And she's"Not now.
• 55:51
  Dr. Komal Patil-Sisodia: Not now." And I was like,"Okay, that's fair.
• 55:53
  Dr. Komal Patil-Sisodia: That might traumatize him with the blood draw," but- If
• 55:55
  Dr. Harpreet Tsui: You can start as early as the age of two if you have a family history of early cholesterol.
• 56:00
  Dr. Komal Patil-Sisodia: Yeah.
• 56:00
  Dr. Komal Patil-Sisodia: And back then, that wasn't the guideline,
• 56:02
  Dr. Harpreet Tsui: wasn't the case,
• 56:02
  Dr. Komal Patil-Sisodia: yeah.
• 56:03
  Dr. Komal Patil-Sisodia: But we've checked it now, and it seems to be fine, and so we're gonna watch it.
• 56:06
  Dr. Komal Patil-Sisodia: But I do think once he hits puberty And things are gonna change throughout your lifetime, all of these different shifts that we have come with new health problems or potential for health problems.
• 56:16
  Dr. Komal Patil-Sisodia: Not always health problems, but potential for it, and if you're not watching, you're gonna miss something.
• 56:20
  Dr. Komal Patil-Sisodia: So that's really my shout-out to all of our amazing primary care docs who are out there.
• 56:26
  Dr. Komal Patil-Sisodia: These amazing physicians and APPs are the ones who keep you in check.
• 56:31
  Dr. Komal Patil-Sisodia: So go, make sure you make your visits.
• 56:33
  Dr. Komal Patil-Sisodia: Make sure you're seeing a primary care doctor once a year.
• 56:35
  Dr. Komal Patil-Sisodia: I know the system is frustrating.
• 56:37
  Dr. Komal Patil-Sisodia: What I hear from my patients is"Oh I saw my primary.
• 56:39
  Dr. Komal Patil-Sisodia: I really liked them, but then they left." It's a real problem, but when you find somebody, you hold onto them.
• 56:45
  Dr. Komal Patil-Sisodia: I drive 20, 30 minutes to see mine'cause she's that far away, but she's amazing and I will try and follow her wherever she goes.
• 56:52
  Dr. Harpreet Tsui: Primary care doctors need their own primary care doctor.
• 56:54
  Dr. Harpreet Tsui: Yeah I haven't had a primary care doctor in a while, but yes.
• 56:57
  Dr. Komal Patil-Sisodia: Yes.
• 56:57
  Dr. Komal Patil-Sisodia: Correct.
• 56:57
  Dr. Komal Patil-Sisodia: Also, for our physician colleagues, take care of yourselves, especially our female physician colleagues, because I hated that data that came out that showed we have a higher mortality rate than any other profession.
• 57:08
  Dr. Harpreet Tsui: I was at a women's breakfast speaking on a panel and I- shocked the entire room by saying that female physicians have the same risk and age of death as Caucasian males in the US.
• 57:17
  Dr. Harpreet Tsui: They were like,"What?" I'm like,"Yeah."
• 57:19
  Dr. Komal Patil-Sisodia: Not a fun stat
• 57:20
  Dr. Harpreet Tsui: check that HSCRP, ladies.
• 57:23
  Dr. Harpreet Tsui: Get that done.
• 57:23
  Dr. Harpreet Tsui: Let's do it.
• 57:24
  Dr. Komal Patil-Sisodia: Thank you so much for your time today.
• 57:26
  Dr. Komal Patil-Sisodia: This was an amazing conversation.
• 57:28
  Dr. Komal Patil-Sisodia: I hope it is helpful to all of the listeners that are out there, and I will look forward to seeing you all on the next episode.
• 57:36
  Dr. Komal Patil-Sisodia: Harpreet, where can patients find you?
• 57:38
  Dr. Komal Patil-Sisodia: If they're in Nevada and lucky enough to see you, tell us about your practice, and then also your socials so they can follow your amazing content.
• 57:44
  Dr. Harpreet Tsui: Thank you so much for having me today.
• 57:46
  Dr. Harpreet Tsui: This was great.
• 57:46
  Dr. Harpreet Tsui: You can find me in Henderson, Nevada, coronadohealthdpc.com, on socials on Instagram as drharpreet.tsui, on TikTok as dr.harpreet.tsui.
• 57:57
  Dr. Harpreet Tsui: But I always tell people, just put Harpreet Tsui into the search Google and you will find me somewhere-
• 58:03
  Dr. Komal Patil-Sisodia: the world.
• 58:03
  Dr. Komal Patil-Sisodia: There's only one.
• 58:04
  Dr. Komal Patil-Sisodia: I don't know another Harpreet Tsui.
• 58:07
  Dr. Komal Patil-Sisodia: That's it for today, but the conversation doesn't have to stop here.
• 58:10
  Dr. Komal Patil-Sisodia: Come find me on Instagram or TikTok at drpatilsisodia.
• 58:14
  Dr. Komal Patil-Sisodia: And if something from today's episode resonated, I'd genuinely love to hear about it.
• 58:19
  Dr. Komal Patil-Sisodia: Leave a review, which makes the podcast searchable, share the episode, or just send me a message.
• 58:24
  Dr. Komal Patil-Sisodia: The more women who have access to this information, the better.
• 58:27
  Dr. Komal Patil-Sisodia: I'll see you next week on the next episode.