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

1. 0:00 – 0:04

   Intro

   1. PAPeter Attia0:00

      [upbeat music]

2. 0:04 – 7:21

   Week of Tom: Series Overview and Tom Dayspring's Bio

   1. PAPeter Attia0:04

      Hey, everyone. Welcome to The Peter Attia Drive. I'm your host, Peter Attia. The Drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions along the way. I've spent the last several years working with some of the most successful top-performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information on today's episode and other topics at peterattiamd.com. [upbeat music] Hi, everyone. Welcome to this special edition of The Peter Attia Drive. This is a special edition because it is the longest podcast ever recorded in the history of podcasts, maybe. It was a seven-hour, only getting up to pee once interview with Dr. Tom Dayspring, who a number of you will immediately recognize by name. Tom is one of my most important mentors and is generally the mentor to the mentors in the field of lipidology. We're breaking this into five parts, so this is gonna be The Week of Tom. So today, if you're listening to this in modestly real time, on Monday, we're releasing Part I, and there will be a part released each day, Monday through Friday. So this seven-hour podcast will be released over the course of a week. I'll call it The Week of Tom, and what you're listening to right now is Part I. I'm gonna use Part I to give the bio and background on Tom and give you just the insights over what is covered in Part I or Episode One, and then prior to each episode, I will just highlight what's going on there. Tom Dayspring is the chief academic officer for True Health Diagnostics, a laboratory company. Tom is a fellow of both the American College of Physicians and the National Lipid Association. He's board certified in internal medicine and clinical lipidology. He practiced medicine in Jersey for just under 40 years, and in the last two decades, he's given about 4,000 domestic and international lectures to lipidologists and cardiologists everywhere, including a little over 600 CME programs on this topic. He's listed in the Guide to America's Top Physicians and is on the editorial board of the Journal of Clinical Lipidology. He's authored and co-authored more manuscripts than I was able to count, although that's obviously a countable number, and he has received the 2011 NLA, National Lipid Association President's Award for Service to Clinical Lipidology. I actually spoke to the president of the NLA who gave him that award, and he described it as the most important award he had ever given out. Tom's really active on Twitter @DrLipid. That's D-R-L-I-P-I-D. And more than anything else, as I think comes across in these interviews, I share just the greatest affection for Tom. He can be rough around the edges, and when I ask Tom a dumb question, boy, do I get an earful about it. And he'll always tell you, "I'm sorry. I'm just a Jersey boy. I just don't know how to sugarcoat it." But I don't know how to express my gratitude towards Tom other than the way I probably do so in this podcast. And I really wanted to do this to share so much of the knowledge that Tom has given me with so many other people. There's obviously been such an interest in understanding this space. As I think I probably allude to in this podcast, back in 2011 and '12, and maybe even into '13, I wrote a nine-part guide on cholesterol called The Straight Dope to Cholesterol. It was about 30,000 words. It was quite a lot of work. Obviously could not have done that without Tom's help, and to this day, Tom is probably the single most important clinical mentor that I have. In this first episode, which is probably gonna be a little bit longer than the others, this is where I'm gonna really kind of introduce you to what I call the national treasure, and that's just the way I describe Tom. He is just a national treasure, and I am not the only one to say that. You ask any card-carrying lipidologist who they look to as their go-to guy on education, and it's gonna be Tom. We talk about some of the definitions of things, but we actually start by talking about things about Tom's personal life that most people don't know, his obsessions, firefighting, hockey, and ultimately lipids, and there's a common thread to Tom's obsessions. He's an amazing author and illustrator, and we talk a little bit about some of that stuff and his gift to teaching. So in many ways, the first episode is the soft one. This is the one that kinda gets you warmed up, gets you ready to think about what we're about to do. And then in episodes two through five, we get into sort of the more technical stuff. The [chuckles] other thing I just wanna say for this episode, as some of you may recall for the episode with Dave Feldman, we splurged on getting a transcript so that we could, you know, really make this technical information available. Tom was so kind to go through and edit and correct all the things that Dave and I had said incorrectly, which is invariably gonna happen in a long podcast, and he also did the same thing for this podcast. So when this podcast came out, I, I wanna say it was 80,000 words or 90,000 words. It's basically a book, medium-sized book. Tom went through with a fine-tooth comb and made all of the corrections there. So what you'll also find in the show notes is sort of an editorialized, corrected version of the transcript. I think it is safe to say that you could learn more in the next seven hours, meaning episodes one through five, than you would learn in a lipid fellowship, and I suspect that many people who are studying in a lipid fellowship will find great value in this. That's the level of detail we go into. And at the same time, if you're a patient, if you're a primary care physician, I think you will still find this incredibly valuable. So this was a little more work than usual to prepare for it, to record it, to edit it, to break it down, to do all of the things we did, but I believe it's worth it and I am so happy to have been able to have done this because I think of... There are few things that I get more pleasure out of than sharing Tom's knowledge with other people. So with that, welcome to episode one of The Week of Dayspring. [upbeat music] Hey, Tom. How are you?

   2. TDDr. Tom Dayspring6:21

      I'm very good, Peter.

   3. PAPeter Attia6:23

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

   4. TDDr. Tom Dayspring6:27

      Not the world's longest journey.

   5. PAPeter Attia6:29

      [laughs] I think a lot of people have been looking forward to this. I think many people have sort of relied on your insights, your knowledge over the years, as I have. And I think what follows, and I have no idea how long this is going to be, but I suspect it will not be one episode, but this will, this will certainly be the master's class in lipidology, but not just for physicians who wanna understand this more, but I think for patients, too. But there's so much stuff to talk about before we get into that, and I figure if you're willing to talk about it, what I'd love to do is, uh, have you explain a little bit about this kind of remarkable physical transformation you've undergone in the last year, which this is only-- This is actually the first time I've seen you in person in eight months, and I could barely recognize you as you walked down the hall to my apartment yesterday.

3. 7:21 – 16:48

   Dayspring's 67-Pound Transformation Through Modified Fasting

   1. TDDr. Tom Dayspring7:21

      Well, uh, many people who have seen glimpses of me on the internet or whatever in person, God knows how many lectures I've done across our great country, have always known, "Geez, for a, a lipid guy and a cardiometabolic guy, he's kind of obese, so he probably doesn't always practice what he may be preaching and everything." So indeed, I've had a, a long, long, uh, experience with obesity and insulin resistance and cardiometabolic disarray and everything, and, uh, always had, uh, the usual million excuses why I didn't have to do anything about it or so. I felt good. Nothing was happening to me. And, uh, I just did kept ignoring it. But I did keep aging. So for those who don't know, I'm reached, uh, seventy-two years of age this year, seventy-one last year. And, uh, I've been great friends with Peter for a long time, and Peter, of course, has been harping at me, uh, to do better nutritionally and everything. And I, I just stumbled into his podcast done up at MIT, where he talked, uh, a lot about longevity and, hey, the average age of death in the United States. And as an old man, uh, I, you know, I can see a little light at the end of the tunnel, like, "Geez, if eighty is the average age of death, how much longer do I got to go?" And over the last five, six years, I've dealt with a bunch of morbidities, a lot of them arthritic in the spinal nature. But, uh, cholecystectomy and fatty liver and things like that were sneaking up on me. Even though, o-other than my bone issues, I felt pretty bad, so I just said, "You know, since th- I do see the end of the tunnel and Peter's making a lot of sense what he's talking about, all about longevity here, maybe I ought to listen, uh, to what he's preaching here." And, uh, he did raise the topic of intermittent fasting during that talk and everything. I sort of figured I gotta do low carbs finally more than I ever did. But the fasting was kinda new to me, y-you know. And, uh, in further conversations with Peter, he just put me on an incredible regimen he's developed. Uh, it's a modified intermittent fast that I said, "I can do that." And I did it, and, uh, as Peter says, that was, uh, sixty-seven pounds ago over, uh, the last 11 months. I just finished my 11th month of a... I do one week a, a month of seven hundred calories or less, pretty significant carb restriction. And it's not only the weight has gone off, but, I mean, a bunch of residual orthopedic symptoms that I was having that I just thought I'm gonna have to live with the rest of my life. I've had hip replacements, several spinal surgeries. I almost 90% of the time, 95% I feel like I've got my normal hip back, my normal spine back. I can walk again.

