Episode Transcript
Dr. Diana. Welcome. We're so excited to finally meet you.
and have this conversation.
Daiana Castleman (01:18)
I'm so excited too, thank you for having me.
Mikelle Ethier (01:21)
⁓ our pleasure, our pleasure. We, ⁓ want to talk with you about all things heart health today, ⁓ cardiovascular health. you had an Instagram post this summer that I suspect probably shocked a lot of people, where you stated that you're a naturopathic doctor and you recommend statins. Tell it, tell us about that post and, ⁓ let's dive in.
Daiana Castleman (01:27)
Mm-hmm.
Mm-hmm.
Mm-hmm.
Yes, definitely raised some questions from some people for sure. I'm really happy to discuss that today. I really wanted to make that post because I was having so many conversations in my office about medication use in certain situations where I really thought the patient was a good candidate. And a lot of my patients told me they felt like a failure because they had to go on medication. And I think it just opened up
this conversation about how we are not failing if we need that medication to help prevent cardiovascular disease. yeah, I really became passionate about more openly talking about that. And I've actually received a lot of positive responses as well from many women who follow me who felt very validated in that actually because they…
⁓ Yeah, they had a lot of shame, a lot of guilt around needing that medication. And I think we really need to crack open that conversation more and talk about it more.
Mikelle Ethier (02:49)
Amazing. maybe let's, what are statins?
Michelle Stainton (02:52)
Yeah,
I actually have like zero knowledge on this subject today. I'm so excited to hear about all of this.
Daiana Castleman (02:53)
Yeah, yeah, yeah. Okay,
so I think to have this conversation, if it's okay, why don't we back up a little bit and just talk about in general, like what is cholesterol? Like what is your LDL cholesterol? Because then it will kind of lead into what statins are. So if you get like a lipid panel, a cholesterol panel, when you go get blood work with your doctor, you will see that part of that panel will be something called LDL cholesterol.
Mikelle Ethier (03:07)
Sure.
Michelle Stainton (03:07)
Yes.
Mikelle Ethier (03:10)
Perfect. Perfect.
Daiana Castleman (03:22)
And so LDL stands for low density lipoprotein. Basically, it's a type of particle that carries cholesterol throughout your bloodstream. And I always explain it to my patients, like think of them as balls. They're these balls that are floating around in your bloodstream that carry cholesterol. And so that LDL cholesterol measurement that you see is looking at the amount of cholesterol that's inside these balls, right? That are floating around. And so it doesn't actually tell us
How many balls do you have though? Like how many of those are in your bloodstream? And that's where we use another marker called APO-B. I don't know if you guys have heard of APO-B. It stands for apolipoprotein B. It's basically a protein that's found on the surface of these lipoprotein balls, so to speak, that are atherogenic, that basically can cause that plaque buildup. And so each of these balls has exactly one APO-B.
on it. And that's where it will give us a more accurate representation of like how many of these, if we want to call them bad, like you know particles, bad balls are floating around in our circulation. So if we think about like a highway analogy, APOB is looking at how many cars do we have on the highway and LDL cholesterol looks at like the passengers in these cars, like how many passengers do we have? So I kind of like that analogy and it helps my patients to really understand.
Michelle Stainton (04:42)
⁓ OK.
Daiana Castleman (04:48)
because ApoB has actually been talked about for many years and it is another marker that you can get on your blood work and it kind of gives us some more, you know, full picture of your ⁓ cardiovascular risk. And so basically if we have less ApoB, that means we have less of these balls, that's less of a probability that that ⁓ ball can cause damage to our artery wall. So yeah, I'll pause there if you have any questions.
Michelle Stainton (05:14)
So, yeah, like, so, so
if I have a really high LDL, but a really low APO-B.
Daiana Castleman (05:19)
Mm-hmm.
Typically, they go hand in hand a lot because about 90 % of our particles that carry APO-B are LDL cholesterol particles. So oftentimes, they do go a little bit hand in hand. If someone has high LDL cholesterol, they typically have elevated lip at APO-B. But again, APO-B is also looking at other particles that also are atherogenic. It's not just LDL cholesterol. There are other particles like
Michelle Stainton (05:25)
hand in hand.
Daiana Castleman (05:51)
lipoprotein little a, which I'll talk about in more detail, but they often go a little bit hand in hand. Yes, I'm going to talk about that. Yes, I know. So basically, when we use the word ⁓ atherosclerosis, this is a common word that we use in the cardiovascular disease space. I want you to think about your arteries, your blood vessels as these flexible pipes. And over time, if we have, let's say too much cholesterol in our bloodstream, we can have what
Mikelle Ethier (05:56)
And when you say arthrogenic, can you describe that what that is? Okay, perfect.
Daiana Castleman (06:20)
are called these fatty deposits or what we call plaques. They can start to build inside of these pipes. And so basically they can make those ⁓ walls thicker and stiffer. And so these pipes are not as flexible anymore. And if we have a rupture of any of these plaques, that's essentially what can lead to, let's say, a block of blood flow. And that could be like a heart attack, a stroke, things like that. So when we say atherosclerosis, we're talking about that.
buildup of plaque within our arteries and atherosclerotic cardiovascular disease is the most common type of cardiovascular disease and that's why we focus so much about on it is because it's the leading cause ⁓ of death and disability globally so that's why we often use that term a lot we're trying to prevent atherosclerosis from happening.
Michelle Stainton (07:11)
Okay.
Daiana Castleman (07:11)
Does that help?
Mikelle Ethier (07:11)
Also the leading cause of death
of women who are post-monopausal, right? Yeah, yeah.
Daiana Castleman (07:14)
Correct, post-menopausal, correct. Yes, yes. And this is why it's such an important conversation because the best thing we can do is prevention, right? We can work on prevention. And so this is what I talk a lot about is that the things you do now in your 40s and 50s and in this perimetapause stage is going to affect your health outcomes for decades to come, right? But that can be a very empowering thing that things we do now are going to really benefit us for decades to
Michelle Stainton (07:16)
Yeah.
Mikelle Ethier (07:23)
Mm-hmm.
Michelle Stainton (07:41)
Absolutely. I don't want to jump around too much, am I like at what age do I start getting tested? Do I every time I go in front like I'm going for a blood work ⁓ blood panel next week. Will they automatically be testing for this as well or?
