Coronary Artery Calcium (CAC): A Direct Measure of Cardiovascular Disease Risk [transcript]

Written by Christopher Kelly

Aug. 20, 2019

[0:00:00]

Christopher:    Ivor Cummins, fantastic talk here at the Real Food Rocks Festival in beautiful -- where are we -- Lake Windermere.

Ivor:    Yeah, the Brathay estate, very nice indeed. I agree. 

Christopher:    Absolutely incredible backdrop. Maybe I'll get some pictures that we can share with people how beautiful it is here. I'm really enjoying the Real Food Rocks Festival. What do you think about this idea of real food versus Paleo or Keto or anything else that you've seen? People have got to put a name on it, haven't they? I think I do want to get behind real food. Of all the things that I've seen come and go, I think that real food might be the right brand. What do you think?

Ivor:    Yeah. Well, I'd agree. Real food is kind of all-embracing, so we've got people who are vegan and vegetarian and then even carnivore nowadays and they're all eating real food. That's the unifier. 

Christopher:    Yeah. Actually, that's the unifying -- right. 

Ivor:    Yes, so I think people who have severe disease and they want to change their lifestyle, they might go with an omnivore or meat-heavy diet. They might go with a very healthy vegetarian diet with the right supplements, or even vegan, but there are lots of ways to take away the Standard American Diet and start resolving your disease. So it would be nice if you're all united in just eating real food, the right foods with magnesium, potassium, the right nutrients, nutrient-dense, and get away from this kind of faction fighting. 

Christopher:    Right, nutritional bogeyman. 

Ivor:    Yeah indeed. It's gotten pretty hot there out there because I think people who have ideologies, they are fighting for their corner and their belief system. It might settle down now and everyone just gets behind the real food message perhaps. 

Christopher:    Talk about cardiovascular disease. Why should we care about cardiovascular disease?

Ivor:    Oh, well, yeah, the biggest killer in the world, though cancer is giving it a run for its money in the past couple of decades, but they're all modern chronic diseases with common soil or similar root causes from environment and nutrition broadly, not so much genetics. Cardiovascular disease in Medscape last year -- I remember putting up a slide in Breckenridge, Colorado and it basically said in Medscape that "the rates of cardiovascular disease are going beyond our ability to control them". That was a quote. It said we're seeing rates in 2015 that we decades ago predicted for 2030, so it's a massive issue. Other autopsy studies have shown that from the '70s to the '90s, subclinical or non-diagnosed atherosclerosis, vascular disease in cadavers was actually falling down, but from the '90s, it began to rise again. Now with diabetes, obesity and all our problems, it's rising again. Heart disease is a huge deal, yeah. 

Christopher:    Have you got a two or maybe five-minute elevator pitch of what causes it? We just talked about real food and Keto and all of that kind of stuff and I think sometimes we're a little bit quick to jump to that as the treatment for cardiovascular disease, but can you explain what causes it?

Ivor:    If you look at the causes in terms of biochemically or physiologically, yeah, they're not food. The causes, one of the big ones is hyperinsulinemia or high blood insulin and insulin-resistance often resulting from high insulin or other issues, high blood glucose and particularly spikes in blood glucose after a meal. There's a lot of evidence to suggest that a steady, slightly high blood glucose may be not so bad, but big spikes and drops in glucose, which you associate with diabetic physiology, they can be very damaging through glycation and damaging of your cholesterol particles. So the insulin-glucose axis and all of that diabetic type physiology, that's probably the biggest driver bar known, but then there are many other drivers as well. Autoimmune conditions, lupus, arthritic conditions, anything where your immune system is overactivated can have a knock-on effect of damaging your vasculature, so there's a lot of that also. Heavy metal contamination is being acknowledged now. The lead over the '70s and '80s in petrol -- 

Christopher:    That's a disaster putting that in view. 

Ivor:    Yeah, and in fairness to the world, they did wake up and they took all the lead out, but it's suspected now that that caused a huge surge of cardiovascular disease. But in the 20th Century, the real rise in cardiovascular disease besides the triad of refined carbs, vegetable oils, and sugars, there was of course smoking from 1900s up to 1970. There's a huge rise in smoking which drove masses of heart disease. A lot of the fall in heart diseases leveling in the last 30 years has been the huge reduction in smoking. Yeah, there were medications, procedures, but a lot of it was smoking cessation. Now, we've replaced smoking with our massive problem with insulin and glucose in the population. 

Christopher:    Yeah, I'm starting to notice it now, the reduction in smoking. When I first moved to California 15 years ago, there was a huge difference. They've already banned smoking in public in California whereas before in the UK, you sit down in a restaurant and there could be someone smoking really close to you like what the heck. 

Ivor:    It was insane. I was in San Diego working with Hewlett-Packard in 1996 and at New Year's Eve '96, they brought in the first ban in California in bars and people suddenly have to go outside, so it was a long time back.

[0:05:06]

    But from the '70s and '80s with the surgeon general warnings, that's where the real drop in smoking happened, and then you saw the drops in lung cancer following that, and of course, cardiovascular disease began to recover or at least level off. It was a huge factor, but I agree. It's way down, but now, we have new demons to deal with. 

