[MICHELLE ROUTHENSTEIN] (0:00 - 0:06)
Heart disease is the number one killer group, especially in women, but 80 to 90 percent is preventable.

[ANGELA FOSTER] (0:06 - 0:13)
We've heard a lot about HDL and LDL, but ApoB still isn't routinely measured. Why is it so important?

[MICHELLE ROUTHENSTEIN] (0:13 - 0:24)
ApoB can tell us the direct measure of these plaque-forming lipoproteins that if it's high, it means you have a higher risk of forming plaque in your arteries.

[ANGELA FOSTER] (0:24 - 0:27)
What are the things that drive inflammation in our body?

[MICHELLE ROUTHENSTEIN] (0:27 - 0:43)
We're eating too much saturated fat, high sodium, high refined carbohydrates. We need to really focus on your heart health nutrition to look at your labs and know your targets and achieve them and maintain them in optimal levels.

[ANGELA FOSTER] (0:43 - 0:47)
How much can exercise help protect our cardiovascular health?

[MICHELLE ROUTHENSTEIN] (0:47 - 0:49)
Exercise is so important.

[ANGELA FOSTER] (0:49 - 1:14)
We need to be looking at it in three buckets. First is always going to be... Michelle, you are a specialist preventative cardiology dietitian focused on women's health, and you sit on the medical advisory board of the National Menopause Foundation.

Heart disease is still the number one killer of women, yet most women don't see themselves as being at risk, particularly in peri and postmenopause. Why do you think that disconnect exists?

[MICHELLE ROUTHENSTEIN] (1:15 - 2:18)
There are many reasons, but I would say heart disease is not really looked at, primarily because it silently brews in someone's body. Most people have this idea that in order for heart disease to happen, you have to look a certain way. You may not be performing or exercising at full capacity.

That means if someone is exercising a lot, they're eating clean, they have a lean figure, they may think they're immune to heart disease, but heart disease can silently brew. We don't feel it. We don't feel plaque in the arteries.

A lot of times it gets either dismissed, it's not looked at in full capacity until unfortunately an event happens, and we don't feel it. We don't feel high blood pressure, we don't feel high plaque, burden, cholesterol in our body. We don't even feel a lot of times systemic inflammation, which are all drivers of heart disease.

If we are asymptomatic, we don't feel it. We can easily ignore it because we're judging it based off of our outwards appearance versus understanding what's going on internally.

[ANGELA FOSTER] (2:18 - 2:33)
I think that's kind of one of the scary things, isn't it? That it's so silent. We've heard a lot about HDL and LDL, but ApoB still isn't routinely measured.

What does ApoB actually tell us about cardiovascular risk and why is it so important?

[MICHELLE ROUTHENSTEIN] (2:34 - 3:22)
We want to make sure that we are testing because we can't see or feel heart disease. If we can test your labs, we can take an Empower approach and catch it before it turns into plaque-forming cholesterol that invades into the arterial wall. ApoB is a protein that sits on all types of lipoprotein cholesterol carriers that invade into the arterial wall to cause plaque.

ApoB can sit on atherogenic LDL, it can sit on atherogenic IDL, VLDL, LP little a. It invades into the arterial wall and can start the plaque formation process. ApoB can tell us the direct measure of these plaque-forming lipoproteins that, if it's high, means you have a higher risk of forming plaque in the arteries.

[ANGELA FOSTER] (3:22 - 3:32)
If someone listening to this has done their labs and they have high ApoB, could they meaningfully reduce ApoB through diet and lifestyle?

[MICHELLE ROUTHENSTEIN] (3:32 - 4:42)
Yes. ApoB can be reduced substantially through diet. I always kind of look at, well, where's your target?

What's your risk profile? What's going on underneath the surface? ApoB targets are actually based off of the person's risk profile.

Someone who's had a cardiovascular event has much lower thresholds than someone who doesn't. We kind of look at high risk, moderate risk, and low risk and determine ApoB targets based off of that. Determining on where you need to be and where your starting point is, I like to always trend ApoB levels.

If you see ApoB is high, we add in targeted nutrition to lower it. Then we test it in three months and see where we have reduced it. In my practise, I've seen people reduce their ApoB by 90 points in four months.

I've also seen it reduced by 30 points. There's a very wide range. That could be determined based off of individuality.

We always want to test to assess, okay, where has the dietary strategies brought us so that we can assess, okay, what do we need to tweak further and make sure that we are addressing that number specifically.

[ANGELA FOSTER] (4:43 - 4:51)
For someone who's listening to this, who hasn't had a cardiovascular event, what should they be aiming for in terms of their ApoB level?

[MICHELLE ROUTHENSTEIN] (4:52 - 5:40)
This also is dependent on your LP little a. Your lipoprotein little a is mostly genetic determined. However, in 30% of women during a menopause, they have an uptick in LP little a.

It can also be increased inflammation, but most of it, 70% of LP little a is genetically determined. If someone has a high LP little a, their ApoB targets are lower because at lower thresholds, their body likes to make blood. If someone does not have high LP little a, their ApoB targets is around less than 90 milligrammes per litre.

If their LP little a is high, it may be closer to less than 70.

[ANGELA FOSTER] (5:42 - 5:59)
Interesting. You mentioned there that LP little a is, did you say 70% genetic? It is possible to move that LP little a number, but we only have around 30% control over it.

[MICHELLE ROUTHENSTEIN] (5:59 - 7:45)
Right. That's important to recognise. If someone's LP little a less than 75 animals per litre is normal.

If someone's LP little a before menopause is let's say 70, during menopause, it can go up into the higher risk profile. And so their targets would then have to be lowered even further. But if someone's LP little a is 190, it's not going, you know, you could reduce inflammation.

We can control, we can study hormone balance, but it's not going to get to target. So it's still elevated. So we don't chase LP little a.

We're not chasing and targeting LP little a alone. We're understanding that LP little a means there is an increased risk of heart disease because your body likes to make plaque at lower thresholds. And it's like to target sneaky places in the body.

So for instance, it likes to create plaque in the aortic valve leading to aortic valve stenosis. And so with that information, we want to make sure we're controlling the environment. We look at ApoB and target that, but we have to also recognise that it's a multi-stage process in which plaque is made.

