# The Cholesterol Code Screening + Panel Discussion with Nick Norwitz & Chris Palmer

## Метаданные

- **Канал:** Chris Palmer, MD
- **YouTube:** https://www.youtube.com/watch?v=tB6i3go2EYA
- **Дата:** 03.05.2026
- **Длительность:** 36:24
- **Просмотры:** 2,405

## Описание

Post-screening discussion with Nick Norwitz, MD, PhD, Chris Palmer, MD, and Dave Feldman at the Boston AMC with a focus on the latest research around metabolic health. 

The Cholesterol Code is a feature-length documentary that challenges conventional wisdom about cholesterol, health, and longevity. Attend a screening near you: https://cholesterolcodemovie.com/host-a-screening/

## Содержание

### [0:00](https://www.youtube.com/watch?v=tB6i3go2EYA) Segment 1 (00:00 - 05:00)

— All right, opening question. This one's for Nick. For clinicians in the room who feel confident in the current cholesterol model, what's the single strongest reason they should be willing to re-examine it? I mean, there's a scientific answer to this question that I could give, but I think everybody that just watched the film the human answers speak for themselves. So, I'm going to tangent off your question and answer the question that I want to ask. wanted you to ask. Or one answer, which is it like when I entered my PhD program in medical school, I had this very cold, raw sense of like what science is and should be. And what I've come to realize is that stories you wrap around it really are part and parcel with how the cold and perfect process of science is executed in the real world. And I think those things need to go hand in hand, so we can talk about the nuances of the data from the what dozen studies we have now. And you know I love to do that hours on end, but at the end of the day it's like people like that who are caught in a rock and a hard place. And you see how much they're struggling and just to say look have the humility to say we are at the boundary of what we know and how can we grapple with these really difficult personal decisions in the absence of perfect or complete data because that's effectively what medicine is. It's making hard decisions with perfect or incomplete data, so that would be my answer. Uh Chris, we often hear quote the science is settled. So, in your field of psychiatry, how often has that statement turned out to be premature? And what does that teach us about humility in medicine? I would actually say in psychiatry, at least in my experience of psychiatry, I have almost never heard the science is settled. Um I hope lipidology is listening up right now. We We in psychiatry, you know, since for as long as psychiatry's been around, I mean, we do our best. We pour our hearts and souls and minds into trying to help people and relieve their suffering. And despite our best efforts, we all have patients who are not getting better. And um it's heartbreaking. And so, I really honestly, I don't think I've ever heard a psychiatrist say the science is settled on like what causes mental illness and how to treat it. Um And so, uh So, yeah, I think in some ways um this film is phenomenal because it's asking tough questions. It's challenging the status quo. The um But the thing that touched my heart from the film is it almost like there are always risks and benefits to every treatment. And when the benefits so far outweigh a theoretical risk of a lab biomarker, it really becomes kind of a no-brainer. And I mean, I think it's great that you included the examples of people who are trying to ameliorate it by eating a sweet potato, a half quarter of a sweet potato. And the benefits evaporate. And then it just becomes a no-brainer. It like the science is not at all settled. Um And I really do want to understand what is the optimal solution for these patients. Like let's follow them over time. And if it isn't what we hope, if they if they aren't fully protected, what should we be doing? Should they all go on statins? aggressive other types of medications? Like what should we do to optimize their health? But for right now, I think the clear answer, like Robin's story and so many of the patients that I see, it's a no-brainer. And the good news, I just want to say for those of you who don't know, the overwhelming majority of people who do ketogenic therapies are not lean mass hyper-responders. Their LDL does not skyrocket like this. The majority of patients I see, the LDL comes down because they're all overweight or obese. Like across the board, their heart health and the risk for heart disease improves. That's actually something I hope came through in the film because even though we're focusing on a number of people that are lean, we're focusing we're pointing out that