Christopher:    Talk about the glycocalyx. That didn't make it into your talk today, but I find that incredibly interesting. I have heard you talk about the glycocalyx before and I wondered where it fits in in terms of the key risk factors. Obviously, hyperinsulinemia is involved in smooth muscle cell proliferation and all of this stuff that leads to disaster. I wonder whether the first step is the glycocalyx, but it's still what you just said, right? If you send these huge glycemic spikes and you're stripping away the glycoprotein layer then you can damage the endothelial cells. Obviously, you don't think it's important enough to go into your talk that you gave today. Do you think that hyperinsulinemia is still more important?

Ivor:    Yeah. I think the glycocalyx is a fascinating part of the process and I do have a paper -- well, I have tens, if not hundreds, of papers in glycocalyx now which I delved into last year, but essentially, the glycocalyx, the paper I have that's a really good summary is glycocalyx issues are the first step in atherothrombotic process progression. There are papers out there and it's arguable that the very first initiating step of having a problem in your artery is that the glycocalyx is damaged in that area and it sieves or it controls LDL particle access to the inner wall of the artery. It controls by a fluidic canal sense or moving in blood flow. It actually releases nitric oxide and it brings in inflammatory components and allows them access to the wall when there's an inflammatory problem, so it's like this slick shield, a nonstick shield, but with loads of signaling functions. It's amazing.

    So yeah, if you do something to damage your glycocalyx -- and certainly the papers are out there. Blood glucose spikes are the classic one. There's not much research on it though because it was so delicate. It wasn't discovered until 20 years ago and there was no real drug to help with it, so it didn't get a lot of focus, but the glucose spikes is the one true thing shown to damage the glycocalyx. Another interesting thing is atherosclerosis is focal, so you can have an enormous atheroma that's going to kill you tomorrow in your artery, in your tube, and right beside it or across the wall, the artery is perfectly healthy. Then 2 mm away, you have another enormous atheroma that could kill you and all around it, the artery is healthy. 

Christopher:    Interesting. 

Ivor:    So it's very focal and there are papers as well which have tied the glycocalyx thinning at branch points to the focal nature of where it occurs. So yeah, it's very important, I'd say, and it's a very important step damaging it of initiating that damage to the wall that leads to atheroma and these postules. 

Christopher:    That's incredibly interesting. You talked about cardiovascular disease as potentially having an autoimmune component. Tell us about that. I wanted to expand on that when you talked about that in the talk you gave this morning. 

Ivor:    Yeah. I interviewed Gabor Erdosi who's a microbiologist in Hungary and he does deep research that makes me jealous. More and more it's coming up that autoimmune conditions carry a much higher risk for atherosclerosis and it's arguable that your immune system over-responds when it's chronic, so the immune system responds to insults. The inflammation is not the problem. It's what caused you to have an inflammatory response. If that's acute, it's perfectly correct. You've got a cut. It swells. It gets painful. Inflammation occurs, but that's to resolve the issue. If your immune response is to resolve an acute issue, that's great and it's an amazingly powerful machine. That's a terrifying weapon, our immune system. It's just incredible.

    If it gets overexcited in a chronic sense, it through many mechanisms can actually enhance the atherosclerotic process, so more monocytes, more macrophage, the immune killer cells coming in to engulf cholesterol, entrapment of cholesterol. This whole inflammatory cascade is intended to fix an acute problem, but it would appear that it is actually making a problem worse when it's continually or chronically stimulated. So there, you have lupus and arthritic conditions, and even psoriasis now intimately linked to atherosclerosis progression, a whole range of immune conditions. So when your immune system, the most powerful weapon in the world, is overactivated, there are many pathways where it will actually exacerbate the situation. That's kind of a simple summary. 

Christopher:    Talk about your risk. How is that message being spread? How well is it being received? Are people going to get their coronary artery calcium scan? I had one done recently and it was zero, of course. 

[0:10:06]

Ivor:    Of course. 

Christopher:    I would've been very upset with anything less than a zero, and the reason I say that is because -- I mean you showed in your talk that by the time you've got calcification, you're pretty far down that disease process and it's not necessarily true that there's no disease there. A zero score at age 43 is just telling me, well, you're not completely screwed, but you're not necessarily all in the clear either. Talk about the coronary artery calcium scan and are people -- you're going and doing talks like you did just now and people are rushing out and getting them done.

Ivor:    Generally speaking, yes, it's a long-term battle to get the message out there because for many political and economic reasons, the scan was kind of fought against by the medical business and pharmaceutical for 30 years. The Widowmaker movie, if people Google "Widowmaker CAC", those two words, they'll get a one-hour version of the movie and that explains why we have a problem with awareness, all the conspiracy stuff, but it's actually true, so that's one problem.

    I'm pushing to get out there, and yes, the answer is I'm getting more and more emails, messaging in Facebook, streams of people coming back with their scores, hugely thankful to David Bobbett and IHDA and myself for getting the message out. It's hard to quantify exactly how much, but I had a beautiful comment on YouTube recently -- and in the UK on IHDA.ie, the website, all your resources are in the homepage for the calcium scan, the professors discussing, explaining, but we now have all the scan centers in Ireland, UK, and America, a couple of hundred in an interactive map. One person came back to me and said they went to the lowest cost in the UK, which we recommend at the Rivers Hospital, and said when they got there, the lady was lovely. They're still at £230 and she said in the last year or so, they are inundated with people looking for calcium --

Christopher:    That answered my question, right?

