Latest / The YMyHealth Podcast | Wellness and Healthcare Insights for Millennials / Why High Cholesterol Is Increasingly Common in Millennials

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Why High Cholesterol Is Increasingly Common in Millennials · The YMyHealth Podcast | Wellness and Healthcare Insights for Millennials

• Melissa Schenkman (02:32) On this episode, we are going to talk about topic that has become a hot topic amongst Millennials and I think if you haven't heard about it already, I guarantee you at least one of your friends is going to talk to you about it. And that's what I'm finding, which is high cholesterol and statins. And for me, high cholesterol has been something I've known about, unlike maybe other people, my entire life because we have family history of it. And when I was a very skinny second grader, I went and I got my... you always people associate well maybe you know people who have a certain weight have high cholesterol well let me tell you that is not true and so yeah I am I went from my like regular physical never forget this and my cholesterol was I want to say it was 210 or 220 and I was like this skinny and I had I didn't know what cholesterol was for obvious reasons back then and I had a real education about all the things that I like to eat that were very high in cholesterol like McDonald's back then, which I'm now a pescatarian, times changed. But that I could not do that anymore with my family history. And so for me, and I'm finding more people like this who I've been talking to in the community where you found a way to control your tendency towards high cholesterol through exercise and also through part of your diet. But now... people getting up to 30, 35, they hit 40, all of sudden, their numbers are starting to creep up despite the fact that all these years they've taken these different measures with exercise and not eating dessert every day and other things. so now enters the conversation enters about statins. And so I thought that was a really important topic for us to cover. I know a lot of people are either starting to hear about this or they're just really frustrated and they don't really know what to do. So, on today's episode, we are very fortunate to have Dr. Garrett Ruth with us here. He is a cardiologist in South Carolina and he knows all about cholesterol and statins very well and having these conversations with patients. And so just really wanted to kind of ask you some basics to start and really kind of go into detail with some of the challenges that we're all facing. welcome to the podcast. Dr. Garrett Ruth (02:58) Thank you for having me. Melissa Schenkman (03:00) Very welcome. Thank you for joining us. when it comes to cholesterol, what should we be concerned about, say, in your 20s versus 30s versus 40s? And I know there are a lot of different things, but kind of in general. Dr. Garrett Ruth (03:15) The basic thing, so you start getting screened, your primary care physician may screen you earlier, certainly if there's some other family risk, what have you, but usually most people get some sort of lipid panel drawn in their 20s and certainly it's supposed to, by the preventative task force, be drawn in your 30s. So you may or may not at that point see, oh, these numbers are red. Why are they red? And that's what we all start to say is yes, as we age, the general aging process, your cholesterol is going to slowly increase and we can talk about the kind of more of the nuts and bolts of that Yeah, briefly a little bit but goes off and there's other reasons there can be other reasons and it's important to know or at least be aware of some of these reasons where hey I need to my cholesterol check now or sooner and allow this brain first and foremost to span history Proceed you and certainly if you have a sibling heart attack has had surgery, stand at age 30 or 40. Those are red flags in my mind for a young person who comes into my clinic that we need to do some a little bit more investigating because yeah, sure. I'm not going to put a 20 year old or a 30 year old on the statin. It's not really indicated at that point unless there's some things that would say otherwise. So family history is a big one. Your ethnicity, your race, know, there's some people, most notably South Asians, Hispanics, they tend to run a higher LDL in general, just based on ethnicity. being cognizant of that as well. then certainly the big things we think about diet, poor diets. That is one of the one-to-one contributors of high cholesterol is a high fat, high saturated fat diet, you name it, that contributes heavily. And in turn to that, weights, it's another thing that can be a stigma as well in today's society, but it's something that needs to be brought up in cardiology because it is also just as bad as poor diet, which in itself kind of comes with the package. But being overweight significantly leads to very significant higher risk of heart disease. And those are the big things kind of as far as things to be aware of as why should I get screened earlier if I should do something about it, if these characteristics are something that, you're saying, I have that, I'm that, you know, I've got those profiles. Yeah, I think it's a discussion with your primary care or if you have a cardiologist at hand, you know, yeah, bring it up, bring it up. And we'll talk about this, I'm sure momentarily, but we'll talk about the screening mechanisms and why and what needs to potentially be utilized. Melissa Schenkman (05:45) That's all very incredibly interesting to hear but also very, very helpful because trying to figure out how to navigate this just even early can be really hard and those give us some really great things to think about as we do that. And kind of you were saying as we get older, kind of it does increase, regardless just from age alone it sounds like with cholesterol but in terms of that trajectory, how would you say kind of that looks in terms of our body's ability really to remove cholesterol which is A big part of also what it comes down to, but as you go from your 20s into your early 40s, I'm wondering is it at 25 you start to see a creep up, or is it really more at 30 that could be something more significant? How does that in general tend to go? Dr. Garrett Ruth (06:32) Yeah, and it's, think it's person-dependent, but you'll see, and there's also some other variables at hand and I'll go into that too, but you'll start to see it creep up into your 30s, into your 40s and cholesterol is important. It's in the body, it helps cells, membranes form, it helps your hormones be produced, all these things. And there's various different types of cholesterol particles. Your low-density lipoprotein being the bad cholesterol, the high-density lipoprotein being the quote unquote, good cholesterol. And as you age, your HDL goes down and typically your LDL goes up. And that's because the receptors in your body for that LDL tend to go down. So then you have more circulating LDL in your blood and the blood, has to go somewhere. And then that's when plaque deposition occurs in the body. So that's kind of the big mechanism of why as we age that we see that go up is because we're losing a lot of ability to get rid of those. LDL particles in the blood leading to plaque deposition. Melissa Schenkman (07:34) No, absolutely. And as far as family history, which is a big player in all of this, if you could talk a little bit about that role of family history because there are things like familial hypercholesterolemia is very different, let's say, than for me, just having a family history of a few members with high cholesterol, not significantly high per se, but just they have ended up, let's say, on a statin by the time they were 50. And I know this. So kind of if you could talk a little bit about the general family history, but also if you have something else where it's like significantly high. Dr. Garrett Ruth (08:12) Yeah. So, um, like you alluded to familial hyperlipidemia, there's, various degrees of that, depending on what gene is mutated and what's inherited. being less common, some being extremely rare and some being more, more common. Yeah. So you'll see, you'll see your, your otherwise healthy 20 to 30 year old, they're, they're eating healthy. They're doing what they should be doing, but they get their lipid panels drawn and their, their cholesterol again, that LDL is 150. Yeah. I'm doing everything I can what else someone's supposed to do. And then that kind of leads to a presumptive diagnosis of a genetic-based hyperlipidemia. And you can test for those, you can do gene testing, but usually it's not necessary. Usually it's just at that point, it's about risk assessment and... doing those screening studies to see is, yeah, you have high cholesterol. Do we need to treat it? Do we need to be on a set? Do we need to be on something else? Since you're already doing all the things necessary to avoid that and being healthy. And these people are not as common, but it's there. And that's why I always think it's very important to be in charge of your health when you do have that family member with that history and to be on top of it. Because yeah, you might be a healthy BMI. You might be as active as can be, but... There's people that I see that kind of go under the cracks for years and years and then they turn 50 and then they have heavy degree of coronary disease and I meet them by heart cath and then we missed 20 to 30 years of risk factor modification and we could have avoided that in the interim. Excellent. Melissa Schenkman (09:47) That's an excellent point and so much of what is so important to us to get out there for Why My Health is having that tool to notice that, to recognize that and to go forward and manage it earlier on because to your point, so much of this develops. Honestly, mean, even as a kid, realized depending on family history, you can start developing then. But on average, this is developing during the age range that we are now. And now is really the time to manage this before we get to that 50 and over, which is sometimes very hard to even comprehend at this point, even for the 40s. still, it's like, no, that's not us. But now is the time. And in terms of preventive screenings, obviously there is going and getting, as you mentioned, regular screening for cholesterol levels when you go to your internist or if you already are working with a cardiologist. But there are also things that we hear about like calcium screening. And so I was kind of wondering, we could talk a little bit about what diet and any other preventive screenings that you would recommend in this space, but also where calcium screening is appropriate in this millennial age spectrum. Is it better to do it early in the 20s? Is it better in the 30s, early 40s? So if you could tell us a little bit about that. Dr. Garrett Ruth (11:02) Sure, yeah. I use Calcium scores frequently. It's the right population. There's some populations where you would not utilize it and then