250: Seven Years, 700 Cholesterol, Zero Plaque: What Dr. Nick Norwitz's Case Report Changes

Nick Norwitz has an MD, a PhD, and a cholesterol level that should have killed him — at least according to the standard model of cardiovascular disease. For seven years, his total cholesterol held above 700. His LDL sat in the high 500s. Every clinical algorithm flagged him as a cardiac emergency. He took none of the prescribed medications.

His just-published case report shows zero coronary plaque. Not reduced. Not minimal. Zero.

This episode isn't a victory lap. It's a serious conversation about what that result means — for how medicine measures risk, how it handles outliers, and why the incentive structures that shape clinical decisions may be more dangerous than any single cholesterol number. Dr. Philip Ovadia and Nick Norwitz also go deep on a fraudulent case report published in Circulation, why statins suppress GLP-1 levels and almost no cardiologist knows it, and what happens when the patient who refuses to follow the algorithm turns out to be right.

#metabolichealth #cholesterol #ketodiet #heartdisease #LDLcholesterol #evidencebasedmedicine #lowcarb #preventivecardiology

BIG IDEA

A patient with seven years of astronomically high cholesterol and zero coronary plaque is not an outlier to dismiss — he is a question medicine is obligated to answer.

Nick Norwitz Contact Info

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Threads: https://www.threads.net/@nicknorwitz
Facebook: https://www.facebook.com/nicknorwitz

Nick's Case Report:
Seven Years of 700 Cholesterol Without Coronary
Atherosclerosis: A Lean Mass Hyper-Responder Case Report

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Transcript

0:34

welcome, folks. It is Stay Off My Operating Table with Dr. Philip Ovadia, and we are joined today by, first time I've e- I'm ever using this label, my favorite double-degreed provocateur. I like that one. I think. What do you think? Pretty good? I like it. Double de- I have a secret. So sometimes when I give lectures, after my MD, PhD, I throw in some other letters. There's two sets of letters, PGP and PP. No one ever asks what they stand for. They're Professional Guinea Pig and Professional Provocateur. And I'm just like... I play on the letter thing because everybody just likes tossing letters in the left and right. I'm old enough to- So I, I like to play with it I'm old enough to remember when PGP meant Pretty Good Privacy,. Hey, Phil, it's your show. Would you like to say something? Awesome. No, actually today I'm probably just gonna wanna listen. Very excited to have Nick Norwitz back on with us. When we last checked in with Nick I believe you were maybe just getting ready to start third year of medical school. A lot has happened since then. And would love to let the audience who hasn't been following maybe catch them up on what you've been up to. And we really we'll let everyone behind the curtain a little bit. This is one of those breaking episodes that Nick had a case report published just I think it officially published last week, but really just breaking this week. So we're recording this on Monday. It's coming out tonight at midnight, and really excited to get into that and talk about the implications. But yeah, before we get to the, that, Nick, let, how'd the rest of medical school go, and what kind of stuff are you up to now? To cut to the chase, or let's say frame this discussion, I'm building off what, how Jack opened it with double-degreed double doctor provocateur. The funny thing about me, and people who know me closely, is I'm completely an introvert. The idea that Nick would be a public figure in any sense five years ago would've been ridiculous. My journey through my own health issues and then medical school really set a fire in my belly, not sh- because I want to be a rabble-rouser, but, I'm sure I'm preaching to the choir here with you and your audience that there are things in science and medicine that are just screwed up. And far more than we're gonna discuss on this podcast. There's a lot I saw behind the scenes, and one of the most oppressive things was a resistance to look at what I thought were important questions in medicine, those that really serve science and the patients. And what I kept coming back to is that the questions that were being asked, the data that were being amplified, weren't on the basis of meritocracy, weren't on the basis of importance. It was on a basis of how we'd built the system and the incentive structures. And when I say that, it's not conspiratorial, it's not pointing fingers at anybody, not even pharma. It's just to say we have a system that's built in a very particular way that directs the spotlight of medicine on certain things, and if you just step back and think about it, there have been some abysmal failures. I think heart health is one obvious example. Irrespective of what your particular belief is, you have to admit, for half a century or so of chasing one, rabbit down a hole, cholesterol, and investing many billions of dollars in it, more than most other fields, we've made remarkable, remarkably abysmal progress, and that needs to be owned by the scientific and medical community to figure out innovative solutions. So sometimes things that are, quote-unquote, naturally provocative, like the existence of me as a patient, which shouldn't necessarily piss off people, but seems to, I have no problem amplifying those questions, and if somebody gets ticked off, my rule is ask a question. If you don't get a satisfactory answer, keep asking. If people get pissed off at you, you're probably asking a really important question. So I won't be bullied into submission if I genuinely think a question is important. The provocateur nature comes from the fact that asking some questions is perceived as taboo, and that is not how science works if it's a legitimate question. So to cut to the chase, I finished up medical school. As I was finishing up, a lot of opportunities were falling at my feet in the business world, in the research world, in the public-facing world of public education, and I'm lucky. Unlike prior generations like my parents or I guess even you when you were going through training, we now have a very different information ecosystem. And my perception is that the internet, social media, the availability of science is creating a democratization with respect to health information and that medicine as a team sport is evolving, and there are gonna be people in my generation who are stepping up as primarily the people who are the educators. So that's what I wanna specialize in. I'm doing a lot of things, but I'm like, I wanna devote my life to reading data, communicating it, more so than being a boots-on-the-ground clinician, which is also incredibly important. That's why I say team sport. It's not that I've lost any respect for the profession. It's remarkably admirable. The people in my life who are physicians, my parents, my siblings are in medical school, my girlfriend's a surgeon. What they do is nothing short of heroic, and I find myself just with a