The Peter Attia Drive - #20 - Thomas Dayspring, M.D., FACP, FNLA – Part I of V： an introduction to lipidology

00:00:00.000 Hey everyone, welcome to the Peter Atiyah Drive. I'm your host, Peter Atiyah.

00:00:10.140 The Drive is a result of my hunger for optimizing performance, health, longevity, critical thinking,

00:00:15.600 along with a few other obsessions along the way. I've spent the last several years working with

00:00:19.840 some of the most successful, top-performing individuals in the world, and this podcast

00:00:23.600 is my attempt to synthesize what I've learned along the way to help you live a higher quality,

00:00:28.360 more fulfilling life. If you enjoy this podcast, you can find more information on today's episode

00:00:33.000 and other topics at peteratiyahmd.com.

00:00:41.340 Hi everyone, welcome to this special edition of the Peter Atiyah Drive. This is a special edition

00:00:48.000 because it is the longest podcast ever recorded in the history of podcasts, maybe. It was a seven

00:00:54.300 hour, only getting up to pee once interview with Dr. Tom Dayspring, who a number of you will

00:01:02.220 immediately recognize by name. Tom is one of my most important mentors and is generally the mentor

00:01:08.140 to the mentors in the field of lipidology. We're breaking this into five parts. So this is going

00:01:14.840 to be the week of Tom. So today, if you're listening to this in modestly real time, on Monday, we're

00:01:21.160 releasing part one and there will be a part released each day, Monday through Friday. So this seven

00:01:26.740 hour podcast will be released over the course of a week. I'll call it the week of Tom. And what you're

00:01:32.440 listening to right now is part one. I'm going to use part one to give the bio and background on Tom

00:01:37.960 and give you just the insights over what is covered in part one or episode one. And then prior to each

00:01:45.860 episode, I will just highlight what's going on there. Tom Dayspring is the chief academic officer

00:01:51.800 for True Health Diagnostics, a laboratory company. Tom is a fellow of both the American College of

00:01:57.560 Physicians and the National Lipid Association. He's board certified in internal medicine and clinical

00:02:02.080 lipidology. He practiced medicine in Jersey for just under 40 years. And in the last two decades,

00:02:09.280 he's given about 4,000 domestic and international lectures to lipidologists and cardiologists

00:02:15.820 everywhere, including a little over 600 CME programs on this topic. He's listed in the guide to America's

00:02:22.860 top physicians and is on the editorial board of the Journal of Clinical Lipidology. He's authored and

00:02:29.140 coauthored more manuscripts than I was able to count, although that's obviously a countable number.

00:02:33.920 And he has received the 2011 NLA National Lipid Association President's Award for Service to

00:02:40.780 Clinical Lipidology. I actually spoke to the president of the NLA who gave him that award and

00:02:47.520 he described it as the most important award he had ever given out. Tom's really active on Twitter

00:02:53.040 at DrLipid. That's D-R-L-I-P-I-D. And more than anything else, as I think comes across in these

00:03:00.280 interviews, I share just the greatest affection for Tom. He can be rough around the edges. And when

00:03:06.680 I ask Tom a dumb question, boy, do I get an earful about it? And he'll always tell you, I'm sorry,

00:03:12.720 I'm just a Jersey boy. I just don't know how to sugarcoat it. But I don't know how to express my

00:03:18.220 gratitude towards Tom other than the way I probably do so in this podcast. And I really wanted to do

00:03:24.120 this to share so much of the knowledge that Tom has given me with so many other people. There's

00:03:30.040 obviously been such an interest in understanding this space. As I think I probably allude to in

00:03:34.400 this podcast, back in 2011, 12, and maybe even into 13, I wrote a nine-part guide on cholesterol

00:03:41.620 called The Straight Dope to Cholesterol. It was about 30,000 words. It was quite a lot of work.

00:03:46.600 Obviously could not have done that without Tom's help. And to this day, Tom is probably the single

00:03:53.380 most important clinical mentor that I have. In this first episode, which is probably going to be a

00:03:59.900 little bit longer than the others, this is where I'm going to really kind of introduce you to what

00:04:03.580 I call the national treasure. And that's just the way I described Tom. He is just a national treasure.

00:04:08.820 And I am not the only one to say that. You ask any card-carrying lipidologist who they look to

00:04:14.760 as their go-to guy on education, and it's going to be Tom. We talk about some of the definitions of

00:04:20.760 things, but we actually start by talking about things about Tom's personal life that most people don't

00:04:25.260 know his obsessions, firefighting, hockey, and ultimately lipids. And there's a common thread

00:04:30.640 to Tom's obsessions. He's an amazing author and illustrator. And we talk a little bit about some

00:04:35.920 of that stuff and his gift to teaching. So in many ways, the first episode is the soft one. This is

00:04:41.400 the one that kind of gets you warmed up, gets you ready to think about what we're about to do. And then

00:04:45.920 in episodes two through five, we get into sort of the more technical stuff. The other thing I just want

00:04:53.060 to say for this episode, as some of you may recall for the episode with Dave Feldman, we splurged on

00:04:58.800 getting a transcript so that we could really make this technical information available. Tom was so

00:05:03.240 kind to go through and edit and correct all the things that Dave and I had said incorrectly, which

00:05:07.740 is invariably going to happen in a long podcast. And he also did the same thing for this podcast. So

00:05:12.840 when this podcast came out, I want to say it was 80,000 words or 90,000 words. It's basically a book,

00:05:19.340 medium sized book. Tom went through with a fine tooth comb and made all of the corrections

00:05:24.840 there. So what you'll also find in the show notes is sort of an editorialized corrected version of

00:05:30.500 the transcript. I think it is safe to say that you could learn more in the next seven hours,

00:05:35.440 meaning episodes one through five, than you would learn in a lipid fellowship. And I suspect that many

00:05:41.240 people who are studying in a lipid fellowship will find great value in this. That's the level of

00:05:46.160 detail we go into. And at the same time, if you're a patient, if you're a primary care physician,

00:05:50.940 I think you will still find this incredibly valuable. So this was a little more work than

00:05:56.280 usual to prepare for it, to record it, to edit it, to break it down, to do all of the things we did,

00:06:02.000 but I believe it's worth it. And I am so happy to have been able to have done this because I think

00:06:06.920 of there are a few things that I get more pleasure out of than sharing Tom's knowledge with other people.

00:06:11.680 So with that, welcome to episode one of the week of Dayspring.

00:06:20.000 Hey, Tom, how are you? I'm very good, Peter.

00:06:23.140 Thank you so much for schlepping all the way up to New York to talk with me.

00:06:27.520 Not the world's longest journey.

00:06:30.940 I think a lot of people have been looking forward to this. I think many people have sort of relied

00:06:36.860 on your insights, your knowledge over the years as I have. And I think what follows,

00:06:43.020 and I have no idea how long this is going to be, but I suspect it will not be one episode.

00:06:47.860 But this will certainly be the master's class in lipidology, but not just for physicians who want

00:06:54.700 to understand this more, but I think for patients too. But there's so much stuff to talk about before

00:06:58.800 we get into that. And I figure if you're willing to talk about it, what I'd love to do is

00:07:04.180 have you explain a little bit about this kind of remarkable physical transformation you've

00:07:08.920 undergone in the last year, which this is only, this is actually the first time I've seen you

00:07:13.440 in person in eight months. And I could barely recognize you as you walked down the hall to

00:07:19.320 my apartment yesterday.

00:07:21.360 Well, many people who have seen glimpses of me on the internet or whatever in person,

00:07:26.620 God knows how many lectures I've done across our great country, have always known,

00:07:30.860 geez, for a lipid guy and a cardiometabolic guy, he's kind of obese. So he probably doesn't

00:07:37.260 always practice what he may be preaching and everything. So indeed, I've had a long, long

00:07:44.260 experience with obesity and insulin resistance and cardiometabolic disarray and everything.

00:07:51.380 And always had the usual million excuses why I didn't have to do anything about it or so. I felt

00:08:00.460 good. Nothing was happening to me. And I just did kept ignoring it. But I did keep aging. So for those

00:08:08.680 who don't know, I reached 72 years of age this year, 71 last year. And I've been great friends with

00:08:18.420 Peter for a long time. And Peter, of course, has been harping at me to do better nutritionally

00:08:24.060 and everything. And I just stumbled into his podcast done up at MIT, where he talked a lot

00:08:31.880 about longevity and Haiti average age of death in the United States. And as an old man, I can see a

00:08:40.340 little light at the end of the tunnel like, geez, if Haiti is the average age of death, how much longer

00:08:44.660 do I got to go? And over the last five, six years, I've dealt with a bunch of morbidities,

00:08:50.400 a lot of them arthritic in the spinal nature. But cholecystectomy and fatty liver and things like

00:08:57.980 that were sneaking up on me, even though other than my bone issues, I felt pretty bad. So I just said,

00:09:04.500 you know, since I do see the end of the tunnel and Peter's making a lot of sense what he's talking

00:09:10.160 about a little about longevity here, maybe ought to listen to what he's preaching here. And he did

00:09:17.180 raise the topic of intermittent fasting during that talk and everything. I sort of figured I got

00:09:22.880 to do low carbs finally more than I ever did. But the fasting was kind of new to me, you know, and

00:09:29.220 in further conversations with Peter, he just put me on an incredible regimen he's developed.