So LP little a is stickier. It's more prone to plaque formation. We need to make sure we're controlling blood sugar levels and blood pressure and inflammation and blood sugar, and ensuring that we're adding in nourishing nutrients that help to protect the blood vessel lining so that it could do its job most effectively.

So with LP little a, our position is really to avoid the damage that it can cause by ensuring the environment in which it is in is more conducive to heart health and reduction of that plaque formation.

[ANGELA FOSTER] (7:46 - 7:50)
Very interesting. So what exactly is LP little a?

[MICHELLE ROUTHENSTEIN] (7:50 - 9:48)
LP little a is genetically inherited cholesterol, but it has, it tends to also carry a lot more ApoB particles with it in many situations, and it is more stickier. So it has the propensity to invade into the arterial wall and stick to the artery leading to more plaque formation. So we aren't trying to talk, we've known about LP little a for a long period of time, for decades.

I have high LP little a, and we've tried to target it by itself. And what we found was that it actually, when we target it by itself, for instance, with high dose niacin therapy, it increased vascular inflammation. It did not reduce the long-term end game of cardiovascular disease.

And so then realise people who live in their hundreds with a high LP little a, they control their environment. They reduce their ApoB. They ensure their blood pressure, vascular health, cardiovascular respiratory fitness, all of the factors that matter are well controlled.

And so that is what we really target at this point. Because if you just target LP little a alone, it ends up going through a rabbit hole where all your other risk factors can be, come elevated, and then you can make more plaque. Interestingly also, we've seen studies where somebody who has genetic risk, a high genetic risk of heart disease, and they reduce all of their risk factors and modifiable risk factors, they have less risk of a cardiovascular event comparatively to someone who has no genetic risk factors, but who has one, two, three risk factors that are not controlled.

Because plaque doesn't just get created because you have a genetic predisposition to it. Plaque gets created when we have high ApoB that invades into the arterial wall, becomes oxidised, becomes inflamed, and goes through a multi-stage process that leads to plaque formation.

[ANGELA FOSTER] (9:48 - 10:23)
Interesting. So what I'm hearing is we need to measure our LP little a, but not get too hung up on it or fixated on it because that's not the thing that we have so much control over. But then we need to factor in our ApoB.

And if that's high, we need to look at bringing that down while simultaneously having nutrients that support blood vessel health, that lower oxidative risk, and that also lower inflammation. I'd like to, I think, dive into those three things next. Inflammation.

What are the things that drive inflammation in our body?

[MICHELLE ROUTHENSTEIN] (10:23 - 13:00)
So inflammation can come from many different sources. One could be from gut health. When someone has poor gut health, they don't have a diverse gut microbiome, that can be a source of inflammation.

It could symptomatically appear as acid reflux, constipation, bloating, or diarrhoea. So GI symptoms are a big bucket to be considering. The other one is from our diet, both from an aspect of, are we eating too much saturated fat, high sodium, high refined carbohydrates?

What are we eating in excess that could be inflammatory? But on the flip side of what my clients typically come to me, it's that they're not having those things in large volumes. It's that they're not paying attention to all the nutrients their body needs.

And it's not one specific nutrients. For instance, I have people who come to me who are vegan, and I have people who come to me who are, who eat, are a carnivore diet. And they may have very different nutrient deficiencies that can lead to inflammation.

So when someone is malnourished, that's a sign of inflammation. And that malnourish means that you're deficient in certain nutrients, whether it is omega-3s, B12, selenium, zinc, folate, potassium, any nutrient deficiency can lead to some inflammation in the body. So we want to make sure we're understanding that.

But it can also come from inflammation around the liver. It can come from autoimmune like Hashimoto's thyroiditis, it can come from a lot of different angles of inflammation, but we have to understand what what is it coming from, and so that we can address it. But most of the time, I find that it's really centred around gut health.

And it's really centred around nutrient deficiencies relative to what they're someone's eating on a regular basis. And I also mentioned that, you know, in midlife, a lot of times our body distribution changes. So many women will go on a very strict caloric deficit to try to compensate for it.

And they end up being nutrient deficient because of that, because they're not nourishing their body. And so it's important that we recognise that. And if someone has, let's say an allergy to gluten or dairy, we don't want to ever introduce that into their system.

But we have to be strategic and say, well, what are the nutrients you're getting from other foods you can tolerate and eat, that when you're removing a food, you're now replenishing it with the food your body needs, so that you don't become nutrient deficient.

[ANGELA FOSTER] (13:01 - 13:25)
Very interesting. When you're looking at the nutrient sufficiencies of someone, you mentioned quite a few nutrients there, B12, zinc, omega three, I like to test omega three levels within the body that's done through typically these many of these tests are done through blood testing. What would you recommend people do?

Is it looking at blood testing for this? Or do you also look at things like organic acid testing? Where would you encourage people to look?

[MICHELLE ROUTHENSTEIN] (13:26 - 15:16)
Yeah, so many tests, many of these tests can be done through blood tests, like your omega three index, what's the omega three in your red blood cells, and that's a great indicator. We do like that to be above 8%, because that can help show reduction in inflammation in the arteries as well reduce cardiovascular disease risk. For B12, serum B12 is not the greatest one to be testing, but we can look at NMA, methylmalonic acid to see the functioning of B12, especially as we age.

So there's a lot of ones where I do recommend blood tests to determine that. But some blood tests won't really give us some answers. So for instance, calcium, a lot of women are having experiencing a lot more bone loss during menopause and has age.

And if they're not consuming enough or adequate amounts of calcium, it comes from the bones and osteoporosis and heart disease are very connected, because it's a metabolic bone disease and that calcium can go into the arterial wall and cause calcification if it's conducive to do so. And so calcium on a blood test does not actually tell us if you're eating enough calcium. Calcium on a blood test is does your parathyroid hormone function well, so that it takes the calcium from your bones and puts it in your blood, because you need calcium in order for your heart muscle to contract well.

