OneMedicine Podcast

Rob Lutz 00:02
Hello, and welcome to the OneMedicine Podcast with Today's Practitioner. In each episode, we share the expertise of a respected thought leader. Some you'll know and others you'll probably meet for the first time. We cover topics important to you, always with a focus on improving the health outcomes of the patients you treat, while expanding your understanding of the many healing modalities being used today.

Rob Lutz 00:24
Hello, and welcome to this episode of the OneMedicine Podcast, powered by Today's Practitioner. I'm Rob Lutz, your host. I'm also the founder and editorial director at Today's Practitioner. I'm joined today by Dr. Sarah Hung, a licensed and practicing naturopathic doctor. We'll be discussing natural strategies to address cardiovascular health in women. Welcome, Dr. Sarah. Please share a little bit more about your background in any context related to the topic today.

Sarah Hung 00:51
Absolutely. I'm really excited to be here today. Thanks so much for having me. In terms of my background, I'm a naturopathic doctor, a licensed acupuncturist, an herbalist. I have a practice in Naperville, where I see a wide--patients of pretty much all ages, from very young to very old. We focus on things like cardio and metabolic health, cognitive health, hormonal health, and mental-emotional health. So, it's a wide variety of everything from TCM to functional medicine, and been in practice for six years now. So, excited to be here, and excited to talk with you.

Rob Lutz 01:31
Where did you go to school? Where did you get your degree?

Sarah Hung 01:35
Yeah. National University of Health Sciences. It's in the Illinois corner of the naturopathic map.

Rob Lutz 01:41
That's great. Yeah. Well, thank you. So, you know, this topic that we're going to be talking about today is definitely near and dear to my heart. My mother, who's 87, she had a major heart attack back in January. She's doing great now, but her--she had 100% blockage of her LED, and she really had no risk factors, or symptoms I should say. She was seeing a cardiologist, and she was on a very low-grade statin, so it was a surprise for sure. And it was interesting. I was there when the paramedics arrived. We can maybe talk a little bit about that as well. But you know, so I'm curious. I've been tested myself, and I know that my LP(a) is very high, and I'm guessing, since that's hereditary, maybe I inherited it from her. She hasn't been tested for that, but really had no other risk factors. But anyway, this is, again, a topic I'm very interested in for myself, and so very excited to hear your input on this. So, I'll kick it off with a question: How women and men differ in their presentation of heart disease, if that's something you could maybe talk about a little bit.

Sarah Hung 02:44
Yeah, and what you said, Rob, about kind of just having a recent incident with your mother, that's really important to know, because there's been some studies--for example, I think there was a 2019 study by the American Heart Association that showed that compared to men, in which 65% of men were able to identify when they were having a heart attack correctly, only about 44% of women were able to identify when they were having a heart attack correctly. And so there's a lot of different reasons why this is. Women, as you're probably well aware, tend to have a lot more atypical symptoms of heart disease, or when they're having a heart attack, so that can include things like unusual fatigue, shortness of breath, even GI symptoms like nausea or indigestion that actually can be a symptom of a heart attack or a blockage of one of the main arteries. Part of this is because women were underrepresented in research up until very recently. Now, there's a lot more research going into women and heart disease. So as you said, it being near and dear to your heart, it's also near and dear to my heart, because I also--my grandma was hospitalized recently for a stroke, so I, also, it's near and dear to my heart as well.

Rob Lutz 04:12
Yeah, thank you. Yeah, so her symptoms--she called me, and we won't spend too much time on her situation, but first she thought it was indigestion, and so she took a Tums, and it didn't go away. She was having some other GI symptoms, felt very sweaty, you know, kind of overheating, had some upper chest area. And when the paramedics arrived, they looked at her and they go get some masks. "Oh, ma'am, you have COVID," is what they said. And so then they came back in with their masks on and hooked her up to something to check her heart, and you know, it's, "Oh no, you're having a heart attack." I think if it was a man having a heart attack, there's very clear symptoms. Right? They're kind of--and so it's a little different. Anyway, that's just an interesting point. Any statistical differences really between women and men in heart disease?

Sarah Hung 04:58
Yeah. Yeah, absolutely.

Rob Lutz 05:00
Right. Yeah.

Sarah Hung 05:01
Well, for one, women are--they are more likely to actually die from heart disease as compared to men, and they're more likely to wait longer in the emergency room if they're having a heart attack. And part of the reason for that is probably some of the things that we mentioned, just the symptoms may not seem as obvious, and maybe, especially in the past, some women may have been kind of written off as just having anxiety or a panic attack, and they may have been put lower on the triage list as compared to someone that has very obvious symptoms. So, the higher risk of cardiovascular death is very noteworthy. Also, another interesting fact is that women tend to have their first heart attack at an older age than men do. So, the average age for a first heart attack for women tends to be around 70 years old, so a few years older than men. Part of that is believed to be due to the protective effects of estrogen. We'll talk more about menopause, how that can also change heart disease risk too, because that's very important, especially for women.

