2011-03-10 Joe D. Goldstritch MD Integrative and Preventive Cardiology in the 21st Century – 50 Years of Clinical Experience
50 Years of Clinical Experience
An Interview with Joe D. Goldstrich, MD
March 10, 2011, By Kirkham R. Hamilton, PA-C
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KIRK HAMILTON: Hi, my name is Kirk Hamilton, your host of Staying Healthy Today. Our message is simple: To provide you credible usable health information from interviews and our educational resources to help you Stay and Be Well in the busy modern world. Please take a few moments before or after listening to this interview to browse through the Prescription2000.com website, the home of Staying Healthy Today Radio, for our free educational services.
Today's show topic is "Integrative and Preventive Cardiology in the 21st Century. 50 Years of Clinical Experience." Our guest today is Joe D. Goldstrich, M.D. a board-certified cardiologist who has 50 years of clinical experience, has authored five books, and specializes in integrative cardiology combining diet, nutritional supplements, and selective pharmaceuticals.
Welcome Dr. Goldstrich. Thank you so much for coming on the show today.
DR. JOE D. GOLDSTRICH: My pleasure, Kirk.
KIRK HAMILTON: Well we go way back to the Clinical Pearls days and I was always impressed by just your interest in nutrition and as a cardiologist. But if you could go backwards a little bit and tell us about when you got into medicine, what kind of steered you in your journey towards cardiology, and then towards nutritional approaches to cardiovascular problems.
DR. JOE D. GOLDSTRICH: Well I was interested in cardiology because a lot of members of my family had cardiovascular disease and I was drawn to that. But once I started my training as a cardiologist, I didn't like it so much. I didn't like sticking tubes in people and poking their femoral arteries and I always felt nervous when I had a catheter inside somebody's heart. So I didn't really like being a cardiologist once I got into it. So I opened a practice and saw patients for a couple of years. But when the American Heart Association moved their corporate office from New York to Dallas where I was living and practicing the individual who was heading up their prevention program, what's called Education and Community Programs, that person decided they didn't want to leave New York. So there was a position at the American Heart Association who was moving their corporate headquarters to Dallas. And I had been active in the local heart association so I applied for the position and much to my delight I was selected to be the National Director of Education and Community Programs for the American Heart. So that got me truly involved in preventive cardiology. And I did that for a while and then I had a personal situation with my marriage. And I always had a dream to go back to California. And so when my marriage ended I packed my bags, I bought a pickup truck and put a camper on the back and headed for California.
KIRK HAMILTON: Let me ask you one thing just before you leave Dallas, Texas here. The American Heart Association at that time, what were they preaching as far as prevention? And you could give me a year, because I know you've been practicing cardiology a long time. I don't want to date you...
DR. JOE D. GOLDSTRICH: Well they were actually doing the best that they could. The nutrition department, there was a woman who had a PhD, her name was Mary Winston. She had a PhD in nutrition and she read the literature and she organized nutrition for the Heart Association. She had some of the most respected researchers in the field who were on the nutrition committee which I helped staff. And the American Heart Association was doing the best they could to provide solid nutritional information to the public.
KIRK HAMILTON: And at that time, Dr. Goldstrich, what year was that? And then were they just saying cut down your meat intake to lower your saturated fat? Was that the big message then?
DR. JOE D. GOLDSTRICH: Pretty much. Pretty much. That was, that would have been 1973, ‘74, '75. And it was the healthy, it was a healthy diet. So when I got to California and I had heard about Nathan Pritikin because he was advocating this semi- or almost completely vegetarian diet that shouldn't have any fat at all in it. He was totally against fat. I had seen him on 60 Minutes and I had seen these patients who were reporting these benefits that their angina was going away when they adopted his diet. Now I had seen lot of patients with angina in the couple of years that I practiced and during my training and I never saw anyone who made a dietary change have improvement in their angina. So when I heard what Pritikin was doing I thought, well you know if he can do that I want to do that, too. So I went and knocked on his door one day at his office and told the receptionist that I wanted to see him and she said, "Well who are you?" And I said, "I'm Dr. Goldstrich." And the word just came out of my mouth, I don't remember hearing it before that, but I said, "Tell him I'm a preventive cardiologist."