00:09:34.940 It's a modified intermittent fast that I said, I can do that. And I did it. And as Peter says,

00:09:42.960 that was 67 pounds ago over the last 11 months, I just finished my 11th month of a, I do one week,

00:09:50.960 a month of 700 calories or less, pretty significant carb restriction. And it's not only the weight has

00:09:57.640 gone off, but I mean, a bunch of residual orthopedic symptoms that I was having that I just thought I'm

00:10:03.920 going to have to live with the rest of my life. I've had a hip replacement, several spinal surgeries.

00:10:09.940 I almost 90% of the time, 95%, I feel like I've got my normal hip back, my normal spine back.

00:10:16.780 I can walk again.

00:10:18.820 We walked to dinner last night and you said that that was a walk you would not have been able to do

00:10:23.060 a year ago.

00:10:23.560 Yeah, a year ago, I could walk on a short block and I'd have to sit down and wait for my bones to say,

00:10:29.380 okay, try it again. And now they just don't have any of those limitations. So it's been miraculous

00:10:35.540 in a lot of way. And I think it's way beyond just the weight loss too. I think this fasting and

00:10:41.660 whatever else it's inducing in me has just changed a lot of things. And we know that because, look,

00:10:48.180 I work for a laboratory. I can do a lot of sophisticated testing on myself and checking

00:10:53.580 every cardiometabolic marker that pretty much a lab can do nowadays. And there was some ugliness

00:10:59.240 to my report a year ago. And it's, those who follow the lab I work for know it's reported in

00:11:06.780 red, yellow, and green, and green as you've got an optimal level of whatever. And it went from a

00:11:13.240 pretty yellow red report to a 100% green report. So it's not only, geez, I'm feeling so much better

00:11:20.260 biochemically. I'm doing an unbelievable amount. And I mean, I'm happy about all of that,

00:11:26.100 but the disappearance of the aminase levels have been especially impactful.

00:11:30.820 Yeah. So I'll interject to just add some commentary. So the first thing I would say is

00:11:35.380 you were quite resistant, I recall, when we first had the heart to heart. So you called me after you

00:11:41.500 saw the MIT video. I don't even know why you saw it. I don't think I sent it to you.

00:11:45.380 You think you linked it to me?

00:11:46.560 And one last joke about that, you know, I'm good friends with Peter. I don't want to ignore

00:11:51.560 anything he sends me. I send him a lot of stuff and I know he reads most of it. And I said, all right,

00:11:56.580 I'll humor him. I'll listen to 10 minutes of this lecture. And at least I can be honest, say, yeah,

00:12:02.080 I listened to it. And I put it on and I'm a busy guy. I don't have an hour and a half to listen to a

00:12:07.540 podcast. And I just couldn't stop listening to it. I went right to the end. I've listened to it one more

00:12:12.400 time. I've referred it to many other people to listen to. So it's one of these things in life

00:12:18.340 that somehow it really impacted me on that day. Which is interesting because the first 10 minutes

00:12:24.600 are not particularly interesting. So I don't know. Luckily, we snuck you through. But so I'd always

00:12:29.840 had this concern because over the past seven years, we've known each other, you know, you see my labs,

00:12:34.720 I see your labs. And I'd always been kind of concerned about those LFTs. And it was like they were

00:12:39.720 getting higher and higher. And there were a number of other things I was concerned with. So

00:12:42.820 when you responded to me saying, hey, I want to do something about this. And I said,

00:12:49.080 you know, in the past, you've had a hard time just adhering to carbohydrate restriction. I think we

00:12:54.420 need to try something a little bit more extreme. And so what I proposed, as you said, was this idea of

00:13:00.040 doing a modified fast. And this is sort of loosely based on Walter Longo's five-day FMD, but we kind of

00:13:06.880 took it a little more extreme. So a slightly higher ratchet up on the caloric restriction during

00:13:11.760 five days and also doing it every single month as opposed to quarterly. And also in Longo's version

00:13:18.560 of the fast, it's focusing on the restriction of protein. So it's actually relatively high

00:13:22.380 carbohydrate. We wanted to restrict carbohydrates both inside and outside of the FMD. Well, you expressed

00:13:29.220 enormous reservation just at a practical level. Like I, Peter, I don't think I can do this.

00:13:34.820 So what I think I wanted to point out was that it was amazing that you took that plunge the first

00:13:40.680 time. Because I remember that first one you did last, I think, October. And you worked very closely

00:13:46.320 with Nicole, who's our dietician inside the practice. And she, you know, was just incredible

00:13:52.300 at sort of guiding you through the logistics of what does it actually mean to eat 700 calories a day

00:13:58.120 of basically no carbohydrates. And then once you emerge from that, what are you going to?

00:14:03.760 Do you remember what it felt like after that first time?

00:14:06.380 Yeah. And look, I was highly motivated because of morbidities I had, my age, and I'm a time bomb.

00:14:13.800 Something more is going to happen. I sure don't want to undergo more orthopedic, degenerative,

00:14:17.880 arthritic changes. My gallbladder's gone. But that fatty liver, how many liver cells do I have left?

00:14:24.240 My big worry for what I do is cognitive impairment as time goes on. And I was certainly headed

00:14:28.940 towards ugliness in that direction also. So, and as you start approaching it, I want to hang around.

00:14:36.560 I got a son. I got a great life. I want to be here for a while. I was super motivated,

00:14:42.640 which 20 years ago, if we even knew this stuff, I don't know how motivated I would have been.

00:14:47.100 So the end was near. And just being so motivated, even though when I looked at Peter's recommendation

00:14:52.700 and Nicole's, wow, I don't think I can do this. You want me to, to me, the caloric restriction for

00:15:00.240 those five days was you're starving yourself. And I just didn't think my body would allow me to do

00:15:05.200 that as a guy who's used to nibbling all day long, every day of the week and everything. But the

00:15:10.860 motivation made me, I'll try it. If it doesn't work, it doesn't work. But he had convinced me in

00:15:16.780 that talk. There was a good chance to shut down a lot of these metabolic pathways that were

00:15:23.380 contributing to my morbidities. So with Nicole's great help in understanding how to put together

00:15:28.740 meals, especially during that week, and with an incredible wife who's willing to prepare my meals

00:15:34.420 and everything, I did it. And that first five-day fast, by day two or three, the hunger pangs are

00:15:43.740 there. And oh my God, can I do it? But no, I got to do this. And it's kind of funny. Like after day

00:15:48.980 three, the hunger disappeared. And on subsequent fasts, sometimes I go five days, I don't even feel

00:15:54.960 hungry during it. Maybe some, like last month I did it, the third day, which I do it a Monday

00:16:00.980 through Friday, the Wednesday, oh God, I'm kind of hungry. I feel kind of weak today. But it lasted

00:16:06.200 half of that day and then just passed. So I'd really tolerate those five-day fasts well. And the results

00:16:12.020 are so astronomical, the weight just poured off. We rapidly repeated some of the biomarkers. And

00:16:18.260 for a guy like me, my life is looking at biomarkers in people and seeing it was just so impressive that

00:16:25.820 this has got to be doing good things to my body. And symptom-wise, symptoms disappeared that I didn't

00:16:32.440 realize. I didn't realize I couldn't walk up a flight of steps without being a little bit dyspneic

00:16:37.080 or things like that. And that's just all gone. And so there were a lot of rewards that came

00:16:43.720 quickly. And the fasting wasn't as horrific as I thought it was going to be.

00:16:48.420 Yeah. I think people who listen to me talk have got the sense that I've become more and more a

00:16:53.380 proponent of fasting as an adjunct to dietary restriction. Of course, dietary restriction,

00:16:58.200 meaning the restriction of certain macronutrients. So carbohydrate restriction would be a form of

00:17:03.100 dietary restriction. Protein restriction would be meat restriction for those who choose to be

00:17:08.140 vegetarian or vegan. That would be a form of dietary restriction. And all of these things can

00:17:12.220 offer benefits potentially. But caloric restriction, the actual restriction of the total number of

00:17:18.380 calories for limited periods of time, I think has to be a cornerstone of what we do. Because it is

00:17:26.280 simply the most powerful way to deplete glycogen. It is simply the most powerful way to reduce insulin.

00:17:32.040 It is the most powerful way to turn those nutrient sensing organelles and molecules off. And we know

00:17:40.880 that we don't want those things off indefinitely. But we know that our current living environment,

00:17:46.760 where they're basically always on, you have these, you are constitutively fed. It's evolutionarily

00:17:52.120 unnatural. And in the metabolically ill person, it might be the single most destructive thing you can do.