Ivor:    It's a one data point, but she was bemused by it and not realizing why, and I think it is -- it's been around a year I've been pushing for UK people that Rivers Hospital is the low cost one, so I think across America as well -- it's a pity we don't from a corporate world have the metrics to be able to measure --

Christopher:    Right, no conversion rates. 

Ivor:    But I think we just know. I'll give another quick example. I had a friend in Corvallis, Oregon in Hewlett-Packard. His name is Hugh and he wrote me on LinkedIn. He says, "Ivor, my brother is a senior registrar in internal medicine in a hospital here in Portland and I was talking to him about heart disease and he says, 'Hey, you've got to see this guy, Ivor Cummins.'" This was two years ago. He said, "Ivor Cummins? Hardly," and he Googled and he said, "Wow. My brother randomly in America told me I've got to see you and he's an internal medicine specialist," so we're getting a lot of that all over the world, which is great. The more doctors know and become aware, the more they can help their patients understand. "Direct dough" to the masses is important too. This is great, 700 people here, we had packed rooms from my talk.

Christopher:    Oh yeah, standing room only. It's great. 

Ivor:    It's great because this is less low carb Keto, kind of nerdy. Real Food Rocks is real people and more and more that's what myself, David Bobbett, and the Irish Heart Disease Awareness want to get to medical professionals and real people. The low carb Keto people, I think, mostly have kind of got the message because I'm quite known, but how do we get to the masses and save the masses?

Christopher:    Yeah, so at the moment, you've just got people like me who -- I think I went through website and found a scanning sensor close to me in Walnut Creek, California and I didn't need a doctor referral. I just phoned them up and they said, "Sure. We'll take your $400 and put you in the CT scanner." That's great. That was the only people who were there. We're all there to get our coronary artery calcium scan, so I don't know whether -- I should've asked like, "How did you find out about this scan?" Are you really going to solve this problem at the population level if it's going to require people watching a one-hour documentary and then understanding the value of the coronary artery calcium scan and then going and paying good cash money to get their own scan done or is this going to have to be, well, my local GP knows about it and they're going to refer me for it? If everybody was doing it, to run that CT scanner, it only takes -- how long does it take to get the scan done?

Ivor:    It's a few minutes in the scanner and then the machine algorithm calculates the score, so there isn't really human involvement. It's super fast. The machines are expensive, but that's a capital cost and they're there and all they need to do -- and they do for many CT scanners -- is simply put in the software, the protocol for doing the CAC. Yeah, I'd agree. People need to look at it like a couple of hundred euros or sterling or $100 up to $400 in the States.

Christopher:    Yeah. Mine was actually very expensive because I'm in Silicon Valley and I've heard that it can be as cheap as $150 in Denver, Colorado. 

Ivor:    Fifty.

Christopher:    Oh, really?

Ivor:    Yeah.

Christopher:    Well, like you said, it's like a fixed cost. The CT scanners pay for itself. Cost of goods sold is basically zero, right?

Ivor:    Yeah, exactly. The thing is the companies will begin to realize that yeah, you've got to work the capital. Of course, the annuities or maintenance is not too big, so yeah, you want to get as many scans and save as many people as you can, but people just need to understand that if you have a high score or a very low score, your doctor won't know.

[0:15:09]

    You can look at your cholesterol and your blood, but that's guesswork. You get a scan, you get a really high score, you're 20 times or more likely to have a heart attack in the next ten years.

    Another thing I like to tell people from a really good study, an eight-year-old with a low score is around 20 times less likely to have an event in the next ten years than a 50-year-old with a high score. If you just think about that, there are 50-year-olds, myriad 50-year-olds, walking around unknowingly, his cholesterol looks fine, who have 20 times the risk of a heart attack in the next ten years than an eight-year-old with a low score, and no one knows because so few are measuring. There is one important point. It's not just myself and Irish Heart Disease Awareness. The 2018 Guidelines, Cholesterol Treatment Guidelines in the US from the American --

Christopher:    Cholesterol treatment, you're making me [gnarling].

Ivor:    Well, it's the mega guidelines for heart disease prevention, so it's tied to cholesterol, but the key thing was that in 2018, they took coronary calcification scan and they brought it right up to 2a evidence level. That's really high. They are now recommending as we have pushed for years for middle risk people, which is the largest group, to be quite honest -- middle risk means you're somewhere in the majority and no one knows if you're high or low. A calcium scan will take 70% of middle riskers and take them out into high or low risk because it's actually looking at the disease. That's an engineering tool.

    ACC/AHA 2018 Guidelines have enshrined calcification and the concept of the power of zero. If you have a zero even with blood risk factors indicating a potential problem, you're a really low risk patient. If you have middle risk blood risk and are not sure about medication or preventative treatment or the extents you need, well, you come out at a really high score. You're a high-risk patient at the moment. You can just see that the separating people out into what their real risk is and getting the proper treatment before they have a heart attack, that's crucial. We can all jump in with catheters and bypasses after the attack and one-third had died, so we can't do anything, but why go in later when you can use a scan and find out who we need to treat upfront maybe ten years before they have a heart attack or maybe have them never have one.

Christopher:    Well, that's interesting. It seems that you'd disagree with my sentiment then that it's either bad news or no news. 