Rob Lutz 06:09
Yeah, so how does that--what's going on? How does menopause change risk factors for women?

Sarah Hung 06:15
Yeah, it's a wide variety of things. So the sudden--not sudden, but gradual--decline in estrogen: estrogen does have a protective aspect in terms of cardiovascular health, especially in terms of the endothelial lining of the arteries. And so when we do see that decline in estrogen, a lot of times you can see a decrease in bone density, an increase of lipids. You can see increased blood pressure. That's just some of the changes that we see. And then, in addition to that, well, with a low bone density, that's also been associated with increased cardiovascular risk as well.

Rob Lutz 06:58
I wonder why. Why is that? What's the connection between those two? Do you know?

Sarah Hung 07:04
Bone density and estrogen, or bone density and heart attack? What'd you say?

Rob Lutz 07:07
Bone density and heart attack. Yeah.

Sarah Hung 07:10
Okay. So, my understanding is it's not completely understood, the mechanism, but just the correlation between estrogen can have a protective impact on bone density and estrogen also simultaneously can have a protective impact on the vascular system, the circulatory system as well, and just another--so, in terms of the exact mechanism, I'm not sure, or at least I haven't come across the exact research on why the mechanism of that is, but just the correlation is very, very clear. And then another thing that's very interesting is that--and this is important for women that are on, for example, bioidentical hormones--there was a Finnish study that showed that women who discontinued bioidentical hormones before the age of 60 had an increased risk of a heart attack in that following year after discontinuing hormone replacement therapy, just for women that were under 60. So that's something really for clinicians to keep in mind, especially if they're prescribing a lot of bioidentical hormone therapy, that it's important not only to, if you're going to take hormone replacement therapy, to not only take it during menopause, but even into the later years of menopause as well.

Rob Lutz 08:31
And how much longer would you say it is important for them to continue with the hormone replacement therapy?

Sarah Hung 08:38
So, based on the study, the protective--the increased risk only was until the age of 60, and then that increased risk of heart disease in the following year after discontinuing hormone therapy was not seen after the age of 60.

Rob Lutz 08:53
Okay. Okay, that makes sense. You know, there's a lot of testing that can be done, functional medicine testing, and this is a conversation I had with Dr. Mark Houston on a similar podcast about a year and a half ago, you know, about some of the additional tests that can be done, some more advanced lipid testing, and you know, why some of those traditional lipid tests fall short. Can you talk about the test that you recommend and what you look for? And are you a fan of the advanced lipid testing and the data that you can get from that?

Sarah Hung 09:24
Yes, I'm a huge fan of a wide variety of advanced lipid testing. So, I'm a fan of the NMR profile, whenever patients are willing to order that. I love working with the Boston Heart Lab and the Cleveland Heart Lab, because the traditional lipids test only provides us just a small screenshot of what's really going on in the body. Even the LDL cholesterol, for example, that's pretty much just looking at the amount of cholesterol in the LDL particles, and it doesn't even show what type of LDL particles they are--if they're small, dense LDL particles versus large and fluffy LDL particles that are more likely to be returned to the liver or deliver cholesterol to the cells and the tissues of the body, which there are many functions that we need cholesterol for, for example, steroid and hormone production. So, if someone has high LDL cholesterol, it's again not going to show if, again the size of the particles. Small, dense LDL particles are going to be more likely to become attached to the arterial wall, especially if there's arterial injury and inflammation or endothelial dysfunction, which can be caused by a wide variety of inflammatory factors, so that's one aspect there.

Rob Lutz 09:24
I ended up doing the Boston Heart, you know, for some pretty thorough testing, and one thing that I liked about that, because I'm not a clinician, but they provided a presentation essentially telling me what the results meant. And so, that was very helpful for me. I also had a calcium score done, and you know, it's recommended by Dr. Houston. And that, so anyway, I'm personally--I was just trying to find as much information as I could about my heart health, and you know, cardiovascular. So, are there other tests that you look at or anything specific that you really narrow in on, particularly for women, as you're looking at their cardiovascular risk or treatment plans?

Sarah Hung 11:28
Yes, absolutely. So, definitely hormone testing too. I always look at that. The estrogen to progesterone ratio is important, calcium levels, but going back to what you were saying about the Boston Health Lab and the Cleveland Health Lab, there are very, very helpful markers in that panel. So, that's going to include things like phospholipase A2, myeloperoxidase or MPO. These are two markers that are going to look at not only if there's damage to the endothelium of the arteries, but is there potential of unstable plaque. So, if we do something like a calcium score, a CAC, that's going to look, it's going to be able to detect calcified plaque. However, it may not necessarily pick up uncalcified or soft plaque, which sometimes that can be a little bit more unstable as compared to the calcified plaque, which.

Rob Lutz 12:26
There's probably a lot more risk around those types. Right?

Sarah Hung 12:30
Correct.

Rob Lutz 12:31
What is the test that you do to look for that?

Sarah Hung 12:34
For the unstable plaque or?