Daiana Castleman (07:52)
Yep.
Great question.
So cholesterol, for sure, is typically part as like your sort of comprehensive screening that you do with your family doctor. Some other markers are not always included. So APOB, for example, typically you do have to ask for. There is another marker that I encourage my patients to ask their doctors about, which is called lipoprotein little a. So lipoprotein little a is a form of an LDL, like this atherogenic particle.
⁓ It also can promote that formation of plaque in the arteries, but it's a very highly genetically determined marker. So over 90 % of it is genetically determined. So you can have amazing nutrition, lifestyle, diet practices, but they don't significantly impact it. And the Canadian Cardiovascular Society recommends that everyone over the age of 40 test this once in their lifetime. So you don't need to repeat it because it's genetically determined.
Mikelle Ethier (08:32)
Mmm.
Daiana Castleman (08:50)
And about one in five people have elevated levels. So about 20 % of the population, I mean, that's not insignificant, right? ⁓ And so what I like to tell my patients, it's not something you did to cause these elevated levels, but we should know if it is elevated because it's going to add an additional risk factor that we need to take into account. So elevated levels, if we're talking, ⁓ again, in Canada.
and you're looking at over 100 nanomoles per liter on blood work, that would be considered an elevated ⁓ amount. Again, you only need to test this once in your lifetime. But for example, if I have a patient who has elevated lipoprotein A, it means we might be a little bit more aggressive in our prevention approach, knowing that they have this additional risk factor. So it's really important to know. And I think that's a really ⁓
a great part of a comprehensive cardiovascular risk assessment at midlife. Yeah, you're welcome.
Michelle Stainton (09:46)
Yeah, thank you for that. I'm gonna get that added. Thank you. Now I'm like, ⁓ my
gosh, my mother died of a heart attack. I'm like, very interesting. Okay, thank you.
Daiana Castleman (09:53)
Hmm. Yeah.
Yeah, yeah, you're so welcome. And then the other thing I always like to talk to my patients about is what happens at menopause because this is everyone's question. They're like, I never had elevated cholesterol and now like what's happening, right? What, what, why am I all of sudden seeing this increase? So what we see in the research is that over the span of about 20 years, from 40 to 60 years of age,
Mikelle Ethier (10:04)
Mm-hmm.
Daiana Castleman (10:21)
Our LDL cholesterol increases on average about 0.05 milimers per liter on blood work. So over the span of 20 years, that's about one point. So let's say you had an LDL cholesterol of three, can go to four, right? Kind of, again, over the span of 20 years, it's not happening overnight. But there's kind of some thoughts about why this is happening. We know that as our ⁓ estrogen declines, there can be some impact there because estrogen does play
a really important role in cholesterol metabolism. And basically, it's going to cause down regulation of our LDL receptors at the liver. So what that means is just that we're not clearing that cholesterol as efficiently at the level of the liver. We know that body composition changes around this time. So a lot of women can see, right? Those body composition changes, maybe they have more visceral fat, which we know can contribute to higher cholesterol. Of course, lifestyle factors, right? Like if we're maybe
really suffering with symptoms, maybe we're less active, changes to our diet. So there's, you know, kind of a multitude of factors that can play a role here. But the key here, the key thing here is that if we are seeing these increases, and we're only going to see them if we're, you know, testing on our blood work, that we are creating an action plan and we're creating a treatment plan about what we're going to do about it.
Mikelle Ethier (11:41)
Amazing.
Michelle Stainton (11:41)
Yeah, I'm a little overwhelmed right now. Like just in the sense that I feel healthy and I feel like I shouldn't, I shouldn't be worried about this, but I kind of am now. Anyway, thank you for this conversation. hopefully by the end I'll be relaxed again, but I feel like I need to take some action.
Daiana Castleman (11:49)
Yep.
Thanks.
Yeah,
Mikelle Ethier (11:59)
You
Daiana Castleman (12:01)
think with the information you'll be empowered. I really, I understand at the beginning can be overwhelming because maybe this is the first time you maybe have had a conversation with your practitioner about it, but I do truly believe prevention is everything. And the more that we have these conversations and open up and understand what our numbers mean, the number of times that I've said to my patients, what is your LDL cluster? What has been over the years? And we don't know.
Michelle Stainton (12:26)
now.
Daiana Castleman (12:26)
Like
we don't know what those numbers are and that's okay. It's never too late to learn but like let's understand those numbers. Like I think that that's instead of you know doing your blood work and then you know we never get a call back and then like it just you know it you know that's that's it we don't know what to do about it. I really like to put my patients in the driver's seat of their health and say okay like if you are going you know for annual or every two year blood work whatever that is for you like here's what your number should be and make sure you track it right because
Mikelle Ethier (12:26)
No.
Daiana Castleman (12:55)
You're not gonna feel increases in your cholesterol. I explain, it's not like, you you have a migraine headache, you know, you take something for it, it goes away. Cholesterol is not that way. You're gonna work on your cholesterol. If it's high, it's gonna come down. You're gonna feel the same. Like it's really, you're not gonna feel symptoms unless of course an event happens. And so this is why we need to be on top of our screening and understand those numbers.
Mikelle Ethier (13:03)
Thank
Are there, ⁓ can we talk about ranges? Is that appropriate? Yeah. And I, yeah, I'd love to just to get your, your perspective on that. And for our listeners who are like, God, I need to really get on this. My doctor's maybe not as proactive as I would like. And what, what do I, you know, what's the context for these results?
Daiana Castleman (13:23)
Yeah, for sure, definitely.
Yeah.
Yeah.
Michelle Stainton (13:39)
What are the…
Daiana Castleman (13:42)
Yeah.
Michelle Stainton (13:43)
And these will be ranges for Canada. We do have listeners from across the globe. And I think the ranges are probably different even between Canada and the States.
Daiana Castleman (13:47)
Yes.
Correct.