   2. PAPeter Attia10:18

      Yeah, we walked to dinner last night-

   3. TDDr. Tom Dayspring10:20

      Yeah

   4. PAPeter Attia10:20

      ... and you said that that was a walk you would not have been able to do a year ago.

   5. TDDr. Tom Dayspring10:23

      Yeah, a year ago, I could walk a short block, and I'd have to sit down and wait for my bones to say, "Okay, try it again." And now they just don't have any of those limitations. So it's been miraculous in a lot of way, and I think it's way beyond just the weight loss, too. I think this fasting and whatever else it's inducing in me has just changed a lot of things. And we know that because... Look, I work for a, a laboratory. I can do a lot of sophisticated testing on myself and checking every cardiometabolic marker that pretty much a lab can do nowadays. And there was some ugliness to my report a year ago. And it's, uh, those who follow the lab I work for know we-- it's reported in red, yellow, and green, and green is you got an optimal level of whatever. And, uh, went from a pretty yellow, red report to 100% green report. So it's not only, "Geez, I'm feeling so much better biochemically. I'm doing an unbelievable amount." And I mean, I'm happy about all of that, but the disappearance of the aminase levels have been especially impactful.

   6. PAPeter Attia11:30

      Yeah. So I'll, I'll interject to just add some commentary. So the first thing I would say is you were quite resistant, I recall, when we first had the heart-to-heart. So you called me after you saw the MIT video. I don't even know why you saw it. Did I-- I don't think I sent it to you.

   7. TDDr. Tom Dayspring11:45

      I think you linked it to me.

   8. PAPeter Attia11:46

      Did I? Uh...

   9. TDDr. Tom Dayspring11:47

      And one last joke about that, you know, I'm good friends with Peter. I don't wanna ignore anything he sends me. I send him a lot of stuff, and I know he reads most of it. And I said, "All right, I'll humor him. I'll listen to ten minutes of this lecture, and at least I can be honest, say, 'Yeah, 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 podcast, and I just couldn't stop listening to it. I went right to the end. I've listened to it one more time. I've referred it to many other people to listen to. So it's one of these things in life that somehow It really impacted me, uh, on that day

   10. PAPeter Attia12:23

       Which is interesting 'cause the first 10 minutes are not particularly interesting, so I don't know. Luckily, we snuck you through. But so I'd always had this concern because over the past seven years we've known each other, you know, you see my labs, I see your labs, and I'd always been kind of concerned about those LFTs, and it was like they were getting higher and higher, and there were a number of other things I was concerned with. So when you responded to me saying, "Hey, I want to do something about this," and I said, "You know, in the past, you've had a hard time just adhering to carbohydrate restriction. I think we need to try something a little bit more extreme." And so what I proposed, as you said, was this idea of doing a modified fast, and this is sort of loosely based on Valter Longo's five-day FMD, but we kind of took it a little more extreme. So a slightly higher ratchet up on the caloric restriction during five days, and also doing it every single month as opposed to quarterly. And also in Longo's version of the fast, it's focusing on the restriction of protein, so it's actually relatively high carbohydrate. We wanted to restrict carbohydrates both inside and outside of the FMD. Well, you expressed enormous reservation just at a, a practical level, like, "Uh, Peter, I don't think I can do this." So what I think I wanted to, to point out was that it was amazing that you took that plunge the first time, 'cause I remember that first one you did last, I think, October.

   11. TDDr. Tom Dayspring13:44

       Right.

   12. PAPeter Attia13:45

       And you worked very closely with Nicole, who's our dietician inside the practice, and she, you know, was just incredible at sort of guiding you through the, the logistics of what does it actually mean to eat 700 calories a day of basically no carbohydrates. And then once you emerge from that, what are you going to? Do you remember what it felt like after that first time?

   13. TDDr. Tom Dayspring14:06

       Yeah.

   14. PAPeter Attia14:06

       You like-

   15. TDDr. Tom Dayspring14:07

       And, and look, I was highly motivated 'cause of morbidities I had, my age, and I'm a time bomb. Something more is gonna happen. I sure don't want to undergo more orthopedic degenerative arthritic changes. My gallbladder's gone, but, uh, that fatty liver, uh, how many liver cells do I have left? My big worry for what I do is cognitive impairment as time goes on, and I was certainly headed towards ugliness in that direction also. So and as you start approaching it, hey, I wanna hang around. I got a son. I got a great life. I, I wanna be here for a while. I was super motivated, which 20 years ago, if we even knew this stuff, I don't know how motivated I would've been. So the end was near, and just being so motivated, even though when I looked at Peter's recommendation and Nicole's, wow, I, I don't think I can do this. You want me to-- To me, uh, the caloric restriction for those five days was you're starving yourself, and I just didn't think my body would allow me to do that as a guy who's used to nibbling all day long every day of the week and everything. But the motivation made me, "I'll try it," you know? If it doesn't work, it doesn't work, but he had convinced me in that talk there was a good chance to shut down a lot of these m-metabolic pathways that were contributing to my morbidities. So with Nicole's great help in understanding how to put together meals, especially during that week, and with an incredible wife who's willing to prepare my meals and everything, uh, I did it. And, uh, you know, that first five-day fast, you know, by day two or three, the hunger pangs are there and, oh, my God, can I do it? But, no, I gotta do this. And it's kind of funny, like, after day three, the hunger disappeared, and on subsequent fasts, sometimes I go five days I don't even feel hungry during it. Maybe some-- Like last month I did it, the third day, which w- I do it a Monday through Friday, the Wednesday, oh, God, I'm kinda hungry. I feel kinda weak today. But it was-- lasted half of that day and then just passed. So I'd really tolerate those five-day fasts well, and the results are so astronomical. The weight just poured off. We rapidly repeated some of the biomarkers and whether-- For a guy like me who's-- [chuckles] My, my life is looking at biomarkers in people and seeing-- It was just so impressive that this has got to be doing good things to my body. And, uh, symptom-wise, I mean, just symptoms disappeared that I didn't realize. You know? I didn't realize I couldn't walk up a flight of steps without being a little bit dyspneic or, or things like that, and that's just all gone. And so, uh, there were a lot of rewards that came quickly, and, uh, the fasting wasn't as horrific as I thought it was gonna be.

   16. PAPeter Attia16:48

       Yeah.

4. 16:48 – 20:48

   Motivation, Adherence, and Why Attia Champions Fasting

   1. PAPeter Attia16:48

      I think people who, who listen to me talk have, have got the sense that I've become more and more a proponent of fasting as an adjunct to dietary restriction. Of course, dietary restriction meaning the restriction of certain macronutrients. So carbohydrate restriction would be a form of dietary restriction. Protein restriction would be, you know, meat restriction for those who choose to, you know, be vegetarian or vegan. That would be a form of dietary restriction. And all of these things can offer benefits potentially. But caloric restriction, the actual restriction of the total number of calories for limited periods of time, I think has to be a cornerstone of what we do because it is simply the most powerful way to deplete glycogen. It is simply the most powerful way to reduce insulin. It is the most powerful way to turn those nutrient-sensing organelles and molecules off. And we know that we don't want those things off indefinitely, but we know that our current living environment, where they're basically always on, you have these-- You are constitutively fed. It's evolutionarily unnatural, and in the metabolically ill person, it might be the single most destructive thing you can do. And I've said this before, and I'll say it again, Tom. My intentions, I wish I could say it was just altruistic. It was incredibly selfish, my motivation for this. I remember sitting down and saying this to you in October, September last year. I was like, "Look, Tom, the impact your teachings have had on me personally, and therefore by extension on all of my patients, it can't be measured." And so I started jokingly-- And I, I'd been calling you this [chuckles] for a couple of years. I've been referring to you as the national treasure. And I remember saying this to your brother when we had dinner with him a few years ago, and he kinda rolled his eyes at me. I'm sorry, to your son, to Brad. And so I just said, "Look, this is a, uh, selfish motivation that I have to keep Tom around as long as possible." So as long as I can be transparent about that.

   2. TDDr. Tom Dayspring18:43

      Oh, you're very kind. And, uh, the other good thing about your talk... Look, I'm basically a scientist. I don't try and ad-lib and make things up like so many people do to support whatever they believe. There was just so much plausibility, and the science behind a lot of what you said seemed very real to me. And then did a little reading, and so that sort of boosted me, too. Peter's just not making this stuff up. It's beyond the theory stage, I think. And if we look at our evolutionary genetic ancestry and what our human ancestors, the way they ate years ago, it just makes a lot of sense. So here I am-

   3. PAPeter Attia19:20

      So I'm, I'm holding out-

   4. TDDr. Tom Dayspring19:21

      And I, I'm not giving it up anytime soon.