Rob Lutz 12:36
Yeah.

Sarah Hung 12:37
Yeah, so MPO and the phospholipase A2 can sort of, can indicate that there is some inflammation occurring and some potential unstable plaque, because myeloperoxidase is this enzyme that is produced by white blood cells when there is injury or inflammation occurring. There's also something called the Cleerly test. I'm not sure if you've heard of the Cleerly test before, but that is actually a CT angiography, and so that's going to actually provide a map of plaque that's both calcified and non-calcified. So especially for patients that maybe did have very high levels of myeloperoxidase or PLAC, the Cleerly can help identify how much plaque is there, especially if the CAC score was 0, and they kind of wonder, "Well, do I also have--is it possible that I may have some unstable plaque that was not detected there?"

Rob Lutz 13:34
And where do those tests typically--are they at hospitals? Are they at other clinics? Where--for that particular one, that test, where does a patient typically go?

Sarah Hung 13:43
Cleerly, there are providers around the country that offer it. So, I believe there's a website for Cleerly, and you can look specifically for cardiologists that administer the Cleerly around the country.

Rob Lutz 13:56
Yeah. Thank you. So, how important is diet would you say in this entire conversation that you're having with a woman, regardless of what her age is? But how much emphasis do you put on diet and lifestyle?

Sarah Hung 14:11
Oh, huge. It's the foundation of everything that we do as naturopathic doctors, so it's definitely going to be a part of the conversation, whether it's regarding prevention or whether it's someone that has a strong family history of cardiovascular disease, or if someone had a cardiovascular event already, then diet is going to be huge, of course. And so, really in my practice, I really try to get people to eat as many plant foods as possible, so you really focus on things like the Mediterranean diet. In the last few months, I've been telling patients more and more about the Portfolio diet, that also.

Sarah Hung 14:52
The Portfolio diet was, it was a study done in 2021 and it looked at about 5,000 people, so--actually no, it was women specifically, and about 2,500 were Caucasians, 2,500 were African Americans in the study. And it followed--so, it gave the patients kind of a list of foods to really, really focus on for heart disease prevention, and they monitored how, kind of, adherent the patients were, or the participants were, to those particular foods. So those particular foods included things like viscous fiber, so things found in oatmeal, psyllium husk, fruits, vegetables, whole grains; as well as plant proteins, so things like legumes and beans; also phytosterols, a compound again that's found in many plant foods. And the patients that were, or the participants that were, in the top 20% of the study in being the most strict or getting the most amounts of these foods were found to have a 52% decreased risk of a cardiovascular event as compared to baseline. So I love sharing that with patients, especially if they have some of these elevated risk factors, such as a strong family history or elevated cholesterol, elevated markers on the Boston Heart Lab, etc.

Rob Lutz 14:57
What is that?

Rob Lutz 15:43
What about glucose levels? How much of a role do you think that can play? If someone, you know, has their fasting glucose and they're, let's say, pre-diabetic, what other--what else might that be causing in that patient?

Sarah Hung 16:29
Yeah.

Rob Lutz 16:31
From a cardiovascular standpoint?

Sarah Hung 16:39
it's a great question, because blood sugar regulation, insulin resistance, and cardiovascular disease, they all kind of go hand-in-hand in the way that they impact the arteries. And so, someone that has a high HbA1c, for example, or a high fasting glucose, as you've mentioned, that can potentially lead to further endothelial dysfunction. It can lead to arterial stiffening, which can impact--it can make plaque build-up more likely, and then it can also lead to high blood pressure. And so it's just, it's amazing how all these markers for general health, whether it's insulin sensitivity, high blood pressure, cholesterol, inflammation, how they all kind of create this symphony of things that can impact our arteries.

Rob Lutz 17:27
And when you mentioned this diet, I'm thinking, you know, probably it's going to be not a whole lot of processed foods or sugars or pastas or things that are going to raise your glucose.

Rob Lutz 17:41
And, you know, so I wonder if, you know, there's some of these patients that that is one of the causes, so to speak, of their issues is probably their diet, the way it was. And so to correct that and really improve it could make a pretty big impact.

Sarah Hung 17:42
Right.

Sarah Hung 17:55
Absolutely, like you said, especially the--if there's a lot of ultraprocessed foods that don't have a lot of natural ingredients in it, low-fiber diets. The Mediterranean diet, for example, has almost 30 grams of fiber daily, for example, which as Americans, we fall very short of that. As Americans, we also tend to be very magnesium deficient, which is another nutrient that is incredibly important for heart health, and we tend to have a very--we tend to not have an optimal ratio of omega-3 to omega-6, either, which in, kind of ancestral times, we had an omega-3 to omega-6 ratio of maybe 2:1 or 4:1. If we're eating a standard American diet with not a lot of nuts and seeds, not a lot of fish, and we're just eating a lot of, well, concentrated, meat that comes from concentrated animal feeding lots, not grass fed, for example, then that's going to really--and lots of seed oils, then we may see omega-6 to omega-3 ratios of up to 20:1, which is very inflammatory.