00:17:58.900 And I've said this before, and I'll say it again, Tom, my intentions, I wish I could say it was just

00:18:03.480 altruistic. It was incredibly selfish, my motivation for this. I remember sitting down and saying this to you in

00:18:09.860 October, September last year, I was like, Look, Tom, the impact your teachings have had on me personally, and

00:18:17.720 therefore, by extension, on all of my patients, it can't be measured. And so I started jokingly, and I've been

00:18:24.540 calling you this for a couple of years, I've been referring to you as the national treasure. And I

00:18:28.820 remember saying this to your brother when we had dinner with him a few years ago, and he kind of

00:18:32.100 rolled his eyes at me. I'm sorry, to your son, to Brad. And so I just said, Look, this is a selfish

00:18:37.340 motivation that I have to keep Tom around as long as possible. So as long as I can be transparent about

00:18:42.800 that.

00:18:43.760 Oh, you're very kind. And the other good thing about your talk, look, I'm basically a scientist,

00:18:50.220 I don't try and ad lib and make things up like so many people do to support whatever they believe.

00:18:56.200 There was just so much plausibility. And the science behind a lot of what you said seemed very real to

00:19:02.060 me and did a little reading. And so that sort of boosted me too. Peter's just not making this stuff

00:19:07.420 up. It's beyond the theory stage, I think. And if we look at our evolutionary genetic ancestry and what

00:19:14.380 our human ancestors, the way they ate years ago, it just makes a lot of sense. So

00:19:19.200 Here I am. And I'm not giving it up anytime soon.

00:19:23.140 Well, and I'm holding out hope that my dad is listening to this or will listen to this. I don't

00:19:26.960 think he's ever listened to one of my podcasts. But I might insist that he at least listened to

00:19:31.380 this portion of this podcast. Because if I could get my dad to do this, that that would be again,

00:19:37.460 probably for selfish reasons, that would be sort of the highlight of my life. And you generously offered

00:19:42.400 to speak with my dad. Because I don't, I mean, he certainly won't do what I would recommend. So it would

00:19:48.260 have to be Nicole and you sort of cajoling him into trying this. And Nicole has also offered to help

00:19:56.000 in any way. So dad, if I can get you to listen to this, I hope you'd consider doing this. So with that

00:20:00.720 said, thinking a lot about, well, first of all, just watching the transformation you've just described

00:20:07.660 unfold over the last seven, eight months, it's blown my mind. Because I've worked with many patients

00:20:13.840 over many years, and I've almost never seen the level of fastidious dedication to adherence that

00:20:21.640 I've seen from you. And I've known you for many years before, and you'd been sort of ambivalent

00:20:26.420 towards this. So it was sort of this question of once the switch flipped, there was no wavering.

00:20:33.220 Now, I didn't make the connection at the time. But I think more recently, I've realized that's

00:20:39.760 just kind of the day spring way. So before we get into lipids, I want you to tell me about the very

00:20:45.820 first obsession you had. Well, I've had a few obsessions in my life, there is more to me than

00:20:51.800 just understanding biochemistry and cholesterol and other lipids or so. And probably the first thing

00:20:58.260 in my life was being born to two incredible parents, one of whom was a professional firefighter

00:21:04.680 in the city of Patterson, New Jersey, New Jersey's third largest town. So when you're a son of a

00:21:11.220 firefighter real early in life, you're visiting firehouses and being exposed to the incredible

00:21:18.280 men who are firefighters and all their glorious machines that are sitting there in the fires,

00:21:24.040 these big red things with bells on them and sirens that when they start them up, make a lot

00:21:29.740 of noise. Every once in a while, your mom brings you to some major conflagration where you see your

00:21:35.440 dad running in and out of buildings that are collapsing and on fire. So I just developed an unbelievable

00:21:42.380 passion and love of firefighting, which remains to this day. I'll put in a plug, I run one of the most

00:21:50.480 viewed and largest historical firematic firefighting websites in the United States. It's PattersonFireHistory.com

00:21:59.180 if anybody would like to do it. And you'll see, and there's just thousands of pages of thousands

00:22:05.340 of photographs and incredibly documented data on the Patterson, New Jersey Fire Department, which has

00:22:11.680 very unusual United States. It goes back 200 years. Patterson was formed by Alexander Hamilton right

00:22:17.660 after the Revolutionary War as a mega industrial town because of a giant waterfall that was in the

00:22:23.300 town. So they had a need for firefighting early on. So you can really trace the entire history of

00:22:29.460 firefighting in the United States by focusing on Patterson. And it applies to New York and other

00:22:34.720 towns that have been around for a long while. So I've just had a great passion doing that. So of course,

00:22:40.340 I want it to be a firefighting too. So look, to collect the 30, 40 years of data that is now my

00:22:46.900 website, you got to be a little bit of a nut job with a passion for firefighting to do that. And I

00:22:53.380 was able to collect that material through, of course, having a father who is well-connected in

00:22:58.220 firefighting world and everything. But I put my heart and soul into it. When I was an adult after med

00:23:05.200 school, I used to go to every antique market around firematic flea shows to collect. I collected

00:23:12.280 one of the largest displays of firematic antiquities that were around in the United States outside of

00:23:19.260 a museum. So I didn't even know that was a word, by the way. I just liked the way that sounded.

00:23:23.760 Firematic antiquities.

00:23:25.040 Yeah. And there are a bunch of nut jobs like me who are very much into this.

00:23:30.680 It's funny. You were recently given an award.

00:23:33.640 I was because of my dedication to Patterson documenting all this. They're so proud of it.

00:23:39.900 It's probably the most visited historical fire department website in the United States.

00:23:44.860 The department very much respects what I do. At a certain point, they became very cooperative with

00:23:51.280 sharing some of their archival material that my father hadn't stolen when he was a chief officer

00:23:56.240 department years ago. So the latter years have had their cooperation. But they brought me up to a

00:24:03.400 memorial ceremony they had in June recently because they have a monument up there where

00:24:08.440 if you make the supreme sacrifice, if you're a firefighter who dies in the line of duty,

00:24:13.260 you get your name on this beautiful bestowed monument outside their fire headquarters.

00:24:18.720 And they've had 28 firemen, unfortunately, have their name on that monument over the last

00:24:23.700 couple hundred years. And through my archival analysis in 1938, I found the name of a firefighter

00:24:31.060 who died on the job. He dropped dead as he was carrying a big hose running to a fire hydrant to hook

00:24:36.180 it up. And it sort of got ignored. Now, in 1930, he obviously died of a heart attack at the scene. He was

00:24:43.000 50 some years old. Dying of a heart attack while you were fighting a fire was not considered a

00:24:48.740 fireman's death at that time. If a wall collapsed on you, it would have been. But nowadays, it certainly

00:24:54.600 is. If you have a heart attack at a fire, you would get your name on the monument. Your colleagues would

00:24:59.660 mourn you heavily. So I actually found the data buried deep in the files that this guy dropped dead

00:25:05.220 on a fire scene. I went to the library, got the newspapers that documented that, and I presented it to

00:25:10.940 the department. So lo and behold, they added the 29th name to the monument, a fireman, Edward Moore,

00:25:16.800 who died in 1938. So a little belatedly, but his name is there. So I wanted to go up and see that

00:25:22.900 presentation. And the chief said, Tom, would you get up and just tell this crowd a little bit about who

00:25:27.780 Edward Moore was? Because none of them will certainly know him. So I made a little three, four minute

00:25:32.540 speech on who he was, what happened to him. And I started to walk back to my seat. And the chief said,

00:25:38.060 no, Tom, don't leave the podium yet. And he said, to make a long story short, what you've done for

00:25:45.620 the department, we are, for the first time in the department history, making you an honorary

00:25:51.840 battalion chief. It's the highest honor a professional fire department can ever give to

00:25:57.000 a civilian. They will never give you a rank above a battalion chief, a deputy chief, assistant chief,

00:26:02.680 or a top chief. But me, a battalion chief, my dad was a chief for 30 years in the Patterson fire

00:26:08.600 department, starting as a battalion and a deputy and assistant. So it was a, I just can't display

00:26:15.780 the emotions that went through me. Because my life, I always wanted to be a fireman. Dad twisted my arm

00:26:22.280 and said, no, you're going to college and you're going to study whatever you want to study, but you're

00:26:26.100 not joining the fire department out of high school, which I probably really wanted to do.

00:26:30.200 And as tears were in my eyes, in a row, 400 people in the audience at this big ceremony,

00:26:36.940 I just looked to the skies and hoped I was additionally making my father very proud of me.

00:26:43.500 And he was a very proud man of me because of my medical career, of course. But so my love and

00:26:49.720 passion of firefighting got me this. And just to finish that story, because they told me you're the

00:26:57.180 first person that's ever we've awarded a battalion chief to, but they didn't know. I know their

00:27:01.760 history. Back in the 1960s, a woman was made an honorary battalion chief in the Patterson fire

00:27:09.260 department. And it happened to be a nun at one of the big hospitals in Patterson, a Sister Loretta

00:27:14.280 Agnes. Now, what do you know? One of the major reasons I'm a doctor and that I trained actually at

00:27:22.880 St. Joseph's Hospital in Patterson, New Jersey, because I really wanted to practice in that area.

00:27:27.880 She was a friend of the family, a nun, and would visit our house all the time. And she knew I was

00:27:33.960 pursuing a medical career. And she used to always harp on me, oh, you've got to come and visit our

00:27:38.960 hospital. I'll give you the grand tour. And you can hang out there in the emergency room if you want.