### [5:00](https://www.youtube.com/watch?v=tB6i3go2EYA&t=300s) Segment 2 (05:00 - 10:00)

our own research that we've published actually shows exactly what you're describing. That many people who are adopting a ketogenic diet, whether it's for uh mental health efficacy, typically are those who are much more obese. And so, the fact that so many worry about what's going to happen to their LDL cholesterol, I like that we're at least highlighting that as well. Well, I think that actually speaks to like what a obstacle this is and why that question needs to be addressed. Because if the fact of the matter is if most people go low carb, every single heart health biomarker including lipoprotein particle counts improve. But that's not the prevailing narrative. The prevailing narrative is if you go keto, your LDL will go up. So, the minority drives the narrative because it's something that is that feared, which means it's an even more important question to tackle. Well, and it goes along with bias because the bias is if you're going to eat a lot of fat, it must be bad for your heart. And so, the people who buy into that dogma and bias are looking for the examples that support their hypothesis and then they rationalize away and marginalize the examples that don't support the hypothesis. So, when I say I have an obese bipolar patient who not only put their bipolar disorder into remission, but also lowered their LDL cholesterol, raised their HDL cholesterol, lowered their triglycerides, lowered their blood pressure, lost a lot of weight, and improved their insulin resistance. They just ignore that. They're like, "Oh, well, that's just an outlier. " — Because you can't be eating all that fat and do all that. Like it's just around the corner. Just wait, Chris. Give it another week and then it's going to the shoe's going to drop. Then their LDL's going to spike. Then their heart attack is going to happen. And it's like, "Well, really? Like this person's life was decimated. — And you really just out of theory, you're terrified of this diet. " If the science is settled is the least scientific thing I've ever heard. The second least scientific thing is they're just an outlier. Because how many times in history have we learned the most from the outliers including homozygous familial hypercholesterolemia, which won what was it? 1985 Nobel Prize? Like we always learn the most from looking at the outliers. So, if you have an outlier patient who has that dramatic response, it's like, "Well, what happened in them? And how can we replicate it learn from it? " Which is the thesis behind the film. It's not that everybody's going to be a lean mass hyper-responder. It's that this is really interesting. And it needs to be pursued because there's something here, an answer that could unlock like information that could help tens of millions of people. Because the fact of the matter is like whatever your model of what really causes heart disease and what's most important, we've spent billions in research resources trying to tackle this from one angle for half a century and it just worked abysmally. So, is it so extreme to consider we might be barking up the wrong tree? One of the challenges that I think you kind of bring to light. And for somebody like yourself who's directly treating patients with these kinds of disorders is that you're actually seeing efficacy in the right now, right? In the immediate. But that concern of cardiovascular disease down the road is of such a high degree that it is fascinating for people like Robin Dobbins to be, you know, actually trying to do something about it, finding out it's not working, and then having to make that choice now. They're all waiting for this research. They need to get that data coming back. Do you think that there's going to be a wider embrace eventually and not just your field, but also just with many of your colleagues to consider this particularly given a lot of the immediate benefits that you're seeing with a lot of the research you're doing now. So, so I would say that the selling this to psychiatry, at least in my mind has not actually been that challenging. And I I think there are a couple of a few reasons. One is that you have to compare this treatment to the standard of care. And the standard of care right now are antipsychotics largely for bipolar and psychotic disorders. I mean, some patients with bipolar disorder don't necessarily end up on long-term antipsychotics, but many of them do and that becomes their mood stabilizer as well.