   5. PAPeter Attia19:23

      Well, and I'm holding out hope that my dad is listening to this or will listen to this. I don't think he's ever listened to one of my podcasts, but I might insist that he at least listen to this portion of this podcast because if I could get my dad to do this, that, that would be-- Again, probably for selfish reasons, that would be sort of the highlight of my life. And you generously offered to speak with my dad because I don't-- I mean, he certainly won't do what I would recommend, so it would have to be Nicole and you sort of cajoling him into trying this. And Nicole has also offered to help in any way. So Dad, if I can get you to listen to this, I hope you'd consider doing this. So with that said, been thinking a lot about... Well, first of all, just watching the transformation you've just described unfold over the last seven, eight months, it's blown my mind because I've worked with many patients over many years, and I've almost never seen the level of fastidious dedication to adherence that I've seen from you. And I've known you for many years before, and you'd been sort of ambivalent towards this. So it was sort of this question of once the switch flipped, there was no wavering. Now, I didn't make the connection at the time, but I think more recently I've realized that's just kind of the Dayspring way. So before we get into lipids, I want you to tell me about the very first obsession you had.

5. 20:48 – 30:25

   Firefighting Obsession and the Honorary Battalion Chief Award

   1. TDDr. Tom Dayspring20:48

      Well, I've had a few obsessions in my life. There is more to me than just understanding biochemistry and cholesterol and other lipids or so, and probably the first thing in my life was being born to two incredible parents, one of whom was a, uh, professional firefighter in the city of Paterson, New Jersey, New Jersey's third-largest town. So when you're a son of a firefighter, real early in life, you're visiting firehouses and being exposed to the incredible men who are firefighters and all their glorious machines that are sitting there in the firehouse, these big red things with bells on them and sirens that when they start them up, make a lot of noise. Every once in a while, your mom brings you to some major conflagration where you see your dad running in and out of buildings that are collapsing and on fire. So I just developed an unbelievable passion and love of firefighting, which remains to this day. I'll put in a plug. I run one of the most viewed and largest historical firematic firefighting websites in the United States. It's patersonfirehistory.com, if anybody'd like to do it. And you'll see, and there's just thousands of pages of thousands of photographs and incredibly documented data on the Paterson, New Jersey Fire Department, which has, very unusually in the United States, it goes back 200 years. Paterson was formed by Alexander Hamilton right after the Revolutionary War as a mega industrial town because of a giant waterfall that was in the town, so they had a need for firefighting early on. So you can really trace the entire history of firefighting in the United States by focusing on Paterson, and it applies to New York and other towns that have been around for a long while. So I've just had a great passion doing that. So of course, I wanted to be a firefighting, too. So look, to collect the 30, 40 years of data that is now on my website, you gotta be a little bit of a nut job with a passion for firefighting to do that. And I, I was able to collect that all, uh, material through, of course, having a, a father who was well-connected in the firefighting world and everything. But I put my heart and soul into it. When I was an adult, after med school, I used to go to every antique market around firematic flea shows to collect. I, I collected one of the largest displays of firematic antiquities that were around in the United States outside of a museum, so-

   2. PAPeter Attia23:20

      I didn't even know that was a word, by the way. I just liked the way that sounded.

   3. TDDr. Tom Dayspring23:23

      Firematics.

   4. PAPeter Attia23:23

      Firematic antiquities.

   5. TDDr. Tom Dayspring23:25

      Yeah. [chuckles]

   6. PAPeter Attia23:26

      I don't know.

   7. TDDr. Tom Dayspring23:27

      And there are a bunch of nut jobs like me who are very much into this. It's funny-

   8. PAPeter Attia23:32

      You were recently given an award.

   9. TDDr. Tom Dayspring23:34

      I was, because of my dedication to Paterson, documenting all this. They're so proud of it. It's probably the most visited historical fire department website in the United States. The department, uh, very much respects what I do. At, at a certain point, they became very cooperative with sharing some of their archival material that my father hadn't stolen when he was a chief officer [chuckles] of the department years ago. So the latter years have had their cooperation. But they brought me up to a memorial ceremony they had in June recently, 'cause I was very mu-- They have a monument up there where if you make the supreme sacrifice, if you're a firefighter who dies in the line of duty, you, you get your name on this beautiful bestowed monument outside their fire headquarters. And they've had 28 firemen, unfortunately, have their name on that monument over the last couple hundred years. And through my archival analysis in 1938, I found the name of a firefighter who died on the job. He dropped dead as he was carrying a big hose running to a fire hydrant to hook it up, and it sort of got ignored. Now, 1930... He obviously died of a heart attack at the scene. He was 50-some years old. Dying of a heart attack while you were fighting a fire was not considered a fireman's death at that time. If a wall collapsed on you, it would've been. But nowadays, it certainly is. If you have a heart attack at a fire, you would get your name on the monument. Your colleagues would mourn you heavily. So I've actually found the data buried deep in the files that this guy dropped dead at a fire scene. I went to the library, got the newspapers that documented that, and I presented it to the department. So lo and behold, they added the 29th name to the monument, uh, Fireman Edward Moore, who died in 1938. So a little belatedly, but his name is there. So I wanted to go up and see that presentation, and the chief said, "Tom, would you get up and just tell this crowd a little bit about who Edward Moore was? 'Cause none of them will certainly know him." So I made a little three, four-minute speech on who he was, what happened to him, and I started to walk back to my seat, and the chief said, "No, Tom, don't leave the podium yet." And he said, "You know, to make a long story short, what you've done for the department, we are, for the first time in the department history, making you an honorary battalion chief." It's the highest honor a professional fire department can ever give to a civilian. They will never give you a rank above a battalion chief, a deputy chief, assistant chief, or a top chief. But me, a battalion chief? My dad was a chief for 30 years in the Paterson Fire Department, starting as a battalion and a deputy and assistant. So it was a... I, I just can't display the emotions that went through me. 'Cause my life, I always wanted to be a fireman. Dad twisted my arm and said, "No, you're going to college, and you're gonna study whatever you want to study, but you're not joining the fire department out of high school," which I probably really wanted to do. And as tears were in my eyes, and there were around 400 people in the audience at this big ceremony, I just looked to the skies and, and hoped I was additionally making my father very proud of me, and he was a very proud man of me because of my medical career, of course. But so, yeah, my love and passion of firefighting got me this. And just to finish that story, 'cause they told me, "You're the first person that's ever we've awarded a battalion chief to." But they didn't know I know their history. Back in the 1960s, a woman was made an honorary battalion chief in the Paterson Fire Department, and it happened to be a nun at one of the big hospitals in Paterson, a Sister Loretta Agnes. Now, what do you know? I th- One of the major reasons I'm a doctor and had I trained actually at St. Joseph's Hospital in Paterson, New Jersey, 'cause I really wanted to practice in that area, she was a, a friend of the family, a nun, and would visit our house all the time, and she knew I was pursuing a medical career, and she used to always harp on me, "Oh, you got to come and visit our hospital. I'll give you the grand tour, and you can hang out there in the emergency room if you want and just get to know our hospital." Mr. Smart Ass here, "No, I'm gonna go to some big university hospital here inside. I want nothing about a hospital in Paterson, New Jersey," even though it's 700 beds and it's a gigantic hospital with a teaching program. But I took her up on it as... And I was a freshman medical student at the time, and I ju-- she just hang-- let me hang out in the emergency room, and I hooked up with a couple of docs who would work. I would go in the evening. After finishing classes, I'd go hang out in St. Joe's, and, uh, I don't know, it's a large part of who I am, what I do. It fit in perfect. I'm a fireman. Emergency room is where all the action is happening and stuff. So Sister Loretta had a mega influence and, and I did go to train there, and she was a godsend to patients, so I interacted so much. But Sister Loretta was made an honorary battalion chief by the department because of her care that she extended to every firefighter who was ever brought to St. Joseph's Hospital in Paterson, New Jersey. So the two honorary chiefs in our history are, are linked in other ways.

   10. PAPeter Attia28:49

       They're linked.