different skill set and different passions that lends itself to talking to people, educating people, yes, in certain circumstances provoking Because, and this is the last thing I'll say before I'll shut up- You can speak to this I'm sure, Dr. Ovadia, is that like in a medical system, especially for people who are lower on the totem pole, you just have to stay in your lane. So even if something's interesting, even if something's important to the patient, you just have to suck it up, stay in your lane, bite your lip. And I'm, first of all, not good at that. So long story short is I didn't even apply to residency, and ended up going down an alternate path with research, education, and I will be building some things, probably including a telemedicine company. But it's not gonna be a conventional route. I could always go back to residency if I want, but at the end of medical school I decided not to apply and do something else. So now I find myself here. Actually, the room we're standing in, I keep on lying, is gonna be my new studio, so I have to build it out. But I got, I bought a property and I'm gonna be upgrading the content game, probably starting a podcast. Just getting more bells and whistles than recording in my medical school dorm, which has been, Oh historically the game. So leveling up. I'm gonna miss the dorm room, Nick. Oh, geez. I'll always have a little me flare, childish goofiness, even when I'm 60. But time to level up, and I'm excited about it. Now, one of the- Anyway... things I think it's really important that people who don't know who you are know about you, you described yourself as your existence as a patient should trigger some questions. Real quickly if you would, please, for those who haven't followed you, explain why your mere existence as a patient is offensive. Yeah. That is a multi- multifaceted answer because it's actually a pattern. It's been a pattern where I was the patient who walked into the doctor's office, and there's a saying in medicine, if you hear hoof beats, look for horses, not zebras, which is the idea that, you want the most common explanation's probably right. The issue is if you have a zebra that walks in, you have to look and see the zebra, and it seems like that doesn't happen. And the fact of the matter is most of us aren't the population average. We're different in some way, shape, or form. So what I was finding again and again through my health journeys I could say, is I'd walk in and I wouldn't get critical thought about what made me unique as a patient, and then I wouldn't get optimal care. And I found myself, even as a kid, like having to think through this by myself. In fact, the first paper I ever wrote was a case report on I had ended up with a weird bone condition, and I thought they misdiagnosed me. I was like 20 at the time. And I'm like, "This does not make sense. Your diagnosis doesn't make sense, so I'm gonna write a paper on it." So I have more, background and resources to do that kind of thing, but that happened again and again. And most recently, and maybe most pertinent and interesting to your audience was- my cholesterol story, where I had pretty bad inflammatory bowel disease. I went on a ketogenic diet. It treated the inflammatory bowel disease. I got my life back, but my cholesterol went through the roof. And I walked in, and I got the rule book thrown at me. You fit here in the algorithm, so here's what we're gonna do." Even though I knew the algorithm was built on people who were not like me, and I kept on trying to enforce that. This is what makes me different, this is what makes me different, so can't we think about my case as an individual? Which is what medicine is, it's treating the individual in front of you, and I think that sometimes gets lost. So- ... it makes people very uncomfortable to see somebody walk in, again, focusing on cholesterol, with my cholesterol profile. My total cholesterol has historically been over 700, my LDL in the high 500s, and that just s- sets alarm bells off, because there's no point of reference for a patient like that other than some very rare genetic conditions which I do not have. So you end up in a position where, yeah, your existence is a challenge. A refutation. You're exposing a gap in knowledge, and when you push on that button, especially when you choose to do so publicly, and I won't say whether or not that was a smart thing to do. The fact of the matter is I did it. I've been public about my health background and who I am as a patient, a cholesterol patient, what's happening to me. So when you then amplify your story, it takes that uncomfortable cognitive dissonance and scales it, because it's a threat- ... to conventional models. I wanna pause and focus on this. People talk about whether or not LDL is causal, how important it is. The fact of the matter is the way we think and treat cholesterol is almost like it is the disease. Almost like it is heart disease. So if you have a patient with astronomically high cholesterol, where the expectation is their heart is gonna be clogged, up with plaque, and they're gonna be having heart attacks by, if you use the reference population, homozygous FH, before they turn age 10. And then that patient, and this is a spoiler alert to the case report, ends up having absolutely no plaque whatsoever, not soft, not calcified, nothing, zero millimeters cubed, that spits in the face of the conventional model. Now, there's always mental acrobatics like, "Oh it's an outlier." The fact of the matter is we learn the most from studying outliers. That is not a sufficient explanation. You have to say, "Okay why does this person break the rule? Like, why am I the exception?" It's not magic. There's physiology there, and what is the unique physiology? The fact of the matter is I'm not alone, but the point is even one case, one extraordinary case that butts against the rule deserves attention and discussion. So that's what I mean by my existence is an offense, and implicitly provocative. And what you started off talking about, right? Is something that I think is so important and doesn't get recognized. Because it would be one thing if- managing cholesterol was truly fixing heart disease, right? And then, okay, maybe there's this outlier that, he can have high cholesterol and doesn't have heart disease. But, we can't even talk about in medicine, it doesn't get talked about in medicine, that fixing heart... fixing cholesterol is not fixing heart disease, right? And, I- I've said it a few times on this program, right? When I was figuring out, 25 years ago what area of surgery I wanted to specialize in, and I told my mentors I wanted to go into heart surgery, they told me I was an idiot and I shouldn't do that because there's gonna be nothing left for us to do. We figured out heart disease. We have these miracle m- medications. We lower cholesterol and heart disease is done, and you're gonna have no job. And here I am 25 years later, and there is a massive shortage of heart surgeons that we cannot... there aren't enough surgeons to go around and do the amount of surgery, and no one is