### [10:00](https://www.youtube.com/watch?v=tB6i3go2EYA&t=600s) Segment 3 (10:00 - 15:00)

well. And we know that those standard evidence-based treatments come with significant risk for impairing metabolic health. They weight gain and oftentimes massive weight gain. Um like 50 lb, 100 lb, or more. Um and a worsening of LDL cholesterol. And an increase in triglycerides, and a decrease in HDL cholesterol, and a worsening of insulin resistance, and new onset type 2 diabetes. And we in the field of psychiatry have never been happy about doing that to our patients. We've never We've never felt great about the treatments we're offering. But we have felt like we're between a rock and a hard place. This human being is going to die of their psychosis and erratic dangerous behavior if we don't calm their behavior with these medications despite all of the risks and all of the side effects complaints from the patients and the suffering that they say these medications and treatments induce in them. This makes me a zombie. I can't think straight. I'm getting fat. I hate this. Please don't make me do this, doctor. And we implore the patient, "Please just comply with this treatment because this Otherwise, you're going to die. get manic and psychotic and you're going to do something really dangerous and erratic, and you're going to end up dead, or homeless, or something. Like something horrendous [snorts] is going to happen to you. " And so, we've long accepted metabolic risks with treatments. So, that part of the story isn't too hard because I can say the ketogenic diet's going to help your patients lose weight and improve almost every other metabolic biomarker, and LDL at most usually might go up a little. Other than a lean mass hyper-responder. And again, for the most part I have had almost no lean mass hyper-responders in my practice. Matt Baszucki, I consulted to him. He's not officially my patient. He's the closest that I get to a lean mass hyper-responder, and otherwise, I haven't had any. And um but the other thing that we can do in the field, and that everybody can do is there is this risk calculator for cardiovascular disease from the American College of Cardiology. And shockingly, if you don't know this, it includes more than just LDL cholesterol. It really does. And you're supposed to plug in these numbers, and it will tell you the risk, the 10-year risk for a heart attack. — [snorts] — And the overwhelming majority of people doing ketogenic therapy if you do a before and a 6-month after ACC 10-year risk of a heart attack it goes down. The Virta trials demonstrated this time and again, even though in the Virta trials, the LDL cholesterol did go up slightly, everything else improved dramatically, and the risk for a heart attack went down. And that is evidence-based American Heart Association endorsed science. That is the current evidence base. And why would we look the other way? Why would we not use gold standard evidence-based cardiology to assess risk? And again, with a lean mass hyper-responder, I haven't plugged in the numbers. I don't know how that — would — the calculator. Yeah. You can't put me in that calculator. I'd break it. — I'm not kidding. You think okay, Mike, these calculators are not trained on — of things. Nick does break a lot of things. — Actually, this So, this was a This was actually the next question I was going to have for you because uh at the end of the film, we're seeing the assessment of everybody toward the end, especially where they stood with their own scans. The scan that you got it spoiler alert, when we did the filming, it was 3 and 1/2 years ago, something like that with Nick. — have even more. It was like over 2 years into starting a ketogenic diet. Yes, but it had even been a little ways from when you had gotten your scan completed. And the interesting thing is you've just

### [15:00](https://www.youtube.com/watch?v=tB6i3go2EYA&t=900s) Segment 4 (15:00 - 20:00)

now completed another scan. That's actually going to be coming out soon. So, you're not only an example within the film of the researchers, the three of us, the three that you saw at the table you have the highest LDL of all of us. And you are in fact publishing that coming soon, right? The case report is under review. 7 years, cholesterol 700. So, we'll see what the data say. And we did get AI quantification, so they'll be down to the lowest millimeter cubed the results. And uh I'm a terrible liar. So, if you see a smirk on my face you can just probably into it what the results might be, but I'll uh I'll let the number drop when the number drops. But you would say what Let me ask you this. As far as the film goes we wanted to be sure that the doctors who were portrayed in the film, who do have an opinion that they would consider to be nuanced, we wanted to be sure that we portrayed their opinion fairly well, which is that for many of them that we filmed, they would say, "Hey, if your LDL goes up on a ketogenic diet then the next most important step is imaging. " You getting back to the mammogram of the heart if you've got CAC. However, many of them would take it a step further and say, "If the imaging didn't came back it didn't come back very well you may want to consider taking that a little bit more seriously with regard to what steps you take. As far as what steps it is that may be different from one doctor to the next, but certainly a lot of doctors I know that are low-carb may then in that scenario consider taking steps with regard to um certain therapies. Is that your opinion? Yes and no. You know, with me and everything nothing is ever that simple. I guess it's better to have that triage point of treatment of we're going to look in your heart. Is there disease? If there's disease, then you have less buffer room, let's treat it. It's better than the triage point of here's a lipid cut point, now we're going to treat. But as always, I think it's more complex and web-like than any sort of linear cascade, and I realize that's hard to operationalize in a medical system. Um where I'm going with this is there are so many different like treatment modalities for an individual that I think can optimize their overall health. And one of the themes of the film, and what Chris are just speaking to, is that like it is about the whole person. How does a treatment regime fit in to their overall health regime. So, like I've been experimenting with not statins, but other what are classified as cholesterol-lowering drugs for not even a reason that has to do with cholesterol, but for other things that they can do in my body. I think we get very locked into what is the first triage point and then treat or not treat, rather than going from uh what are all the risks and benefits of this treatment in this individual given all the factors, one of which is a cardiac scan. But only one of which. Sorry, that's a little bit of an indirect answer, but these things aren't meant to be simple, and I think people want a simple heuristic to go off of, rather than just immersing in the hey every single case is going to be complex, and we need to take everything we know to make a case-by-case decision. Uh especially when the data are incomplete or imperfect, but then we need to figure out what those gaps are and fill them in a nuanced manner, which this study is doing with respect to a particular population that just hasn't been studied. There is a kind of an interesting footnote to it, which of course, our own data, in order for you to see plaque regression there had to be existing plaque. So to an extent, some number of our participants do have plaque, do have disease, but then actually saw a only and we only wanted to feature those who had confirmed plaque regression. So, hats off to the team to confirm it directly. We don't want to just go by the numerics. But that proved to be rather important. One of the really important things about the findings that especially on social media gets overlooked is like again and again every single analysis, and there were at least four, there was no relationship between LDL and apoB and plaque progression. None. And this was the study with the large the single largest LDL and apoB spread of any prospective imaging study ever. And there was no relationship. So, the assumption is this is the thing that's driving plaque progression if there's progression, and that's assumption falls apart here, too. And there's signals in the literature as well that like we might be misattributing benefits of treatment to LDL and ApoB. If you actually look at meta-analyses of the statin trials, where there are improvements in