So we have to recognise that there are certain things that our body, you know, is not going to be relative to what you're eating. Potassium on a blood test, your kidneys, if they're functioning well, will ensure a homeostasis in the blood. So a lot of that actually has to do with looking at what you're eating and assessing are you meeting your adequate nutrient needs so that it's not going to compensate and harm another pathway in your system.

[ANGELA FOSTER] (15:16 - 15:53)
If you're getting value from this show, the single best thing you can do to help us keep bringing you the highest calibre guests is to subscribe or follow wherever you listen or watch. It takes 10 seconds, but it genuinely makes a difference to the quality of the guests we bring you week after week. Would you suggest then based on that, and because of the food matrix and the way it works, that we are better trying to find these nutrients with a food first approach rather than through supplementation with multivitamins, for example, or even isolating different things like B-complexes and taking those?

[MICHELLE ROUTHENSTEIN] (15:53 - 17:48)
Yeah, so food first is always going to be A, the safest, but B, the most effective because your body can absorb these nutrients a lot better when they're in the whole food matrix. For instance, calcium. A lot of calcium-rich foods are paired naturally with magnesium, with vitamin K that helps with better absorption and facilitation into the bone where it belongs.

So it's important to recognise that nature has this beautiful complex to do so. And we see in studies, for instance, with calcium, high-dose calcium can lead to vascular calcification because your gut only absorbs 500 milligrammes of calcium at a time. So if you're taking 1,200 milligrammes in one pill, that extra excess can lead to potential vascular calcification in many studies.

So from a heart health perspective, a lot of nutrients are so much better to be absorbed through actual food versus high-dose supplementation. When I say nutrient sufficiency, I mean not too little and not too much. It's the adequate amount for you.

And that's important because if you just go and say, oh, I need this supplement, I need this supplement, or someone's advertising one of those supplements, well, do they know what you're eating? Do they know your labs? Do they know how much you really need?

The dosing is important. There are times where we will supplement, right? If someone's vegan, they can't get B12 through their diet.

They do need to supplement. If someone is a homozygous carrier of MTHFR and their homocysteine level is through the roof, they need to have methylated B supplements. There are certain times where, yes, we do need a supplement, but typically speaking, people generally don't need more than five or six supplements in their regular regimen, depending on what they're eating.

[ANGELA FOSTER] (17:48 - 18:11)
For tracking nutrient sufficiency, would you suggest using something like, I'll use my client's chronometer, which kind of gives you an idea of the nutrients that you're getting, a pretty good idea from your food. Are there things like that that you would recommend people use, not on a consistent basis necessarily, but to gain an understanding of what their diet comprises and where they might make changes?

[MICHELLE ROUTHENSTEIN] (18:11 - 19:29)
Yeah, so I use chronometers with a lot of my clients. But sometimes the targets do need to change. So we need to set the targets to what you need for your heart because some of them are low, some of them are too high.

So once you kind of understand where you fall, you could then kind of assess, okay, what do I need to change or what I don't. And I also love that app because you can add, they have a biometric tab where you can add in your stool on the Bristol stool chart. You can add in your blood pressure and sync that with your blood pressure cuff so you can see real-time patterns.

You can sync it with your Oral Watch, you can sync it with your Apple Watch, all these different things and kind of assess patterns. But I will say we live in an age where some people use a lot of these tracking devices, and for some it works beautifully, and in others it's quite overwhelming and it can lead to more anxiety. So I always have to meet the person where they are.

If that's too much, we don't go there. But I think that over time, it's really nice to see, okay, where are my gaps? What can I tweak?

How is this responding to my blood pressure and using it as good information? But if it's causing more overwhelm, we want to take that into account because your stress and anxiety levels are also a key component when it comes to heart health.

[ANGELA FOSTER] (19:29 - 19:41)
Saturated fat remains one of the most debated topics in nutrition. Are saturated fats actually harmful for cholesterol and heart health, or is the picture more nuanced than that?

[MICHELLE ROUTHENSTEIN] (19:41 - 21:22)
Quite nuanced in the sense that saturated fat can be composed of different types of fatty acids, whether it's stearic acid or palmitic acid, whether that can raise LDL or not raise LDL, it's very nuanced. But generally speaking, we can't look at saturated fat as a whole as a okay food to eat in a very large volume, because a high level of saturated fat, particularly if it's very concentrated in palmitic acid, it really clogs up the LDL receptors on the liver from doing its job. So if these LDL receptors are clogged up, and during menopause, our activity of our LDL receptors declines, so we have less amounts of functioning LDL receptors, which is why a woman might say, Oh, wow, I'm not changing my diet, but my cholesterol is high.

But if all of that is if you have a very high saturated fat diet, those LDL receptors get clogged. And if those LDL receptors that also are ApoB receptors get clogged, well, then LDL, there's gonna be more in the bloodstream, and it's going to signal your liver to make more ApoB and more LDL cholesterol, so it's going to raise it. You know, a lot of people who go on, let's say the carnivore diet, and they have a very high saturated fat diet, they've seen their LDLs go up to 700, because of the high volume and the inability of their body to excrete it and overproduce it as a result.

So saturated fat can't be a free food, but the allotment and the amount and the type is all important in the nuanced discussion about saturated fat.

[ANGELA FOSTER] (21:22 - 21:32)
You reported that figure there, it's very interesting that their LDL on the carnivore diet can go as high as 700. What do you typically see their ApoB go to on that diet?

[MICHELLE ROUTHENSTEIN] (21:33 - 22:45)
That's a great question. I've seen it go into the 200s as well in the ApoB. A lot sometimes though, ApoB is not always done on a routine exam.

Sometimes you have to ask for it. So if it is not available to you, or you don't have an ApoB, for the listeners here, another great surrogate marker for ApoB cholesterol on a standard lipopanel is something called the non-HDL cholesterol. So you take your total, you subtract your HDL and you get your non-HDL cholesterol, which is a good marker for the other types of cholesterol, remnant cholesterol that can have an ApoB lipoprotein proteins attached to it.

So non-HDL cholesterol can be helpful. And the targets for that are also based on your risk. So if you have low risk, we want that non-HDL cholesterol to be less than a hundred milligrammes per decilitre.

If you are at moderate risk, less than a hundred milligrammes per decilitre. And if you're at very high risk, less than 85 milligrammes per decilitre. So that can help understand what that looks like.