stepping back, not the American Heart Association, not, any of the, leading health organizations. No one is stepping back and saying, "What did we miss?" Why isn't heart disease going away like it should if it was all about cholesterol? Yeah. I mean, there are a few things I really want to dig into, nuances that I think people overlook, because you're 100% right. Sometimes I feel like we're playing cholesterol Uno, where it's oh, there's still cardiovascular disease, atherosclerosis in people with an LDL of 55. So m- like, you just need to get it to 40 or 30, and then it's just like we're trying to get to zero, basically. And there's always an excuse for, why the LDL cholesterol is a problem, why lower is better, et cetera, et cetera. And I think what's interesting to observe is how people get hung up on particular concepts and use them as an excuse. So I'll lean into one word that I know you both have heard a lot, which is causality. I hate causality because every time causality comes up, it's conflated with importance. We hear people talk about, like Peter Attia was on Huberman, and he was like,"I'm obsessed with causality." And I'm like, you can have a causal variable that is actually not important. It's part of the domino chain, but it doesn't mean you need to treat it. And very importantly, it doesn't mean treating it's a good thing. In fact, one of, and I will use Peter again for his own analogy, an analogy he used early on when he had his podcast with Dave Feldman, was to describe the relationship between LDL cholesterol and atherosclerosis as oxygen and fire, since oxygen- is necessary and causal for a fire, which is hilarious because what happens if you lower oxygen more and more? The chance of me spontaneously combusting into flames does go down. But you'd also suffocate and die if you hit zero oxygen. Now, obviously that's an extreme analogy, but you could use many analogies, like a biological male, their equipment being causal for certain STDs. Do you want to remove that causal variable? I would argue that would cause more harm than good. So this idea of causality that always gets brought up with the Mendelian randomization, I'm like, it misses the point completely, because it doesn't actually mean the treatment is actually going to have the benefit. And even worse than that, or not worse than that, but compounding on that, th- there are, like, things that then seem like, oh, the trump card. Oh, in these populations statins improve cardiovascular outcomes. But if you actually look at some of those studies and then do the meta-analysis to see, okay when statins improve cardiovascular mortality, like in metabolically sick populations, is there an association with how much they lower LDL? And the R squared ends up being like 0.0 to 0.1, so basically no relationship. So maybe there's something there, but it's being misattributed to a reductions in LDL when maybe the effect is, oh, statins are improving endothelial function in people with high baseline inflammation who are metabolically unhealthy. We can go down the rabbit hole. The point is not that LDL and ApoB aren't important at all or aren't causal at all, but I think it's really hard to make an argument that they deserve all the oxygen they're getting. They're a small side player. In the forest of cardiovascular disease, they're a stupid little shrub. So why are we spending billions of dollars and all our attention on the stupid little shrub, is my provocative presentation. Yeah I could hazard a guess, and it might be that we have a pill that will affect the number when we measure it. Oh, I think that is- That is the answer. But it's actually more sinister than that. Oh, God. Not sinister. No, sinister's not the right word, because sinister implies malintent. It's more problematic than that- There we go ... because I think people really buy in to the fact that we have a pill, this is an actionable item, and you can do something and help someone. There's a very tempting story. The issue with that story is to provide proper informed care, the patient and the doctor need to be informed. So what if you have an ecosystem that amplifies and over-exaggerates the benefits and suppresses the harms? And we have this ecosystem, and I see it again and again. So for example, here are just facts. One of the most popular statins of all time, like atorvastatin, is known to suppress GLP-1 levels in human controlled trials, which is GLP-1 being now one of the most sexy hormones of the era, you'd think that would be something that gets a little bit of attention. None. When I found that study I walked around asking cardiologists if they'd ever heard about it. No. It's not because they were malicious and trying to avoid it, it's just that there was no incentive to amplify those data, which clearly had serious potential implications for health. Or another example, women. I did not learn in medical school that women are more likely to be harmed by statins than men. Apparently, it's a very well-documented finding, and the reason is also known, more or less, which has to do with change- differences in sex chromosomes. So women have two sex chromosomes, and therefore have a different dose of certain genes, and this ends up interacting with statins, actually through omega-3 pathways. In fact, these studies provide solutions. In women you can just give an omega-3 and it can help with blood sugar increases on statins. All that's besides the point. The point is there are these signals for both harms, and then also solutions to those harms that are potentially very clinically important, but they don't get elevated because there's no business model around them, to your point, Jack. And I think that's a huge problem. At this point, what do you think the average doctor needs to do differently when considering things like, the zebras, the b- the black swans, right? A case like yours and again, to get to the punchline your case report that was just published, Seven Years of 700 Cholesterol Without Coronary Atherosclerosis: A Lean Mass Hyper-Responder Case Report. And we'll have the link to the publication and to a video of you discussing it in all the show notes. But, the average doctor is just trying to get through their day, right? And here comes Nick into the office saying, "Yes, my cholesterol's 700. Yes, every algorithm, leading society across the world says that's something that needs to be treated, emergently. And here I am, having had this for a long period of time without any problems related to it that anyone can document now using the best imaging we have." To be quite frank the average doctor, that, that hurts their brain, and they don't want to think this much about it. And where do we go from here? What are your thoughts now, having trained, gone through medical school and all of this, and having experienced it as a patient, as to the doctors that are out there listening, how they start to integrate this into their lives? Yeah. That is a very good question, because I'm trying not to assume that every clinician will have access to, all the data in my brain, because now I specialize