### [20:00](https://www.youtube.com/watch?v=tB6i3go2EYA&t=1200s) Segment 5 (20:00 - 25:00)

cardiovascular outcomes, there are. If you look at what is the correlation between how much LDL goes down and what the improvement is, sorry to get a little bit statistically and technical, but the R squared is 0 to 0. 1, which is basically like no relationship. It's terrible. So, again, to the theme of there's more going on here in metabolism and physiology than oh, there's one biomarker and we snapped our fingers, gave a medication, and moved this thing in isolation. That is not happening, but that is the narrative that has, I think, been perpetuated. That this is the central thing we need to modify and toggle to change your risk. Yeah, that And bottom line is this, we already know, and we were chatting about this a little bit offline before, we already know that at least the association of change with an intervention, going back for example to the 4S trial, attenuates the more that you have greater and greater metabolic health. So, ironically, an intervention to do something, the only one that we have that's fairly broad for an association, didn't have that much benefit for those who are more metabolically healthy. So, in my opinion, the takeaway seems to continue to be if you fix your metabolic health, you get less benefit because of how much benefit there is to the metabolic health itself for the potential benefits that you could look at. Sorry, I probably butchered that a little bit. But, getting back to the intervention, you know, Chris, I just to get personal for a second, part of why I was so excited to for you to be seeing this for the first time here is I thought about you a lot when we were putting this film together cuz I kept thinking I feel like this is something Dr. Palmer in particular would probably like this would resonate a lot because people don't see the personal stories in the same way. Something that you did that I still remember very vividly, the first time I got to watch you talk, you brought on a patient. Do you remember that? At Metabolic Health Summit. That's right. Yeah. So, I don't know when you first saw me, but that's the that must have been the That was it. It was the first time I'd seen a speaker basically for their talk bring up a patient, talk be interview them, but also in a way that could in a more visceral sense bring their story to life for everybody in the audience. And again, we need to do it all, right? We need to get we need to do the science, we need to get as big a populations as we can, etc., but the personal stories are what connect us, right? And I thought about that a lot when we were putting this film together. Uh another hats off to Jen Izenhart because when we were first like talking about putting this film together, in my mind I was like, yeah, like 70% of this is going to be getting into the lipid energy model and getting into all the other aspect and more and more, no, it the personal stories carried the weight, right? Of what this really is at a deep ground level. When you're actually watching the family members talk about it along with the patients, you really get it. You get how truly real this is for them. It's not just numbers on paper. You know, I would I guess the reason I am Is the mic on? Here, let me just Thanks. Um I think, you know, I think the reason that I'm so passionate about this work and I guess the thing that emboldens me to do this work with such confidence is that um again, in the mental health field, like I really don't I've never really had the privilege of working with the worried well. — [snorts] — I don't I don't get like people with their first episode of depression and they go on an SSRI and it works beautifully and I don't get those people. I get people who have been suffering for years or decades, who have tried dozens of medications, who have tried electroconvulsive therapy, who have tried ketamine, nothing works and then they come to me. And and honestly, we in psychiatry use treatments that like I was saying before, we're not really happy with the side effects that we are delivering. I don't think most psychiatrists are really thrilled about the fact that we still apply electricity to people's brains in order to relieve suffering. We're definitely not happy about making our patients gain 100 lb.