So they're going to be different units also in the States. So if you're in the United States, they're just different units. So just keep in mind, you're going to have to convert these numbers that I mentioned. So what I want to say here, let's talk about LDL cholesterol. The number that we're looking for is going to depend on someone's risk factors. So I mentioned to you lipoprotein A. So that's a risk factor that can enhance someone's risk. And so if someone has elevated lipoprotein A, we might want their LDL cholesterol to be even lower.
than someone who doesn't have it elevated because they just have additional risk, right? So it's hard to kind of give a very ⁓ concrete number. However, I can kind of give some guidelines around this. What we know for sure is anything over 4.9 millimoles per liter on blood work for LDL cholesterol is considered very high and needs to be treated, okay? So that we know for sure it's included in the guidelines. ⁓ And again, that's gonna get stricter as someone's risks.
go up, right? So if someone is, you know, has high blood pressure, they're also a smoker and they have elevated lipoprotein A, right? As you can see, they have more risks than we need to make sure their LDL is more in check. Now, if you go, for example, to LifeLabs, you will see that when you get your cholesterol numbers back, they will say anything under 3.5 is considered normal. So that's kind of like the overall range that you will see on
blood work and again if someone is in know general good health, know We can sort of use that as a guideline as a benchmark to kind of say, okay, maybe you know, we don't need to You know initiate medication at the stage or you can continue your diet lifestyle practices, right? And then we can monitor your risk as we go ⁓ there were recent a recent paper that was published by the Lancet which is like a procedures medical journal that looked at ⁓ look
at it being under 3.3 for optimal health. So sometimes different studies will quote these, especially for like dementia prevention and optimal brain health, they kind of quote under 3.3. So it's a ballpark range. But like I said, the more risk factors you have, the more that we maybe need to be stricter with our criteria. So I hope that helps.
Mikelle Ethier (16:01)
Very helpful. Very helpful.
Michelle Stainton (16:01)
Yeah, absolutely. Sorry,
what is the connection with cholesterol and dementia?
Daiana Castleman (16:08)
Yes, that's a big topic. It's one that definitely I get a lot of questions about. I'll check in in about 10 minutes. So the dementia conversation. So there is a report that got released last year in 2024 by The Lancet. So I mentioned The Lancet. It's one of the world's most influential peer-reviewed medical journals.
Michelle Stainton (16:12)
I'm still not getting more relieved. getting… I'm like, ⁓ no.
Mikelle Ethier (16:15)
Yeah
Daiana Castleman (16:37)
And they have a group that basically looks at dementia risk factors. And they have periodic updates, basically, as we have new evidence. So as of 2024, they added high LDL cholesterol to the list of modifiable dementia risk factors. So now there's 14 modifiable risk factors for dementia, meaning there's something that we can do about it to reduce our risk. And those 14 modifiable
modifiable risk factors, it estimates about a 45 % of dementia cases that could be prevented, right? So that's quite a large amount if we focus on that. So basically almost half, right? Almost half that we can focus on prevention. So again, that's empowering. Like there's a lot that we can do there. And that includes, you know, exercise and nutrition and a lot of those good stuff. But now they've added high LDL cholesterol as something that we should be targeting starting in midlife as part of our dementia prevention.
Mikelle Ethier (17:11)
Wow, that's a huge amount.
Michelle Stainton (17:12)
Yeah. That's what
we're talking about next. Wow.
Daiana Castleman (17:33)
And again, that's alongside blood pressure control and diabetes prevention, smoking cessation, all those things that we know. But this is one that actually a lot of people don't know, that they've included this now as part of the dementia prevention to make sure that we are keeping those levels in check. Because again, the biggest thing that I also talk to my patients about is this concept called cholesterol years, which basically looks at the longer that we have this elevated cholesterol,
the higher our risk, right? So if I have someone, let's say, I'm throwing numbers out there. Let's say she's 52. She's coming into my office. ⁓ And let's say brain health is a goal of hers, amazing health goal to have, to optimize her brain function. And she's had elevated LDL cholesterol for 10 years, but quite high elevated levels. I probably would be way more aggressive in my approach than someone who's had it elevated for six months.
Right? Because that's 10 years of that additional potential atherosclerosis that could have been occurring. So we're going to be a little bit more aggressive in our approach and trying to get that down. Right? So keeping that in mind, too, of how long it's been elevated is an important concept to keep in mind.
Michelle Stainton (18:48)
Okay, so we keep talking about your approach and what you would do. so it's like, walk me off the ledge. What do we do? Tell me.
Daiana Castleman (18:54)
Yeah. You're like, give me all the things. ⁓ So ⁓
there's one other thing I want to mention with assessment, sorry, because I think this is really, really important and I want listeners to know about this. ⁓ There is a ⁓ calculator score basically that we can look at someone's 10-year cardiovascular risk. And it's commonly run in many practices. In Canada here, we have what's called the Framingham Risk Calculator.
Michelle Stainton (19:03)
Yeah.
Daiana Castleman (19:20)
So it's going to basically ask you your age, your sex, your total cholesterol levels, your HDL cholesterol, your systolic blood pressure, if you have diabetes, if you're a smoker, if you have family history of premature cardiovascular disease. So it's going to ask you all these questions. And then it gives you this 10-year risk score, basically. it's saying, in 10 years, what is the likelihood of you having an event? And the number one thing I want to highlight with this risk calculator
it is going to fail to identify younger women who could really benefit from early prevention, meaning that you could have that LDL cholesterol of 4.9, but you will still be labeled as low risk, under 10%, because it's basically because of your age, exactly, because risk scores are really driven by age. So if you're 49, it's going to say, well, by 59, you're still quite low risk, right? And so the reason why I really want to
Mikelle Ethier (19:54)
Hmm.
because of your age.
Hmm
Daiana Castleman (20:18)
bring this up because this is such a missed opportunity for early prevention because again, it's not flagging younger women. It's not going to flag women in their 30s, 40s, 50s. It's saying you're not high risk. And so what that's going to do is that if we're using just that marker alone to determine what our treatment plan is, we're going to delay treatment, right? We're going to delay doing something about it because we're saying, well, you're little risk, you're under 10%. And so we can still do these calculators and use it as a
Mikelle Ethier (20:41)
Mm-mm.
Daiana Castleman (20:46)
guide, but it's not the full picture. So I just want to highlight that because I think it's a really, important conversation. So again, if we're just relying solely on that 10-year score, it's going to really underestimate risk in midlife women.