Rob Lutz 19:07
Yeah. Yeah, that's interesting. Yeah, you think about what we ate a thousand years ago, right?

Sarah Hung 19:13
Yeah.

Rob Lutz 19:14
We probably didn't have any of these, and we were--well, it wasn't exercise, it was basically surviving and living your life. And the foods that you ate were local and they were, it was probably a lot of game and things like that, that does have DHA and things like that in it.

Sarah Hung 19:27
Yeah.

Rob Lutz 19:29
Yeah, that's--I think that's really interesting. How, what a huge role that diet can play in keeping you from getting to that point, but also probably helping you to reverse some of these things that the patient's experiencing.

Sarah Hung 19:41
Oh, can I add one more point?

Rob Lutz 19:43
Please. Yeah.

Sarah Hung 19:44
Yeah, and one other thing, since you mentioned diet and lifestyle. So movement, at least, you know, 150 minutes of moderate to intense exercise weekly has been shown to be protective, but 250 minutes weekly even more so, improving the risk reduction from 20% to 30% with that increase of activity. So, like they say, sitting is the new smoking, and that's true for cardiovascular health too. And then stress management is another huge one. Rob, are you familiar with any of the research that Dean Ornish did?

Rob Lutz 20:23
Some, but please elaborate. I'd love for the audience to hear more about that too.

Sarah Hung 20:27
Okay, great. Dean Ornish was a physician--I believe it was either in the early 2000s or the 90s--and he did a study on heart disease patients, in which he focused on a plant-based diet, stress reduction, and activity. And so in those patients that follow this protocol, they, some of them that actually had plaque formation, were able to reduce the plaque formation on angiography by about 7%, whereas patients that were not following his protocol actually increased plaque production by about 11%. And so, given the fact that--it's amazing to think about actually being able to reverse plaque formation or reduce it.

Rob Lutz 20:50
It is, and it's--you know, what that made me think about was a question I wanted to ask you. It's about compliance. So you know, you're a practitioner, you're meeting with a patient that really needs to make some serious changes in their diet and their lifestyle, and you give them all this data. How do you get them to follow that? I mean, I guess they have to buy into it, but how? Do you have any kind of secret Jedi mind tricks that you use?

Sarah Hung 21:36
I don't know about Jedi mind tricks, but I think just making it as positive and exciting for patients as possible, so and then also trying to meet patients where they're at. So if a patient, for example, says, "I don't like fish," well, then we're not going to eat fish, you know. We're going to focus on the fish oil and focus more on the nuts and the seeds. And so really kind of trying to meet patients where they're at, kind of walking beside them and creating a plan that speaks to them, that gets them excited to join the bout. Or if there are patients, maybe, that are not excited about giving up lots of fatty meats, for example, focusing the benefits of adding more plant foods in, in addition to those fatty meats. You'll get some patients that don't like to swallow a lot of pills, so then it's a matter of, "Well, can we find this in a liquid form? Can we get it in a powder form and make a giant smoothie that is tasty to you?"

Rob Lutz 22:33
Yeah, that's great. You know, the other thing I think is, it can be surprisingly powerful from what I've seen, just from personal experience, is going for a 20-minute walk after dinner, or after a meal. And so I've been just playing around measuring, you know, with a continuous glucose monitor, and watching how dramatically my glucose levels drops just after a 20-minute walk after dinner. So that, it was interesting to have that glucose monitor, because it's real time. You can really see what's going on.

Sarah Hung 23:01
Yeah.

Rob Lutz 23:01
Knowing what the benefits of that will be for me. But yeah, so that's one I feel like--you know, I recommend it to everybody at this point, you know. It's so simple, and it's also good for stress management and all that kind of stuff, getting out for a brief walk after your meal.

Sarah Hung 23:18
And good for digestion, too.

Rob Lutz 23:20
Good for that, yeah. Exactly. All these things, you know, they all kind of work together. Well, let's kind of dig into some of the supplements that you typically use for your patients, and how you approach that. What are some of your favorites? What do you really look to?

Sarah Hung 23:36
Yeah, so supplements are, well, one of the most--one of my favorite things about naturopathic medicine is just how individualized it is. And so one patient may--there's never going to be a patient that has the exact same supplements that are recommended for them. And again, that's one of the reasons why I love being a naturopath is just we're looking at things like family history, their blood work, and their specific biomarkers to determine what are the best supplements to be taken. And so, of course, again it's going to be highly individualized but some of the main ones that I might typically use might be things like resveratrol, hibiscus, CoQ10, curcumin, mixed tocopherols, hawthorn, and omega-3.

Rob Lutz 24:27
Great. I would love to hear just a little bit more about each one of those, if you don't mind. Just, why CoQ10? Do you also think about ubiquinol? Because I know there's a discussion around that. And how much do you typically--what's a range for CoQ10 or ubiquinol? What do you typically look at for that?