00:27:44.180 And just get to know our hospital. Mr. Smartass here. No, I'm going to go to some big university

00:27:50.460 hospital here. And so I want nothing about a hospital in Patterson, New Jersey, even though

00:27:54.740 it's 700 beds and it's a genetic hospital with a teaching program. But I took her up on it as,

00:28:01.300 and I was a freshman medical student at the time. And I just, she just hang, let me hang out in the

00:28:07.340 emergency room. And I hooked up with a couple of docs who would work. I would go in the evening after

00:28:11.320 finishing classes, I'd go hang out in St. Joe's. And I don't know, it's a large part of who I am,

00:28:18.060 what I do. It fit in perfect. I'm a fireman. Emergency room is where all the action is happening

00:28:23.960 or stuff. So Sister Loretta had a mega influence. And I did go to train there and she was a godsend

00:28:30.640 to patients. So I interacted so much. But Sister Loretta was made an honorary battalion. She

00:28:36.420 by the department because of her care that she extended to every firefighter who was ever brought

00:28:41.640 to St. Joseph's Hospital in Patterson, New Jersey. So the two honorary chiefs in her history are

00:28:47.020 linked in other ways, you know. So it's just kind of spooky there how that turned out,

00:28:52.300 you know. But just a great honor. And on my desk at home, I have a blotter that, you know, is like

00:28:59.340 a plastic top. So I can stick things that are important to me underneath it. I have my mother

00:29:04.820 and father's, the little card that was at their funeral, that funeral home's put out. I got some

00:29:09.460 pictures of my son there. And I've got a mask card that my wife and I gave to Sister Loretta on her

00:29:15.880 passing. It's just such an impact on. Last but not least, the fire department actually now does

00:29:21.800 an annual Sister Loretta Agnes dinner for the clergy in Patterson and stuff. And I kind of laughed about

00:29:27.440 two years ago. They called me up and said, oh, you know, did you ever hear Sister Loretta Agnes?

00:29:34.580 Because of bear shit in the woods.

00:29:36.020 Yeah, yeah. So actually on our website now, I have a whole page dedicated to her and what she's done for

00:29:41.960 the fire department and everything. So it's kind of funny.

00:29:45.380 Well, we could probably spend another hour talking about that. And I know that our listeners would

00:29:49.720 actually appreciate it. But that said, there are a couple other things I want to get to even before

00:29:53.620 we get to the lipid stuff. The other thing that we connected on pretty early was I realized you were

00:29:59.500 a hockey fan. Of course, I grew up in Toronto. And I don't think you can grow up in Canada without

00:30:04.580 being a hockey fan, without playing hockey and being obsessed with it. You know, and certainly when I was

00:30:08.920 a really young kid, probably till I was about 13, it was hard to think of anything but hockey.

00:30:14.460 And it turns out you kind of, just as you had this sort of light switch moment with it, you know,

00:30:20.920 all these things we've talked about, you've had kind of that flip of the switch moment in hockey too,

00:30:24.660 right?

00:30:25.340 I sure did. And it was very easy to grow up in New Jersey in the 1950s and early 60s without knowing

00:30:32.080 what ice hockey was, or even ice skating per se, other than a month or two on a pond, maybe in

00:30:38.460 January. You know, when I was a young boy, a defining moment in my life was the first visit.

00:30:44.340 My dad picked me up in a car and brought me to Yankee Stadium. And I walked into,

00:30:49.340 probably in the early 50s, into that stadium in the green grass and these Yankees running around

00:30:55.460 in their white uniforms and pinchers. So I became a mega baseball fan growing up and a New York Yankee

00:31:01.040 diehard, which I remain to this day. And that was a transforming moment to be sure.

00:31:07.280 It's the sport we played as a kid, wiffle ball all the time, me pretending I'm Mickey Mantle and

00:31:12.020 the pitcher would be Whitey Ford throwing to me and everything. But in 1962, while in high school,

00:31:19.840 my best friend was another young man who also had firefighting as a passion. I always joke,

00:31:25.980 I think I became his best friend because he knew my father was one of the fire chiefs in Patterson.

00:31:30.000 He wanted to hang around with a fire chief's son. But who cares? I love the guy. And we grew,

00:31:35.320 became so close in high school and everything. But some reason, he was a hockey fan or something. He

00:31:40.360 says, I want you to, you know, I go to Madison Square Garden occasionally. I'd like you to come.

00:31:45.780 Why not? You know, so I went over and I remember to this day, it's probably 1962,

00:31:51.460 maybe it was a freshman, sophomore in high school. You walk into the old, and I'm talking the old

00:31:56.740 garden up on 8th Avenue, 49th Street. It was a dark, dingy place. You're walking in, you almost

00:32:01.960 need night vision goggles. But all of a sudden, you walk into a spot where the glow of that white

00:32:08.100 ice strikes you. And out come these guys in red, white, and blue, the New York Rangers, who at that

00:32:14.700 time were wearing no helmets. And you really, and the other team, there were only six teams there,

00:32:20.760 so the competition was unbelievable. So I just fell in love instantly. One game, I knew I just

00:32:27.860 have to start following this sport. And I told Peter, within the year, not only did I say, I have

00:32:33.380 to watch this, I went out and bought myself a pair of skates, which wasn't easy to do back in those

00:32:38.140 days. And me and one other buddy, at night in the winters, we started going to a local pond we knew

00:32:44.560 about. We're the only two people out there, and we just taught ourselves how to ice skate, bought some

00:32:48.620 hockey sticks, started playing. One thing led to another, convinced a few other young friends to

00:32:54.440 do it. And within a year or two, we knew the one or two rinks that were in 50 miles of our house. So

00:33:01.500 we would drive down here and rent the ice for an hour. And so I became a pretty decent hockey player,

00:33:06.700 considering I didn't grow up in Canada and everything, at least playing against New Jersey

00:33:11.280 competition. And over time, joined men leagues. And some of my best friends in life now are not doctors.

00:33:18.620 There are guys I played men's league ice hockey with, beer hockey, as they call it nowadays or

00:33:24.460 whatever, because after you're done with the rink, you know where you wound up for a while.

00:33:28.720 And I played until I was 50 years old. And the last part of my hockey story, of course,

00:33:34.420 when I was so lucky, my wife and I, to have a child who turned out to be a boy, when he came home from

00:33:40.660 the hospital, my wife and I drove him home, brought him upstairs, put him in this wonderful bedroom we had

00:33:46.440 put together with a crib in it. And what was laying in his crib, a small hockey stick that was about

00:33:51.740 four feet long. I wanted him to imprint on it like the ducklings do to mother duck.

00:33:57.420 And as it turns out, my son turned out to be an incredible lifelong hockey player at every level,

00:34:03.800 youth hockey, high school and college.

00:34:06.360 He was a team captain in college, wasn't he?

00:34:09.620 He just had leadership abilities. I credit that to my father. And yeah, he was probably the captain

00:34:16.280 of every team he was ever on from right up through high school and into college. And so very proud of

00:34:22.040 him. So a large part of my life was not only playing hockey as I grew up watching hockey, but when he

00:34:28.440 started getting it every night of my life, I was at a practice watching him. And so again, some of my best

00:34:34.460 friends were other hockey parents and stuff. Again, I wasn't hanging out with all the docs and going to

00:34:39.360 the doctor's balls and that kind of stuff. They never saw me. And in practice for 37 years, I just

00:34:46.260 had a godsend of a fellow, I'm a brother really, my associate who just covered my tail every time I

00:34:53.720 wanted to run to a, hey, I got to go to practice with Brad or I got to play hockey. He just covered the

00:34:58.060 practice and it was made my life easier. So, so yeah, that's the other super passion. When I say

00:35:06.220 dedicated to hockey, even when I was in med school, when class was over, I was going to a rink or

00:35:12.780 someplace or I'd show up in my greens because they guys cover for me for a few hours. We got a game

00:35:20.020 tonight. And that's how crazy I was in my medical school yearbook. You'll see a picture of Tom

00:35:26.100 Day Spring and the class voted, you know, we're going to predict what everybody's going to wind

00:35:31.420 up. And I was predicted, of course, to be the future New York Rangers team physician,

00:35:35.580 which I never did achieve, but close enough. Well, it's not too late. So we should add that

00:35:42.480 to the list of things that we might try to figure out how to tee up. You know, it's so funny because

00:35:46.460 I grew up in Toronto, of course, the Maple Leafs were also one of the original six. Now I grew up

00:35:51.100 in the seventies and eighties. So by then the league had expanded and I very quickly fell in

00:35:56.280 love with the Edmonton Oilers who would very soon go on to become the most dominant team of the

00:36:01.660 eighties. But even watching them come up before they became that most dominant team, they were

00:36:05.740 just electrifying thanks to, of course, Wayne Gretzky, but also guys like Mark Messier, who would

00:36:10.660 go on to become captain of the New York Rangers and finally bring glory back to the Rangers after one of

00:36:16.600 the longest hiatuses in sports. It was 94 when they won the Stanley cup again. Right. Yep. But

00:36:21.920 it's the same experience. I remember the first time my dad took me to Maple Leaf gardens, which of

00:36:26.540 course is not where they play anymore, but it was this old sort of, you know, historic kind of dingy