KIRK HAMILTON: I gotta tell you, Dr. Goldstrich. Here's the one great thing I just want to give you praise for is that you know most physicians wouldn't travel somewhere to meet a non-physician. If I'm correct, he was a engineer, Nathan Pritikin.
DR. JOE D. GOLDSTRICH: Right.
KIRK HAMILTON: And ask advice about how to treat heart disease. So I give you tons of credit for just being a caring and interested student of health. I mean that to me, I want to give you a pat on the back for that. But anyway, keep going with the Pritikin story.
DR. JOE D. GOLDSTRICH: So she called him up. This was in Santa Barbara. And the clinic was down at the coast in a hotel where people came and stayed, and Pritikin lived in Montecito which is the fancy part of Santa Barbara. So she called him up and said there's a guy here. His name is Goldstrich and he says he's a preventive cardiologist and he wants to talk to you. So Pritikin said send him up. So they gave me directions. Now I must tell you at this time I was still a smoker. I knocked on Pritikin's door. He smelled the smoke on me and this beautiful house up in the hills in Montecito and he was a crafty guy. So what he did is he invited me into the house and then he said, "Let's take a walk." So we went out into the backyard and there was a big huge backyard and there was like a trail there. And we started walking and he started to pick up the pace and I wasn't exercising at the time and I got short of breath trying to keep up with this skinny little guy who was walking me around his backyard. And it was after I met Pritikin in the coming months that I decided I would stop smoking. That I would make that commitment that it didn't serve me to promote health to others and ask other people to stop smoking if I were still a smoker myself. So I stopped smoking that next year.
KIRK HAMILTON: How impressed was he with a preventive cardiologist announced who was smoking?
DR. JOE D. GOLDSTRICH: He really - you know he was quite open. He didn't approve of it. But he approved of me and so he accepted me. And what he did is he said, "I want you to see the improvement that's made on this diet so you have free access to all of the research, to all of the files, all of the laboratory work. So go over it and tell me what your conclusions are." And in the process of doing that, I discovered that he was anemic and that led me to ask him about his anemia and if that was due to the diet because the diet was deficient in iron. And he said no, he said that's something else. He says I've had a chronic leukemia and the anemia is the result of that. And he told me the story about how he had been irradiated for a skin condition many years previously and he thought that was the cause of his leukemia which was in remission. And didn't require any medication and he had a hemoglobin, as I recall, around 10 and a half.
KIRK HAMILTON: Well that's interesting. That's how you and I got back in touch because I saw a blog about you writing about how Nathan Pritikin died. And was it due to his diet or was it due to his leukemia or combination thereof? And your answer was in that little blog, in your opinion?
DR. JOE D. GOLDSTRICH: Well he went to UCLA to get an opinion about his leukemia and they were convinced that it was a hairy cell leukemia and that he should take the chemotherapy of the day that was supposedly effective against hairy cell leukemia. And he did that and he got really sick from the chemo. He had both liver and kidney failure and lost about 30 pounds. He was a skinny guy before he lost any weight and he really couldn't afford to lose any weight. But he lost about 30 pounds, his liver wasn't working, his kidneys weren't working and he went to Albany, New York under an assumed name for a second opinion. And they told him that he would surely die within the next six months and that there was no hope. And so he sent his family away and sent them out to dinner and when his family came back he was gone. Then the family, I think because it was a suicide, he had to have an autopsy. It was mandatory. I'm sure he would have wanted one anyway. But the autopsy showed that his coronary arteries were totally clear of atherosclerosis. He had no plaque whatsoever. And that was published in the New England Journal and in that blog that you read I gave the reference, the exact day which I don't recall off the top of my head [NEJM, July 4, 1985;52].
KIRK HAMILTON: Well let me just stay on Pritikin because it kind of leads us into the next conversation. But where he did get the idea of a no-fat, low-fat vegetarian diet that might help reverse atherosclerosis?