And so someone with an LDL of 700 has a very high non-HDL cholesterol, very high level.

[ANGELA FOSTER] (22:45 - 22:55)
For someone who has either high non-HDL or high ApoB, what are the first five things you would have them do to reduce it?

[MICHELLE ROUTHENSTEIN] (22:56 - 24:53)
So I would first look at their saturated fat intake, how much are they consuming? And I would assess that level so we can decrease that to help with the body's ability, the liver's ability to recycle LDL. The second thing I would do is I look at their unsaturated fat intake and I would see, okay, saturated fat, are they having a lot of marbled red meat?

Can I switch some of those to an unsaturated fat, for instance, omega-3 rich fish, because unsaturated fat helps make HDL more functional to help bring more LDL back to the liver to be recycled. Okay, so that's going to help lower those numbers. The third thing is I would look and assess their fibre intake, their total fibre intake for the entire day.

And if that's very low, I'm not going to all of a sudden bring them to four or five times that volume. They'll have a lot of GI distress. I will assess, okay, their total fibre is this much.

Now, how can we add more into it slowly so that they body can tolerate it? The fourth thing though, I would say is determining the difference between their soluble fibre intake and their insoluble fibre intake. Okay, how much is it of the binding cholesterol, the soluble fibre, the viscous fibre, and make sure we're adding more of those relative to also insoluble fibre, which is the broom that pushes it through.

So we need to be looking at both soluble and insoluble fibre as well. And then ensuring good hydration. If we're adding in more of the fibre, you need to make sure that you are hydrated or also become constipated and the ability to excrete the cholesterol diminishes without good bowel movements.

So we want to make sure you're adequately hydrated as you transition into a good soluble and insoluble ratio in your diet to allow for proper excretion of cholesterol.

[ANGELA FOSTER] (24:54 - 25:03)
I love how practical you just made that soluble fibre. What are the top three sources of soluble fibre that we can eat to help kind of sweep up that cholesterol?

[MICHELLE ROUTHENSTEIN] (25:03 - 25:25)
Yeah, so it's found in things like oats. That's a good source. raspberries is a great source.

And things like chia seeds are a good source. You know, when you put things in water that expand, you put chia seeds in water, they goop up all the water, that shows some level of solubility that will help bind the cholesterol.

[ANGELA FOSTER] (25:27 - 25:33)
So for breakfast tomorrow, then everyone needs to be having oats with some chia seeds and tarts with raspberries.

[MICHELLE ROUTHENSTEIN] (25:34 - 26:32)
I'd actually be careful because if someone's not used to eating soluble fibre, they may feel really bloated after that meal. So I wouldn't recommend that if you have no soluble fibre in your diet, because it's too much, it's going to cause you to be backed up, because it's too much soluble fibre. So it actually assess what you're eating.

If someone's having, let's say an egg, like an egg breakfast, maybe you add in half a cup of raspberries as your transition point and see how your body does. When we add in soluble fibre, slow and steady is very important in this in this, in this diet plan, because if you don't have it slow and steady, and you become constipated, A, that doesn't feel good. B, it's not doing the mechanism of action you want it to, and it's not sustainable.

So it's important to say, what am I already doing? And what's that one or two small changes I can make to make this A, tolerable on your GI tract, enjoyable, and then we can easily add more and more as your body tolerates.

[ANGELA FOSTER] (26:32 - 27:06)
So go slowly and start small, I think is what I'm hearing there, which I think is really important. Because actually, a lot of the women that I see who have gone kind of gone for the carnivore diet or something like that is because they've been experiencing bloating as part of their perimenopausal symptoms. And so they go with that more kind of sort of protein forward, less plant based approach.

And I think building up slowly is so, so important, as you say. One of the other things you mentioned here is that we need to create the environment for good blood vessel health. How can we do that?

[MICHELLE ROUTHENSTEIN] (27:06 - 29:23)
Yeah. So as women age, and as men age as well, our nitric oxide bioavailability declines. Oestrogen was protective because it also helped make our arteries more flexible.

As nitric oxide declines, our blood vessel, instead of being more in the ability to vasodilate, it could be more in the constricted state. So blood pressure oftentimes can increase during peri and postmenopause. It's another silent factor.

Most people are not checking their blood pressure routinely, and we want to make sure that we are checking it at home. So your blood pressure helps us assess for one component of endothelial health. Now, nitric oxide bioavailability decreases.

That doesn't mean we can't produce it. It just means that we need to really focus on that. There are many foods you can eat to increase nitric oxide bioavailability.

Beets, leafy greens, all of that is wonderful, but you may not see a movement on your nitric oxide test strips if your gut microbiome is diminished. So in order to make nitric oxide, your gut communicates with your oral microbiome to make nitric oxide. If your gut health is not in optimal condition, you may not have much nitric oxide bioavailability.

And just to go back to the carnivore comment, I've seen people who are on the carnivore diet for a year or two, and they have a heart attack, and they've come to see me. It is much harder for me to get them, or much slower for them to get to their fibre goals, because I need to shift their gut microbiome from being more in a gramme negative bacteria environment to be in a more conducive environment to be able to digest plants. The carnivore diet is a strict elimination diet.

So many people feel better because they're taking out one or two of the culprits that was causing them the bloating. If we can identify what those parts were, then we can address that much easier and also keep your gut health, your heart health, your brain health really in check as we age.

[ANGELA FOSTER] (29:24 - 29:29)
What have you found are the top foods that cause bloating?

[MICHELLE ROUTHENSTEIN] (29:30 - 30:22)
I mean, for bloating, there are the specific cruciferous vegetables, the beans, the whole grains that people mentioned cause bloating. But why does bloating happen? Your body's having a hard time digesting those foods, whether it's because you don't have the right bacteria to digest them, or whether you have a history of slow motility.

And those foods that are higher in viscous soluble fibre are slower to digest. So what are you eating it with? Do you have too much soluble fibre and not enough insoluble fibre?

There's usually other causes. Many people think that, oh, beans are the problem, whole grains are the problem, but actually it comes down to your gut health. And that's where we need to focus on first before we introduce these foods.