00:36:32.380 arena. And, um, I remember one game cause at that there was like, uh, gold seats were the best

00:36:38.800 then red, blue, green, and gray. And, you know, we could afford the grays, but I remember on for an

00:36:44.280 exhibition game where the tickets were a bunch cheaper, the Oilers came to play the Leafs and we

00:36:48.760 got gold seats. And I mean, I couldn't, I couldn't believe what it was like to sit 10 feet, maybe a

00:36:57.620 bit more, maybe 20 feet from the glass and actually see, you know, at the time there was a goalie named

00:37:04.320 Grant Fuhrer who was like, I was a goalie. I played goalie in hockey. So Grant Fuhrer was actually the guy

00:37:08.980 that I was trying to emulate and to see these guys, you know, Yari Curry, Glenn Anderson, Paul

00:37:14.160 Coffey, Mark Messier, Wayne Gretzky. I mean, I don't know. Yeah, it's just, it was a very special

00:37:19.180 thing to do as a kid. And I can certainly relate to that. And the older I got, the more I realized

00:37:26.240 that the experience I had was basically going to be shared by every kid growing up in Detroit,

00:37:32.200 Chicago, New York. I mean, the, the stuff that, you know, you would have seen Montreal,

00:37:37.300 nevermind. I mean, you know, you might argue that it was even more fanatical in, in Montreal

00:37:41.400 than any other place. So. Let me just expound that. Peter is right. If you ever have the

00:37:47.300 opportunity, I mean, any hockey game is great, but if you can get such a seat and way back when we

00:37:53.620 were kids going over to the garden, you know, the, the lower best seats, a lot of them were corporate,

00:37:59.360 you know, those who could afford those seats, but they didn't always show up those guys.

00:38:03.180 So almost always by the third period, we'd be sneaking down there and sitting there as young

00:38:08.060 kids and the ushers wouldn't give you too much trouble if you were showing up in a third period

00:38:12.880 there. And it's just a different game back then. And look, I love the military. Nothing can be like

00:38:18.740 in a foxhole when you're fighting for your life. But when you see what those guys with the way they

00:38:23.460 look at each other and the way they hit and at top speeds, wow, it's a different sport.

00:38:29.880 Yeah. It's funny you bring that up. I totally forgot. But as a kid, that was my MO was we'd

00:38:34.240 get the gray seats, which I think were $5, maybe $9, but they were, you know, that was what we

00:38:39.240 could afford. And we would just take binoculars and lock eyes on seats where we thought people

00:38:44.840 had left. And then we'd weasel our way down. And it's the same thing. I, it was just a different

00:38:50.100 era back then. They weren't electronically scanning tickets. So usually by the end of the game,

00:38:54.600 you were sitting close, very, very close. Yes. Oh God. Just, just special memories. Well,

00:39:01.120 let's get to what everyone really wants to hear. I'm sure nobody wants to hear us bullshitting about

00:39:05.580 hockey and stuff like that. Like I said, I don't even know how we're going to organize this. I mean,

00:39:10.500 we've talked very briefly about kind of like a loose framework for what we want to talk about.

00:39:15.200 I don't want to put any restrictions on time. I just want to go as long as we got to go. I've set

00:39:19.340 aside an entire day, which for me is almost impossible to do. I think I'm seeing one patient

00:39:24.060 all day today and then we'll divvy this up in the end. So let's just start with kind of definition.

00:39:30.140 What, what's a lipid? What's cholesterol? What are these things?

00:39:32.340 Before we even do that, let me tell you how I wound up in this world or so. Now, look, I,

00:39:37.760 you went to med school 68 to 72, a residency in internal medicine for three years after that.

00:39:43.800 And I've already told you, I've done a extensive amount of time working in emergency rooms,

00:39:50.440 you know, where everybody comes in. In those days, acute myocardial infarction was,

00:39:57.220 you know, very, very common. You didn't spend the night in the ER without seeing a couple of them,

00:40:02.640 people coming in and pulmonary edema and everything. And, you know, I just recognized early on

00:40:09.600 that atherosclerotic heart disease and its clinical endpoints are bad news. And a lot of those people

00:40:16.840 were young and dying way too prematurely. And in those days, when you came in, even if we got you

00:40:21.700 through your acute coronary syndrome, pulmonary edema, I mean, it's 50-50. So most of them were

00:40:28.160 dead by morning or those that survived then had this morbidity you had to deal with. So I grew up in

00:40:34.240 an era when it was rampant, the acute episodes that I don't think they see anywhere near with the

00:40:39.620 frequency that I did back then. And I just latched on to it. And I was lucky those were the days when

00:40:46.700 the concept of a coronary care unit was invented. Mason Soans invented coronary angiography at that

00:40:53.040 time. And our hospital developed a big, one of the probably first departments in New Jersey that was

00:40:58.080 doing coronary angiography. And that's the world I decided to start hanging out in. My elected

00:41:04.180 in medical school were all spent in the coronary environment. One year of our residency, the third

00:41:10.220 year was pretty much elective. So all I did was hang in the angiography lab or the coronary care unit

00:41:16.180 or the post-coronary floors providing care. My first opportunity to go into practice, a cardiology

00:41:22.600 group actually brought me in to, hey, you manage our hypertension, you do stress testing, which I had

00:41:29.560 done a lot of as a resident. And of course, I'd be taking call every fourth night in that group too.

00:41:36.220 And, you know, it dawned on me, God, every night I'm being called back to the hospital at two,

00:41:41.340 three in the morning. It's another acute MI, for God's sakes. So I jumped really on to the prevention

00:41:47.520 strategy. It would be far better to prevent heart attacks than getting up at three in the morning and

00:41:52.400 praying you could help them survive this episode that they at least made it to the hospital with.

00:41:58.080 So early on in life, I just said, what's involved with atherosclerosis? And early in my career, hey,

00:42:05.840 please don't smoke. Try not to be fat, which I was not the best example of. And let's attack your blood

00:42:12.560 pressure aggressively.

00:42:14.840 Yeah, I want to pause for a second here because you said something really interesting that I just hear

00:42:18.900 so often from physicians of your generation, including a physician I'm really close to here in New York

00:42:25.120 who I share office space with. And he's, you know, he's about your age, runs a very nice concierge

00:42:31.320 practice in the city. And he basically said the exact same thing you just said, which is,

00:42:35.680 we just saw MIs all day, every day, nonstop. You know, a week couldn't go by where one of his patients

00:42:43.020 didn't have an MI. And then he contrasts it with today. He's like, I don't know the last time I saw

00:42:48.400 one. I don't know the last time I saw a Q-wave MI. I just, you know, he doesn't recall.

00:42:53.640 I get that all the time from young docs, residents, or physicians who've been in practice,

00:42:58.780 but they're not in a baby boomer of my age or anything. And they've all seen, obviously,

00:43:04.940 acute coronary syndromes or things, but it's a different type of acute coronary syndrome.

00:43:08.520 They don't see these people coming in and fulminant pulmonary edema. They just don't

00:43:15.320 know what it's like to massive transmural MIs with Q-waves developing, dropping dead before your

00:43:21.840 eyes, because they're rushing them right to the cath lab now and dissolving their clots and

00:43:26.140 everything. They never just saw how these people survived or didn't. So I was talking to Peter last

00:43:32.320 night, and it would not be unusual during my residency if you were the first year resident

00:43:38.340 where you covered every admission in our 700-bed hospital. There were nights where I'd get a dozen

00:43:44.480 admissions to the coronary care unit, a dozen of some sort of exacerbation or a clinical event related

00:43:52.560 to atherosclerotic heart disease, most of them of our most horrific nature. And I just don't believe

00:43:57.980 that they see that nowadays. Yes, they see acute coronary syndromes, but they don't see the type

00:44:04.020 of acute coronary syndromes we saw back then. So it has changed. And look, we've got a long way to go

00:44:09.460 to still eliminate this heart disease. And I think if we all jumped on prevention much earlier in life,

00:44:13.960 we'd end this disease. But yeah, it was a different world back then. It surely was.

00:44:19.240 Is there one person that would sort of be your first mentor, the person that specifically got you,

00:44:24.580 not just interested in cardiovascular disease, but pointed you towards lipids, like something about

00:44:29.560 these lipids matter? No, I sort of discovered lipids by myself. As I said, it was evolving. I

00:44:35.220 wanted to be a preventionist. So I was on the hypertension bandwagon, and it became pretty obvious

00:44:40.500 after a lot of the big epidemiologic trials started coming in with more data framing him. Mr. Fit,

00:44:47.500 that lipids, specifically cholesterol, was the one they sort of focused on early on, was

00:44:53.240 a real big player in here. So I realized, and I'm a self-education guy in most of the things that,

00:45:00.580 all right, I'm as up to date as I can be on hypertension in the 1980s. Now it's for me to

00:45:06.640 start doing some lipid education. So I started doing a lot of reading and stuff. And first course

00:45:12.480 I ever went to take lipids to a different level was out there at the Cleveland Clinic.