in reading all these papers. And so you're gonna have to make a hard call based on something you pr- might not have seen before or might not have learned about. So where do you start? I think step one is a little bit of introspection about what you assume to be the default safe path. Because the interesting thing is the default assumption is that e- even if it's been a long time, better part of a decade, very high cholesterol, there's no plaque, still hedge your bets, take the statin, just in case. So the default is the safe thing is to take the powerful pharmaceutical that also has side effects. Is that reasonably the default safe assumption? I would argue probably no. That doesn't mean it's not a defensible path, and that's one of the things is in these situations there are multiple defensible paths. So step one is to interrogate are your assumptions about what the safe path is fair, should that actually be the default, or should you be going with an alternative default? And then thinking about the whole system. So for example, after my seven-year scan, and I did this intentionally after, I considered restarting ezetimibe. Now, somebody might be asking, okay, wait, ezetimibe is another cholesterol-lowering drug. It's not a statin. But why now if you are stipulating that you don't have high cardiovascular risk, you have no plaque, would you take a cholesterol-lowering med? And this is where we genuinely need open-mindedness on both sides because even that idea, be it a statin, ezetimibe, something else, a quote unquote cholesterol-lowering med is a very narrow scope. We have named it a cholesterol-lowering med because of what we care about tracking, but the fact is biology and physiology doesn't give a crap what we name things. So often things have off-label use. Actually, a lot of medications are used off label for other indications, and I happened to come across some data that I can send you now. I will caveat it's very preliminary early data, but nevertheless was intriguing to me that ezetimibe might have potential neuroprotective effects completely independent of cholesterol. Not a cholesterol story. It goes into the brain and can interrupt interaction between two proteins that might otherwise increase risk for Alzheimer's, which is important to me. Based on the safety profile and even those early data with all their caveats, I'm like, the risk-benefit analysis in me, if I tolerate it, probably is helpful for brain purposes. The reason I present that is because, from the clinical point of view, just taking a step back and thinking, look, whether I'm a cardiologist or a primary care clinician, there's a whole person in front of me. What are the true risks and benefits of every option? And then, what does the patient care about? I care a lot about Alzheimer's disease. And then having that discussion. I mean, that's patient-centered medicine. So literally list out pros and cons, all that you know about, try to find those that you might not. And then decide is this something worth trying, and then collect data, right? It's really about what the patient is willing to try out. But me, you know me like do- I like doing experiments, sometimes it's maybe you're worried about a side effect, a temporary one, muscle pains, like you could just try and see what happens. It's not a signature you're signing up for life. You can be like, "I'm gonna try this, see what it does to my overall metabolic profile, my lipids, how I feel, and then reevaluate." So I think the difficult thing is approaching this with acknowledgement of the unknown, and that you might revise your decision as more information arises. But I think starting with imaging studies, starting with figuring out what your default assumption is as to what is the conservative safe path and whether that's correct, and then looking at the whole person. There's no good algorithm because humans are a web, and I hate when s- people try to like fit humans down a linear algorithm because we are a complex web. So those al- like linear algorithms don't often work well at the individual level. And I know I'm talking a lot. No. But I... And one last thing I wanna say, because I often get kickback from senior clinicians where they're like, "Know your place. You don't have my 20 years of clinical experience." And I wanna respect and also push back hard on that point, because clinical experience can be amazing. It can give you intuition for things that you can't gain through textbooks, but it's a double-edged sword because it also is like just, confirmation bias. Sometimes it is just confirmation bias. Just because somebody sits with patients over the course of decades and has dominion over a prescription pad does not mean they're actually practicing good medicine. In fact, they might have a tendency to be cemented in an idea that is suboptimal. So clinical experience can have value, but it is not in and of itself sufficient to discredit critical thinking. There is a... I put a post up the other day. You know that like plaque, that meme that's "Don't for- don't mistake your Google search for my medical degree"? I have a variation that is, "Don't confuse your prescription pad for critical thinking," 'cause it's true. It's like there's a tendency to be like I'm experienced." What is experience truly worth is a larger question, and I think that is a bit of a double-edged sword. Yeah, I mean, it's a big blind spot that I think a lot of doctors have in that we, whi- which zebras will we pay attention to, I guess, is what I'm getting at, right? Because, li- listen, if you have a heart attack, five years from now, right? Every cardiologist, every doctor, all the AHA and all of them are gonna come out of the woodwork and say of course-" Nick had a heart attack because he had a cholesterol level of 700 and he didn't take a statin, right? He didn't lower his cholesterol. And yet the m- average cardiologist if you ask them"How many of your patients on these medications have heart attacks," right? I think they're going to vastly underestimate that number, right? And they tend to think the ones that did, it's because they weren't really... they didn't start soon enough," or, "They weren't really taking the medicine," right?"They were non-compliant," right? We blame all of this stuff and we just don't realize the shortcomings of these algorithms. What you said earlier, I think is one of the most important things that we have forgotten in medicine. Humans are incredibly complex, and the combination of the complexities within each individual human is still way beyond our capacity to, conceive and compute, right? Even with all the stuff we have available to us today. Yeah. And to say that we're gonna, be able to take the vast majority of people on whatever topic you wanna pick and put them into an algorithm i- is really a kind of a foolhardy pursuit, and I think it's been problematic the more that we have tried to do that in medicine. Yeah. And, you're speaking to confirmation bias, and it's so much worse than I think people realize. Speaking of case reports, so we're f- we're, comparing, apples to