   11. TDDr. Tom Dayspring28:49

       You know? So it's just kind of spooky there how that turned out, you know, but just a great honor. And on my desk at home, I have a blotter that, you know, is like a plastic top, so I can stick things that are important to me underneath it. I have my mother and father's, the little card that was at their funeral that funeral homes put out. I got some pictures of my son there, and I've got a mass card that my wife and I gave to Sister Loretta on her passing. It's just such an impactful... Last but not least, the fire department actually now does an annual Sister Loretta Agnes Dinner for the clergy in Paterson and stuff, and I kind of laughed about two years ago. They called me up and said, "Oh, you know, did you ever hear of Sister Loretta Agnes?" [laughs]

   12. PAPeter Attia29:34

       [laughs] Does a bear shit in the woods?

   13. TDDr. Tom Dayspring29:36

       Yeah, yeah. So actually, on our website now, I have a whole page dedicated to her and what she've do- she's done for the fire department and everything. So it's kind of funny.

   14. PAPeter Attia29:45

       Well, we could probably spend another hour talking about that, and I know that our listeners would actually appreciate it, but that said, there are a couple other things I want to get to even before we get to the lipid stuff. The other thing that we connected on pretty early was I realized you were a hockey fan. Of course, I grew up in Toronto, and I don't think you can grow up in Canada without being a hockey fan, without playing hockey and being obsessed with it at, you know... And certainly when I was a really young kid, probably till I was about 13, it was hard to think of anything but hockey. And it turns out you kind of, just as you had this sort of light switch moment with a, you know, all these things we've talked about, you've had kind of that flip of the switch moment in hockey too, right?

6. 30:25 – 39:32

   Hockey Fandom and Memories of the Original Six Era

   1. TDDr. Tom Dayspring30:25

      I sure did, and, uh, it was very easy to grow up in New Jersey in the 1950s and early '60s without knowing what ice hockey was or even ice skating per se, other than a month or two on a pond maybe in January. You know, when I was a young boy, a defining moment in my life was the first visit my dad picked me up in a car and brought me to Yankee Stadium, and I walked into, probably in the early '50s, into that stadium and the green grass, and these Yankees running around in their white uniforms and pinstripes. So I became a mega baseball fan growing up and a New York Yankee diehard, which I remain to this day. And that was a transforming moment, to be sure. It's the sport we played as a kid, wiffle ball all the time, me pretending I'm Mickey Mantle, and the pitcher would be Whitey Ford throwing to me and everything. But in 1962, while in high school, my best friend was another young man who also had firefighting as a passion. I always joke, I think I became his best friend 'cause he knew my father was one of the fire chiefs in Patterson [chuckles] and he wanted to hang around with a fire chief's son. But who cares? I loved the guy, and we grew, we became so close in high school and everything. But some odd reason, he was a hockey fan or something. He says, "I want you to c- you know, I go to Madison Square Garden occasionally. I'd like you to come with." Why not, you know? So I went over, and I remember to this day, it's probably 1962, maybe I was a freshman, sophomore in high school. You walk into the old... And I'm talking the old Garden up on 8th Ave and 49th Street. It was a dark, dingy place. You're walking in, y- you almost need night vision goggles.

   2. PAPeter Attia32:03

      [laughs]

   3. TDDr. Tom Dayspring32:04

      But all of a sudden you walk into a spot where the glow of that white ice strikes you, and out come these guys in red, white, and blue, the New York Rangers, who at that time were wearing no helmets, and you really... And the other team. There were only six teams there, so the competition was unbelievable. So I just fell in love instantly. One game, I knew I just have to start following this sport. And I tell Peter, within a year, not only did I say I have to watch this, I went out and bought myself a pair of skates, which wasn't easy to do back in those days. And me and one other buddy, at night in the winters, we started going to a local pond we knew about. We're the only two people out there, and we just taught ourselves how to ice skate, bought some hockey sticks, started playing. One thing led to another, convinced a few other young friends to do it, and within a year or two, we, we knew the one or two rinks that were within 50 miles of our house, so we would drive down there and rent the ice for an hour. And so I became a pretty decent hockey player, considering I didn't grow up in Canada and everything, at least playing against New Jersey competition. And over time, joined men leagues, and some of my best friends in life now are not doctors. They're guys I played men's league ice hockey with, beer hockey as they call it nowadays or whatever, 'cause after you're done with the rink, you know where you wound up for a while. [chuckles] And I played until I was 50 years old. And the last part of my hockey story, of course, 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 the hospital, my wife and I drove him home, brought him upstairs, put him in this wonderful bedroom we had put together with a crib in it. And what was laying in his crib? A small hockey stick that was about four feet long.

   4. PAPeter Attia33:52

      [laughs]

   5. TDDr. Tom Dayspring33:52

      I wanted him to imprint on it like the ducklings do to mother duck.

   6. PAPeter Attia33:56

      [laughs]

   7. TDDr. Tom Dayspring33:57

      And, uh, as it turns out, my son turned out to be an incredible lifelong hockey player at every level, youth hockey, high school, and college. And, uh-

   8. PAPeter Attia34:07

      He was a team captain in college, wasn't he?

   9. TDDr. Tom Dayspring34:09

      He's just had leadership abilities. I credit that to my father. And, uh, yeah, he was probably the captain of every team he was ever on, from mite up through high school and into college. And so very proud of him. So a large part of my life was not only playing hockey as I grew up, watching hockey, but when he started getting... Every night of my life, I was at a practice watching him. [laughs] Uh, and so again, some of my best friends were other hockey parents and stuff. Again, I wasn't hanging out with all the docs and going to the doctors' balls and that kind of stuff. They, like, never saw me. And in practice for 37 years, I just had a godsend of a fellow, call him a brother really, my associate, who just covered my tail every time I wanted to run to a, "Hey, I gotta go to practice with Brad," or, "I gotta play hockey." He just covered the practice, and, uh, it was... Made my life easier. So, so yeah, that's the other super passion of mine. And when I say dedicated to hockey, w- even when I was in med school, when class was over, I was going to a rink or someplace, or I'd show up in my greens 'cause, "Hey, guys, cover for me for a few hours. We got a game tonight." And that's how crazy I was. In my medical school yearbook, you'll see a picture of Tom Dayspring, and the class voted, you know, we're gonna pre- predict what everybody's gonna wind up, and I was predicted, of course, to be the future New York Rangers team physician, which I never did achieve, but close enough.

   10. PAPeter Attia35:38

       [laughs] Well, it's not too late. So we should add that to the list of things that we might try to figure out how to tee up. You know, it's so funny because I grew up in Toronto, of course, the Maple Leafs were also one of the original six. Now, I grew up in the '70s and '80s, so by then the league had expanded, and I very quickly fell in love with the Edmonton Oilers, who would very soon go on to become the most dominant team of the '80s. But even watching them come up before they became that most dominant team, they were just electrifying, thanks to, of course, Wayne Gretzky, but also guys like Mark Messier, who would go on to become captain of the New York Rangers and finally bring glory back to the Rangers after one of the longest hiatuses in sports. It was '94 when they won the Stanley Cup again, right?

   11. TDDr. Tom Dayspring36:21

       Yep.

   12. PAPeter Attia36:21

       But it's the same experience. I remember the first time my dad took me to Maple Leaf Gardens, which of course is not where they play anymore, but it was this old sort of, you know, historic, kinda dingy arena. And, um, I remember one game, 'cause at that there was like, uh, gold seats were the best, then red, blue, green, and gray, and, you know, we could afford the grays. But I remember on, for an exhibition game where the tickets were a bunch cheaper, the Oilers came to play the Leafs, and we got gold seats And I mean, I couldn't, I couldn't believe what it was like to sit 10 feet, maybe a bit more, maybe 20 feet from the glass and actually see... You know, at the time there was a goalie named Grant Fuhr who was like... I was a goalie. I played goalie in hockey, so Grant Fuhr was actually the guy that I was trying to emulate. And to see these guys, you know, Jari Kurri, Glenn Anderson, Paul Coffey, Mark Messier, Wayne Gretzky, I mean, I don't... Yeah, it's just, it was a very special thing to, to do as a kid, and I can certainly relate to that. And the older I got, the more I realized that the experience I had was basically gonna be shared by every kid growing up in Detroit, Chicago, New York. I mean, the, the stuff that, you know, you would've seen. Montreal, never mind. I mean, you know, you might argue that it was even more fanatical in, in Montreal than any other place, so.