Mikelle Ethier (21:01)
Yeah, so, so important, right? And even just getting a baseline so that you understand at age, let's say 40, 35, whatever, what your LDL level is. then, because I'm assuming all of the things you've talked about, the context of how much it's gone up is also as important as what the actual number is, right? Like if you've been, yeah.
Daiana Castleman (21:09)
Exactly.
Yes.
Mm-hmm. Exactly. ⁓ 100%. Exactly. It's like trends over time. Like, what is the trend?
Michelle Stainton (21:27)
Yes.
Daiana Castleman (21:30)
Exactly.
Mikelle Ethier (21:30)
Yeah, yeah, because if
you've been 3.2 and then suddenly you're 3.5 at whatever age, but if you were two and then suddenly, right?
Daiana Castleman (21:34)
Yeah.
Mm-hmm.
You're getting the concept. I love it. Yeah, it's exactly it.
Mikelle Ethier (21:47)
Wow. Wow. Yeah.
Michelle Stainton (21:48)
Yeah.
Mikelle Ethier (21:49)
We're all going to get blood work tomorrow.
Michelle Stainton (21:52)
You mentioned HDL. Is that the quote unquote good cholesterol? that what that
Daiana Castleman (21:55)
Mm-hmm. Yes. I'm so
glad you brought this up. ⁓ Yeah, people hold on to their HDR.
Michelle Stainton (22:02)
Yeah. ⁓
Mikelle Ethier (22:03)
⁓
Doesn't matter, my HDL is good, but look at this number.
Daiana Castleman (22:05)
So exactly, yeah,
that's actually part of one of the myths that I always bust is that because people feel like, well, my HDL is fine. And because it's historically been labeled as this good cholesterol, they're like, it almost, it implies that it's protective. Like it's protective against your LDL cholesterol. It is not. And I really want to highlight that. we are, with HDL cholesterol, we are actually, think, truly in the infancy of really understanding like what this.
Mikelle Ethier (22:10)
Mm.
Wow.
Ha
Daiana Castleman (22:35)
⁓ what this cholesterol particle does because we like when we've looked at, for example, increasing it in studies, right, it never actually led to any significant benefits like, you know, to people like cardio protective benefits. So we don't try to increase it. ⁓ So, you know, if someone's if that is the goal of yours, please don't let that be a goal of yours. It's not going to be lead to cardio protective effects. So even if your HDL cholesterol is good, we again, even the arbitrary cut off of like
you want it to be over 1.3. Like it's just such an arbitrary number that is thrown there. It's really not our focus. It's because LDL cholesterol is causally related to cardiovascular disease, right? And that's been proven time and time again with many, many, different studies. So every time when we lower LDL cholesterol in a group of people versus not lower it, the group that has the lower LDL cholesterol has consistently lower heart disease risk, right? Like it's just…
It's not even refutable. ⁓ We have so many studies on that. It's clear. That is not the same for HDL cholesterol. ⁓ yeah, that's just something to note. So even if, for example, you're looking at studies and they will report, well, there was an increase in HDL cholesterol. mean, doesn't really mean too much for us. Yeah, I'm glad you brought that up. Yeah.
Mikelle Ethier (23:38)
Right, right.
Wow.
Michelle Stainton (23:53)
fine but it yeah.
yet, yet, maybe,
maybe sometime soon.
Mikelle Ethier (24:00)
Fascinating.
Daiana Castleman (24:01)
Yeah. So to circle back, think we were going to go on statins, and here we are. Yeah.
Michelle Stainton (24:05)
Yeah.
Mikelle Ethier (24:06)
Here we are. Well, think right where you've really,
really in a very easy to understand way outlined what matters and why. And yeah, like please tell us. So what do we, what does prevention look like? Obviously context is important, but in general, what are the things that we people and women in particular given we're on a
Daiana Castleman (24:14)
⁓ Exactly.
Yes.
Mm-hmm. Yep.
Mm-hmm.
Mikelle Ethier (24:33)
podcast about perimenopause, what do we need to do to give us the best shot possible of living long, healthy life? Vibrant. Yeah. Yeah.
Daiana Castleman (24:37)
Mm-hmm.
Yes.
Michelle Stainton (24:44)
Vibrant, yeah. Yeah.
Daiana Castleman (24:45)
Yeah, lives. Yeah, vibrant, I love it.
So I just wanna highlight when I'm gonna be talking about medications, this is not ignoring diet lifestyle pieces. Cause I think ⁓ people kind of sometimes feel like, we're talking about medications that automatically means we're ignoring all the other things. That is not the case. And we often obviously get the best outcomes when we look at incorporating those pieces, right?
Mikelle Ethier (24:58)
Yup.
yet know.
Daiana Castleman (25:13)
I always talk about the pillars of our health, the pillars of health being exercise, nutrition, stress management, and sleep. They're always going to be incredibly important and always part of our treatment plan. Always, right? So yeah, go ahead.
Mikelle Ethier (25:28)
Sorry, I just want to jump in and I don't know if this is the right time, but I think nutrition and cholesterol, if we could go down a bit of a rabbit hole or talk about that a little more in depth than maybe you were already going to. But I think that would be like, are eggs evil in the context of cholesterol? are they not? You know, just I would love to get ⁓ your expertise on how you should be eating in the context of cholesterol. Yeah.
Daiana Castleman (25:38)
Mm-hmm.
Yeah.
Yeah, 100%.
So typically when we focus overall on cholesterol, what we're trying to do is decrease saturated fat intake and increase our fiber intake. That's always going to be kind of like the principles of what we're going to try to do. And that has the biggest impact. At best, if someone is really adhering to a Mediterranean style diet, like that is the gold standard diet for cardiovascular health,
we're going to see about a 30 % improvement, right, at best. Now, that can vary, again, from person to person. It also depends what your starting risk is. But at best, we can see about 30 % improvement. So what that means when we're talking about saturated fat, decreasing things like red meat intake, again, depending on what someone's baseline is. So the carnivore diet is the worst diet for cardiovascular health. We don't want to engage in that one. ⁓
Michelle Stainton (26:47)
You
Daiana Castleman (26:51)
There are certain it's not for example, like all dairy, but some dairy, of course, will have higher saturated fat intake. So just looking at those portions and those amounts is what I like to guide my patients in fiber. want to be aiming for about that, you know, 25 to 30 grams of fiber a day. And we want at least 10 grams of that to be soluble fiber. So we get soluble fiber from a few different sources. It could be things like oats and oat products.
psyllium is a great example. And actually psyllium is what is in metamucil, right? So for example, a lot of people, you know, take metamucil, it's really psyllium husk is what is in that. And that has had good studies, you know, to really help support ⁓ overall cholesterol. So that's kind of like the main sort of base that we focus on. Of course, we also talk about like alcohol intake and those pieces too. It's important to address.