Sarah Hung 24:45
Sure. Well, one, CoQ10 can actually be tested in the blood, so that can always be helpful with testing such as the vibrant micronutrients panel. That can be very helpful, especially after menopause for women, and just men of all ages, too. As we age, we produce less CoQ10 in our bodies. So, CoQ10, it is a fat-soluble nutrient, so it's best taken with a fat-containing meal. That's something that is sometimes missed, unfortunately. As you mentioned, ubiquinol is going to be the superior form. It is the most active form of CoQ10. Usually, I recommend in my practice anywhere between 100 to 200 milligrams, and it's going to be especially--for most patients that have any type of cardiovascular system, usually CoQ10 is going to be a part of that. It's going to be especially important if someone is on statins of any type, even if it's a low-dose statin. As you're probably aware, statins actually inhibit the production of CoQ10, so very, very important, if that's the case.

Rob Lutz 25:59
You also mentioned resveratrol. Talk to me a little bit more about why that's an important one, and why--because I think you mentioned that first. Why did that make it to your list? And how do you look at that?

Sarah Hung 26:11
Yeah, so resveratrol is a wonderful nutrient in terms of heart disease prevention, and especially for women, since there's some research that indicates that it can act as a selective estrogen receptor modulator. And it can also support bone health, which is very important for women as they approach and after they pass menopause. It's been shown to--not only is it a potent antioxidant, so it can help with things such as oxidized LDL. I think that's one marker we didn't discuss is--that's another common marker that is on the Cleveland Health Lab panel and Boston Health Lab panel. And that looks at if there is oxidation occurring with the LDL particles. And if someone has a high amount of oxidative stress, or they test for high oxidized LDL. resveratrol is a wonderful nutrient to add in. Resveratrol can also be found in our diet too, but usually the dietary sources of resveratrol are much, much lower than what you would get from a supplemental form. So it might be two or three milligrams that are found in grapes or red wine as compared to 100 or 200 milligrams that can be found in supplemental form. So it's kind of in these higher doses that we can see more of that selective estrogen receptor modulation effect. We can see also some studies indicate that it can lower levels of TNF-alpha, which is an inflammatory marker, as well as interleukin 6. It can reduce LDL cholesterol and help support endothelial dysfunction, which pretty much most natural things that are antioxidants support endothelial function.

Rob Lutz 28:01
Great. Yeah, it sounds like a really great one for practitioners to take a close look at when they're looking at their patients for heart health. Now we've mentioned magnesium a couple times. Is there a particular form that you look at for cardiovascular health in particular?

Sarah Hung 28:17
Yes. So I especially look at magnesium taurate in terms of being the most effective for cardiovascular health. Now, some patients, unfortunately, will have issues with bowel tolerance with magnesium taurate or other types of magnesium, especially if they have a very sensitive stomach or are prone to lose stools. So, you just have to be careful about that and just kind of work within bowel tolerance. Magnesium glycinate can sometimes be a little bit more well-tolerated for patients that do have issues with bowel tolerance. And so for the magnesium, of course, it's going to depend on bowel tolerance, but the dosing could be anywhere from 250 milligrams all the way up to 800 milligrams sometimes.

Rob Lutz 29:05
And would you take that throughout the day, or would you take it, you know, one dose, if it's a larger dose like that? Or is that going to cause the intolerance that you were talking about?

Sarah Hung 29:17
Exactly. So definitely, dividing up the dosages could, is usually recommended at that point, because that--of course, it's smaller amounts of the mineral which allow it to be absorbed and less, kind of, of a load for the digestive tract to, kind of, pull through. So, that's kind of--and magnesium just has so much benefit for the cardiovascular system. It increases intracellular levels of both magnesium and potassium, and it actually decreases intracellular levels of calcium and sodium, so kind of a similar mechanism to a calcium channel blocker, which is.

Rob Lutz 29:58
Okay.

Sarah Hung 29:58
Pretty amazing. It increases nitric oxide production, and just like resveratrol, it improves endothelial dysfunction, helps with vasodilation. It actually works synergistically with most hypertensive medications to help lower the blood pressure as well.

Rob Lutz 30:16
Yeah, that's great. So you talked about a couple of other botanicals. You mentioned hawthorn and hibiscus. Do you want to talk a little bit about those and how those fit into your protocols when you're working with a patient?

Sarah Hung 30:28
Sure. Hawthorn, I would say, is just a very gentle botanical. It's a very gentle hypotensive. It helps strengthen heart contractibility, and it's a very--it has a very good source of flavonoids in it. So, these flavonoids act as antioxidants, and they support both arterial health as well as the heart muscle itself. In terms of hibiscus, hibiscus is very convenient. Well, hawthorn, too. Some people will actually get the hawthorn berries and eat them as a food, especially if they're not particularly fond of taking lots of pills. Hibiscus, that's--so, it can be taken as a tea. There have been many, quite a few, studies done in Iran, for example, that have shown that three cups of hibiscus tea daily can significantly lower the blood pressure, sometimes by up to 10 millimeters per mercury or more.