apples here. I don't know if you remember, I think it was a couple of years ago, that case report in Circulation. It was entitled, I remember the title was Rapid Progression of Coronary Artery Disease After Stopping a Statin and Starting a Ketogenic Diet in a Lean Mass Hyper-Responder. And that, I'm sure, gets much more play in academia because just like you said, like that's the cautionary tale. Whoa, lean mass hyper-responder, he stopped his statin, he went keto, now he had a heart attack. Bummer. I will tell you, and people can look this up, Google the name I, the title I just wrote the case report wasn't only sloppy, it was a lie. It was a- ... completely bold-faced lie. And Circulation, which is a major cardiology journal, accepted it, and then it was presented at an American Heart Association conference. So what actually happened in this case, first of all, didn't meet lean mass hyper-responder criteria, so they're labeling him incorrectly. S- But then, more appallingly, the actual patient history was the guy, before ever trying a ketogenic diet, had to go into the operating room, probably to have a stent put in, a percutaneous intervention. I'm not sure exactly what they did, but presumably he had a stent put in his left anterior descending artery because it was all clogged. While they were in his heart, they're like, "Oh look, his other artery, his right coronary, is mostly clogged or partially clogged." There was moderate blockage."Okay, so we'll stent up in the one artery. We'll send him on his merry way with some treatment, some statins, along with other meds." Then multiple years pass. They're not doing follow-up imaging during these multiple years, and he's presumably on his medication. Then what happens is he stops his statin, starts a ketogenic diet, and then has a basically a heart attack, a STEMI. They did not say how long he was on keto. They did not say what the ketogenic diet was. This literally could be... And they o- they omitted time points and durations in a way that made it im- impossible to figure out the timeline, almost like it seemed almost intentional. So there's a serious possibility here that the case was something like dude was eating a standard American diet, nearly had a heart attack. They did procedure, put in a stent, gave statins. The other artery was already clogged. He went off for a couple of years, and then, he stopped taking a statin for a week, and during that week, he ate a little bit more bacon with his toast. And we'll call it keto and just blame it all on the keto. Oh, by the way, let's call him a lean mass hyper-responder for good measure. It was a complete lie. It was a bold-faced lie, and that kind of stuff passes, and I'll tell you it is not a one-off. So this idea that we're actually good at, identifying what, as you said, what zebras to focus on and what outliers we can learn from, there are grotesque double standards, and there's always mental gymnastics to explain why the current model is defensible despite, at a population level, an abysmal failure- Yeah of cardiology at actually curing, treating, or making heart disease a rarity, which it should be by now. Oh my goodness. Oh. And to I mean, to properly, I think, bring focus to why this is such an important question, right?'Cause, many people might hear your story, Nick, and just say why don't you go off the diet," right? Or, "Why don't you just, take the medication to lower your cholesterol while you're on the diet," right? And, I think again what gets lost is the unbelievable benefits, right? That you and many others have gotten from this, right? This wasn't like you just wanted to lose a few pounds, so you went on a ketogenic diet, right? And your cholesterol went up, and now you're just being sort of a difficult person, right? You had a serious life-threatening condition, right? If I remember correctly, you were literally placed on hospice care because of this condition. And- I was in a PAL care ward. PAL care. I wasn't quite hospice. I wasn't six months to live, but I was sick. Yeah. And this is the only thing that has fixed it, right? You had tried all of the traditional medicines and stuff to address your ulcerative colitis and the ketogenic diet is literally the only thing that has fixed it. And so going off this diet isn't really an option for you. Not a reasonable one, no. Yeah. You're not unique in that. We have hundreds of thousands of people at this point, in the low carb community who have similar stories to you. They have very serious medical issues, whether it's diabetes, inflammatory bowel disease, s- neuropsychiatric conditions, right? That only respond well to this diet. And so to dismiss the diet and say... A- and this again, is exactly what the mainstream system is trying to do. This isn't about individual cases of, this isn't valid, right? They are trying to say that the ketogenic diet is not a valid dietary approach for people because some people see increased cholesterol when they go on these diets. Yeah. It's a very reductionistic point of view and honestly, not supported by data, unless you consider lies and circulation data. One other thing I wanna point out- Yeah ... if in case it went over people's heads with respect to my own case, whether or not people like me or don't like me, and there are definitely a lot of people who aren't fans, and I appreciate them just as much, but I don't think anybody thinks I'm stupid. And no- people I think are aware that I come from a, like a medical background. Not only having, a medical degree myself, but my parents have medical degrees. I come from a family of doctors. So with that in mind, take my case, 700 cholesterol, seven years, no plaque. It's one thing to say, "Oh, it's just N equals one." And again, there are more people like me, but bear in mind this isn't a matter of I had a magic eight ball, and seven years ago, I'm like, "I know how this is gonna turn out. Let me wait and then I'll amplify the story as N equals one." This was something I bet on prospectively, because back when I was 23, there was a choice. There was a choice of take the medication or don't take the medication, and I made a choice and was bold enough to make a bet while knowing that decades of cardiology, quote unquote, wisdom built by people with far more clinical experience than me said otherwise. But I made that bet, and I was right. So was I just incredibly lucky, or did I maybe have an idea that is legitimate? And I, I ask that as a, not just a rhetorical question, but something to seriously ponder. Maybe I was lucky. Maybe 99 times in alternate universes out of 100 alternate universes, I died. I don't think that's the case. I think there's something here and I think that is at least a discussion worth having. Sadly, as you probably well know, very few of the critics are willing to actually have a long-form discussion. Yeah. Make some snarky remark and then run away. Yeah. And I think that is also telling. There's a, an old saying that has hung around for thousands of years because it carries so much truth with it, where there's smoke, there's fire. And what we are seeing