But let's say I have someone coming into my office. They have slightly elevated cholesterol. This was something new that's come up for them. It is completely reasonable, of course, to take that dietary lifestyle approach. And let's say, let's give it three to six months. Let's do these changes. I think where people sometimes get overwhelmed ⁓ in their doctor's offices, and I understand it's often a time limit in the amount of time you can spend with your doctor, is they will tell you, ⁓
okay, here's the Mediterranean diet. The problem is you go home and you read this, and you're just so overwhelmed. You're like, where do I even begin? Obviously, there's this entire 14 pages that I have to read and where do I start? So what I really try to do in my practice, I have the fortune of being able to spend time with my patients. And so
Michelle Stainton (28:18)
Yeah.
Mikelle Ethier (28:18)
Yep.
Daiana Castleman (28:33)
What I will do is I will really try to understand what your day-to-day looks like. I will ask very specific questions. And then I'm going to give you like four tasks, right? I'm going to say, I want you to do this, this, this, and this until next time we meet. And let's just focus on those things to help see how it's going to help your cholesterol levels. That might not mean in three months it's completely normalized, but you'll see changes, right? You'll see if you're on the right path. Because again, we'll talk about medications. But I understand sometimes that's not everyone's first approach. And we're not saying here that it
to be, right? It's about having a targeted plan and a plan of action and then making sure that we are retesting. Because often what can happen too is, let's say you're making some really great changes and we're not retesting and then all of a sudden two, three years, four years later, we're like, ⁓ I think I should check my cholesterol again and see what's happened. And maybe if it hasn't come down, right? Like again, we just want to make sure we have a plan of action. Yeah.
Michelle Stainton (29:27)
You've wasted those years. Yeah.
Mikelle Ethier (29:30)
Yeah,
and that you're moving the needle in the right direction.
Daiana Castleman (29:35)
Do you want me to go into the statins conversation? Okay, so statins are a type of medication that helps to lower cholesterol. They basically work by blocking cholesterol production in the liver. So basically it blocks this enzyme called HMG-CoA reductase, and it's a key enzyme in the liver that is used to make cholesterol.
Michelle Stainton (29:37)
Yeah, yeah.
Mikelle Ethier (29:37)
Yeah.
Daiana Castleman (29:57)
So that's essentially how it works in a nutshell. They've been studied for decades. We have a lot, a lot of research on them. Actually, the first statin was released in 1987. So we have a lot of data, including in women, obviously research. Yep. No, no, there have been studies in women. Of course, we always need more research. You know, when it comes to women's health, I will always say that, of course.
Michelle Stainton (30:12)
I was going to say, it all on men?
Daiana Castleman (30:24)
But there have been studies done in women. And so if you ever hear like, no, they don't work in women, that's actually not true. They have been studied in women as well. I think there's a few different reasons why, again, the conversation has become polarized. I think in a lot of ⁓ wellness circles, there's often, again, the strong emphasis that natural is better. Medications can, again, be seen as last resort or a failure.
⁓ There can be side effects concerns and I feel like the side effects really get amplified online even though majority of people really tolerate them well. I think the side effects are spread quickly, right? Even though like we have millions of people that take these medications successfully and you know, don't post about it, right? So it can be kind of that bias. Sometimes women also have…
experiences with the medical system, right? They maybe feel dismissed, ⁓ rushed, or they're prescribed that medication without explanation. And so kind of this creates the skepticism about what this is really going to do for me. ⁓ And then also, if we've had family members or relatives who are maybe over-medicated, right? Like we may resist this idea of needing medication ourselves because we have this certain viewpoint of what it's looked like for ⁓
Mikelle Ethier (31:19)
Mm-hmm.
Daiana Castleman (31:37)
family members. And then I mentioned that guilt component, right? That idea of like, important to reframe it as a tool and not a personal failure.
Mikelle Ethier (31:46)
Yeah. And I think
maybe good context here as well. Something else you say that probably shocks a lot of people, particularly because you are a natural path is the fact that you can't out lifestyle your genetics, right? And so there's a lot you can do, but sometimes in your point about if you have the genetic predisposition of the marker for, ⁓ what was it? LDL or lipo, liver, liver protein, little a.
Daiana Castleman (32:01)
Mm-hmm. Mm-hmm. Yep.
Yeah. Lipple protein little A. I also will say,
yeah, even if, let's say, lipoprotein little A is not elevated for you, it doesn't mean that there might not be other genetic factors that play because there's so many genes, of course, that have a role in cholesterol metabolism. But yes, it's this idea of if you've, again, given it a really good runway, a really good shot, and you're doing all the things, and it's not where we would like it to be.
Mikelle Ethier (32:22)
Yeah, yeah, right, right, right.
Daiana Castleman (32:38)
you know, again, it's this idea of, then maybe we could potentially explore that option for you, right? Because again, it is about prevention, right? This is where we are going to make the biggest impact. ⁓ And so I think when it comes to women's health, when we discuss the effectiveness of STATens in women, we have, again, really concrete data for like secondary prevention, right? So we know there's significant evidence that STATens work. ⁓
Mikelle Ethier (32:46)
Yeah. Yeah.
Daiana Castleman (33:06)
Equally as effectively in women in the studies that did include women in secondary prevention, meaning that an event has already happened and we're trying to prevent another one. I think where the controversy is, and this is where there's a lot of he said, she said, like, depending on who you follow online, the controversy is more do statins help in primary prevention in women, meaning that they've never had a cardiac event and we're trying to prevent the first event. Right. And that's where definitely we could
Mikelle Ethier (33:13)
Yep.
Mm-hmm.
Great.
Michelle Stainton (33:32)
Right.
Mikelle Ethier (33:33)
Yep.