### [25:00](https://www.youtube.com/watch?v=tB6i3go2EYA&t=1500s) Segment 6 (25:00 - 30:00)

But, we do those things because we see just profound despair. Just absolute it just it really is just absolute hell for people. And so, we use desperate measures for desperate times. And when the ketogenic diet can stop that kind of suffering and help people lose weight and help improve so many other biomarkers, I really honestly just don't give a about LDL cholesterol. I just don't. Like, how on Earth could anybody get worked up about LDL cholesterol when you can relieve suffering, turn somebody who is suicidal and disabled into somebody like Robin, like we saw, I now have a relationship with my children for the first time ever. And her own kids are saying, I didn't know my mom before. She was always depressed and bipolar. Like, how on Earth would anybody want to stand in the way of this treatment? Does that mean we're done and no more research? No. I like I am so grateful for all of the research you're doing because again, we let's optimize it. Let's try to have our cake and eat it, too. Keto cake, of course, and eat it, too. But, um but so let's realize full health potential of ketogenic therapy and help them live long, healthy lives and not have cardiovascular disease. And let's explore the science to figure out what biomarkers do matter and what can we do about those biomarkers and what should biomarkers. But, um but yeah, I mean, this work for me has always been about humans and people who are suffering and trying to relieve their suffering. Um we're getting a little mic swap here. One more question. This is one that was brought in and this is on one of the cards. I think it's actually a good one. This is for both of you. Cholesterol is often tested every year at patient annual exams, but fasting insulin is rarely tested unless requested by a patient and I'll just say that that's sometimes that doesn't happen, either. Why is that? And how important is fasting insulin for a clinician to assess a patient's metabolic health? We'll start with you, Nick. I mean, I think the question as to why is because of the incentive structures that we've built and the business models. And to be clear, that's not pointing fingers at anybody. That is just the reality of the world we live in. We have a marker. We have an industry that is built around treating that marker. That marker is assumed to be a causal risk factor. So, easy win. Prescribe. Everyone's happy. And it's based on the evidence, the strongest evidence. And I put quotes there because I think one thing I've come to learn is that evidence-based medicine does not mean the most effective medicine. It means the medicine that has had the studies done that have checked the boxes because we've been willing to fund those studies because there's an industry around them. So, that's the answer. It's the easy win with the incentive structures built around it. A fasting insulin is arguably a better marker of cardiovascular risk. We saw the one graph in the paper about lipoprotein insulin resistance, which is kind of a proxy, a much, much larger um risk association with cardiovascular disease. But, what is the solution? It's not a business model around that. It is changing your lifestyle. Maybe there is now with GLP-1s, so we'll actually, it's an interesting case to see how this will change where the spotlight of medicine goes now that there is a business model around it. I have my own predictions. Um and that's not to say any of these things are good or bad, but I would just want to emphasize like the things that get tested and treated are not necessarily the things that are the most important for the patients, so the things that the business models, the incentive structures are directing the spotlight to. And we're all caught up on that. When I say all of us, I mean scientists, patients, physicians. And it's something that I think is a unifying battle, but in order to properly fight that battle for the betterment of person's health, we just need to acknowledge what the problem is. And one of the problems is I think a dysfunctional incentive structures where the interests of a medical system and the interests of doctors and their patients aren't actually aligned and science for that matter, good science.