Ivor:    Yeah. The high score, I get a lot of emails, people who got a high score and they're concerned and all. That's why I keep explaining it's not the high score. A high score means you now know and you've got a project to do. 

Christopher:    But a zero score means you know nothing. 

Ivor:    Well, a zero score knows you have a very low level of disease. Essentially in heart disease and heart attacks, it's soft plaque in the interface between the calcified and soft plaque where most ruptures occur. The key point is if you have zero calcium, it means you have a very low burden of dangerous soft plaque. The higher the calcium score, the more masses of soft plaque you have, the iceberg under the surface. The calcium is the tip. If you get a zero score, you basically know you have a very low level of heart disease, so you're very low risk. All the data says this. It doesn't mean zero. You could still have an electrical problem of a heart attack. You could have a single large atheroma from a genetic weakness at one spot in your arterial tree. We have had a couple of people with a zero score who within six months had a heart attack, two cases we know of. They both have a single atheroma and completely clear arteries elsewhere, but none of this takes from the power of the scan because the scan is vastly better than the blood risk algorithms overwhelmingly.

    In fact, a scan result beats all of the blood risk factors put together and then some. It's an engineering test. It doesn't mean it's 100% perfect because nothing is, but AHA-ACC, it's in the guidelines of 2018. It's on IHDA.ie website. You can see a Medscape doc there explaining and its time is coming the next ten years. The fascinating thing is we're going to see a lot of interesting stuff when we start scanning people. Not only will we save the lives of the high risk by treating them before the heart attack, but we'll also take people off unnecessary meds who get a low score. That's all great, but we're going to start seeing people with low cholesterol with huge disease. We're going to see people with super high cholesterol with zero disease. 

Christopher:    As someone said in the audience today, they must have had familiar hypercholesterolemia and yet zero on the scan. 

Ivor:    We have many people in terms of British units or EU scores of LDL at 10 mmol with zero scores in -- 

Christopher:    So what's that in old money? I still think -- 

Ivor:    That's around 400 mg -- well, 380 of LDL alone, not total.

Christopher:    That's amazing.

Ivor:    But they're getting zeroes. Now, I often have to stress that's not to say you ignore cholesterol. Cholesterol values are a very good proxy for insulin resistance.

[0:20:02]

Christopher:    Right. I want to know your triglycerides. I want to know your thyroid. 

Ivor:    Yeah, but if you change your diet and your cholesterol shoots up, it could be fine like those people we're talking about who actually have no problem or the cholesterol shooting up or the ratio shifting could mean your diet is not actually ideal for you even if it's low carb. So the cholesterol can be a warning to look deeper at your other metrics and certainly refer to CAC or progression to be truly informed. It's not to say cholesterol is completely rubbish. It's just hugely misunderstood and it should be used as an indicator to tell you to go and look deeper at the real measures of disease. 

Christopher:    Talk about how people are handling getting a non-zero score. I know Tommy has written about this before. It's not really about the absolute score. It's the progression over time, and you've mentioned that again in your talk today, but how do people handle that psychologically when they go get a scan and it's not the zero they were hoping for?

Ivor:    Yeah. It's a good question because some people are very pragmatic about it. They're very engineer-like and they say, "I thought I might get a zero. I'm a slim guy, didn't smoke. I was eating a healthy food pyramid and I've just got a 900." That happens and their doctor thinks they're bulletproof. My own sponsor, David Bobbett, who set up Irish Heart Disease Awareness, his campaign is because he was passing stress treadmills, ECGs, and executive medicals. Now, he owns a $600 million business, so he got good medicals. He was told he was top 10% of fitness and he was really focused on health, non-smoking, slim as when he was 20 at 52, and acing all tests, and then he got a calcium scan and he got a 906. In a subsequent angiogram, he had three blocked arteries in 1990, 70% blockages. The reality is in America, they rightly told him no stents, no surgery because you are asymptomatic. You have very high disease levels, but optimal medical therapy and lifestyle will match a stent. A stent does not stop heart attacks or extend life. It just relieves symptoms.

    For people like him who are asymptomatic, now, I'll be very clear, a stent can save lives on the table and in an emergency, but the COURAGE trial and ORBITA and the other trials have shown that for decades unfortunately, they thought the stent would extend life or stop heart attacks. It's no better than medical therapy and lifestyle. The reason is because you have an extensive coronary tree and if you go into three narrowed spots --

Christopher:    It's very naïve to think that -- 

Ivor:    Yeah. The rupture that kills you could be myriad other places and that's why the stent helps in three spots, but it just doesn't reduce the chance of another --

Christopher:    Right, but everybody listening to this will know someone that's had one put in and have seen the change in symptoms, right? They see someone -- in fact, I can think of a teacher that I saw a couple of years ago that was teaching. He was like gray and sweaty and just terrible under the lights. Then he was in the emergency room, had stents put in, and he looked great two weeks later. He looked fantastic. All the skin color had come back to his skin and it's like, oh, problem solved, right?

Ivor:    In crisis kind of mode where you've got major restriction and you have a lack of collaterals -- because David Bobbett actually had so many collaterals. The heart had widened all the other vessels, so he had full flow under heart insurance. 

Christopher:    He actually adapted to it. 