DR. JOE D. GOLDSTRICH: He was an engineer. Many of the patents, and he was quite well to do as a result of his patents. He did the research and the engineering on many of the instruments that went up in the early weather balloons. The barometers and other paraphernalia that went up, those were his inventions. And so he was - he knew how to research a subject. Now in your interview with Dr. Castelli, Castelli mentioned when he was in Belgium that when they did autopsies, the senior pathologist made the comment that "it's coming back." I believe those were the words that Dr. Castelli used. And what they were referring to was the atherosclerosis when the autopsy was done. Pritikin was aware of that same phenomena. He was aware that during World War II when people didn't have enough to eat and there weren't enough calories and there was significant weight loss and normalization of weight that the atherosclerosis went away. So he got the idea that, one, cutting calories would be important, and it turns out that it's very important for longevity, not just for cardiovascular disease. But he thought - I'm not sure whether he thought that, if I tell people to eliminate all fat, they will most certainly eliminate the saturated fat. Or whether he believed that all fat was equally detrimental to the heart and to the arteries and caused atherosclerosis. I'm not sure of that, but he knew the saturated part, but to lead to all fat, I'm not exactly sure how he got there. Well I remember, he showed the patients. He had a movie that was made of the capillary blood flow in a hamster's pouch, the buccal pouch of a hamster. And in that video it showed the red blood cells moving through the capillaries and then the hamster was given a fatty meal, maybe cream, and then what happened was the red blood cells stuck together. And Rouleaux formation occurred and the circulation almost came to a halt. And Pritikin believed that because the red cells deliver oxygen to the heart that fat caused sluggish circulation and that was responsible for the angina, and that if you eliminated the fat then your red blood cells wouldn't stick together and you'd have the ability to deliver more oxygen. And I remember that's how he came to that opinion. And I remember him being - he didn't allow nuts in his diet. And I remember one day he showed me this letter from a patient who had gone through the clinic and their angina had gone away and the person - it was in the Fall, and the person wanted to eat some fresh walnuts. And he wrote this letter to Pritikin saying that after eating three or four walnuts his angina came back. And so Pritikin used that as an argument to support the fact, that the fat in those nuts was enough to make this person limit their oxygen delivery to their heart muscle because nothing else had changed. And when they stopped eating the nuts the angina went away again.
KIRK HAMILTON: Yeah. I'd like to move from Pritikin. I think it's a fascinating story, Pritikin's life. But I want to ask one more question and then I want to move through and get to some of the other topics in cardiovascular disease. When you were director there, did you see results in a majority of people who stayed on the program?
DR. JOE D. GOLDSTRICH: Yes. Absolutely. They all lost weight, their LDLs came down and most of them who came in with angina could do more exercise and have less chest pain with more exercise than when they came in.
KIRK HAMILTON: What were the frequent side effects?
DR. JOE D. GOLDSTRICH: Some of the people who came back for refresher courses six months or a year later, I saw some people that had what appeared to be some fatty acid deficiencies. Dry skin and some rashes, but that was the only adverse effect that I saw. And then later on about seven or eight years down the road Pritikin included one salmon meal a week as part of his diet because he recognized that there was a need for essential fatty acids that was being neglected. So he actually made that recognition and incorporated it into his diet.
KIRK HAMILTON: Well then let's move on then because now we're opening up a whole world. I just - that's a fascinating topic to me is Pritikin's life. And now would you approach a cardiovascular disease patient, and a lot is made to do and I sent you the information or the interview you know with regards to Castelli. But how do you evaluate cholesterol and lipids in your cardiovascular risk patients and what importance is it?
DR. JOE D. GOLDSTRICH: Well I'm still in part or in a large part from the old school. I still think that cholesterol matters. I know there're a lot people going around saying cholesterol doesn't matter, it's not important, it's all about inflammation. Well inflammation is the mechanism by which the cholesterol gets incorporated into the plaque. But if there's no cholesterol around, there's not going to be any plaque. That's in part what happened in those people in Europe who weren't eating during World War II. So I like to get the most sophisticated evaluation of the cholesterol that I can and I either use an NMR profile or a VAP to give me more than just the LDL, triglycerides and HDL and total cholesterol. I like to look at particle size. I like to know if they're small dense LDL. I agree with Castelli the large particles of LDL still cause atherosclerosis, they just don't do it quite as rapidly as the small dense particles, but they are important. Many people with familial hypercholesterolemia have large particles, not small, and they still get significant amounts of atherosclerosis. So I like to get that - and a test maybe we could talk about for a few minutes, that I think is not talked about very much and I think is very important is the apolipoprotein E status of the individual.