   13. TDDr. Tom Dayspring37:43

       Let me just expound that. He- Peter is right. If you ever have the opportunity, I mean, any hockey game is great, but if you can get such a seat... And way back when, when we were kids going over to the Garden, you know, the, the lower best seats, a lot of them were corporate, y- you know, those who could afford those seats, but they didn't always show up, those guys. So almost always by the third period, we'd be sneaking down there and sitting there as young kids, and the ushers wouldn't give you too much trouble if you were showing up in the third period there, and it's just a different game back then. And look, I love the military. Nothing can beat like in a foxhole when you're fighting for your life, but when you see what those guys with [laughs] the way they look at each other and the way they hit, and at f- top speeds, wow. It, it's a different sport.

   14. PAPeter Attia38:30

       Yeah, it's funny you bring that up. I totally forgot, but as a kid, that was my MO, was we'd get the gray seats, which I think were $5, maybe $9, but they were... You know, that was what we could afford.

   15. TDDr. Tom Dayspring38:39

       Right.

   16. PAPeter Attia38:40

       And we would just take binoculars and lock eyes on seats where we thought people had left, and then we'd weasel our way down. [laughs]

   17. TDDr. Tom Dayspring38:47

       Yep. Wow.

   18. PAPeter Attia38:48

       And it's the same thing. I... It was just a different era back then. They weren't electronically scanning tickets. So usually by the end of the game, you were sitting close, very, very close. Yes, but oh, God, just, just special memories. Well, let's get to what everyone really wants to hear. I'm sure nobody wants to hear us bullshitting about hockey and-

   19. TDDr. Tom Dayspring39:06

       [laughs] Yeah

   20. PAPeter Attia39:06

       ... stuff like that. Like I said, I don't even know how we're gonna organize this. I mean, we've talked very briefly about kind of like a loose framework for what we want to talk about. 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 aside an entire day, which for me is almost impossible to do. I think I'm seeing one patient all day today. And then we'll divvy this up in the end. So let's just start with kind of definition. What, what's a lipid? What's cholesterol? What are these things?

7. 39:32 – 44:19

   Dayspring's Path from the ER to Prevention and Lipids

   1. TDDr. Tom Dayspring39:32

      Well, before we even do that, let me tell you how I wound up in this world or so. Now, look, I went to med school '68 to '72, a residency in internal medicine for three years after that, and I've already told you I've done a extensive amount of time working in emergency rooms, y- you know, where everybody comes in. In those days, acute myocardial infarction was, you know, very, very common. You didn't spend the night in the ER without seeing a couple of them, people coming in in fulmin- pulmonary edema and everything. And, you know, I just recognized early on, uh, that atherosclerotic heart disease and its, uh, clinical endpoints are bad news, and a lot of those people were young and dying way too prematurely. And in those days, when you come in, even if we got you through your acute coronary syndrome, pulmonary edema, I mean, it's 50/50. So most of them were dead by morning, or those that survived then had this morbidity you had to deal with. So I grew up in an era when it was rampant, the acute episodes, that I don't think they see anywhere near with the frequency, uh, that I did back then. And I just latched onto it, and I was lucky. Those were the days when the concept of a coronary care unit was invented. Mason Sones invented coronary angiography at that time, and our hospital developed a big depart- one of the probably first departments in New Jersey that was doing coronary angiography, and that's the world I decided to start hanging out in. My electives in medical school were all spent in the coronary environment. One year of our residency, the third year, was pretty much elective. I-- So all I did was hang in the angiography lab or the coronary care unit or the post-coronary floors providing care. My first opportunity to go into practice, a cardiology group actually brought me in to, "Hey, you manage our hypertension. You do stress testing," which I had done a lot of as a resident, and of course, I'd be taking call every fourth night in that group too. And y- y- you know, it dawned on me, God, every night I'm being called back to the hospital at 2:00, 3:00 in the morning. It's another acute MI, for God's sakes. So I jumped really on to the prevention strategy. It'd be far better to prevent heart attacks than getting up at 3:00 in the morning and praying you could help them survive this episode that they at least made it to the hospital with. So early on in life, I just said, "What's involved with atherosclerosis?" And early in my career, "Hey, please don't smoke. Try not to be fat," which I was not the best example of, "and let's attack your blood pressure aggressively." And-

   2. PAPeter Attia42:14

      Yeah, I want to pause for a second here, 'cause you said something really interesting that I just hear so often from physicians of your generation, including a physician I'm really close to here in New York who I, I share office space with, and he's, you know, he's about your age, runs a very nice concierge practice in the city, and he, he basically said the exact same thing you just said, which is, "We just saw MIs all day, every day, nonstop." You know, a week couldn't go by where one of his patients didn't have an MI. And then he contrasts it with today. He's like, "I don't know the last time I saw one. I, I don't know the last time I saw a Q wave MI." I just... You know, he doesn't recall.

   3. TDDr. Tom Dayspring42:54

      I get that all the time from young docs, residents, or Physicians who've been in practice, but they're not in a, a baby boomer of my age or anything, and th- they've all seen obviously acute coronary syndromes or... But it's a different type of acute coronary syndrome. They don't see these people coming in in fulminant pulmonary edema. They just don't know what it's like, the massive transmural MIs with Q waves developing, dropping dead before your eyes, 'cause they're rushing them right to the cath lab now and dissolving their clots and everything. They never do saw how these people survived or didn't. So I, I was talking to Peter last night, and, uh, it would not be unusual during my residency if you were the first-year resident, well, you covered every admission in our 700-bed hospital. There were nights where I'd get a dozen admissions to the coronary care unit, a dozen of some sort of exacerbation or a clinical event related to atherosclerotic heart disease, most of them of a most horrific nature or so. And I just don't believe that they see that nowadays. Yes, they see acute coronary syndromes, but they don't see the, the type of acute coronary syndromes we saw back then. So it has changed. And look, we got a long way to go to still eliminate this heart disease, and I think if we all jumped on prevention much earlier in life, we'd end this disease. But yeah, it was a different world back then, surely was.

8. 44:19 – 51:29

   Self-Taught Lipidology and Early Mentors

   1. PAPeter Attia44:19

      And is there one person that would sort of be your first mentor, the person that specifically got you not just interested in cardiovascular disease, but pointed you towards lipids? Like, something about these lipids matter.

   2. TDDr. Tom Dayspring44:31

      No, I sort of discovered lipids by myself. As I said, I was evolving. I wanted to be a preventionist, so I, I was on the hypertension bandwagon, and it became pretty obvious after a lot of the big epidemiologic trials started coming in with more data framing him, Mr. Fit, that lipids, specifically cholesterol, was the one they sort of focused on early on, was a real big player in here. So I realized, a- and I'm a self-education guy in m- most of the things, that, all right, I'm as up to date as I can be on hypertension in the 1980s. Now it's m- for me to start doing some lipid education. So I started doing a lot of reading and stuff, and first course I ever went to, uh, to take lipids to a different level was out there at the Cleveland Clinic. But the guy that I hooked on earliest that really became a major mentor, a good friend, was Dan Rader down in Philadelphia, he, who's turned out to become a world high-density lipoprotein expert, but, uh, just an expert in my mind in all things lipid. He was so far [laughs] ahead of the curve. So Dan was one of the real early ones. Others I had jumped onto were Tony Gotto and Virgil Brown and Alan Sniderman and Ron Krauss and people like that who are really doing the type of investigations that when you started doing lipid r- reading, you'd find that they were saying-

   3. PAPeter Attia45:54

      Yeah, all roads keep pointing to these guys.

   4. TDDr. Tom Dayspring45:57

      Yeah, really did. And, uh, they were gifted enough also that you could semi-understand what they were writing about and talking about. I told Peter, he said, "How long did it take you to ma?..." It was 10 years of serious reading, anything you could get your hands on. I think the first five years was you read something you didn't even know what you read, but, uh, you're just motivated to keep going back sooner or later, and one day I woke up and it sort of, sort of all made sense or so. So it took a lot of education. And I think it's easier nowadays 'cause there are phenomenal reviews have been put together by a lot of peop- they, they just didn't exist in those days. You had to sort of discover it yourself if you didn't spend two years at the NIH doing research on it, and, uh, you would be exposed to it that way or so.