Ivor:    Yeah, whereas that guy probably genetically may have had fewer collaterals that could expand, so he's really suffering the restrictive flow from those major arteries and the stent is opening them up and giving him a lease of life. Now, often people who go in with a bit of a problem, they're also getting medications and other things too, so even then, it can be a bit confounded. There is a placebo effect. This is a bit controversial, but the ORBITA trial came out last year and what they did for the first time in history is they did sham operations with stents to explore if there was a placebo effect with stents. Now --

Christopher:    Who would sign up for that?

Ivor:    It was a big deal. They did enough to power it and they did a hundred each. The people who went in under anesthetic, no one knew who got the stents. Incredibly, they saw that the relief of symptoms for these asymptomatic or not so symptomatic, not too severe disease people, a hundred each, it actually was a placebo effect, so they did not see a benefit with the stent once you did sham surgery. 

Christopher:    Wow.

Ivor:    The stent will relieve severe cases, but in terms of preventing future heart attacks or death, it doesn't really have a role. Once you use optimal medical therapy then you get pretty much the same result. It's very interesting. I think with the scan, the crucial thing is -- and I often use this analogy -- mammograms are maybe not a great comparison because they overdiagnose sometimes where CAC just sees what you've got. Imagine a woman, instead of going in with a concern in breast cancer and some signs and they do a mammogram and they find a mass and then they give treatment, surgery, chemo, whatever is needed, imagine you said to a woman, "Well, we're going to ask you a few questions and look at a blood test and we'll work out your probability of having breast cancer." 

[0:25:08]

    Then they find out you're a high-ish risk. You smoke and your blood tests aren't great. "We'll give you a little bit of radiotherapy." That's what happens with heart disease with men and women. It's basically a risk calculator instead of just scanning them and finding out if they're high or low risk. Years ago, I discovered this and I had to pinch myself -- and to be quite honest, Christopher, to this day when I think about what I just said, I have to pinch myself. It's just an enormous group think that has led to us taking the most serious disease in the world and not using the technology that tells you in five minutes what level you have and what treatment you need. 

Christopher:    I have my own biases about why that might be the case, but I'd love to know yours. 

Ivor:    I'd say The Weathermaker movie covers everything. Just briefly, when the scan was discovered, there was huge excitement, enormous excitement, so the high speed [0:25:55] [Indiscernible] could freeze the heart like a strobe and see the calcium. Immediately, the business of cardiology got concerned because a Mayo Clinic study -- and this is on the record. It's in the movie. A team in the Mayo Clinic, which is a very, very good clinic, discovered that if we scan everyone with this new quick scanner, around 50% of our people who go into invasive cath -- that's a massive revenue generator -- 50% of zeros [0:26:20] [Phonetic] and there's no point I'm going in, if you have a zero score at middle age, it's a 99.4% or 99% elimination of a stenosis, over 70% being found. So basically, they realized we can have the number of people going onto the table with this invasive surgery, which has risks. The management team shut down the project immediately because 30% of the revenue at the Mayo Clinic was coming from the cath lab. Are you going to lose 15% of your top line revenue? I don't think so. This is not a conspiracy. If I was a manager there, I would do the same. I'm sorry to admit it. I would do the same. I'd have to.

Christopher:    But what about in the UK then, the NHS? They're not driven by money? I mean they have a finite -- 

Ivor:    [0:26:59] [Indiscernible] America leads the world in dietary guidelines and cardiology. All of the US guidelines I've told you that puts CAC in the 2A, in a year or two, the ESC European Guidelines are going to follow. They followed in 2010. They followed in 2016. So to be honest, it doesn't matter if Europe is maybe a little clever or a little fairer with these things. Everything in medicine largely still flows from America especially cardiology, so we're kind of caught there. 

    The other thing is Pharma 6. Big pharma companies back in the '80s were brought in. I interviewed the professor who invented the scan and they brought them in. I said, "Guys, we're going to be able to help you identify who needs your meds." They did the analysis and said, "Sorry. More people will come off our meds who don't need them than will go on them who do need them. Forget it," so all pharma walked away. This is all in the record in the interviews I've done with these people. Money talks. It's not a conspiracy. I'm a corporate guy for 30 years. I hate to say it, but it's just a no-brainer. You are doing your job in your business for the profits and for the quarterly revenues. You can't hazard that. In fairness, you're not necessarily killing people. You're just kind of not using a certain tool. 

Christopher:    Right. 

Ivor:    It's like you're giving a medication that you know is ineffectual and you exaggerate its efficacy. You're not killing people by pushing the med. They're just buying something they don't really need so the people can sleep at night. 

Christopher:    I get it, and it's a business and the primary purpose of the business is to make money and you have a fiduciary responsibility to your investors, right?

Ivor:    Absolutely. 

Christopher:    Talk about my chances of regressing my score back to zero. 

Ivor:    Ah, the Holy Grail, I think. 

Christopher:    The Holy Grail.

Ivor:    I'm beginning to speak of that. We made a documentary in Ireland last year with a substantial budget, David Bobbett and IHDA-funded, and we scanned around 45 super sportsmen from the '90s, the big Gaelic football people. We got a quarter of them with very high scores who needed immediate follow-up with cardiology and they were all deemed to be healthy, the 45. We found a quarter of them, and it's the same in the population, very high risk. We got a few to take steps, low carb, magnesium, K2, blood glucose meter, kind of eliminating all the foods that spike their glucose, and I'm happy to say that four out of four we intervened with and gave advice to, two have stopped progression, which is unheard of in the medical literature. 