week after week for 250 episodes, we've had interviews with healthcare professionals and normal patients whose lived experience, I'm gonna use that phrase even though I hate it, contradicts official medical dogma. And the rational response when you walk into your house and there's smoke pouring out of every window is to go look for the fire. And what I've, what I have seen in my own experience and the experience of my family, and the sp- experience of the hundreds of people that have been affected by the work that we're doing here, is the fire and smoke analogy may be a little misleading but if, for example, statins did what they told us they'd do 30 years ago, then Phil wouldn't have a job. Yeah. I mean, the only advantage really- And I'm not a medical professional but I can add one and one together and I'll come up with two almost every time. If statins actually were solving the s- the root problem, then the root problem would go away. And not only has it not gone away, it's worse than it's ever been. In some senses. In some sense, I mean, I think I think, you can correct me if I'm wrong, mor- mortality's gone down, but that again is because of emergency medicine. If you have a heart attack, we're much better at not letting you die in the moment, but in terms of actual morbidity and overall burden of who has cardiovascular disease, yeah, over time, LDL levels have been dropping more and more as we come up with more and more ways to plummet it down, and people still get heart disease because the landscape has changed. There's more people with obesity, metabolic syndrome. Now, you know what will be really interesting? With the advent of GLP-1s and their evolutions, and I think, a focus now on adiposity, insulin sensitivity, I think we're gonna see a changing landscape in what we focus on probably as a function of that, which isn't necessarily bad. I think a large question that I don't have an answer to is- You know we talked earlier about incentive structures. Yeah. How the incentive structures of the system are misaligned with what's best for patients. Th- the question that, is in my mind is not like we're gonna let altruism rule the day,'cause i- in, in a capitalist economy it's not going to. The question then becomes how do we create a system where the incentive structures, the financial, business, economic incentive structures of the system are aligned with what's best for patients? Now, is it... It's possible that the advent of GLP-1s and similar drugs are just gonna do that by serendipity at least temporarily. Maybe. And if so, fantastic for a generation. But how do we keep that consistent where the incentive structure's parallel interests the patients? How do we generate that system? Because that would be a system that is really robust in improving individual healthcare. So food for thought. Yeah, we're... And for... I would say for the first time in a long time, I'm hopeful that maybe we are starting to get there. For instance our RFK and HHS and I think this was just last week or the week before I saw this, that they now are going to have a... A- and it was specific to neuropsychiatric, but they're gonna have a code for deprescribing basically, right? Doctors will be able to bill for and get paid for deprescribing- Huh ... medications. And this was around SSR- SS- SSRIs and psychiatric conditions I saw that. That starts to move us a little bit towards the right direction. There's still a lot of work to be done there. But I'm hopeful that, and again, because of questions that are being raised from the low carb keto community, right? These things are starting to be looked at finally. A lot of work to be done, but I do have some optimism at least. I think we have to be optimistic to some extent. Yeah, I think we always have to be optimistic. And I think more importantly though doctors and patients need to be need to be properly focused on this, right? Again, one of the things that I would say I'm most critical of my colleagues these days about is we've forgotten who we're working for, right? Yeah. We as doctors, we work for the patient. Our goals should all be around, What is going to help the patients. And we've lost that plot line in medicine largely. And the more that we can get back towards that's what I think really starts to turn this around. And again, maybe it's my own confirmation bias, but I see that happening more within the low-carb ketogenic community than I do in the mainstream medical community these days. Yeah. It's a difficult thing for me personally because I'm also very keenly aware of the changing landscape of medicine and the pressures that are on, especially like young clinicians in training, the amount of time they have, like the forces that are pressing them in a particular direction. And the last thing I want to do is have those people who are working so hard to do the right thing feel alienated by creating this us versus them mentality of the metabolic health community's doing the right thing, and you by prescribing medications are doing the wrong thing, because that's not how this divide works. So if nothing else, just take a moment to acknowledge that the system is creating a very difficult situation for the doctor and the patient. I think especially young doctors in training where there, I can tell you from knowing people in my class, in my life, there's a lot of will to always do what is best for the patient and just a very little permissible autonomy. And I'm not a person who's qualified to tell, say what the solution is for that. I just wanna say like it's a privilege for me to be able to talk on these things so openly and directly because of the choices I made. If I had made other choices, I wouldn't be able to, not only because of my time, but because of the amount of trouble I could get in for even voicing all the things I've said thus far, which, maybe they're provocative, but I hope they're pretty reasonable. I try to be pretty precise with my wording and my claims even if they're ex- excited. I think I'm generally pretty on point, but like you said, we've been saying earlier, some of the things are implicitly threatening to the present model, and it's really sad that in medicine there isn't like a meritocracy for ideas. I talked about this with, a lot of people probably know Dave Feldman. He's "If you're an engineer, like you're a junior engineer, you have a good idea, you tell the senior engineer what's up," and they'll be like, "Oh, good idea." Doesn't work like that in medicine. A junior person pushes back, even if it's completely legitimate, you can get in a lot of trouble. It can harm your career. So it puts let's say, the new innovative thinkers in a very difficult position. Yeah, and, again i- it, it didn't used to be that way, right? I, again, obviously I have my bias as a heart surgeon, right? But the story around how heart surgery came to be i- in the history of medicine is just a fascinating one, right? And, it was dogma, right? That there is no way that anyone could ever touch the human heart without killing the patient. And, we look at the innovators and the, the