there's others that it helps. I like to call it a tiebreaker. The way we kind of look is, yeah, you said in your 20s, you're at low risk for cardiovascular disease. You're unlikely without some familial component going to have a heart attack at that point. That's just based on age and lack of... lack of risk. But the way we kind of assess that is the American College of Cardiology years ago in the 2000s came out with kind of a risk assessment after they pulled hundreds of thousands of people and kind of looked at various risk factors to include your age. Do you have a diagnosis of hypertension? Do you have a diagnosis of diabetes? Are you a smoker? And then obviously putting in the numbers of your cholesterol panel. And then that kind of looks at say it pops out a number more or less and it gives you your risk of a 10 year event, meaning are you going to have a stroke in 10 years and what's that risk? And for people who are in the low risk range, you know, like a 28 year old with a great cholesterol panel, non-smoker, non-diabetic, no, we would never put medical therapy on them. Keep doing what you're doing even if they have a little bit of elevated cholesterol, we say yeah, diet and exercise, keep doing what you're doing. You're not at high risk. Now, then we fast forward to say a 60 year old who's been smoking for 30 years and is diabetes. that person's high risk. should 100%. They we we assume that they have some plaque in their coronary arteries. And they should be on a statin already. that's not a calcium score help there. So that the moderate risk range person. So you know, you have a guy who's 40. And he's had high cholesterol for years, but not a smoker and I've died about it. You know, his risk range might be kind of in the middle and I don't necessarily want to put somebody on statin therapy at age 40 because we're talking about possible indefinite medical therapy, which is a big change in somebody's lifestyle. I don't want to take a medicine if I don't have to. Melissa Schenkman (13:00) Exactly. Dr. Garrett Ruth (13:01) But I want to, and I want to make sure I'm treating my patients well if I think it's going to help them out long term. So their risk might be in the moderate risk range. And that's where I'll bring in some other tests, calcine score being one of them. It's a very low radiation CT scan, not used with dye. You go in, it's very quick. We scan your heart. And that shows if there's any calcific plaque that has been deposited in the coronary arteries. If that score is zero, that risk is much lower than we were worried about. As opposed to the other side, if we see some calcium deposition, that pushes us one way to say, okay, yeah, you're 40, yeah, you're generally healthy, but we see some plaque build up already and we should be on top of this and we should control your cholesterol very aggressively because you're only 40 and we won't want to have anything build up into your 50s, 60s, and certainly avoid heart attacks. So calcium score used in the appropriate clinical setting can really help have that risk discussion with a patient who may or may not benefit from statin therapy at a younger age. Melissa Schenkman (13:59) That's a really helpful way to think about it. I know that's something that I would suspect and I just know from other people I've talked to is something that people have had recommended to them to do who are on that borderline but most likely did not know that that was the reason behind all of it. I appreciate that and I just have to say on the personal side, I had one of those several years back and just so people know if that is something getting a calcium score test that has been... told is something in your plan in the next year after visiting your doctor. I will tell you it is so easy. It is like a 10 minute thing to do. It's one of the easiest tests I've ever. And it's relatively inexpensive too. Melissa Schenkman (14:41) Yeah, it is. So just have to make a plug for the calcium. If others were just as easy, they would be great. Dr. Garrett Ruth (14:50) And honestly, it's also more convincing too as well. If someone just says, my numbers are high, what's the big deal with that? But then when I tell them, yeah, but now you've been depositing plaque in your arteries, it's helpful to say, yeah, this is a little more alarming than just your numbers being read on your blood work. Melissa Schenkman (15:02) That's a different story. Dr. Garrett Ruth (15:12) And sometimes it helps people say, yeah, okay, I get it. I see it now. And yeah, I think I'm gonna try that now. So it's not to really scare people, but it's just to really help decide, you can really potentially reduce your risk of a heart attack if we start doing this. So, good to. Melissa Schenkman (15:29) Great point. no, absolutely. And the other thing that I find to be kind of a buzzword out there a little bit these days is the apolipoprotein. Dr. Garrett Ruth (15:44) We call it Apo B if you want to for short. Melissa Schenkman (15:47) Yeah, that was the other I was trying to think. I've heard it both ways. But what if you could talk a little bit about what is that for people who are not as familiar or they just hear the term, they're like, oh, you want to get one of those tests? And kind of what what is the purpose that it that it serves in helping us to kind of be proactive about our heart? Dr. Garrett Ruth (16:04) Yeah, so yeah, so I like to compare things. normally the standard screening is going to be a limpet test where it shows your