00:45:17.120 But the guy that I hooked on earliest that really became a major mentor, a good friend was Dan Rader

00:45:24.700 down in Philadelphia, who turned out to become a world high-density lipoprotein expert, but just

00:45:31.680 an expert in my mind in all things lipid. He was so far ahead of the curve. So Dan was one of the real

00:45:38.520 early ones. Others I had jumped on to were Tony Gatto and Virgil Brown and Alan Snyderman and Ron

00:45:45.820 Krauss and people like that who are really doing the type of investigations that when you started

00:45:51.020 doing lipid reading, you'd find what they were saying. Yeah, all roads keep pointing to these guys.

00:45:57.180 Yeah, really did. And they were gifted enough also that you could semi-understand what they were

00:46:03.880 writing about and talking about. I told Peter, he said, how long did it take you to math? It was 10

00:46:09.280 years of serious reading, anything you could get your hands on. I think the first five years was

00:46:14.980 you read something you didn't even know what you read, but I was just motivated to keep going back

00:46:19.620 sooner or later. And one day I woke up and it sort of all made sense or so. So it took a lot of

00:46:26.080 education. And I think it's easier nowadays because there are phenomenal reviews have been put

00:46:31.560 together by a lot of people. They just didn't exist in those days. You had to sort of discover it

00:46:36.080 yourself if you didn't spend two years at the NIH doing research on it and you would be exposed to

00:46:42.440 it that way or so. Well, you've also played a big role in that. I mean, when I now get to think about

00:46:47.100 how I got into this interest, you know, what sparked my interest was there wasn't a single moment,

00:46:52.860 but I do remember reading a single document that you had written in 2011. And I think I was

00:47:00.640 introduced to it by, uh, remember that guy Greeny up in Reno? Yeah. Yeah. So I think Greeny had sent

00:47:06.060 me a document you wrote and it was the first time I'd even heard of NMR. I mean, I knew what NMR was

00:47:12.320 for, from chemistry, but I didn't know what NMR was with respect to lipids. And so he sends me this

00:47:17.280 document. It was like a PowerPoint, but with notes embedded. So it was printed as a vertical, you know,

00:47:23.120 I printed it as a vertical and each, so each page had a slide, which I would learn to go on were like

00:47:28.460 famous dayspring figures at the time. I didn't realize that. And then, you know, just great text

00:47:33.300 and prose explaining it. And it was 26 pages long or something like that. And it was dense. Like you

00:47:39.820 can't imagine, well, you can imagine because you made it, but it was, there was a density to it that

00:47:45.140 I was like, and I'm thinking, okay, I know I'm just kind of a dumb surgeon. So it's not like I ever

00:47:50.060 knew this stuff, but I'm, it was just so, it was just so captivating. I was like, it was like,

00:47:57.440 there was a whole other world that I didn't know existed. And these particles mattered.

00:48:02.560 And I never, I remember feeling like, how did I not want to know this when I was going through

00:48:07.500 medical school and training? You know, I was just, you know, I guess when you go down that surgical

00:48:11.660 path, you're not thinking about this stuff. You're thinking about, you know, the surgical ways to

00:48:16.260 address these problems. And I mean, I read it so many times because the first few times I was kind

00:48:22.840 of frustrated. I was like, I don't know what the hell is going on here. Like, I really have no clue

00:48:26.920 what he's talking about. And what are these APO this and APO that. And I just kept getting confused

00:48:33.700 by the concordance and the discordance between all these particles. But that, you know, mid 2011 was

00:48:40.400 kind of when I just, I don't know, I guess that was just the bug that bit me too. But to your point,

00:48:46.220 I think so many people today, whether it be physicians, patients, anybody who wants to understand

00:48:51.560 this topic better really can look to you and your work as a great way to synthesize the work of these

00:49:00.240 luminary folks that you've alluded to. It's kind of funny because who could have ever imagined that

00:49:05.240 when I started my lipid journey, I just was a real world internist with a big practice in Northern New

00:49:12.820 Jersey. My only real goal was to be a better internist to my patients, most of whom were getting

00:49:18.340 atherosclerotic or cardiovascular events. So rather than mastering ulcers and GI bleeds, I just

00:49:26.680 went where the money was atherosclerotic heart disease. And I invested all my time and effort on

00:49:32.140 learning this with no grand design that, Hey, I'm a day of spring, whether you know it or not,

00:49:38.760 within 10 or 15 years, you're going to be the most requested lipid educator in the United States.

00:49:44.160 How did that ever happen? And it just happened because I self-taught myself as a dumb real world

00:49:51.200 internist made it understandable to my brain. Part of the day spring learning curve is visual.

00:49:58.240 You said you used to draw.

00:49:59.720 I draw graphics as I'm reading this stuff initially, and I have no artistic skills,

00:50:06.300 whatever. If I draw a human being, it's that stick figure with a circle as a head. But PowerPoint came

00:50:12.520 along. And there are tools there which are not that hard to master. So I was able to draw, and

00:50:18.260 I'm now known as one of the best lipid lipoprotein illustrators in the country.

00:50:23.300 Yeah, we're going to probably, not probably, we will unquestionably link to maybe your 50 finest

00:50:29.360 diagrams in this podcast, which is to say about 1% of what you've produced. But I remember the first

00:50:35.140 time you sent me one of your PowerPoints, I was like, oh, that's really interesting. Like either

00:50:40.460 Tom has contracted with an illustrator to do this, or he's found somebody else that's already done

00:50:47.120 these. And when you said you had done them, I was blown away because you have to remember,

00:50:52.240 I cut my teeth in PowerPoint at a place like McKinsey, where we're PowerPoint ninjas. I could do

00:50:58.620 anything in PowerPoint. I couldn't do what you had done simply because I couldn't, I didn't have the

00:51:04.380 time. Like those were such complicated figures that like if I ever came across something that was

00:51:10.900 that complicated that I needed to make a slide for, I would just get the illustrator to do it. I

00:51:14.940 wouldn't actually be able to sit there and make it happen. So I couldn't believe it. And I think

00:51:18.620 the listeners who aren't familiar with your illustrations are going to find themselves

00:51:24.180 incredibly surprised and grateful for that sacrifice. So illustrating things made me

00:51:31.120 understand. I mean, look, my illustrations got better and better as time went on. Early on,

00:51:35.980 they were a bunch of colored circles and stuff. And then I learned shading and making them move and

00:51:41.460 animate on the slide. So I've really progressed there. But I just learned by illustrating. I've since

00:51:48.620 had serious educators tell me the human brain just understands things better by seeing pictures

00:51:54.080 and graphically than reading thousands of words put together. And there is no doubt my gigantic

00:52:00.740 success as a lipid educator where I could dumb down the talk and try and make you understand complex

00:52:08.260 enzymology or anything else, the apoproteins and how to interact. But as I'm saying it in my dumbed

00:52:15.140 down version, you were looking at it moving on a screen with a graphic. So it made comprehension of

00:52:22.580 advanced lipid-related areas much easier for either a layman or certainly a physician to understand or

00:52:30.980 so. So just the part of who I became. And then somehow, because of all my intense prepper writing

00:52:37.320 slide notes, as Peter said, I became pretty good at putting together prose. So I've done a little bit

00:52:44.720 of research in my time because of places I wound up on and have authored research publication. But

00:52:51.420 most of the things you'll find in the literature of me are reviews and discussing this, trying to make

00:52:57.840 you understand concepts. Then you can go read the geniuses' studies and you'll understand what

00:53:02.320 they're talking about and everything. So I just evolved into that. And actually, the first guy,

00:53:08.120 there was a cardiologist down in Florida, Michael McIver. He's the first guy I ever saw use PowerPoint

00:53:12.840 for lipids. And I just used him. And he shared a lot of his early stuff on it. And I learned off

00:53:18.700 of him. And it's made my life as a well-known lipid educator. I've got opportunities to start

00:53:26.000 doing lipid education. And if you go out and you're lucky enough to have some people come and listen to

00:53:33.700 you, you better be good at what you do or they're going to badmouth you and you'll never be invited back.

00:53:38.740 Or if you do want to come back, they're going to like you. They're going to be in touch with you.

00:53:44.260 And I just developed ways of explaining lipids and illustrating lipids that became huge.