people that led the development of heart surgery, and it really should be a model for how we approach, everything in medicine. And yet, if we had to start from the beginning today and try and establish heart surgery, never would've happened, right? There are so many crazy stories from, just the history of heart surgery and that just there's no way they could ever happen in today's environment. And again, what I see as a clinician is the m- the more we stifle that innovative thinking and the independence of physicians the worse spot we're ending up in. Yeah. What I guess I'd love to hear a little bit more about, your decision-making around, not going down the traditional route, not, continuing on to a residency after you graduated medical school. I think the audience would love to hear, Yeah ... what has led you in the pa- down the path that you're going down now. Yeah, I mean, there were many layers of motivation. I think the thing I needed to push the most against was feeling that I was letting down the people in my life or in some way giving up on what was, quote-unquote, the right thing to do. Because when you grow up in that environment when your entire life is geared towards it, when you've worked so hard to get to a point where it's all supposed to culminate, I mean, which is to, I had a lot of privileges and I acknowledge those. I still worked incredibly hard in college to get a scholarship to do my PhD, to get into medical school, to go through medical school. It's a long road. And the whole idea is then at the end of the road you become a clinician. That is the concept. And there's also a pride one takes in adopting that calling. But to sit and care for people, I mean, is there anything greater, more admirable? And you wanna be that person. You wanna be the person who's "I wanna get up every day and sacrifice myself for my patients." That was the narrative I was told and for some people it's true. It's an incredible narrative. I have friends, I have loved ones who that's what they do. And for me it was interesting'cause I like caring for people, but I was realizing there were different ways to care for people and things that really made me excited. And this is i- it was very hard for me to say the first time, but there was like, I just didn't love patient care. I would end up in a patient room and I'd be thinking about the Nature paper I read that mor- that morning, and I had a terrible amount of guilt for it because I'm like, "This person deserves my attention. This human deserves my attention," but it's also not where I wanna be. It's not where I'm excited to be. Me, Nick, where I'm excited to be. And I realized through what I was doing on the side that there actually is another opportunity here to help people, but do it through my skill set and what I love, which is teaching. To take information, even like basic science, cell science, nature, and get people excited about how their bodies work, and teach them how to take control of their own health journey as a complement to the support they might be getting from conventional medicine. Because that doesn't get serviced. It's something that I wish I had. The power of information, the power of, not to be too cheesy, but curiosity, like curiosity in your own health path, and be like, look, this is hard. Yeah, it's always gonna be hard. My job is not to make it easy for you. My job is to be like, it's gonna be hard, but it can also be a privilege and fun, not a chore, to figure out how your body works and how you can attrea- treat your whole life as an experiment. And what I was finding was, as this started to scale, and people can accuse me of confirmation bias here, but I've decided I can help a lot more people this way, and as a person selfishly be happier doing it. But I actually think there's an alternate path for me as an individual where I can help a lot more people with their health doing what I'm going to do than treating patients one-on-one. Not to devalue that by any means, but it was my personal recognition about what I wanted to do and where I would fit in the evolving sport of medicine. Okay. So that was ultimately my decision. You can imagine it was hard to tell my family my mentors, but once I decided that was what I was gonna do, that's what I did. There was, like, n- nothing left to prove, I proved what I need to prove to myself. I know how to play this game, and I know I'm gonna get some hate for not quote unquote, "completing the journey," 'cause now I've gone from being as inside the insiders as you could be to being on the, quote unquote,"outside," but I'm like... People who know my background know I... it's not that I couldn't do it, it was that this is a very conscious d- choice to, quote unquote, "give up" and that on one path and go on another, but- It was the right thing for me and I guess it took me 30 years to develop... 28, I guess, develop the confidence to make that leap and do what I thought was best for me and for what I can do for the world. And I, now being a year out from school, am tremendously confident in that choice. And some people can hate on it, some people can accept it, but it was 100% the right choice. Oh, I have no question it was the right choice for the public at large. Your skills would be wasted in a tiny little examination room one at a time. You're a tremendous communicator, which is something that is a little rare amongst practicing physicians. It's a gift that you're able to do this. Thanks. Phil, I have all kinds of things I could comment on. Coming at it from the patient point of view I'm a massive fan of what Nick is doing because as a patient, I've sat in too many examination rooms and been treated as the average of an algorithm rather than as an actual human being who has a unique set of backgrounds and circumstances and motivations and pre- presenting symptoms, and I... it just drove me crazy. That's why I gave up on, on the traditional medical community 20 years ago. Yeah. I was tired of not being listened to and treated as a... Yeah. It's too common. I mean, that's where I speak from a place of authority. If y- We were talking about clinical experience earlier. It's "Oh, you don't have clinical experience." But I have a patient experience. Set aside my doctorates, whatever. I know what it's like to be in that position and that's what I'm willing to fight for. And if I need to fight fire with fire and have a little letters and fancy affiliations screw it. Fine. Whatever. I'll use that. I'll use that, but really my motivation and my ethos, my experience is, that happened to me again and again, and it's happened to so many people. And so I, I love teaching, but it's also part of the broader effort to scrap for the right of that person to advocate for themselves in an informed manner. And so where do you see this kind of fitting into the future of medicine? You alluded to that the, doctors... the medical profession were sort of, the gatekeepers of the information in the past, right? No one else had access to it. But we're in a much different era now. Everyone has access to the information, right? That