LDL or your HDL. What an APO-B test is a more specific marker of the LDL. And the LDL kind of correlates is like I kind of mentioned, the more LDL to have, lack of, you know, starts depositing plaque into the various... all over the body, but the APO-B specifically breaks down more so the particle of the LDL that is what we call atherogenic or the one that's really going to cause plaque deposition and inflammation. So it's just a more specific marker of LDL. And usually, again, same thing for that moderate risk range patient where we're really trying to decide is medical therapy warranted that APO-B can be a tiebreaker because somebody can have a discordant lipid panel and meaning their LDL could be low or in the nominal range, but then their APOB is very, very high. So that's telling us that they're at higher ratio in flat deposition despite having a moderate risk range LDL. So they can be discordant and that can say, okay, yeah, you're in a higher risk quartile because of these APOB particles being much higher. So again, just more data that we can utilize to help really risk prognosticate people who may or may not benefit from medical therapy. And yeah, it's definitely a new popular word that people are utilizing. Melissa Schenkman (17:35) No, and I'm curious on that, do you think that if you or somebody, let's say over 35 in the millennial age spectrum, have family history and have never had that test done before? You've had your cholesterol panels, you're well aware that things are either creeping up or kind of staying stable, but you're now hearing this buzzword and you're like, I wonder if I'm a candidate for this. Would you recommend bringing that up in conversation with their doctor? Dr. Garrett Ruth (18:01) I think it's a great thing to bring up. It just depends on who you're speaking with and how many cares are... Again, it's relatively somewhat new and it's becoming more prominent. Some more so than not, but it's something that's certainly great to bring up and have that risk. It's again, risk discussion is like, would you do this now or not? And we can kind of help kind of figure out if it would be helpful or if other tests are more helpful than APO, BRAVE-E or something like that. So yeah, I fully advise bringing it up, especially if you're concerned about your risk. Melissa Schenkman (18:37) Awesome, very, very helpful to hear. another thing I think that for us and for people I've heard from that, because as people start to read about this, and I say this, because I was talking with somebody recently, big exerciser, their entire life and has also just happened to randomly bring this up to me, that they knowing what we do with YMyHealth and they said to me, my numbers are creeping up. I'm so frustrated. I don't know what to do and I'm eating this, this and this. It's healthy and I've cut that, you know, all these things out. And I was doing some reading of my own after they told me this because this is somebody who you like with a lot of people from the outside and this is so true with millennials all the time. What looks one way on the outside and what is going on inside the body may be very, very different and be deceiving. And I started looking up and I noticed there's a lot out there about how women after age 35 kind of start to see this increase in particular with their cholesterol and there is some relationship with hormone levels as you go through and there's talk about as you progress through your 40s, get into your 50s and even your 60s, somebody who may be able to get through their 40s without a statin could end up being that they need to have a statin, say at 50 or maybe even at 55. Kind of wanted to know your thoughts on that…And that's whether or not they have a family history too. Why is it, you what is that connection for women specifically the role that the hormones can play in these upcoming decades? But even as you're passing that 35 mark. Dr. Garrett Ruth (20:12) Sure, And estrogen is the hormone that we're all talking about. And as we get into our 40s, you'll see males, their cholesterol structure raise as they advance into the 30s and 40s, where there seems to be a little bit of a lack. Estrogen is pretty protective in a lot of ways. It helps regulate the metabolism of the lipids in conjunction with the liver. So as that estrogen begins to drop as you approach menopause, that then in turn leads to higher LDL levels as you go on in life. And there's been studies done before that there's women that experience early menopause and sometimes those women are at a two-fold risk for cardiovascular disease and cardiovascular events than the normal population. So it clearly plays a direct role in lipid metabolism. yeah, so same being on a lookout for that as you age and approach. Fortunately, menopause as you get into their 40s and 50s is something to be on top of. Melissa Schenkman (21:11) And in that regard, is there anything that we can do starting at a certain age, knowing that this change is coming, that we can do to improve kind of that response from the body in terms of cholesterol when we get there, if we begin to intervene sometime, say early 30s even? Dr. Garrett Ruth (20:31) What you'd expect, there's nothing really specifically primary treated for that. People bring up hormone replacement therapy, but there's a lot of highly debated topic there because although yes, we think it may be cardio protective and reduce atherosclerosis rates, it also has its own set of problems, increasing cancer risk for