So make sure that you can digest it and it reduces the bloating.

[ANGELA FOSTER] (30:23 - 30:32)
Yeah, so, so important. Oxidative stress. You also mentioned this.

This is important. How can we reduce oxidative stress in the body through nutrition?

[MICHELLE ROUTHENSTEIN] (30:33 - 31:40)
Yeah. Well, first I like to say, well, how, why does oxidative stress happen? It can happen from many things.

It can happen from under-exercising as much as it can happen from over-exercising and not pairing that with appropriate nutrition. It can happen from disrupted sleep, poor sleep quality. It can happen from having too much refined sugar, having too much saturated fat, having too much sodium.

It can happen even from high levels of stress in our body. So there are many things we need to understand or, and it also can happen from sleep apnea that's not controlled. So we need to understand kind of what's driving it.

And then, then from there we address those, but then we also need to make sure that we are having a high antioxidant rich diet and that we're really honing into pathways that help to reduce oxidative stress like the glutathione pathway. So the glutathione pathway needs adequate amounts of protein. It needs selenium.

It needs sulphur containing foods like our cruciferous vegetables and our alien vegetables as well.

[ANGELA FOSTER] (31:41 - 31:45)
Is taking oral glutathione helpful here?

[MICHELLE ROUTHENSTEIN] (31:46 - 33:07)
So oral glutathione is a end product. We want to make your body make glutathione. So eating your food helps to make it.

So a lot of that is just expensive marketing. And I know it's so easy to fall into these marketing traps, but it's really important to take a step back and say, my body can make this. I want to ensure it's making it by eating these foods that will help.

And at the end of the day, I know I keep talking about gut health, but the way your body absorbs these nutrients and produces these metabolites all stem from how your gut absorbs it. So if cruciferous vegetables makes you gassy, we got to go back to the source of why you probably don't have the right bacteria, whether it's from eating a high red meat diet, whether it's from courses of antibiotics, there are many causes, also stress. If someone has had, and I've seen this a lot, a lot of grief, a lot of stress for multiple years, it can go to the gut where the vagus nerve is situated also, and it can lead to this dysbiosis.

And we need to support the vagal tone, we need to help with stress reduction therapies, and also recognise the role of chewing our food and taking that downtime and reducing our overall stress to support our gut health too.

[ANGELA FOSTER] (33:11 - 34:37)
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You mentioned earlier thyroid. This is a common thing as well for women in perimenopause. We often see an increase in autoimmune diagnoses.

How is the thyroid affecting our cardiovascular health?

[MICHELLE ROUTHENSTEIN] (34:37 - 35:14)
It can do it in many ways. A lot of times it can actually, if we have uncontrolled levels of our inner thyroid panel, it's linked to higher cholesterol. It's always something we want to look at as a whole picture.

It can also cause a heartbeat irregularities if it's not controlled. It's also coming down to, are you feeding the nutrients your body needs for your thyroid to function well? Are you having a good anti-inflammatory diet to improve the inflammation that may be associated with it as well?

There's a lot of connections. Looking at a full thyroid panel is always something I highly recommend.

[ANGELA FOSTER] (35:14 - 35:31)
For someone who's listening to this, who has either been on thyroid medication or maybe they've actually managed to get their thyroid back within a range, but they're still seeing high antibodies on their lab work. How much do you see that posing a risk?

[MICHELLE ROUTHENSTEIN] (35:32 - 36:59)
It can definitely pose a risk because there is this level of potential inflammation in the body. We do want to attempt to reduce that level as much as possible, but also look at a lot of different components too. When we look at inflammation, there are many inflammatory markers and you may say, okay, well, let me just look at one, but one could be normal and the other can be high.

We know that anytime there is inflammation in the body, it increases risk of cardiovascular disease. Whether that's psoriasis, atopic dermatitis, whether it's from Hashimoto's, whether it's from lupus, anything that has some level of inflammation increases cardiovascular disease risk because it's an accelerator of plaque formation. If there's inflammation, LpA is also more aggressive.

It also can increase the LpA as well, but inflammation, it accelerates plaque formation and plaque formation starts off as soft plaque, which is a lot more vulnerable and it becomes more lipid rich and inflamed and where that can rupture and cause a cardiovascular event. When it becomes calcified, it's actually a lot more stable, but in the intermediary stages is very inflammatory. We want to make sure we are addressing any potential level of inflammation, no matter where it's coming from, to help reduce the acceleration of that plaque formation in any artery above body.

[ANGELA FOSTER] (37:00 - 37:30)
What I'm hearing from you is that if somebody has autoimmune antibodies showing it could be relating to their thyroid, it could be relating to something else and all their inflammatory markers are higher. The key thing is to try and get that inflammation under control. In terms of bringing down and helping to control that autoimmune reaction, we hear a lot about gluten being the sort of enemy here.

Do you agree that gluten is a risk for these patients and are there other foods, for example, that increase risk?

[MICHELLE ROUTHENSTEIN] (37:31 - 38:39)
Yeah. I mean, so the research is kind of partial in terms of some people gluten is a risk, some people it's not. So it's definitely a conversation to be had.

And it's definitely something that can be used as a trial from an elimination standpoint, right? So if we're struggling to lower it, and we then say, let's go on a no gluten diet for three to four months and retest it and see how that responds. That's helpful.

I always like to say even before doing that, though, like how do you, how does your body react to certain foods? Like if dairy always causes bloating or diarrhoea or cystic acne, it's not for you. If gluten causes that, it's not for you.

We can definitely test for celiac disease. And then we definitely want to be gluten free, because there is some connection there as well. But we need to really individualise that because I've seen people who are who eat gluten and have normal and lower their antibodies successfully.

So it can't be, oh, no, everyone has to get rid of it. But if you cannot tolerate it, we definitely do not want it in your system.

[ANGELA FOSTER] (38:39 - 38:43)
Are there other foods that you've seen that generally trigger those antibodies?

[MICHELLE ROUTHENSTEIN] (38:44 - 39:05)
A lot of refined carbohydrates, a lot of refined sugar. And sometimes a lot of people think that refined sugar is only if you eat a lot of doughnuts, or if you eat a lot of candy. And while that is refined sugar, it also can be coming from sources like honey, or maple syrup, or things that people are adding in that we want to assess for as well.