00:53:51.000 And just to finish, it's Mike Davidson, who's one of the all-time gods in the lipid world in Chicago,

00:53:57.120 still a university professor there, one of the big founders of the National Lipid Association,

00:54:02.800 did at one time during his presidency bestow their President's Award to me, which is given

00:54:08.960 to people who make contributions to lipidology. But this is the top lipid organization in the

00:54:13.920 country. How does some real-world internists with no formal lipid training ever work his way up to an

00:54:21.240 award like that or so? Mike told me, we polled over the NLA and a lot of people joined this organization

00:54:27.640 because they heard a Tom Dayspring lipid lecture. And Mike was a big advocate of you teach through

00:54:32.500 illustration. I've illustrated many things from Michael over the years. And so he's right. And

00:54:39.300 that's my claim to fame. I hope some of you follow me at Dr. Lipid because Twitter is the way to

00:54:44.720 get a lot of my graphics nowadays. Yeah. And there's a lot of stuff that we'll make sure we link to,

00:54:50.420 but the Lipoholics Anonymous, you used to write a lot more into, I used to read those case reports

00:54:56.240 constantly. We'll have to make sure we can pull all those things out of the archive because there's

00:55:00.640 some amazing cases there. But yeah, we'll make sure people know where to find you on Twitter and

00:55:05.300 all that stuff. Just quickly on that, when I was on this giant lecture tour for 10, 15 years of my

00:55:11.460 life, I did generate a weekly newsletter called Lipidaholics Anonymous, where they were one case

00:55:18.920 discussion, all real world, that were in my practice or sent to me by other docs. And I would just

00:55:24.780 take it into the next level. So I would explain it basically. And then I would, like I'm talking

00:55:29.220 to a Lipidology Illustrated, it became immensely popular. I had several thousand people. It was

00:55:34.280 free. I sent it out each week in a group email, but it really enhanced my, and it found itself on a

00:55:41.240 lot of desktops, you know? So that was a big part of who I was, you know? And I do have most of them

00:55:47.260 still there, but I am really, people give me all it because I don't want you to know what I was

00:55:51.920 saying in the year 2002, because it's mostly all wrong nowadays because we've evolved so much. But

00:55:57.900 if you want to see what we were talking about in the Lipids in 2002, they might have some historical

00:56:03.500 interest. Yeah. Well, you just touched on kind of an important point, which is I like to say facts,

00:56:09.520 all facts have a half-life and some of them are really, really long half-lives. You know,

00:56:13.640 the earth being round is, we would call that an incredibly long half-life fact. We're going to,

00:56:18.340 you know, the half-life is nearly infinite on that. But elevated levels of HDL cholesterol are

00:56:23.800 necessarily a good thing. That's a fact that I think, you know, it used to be deemed a fact based

00:56:29.240 on the epidemiology of Framingham. I think today anyone who's serious about the study of Lipidology

00:56:34.060 would say that's grossly oversimplified, potentially incorrect. That's certainly one of the all-time

00:56:41.140 facts that really disappeared. I personally think it's a waste of time to even put it in the lipid

00:56:47.100 profile other than it's used in certain calculations that are popular nowadays, like non-HDL cholesterol.

00:56:53.980 But I encourage no one to ever make a judgment on any human's cardiovascular risk based on their

00:57:01.920 high-density lipoprotein cholesterol level, or think you know what you're doing to a human being if you

00:57:08.940 somehow change that HDL cholesterol metric in that patient has nothing to do with anything to be

00:57:15.580 all right. So now I'm chomping at the bit. We got to get into this. So where do we even begin? Do we

00:57:19.500 want to start with what's a lipid? What's cholesterol? What let's, and then I want to, you know, let's

00:57:24.020 explain what these things mean, HDLC and stuff. Sure. Well, a lipid is basically a molecule that is

00:57:29.800 not soluble in water. It's might be soluble in certain organic solvents, but not in water.

00:57:36.280 So it's a hydrophobic compound. And oils and fats are what everybody thinks of as a lipid.

00:57:46.000 Some, you know, cholesterol is in there. I never liked calling cholesterol a fat, but it's a lipid.

00:57:52.720 Fats to me are fatty acids and combinations of fatty acids are so glycerides. So that's what lipids are.

00:58:01.520 And different lipids have different degrees of solubility. Some are extremely hydrophobic because

00:58:07.680 both ends of the molecule that can't be seen in water. Some lipids have a, one end is a little bit

00:58:14.800 water soluble, hydrophilic, and the other one is, and that would be where cholesterol fits in,

00:58:20.640 phospholipids fit in. So that's what a lipid is. And there's several types of lipids in your body,

00:58:26.980 but the ones that those of us who live in a clinical lipidology world are focused on are

00:58:32.600 cholesterol, basically two types of cholesterol. And there are fatty acids, but fatty acids stick

00:58:40.520 to a lot of things. And it's sticking is called the sterification in the world of lipids. So they

00:58:45.820 can bind to carbohydrates, cholesterol, a three carbon sugar called glycerol is the most common

00:58:53.200 thing they bind to. So if you have one fatty acid on a glycerol, that's a monoacylglycerol. If you have

00:58:59.280 two, that's a diacylglycerol. If you have three fatty acids stuck on your glycerol compound, that is

00:59:05.640 called a triacylglycerol, which most people would call a triglyceride. If you're as old as me, you're not

00:59:13.200 used to hearing those terms, and you're used to hearing triglycerides, but initially they were just

00:59:18.260 called glycerides. And glycerides would be the whole family of monoacyl and triacylglycerides or

00:59:25.240 so. And it's basically the way in which the human body transports fatty acids or stores them. It

00:59:32.660 transports them in the plasma or stores them in various tissues in case you need a fatty acid for

00:59:39.200 a certain purpose, be it energy or a structural purpose. Then the fatty acids would disconnect from

00:59:45.560 its glycerol backbone. That would be called deasterification. And that fatty acid could be

00:59:51.020 used to whatever, what a cell wanted to do with that fatty acid or so. If the cell didn't need it,

00:59:56.420 it could store it till when it did need it as a glyceride. So those are your basic definitions.

01:00:03.020 But the one glyceride that is of incredible importance, maybe in the future, the one we're

01:00:09.100 going to be looking at most seriously, and the one that nobody ever looks at or even brings into

01:00:14.080 the discussion nowadays are our phospholipids. And phospholipids are simply glycerol compounds.

01:00:21.940 So you got your three carbon alcohol sugar there, and there's two fatty acids attached to it. And

01:00:27.960 there's a lot of fatty acids. And the makeup of every phospholipid might have the same two fatty

01:00:32.960 acids, different fatty acids. Fatty acids come in different lengths, different types of double bonds.

01:00:38.220 And then they got a head group, which is usually got a phosphorosmoid in it. And that's what a

01:00:43.920 phospholipid is. Phospholipids are kind of cool because part of it is water soluble, part of it is

01:00:49.480 hydrophobic or doesn't like water. They're called amphiphiles. Amphipathic is the name or something.

01:00:56.620 And that allows them to sit in certain positions in our body where, hey, their hydrophobic lipid tails,

01:01:03.540 the fatty acids, can exist in a lipid-enriched environment inside the cell, inside a core of a

01:01:11.240 lipoprotein, which is all hydrophobic lipids. But its hydrophilic surface can interact with plasma.

01:01:18.900 So where do phospholipids exist? On the surface of our lipid transportation vehicles, lipoproteins,

01:01:25.860 or on our cell membrane? Every cell membrane in your body is phospholipids.

01:01:30.140 And what nobody seems to know is most of your phospholipids are made in the liver or they're

01:01:37.800 made in the small intestine because the intestine absorbs fatty acids, repackages them into glycerides,

01:01:45.200 phospholipids or triglycerides, and then they become part of lipoproteins that enter your lymphatics

01:01:51.660 from the gut, the chylomicrons, or your liver gets fatty acids. And as phosphorus, it makes

01:01:58.240 phospholipids and your liver makes lipoproteins and excretes them. So few people know that everybody

01:02:06.520 talks of lipoproteins as if they're delivering cholesterol all over the place. That's what we

01:02:10.680 have lipoproteins for. That's probably the last reason we have lipoproteins because every cell in

01:02:15.700 your body makes every cholesterol molecule it needs to do what it has to do, with a few rare exceptions.

01:02:22.560 So if I'm a nose cell, I don't need some lipoprotein to come and deliver cholesterol to my cell because

01:02:31.100 I need cholesterol in my nasal cell membranes. That cell will make cholesterol. Every cell has the

01:02:38.140 genetic power and the protein, the enzymology to make cholesterol to its heart's content.

01:02:44.820 The tragedy is that what we eat, most of our cells make way too damn much cholesterol, which becomes then

01:02:50.660 not a absolutely life-sustaining molecule needed in your cell membranes, but a cellular toxic molecule

01:02:59.380 because it crystallizes and kills that cells. So evolution has given our cells incredible powers

01:03:05.720 to evict, efflux out cholesterol so they don't suffer cholesterol toxicity in those cells. And that

01:03:13.220 will be certainly something we'll get into. How do cells get rid of all this cholesterol? Because of

01:03:18.620 what we're eating, they're making too much of our cell. It's not that lipoproteins are delivering too

01:03:24.300 much cholesterol to most of these cells, although they can in certain areas. Some people do get

01:03:29.900 cholesterol builds up in their skin, xanthomas, and things like that.

01:03:34.160 And I want to just interject for a moment to go back and clarify something for the listener. So we talk a lot

01:03:39.160 about fats, but many people are familiar with the term saturated fats, monounsaturated fats,

01:03:45.720 polyunsaturated fats. You touched on it very briefly, but just so that they understand the

01:03:49.340 broader context, a saturated fat means a fatty acid hydrocarbon that has no double bonds in it.

01:03:56.980 A monounsaturated fat has a single double bond in it, and a polyunsaturated fat has two or more. And

01:04:02.340 of course, depending on the position of the first double bond with respect to its carboxyl group,

01:04:06.780 that's where we get into these omegas and things. But the point here is when people talk about

01:04:12.100 saturated monounsaturated and polyunsaturated fat, they're referring to the positions of these double

01:04:16.640 bonds within these long hydrocarbons that also can be of variable lengths. So for example,

01:04:22.880 a saturated fat can be very short, six, seven, eight carbons in length, or it can be much longer.