KIRK HAMILTON: Let's do it. Tell me.
DR. JOE D. GOLDSTRICH: Okay. So we have two alleles of apolipoprotein E and there are three kinds of Apo E. There's type 2, type 3 and type 4. And we have two alleles, each individual has two. And most people, about 65% of the population are 3,3. There are some people that are 2,2, there's 2,3, there's 4,4, there's 3,4. And the people that have 3,3, which is about 65% of the population, they seem to be able to eat more fat than other people without raising their LDL cholesterol. Whereas people that carry the 4 allele, either one occurrence of it as in 3,4 or in double occurrence as in 4,4, those folks seem to get huge increases in their LDL, especially their small dense LDL, when they eat fat, especially saturated fat, but all fat seems to play a role. So I think that many of the people at Pritikin probably were Apo E4 because the ones that got the best benefit, the best bang for the low fat diet, are those that have Apo E4 alleles. So I think it's extremely important to measure that in the initial evaluation of the cardiovascular patient because it totally determines what their diet's gonna be. So there are people that can eat coconut and use coconut fat and their HDL goes up, and their LDL doesn't go up very much, and their ratio of LDL to HDL improves. But there are other people that when they eat fat, their numbers just go totally bad, and so I think it's important to know the Apo E status of individuals.
KIRK HAMILTON: So let's talk about, I know an area dear to your heart is nutritional pharmacology and evidence-based medicine. You want to talk about how you use nutritional supplements in cardiovascular disease patients, and you can start with I guess lipid management and then go to heart function.
DR. JOE D. GOLDSTRICH: Let me just go back and say there are two supplements that people who carry Apo E4, which is 25% of the population, two groups that don't do well with fish oil. The maximum amount of fish oil that someone who's an Apo E4 carrier should take in my opinion is 500 mg of EPA plus DHA. An absolute maximum of 1000, but definitely not more than that because their lipid numbers will deteriorate if they do. And the other supplement that Apo E4 carriers shouldn't take is quercetin, because the quercetin will lower the HDL of Apo E4 carriers. So I am an Apo E4 carrier. I only discovered that in 2007. And at the time I was taking 3 to 4 grams of fish oil a day and my numbers just went out the roof. I couldn't understand why everything was going bad because I was doing so many good things for myself. And when I made that discovery and then learned about fish oil and its effect on those with Apo E4 I cut down and the improvement was dramatic.
KIRK HAMILTON: Let me ask you then if you can just quickly kind of give me the synopsis of your target numbers for like cholesterol, LDL, HDL, the ratio, and triglycerides. I'm just curious.
DR. JOE D. GOLDSTRICH: My target is get the LDL as low as you can without having any neurological issues. Get the HDL as high as you can and that's the target. Just keep tracking those values and doing experiments as required to see what you can do to get the LDL as low as possible and the HDL as high as possible. One of the things that you get from a VAP is that you get an Apo B which - an Apo B lipoprotein is carried on all the LDL. And all the atherogenic lipid molecules have Apo B. And all of the HDL molecules have Apo A1. So one of the things you get on the VAP is an Apo B to Apo A1 ratio and it's the same thing as the total cholesterol to HDL or the LDL to HDL. They all reflect the same thing. I believe the Apo B to Apo A1 is the most sophisticated of the ratios and you want that ratio as low as possible. In the ASTEROID Study which was a Crestor statin study which was done at the Cleveland Clinic, they saw reversal - they used intravascular ultrasound to look at the atherosclerotic plaque and they actually saw reversal in those people they got their LDLs down around 60 and there was even more reversal when the ratio of LDL to HDL fell below 0.9. So as a working guideline if you can get the HDL higher than the LDL you have a good chance of cleaning out the atherosclerotic plaques.
KIRK HAMILTON: What are your favorite, aside from diet, nutraceuticals that would lower LDL and increase HDL, and then what are some of your favorite pharmaceuticals to complement that?