Christopher:    Right. You better talk about this, the exponential curve, what's supposed to happen to calcification over time.

Ivor:    Yeah. Well, Heinz Nixdorf is the big study, but there are many more, and they said calcification increase is inevitable and kind of exponential based on your age or sex and your starting score and that's just the way it is. There's nothing we could do. An LDL doesn't really affect it and serial scanning is not worth it because it looks like it just keeps going up, so what the hell. Let's just treat people and forget about it. Now, they're correct. That's what you see in SAD, Standard American Diet-eating modern people.

[0:30:00]

    That's what you do see, but the difference with our guys was they did something completely different than the standard procedure. They went low carb and they got blood glucose meter and eliminated -- someone had to eliminate beetroot, bread, certainly [0:30:13] [Indiscernible] was causing huge rises in these people who had high scores, and they basically eliminated the foods that were a problem. They ended up with low carb and they took K2 and magnesium, just some other basic vitamins and minerals that are important for someone with heart disease, and we saw two of the four flatten. One went down slightly, which was unheard of and as per Heinz Nixdorf should never happen, one reduced from around 50 to around 25, and one reduced substantially from a 1200 score at 6 months and then at 12 months had nearly doubled the reduction. That latter person is being -- there's a case study being published by a cardiologist who got wind of it and is fascinated because he also knows about Heinz Nixdorf and he says, "I'm 35 years in cardiology…"

Christopher:    This is not supposed to happen. 

Ivor:    "This cannot happen, but here he is and I've got the scores and I went and done an angio on him" and he just can't believe it. I've got emails from all over the world now. I have a guy from 3600 down to 2600 in around two years. We've got guys down from 1900 to 1200 and scores of 60 down to 40. So in other words, there is no question this is a new paradigm literally for the next decade. This is the biggest thing because [0:31:28] [Indiscernible] got a kind of a grainy resolution of heart disease, slight reversal on imaging. This is CAC reversal. This is taking away all the drivers of the progressive disease and it appears the body actually gently leaches back calcium -- 

Christopher:    Well, that's what I was going to say. Have you any idea what's happening physiologically with this calcium that's not supposed to go anywhere once it's embedded in the soft tissue?

Ivor:    Well, essentially like any scab or any kind of repair process, if you take away the driver of it, often the constituents just gently leach back in. Now, some people appear to just stop and the calcium sits there like a sarcophagus, just like a scar, but it appears that for many people, we're seeing that the calcium is no longer needed, no longer being deposited because there's no disease driver anymore. These people are going to get super safe, maybe 15 times safer than they were when they were progressing. We know that from other studies. It appears the calcium will unsurprisingly actually gently leach back into the system because we sequester magnesium in our bones, we take it back out when we need it, same with calcium. This actually is what you'd expect. Take away the disease process and the minerals get just gently reused. 

Christopher:    Right. 

Ivor:    Some people say, "What if you're taking out the calcium by what you're doing and making them softer and more vulnerable?" and the only answer is that makes no mechanistic sense whatsoever. It could be true like anything could be true. The moon could be made of green cheese, but the reality is this makes absolute sense with all the literature. The only thing is it's completely new. That's what's surprising people. It's scaring and shocking people that this can be done. 

Christopher:    So all these good engineers, they're totally up for going back to their Standard American Diet and seeing if they could put the calcium back for the sake of completeness, right?

Ivor:    Yeah. I could eat Wonder Bread and processed meat and drink Coke and I'm going to get that calcium shoved back in there to shore up those atheroma. That's the reality. The joke tells the story. 

Christopher:    How did you find these guys and how did you get them to commit to the program? Because this is a non-trivial task. Behavioral science is the thing and most people, they tend to put these things off. Hyperbolic discounting was something that Simon talked about on the podcast recently. The general idea is that if I say, "Ivor, do you want 100 lbs now or 120 lbs in two years?" you'll say, "I want the 100 lbs now, thank you very much," and people do the same thing with their health. They say things like, "Oh, I'll just eat the pizza now and I'll get back to my diet on Monday." We know behavior change is non-trivial, but obviously with these people that appeared in the documentary, was it the motivating, "Oh, I'm going to be on the telly; therefore, I must not screw this up" or do you think there was some other motivation for them?

Ivor:    Actually, in this case, we had limited bandwidth. Basically, the genesis of it was Donal O'Neill, who made the Cereal Killers movie --

Christopher:    Yeah, I know. 

Ivor:    He had an idea to do a Gaelic GA football movie because he has a lot of strong contacts and leverage and he thought he'd take the biggest 1991 Meath-Down match -- it was famous -- go at these guys in their 50s and look at their diet and lifestyle and just do a whole thing like Cereal Killers, but then we started talking and I said, "Well, how about you included calcification because that's going to add a whole new dimension to it" and he liked it. So we discussed and then we met with David Bobbett and Irish Heart Disease Awareness a couple of times, negotiated, and David agreed to give the funding that we would be required to bring it up a whole level and that's what happened. It went up a whole level, but the regression was not really planned. We only planned to get the scores and illustrate how a quarter of these healthy guys -- 

[0:35:06]

Christopher:    You knew that --

Ivor:    We knew and now they can get treated. They can go on a better diet and lifestyle. The regression kind of shocked us. The movie version, which is out in November, the half-hour documentary is currently free on IHDA.ie at the top of the homepage. You can watch the half hour, but the movie will be much less sport and football clips and it will be much more the journey of high scorers. We'll have cardiologists brought in. Dr. Scott Murray from Liverpool who's president of the BACPR, we flew him to Northern Ireland to get the second scans where we got the reversal, so he delivers the message on video. It's a really exciting story of hope and reversal. It's going to be fantastic. 