### [30:00](https://www.youtube.com/watch?v=tB6i3go2EYA&t=1800s) Segment 7 (30:00 - 35:00)

Insulin for me. So in um in the clinic that I'm now running, we actually routinely test insulin. It has to be tested with fasting glucose and then you can plug those two numbers together in to get what's called a home IR which will give you a rough measure of insulin resistance. Um because just a fat an insulin on its own isn't necessarily going to tell you the whole story. Um So I actually think because we don't currently have a simple treatment for it, that probably is one of the reasons why we aren't testing it as a biomarker. I will say with GLP-1 receptor agonists, I won't be shocked if 5 years from now everyone is testing insulin and glucose — and that becomes an indication for a GLP-1 receptor agonist. Um because there's strong reason to believe that they will improve insulin signaling um and reduce insulin resistance. And that is a well-funded pharmaceutical machine right now — and uh they are taking over the world. So um So yeah, they will have a vested interest in making sure that otherwise healthy-looking people might want to get their home IR tested and then they automatically become a candidate for a GLP-1 receptor agonist. I actually have an open question that I kind of throw to you guys and just so many brilliant medical people in the audience just to think about which is there's this suspiciousness that arises even as you're talking for me which is like what is the motive? And it's like okay, there's a financial industry behind this so it's not surprising if now given GLP-1s, people are testing glucose and insulin more and that becomes a focus. To be clear, that's not a bad thing. I don't think any of us are saying that is. This might even be a case where metabolic health and the pharmaceutical industry align in a manner that is now like industry and true health are parallel. The question is how do you actually build a model where the incentive structures and patient health are always parallel rather than becoming, you know, obtuse perpendicular because I think that's kind of where we are now and maybe by serendipital serendipity we'll realign, but like how do you make it so we're always on parallel tracks? And I don't have an answer for that. That's like an open question that spins around in my mind. But yeah, I but I would say the solution to the world is not to test everybody's home IR and then put them on a GLP-1 receptor agonist. The solution for the world is to understand why is why are so many people in the world metabolically unhealthy? What is driving that? And what is it in our environment that is driving that cuz it's not genetics. And um and then addressing that and of course that is a probably multi-billion dollar or trillion dollar problem because there are massive industries set up delivering whatever it is, whether you want to go with ultra-processed foods, those of you who like environmental toxins, like it take your pick about what's driving it, but whatever those things are, they are massive industries that are not going to easily change and that even the highest levels of government aren't willing to take on and try to challenge because it will cost a lot of money and it will be quite disruptive. I'll give my one answer and then I'll wrap this real quick, but yes, my answer is I like to compare this a lot to smoking of 60, 70 years ago. You talk to people back then, they did know smoking wasn't good for you. It just was minimized. The harm was minimized. So people would regularly say things like, well, yeah, I know I shouldn't quit, but uh my doctor smokes more than I do and everybody in my company smokes and we're all I mean, yeah, of course it's not perfect, but I'm not a health nut. And so in effect, I feel like the food environment today is the smoking of 60, 70 years ago. It's too minimized. And what really changed it wasn't as much of the broad policies as it was a cultural shift. Sometimes you cannot count on the government and the businesses to jump in front of the culture. The culture is it has to be something that us together, it has to be grassroots

### [35:00](https://www.youtube.com/watch?v=tB6i3go2EYA&t=2100s) Segment 8 (35:00 - 36:00)

that we look more and more at things like the chain which GLP-1 making metabolic health suddenly become useful to assess. Why? Because now there's a business model attached to it. Okay, let's be aware of the data in front of us that in that what it takes for them to become interested in metabolic health is for there to be some kind of you know, model behind it to make it better. So with that, I want to get a show of hands. How many of you remember what my call to action was from earlier? Okay, good. Good, I only have one more thing that I want to add to that which is if you wouldn't mind, right outside the door is what they call a step and repeat. It's kind of like a cool little background and they're collecting a few interviews. So if any of you guys want to add your thoughts, I'm sure they would love to have them. We have room for a few more, right? That would be great. We'd love to hear your thoughts on the film and could you give one last round of applause to our fantastic panelists here? — We so appreciate you watching this film and I hope you'll share it with everybody you know. And once again, thank you for coming. — Great job. Thank you.

---
*Источник: https://ekstraktznaniy.ru/video/51376*