Daiana Castleman (33:36)
have more studies because the studies that even have included women, they don't all report sex specific results, right? And we need those sex specific results to be reported. There are definitely some that have, but a lot that also haven't. ⁓ And so that's where I think more and more research is going to be coming out. But I think even, like I said, with the data we do have in how important it is to manage things like LDL cholesterol, I think we have enough that it really is a
shared decision-making process. It's such an individualized decision to make with your doctor and based on your health history. So this is, again, not a blanket statement, but the cholesterol guidelines state that women should be treated with statins for primary and secondary prevention when the benefit outweighs the risk and it's individualized assessment for the person.
Mikelle Ethier (34:26)
And I think that, what you've just said is the crux of the problem is that we've now had a 38 minute conversation about this in that most people do not have the benefit of this, not just the level of expertise, but the ability to share it in a way that lay people can understand or that patients can understand and, guide us, guide you through.
Daiana Castleman (34:50)
Mm-hmm. Mm-hmm.
Mikelle Ethier (34:56)
all of the nuance and context here right? Like the approach is often it's so I think it's so polarized because there's this binary approach. Statins are bad or statins are good? Well no there's this whole right scale in between that no one's even talking about.
Daiana Castleman (34:59)
Yeah.
Mm-hmm. Exactly.
Yeah.
Yeah, yeah. And it's actually, think you bring up such a good point because I think that the nuance is what is so hard to convey on social media because it's all sound bites, right? Like it's all just little context, 10 second clips. There's no way you can capture nuance in a 10 second clip, but that's what catches attention. ⁓ And so even I have struggled so much with
Mikelle Ethier (35:25)
my God, yeah. Yes, yes.
Michelle Stainton (35:25)
Like impossible. Yes.
Mikelle Ethier (35:37)
Yeah.
Daiana Castleman (35:41)
how do I have this conversation online? Because ⁓ in my office, it's an hour and half conversation. how do I even, yeah, right, right. How do I start to have that conversation? And sometimes it's multiple visits, right? Like someone's not going to necessarily make a decision on the first visit and that's totally fine. ⁓ It's about a continuous conversation, right? And I keep also reiterating because I see this messaging online that
Mikelle Ethier (35:44)
Hmm
Michelle Stainton (35:49)
you do.
Daiana Castleman (36:08)
you know, menopause is like causing heart disease and it's not true. Menopause is not causing heart disease, but yes, the drop in estrogen can essentially just remove a layer of protection. Exactly. It's like a layer of protection that we're removing, but that doesn't mean that there's not so many things that we can do for it. And even if you're not, again, I can get into the whole menopausal therapy conversation as well. Yeah, we're going to dive into that too.
Michelle Stainton (36:20)
protection.
Well, I want to know this too.
Daiana Castleman (36:38)
you can still live a very long and healthy and vibrant life to your point, even without it. And I think, again, that's where the context is missing. Yeah.
Michelle Stainton (36:48)
Okay, let's talk MHT because that's another one where, know, but online again, like some people are saying yes, and some people are saying no, doesn't help. And how do we know? What do we know? What does the data say? Yeah.
Daiana Castleman (36:50)
⁓ okay. To be half four hours. Yeah.
Yeah. Okay. Yeah. I'll give context because
I think that that is my strength. I think my strength lies in educating on the research, educating what we have. And again, I keep coming back to shared decision-making, right? Like, you know, helping the patient come to that decision themselves and what they're looking for. It's a dual relationship, right? So if we look at all of the menopause guidelines globally,
Mikelle Ethier (37:15)
Mm-hmm.
Daiana Castleman (37:27)
They do not recommend menopause hormone therapy for primary or secondary prevention of cardiovascular disease. Okay, so that's kind of listed in all the menopause guidelines. Some people will argue online, well, it's because they're not updated and things like that. That's not true, but I just want to give some context to where that is coming from. So there's a lot of studies I can talk about, but I'll just kind of highlight two key ones ⁓ that are often talked about in this space.
One of the studies is called ELITE. It was a study that was published in 2015. And it was looking basically at the effects of estradiol treatment, so taking estrogen therapy versus placebo on cardiovascular health. And they were specifically looking at one metric, which is what's called carotid intima media thickness, so CIMT. It's basically just an ultrasound test that measures the thickness.
of the inner two layers of your carotid artery walls, which is again responsible for supplying blood to the brain. And it basically helps us assess the risk of cardiovascular disease because it's looking at detecting early atherosclerosis as we talked about. So it's basically looking at that one marker. so participants were split into two groups based on their time from menopause. We had a group that were within six years of their ⁓ last menstrual period and then group that was more than 10 years over the last menstrual period.
And then the treatment group received oral estrogen, one milligram oral estrogen, and then they also had progesterone for uterine protection, and then there was the placebo. And the key finding in the study in ELITE, and this is what often gets talked about as like a, as a pro, like a benefit for MHT for cardiovascular prevention was that if you were less than six years from menopause, you had less progression of the CIMT test in the treatment group versus the placebo.
And that beneficial effect wasn't there if you started over 10 years, right, after your last menstrual period. And so this is where the whole idea of the timing hypothesis comes in, this window of opportunity where it's, OK, if we're going to start hormone therapy for cardiovascular protection, you want to be in this window, right, like in this window recently from your period. And so it just suggested that, hey, maybe there could be this.
Mikelle Ethier (39:20)
Mm. Mm-hmm.
Daiana Castleman (39:39)
cardioprotective sort of role. Now again, it's important to mention they looked at this one marker of CMT. It wasn't looking at adverse clinical events, like heart attack, stroke, things like that. But again, it was a trial that a lot of people cite as saying, OK, well, there is benefits here. Now, when we look at, I always like to differentiate between using menopause hormone therapy versus statins for cholesterol. Because this is one of the number one questions I get asked is,
Mikelle Ethier (40:04)
Mmm.
Mm-hmm.
Daiana Castleman (40:09)
Well, I'm
just going to use estrogen to help decrease my cholesterol. Like, why am I going to use a statin medication? There are some head-to-head trials that have compared statins to menopause hormone therapy. Now, a lot of them are ⁓ smaller, short-term trials that are really focused on that cholesterol component. But in every direct comparison that has been done, the statin lowered LDL cholesterol more than menopause hormone therapy. It outperformed it.
in pretty much every single direct comparison. Now, a few trials did test the combination of menopause hormone therapy anastan, and there could be some additive lipid effects there, meaning that there could be some enhancement ⁓ when you use both. But you will also see that a lot of the menopause hormone therapy trials will say that it uniquely improved HDL cholesterol, which coming back to the fact that it's not really that clinically relevant for us.