us, ovarian, uterine, higher risk of blood clot formation. At present, there's really nothing primarily that we utilize as women approach menopause. other than the standard things, diet, exercise, all of those things to reduce your overall cardiovascular risk, knowing that you're losing that estrogen and that cardioprotective effect. Melissa Schenkman (22:13) Gotcha, no thank you, that's very helpful for us to hear as we think about this. Julie Woon - Commercial (22:18) (Music) I'd like to take a minute to sponsor. We'd like to take a minute to talk about today's sponsor, Diekman Dysautonomia. Have you or a loved one been struggling with symptoms like fainting, a racing heart, or crushing fatigue, only to feel dismissed or unheard by doctors? You may be experiencing dysautonomia, POTS, or long COVID. Dr. Sarah Diekman understands, because she has been there. As someone who faced POTS during medical school, Dr. Diekman knows firsthand the frustration of searching for answers. 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So I wanted to just kind of start with what are some of the misconceptions that you have heard in your practice over the years when that is brought up? Dr. Garrett Ruth (23:51) I have this conversation on a daily basis obviously as a cardiologist if not multiple times a day and I've heard a lot of things and and some of them they bring merit and other ones not but unfortunately when you type statin in Google you're going to get a host of things Google is a great tool but unfortunately it can be a bad tool in some situations but yeah a couple big things that that really come to light.. I'll hear if I'm to average them all out is, hey, it's making my blood sugar up. I'm going to get diabetes if I start this stat. There is some merit to that. It does nominally increase your blood sugar levels. If a pre-diabetic start taking the statin, they may end up getting the full diagnosis a couple of weeks earlier, but they're already on that road to begin with without an intervention. It just may make that diagnosis sooner than later, but they were on their way regardless anyway. And in that fact, you know, we say people that already have that high, higher than normal blood sugar, we're actually probably preventing cardiovascular events in the setting of diabetes than just that nominal increase in blood sugar. So we're actually helping dementia. Remember, there was an old study in the, think I say old now, was in like 2010, 2012. wasn't that long ago, but that's fair. The FDA kind of put this side effect. Melissa Schenkman (25:11) now, yeah. Dr. Garrett Ruth (25:16) profile on statins that put memory loss and confusion as one of those. And that rose a lot of red flags for people. And it's still a widely debated topic. The initial studies that came out were relatively poor quality. They didn't really have good evidence to suggest that, but it certainly concerned people with good reason. And then over the next five to 10 years, in the past 10 years, there's been better studies that come out, better trials, more data, more people. and they have not seen a correlation exactly with that. So it doesn't fully clear that, I can't say that, but you're also talking about the patient population that likely has coronary disease or has had a heart attack or has had a... So if there's plaque in the heart, there can be plaque in your carotids, there can be plaque in your legs. It's usually not localized. And then we're talking about there's plaque in the brain as well. Are we just selecting a bias of people that may have vascular dementia? And that's actually playing a role. So it's hard to really say, but at this point, again, going back to risk and benefit is really is a discussion to be had in regards to that. And some patients just say, no, I have a big dementia history in my family and I don't want to take it. And that's fine. I just want to arm my patients with the knowledge to make sure that they can make the right choice for them. And then lastly, the big one is the side effect profile of my audience or muscle pains. I've heard that a lot. Melissa Schenkman (26:46) Yeah. Dr. Garrett Ruth (26:47) They are, it's, I don't want to say common, but I talk about it frequently, at least from data perspective, about 10 % of patients experience myalgias. Myalgias are muscle pains. It feels like you just went to the gym and squatted and you didn't do that. Your legs are sore. It's usually of the upper limb girdles, your shoulders, your upper thighs, and it just feels like you worked out, but you didn't. And that doesn't go away. I see that all the time. We can mitigate with this, you we can change the dosing, we can lower the dose, we can change the interval of the dose, we can do every other day. We can usually change these things to get them on a dose that's catered to them, that that's made all they need and we're getting them to benefit. And then there's also stem alternatives that you can add on or replace for stem if somebody's completely like the stem intolerant. Those are the big three that I've seen as far as brought to me on a regular basis. Melissa Schenkman (27:45) I had not heard of, I believe, two of the three and they're very interesting ones. I have, as as the myalgias, any side effects, any side effect profile, any other side effects that are pretty common that people kind of bring into the conversation as they're making this decision. Dr. Garrett Ruth (28:03) The myalgia is the main one. There's generalized fatigue. Again, back