DR. JOE D. GOLDSTRICH: You know, I don't think there are any really good nutraceuticals to lower LDL. You know there's red rice yeast but I don't advocate it because you're actually using a statin and it's not standardized and there's a byproduct that about a quarter of the red rice yeast products have that is a toxic byproduct and so I don't recommend red rice yeast. I prefer to use a pharmaceutical statin. But there are a couple of nutrients and I think, it may be important in helping to minimize the coronary atherosclerosis and those are vitamin D and vitamin K and I use both of those now. Vitamin K2 has very good epidemiology for less coronary disease and less coronary calcification. And vitamin D the same. If there's insufficient vitamin D, you put the calcium in the arteriosclerotic plaque instead of in the bones and the same holds true with K. So I use both of those supplements now.
KIRK HAMILTON: What are your dose ranges for K2 and for D?
DR. JOE D. GOLDSTRICH: Well for D I usually start with 6000 IU of D3 a day and then I follow-up with a blood test. I've seen one patient who on 10,000 which a lot of people are recommending, on 10,000 IU of D3 had a little bit of hypercalcemia and some deterioration in kidney function. So I start with 6000 and then three or four months later get a blood level and I like to see them at around 60. I'd go with 55 to 65, but much above that I don't like to do even though there're a number of people that write about it being okay to get all the way up to 100 on the vitamin D level. I think that's a little bit high. And then on the vitamin K, there are not a lot of supplements that have both K1 and K2. K1 is converted to K2 in the body and there's epidemiology on K1 being associated with less coronary disease but I think K2, specifically the NK7 fraction of the K2 is where the action is. One of your test questions was "What is over-hyped?" And nattokinase is one of the things that I think is over-hyped. Natto is the source of vitamin K2 and that's a good thing. But many people are saying that if I'm taking nattokinase I'm not gonna get a heart attack, I don't have to worry about my LDL, it's not important. And I think that's totally inappropriate and untrue. So the doses of K1 can be in the range of 100 mcg and the dose of K2 can be about the same.
KIRK HAMILTON: Talk to me in the few minutes we have left about diet. I know that Pritikin had a pretty straightforward diet. What would you recommend? What is your diet?
DR. JOE D. GOLDSTRICH: The problem with Pritikin diet, aside of we talked about the lack of essential fatty acids, I think you need essential fatty acids. But the problem that I see is if there is an increasing number of individuals in our society today who can't eat carbohydrates because they get hyperglycemia when they eat the carbohydrates. So the diet that I personally use and recommend but it's really hard. It's a degree harder than Pritikin. When I was on the Pritikin diet I could eat bagels and pasta and whole wheat bread and all that good stuff which was wonderful. You know baked potato was a great meal. But as people age and they lose some of the power in their islet cells, they can't handle the carbohydrates. So I think a low fat, low carbohydrate diet is the healthiest diet. Now that requires eating lean meat which I think is okay, particularly from game. I'm particularly fond of buffalo and I have a nephew who shoots me at least one deer each fall which I eat on for much of the rest of the year. And so I think a low fat, low carbohydrate diet is the healthiest diet.
KIRK HAMILTON: So you're then more of an advocate of the Paleo diet.
DR. JOE D. GOLDSTRICH: But the Paleo people really don't limit the fat so much. They like the game, but they don't limit the fat. They think the fat is part of the animal. For example, in the Midwest, if you shoot a deer in the fall it's got lots of subcutaneous fat because those deer have been cleaning out the corn fields after the corn has been harvested. And there's huge amounts of subcutaneous fat but the meat, the muscle flesh of the deer is relatively lean. The deer meat doesn't marble very well. But the Paleo people wouldn't throw away the fat. They would say that's good natural nutrition because that's, you know, straight from the game. And our Paleo ancestors wouldn't have thrown away the fat either. They would have eaten it because it's highly nutritious and it provides lots of calories. So Paleo is okay if you leave off the fat.
KIRK HAMILTON: We've gotta run here, Dr. Goldstrich. Can you give out how people can get in contact with you because I know you do consultations on cardiovascular disease management.
DR. JOE D. GOLDSTRICH: My website is Healthyheartconsultant.com.
KIRK HAMILTON: Dr. Goldstrich, thanks for spending time. I know it went very quickly, but times up and so we'll talk again soon and so thank you very much.
DR. JOE D. GOLDSTRICH: You're quite welcome. Thank you.
KIRK HAMILTON: And I want to thank you, the audience, for listening to this edition of Staying Health Today Radio. And until next time, Stay and Be Well.
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