   5. PAPeter Attia46:43

      Well, you've also played a big role in that. I mean, when I now get to think about how I got into this interest, you know, where, what sparked my interest was... There wasn't a single moment, but I do remember reading a single document that you had written in 2011, and I think I was introduced to it by, uh... Remember that guy Greeny up in-

   6. TDDr. Tom Dayspring47:03

      Yes

   7. PAPeter Attia47:03

      ... Reno?

   8. TDDr. Tom Dayspring47:04

      Sure.

   9. PAPeter Attia47:04

      Yeah, so I think Greeny had sent me a document you wrote, and it was the first time I'd even heard of NMR. I mean, I knew what NMR was for, from chemistry, but I didn't know what NMR was with respect to lipids. And so he sends me this document. It was like a PowerPoint, but with notes embedded, so it was printed as a vertical. You know, I printed it as a vertical, and each, so each page had a slide which I would learn to go on were, like, famous Dayspring figures. At the time, I didn't realize that. And then, you know, just great text and prose explaining it. And it was 26 pages long or something like that, and it was dense like you can't imagine. Well, you can imagine-

   10. TDDr. Tom Dayspring47:41

       Yeah

   11. PAPeter Attia47:41

       ... 'cause you made it. But it was... There was a density to it that 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 knew this stuff, but I'm... It was just so, it was just so captivating. I was like... It was like there was a whole other world that I didn't know existed, and these particles mattered, and I never... I remember feeling like, "How did I not want to know this when I was going through medical school and training?" You know, I was just... You know, I guess when you go down that surgical path, you're not-

   12. TDDr. Tom Dayspring48:12

       Sure

   13. PAPeter Attia48:12

       ... thinking about this stuff. You're thinking about, you know, the surgical ways to address these problems. And I mean, I read it so many times because the first few times I was kinda frustrated. I was like, "I don't know what the hell is going on here. Like, I really have no clue what he's talking about, and what are these Apo this and Apo that?" And I, I just kept getting confused by the concordance and the discordance between all these particles. But that, you know, mid-2011 was kinda when I just... I, I don't know. I guess that was just the bug that bit me too. But to your point, I think so many people today, whether it be physicians, patients, anybody who wants to understand this topic better, really can look to you and your work as a great way to synthesize the work of these luminary folks that you've alluded to.

   14. TDDr. Tom Dayspring49:02

       It's kinda funny 'cause who could have ever imagined it? When I started my lipid journey I just was a, a real world internist with a big practice in Northern New Jersey. My only real goal was to be a better internist to my patients, most of whom were getting atherosclerotic or cardiovascular events. So, uh, rather than mastering ulcers and GI bleeds, I just went where the money was, atherosclerotic heart disease, and I invested all my time and effort on learning this with no grand design that, hey, I'm... Hey, Dayspring, whether you know it or not, within 10 or 15 years you're gonna be the most requested lipid educator in the United States. How, how did that ever happen? And it just happened because I self-taught myself as a dumb real world internist, made it understandable to my brain. Part of the Dayspring learning curve is visual. Uh-

   15. PAPeter Attia49:58

       You said you used to draw

   16. TDDr. Tom Dayspring49:59

       ... I, I draw graphics.

   17. PAPeter Attia50:01

       Yeah.

   18. TDDr. Tom Dayspring50:01

       As I'm reading this stuff an- initially, and I have no artistic skills whatever. If I draw a human being, it's that stick figure-

   19. PAPeter Attia50:08

       [laughs]

   20. TDDr. Tom Dayspring50:09

       ... with a circle as a head.

   21. PAPeter Attia50:10

       [laughs]

   22. TDDr. Tom Dayspring50:11

       But PowerPoint came along, and there are tools there which are not that hard to master, so I was able to draw and I'm now known as o- one of the best lipid lipoprotein illustrators in the country.

   23. PAPeter Attia50:23

       Yeah. We're gonna, we're gonna probably... Not probably, we will unquestionably link to maybe your 50 finest diagrams in this podcast, which is to say about 1% of what you've produced. But I remember the first time you sent me one of your PowerPoints, I was like, "Oh, that's really interesting. Like, either Tom has contracted with an illustrator to do this or he's found somebody else that's already done these." And when you said you had done them, I was blown away because you have to remember, I cut my teeth in PowerPoint at a place like McKinsey where we're PowerPoint ninjas. I could do anything in PowerPoint. I couldn't do what you had done simply because I couldn't, I didn't have the time. Like, those were such complicated figures that, like, if I ever came across something that was that complicated that I needed to make a slide for, I would just get the illustrator to do it. I wouldn't actually be able to sit there and make it happen. So I couldn't believe it, and I think the listeners who aren't familiar with your illustrations are going to find themselves incredibly surprised and, and, and grateful for, for that sacrifice.

9. 51:29 – 57:15

   Teaching Through Illustration and Lipidholics Anonymous

   1. TDDr. Tom Dayspring51:29

      So illustrating things made me understand. I mean, look, my illustrations got better and better as time went on. Ear- early on they were a bunch of colored circles and stuff, and then I learned shading and making them move and animate on the slide. So I, I've really pr- progressed there, but I just learn by illustrating. I've since had serious educators tell me the human brain just understands things better by seeing pictures and graphically than reading thousands of words put together. And there is no doubt my gigantic success as a lipid educator where I could dumb down the talk and try and make you understand complex enzymology or anything else, the apoproteins and how they interact, but as I'm saying it in my dumbed down version, you were looking at it moving on a screen with a graphic. So it made comprehension of advanced lipid related areas much easier for a, either a layman or certainly a physician to understand or so. So just the part of who I became, and then somehow because of all my intense prep or writing slide notes, as Peter said, I became pretty good at putting together prose. So, uh, I, I've done a little bit of research in my time because the places I wound up on and have, uh, authored a research publication, but most of the things you'll find in the literature of me are reviews and discussing this, trying to make you understand concepts. Then you can go read the genius's studies and you'll understand what they're talking about and everything. So I just evolved into that. And actually the first guy I was... It, it was a cardiologist down in Florida, Michael MacIver. He's the first guy I ever saw use PowerPoint for lipids, and I just used him and he, he shared a lot of his early stuff on it and I learned off of him, and it's made my life as a well-known lipid educator. I've got opportunities to start doing lipid education, and if you go out and you're lucky enough to have some people come and listen to you, you better be good at what you do or they're gonna badmouth you and you'll never be invited back or, uh, i- if you do want to come back, they're gonna like you, they're gonna be in touch with you, and I just developed ways of explaining lipids and illustrating lipids that became huge. And a lot of... Just to finish, is Mike Davidson, who's one of the all-time gods in the lipid world in Chicago, still a university professor there, one of the big founders of the National Lipid Association, did at one time during his presidency bestow their President's Award to me, which is given to people who make contributions to lipidology. And this is the top lipid organization in the country. So how does some real world internist with no l- formal lipid training ever work his way up to an award like that or so? Mike told me, "We polled all of the NLA and a lot of people join this organization 'cause they heard of Tom Dayspring lipid lecture." And Mike was a big advocate of you teach through illustration. I've illustrated many things from Michael over the years, and so he's right and that, that's my claim to fame. I hope some of you follow me at, @drlipid, 'cause Twitter is the way to get a lot of my graphics nowadays.

   2. PAPeter Attia54:47

      Y- yeah. And there's a lot of stuff that we'll make sure we link to, but the Lipidholics Anonymous, uh... Well, you used to write a lot more into-

   3. TDDr. Tom Dayspring54:54

      Yeah

   4. PAPeter Attia54:55

      ... I used to read those case reports constantly. We'll have to make sure we can pull all those things out of the archive 'cause there's some amazing cases there. But yeah, we'll make sure people know where to find you on Twitter and all that stuff 'cause, um-

   5. TDDr. Tom Dayspring55:06

      Just quickly, on, uh, when I was on this giant lecture tour for 10, 15 years of my life, I did generate a weekly newsletter called Lipidholics Anonymous where they were one case discussion, all real world, that were in my practice or sent to me by-

   6. PAPeter Attia55:23

      Yeah

   7. TDDr. Tom Dayspring55:23

      ... other docs, and I would just take it into the next level. So I would explain it basically, and then I would, like I'm talking to a lipidology, illustrate it. It became immensely popular. I had several thousand people. It was free. I sent it out each week in a group email, but it really enhanced my... Eh, and it found itself on a lot of desktops, you know? So-

   8. PAPeter Attia55:43

      Yeah

   9. TDDr. Tom Dayspring55:43

      ... that's a big part of who I was, you know? And I do have most of them still there, but I, um, re- people give me all the... Because I don't want you to know what I was saying in the year 2002 because it's mostly all wrong nowadays 'cause we've evolved so much, but if you want to see what we were talking about in the lipids in 2002, they might have some historical interest, you know?