Michelle Stainton (41:01)
Yeah.
Daiana Castleman (41:04)
And so I really like to highlight that because we're talking about specifically the efficacy between menopause hormone therapy and statins for lipid lowering effects. I'm gonna choose the statin every time. And so again, it's this idea of, I'm not saying there can't be some cardio protective benefits of estrogen, especially started within a window. But again, if our goal is lipid lowering, if someone has an LDL cholesterol five, and we're trying to get it,
as close to three or under three, I'm not going to use estrogen for that. Does that make sense? So it also depends what our goals are there. And then there's been a lot of trials that have been neutral, basically saying there is no harm, there's no benefit, but there essentially is really no evidence of cardioprotective benefits. And a lot of the trials have been done with oral estrogen.
which is also important to keep in mind because many women now are taking transdermal estrogen on the skin, like gels or patches. And so the transdermal data is very scarce. There is one trial called KEEPS that was one of the few trials that included transdermal estrogen in it, but that was the one that was neutral. It kind of like no harm, no cardioprotective benefit. And so as you can see, when we have…
some of this mixed data and mixed trials, it's of course difficult for guidelines to make this bold statement to say, OK, it's going to prevent primary prevention of cardiovascular disease or secondary prevention, right? The question is, is this data enough to change guidelines? And I think a lot of experts in the field right now would say, no, it's not enough data to change guideline evidence. But then people will use information like the elite trial that I just explained to say, well,
I want to do because this trial showed that there was potentially some benefit. So again, it's nuanced. It's a nuanced conversation. It's about shared decision making. ⁓ For example, we also know that if someone has debilitating moderate to severe hot flashes, night sweats, it's associated with an increase in potential association. But it's important to note that in the SWAN study, it showed it.
Michelle Stainton (42:57)
Yeah.
Mikelle Ethier (42:59)
Thank
Daiana Castleman (43:17)
potential increase in cardiovascular disease risk. So again, I think it's context. Context matters. It's of the person in front of you. And are they having any other symptoms? What if they had no menopause symptoms and they solely want to take estrogen for cardiovascular prevention? I don't know. I don't necessarily, like I said, have a concrete answer to that based on the evidence and the data. It also depends on the practitioner, I think, maybe would say otherwise.
for solely cardiovascular disease prevention, I don't think it's very robust, especially for, like I said, if we're using transdermal estrogen. So I hope that kind of helped guides. I know that people want the black and white answers for sure, but I think it's also just important to cite the studies and say, hey, here's what we have. How do you feel about it?
Mikelle Ethier (43:55)
Mm.
Michelle Stainton (44:06)
Right, let us make our own decisions. Give us the information. Yeah, yeah, for sure.
Daiana Castleman (44:08)
Yeah, exactly. Give
Mikelle Ethier (44:10)
And
also bust the myth that there is no black and white. And where is the science today? And science is iterative. It's always about getting more information and then making the best decision possible and continuing on that path. And you can't, you know, we…
Daiana Castleman (44:10)
you the information, yeah.
Yeah. Yeah.
Mm-hmm.
Mikelle Ethier (44:29)
Your health requires a toolkit. Paraminopause requires a toolkit. And there are going to be a lot of things in that toolkit. And there is no one magic bullet that fixes anything and everything, right? And unfortunately, the challenge I think is our health care system and globally health care systems are not set up to allow people to understand the context and nuance that is crucial.
Daiana Castleman (44:33)
Exactly.
Mm-hmm.
Mm-hmm.
Mikelle Ethier (44:58)
to their health and to how to best manage their health, right? And that's why naturopaths, I think, are such an important part of our respective teams when it comes to helping us make the best decisions possible because your structure is you sit and have the time to explain, build a relationship, really understand the patient, make sure the patient really understands.
Daiana Castleman (45:03)
Mm-hmm.
Yeah.
Mm-hmm.
Mikelle Ethier (45:27)
and work on a strategy, not just slapping, you know, ⁓ problem solution, problem solution, wait, let's step back and understand you as an individual and what you need. And that is so, so important.
Daiana Castleman (45:34)
Mm-hmm.
Mm-hmm.
Yes, exactly.
Michelle Stainton (45:44)
And now you're with Loom Women's Health. Is that where everyone can come in? that where your practice is? So when you, so I think it's also probably, Loom is a pretty magical spot and we'll definitely link to it in the show notes. Do you want to tell us a little bit about Loom and how that team works together? Because you're, yeah.
Daiana Castleman (45:46)
Yes.
Yes, yep.
Yes. Yeah.
I'd love to. Yes, ⁓ I'm ⁓ really, really happy to be part of the LUME team. So LUME, we're located in Toronto at Blur and Church. We're a midlife women's health clinic, and we really have a team of integrative practitioners. So we have medical doctors, nurse practitioner, pelvic floor physiotherapist. Me as the naturopath, we have a chiropractor.
Michelle Stainton (46:31)
psychologists.
Daiana Castleman (46:32)
Yeah, psychologist, we have a full team ready to help support you, which is incredible. ⁓ I will say, I think this is honestly what every woman wants, right? They want a team ⁓ approach that everyone is working on together. And so a woman has access to be able to access all of us. And the beautiful part about that is because we're all in the same clinic, we can discuss that. I always like, well,
ask permission from my patients to say, are you okay if I discuss this with my colleague? And they're like, yes, please. I'd love to get their input, because we do have ⁓ case study reviews that we do every two weeks together. So we all come together, put our heads together, and we'll discuss, right? We'll discuss the cases. We'll be like, what would you do in this case? Here's how I would approach it. And honestly, seeing all those different angles and all those different experts coming together and sharing.
Michelle Stainton (47:06)
See?
Mikelle Ethier (47:17)
amazing.
Daiana Castleman (47:27)
their expertise, I think is like invaluable. It really is. ⁓ So it's wonderful to be part of the team. Yeah, I'm really honored to help women navigate their midlife care there. And I also I just wanted to highlight I'm in Toronto and then I also have a practice in Oakville as well. Yeah.