[ANGELA FOSTER] (39:06 - 39:12)
I love that. So many tips there on nutrition, exercise, how much can exercise help protect our cardiovascular health?

[MICHELLE ROUTHENSTEIN] (39:13 - 40:43)
So exercise is so important. And we need to be looking at it in three buckets. We have our aerobic exercise of moderate intensity, primarily zone two training at about 150 to 225 minutes, that's going to help protect your heart pump, it's going to help with blood flow, it's going to help with blood pressure, it's going to help also with production in ApoB cholesterol as well.

It makes HDL more functional, it raises HDL, we know that cardio respiratory fitness is super important. Resistance training, it needs to happen as well to protect the bones to help with insulin sensitivity for metabolic adaptation, to preserve lean body mass as we age, which is important for cardiometabolic health as well. And we want to make sure that there's stretching, we want to make sure that we are allowing our body to go to expand, right, if we're kind of always on the go, and our muscles are contracting, but we're not elongating them, that can also have an impact on elasticity in our arteries too.

And that's usually the one that's I find most neglected. You know, it's like, okay, I have only an hour, I'm going to do this, I'm going to do that. I'm like, okay, you don't need to do the stretching after you work out, if that's not where it fits in, anchor it before you go to bed.

So you don't wake up with stiff joints. That's not the way we're supposed to be, we're supposed to help elongate it. So stretching is you if you're not stretching, and most people are like, I don't like stretching, five minutes, start slow and build it into your regimen.

[ANGELA FOSTER] (40:43 - 40:58)
I think you're the first person that has mentioned stretching in relation to arterial health. That's super interesting. So in order for us to have healthy arteries, we need to make sure that we have a stretching practise across our week.

[MICHELLE ROUTHENSTEIN] (40:59 - 41:15)
Yeah, a stretching practise. And also it's a good mind body connection too. You know, you can bring it in from a yoga perspective, you can bring it in from passive stretching, however you like to do it.

But we are contracting our muscles all the time. And we need to stretch to help with good blood flow.

[ANGELA FOSTER] (41:16 - 41:58)
That's what I was going to ask you, Michelle, was what was the connection? So it's helping with the blood flow. Okay.

Interesting. Right. So I'm definitely someone who neglect, I think, because I think the thing with stretching, right, for everyone listening to this or watching this, is I feel like you sort of fall into one of two buckets.

You're either somebody who gets really tight, and you know, you need to stretch, or you fall into the camp of person who can kind of get away with it. And I think I fall into that. So I haven't really prioritised stretching as a practise.

Do you think that actually, this may even play out when we look at arterial health that some people may need to do more stretching because they are naturally that much stiffer?

[MICHELLE ROUTHENSTEIN] (41:58 - 42:49)
It could, it definitely can be as individuality is so important. But I would also really bring it also from a perspective of enhancing your recovery and enhancing your ability to continue going. I had a client who was a big runner, she never stretched.

And she's like, one day I woke up and I couldn't move my hips. She was so tight. She couldn't run for six months.

She went to an acupuncturist. No one can help her. I was like, you need a stretch.

And I just build in a stretch in jail. And she was, she's like, Michelle, my, my tightness went away, I can actually walk again. But like, don't wait until it gets to that point.

Right? Because now you can't even do the exercise you want. So it's important that we're preventing the injury from happening, which is why we want to make sure it's part of our routine.

Because most people who don't stretch are more prone to injuries as well.

[ANGELA FOSTER] (42:50 - 43:09)
Yeah. And there's this cardiovascular risk that I've learned today is super interesting. Vibration plates are super popular at the moment.

I certainly you know, I have clients who swear by their vibration plate for helping with their recovery. And I see it on their metrics. How much do you think these could help us from a cardiovascular health perspective?

[MICHELLE ROUTHENSTEIN] (43:10 - 43:25)
I mean, I think that it's pretty new. So we don't have the solid research, but I don't see there being harm in it. Right.

So I think that if it's helping someone and they feel better using it, and continue doing that, I don't think there's anything to to stop on that front. Mm.

[ANGELA FOSTER] (43:26 - 43:39)
Amazing. Stress, the big one. This is midlife is a time of a source, I guess.

Midlife is a source of so much stress for so many women. How much is stress impacting our cardiovascular health?

[MICHELLE ROUTHENSTEIN] (43:40 - 45:55)
So stress, whenever we look at the different pillars of a heart healthy lifestyle, we have to recognise that it's not really in isolation. When someone's stressed, the priority of their health can't be prioritised, right? So when someone's stressed, it affects their sleep, which affects their hunger and satiety signals, which affects their food intake, it affects their blood sugar levels, it affects their inflammation, it affects their exercise capacity and their recovery.

So it's almost a snowball effect. And I think it's important to recognise that I'm not saying live a stress free life. There's no such thing.

Life is stressful. What I want to recognise and build in is what we call stress resilience. How can we add in the things that help on downtime to build your body's ability to be able to handle stress better?

How do we prioritise you? This isn't a self care component of get your nails done, get your hair done. Those are all great things.

But when we say self care, I'm meaning about setting boundaries, setting saying no, prioritising your meals, prioritising your bedtime, you know, making sure that you are setting up your sleep environment for optimal rest. That is what we mean by self care. And you can still take care of all the people in your life.

But if you don't take care of yourself, you can't take care of them. So start off your day with something for you. Don't touch your phone until you're ready to touch your phone and see the world.

Make sure that you are putting up boundaries for people who stress you out. Don't take a call from your sister who may stress you out at 8 p.m. at night. Take it earlier in the day.

Make sure that you're really taking inventory of is there a podcast? Is there an Instagram account that makes you anxious? Unfollow them.

Really assess where's the stress coming in? How can you set the boundaries? And how can you give yourself joy and put more effort into stress reduction components that will help you be more stress resilient?

[ANGELA FOSTER] (45:55 - 46:27)
I love what you've said there about boundaries. I just think it's so important. The other thing I do with my clients is I ask them to look at how much are you on?