starts to re calculate, I guess, what is the doctor's role in this? What, the information curation, right? Getting that to the patients. Where do you think we're headed with all of this? I think there's gonna be a big uptake in true patient-centered care, not just lip service and individualized care, for the reason you said, which is patients have information, they're gonna be advocating for themselves, they're not looking for gurus anymore, and there really is no option than, other than to service what their desires are and respect their perspectives. Doesn't mean there can't be, like, s- true mutual respect and that patients shouldn't respect their doctors, because they do have training and skillsets, and it should be a teamwork. But I think we're gonna see the rapid demise of paternalism in medicine, which has lasted too long. The funny thing, I'm gonna be provocative right now, is- I s- I see a lot of... paternalism is dying because of the democratization of science, and the f- and there's a certain type of old guard doctor who, in seeing this happen, tries to defend against it by doubling down with more paternalism and arrogance. In effect, accelerating their own demise, and they can't help it, and I see it happening right in front of me, where somebody like a physician on social media will make some snarky remark about the stupid LDL deniers. And I'm like, "You do realize you're losing credibility because people think you're an arrogant dick, so maybe you shouldn't be an arrogant dick. Maybe." They're like how dare you say that? You're my junior." I'm like n- this is the situation we have in. Have the emotional intelligence to see what's going on here and become part of the new ecosystem, otherwise you're going to go extinct." So that is the tough love directive that I can say now because of the choices I make. You can imagine me saying that as an intern. My God, I'd get crucified. But I think that's the matter of fact, and it's gonna pu- piss some people off, and maybe that's necessary. If I were... I am. I would say for the patients, I'd be very optimistic, because n- the power is being shifted into your hands. And I will also just say in parallel with all this are emerging technologies that will enhance individualized care with the combination of AI, bio-tracking technologies. I think we're gonna move towards a lot more personalized medicine. So I am optimistic for the future. I just It's like a slow, large ball rolling in front of me, and I'm just trying to give it some shoves along the way, accelerate it a little bit. I guess that's my duty. I have a friend in the an online friend who operates in a completely different realm of the scientific world who is he's a theoretical physicist, and he has a theory of energy that, Is testable and falsifiable, and has been tested, and is replicable. And he's also flying in the face of accepted theoretical physics for the last 40 years. And because I recognize patterns, I was able to say to him, "You're dealing with a situation that's very common any time you're trying to make a massive change in anything that's got a lot of inertia. First they ignore you, then they mock you, then they fight you, then you win." Yeah. And he is now in the fighting stage. When I met him, he was in the ignoring stage. He's already gotten through the mocking. And I, and I see the same thing here. The l- the low carb diet, when it first started getting talked about, was ignored and we're largely in the mocking stage, and I can see that we're moving to the fighting stage. That's fun. I mean, another way to phrase it is the present sees lunatics and geniuses as the same, and then, history will sort out the difference. I'm not making which claim- I'm I'm not making a claim as to which group I'm in, I'm just saying this is how things operate. People with bold ideas who history sees as the geniuses at a point in time will be like, "You're crazy, you're fringe," and get a lot of hate. Yeah I'm willing to fight for it because obviously I think I'm right. I could end up being wrong, but also that's part of being a true scientist and you you defend your ideas- Yes ... and at the end the data will be what the data will be. And if I end up a laughing stock of history, I will probably die content in the belief that I genuinely did everything I believed was right every step of the way. So that's just how I try to live my life. Hopefully I don't end up that way, but, do what makes you super nice. Yeah. And I think that does, That does hit on a very important point, right? Is that we don't want to fall into the same traps, right? Of the sort of religiosity of just defending o- our ideas when i- if there is evidence to the contrary. And again, going back to your case report, right? And all of this if your CT angiogram showed high levels of plaque, right? That changes the discussion. Yeah. I had a vein on my face. But the fact that it doesn't so far, I think it says that we're, y- you're still on the right path. I was actually struck it was a zero 'cause 'cause, at the time, like this was all coming out, I had talked to the CEO of the company that did the analysis. Yeah, people in their 20 to 30s, like it's pretty common for them to have plaque. And then there were some influencers like Simon Hill, who's also in his 30s, came out. He's like he has 60 millimeters cubed of plaque. I'm like, ooh. So when it was a flat zero, that was surprising even to me. People watched the video, which I released this morning, and I encouraged them to do. You see... I videotaped the moment of my reaction, and I was like, I was flabbergasted. You see me go into the CT machine, get the contrast dye. It's all fun. So I encourage people to check that out. And at the end, I get more vulnerable than I ever have in a video, talking about some of the things we talked about today. So thank you for having me. I do have to jump to my next meeting, but this is a, this was a lovely hour, and I appreciate your hospitality. Oh my goodness, It's been an hour. Time flies when you're having fun. Awesome. Gi- give people the quick where they can find you. Not that you're hard to find, but, Yeah ... we'll have all the links in the show notes. Yeah, X, Instagram, and YouTube, I'm Nick Norwitz. That's N-O-R-W-I-T-Z. No other Nick Norwitzs. I probably put the most information on my Substack now, which is Stay Curious Metabolism. You can find it is now number two best-selling globally in science on Substack, so I'm very proud of that, and that's where we have the most in-depth information coming out. It's also the lifeblood of everything I do. It's financing all of it. If people want the deep dives at least three times a week on all things cutting edge metabolic health, go there. If you want the top of funnel, nice video production quality, totally free within the YouTube channel. Thank you for having me. I'll let you guys get to the rest of your afternoon. All right. For Nick Norwitz and Dr. Phil Ovadia, this has been Stay Off My Operating Table. Thanks for joining us. All the information will be in the show notes, and we'll see you all next time.