Outlive
Kindle Highlights
A far more important measure of strength, I’ve concluded, is how much heavy stuff you can carry.
begin to change my own diet, so as to lower my triglycerides (a contributor to apoB when they are high, as mine were), but more importantly to manage my insulin levels.
possible. Once you understand that apoB particles—LDL, VLDL, Lp(a)—are causally linked to ASCVD, the game completely changes. The only way to stop the disease is to remove the cause, and the best time to do that is now. Still struggling with this idea? Consider the following
Both Beth and Michael Stromsness, a trainer with whom I’d worked in California and who had introduced me to Beth, were familiar with something I had never heard of called DNS. Short for dynamic neuromuscular stabilization, DNS sounds complicated, but it is based on the simplest, most natural movements we make: the way we moved when we were babies.
Monounsaturated fats, found in high quantities in extra virgin olive oil, macadamia nuts, and avocados (among other foods), do not have this effect, so I tend to push my patients to consume more of these, up to about 60 percent of total fat intake. The point is not necessarily to limit fat overall but to shift to fats that promote a better lipid profile.
I suggest visiting the websites for DNS (www.rehabps.com) and the Postural Restoration Institute (PRI) (www.posturalrestoration.com), the two leading exponents of what I’m talking about here. Stability is an integral part of my training program. Twice a week, I spend an hour doing dedicated stability training, based on the principles of DNS, PRI, and other practices, with ten to fifteen minutes per day on the other days.
but running on a treadmill (or a track) could also work. The tried-and-true formula for these intervals is to go four minutes at the maximum pace you can sustain for this amount of time—not an all-out sprint, but still a very hard effort. Then ride or jog four minutes easy, which should be enough time for your heart rate to come back down to below about one hundred beats per minute. Repeat this four to six times and cool down.
I’ve also become semiobsessed with an activity called rucking, which basically means hiking or walking at a fast pace with a loaded pack on your back. Three or four days a week, I’ll spend an hour rucking around my neighborhood, up and down hills, typically climbing and descending several hundred feet over the course of three or four miles. The fifty- to sixty-pound pack on my back makes it quite challenging, so I’m strengthening my legs and my trunk while also getting in a solid cardiovascular session.
I was introduced to this pastime by Michael Easter in his eye-opening book The Comfort Crisis. His intriguing thesis is that because we have removed all discomfort of any kind from modern life, we have lost touch with the fundamental skills (not to mention the frequent suffering) that once defined what it meant to be human. Carrying stuff over long distances is one of these skills; our ancestors likely had to range far and wide to hunt food for their families and then carry their kills back to camp to feed everyone. But it’s so effective that the military has incorporated it into their training. “Carrying shaped our species,” he says. “Our ancestors carried often. It gave them robust functional strength and endurance that was likely very protective. But we’ve engineered carrying out of our lives, just as we have many other forms of discomfort. Rucking is a practical way to add carrying back into our lives.”
Brief Overview of Lipid-Lowering Medications While there are seven statins on the market, I tend to start with rosuvastatin (Crestor) and only pivot from that if there is some negative effect from the drug (e.g., a symptom or biomarker). My goal is aggressive: as rationalized by Peter Libby, I want to knock someone’s apoB concentration down to 20 or 30 mg/dL, about where it would be for a child. For people who can’t tolerate statins, I like to use a newer drug, called bempedoic acid (Nexletol), which manipulates a different pathway to accomplish much the same end: inhibiting cholesterol synthesis as a way to force the liver to increase LDLR and therefore LDL clearance. But where statins inhibit cholesterol synthesis throughout the body, and most notably in the muscles, bempedoic acid does so only in the liver. Therefore, it does not cause the side effects associated with statins, especially muscle soreness. The main issue with this drug is cost. Another drug called ezetimibe (Zetia) blocks absorption of cholesterol in the GI tract.[*10] That in turn depletes the amount of cholesterol in the liver, leading once again to increased LDLR expression and greater clearance of apoB particles, which is what we want. Ezetimibe pairs very well with statins because statins, which block cholesterol synthesis, tend to cause the body to reflexively increase cholesterol reabsorption in the gut—exactly the thing that ezetimibe so effectively prevents. LDL receptors can be upregulated by a class of drugs that we mentioned earlier, called PCSK9 inhibitors, which attack a protein called PCSK9 that degrades LDL receptors. This increases the receptors’ half-life, thus improving the liver’s ability to clear apoB. As a monotherapy they have about the same apoB- or LDL-C-lowering potency as high-dose statins, but their most common use is in addition to statins; the combination of statins plus PCSK9 inhibitors is the most powerful pharmacological tool that we have against apoB. Alas, statins do not reduce Lp(a), but PCSK9 inhibitors do in most patients, typically to the tune of about 30 percent. Triglycerides also contribute to the apoB particle burden, because they are largely transported in VLDLs. Our dietary interventions are aimed at reducing triglycerides, but in cases where nutritional changes are insufficient, and in cases where genetics render dietary interventions useless, fibrates are the drug of choice. Ethyl eicosapentaenoic acid (Vascepa), a drug derived from fish oil and consisting of four grams of pharmaceutical-grade eicosapentaenoic acid (EPA), also has FDA approval to reduce LDL in patients with elevated triglycerides.