And can you counter that with being off? So for example, at the end of a workout, I'll often then programme them in with some box breathing for five minutes, as opposed to doing an intense workout, and then rushing to get home to take the kids to school to do the commute to work. Do you know what I mean?

Because we're just layering on the stress. And even just finding a few minutes, I find just helps bring them back into balance. So we're kind of moving the dial frequently throughout the day.

[MICHELLE ROUTHENSTEIN] (46:27 - 47:15)
I love that. I also like to do little check-ins, right? So if like 30 seconds, a little alarm that goes off at 10am, 1pm, what do I need right now?

Did I not move for three hours? Let me get out. Let me stretch for a second.

Can I have it? Did I drink any water? How many times do people go through the whole day and they go, oh, I didn't drink.

And now it's too late, because then you'll wake up in the night to urinate if you drink that late. Okay, let's have a check-in earlier. Check-ins to see what can I do to help achieve my goals earlier in the day is really helpful in those capacities too, because you take a second.

And I can't tell you, if you take those seconds, you will be more productive, because you're really honing into what you need. And that's going to fuel you to continue doing what you have to do for the rest of your day.

[ANGELA FOSTER] (47:17 - 47:56)
100%. I love that. And I'm such a big fan of walking.

Do you know what I mean? After like, for example, after this, I'll go for a quick walk. And these are like 5-10 minute walks, but I find that they're just such a lovely transition.

And also, if you feel really stressed, you might not be able to sit and meditate or do some breathing. But walking is always accessible. And somehow it just discharges so much of that.

Yeah, I love what you're saying there. I think that when people are looking at their data, they get very hung up on heart rate variability. What would you say to the woman listening to this who has chronically low HRV?

What should she be thinking about?

[MICHELLE ROUTHENSTEIN] (47:57 - 48:39)
I think a lot of people look at this HRV as like, oh, I gotta go harder. Like, why isn't my body recovering? Well, this is a sign that your body's not recovering.

Why isn't? Are you undernourished? Are you not giving yourself downtime and rest time?

Are you, you know, are you hydrated? How's your sleep? How's your sleep environment?

There's a lot of those components that I think are neglected. And HRV is like, okay, just push harder, do this and that. Like, wait a second, your body's telling you something.

How do we help with the ability of your body to recover? And it's going to the foundational basics of stress, sleep, and nourishing your body. And when those things are addressed, HRV goes up.

[ANGELA FOSTER] (48:40 - 49:12)
I'm so glad you said that. And I think, because I think that I think we underestimate how nourishing your body properly with those things makes such a difference. We start thinking straight towards biohacks.

But even for someone who's under eating, adding some carbohydrates, like adding a bit of sweet potato or rice with your evening meal can improve your HRV. Like I see it happen so often. So yeah, I'm so glad you said that.

Is there a resting heart rate that you like clients to have as an indicator of good cardiovascular health?

[MICHELLE ROUTHENSTEIN] (49:13 - 51:35)
So it really is where is your baseline? You know, I think that's a big one. And I also would say that I want you to be focussing a little bit more in tune with blood pressure.

I think a lot of times we look at heart rate and it's important metric 100%. But your blood pressure tells me a lot more of what's going on from a perspective of your heart and the force that it needs to push out that blood to get throughout your entire body. And blood pressure is so important, because if you look at the data of why it's called a silent killer, it's because it increases the risk of heart strokes, heart attacks, dementia, kidney disease, it hurts our heart, it hurts every organ of our body, because that blood flow is so stressful, so impactful at the time that it's putting pressure on all of our organs.

It also is one of the biggest risk factors for having a heart attack because it dislodges soft plaque and can cause more of the blockage of blood flow. So your blood pressure to me is a lot more of a important metric to be following from a target perspective, because 110 over 70 is ideal, less than 120 over 80 is great. There are a lot of times where you may go to the doctor and they might say, Oh, you just are just anxious.

It's white coat syndrome. And they don't say anything else. And you're walking around with a higher blood pressure because you're not checking it at home.

And you don't know what's the target. The reason doctors don't really look and say we're going to intervene until that blood pressure gets too high. It's already causing silent damage.

Nutrition is the first line treatment to lower that blood pressure. And the doctor won't look at it and saving until it's 140 over 90 or 130 over 80 if you're at higher risk. We see in studies plaque goes into the arterial wall, and the high blood pressure is higher because it has more susceptibility to do so because there's that micro chair that allows for the AcoB to invade more readily.

So I want you to be checking blood pressure. I think a lot of times as fitness, you know, performers, people are looking at HRB in heart rate, and those are great. But I want you to pivot into saying, our blood pressure matters here too.

And using a cuff that's on your upper arm, not your watch. It's not a good indicator of blood pressure. You don't really get a good reading on your wrist.

It needs to be on your upper arm.

[ANGELA FOSTER] (51:36 - 52:04)
Yeah, so important. I think having a blood pressure monitor at home, as you say, is just a really, really good step. It's not, you buy it once and you can take all the family, right?

Anyone at home that wants to take a reading can do so. Menopause hormone therapy, when women are going through peri and then into post-menopause, their oestrogen drops, oestrogen is cardiovascularly protective. How much does menopause hormone therapy protect our cardiovascular health?

[MICHELLE ROUTHENSTEIN] (52:04 - 53:34)
So the guidelines are really based off of symptom management for when we utilise it, but also individual, we need to look at individual risks. We need to look at the type of oestrogen that someone's taking, whether it's transdermal or oral in terms of their overall risk here too. But exogenous oestrogen.

So when we, what was protecting us was our body was making it was endogenous oestrogen. Exogenous oestrogen has not been shown to actually replace endogenous oestrogen from a cardiovascular perspective. So it doesn't necessarily help increase LDL receptor activity, increase nitric oxide bioavailability when we take it exogenously.

So we still need to shift our dietary patterns to support our body during the menopause transition. But if someone has insomnia, brain fog, hot flashes, poor sleep, it can definitely be a component to help address those because that is going to increase risk of heart disease if those aren't well controlled. So it depends on the person.