to the brain fog. think we see that if you look up your drug side effect profile, it's gonna be a laundry list of those. But those are the big ones. And in the same regards, I treat them the same way. I say, we can decrease your dose. Let's see how you do on a lower dose or what have you. And some people feel great when we do that. And they're fine with that. I've had some people take it Monday, Wednesday, Friday. I have some people taking it Tuesday, Thursdays at various doses. And there's no rhyme or reason on the person. have, you know, big burly men that can't tolerate a lowest dose of the statin. And then I have 90 year old ladies who've had coronary disease and they're on the highest dose possible. they're like, nope, I haven't felt a thing. So it's just person dependent at this point. Melissa Schenkman (28:53) Yeah, very individualized. And on the flip side of this, let's talk about the benefits because there are so many benefits to it as well. Dr. Garrett Ruth (29:03) Yeah, so, and I think that's where a lot of the stigma comes in status too is because they're so widely prescribed because we know they work in, again, the selected patient. And I'll draw out a picture and I'll show two coronary arteries, one that has a lot of plaque in it. It's almost, it's obstructive disease. It's causing flow problems. And those are the patients I'll meet as they come in for chest pain, they come in for chest tightness. I'll do a stress test and then we'll do a heart cath and we put in a stent. We find that. But then I have the other set of patients that come in as I just found some mild disease. It's not bad. It's not heavy. It's not obstructing flow. They feel good on a day-to-day basis. They don't have any symptoms. The blood is moving as it should. But what can happen is that small plaque, although non-obstructive, can lead to a plaque rupture event where that plaque tears off, blood clots attack that tear, and then you have no flow down that artery. And then you have a heart attack. And I'm meeting you at 2 a.m. to do a heart cath and put a stent in or whatever time it may be. And the benefits of statins, or the most important benefit is that when you start taking a statin, the membrane of that plaque hardens and it becomes a more stable composed plaque. And that's what's thought over time to reduce the risk of heart attack is that it's a plaque stabilizer and it makes that a more composed stable plaque to reduce the risk and chance of a plaque rupture event in your lifetime. So that's why I say, yeah, and you'll hear a lot of times about, yeah, I went to the doctor last week and then I had a heart attack the next, I don't know how they didn't detect it. Well, that's why, it's because you're doing great and then you lead to a plaque rupture event that we could have potentially modified with stat barrier or other medications. So that's the big benefit as far as mortality and heart attack are concerned. Melissa Schenkman (30:46) I really appreciate you explaining all of that to us because it is, I think for so many people, such a challenge to overcome some of the misconceptions you mentioned, but also to realize so many people say the benefits so far outweigh the risk for them thinking about once you're on it and what the rest of those years look like in your life and what you want in terms of your quality of life too. Sure. For sure. As a patient, how do you know when it's time for you to get on one? You know, you're going to get all of the, you're looking at the numbers, you're talking with your doctor, and they obviously are going to be the ones that drive that decision. But as always, the patient's got to be on board with it too. And I think when it's younger patients, like those in our millennial age group, it's a very hard decision to make because to your point earlier, it's going to be a lifelong thing. You're hearing all these things. Kind of how do you know? You know, what are some ways that on the patient side of things you would say as they're looking at the data from their point of view? Dr. Garrett Ruth (31:52) gather the data, use the tools and say, can we do any more testing before I make this big step in my life to start taking this medication potentially and largely for the rest of my life to avoid these problems? Because that's a big step. Know my favorite thing to do in my practice is actually take people off of medicines because I don't get to do it often. But certainly blood pressure medicines, I love taking people off of them because they've changed their bodies, they've done well. I try not to unless that I think it can help them. And that's with statins and really learning your risk and to avoid heart attacks and stroke and everything is super important and really just finding out who will benefit and who won't at that time by gathering all that data. Melissa Schenkman (30:46) That's a great point. And the one other thing that I think for people in our age group in particular that would drive this decision when it comes to women, and I know we were talking about women a little bit before, but the one thing is people today, especially in our generation, are having children later, a lot of them. so you have these women who some may have family history, some may not, the numbers are of creeping up and stuff. …depending on where they are at in their family planning, there's this other topic of statins that they may need to get on at some point and long before 50. And I know from what I've been told in talking with