   10. PAPeter Attia56:04

       Yeah. Well, you just touched on kind of a, an important point, which is I like to say facts, all facts have a half-life.

   11. TDDr. Tom Dayspring56:10

       Yeah.

   12. PAPeter Attia56:11

       And some of them are really, really long half-lives, you know? The Earth being round is, we would call that an incredibly long half-life fact. We're gonna... You know, the half-life is nearly infinite on that. But elevated levels of HDL cholesterol are necessarily a good thing. That's a, that's a, that's a fact that I think, you know, it used to be deemed a fact based on the epidemiology of Framingham. I think today anyone who's serious about the study of lipidology would say that's grossly oversimplified, potentially incorrect.

   13. TDDr. Tom Dayspring56:39

       That's certainly one of the all-time [laughs] facts that, uh, really disappeared. I personally think it's a waste of time to even put it in the lipid profile other than it's used in certain calculations that are popular nowadays, like non-HDL cholesterol. But I encourage no one to ever make a judgment on any human's cardiovascular risk based on their high density lipoprotein cholesterol level, or think you know what you're doing to a human being if you somehow change that HDL cholesterol metric in that patient. Has nothing to do with anything to be honest with you.

10. 57:15 – 1:03:34

    What Is a Lipid? Fatty Acids, Glycerides, and Phospholipids

    1. PAPeter Attia57:15

       All right, so now I'm chomping at the bit. We gotta get into this. So where do we even begin? Do we wanna start with what's a lipid, what's cholesterol?

    2. TDDr. Tom Dayspring57:22

       Mm.

    3. PAPeter Attia57:22

       What... Let's, and then I wanna, you know, let's explain what these things mean, HDL-C and stuff.

    4. TDDr. Tom Dayspring57:26

       Sure. Well, a, a lipid is basically a molecule that is not soluble in water. It's might be soluble in certain organic solvents, but not in water, so it's a hydrophobic compound. And oils and fats are what everybody thinks of as a lipid. Some, you know, cholesterol is in there is... I ne- I never liked calling cholesterol a fat, but it's a lipid. Fats to me are fatty acids and, or combinations of fatty acids or, or triglycerides. So that's what le- lipids are, and different lipids have different degrees of solubility. Some are extremely hydrophobic 'cause both ends in a molecule that can be seen in water. Some lipids have a one end is a little bit water-soluble, uh, hydrophilic, and the other one isn't. That would be where cholesterol fits in, phospholipids fit in. So that's what a lipid is, and there's several types of lipids in your body. But the ones that those of us who live in a clinical lipidology world are focused on are cholesterol, mm, basically two types of cholesterol. And there are fatty acids, but fatty acids stick to a lot of things, and it's sticking is called esterification in the world of lipids, so they can bind to carbohydrates, cholesterol. A three-carbon sugar called glycerol is the most common thing they bind to. So if you have one fatty acid on a glycerol, that's a monoacylglycerol. If you have two, that's a diacylglycerol. If you have three fatty acids stuck on your glycerol compound, that is called a triacylglycerol, which most people would call a triglyceride. If you're as old as me, you're not used to hearing those terms and you're used to hearing triglycerides, but initially they were just called glycerides, and glycerides would be the whole family of monoacyl and triacylglycerides or so. And it's basically the way in which the human body transports fatty acids or stores them. It transports them in the plasma or stores them in various tissues. In case you need a fatty acid for a certain purpose, be it energy or a structural purpose, then the fatty acids would disconnect from its glycerol backbone. That would be called de-esterification, and that fatty acid could be used to whatever s- what a cell wanted to do with that fatty acid or so. If the cell didn't need it, it could store it till when it did need it as a glyceride. So those are your basic definitions, but the one glyceride that is of incredible importance, maybe in the future the one we're gonna be looking at most seriously, and the one that nobody ever looks at or even brings into the discussion nowadays are our phospholipids. And phospholipids are simply glycerol compounds, so you got your three carbon alcohol sugar there, and there's two fatty acids attached to it, and there's a lot of fatty acids in the makeup of every phospholipid. Might have the same two fatty acids, different fatty acids. Fatty acids come in different lengths, different types of double bonds. And then they got a head group, which is usually got a phosphorus moiety in it, and that's what a phospholipid is. Phospholipids are kind of cool 'cause part of it is water-soluble, part of it is hydrophobic, or doesn't like water. They're called amphiphiles. Amphipathic is, is the name or so. And that allows them to sit in certain positions in our body where, hey, they're hydrophobic lipid tails. The fatty acids c- can exist in a lipid-rich environment inside the cell, inside a core of a lipoprotein, which is all hydrophobic lipids. But its hydrophilic surface can interact with plasma. So where do phospholipids exist? On the surface of our lipid transportation vehicles, lipoproteins, or on our cell membrane. Every cell membrane in your body is phospholipids. And what nobody seems to know is most of your phospholipids are made in the liver, or they're made in the small intestine, 'cause the intestine absorbs fatty acids, repackages them into glycerides, phospholipids or triglycerides, and then they become part of lipoproteins that enter your lymphatics from the gut, chylomicrons. Or your liver gets fatty acids and as phosphos it makes phospholipids, and your liver makes lipoproteins and excretes them. So few people know that a gigant... Everybody talks of lipoproteins as if they're delivering cholesterol all over the place. That's what we have lipoproteins for. That's probably the last reason we have lipoproteins, 'cause every cell in your body makes a Every cholesterol molecule it needs to do what it has to do, with a few rare exceptions. So if I- I'm a nose cell, I don't need some lipoprotein to come and deliver cholesterol to my cell because I need cholesterol in my s- nasal cell membranes. The, that cell will make cholesterol. Every cell has the genetic power and the protein, the enzymology to make cholesterol till its heart's content. The tragedy is acco- what we, we eat, most of our cells make way too damn much cholesterol, which becomes then not a absolutely life-sustaining molecule needed in your cell membranes, but a cellular toxic molecule 'cause it crystallizes and kills that cells. So evolution has given our cells incredible powers to evict, efflux out cholesterol so they don't suffer cholesterol toxicity in those cells, and that will be certainly something we'll get into. How do cells get rid of all this cholesterol that, because of what we're eating, are making too much of their cell? It's not that lipoproteins are delivering too much cholesterol [chuckles] to most of these cells, although they can in certain areas. We d- some people do get cholesterol builds up in their skins, xanthomas, and things like that. So-

11. 1:03:34 – 1:07:27

    Saturated vs. Unsaturated Fats and Why Cholesterol Needs Lipoproteins

    1. PAPeter Attia1:03:34

       And, and I wanna just interject for a moment to go back and clarify something for the listeners. So we talk a lot about fats, but many people are familiar with the term saturated fats, monounsaturated fats, polyunsaturated fats. You touched on it very briefly, but just so that they understand the broader context, a saturated fat means a fatty acid hydrocarbon that has no double bonds in it. A monounsaturated fat has a single double bond in it, and a polyunsaturated fat has two or more, and of course, depending on the position of the first double bond within, with respect to its carboxyl group, that's where we get into these omegas and things. But the point here is when people talk about saturated, monounsaturated, and polyunsaturated fat, they're referring to the positions of these double bonds within these long hydrocarbons that also can be of variable lengths. So for example, a saturated fat can be very short, six, seven, eight carbons in length, or it can be much longer, and each one of them has its own name, and the same is true with the monos. So once you get into the monos and the polys, the nomenclature starts to get complicated because you're describing both the position of the double bonds and the length of the hydrocarbon. Now, these things have all of these complex properties, but in many ways it still pales in comparison to the complexity of the cholesterol system. Because those fatty acids can also... I mean, even though they're not soluble in water and therefore they can't float around willy-nilly, they have the luxury of being transported on albumin, right?

    2. TDDr. Tom Dayspring1:05:03

       They do.