Some people don't have any symptoms of menopause and they may not be a candidate by their physician. Others may be a very good candidate. So it all just depends on your age, your risk factors, your labs, and the full picture of assessing it through a cardiologist, your primary care, who's looking at the complete picture and also looking at your family history of heart disease as well.

[ANGELA FOSTER] (53:35 - 54:08)
Interesting. And actually it's the symptoms, as you say, that can be the thing that drives then the cardiovascular risk. Because if you're not sleeping well, for example, then you feel in turn more stressed.

You manage your blood sugar less well. You're more prone to eating unhealthy foods that then increases kind of this knock-on effect as opposed to necessarily a direct impact. Minerals, lastly, we touched on them very briefly about what is and isn't a good way to measure them.

How important are sodium, potassium, magnesium for our heart health and how do we know we're getting enough?

[MICHELLE ROUTHENSTEIN] (54:09 - 55:40)
So important. So our heart, we have three main functions, I like to put it three buckets of how our heart, how we look at heart function. One is the pumping ability, the heart muscle.

The other is the electrical and the other is the plumbing system. Okay. So when we talk about the plumbing system, we're really talking about that ApoV, inflammation, blood sugar, et cetera.

We talk about the heart pump. We do need nutrients for that. That's a lot of the vascular resistance that can come up and show up in blood pressure.

Then the electrical system can, if someone has increased heart palpitations, they have atrial fibrillation, atrial flutter, and they all have nutrition components that are important. We need sodium, magnesium, calcium for our heart to beat regularly. And they're super also important for vascular tone, vascular resistance.

To know if we're getting enough, really hard to determine that through blood tests. There really is based off of symptoms. It's also based off of what you're consuming in a regular basis and what your actual needs are.

So, you know, if someone has restless leg syndrome, is it magnesium? Is it iron? It's kind of rare to hone in and assess, what are you eating on a regular basis?

What are your lab levels? What are, you know, what's going on in other symptoms that you may be having? So we have to look at the whole picture to determine what could be that potential cause and then hone in a little bit closer.

[ANGELA FOSTER] (55:41 - 56:20)
Amazing. Thank you. This has been super interesting.

And I think very, very empowering, Michelle, you've shared so much knowledge here. And I think that for people listening to this, watching this, I think the incredible thing is that we have so much more control over this than we might think that we do. And so much is controlled by really what we're putting in our mouths.

That is just chemical information to our body. And if we can get those right messages in, we really can protect our cardiovascular health in combination with stress resiliency, as you mentioned, exercise and good sleep. Is there anything that I haven't asked you that you feel you'd like to share?

[MICHELLE ROUTHENSTEIN] (56:21 - 58:55)
I think that what you said is important. You know, one of the reasons why I niched down into cardiovascular nutrition about over 14 years ago was because heart disease is the number one killer globally. It's over, and especially in women, over all cancers combined, but 80 to 90% is preventable.

And in those research studies, it included people who had high LP little a. So the empowering message here is, we need to really focus on your heart health nutrition. That's very nuanced to address nutrient efficacy to look at your labs and know your targets and achieve them and maintain them in optimal levels.

We need to make sure that as we age, we're looking at our heart health because without a good blood flow system, it can, it can harm any, any component of our health too. But we don't look at it in solitude. We look at it in relation to, we don't want you to have osteopenia, osteoporosis.

We need to address that. We don't want diabetes. We don't want gallstones, gout.

We want to address everything so that you can enjoy your life and you can do the things you love to do with the people you love to do. So a big component here is recognising there's a lot in your control and we can do it. We just need to personalise it to you.

And just cause you feel good, check your labs, make sure you're checking your blood pressure on a regular basis, make sure everything's in check because it can silently brew. But if we can intervene early and it's never too late to intervene with science-based nutrition, you can live a long, healthy life that's heart healthy. We just have to be proactive in our ability to do so.

And also as women, you have to trust your gut. You have to push back. If you get dismissed because you look great on the outside and you don't need any blood tests, you don't need any calcium score, we don't need to look at your priorities, you don't look like you have heart disease, find another cardiologist.

Push back because we are often dismissed as women based off of appearance. It used to be that heart disease was only thought that it can happen in men. We know that is not true, but we have to be an active participant in your care.

And that means get a copy of your blood work. Don't just say, oh, the doctor said it's fine. Fine for what?

Fine because I don't need medications right now, but maybe later. Take proactive action because you can do so much in your heart health. You have to be at the forefront.

[ANGELA FOSTER] (58:56 - 59:03)
Amazing. So powerful. Thank you so much for coming on and sharing all of this.

Where can people connect with you and your work?

[MICHELLE ROUTHENSTEIN] (59:04 - 59:24)
Yeah. So feel free to go on my website, entirelynourished.com, where you can see my, I have my email list you can join. I sent out Tuesday email lists, newsletters that you may find helpful.

I also pop on to different social media channels, which you can all find on my Instagram, my LinkedIn, YouTube, all my website, entirelynourished.com.

[ANGELA FOSTER] (59:25 - 59:30)
Amazing. Thank you so much. We will link to all of that in the description below.

Thanks again for coming on.

[MICHELLE ROUTHENSTEIN] (59:30 - 59:31)
Thank you so much. It's been a pleasure.

Most of us assume that if we look healthy on the outside, our heart is fine on the inside, but today, preventive cardiology dietitian Michelle Routhenstein explains why that's exactly the assumption that gets women into trouble, especially through perimenopause and beyond.
We get into the two numbers your doctor probably isn't checking, ApoB and Lp(a), the first five diet changes Michelle makes with clients to bring down high cholesterol numbers, why stretching may be doing as much for your arteries as it does for your joints, and why blood pressure, not HRV, deserves far more of your attention as you move through this life stage.

WHAT YOU'LL LEARN

● Why heart disease can silently progress in women who look and feel healthy

● What ApoB and Lp(a) actually measure, and why they matter more than LDL and HDL alone

● The first five diet changes to lower high ApoB or non HDL cholesterol

● Why saturated fat, fiber, and gut health all influence your cholesterol numbers

● Why blood pressure, not HRV, deserves more of your attention in perimenopause

● How menopause hormone therapy really affects your cardiovascular risk

● The minerals your heart needs to keep beating and pumping properly