Rob Lutz 31:25
Wow.

Sarah Hung 31:25
in addition to that, hibiscus can help with insulin resistance. It can help with fasting glucose, for example, and it helps also lower LDL cholesterol. So it's pretty far-reaching.

Rob Lutz 31:39
That's amazing. And I mean, you typically use the whole herb? Are you using extracts? What's your philosophy of that? I'm just curious.

Sarah Hung 31:48
So, it depends. With hawthorn, for some reason, with my client population, we found that the berry is more effective, especially for patients that have abnormal heart rhythms or things like PVCs, things of that nature, or even maybe they're prone to just tachycardia or even AFib, that the hawthorn berries have been most effective for them, which is very interesting. For hibiscus, I believe it's usually--it may be the leaf that we're usually looking at. So in terms of--it's very interesting with botanicals, you can sometimes, you can choose different parts of the plants for different effects. Dandelion root, that's another beneficial botanical that's often used in cardiovascular health. It's high in potassium, for example, and it helps support liver health. If, you know, liver enzymes are elevated for patients that are experiencing cardiovascular issues. So with dandelion root--sorry, with dandelion plant, the leaf is considered to have more of a diuretic effect, whereas the dandelion root actually is more liver-supportive. And so, if you wanted kind of a mixture of both, you could do a mix of both the leaf and the root, whereas if you were specifically looking to support liver health, gallbladder, and detoxification systems, then the root would be what you would be aiming for.

Rob Lutz 33:19
That's interesting. You know, I remember an herbalist telling me this--this was years ago--but you know, dandelion is a diuretic, but if you take the whole herb, the whole plant, you know, when your diuretic can deplete your potassium, so you're eating the plant that has the potassium in it. So it's kind of like this natural balance built right into that particular plant. I find those things interesting, you know, how things work in the natural world that way sometimes.

Sarah Hung 33:45
Yeah.

Rob Lutz 33:47
So, I know we talked a little bit about testing. Are there any other tests or things that you want to touch on? Because I know before we got on, we talked about some--you were going to chat with us a little bit about, you know, women in various stages of their lives as it relates to cardiovascular health, so I want to make sure we're leaving time for that, but are there any other tests or anything else that you want to just bring up regarding testing as part of your approach to cardiovascular health in women?

Sarah Hung 34:14
Well, we look at that. So, cardiovascular testing in women. So as you said, the HbA1c. Insulin is--also that can be even more sensitive for insulin resistance prior to anything shows up in the glucose or the HbA1c. So that's always helpful, especially if there's a family history of any type of insulin resistance or Type 2 diabetes. And so, like we talked about with, after menopause, there are some risk factors that can increase, such as the bone density can change, the cholesterol can go up, blood pressure can go up. One thing I don't think we've talked about yet is visceral fat, that after menopause there can sometimes be an increase of visceral fat, due to redistribution of estrogen in the body. And so, visceral fat, as you know, it can produce more inflammatory markers, so it can be more dangerous for metabolic health in the long run, and it can increase the risk of things like fatty liver disease. And so I think also just keeping track of waist circumference is very important after menopause for women that maybe have a BMI that has increased since then. Sometimes you can see the opposite, that actually women after menopause lose lots of weight, and then you worry about things like bone density, and them getting enough calories. But for many women also just waist circumference, keeping track also of the liver markers if there is a suspicion that fatty liver may be a part of that process as well. So, I think that's important when testing for women, especially after menopause. And then lastly, I don't think we talked--we talked briefly about NMR, but just, the NMR profile helps differentiate between small, dense LDL particles versus large, fluffy particles, and it also differentiates between the LDL particles themselves and the LDL cholesterol. So sometimes someone may have high LDL cholesterol, but they may have a low amount of particles, which can be a higher risk than if the LDL cholesterol is high. So, that's just another test that some patients will kind of bring in, in addition to the Boston Heart Lab. Or sometimes we'll order that as well, just to get additional information there.

Rob Lutz 36:56
That's great. All right, well, I am really interested to hear you kind of walk us through, because the topic is cardiovascular health in women, really kind of across the ages, their ages, their lifespan. And so, if we were to group it into three age groups, you know, women in their 30s, women in their 50s, women in their 80s or thereabouts, can you kind of walk us through, you know, maybe some anonymous patient kind of examples, you know, or whatever you feel comfortable with in that respect. That would be very interesting, I think.