Christopher:    That's amazing. Are you going to get it on mainstream TV? Am I going to see it on the BBC iPlayer?

Ivor:    Well, RTÉ was very disappointing in Ireland, the main Irish channel. They just weren't interested. They weren't involved. We released the documentary for free. 

Christopher:    Why is that? Do you know why that is?

Ivor:    I think it's the way they function. They have subsidiaries and subcontractors who make stuff they ask for, and someone coming in from the side -- and Donal was a controversial figure. He set up the Gaelic Players Union, the first players union, and not everyone was happy with him for doing that, helping the players. There are lots of reasons. I think RTÉ are just very structured and very stiff in what feed channels come to them with product and is really tough. It is the way it is. So I think the movie will be based on a release like Cereal Killers and all other things at relatively low cost, accessible platform. It's done in 4K video, so it's Netflix-capable. 

Christopher:    I was going to say what about Netflix. 

Ivor:    Netflix, but these will come later because I think they have to go in for some awards and you can't release the movie until you've seen if the documentary could win some awards. That's kind of an embargo, but I think towards the end of the year, it should be coming out on very accessible platforms. We'll see then. BBC might pick up and realize what a great kind of idea or concept it has because when you see all these sportsmen, we could do this with soccer. We could do it with cricket. In Africa, you could take any team of guys in their 50s still fit and healthy and you can find a quarter of them with big disease and save them and get them on a treatment program. Then if you go the whole step and take a few of them and start getting reversal, this is great television honestly. I'm biased, but this is superb television. 

Christopher:    Yeah, I agree with you and I'm cringing a bit because the idea of having to have the fancy visuals and the fancy music score and all this stuff in order to get the message out there makes me cringe a little bit, but maybe that's what you've got to do in order to get this message out there, to make this Netflix-worthy that people are going to download it and watch it in the tens of millions rather than in the hundreds of thousands, so I think it would be -- 

Ivor:    That's what we need, Christopher, yeah. This is kind of an Irish flavor. It'll be watched worldwide, but there is that Irish flavor. What we'd ideally like to see is to get it done with the UK or US analogous team. They could do it with basketball. They could do it with these rugby players. It could be done with anyone. The beauty is -- for anyone listening who's interested, the beauty is that when you do sportsmen all over the Western world, you're going to get roughly the same result. Around 15% or 20% of them are going to have shocker scores and are going to get looked after and treated. If you properly implement the right solution as you will, you will see regressors happening and stopping progression, which is against medical dogma. That's very viewer-worthy as well. I just think this story is a fantastic story and hopefully people who are smart will pick up and see how big it could get with the right production values, et cetera. 

Christopher:    What's the best way for people to help you spread this message? If you're listening to this podcast or watching the video now, what's the best thing I could do? I feel really -- maybe it's just because I'm too closely connected to the industry and we run a business that help people improve their performance in health using diet and lifestyle advice, and so I don't feel very comfortable talking to my friends or even family about what they might be doing to improve their health and performance, but maybe other people watching or listening feel differently. What do you think is the best way to evangelize this work to save lives?

Ivor:    Right. Well, on the CAC specifically, an enormous value we discussed, the one-stop shop is IHDA.ie, Irish Heart Disease Awareness, because on the homepage, we've got two three-minute videos, a few of them, very accessible with professors and medicine professors at cardiology, top people, top of their field, explaining the calcium scan and the value very simply, and also the new guidelines are there. In 10 to 15 minutes, you're going to get all of that. I'd like to think that my podcast, The Fat Emperor Podcast --

Christopher:    It's great. 

Ivor:    Yeah. There are a lot of guests talking about all aspects of health. We even had myopia the other day and how we can improve that, but it's mostly cardiovascular and serious chronic disease. That series, if you look up and find one in an area of health you're interested in, already I have 32. I have fantastic doctors, Professor Robert Lustig. That's good for all of the solutions-type discussion. 

[0:40:12]

Christopher:    It's super hard. I've been thinking about -- this is perhaps a postscript and a whacky bonus question, but I spent a lot of time over the last year or two looking at the potential of supervised machine learning to predict something like the results of a coronary artery calcium scan. If we say the scan looks directly at the disease, that's the ground truth, as close as we can get to it reasonably without cutting someone open, then could I train a machine-learning algorithm to do a logistic regression and predict the results of the coronary artery calcium scan using blood chemistry, say, as the independent variables? We've had really good results with trying to predict the results of other tests like that and I'm wondering whether we could do the same. The challenge, of course, is getting hold of the training data like who is sitting on a big pile of blood chemistry data together with a coronary artery calcium scan. I'm not sure anyone has that data, but maybe we could collect it, right?