    3. PAPeter Attia1:05:03

       Which is, which is another protein in the plasma that can hide this hydrophobic part of them in an ability to transport them through. But yet why, why can't we transport cholesterol, which you've just explained is not soluble in water, it's hydrophobic, why can't we transport cholesterol or phospholipids in albumin, something that's so ubiquitous and benign?

    4. TDDr. Tom Dayspring1:05:25

       Well, you can. Cholesterol can attach to albumin. And just be- before I answer your current question, what I was explaining before is y- you know, the lipoproteins, everybody thinks their purpose is to deliver cholesterol to tissues. That's their last purpose. They don't do that. They... Your real purpose of our lipoprotein, our lipid transportation system, is to develop-- to transport energy to tissues that need them. That would be triglycerides, the fatty acids which our cells oxidize to create ATP. So they are brought to tissues that are very good at extracting triglycerides from lipoproteins, muscle cells. But if your muscles f- because you're not using your muscles, don't need any energy today, those triglycerides will be dumped in an adipocyte to be stored as your fatty acids until you need them. But w- what nobody talks about are what else are the lipoproteins delivering, that cells cannot be a cell without? They're phospholipids. And what is the surface of every lipoprotein? Phospholipids. Where do the phospholipids come out of? Lipoproteins produced in the intestine or the liver. So what are the biggest lipoproteins, 'cause they would have the most gigantic surface area? Chylomicrons coming out of your gut, very low density particles coming out of your liver. So we all talk about, oh, they're delivering cholesterol. They're delivering maybe triglycerides 'cause they're very triglyceride rich. They're delivering phospholipids.

    5. PAPeter Attia1:06:56

       So just to clarify again, the spherical lipoprotein has an inside-

    6. TDDr. Tom Dayspring1:07:02

       Yep

    7. PAPeter Attia1:07:02

       ... which carries the cholesterol ester and the triglyceride. But the phospholipid isn't carried inside that-

    8. TDDr. Tom Dayspring1:07:09

       Yeah

    9. PAPeter Attia1:07:09

       ... central cargo. It's actually embedded within the structure of the lipoprotein, and therefore the chylomicron being the largest, followed by the VLDL, the very low density lipoprotein. The larger the surface area of these things, the greater their capacity to carry phospholipids, since the phospholipid is carried in the wall.

12. 1:07:27 – 1:14:31

    Lipolysis, Phospholipid Transfer, and Membrane Function

    1. TDDr. Tom Dayspring1:07:27

       Correct. And when these gigantic triglyceride-rich particles go to your muscles or adipocytes to deliver their triglyceride, in their core, very hydrophobic, in that core is a special type of cholesterol that has a fatty acid to it, cholesterol ester, incredibly hydrophobic also. Those two tissues that I talked about have very powerful triglyceride-dissolving enzyme called lipoprotein lipase, which starts hydrolyzing the core triglycerides. Now, these big dump trucks full of triglycerides like that, they start to shrink when they, the triglycerides are, undergo hydrolysis, deesterification. The particle, as it shrinks, that's called lipolysis, removal of a lipid from a lipoprotein. So you can imagine these big fat balloons full of triglycerides. If you could suck water out of a balloon, it becomes a smaller balloon too, and it would get wrinkles on it. Well, the lipoproteins don't become wrinkles. They just evict their surface phospholipids. Which can immediately attach to a contiguous cell where the decrease in diameter of the lipoprotein is occurring, or they jump on a protein that evolution has given us called phospholipid transfer protein, which then takes all those phospholipids and brings them to cells that say, "Hey, I need phospholipids." Or the only lipoprotein that is not made in the liver or the intestine but s- grows itself, matures itself in the plasma, high density lipoproteins. You couldn't change a baby ApoA-I, which is the structural protein of an HDL, into a big, fat, mature, large HDL if you weren't supplying it with what?

    2. PAPeter Attia1:09:05

       Phospholipids.

    3. TDDr. Tom Dayspring1:09:06

       Phospholipids. Where would an HDL get phospholipids? As these big triglyceride-rich particles shrink and they extrude them, phospholipid transfer protein says, "Here, little baby HDL. Here's your phospholipids."

    4. PAPeter Attia1:09:19

       [laughs]

    5. TDDr. Tom Dayspring1:09:19

       And they can mature into it. So it's just an incredible system.

    6. PAPeter Attia1:09:21

       I, I love the idea. I, I just, I love anthropomorphizing these, these things.

    7. TDDr. Tom Dayspring1:09:25

       [laughs]

    8. PAPeter Attia1:09:25

       Little babies, HDL, and all these other things.

    9. TDDr. Tom Dayspring1:09:27

       It, it helps. So that all being said, I want everybody to real- 'cause nobody, 'cause we don't measure them 'cause it's complex on how to measure them, and there are so many different types of phospholipids based on the, the exact fatty acid makeup, the length of the fatty acid. And remember, a glycerol has three positions. They're called stereospecific number one, number two, and number three. Everything depends. The lipases attack various fatty acids on different positions, and so it's really complicated. So the phospholipids affect a lot of functioning. Since phospholipids are making up not only the surface of lipoproteins, basically 'cause they're water soluble and it allows these dump trucks to float around in plasma, in the cell membrane, what Peter was just talking about, that fatty acid makeup in the phospholipids become so crucial. Because saturated fats are straight. They're rugged. They don't bend. So it gives some structure to a phospholipid. If your phospholipids ca- contain a lot of saturated, hey, you got a strong cell membrane there that's hard to get through. But the real reason cells function and interact with the rest of the cells of your body is they signal each other, and signaling occurs because something occurs at a certain mem- area of the lipid cell membrane that we're gonna call a, a lipid raft, which is a specialized collection of special phospholipids with a little bit of free cholesterol interspersed. But the structural positioning that a phospholipid takes up, if you have several double bonds in that thing, if you've ever seen a 3D view of a phospholipid that's got a, several double bonds and it takes up an incredible amount of space, so it's two legs spread out, and you change the structure of the cell membrane. And that structure of that area called the lipid raft allows certain cellular proteins to locate there, and those are all our receptors that pull things into cells or extrude things out of cells.

    10. PAPeter Attia1:11:36

        So the fluidity of the membrane is highly, highly dependent on the nature of the fatty acids in the phospholipid.

    11. TDDr. Tom Dayspring1:11:42

        The fluidity and the ability to shelter or let certain proteins be expressed in that area. If I'm an LDL receptor or a, some immunoreceptor, there are certain areas of the cell membrane I could never locate to because the phospholipids wouldn't allow it. But there are other areas they say, "Welcome. Here's where you're supposed to be expressed." And cells know that [laughs] and they construct their lipid membranes, hopefully, if you have the right type of phospholipids and everything. So as we start to talk, and those who study and investigate membrane physiology, it's one of the more advanced areas in lipidology, but as we also are starting to understand some of the qualities beyond just measurements of various lipoproteins, their phospholipid makeup is gonna be crucial. And as we talk about HDLs, we're gonna start throwing around the word HDL functionality, and a giant part of HDL functionality, what a specific HDL particle does in your body, what it might be capable of accomplishing or not accomplishing, is due to the fatty acid makeup of its phospholipids. And one day I think we're gonna be analyzing the lipidome of various lipoproteins, and we're gonna have a lot more insight of what lipoproteins do or don't do.

    12. PAPeter Attia1:13:02

        You can find all of this information and more at peterattiamd.com/podcast. There you'll find the show notes, readings, and links related to this episode. You can also find my blog and the Nerd Safari at peterattiamd.com. What's a Nerd Safari, you ask? Just click on the link at the top of the site to learn more. Maybe the simplest thing to do is to sign up for my subjectively non-lame once-a-week email where I'll update you on what I've been up to, the most interesting papers I've read, and all things related to longevity, science, performance, sleep, et cetera. On social, you can find me on Twitter, Instagram, and Facebook, all with the ID peterattiamd. But usually Twitter is the best way to reach me to share your questions and comments. Now for the obligatory disclaimer. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. And note, no doctor-patient relationship is formed. The use of this information and the materials linked to the podcast is at the user's own risk. The content of this podcast is not intended to be a substitute for professional medical advice, diagnoses, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they have and should seek the assistance of their healthcare professionals for any such conditions. Lastly, and perhaps most importantly, I take conflicts of interest very seriously. For all of my disclosures, the companies I invest in and/or advise, please visit peterattiamd.com/about.

Episode duration: 1:14:34