Sarah Hung 37:29
Yeah, absolutely. So, as you said, because of menopause and changes that occur during and after menopause, the way that our bodies respond to naturopathic treatments in particular, in my clinical experience, it can vary based on age. So some of the women that I've seen in their 30s, for example, and many of them will develop some cardiovascular issues after childbirth, for example, especially if they had something like gestational diabetes or hypertension during their pregnancy. And so, sometimes those effects can can linger or recur within a few years after childbirth occurs. And so a part of that picture is addressing potential hormone imbalances if estrogen or progesterone has shifted at all following childbirth. But the good news is, at least in my clinical experience, most of the women in this category tend to respond very well. So for example, some of my patients that have experienced hypertension, for example, after childbirth, they've been very responsive to relatively simple diet changes, so just focusing on reducing the processed foods, increasing foods that are rich in magnesium and potassium, increasing the whole grains and the dark leafy greens, and then doing some botanicals, so. We didn't talk about this yet, but sometimes I like to use herbs like mistletoe and African snake root, if in very severe cases, linden. These are all--and of course, the hibiscus is a very common one too. So these are the type of herbs that thankfully have been quite effective in lowering the blood pressure, in addition to the dietary and exercise changes, so. And that age group, also I feel that most women are very receptive to changes. They're very eager to stay healthy for their children, for example, and so they feel motivated to make dietary and lifestyle changes. Exercise more, stress management for hypertension, especially, can be very important. I'm not sure if you've come across any of these studies, but there have even been studies done on meditation, yoga, and tai chi that show that if you do just 30 minutes of those stress-relieving practices weekly, that can lower blood pressure up to 10 millimeters per mercury.

Rob Lutz 40:10
Wow.

Sarah Hung 40:11
Just by doing those lifestyle changes. And it goes to show that if we're in constant stress, if our cortisol is constantly high, that's going to impact our heart rate and our blood pressure as well.

Rob Lutz 40:24
Yeah, absolutely. I wonder, with the meditation and tai chi, if somehow it's related to vagus nerve tone, you know, that's improving vagal tone or improving some of these other markers that you're talking about. I just--I wonder what the mechanism is. There'll probably be a whole 'nother podcast on that.

Sarah Hung 40:42
Exactly.

Rob Lutz 40:43
Yeah. All right. So that's women, kind of, in their 30s or so. The next kind of, you know, milestone, I suppose, is in the 50s. How--tell me something about, you know, patients that you've been seeing and, you know, how you approach that age bracket.

Sarah Hung 40:58
Yeah, absolutely. So in the 50s, I've seen quite a few women that are kind of looking for prevention. And this is a time when some women are, kind of, going through menopause, some may have already completed menopause at this point, but this is when, this is kind of an interesting time period for women, because due to those shifts in estrogen, not only are you seeing those shifts in body composition--for example, for many women, we talked about the visceral fat increase and the increase in cholesterol, high blood pressure changes, and then, of course, bone density. So for this age group, there can also be changes in cognition too, because when we go through menopause, that actually changes. As estrogen declines, that changes the way that neurons communicate with inside the brain. Thankfully, after menopause has occurred, a lot of women will go back to baseline in terms of cognition, but a lot of women who are actively going through changes in estrogen, oftentimes there will be complaints of brain fog, difficulty remembering names, difficulty with recall, and some will even kind of wonder, "Am I having early dementia?"

Rob Lutz 42:25
Right.

Sarah Hung 42:26
But thankfully, this is a temporary change as the brain adapts over time, so there's just--there are many different factors that are kind of shifting and changing as a result of the changes in estrogen and progesterone. So, a lot of women of this age, I do find that there is more resistance to weight loss because of these changes in estrogen and so, being--also keeping in mind things like cortisol, as well, that while we do want to exercise regularly, and undergoing resistance training can be a part of that as well, we also--this is probably not the age for someone necessarily to go and run a triathlon.

Sarah Hung 43:22
Okay, yeah. So women in their 80s, that's where I've seen the most resistance to changes for things like blood pressure, for example. One of my patients, for example, has been very resistant to changes in blood pressure, despite being on medications and some dietary changes and some botanicals. I think it's a lot more difficult for women in their 80s to make dietary changes, for one, due to obviously, there's some assistance that's needed at that age, and energy levels are lower, and well, just as we get older, we're more set in our ways, and so this definitely comes up in different cases. One thing I wanted to mention too is that I've seen that there can sometimes be a lot of other comorbidities that can play a role in things like blood pressure. So for example, one of my patients had toxin exposure that made her especially resistant. Another patient had an issue with high parathyroid levels, which can also impact both calcium balance and lead to hypertension as well. And so sometimes it involves--there may be some additional pharmaceutical interventions that, kind of, help get to the root cause of that. But I did want to share one, a very, kind of, successful story in this age category, and that is one wonderful patient that I have that's in her 80s. She underwent a very strict anti-inflammatory diet, as well as started taking about 100 milligrams of curcumin with resveratrol, and not only did that improve her hemoglobin levels, as she was low in hemoglobin, but it actually cut her myeloperoxidase levels in half. That's one of the markers we talked about that is--it's a marker for unstable plaque. And so through these dietary changes, she was able to make a tremendous difference on that particular marker. So I just wanted to mention that that can be very helpful.

Rob Lutz 44:37
Right, right. Yeah.

Sarah Hung 44:38
Because of hormonal shifts.

Rob Lutz 44:40
Yeah. Got it. And then I guess the next stage is, you know, women in their 80s. And talk to me a little bit about that category.