Ivor:    Very possibly, yes. It's not something that's our primary focus because the blood tests will always be a proxy, but I agree with you. I have a study which pulled together 19 studies with calcium results for people and it looked at whether they're LDL correlated and the answer was 19 out of 20 didn't correlate. 

Christopher:    Yeah, of course. I understand that. 

Ivor:    Insulin did. I think if you put together the really best post-meal insulin and post-meal glucose and maybe GGT and ferritin and some of the inflammatory markers and you put them altogether and you got a really good predictive algorithm, better than the current ones, which is cholesterol, I think you'd predict pretty well the degree of disease, the calcium, but you've always got to remember that you can do all that and still if you're going for five minutes to get a non-invasive scan, you'll get the answer. 

Christopher:    Yeah, you're right, so that's the big question, is what's the utility of such a test. Well, maybe the utility is I'm going to run this blood test anyway because my GP is running this simple blood test, and then if I could train an algorithm to predict the results of the scan, you would argue just get the scan. I agree, but -- 

Ivor:    Well, it could be -- as an old boss of mine used to always say, it's an "and". In other words, you wanted both things and often that's the case. So you get a calcium scan, but let's say if it's high, what are you going to do and how are you going to track your progress until your next scan? If it's high, maybe in a couple of years, you need to get another and make sure it's not progressing fast. If it's very low or zero then maybe seven or eight years later. You don't have to do many, but what do you do in between scans if that's the final arbiter, the scan result? What do you do in between? Well, there you can use blood tests to keep yourself on the right vector to have no progression, so you're not going to do scans every month. That's absurd. Even a high score might come back in two years, but in between, you can use blood test to best vector you arriving -- 

Christopher:    Right, which way am I headed, so even if the -- so people have done it. We've done it. You can predict mortality using common laboratory tests and you can haul data out to know how good the algorithm is. Say it's off a little bit. You've got the ground truth plus the prediction side by side and then you track in blood rather than doing a CT scan. I mean you can do a blood test as often as you want really. 

Ivor:    That's the advantage. It's the between scans kind of vectoring yourself. Obviously, it's going to be blood tests or even a really good operator with carotid intima-media thickness with limited Doppler like looking at the bulb. If you've got a high score in CAC and you're going to come up with a CIMT that's probably really bad, showing some athero in the bulb in your carotid, well, before your next scan, you might get a carotid measurement, which is ultrasound and easy just to see that you're going in the right direction. Carotid and CIMT and ultrasound is very poor for predicting your risks, so it in zero sense replaces a calcium scan. It's very poor for predicting, but if you're just looking at I'm at 70 on the carotid, am I at least going to 69 or 71 or am I going up to 74? Again, like a blood test, it could help you keep your ship as much as possible in an even keel until your next scan and enhance your ability to have the next scan come back not progressing. I think these are dynamic, shortest term tools, and the long-term arbiter, the final word is of course where's my calcium? But that's more spread out, yes. 

Christopher:    Of course. That's why I used that term, the ground truth. I think that the feedback is important though. It's like how do I know that I'm doing this right? When you look at everything else that people get good at, the game of tennis, for example, you find out pretty quickly whether you're doing it right or not, whereas with health and performance, it's way harder than that. 

Ivor:    Yeah. Chris, if we go back to how we started the conversation, with all the different ways of doing it like a healthy vegetarian or possibly even a carnivore or omnivore or do I take more olive oil or do I eat loads of fish, you need to decide, "Well, how is my diet working for me?" and that's where a blood test comes in. You don't wait for a calcium scan in three years to see what your diet ideal is. 

[0:45:01]

Christopher:    I guess that last five-year period didn't work. I need to take it again. 

Ivor:    Right. Well, I can't go back three years now and start eating this and stop eating that donut. Yeah, blood tests keep you in a good vector until your next scan. I think that's fair to say. 

Christopher:    Well, Ivor, this has been fantastic. I very much appreciate you and the hard work that you're doing. I will of course link to the websites that you've mentioned including your own. Everybody should be listening to The Fat Emperor Podcast by now. I think you're doing a fantastic job with that. Is there anything else I should link to in the show notes for this episode?

Ivor:    No, but I'd say the key one really is IHDA.ie because we revamped the website. All the resources there, for someone who knows nothing, within 10 to 15 minutes, is going to grasp it. Then all the scan centers in America, UK, and Ireland, we're expanding every week an interactive map with all the scanning centers. That's a huge facility that was nowhere available before. Find your local scan center. 

Christopher:    And then tell us when you get a regression in your score. I think that would be fantastic to collect up all of those so it's not just like a single case study like it's well written up and it's not a controlled trial, but you might get to the point where it's undeniable that you've encountered something that works. 

Ivor:    For sure, Christopher. One of them is a black swan and you might argue against it, but even one of them would be hugely interesting. We've already got tens, and in the coming years, we'll have hundreds. Once you have hundreds of regressors that conflict with Heinz Nixdorf, to be honest, you can ask for an RCT, but there's no need. Even a dumbass will realize this is possible and it can be done. "Wow. I want to get into this."

Christopher:    Yeah, that's great. Thank you, Ivor. I really appreciate it. Thank you. 

Ivor:    Thanks a lot, Christopher. Great stuff. Bye now. 

[0:46:37]    End of Audio

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