people and other Why My Health contributors is that it's just, it's very controversial in pregnancy. And I was wondering if you could speak to a little of that to help some of our listeners who are women who may be in the situation where their doctors are talking to them about there's gonna be a statin in the future picture, it's a matter of when. Then how do you do that? And the thought I think for some people is, well, what if I'm not at the point yet that I'm having a family, but really things are looking like it may be time for a statin. Do I get on this statin? Then what do I do when I become pregnant? Do I get off the statin? How does that work? So if you could talk to us a little bit about that. Dr. Garrett Ruth (33:58) And like you said, it's becoming more prevalent. Steer still I'd say is on the rare side, but certainly becoming more prevalent just with, like I said, advancing population, having kids later and just really the advances in modern medicine and the ability to have these kids later, to be honest. Yeah. the general consensus is statins, they're generally stopped in pregnancy. In fact, you're supposed to... by definition, you're really supposed to stop in three months before even trying to conceive at that point. And that's okay. You know, there is a small again, I've never seen it in my practice, but they do in some, at least in studies, they've continued it for the very high risk patient who has had heart attacks, who's had stents who have had, and again, you don't, that's a very rare population to have, but it can be there. But generally, We will stop statins three months before even attempting to conceive and certainly throughout pregnancy because there are some associated risk of possible birth defects, cardiac malformations, abortion. It's not well studied. We don't give statins to pregnant people and study them because of that. So the data is not really there to say one way or the other, again, I keep saying risk and benefit, but the risk at this point highly exceeds what we think would be the benefit. outside of the highest of high risk population. So overall, discontinuation and resumption after even breastfeeding, if you plan to breastfeed because they do seem to cross into the mother's milk. So that's the general consensus is it stopped and restarted once all that is done. And we're talking about a chronic medicine, right? It's not something that's going to affect you. Yeah, your cholesterol might go up in that year, but you know, overall, this is meant for a long-term protective effect as opposed to a short-term. So that's the other reason. Melissa Schenkman (35:52) Very helpful pieces of information for us, absolutely. I appreciate that very much. And when it comes to talking about cholesterol, I know we've talked about a lot of different things, but I'm wondering just from the basics of how we want to approach this when you're going, regardless of whether you're in your 20s, you're now mid 30s, or you're one of the older millennials and you've entered the early 40s, which you can't believe. seriously, how should we approach this? What questions, what are some of the main questions you would say that when we go from year to year that we should have top of mind to ask our primary care doctor, an internist if people have an internist or for women who their sole you know primary care practitioners, a gynecologist, what are some things that we should regularly in those yearly annual appointments be asking about our heart health and about cholesterol? Dr. Garrett Ruth (36:49) Talk about your family, bring them up. It's very important. Talk that it's not brought up. They should be bringing it up anyway, but bring it up. Say, hey, I don't know if you remember this, but my father, he had bypass and he had that when he was 42 and I'm 37. Is that a problem? Because that would, in my mind, that brings up a red flag that we need to do some more investigation into the risk of that is super important. Melissa Schenkman (37:14) Family history is key because you don't know what you don't know, as they say. having that information is so helpful to your point to your healthcare practitioner and really, and for you to know, because then you know when also to bring it up too and to remind them at what point, what age you're at making yourself aware too is a big piece to this. Well, this has been an awesome discussion, so many helpful pieces of information you provided us because this is it really I tell you I going into this episode, I have been so surprised for how many people cholesterol and saddens are very much top of mind and you can you can look at the general to your point information on things and it's not always very helpful a lot not too much helpful in this case on Google to your point and being able to talk to somebody yeah. And be able to talk to somebody like yourself who's in our generation who practices cardiology, who's talking to people about these things every day and sees such a wide age range. It really makes a huge difference. So thank you so much. Dr. Garret Ruth (38:23) Of course, no, it's a good discussion. I'd like to end on a final note saying that statin therapy is not necessary for everybody. They have clear benefits that are well documented in various trials and studies, but having an open discussion with your physician is more than half the battle in deciding what medication could be right for you, especially when it could mean reducing your chances of heart attack and stroke over one's lifetime.