Rob Lutz 45:27
Yeah, that--I love stories like that. How long did it take her to change her diet, and some of the things that you mentioned, before she started to see these impacts on those tests and her situation?

Sarah Hung 45:41
I think for her it was pretty quick that she was able to make the changes, because she had a great team supporting her, a very supportive daughter, very supportive caregivers. So I think, especially in this age group, having a good team that's on board with changes in diet and administering the supplements is of utmost importance. I also wanted to mention--sorry, if you don't mind--I don't think we talked about amla, but I did want to share just a little bit about that particular botanical if we have time.

Rob Lutz 46:15
Of course. Please.

Sarah Hung 46:16
Oh, okay. Just, amla is another botanical that I've been using for both men and women, especially in the age groups of the 50s and above. And so amla is pretty much a medicinal food. It's been used in Ayurvedic tradition for centuries, of course. And so amla, it can either be taken 500 milligrams twice a day or it can be purchased as a powder from Gaia or Banyan Botanicals, and just be added into a healthy smoothie or oatmeal. And amla, it has a lot of potential in the fact that it's a very potent antioxidant, it can lower total cholesterol, LDL cholesterol, as well as triglycerides, and there's even been some small studies that show that it may have benefit for lowering lipoprotein(a).

Rob Lutz 47:14
No kidding. So I need to look into that one for myself. That's interesting. And so you said it's a food. What, is it an herb? Is it a fruit? What is it before they put it into a powder form? I'm just curious. I've never heard of it before.

Sarah Hung 47:30
Yeah. I think the English name is Indian gooseberry, and.

Rob Lutz 47:33
Okay. I have heard of that. Yes.

Sarah Hung 47:35
So very commonly consumed in the Ayurvedic tradition. It's very high in vitamin C, and again, it has lots of polyphenols, a lot of flavonoids that are very heart-healthy.

Rob Lutz 47:50
That's great. Well, we've covered a lot, and this is great. Are there any kind of recaps or key takeaways or clinical pearls we'd like to end with just so, as the audience is leaving, just please remember this, you know, or think of this. Is there anything that comes to mind?

Sarah Hung 48:08
Yeah, I would say the number one important thing is creating that foundation. Supplements are wonderful too. We talked about resveratrol and how concentrated it can be in its supplemental form, but I can take resveratrol until I'm blue in the face if I don't have a good diet, a good exercise routine, and a good--for older individuals, a good supportive team that are on board with changes that that I'm making. And then another kind of key takeaway, I would say, would be the medicinal foods, just--like we talked about just how our diets have changed so much over time when it comes to heart health. So the omega-3 rich foods as opposed to--and even omega-9, which is found in olive oil, that's been shown to be incredibly protective--as compared to, kind of, more the highly processed foods, the foods that are high in refined sugars, refined carbohydrates, that are so prominent in our diet today in America, unfortunately. And just, also magnesium, that the magnesium-rich foods have also been stripped from our diet. So even--you were talking about maybe 200 years ago, most of us would have been consuming whole grains or even rice that had the whole on it, so kind of were the brown rice, a wild rice, things of that nature. So when grains have the bran attached to them, believe it or not, that also has magnesium. Of course, all the dark leafy greens, the nuts, and the seeds, so things like sesame seeds, pumpkin seeds, almonds, things that we tend to not eat as a whole on a society, but are very rich in magnesium. And like you were talking about earlier with synergy, when we get things from food, there is that incredible balance there, so a lot of foods that are high in magnesium also have zinc in them. They have calcium in a particular ratio. The dark leafy greens also will have some vitamin K in there, which is also important for heart health. So anyone that takes vitamin D3, it's important to take it with K2, and so I think if there is any one key takeaway, it would be focusing on food first, the synergy of different nutrients in some of these foods, and then, of course, creating a good foundation and having good support.

Rob Lutz 50:41
Yeah, I love that. You know, and I think the great message there is, you're not going to solve any huge problem, health problem, by taking a pill, whether it's a supplement or a drug. Right? Really, I think if you want to have meaningful change for the patient, it's all the things that you've talked about. It's getting the patient involved and changing their diet, changing their lifestyle, just kind of realigning to more what would be considered healthy practices. And then the supplements can help, and in some cases medications might be necessary too, but--so I think that's a fantastic message. So, thank you. I really enjoyed our conversation, Dr. Sarah. This was great, and I appreciate you being on the show, and I'd love to have you back sometime.

Sarah Hung 51:24
Well, I would love to be back, and I appreciate talking to you. It was a great conversation.

Rob Lutz 51:29
Yeah. Thank you.

Rob Lutz 51:31
Thanks for listening to the OneMedicine Podcast. I hope you found today's episode interesting and came away with a few insights you can apply to your practice. If you're looking for the show notes, they can be found in the link below. If you want to go deeper on this topic, or anything else, please visit todayspractitioner.com and consider registering for our weekly newsletter as well. Thanks again, and I hope you'll join us next time.