01:04:29.360 And each one of them has its own name. And the same is true with the monos. So once you get into

01:04:34.240 the monos and the polys, the nomenclature starts to get complicated because you're describing both

01:04:39.660 the position of the double bonds and the length of the hydrocarbon. Now, these things have all of

01:04:45.920 these complex properties, but in many ways, it still pales in comparison to the complexity of

01:04:51.600 the cholesterol system because those fatty acids can also mean, even though they're not

01:04:56.920 soluble in water and therefore they can't float around willy nilly, they have the luxury of being

01:05:01.660 transported on albumin, right? Which is, which is another protein in the plasma that can hide this

01:05:09.740 hydrophobic part of them in an ability to transport them through. But yet why, why can't we transport

01:05:15.360 cholesterol, which you've just explained is not soluble in water. It's hydrophobic. Why can't we

01:05:20.180 transport cholesterol or phospholipids in albumin? Something that's so ubiquitous and benign.

01:05:24.880 Well, you can. Cholesterol can attach to albumin. And just before I answer your current question,

01:05:31.920 what I was explaining before is, you know, the lipoproteins, everybody thinks their purpose is

01:05:36.740 to deliver cholesterol to tissues. That's their last purpose. They don't do that. They are the real

01:05:41.880 purpose of our lipoprotein, our lipid transportation system is to develop, to transport energy to tissues

01:05:48.400 that need them. That would be triglycerides, the fatty acids, which are cells oxidized to create ATP.

01:05:56.260 So they are brought to tissues that are very good at extracting triglycerides from lipoproteins,

01:06:02.820 muscle cells. But if your muscles, because you're not using your muscles, don't need any energy today,

01:06:09.160 those triglycerides will be dumped in an adipocyte to be stored as your fatty acids until you need them.

01:06:15.720 But what nobody talks about is what else are the lipoproteins delivering that cells cannot

01:06:21.980 be a cell without their phospholipids. And what is the surface of every lipoprotein? Phospholipids.

01:06:29.880 Where do the phospholipids come out of? Lipoproteins produced in the intestine or the liver. So what are

01:06:37.600 the biggest lipoproteins? Because they would have the most gigantic surface area. Chylomicrons coming out

01:06:43.580 of your gut, very low density particles coming out of your liver. So we all talk about how they're

01:06:48.900 delivering cholesterol. They're delivering maybe triglycerides because they're very triglyceride,

01:06:53.680 but they're delivering phospholipids.

01:06:56.600 So just to clarify again, the spherical lipoprotein has an inside, which carries the

01:07:03.920 cholesterol ester and the triglyceride. But the phospholipid isn't carried inside that central

01:07:09.980 cargo. It's actually embedded within the structure of the lipoprotein. And therefore,

01:07:15.300 the chylomicron being the largest, followed by the VLDL, the very low density lipoprotein,

01:07:20.240 the larger the surface area of these things, the greater their capacity to carry phospholipids,

01:07:24.540 since the phospholipid is carried in the wall.

01:07:27.300 Correct. And when these gigantic triglyceride-rich particles go to your muscles or adipocytes to deliver

01:07:33.920 their triglyceride in their core, very hydrophobic, in that core is a special type of cholesterol that

01:07:40.580 has a fatty acid to it, cholesterol ester, incredibly hydrophobic also. Those two tissues

01:07:46.520 that I talked about have very powerful triglyceride-dissolving enzyme called lipoprotein lipase,

01:07:52.340 which starts hydrolyzing the core triglycerides. Now, these big dump trucks full of triglycerides

01:07:59.660 like that, they start to shrink when the triglycerides undergo hydrolysis, de-esterification.

01:08:06.660 The particle, as it shrinks, that's called lipolysis, removal of a lipid from a lipoprotein.

01:08:12.700 So you can imagine these big fat balloons full of triglycerides. If you could suck water out of

01:08:18.220 a balloon, it becomes a smaller balloon to it, and it would get wrinkles on it. Well, lipoproteins don't

01:08:23.380 become wrinkles. They just evict their surface phospholipids, which can immediately attach to

01:08:29.980 a contiguous cell where the decrease in diameter of the lipoprotein is occurring, or they jump on

01:08:36.520 a protein that evolution has given us called phospholipid transfer protein, which then takes

01:08:42.120 all those phospholipids and brings them to cells that say, hey, I need phospholipids. Or the only

01:08:47.740 lipoprotein that is not made in the liver or the intestine, but grows itself, matures itself in the

01:08:54.080 plasma, high-density lipoproteins, you couldn't change a baby APOA1, which is the structural protein

01:09:00.840 of an HDL, into a big, fat, mature, large HDL if you weren't supplying it with what? Phospholipids.

01:09:06.940 Where would an HDL get phospholipids? As these big triglycerides particles shrink and they extrude

01:09:14.020 them phospholipid transfer proteins. Here, little baby HDL, here's your phospholipids. And they can

01:09:19.980 mature into it. So it's just an incredible system. I love the idea. I love anthropomorphizing these

01:09:24.480 things, little babies HDL and all these other things. It helps. So that all being said, I want

01:09:29.940 everybody to realize, because nobody, because we don't measure them, because it's complex on how to

01:09:35.500 measure them. And there are so many different types of phospholipids based on the exact fatty acid

01:09:42.120 makeup, the length of the fatty acid. Remember, a glycerol has three positions. They're called

01:09:47.600 stereospecific number one, number two, and number three. Everything depends. The lipases attack

01:09:54.020 various fatty acids on different positions. And so it's really complicated. So the phospholipids

01:10:00.540 affect a lot of functioning. Since phospholipids are making up not only a surface of lipoproteins,

01:10:06.900 basically because they're water-soluble and it allows these dump trucks to float around in plasma,

01:10:11.560 in the cell membrane, what Peter was just talking about, that fatty acid makeup in the phospholipids

01:10:18.220 become so crucial. Because saturated fats are straight. They're rugged. They don't bend. So

01:10:25.180 it gives some structure to a phospholipid. If your phospholipids can't contain a lot of saturated fat,

01:10:29.880 you got a strong cell membrane there that's hard to get through. But the real reason cells function

01:10:38.240 and interact with the rest of the cells of your body is they signal each other. And signaling occurs

01:10:43.580 because something occurs at a certain area of the lipid cell membrane that we're going to call a

01:10:52.440 lipid raft, which is a specialized collection of special phospholipids with a little bit of

01:10:59.860 free cholesterol. But the structural positioning that a phospholipid takes up, if you have several

01:11:08.380 double bonds in that thing, if you've ever seen a 3D view of a phospholipid that's got a several

01:11:15.520 double bonds and it takes up an incredible amount of space. So it's two legs spread out and you change

01:11:22.200 the structure of the cell membrane. And that structure of that area called the lipid raft allows certain

01:11:28.840 cellular proteins to locate there. And those are all our receptors that pull things into cells or

01:11:34.760 extrude things out of cells. So the fluidity of the membrane is highly, highly dependent on the

01:11:40.440 nature of the fatty acids in the phospholipid. The fluidity and the ability to shelter or let

01:11:46.300 certain proteins be expressed in that area. If I'm an LDL receptor or some immunoreceptor,

01:11:52.800 there are certain areas of the cell membrane I could never locate to because the phospholipids

01:11:56.760 wouldn't allow it. But there are other areas they say, welcome, here's where you're supposed to be

01:12:01.400 expressed. And cells know that. And they construct their lipid membranes, hopefully, if you have the

01:12:08.200 right type of phospholipids and everything. So as we start to talk, and those who study and

01:12:15.020 investigate membrane physiology, it's one of the more advanced areas in lipidology. But as we also are

01:12:20.960 starting to understand some of the qualities beyond just measurements of various lipoproteins,

01:12:28.320 their phospholipid makeup is going to be crucial. And as we talk about HDLs, we're going to start

01:12:34.040 throwing around the word HDL functionality. And a giant part of HDL functionality, what a specific HDL

01:12:41.380 particle does in your body, what it might be capable of accomplishing or not accomplishing,

01:12:46.120 is due to the fatty acid makeup of its phospholipids. And one day, I think we're going

01:12:52.820 to be analyzing the lipidome of various lipoproteins. And we're going to have a lot more

01:12:57.580 insight of what lipoproteins do or don't do. You can find all of this information and more at

01:13:04.760 peteratiamd.com forward slash podcast. There you'll find the show notes, readings and links related to

01:13:10.880 this episode. You can also find my blog and the nerd safari at peteratiamd.com. What's a nerd

01:13:17.020 safari you ask? Just click on the link at the top of the site to learn more. Maybe the simplest thing

01:13:21.740 to do is to sign up for my subjectively non-lame once a week email where I'll update you on what

01:13:26.380 I've been up to, the most interesting papers I've read, and all things related to longevity,

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01:13:36.160 all with the ID peteratiamd. But usually Twitter is the best way to reach me to share your questions

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The Peter Attia Drive - October 15, 2018

#20 - Thomas Dayspring, M.D., FACP, FNLA – Part I of V： an introduction to lipidology

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