Michelle Stainton (47:45)
okay. Awesome. Actually,
it's interesting. The team aspect is really key to me these days. I have a friend who ⁓ has been suffering from anxiety and also from high blood pressure. And finally, they went to a different clinic, but they finally put the pieces together when they had… They were being treated separately by different practitioners for these. And finally, someone looked and went, ⁓ well, you're… ⁓
particular blood pressure meds that you're on that actually there's a known side effect of that is higher anxiety, like anxiety, and like, bam, like if you, if they didn't like, finally, they have a team looking at this and talking and having these conversations and they can go, oh, wait, let's flag this. And now they're feeling a lot better. You know, it's not, it's not magical overnight, but it's so important instead of being in these silos where no one is looking after our whole health. So that's awesome. Yeah. Yeah. So good.
Daiana Castleman (48:20)
Mm-hmm.
Hmm.
100%. Yeah.
Michelle Stainton (48:43)
⁓ What would love to know what is the one thing you want everyone, sorry, I'll ask that question again. What's the one thing, Dr. Diana, that you would love every woman to know about perimenopause and their heart health?
Daiana Castleman (48:56)
So many things. But if I were to summarize this conversation, I would say prevention is where you have the most impact, right? What you do now in your 40s and 50s can change the trajectory of your heart health for decades. So that's incredibly valuable. I do think cardiovascular disease remains under-detected, under-treated in women. I…
wanted to give some tips and tools today of what to look for, right? So that that is not used, that you don't feel like you're being missed because again, perimetopause is critical window of opportunity, right? Where we can really have a big impact. ⁓ Again, we talked about the risk score. So just know that it shouldn't be full treatment plans just based on that risk score itself, that you've not failed if you are taking medication. And the other thing I wanted to mention actually that I… ⁓
got to highlight is that there are also very sex specific risk factors that I think should really be part of your cardiovascular screening. So for example, for women knowing your pregnancy outcomes, did you have preeclampsia, gestational diabetes, gestational hypertension that actually impacts your cardiovascular risk down the road. And again, these are things that risk scores don't take into account, right? Do you have PCOS like looking at your
Mikelle Ethier (50:05)
Hmm.
Daiana Castleman (50:17)
history there because that is associated with a higher prevalence of hypertension metabolic syndrome. So important that we are also as clinicians making sure that we're looking at these specific risk factors. And if you feel like you have not been asked about it in your visits, bringing that up as well in your healthcare visits, because like I said, that does also
change your risk. And I think that's really important to highlight as well. And then the other thing I would really say is that also ethnicity does play a big role. Research shows that South Asian women, Hispanic, Chinese, North American, and Afro-Caribbean women also have greater risk factors of cardiovascular disease. So keeping in mind the ethnicity piece as well. But the good news is you can do a lot of good. Yeah. Yeah.
Michelle Stainton (51:02)
you
Mikelle Ethier (51:04)
Amazing. So Michelle, are
still super stressed or do feel better?
Michelle Stainton (51:07)
No, I'm
good. good now. Actually, yes, I feel good. The blood pressure has come down.
Daiana Castleman (51:09)
Okay, good.
Mikelle Ethier (51:10)
Mission accomplished,
Dr. Diana, mission accomplished. ⁓ Are we going to get to see you in person at the National Menopause Show? Yay. Excellent. Excellent. Good. Well, we will find you. Maybe we can have a little quick chat on the floor. Are you speaking or? Okay. Okay. Okay. Well, we'll get you to speak to us again at the booth. Maybe that'd be great. That'd be great. Okay. Well, we can't wait to see you in person.
Daiana Castleman (51:13)
Good. Good.
Yes, I am going to be there with the Loom team. Yes, yes, yes.
Michelle Stainton (51:19)
Yay! ⁓ good. That's awesome.
Daiana Castleman (51:27)
Yes.
I won't be speaking, but I'll be at the booth, at the Lume booth. Yeah. Yeah. Yes. Looking forward to it.
Michelle Stainton (51:37)
Love it.
Mikelle Ethier (51:39)
⁓ thank you. This mind blowing. And I'm going to make sure that everyone I know listens to this start to actually, once they start, they're going to absolutely want to finish because this is incredible information. Thank you.
Daiana Castleman (51:39)
Yes.
So glad.
Thank you.
Michelle Stainton (51:54)
Yeah, no, was wonderful. Incredible. Thank you. Thank you. Yay.
Daiana Castleman (51:57)
Thank you for having me.
Mikelle Ethier (51:58)
Yay.
Michelle Stainton (52:01)
Make before you. Yeah, I was gonna say, yeah, keep rolling.
Mikelle Ethier (52:00)
I'm going to keep rolling or
I was going to keep rolling. And do you have a few more minutes for us to ask you just a couple of hot tips? Okay. Okay.
Daiana Castleman (52:07)
Yes. Yes, I think
I have time for one, if that's okay. Sorry, I have a meeting at 12. I'm happy to do the vaginal estrogen for the face because I feel like that one's pretty quick and it's such a hot topic.
Mikelle Ethier (52:12)
Yeah, yeah, absolutely. Not a problem.
Okay, that's a hot topic. Okay,
Michelle Stainton (52:19)
Ow.
Nick, do you want to ask it?
Mikelle Ethier (52:22)
sure, sure, okay. Our question today for Dr. Diana Castleman is, I've been seeing posts on social media where women are using vaginal estrogen on their face to improve their skin. Does this work?
Daiana Castleman (52:38)
Great question. So there are some small limited studies, that's the key word, small, that show it can help in certain selected areas. So for example, the area that a lot of my patients ask me about is the area under their eyes, like they're talking about fine wrinkles. There was actually a study, it was published in 1994, that looked at using Premarin cream, like Premarin vaginal cream and…
It did show to have some increases in like skin thickness and also fine wrinkles. Now, here's what I wanna highlight in how I approach this with my patients. I don't think we should be lathering vaginal estrogen all over our face and our necks and everywhere. I think we need to be extra cautious there. It can also worsen melasma. So if you do have melasma being very careful there because it can definitely aggravate it. Again,
with the studies that we do have, if we're using like a small, very small amount, and we're almost like dabbing it under our eyes, we don't necessarily with those studies, again, they were like about 24 weeks. So we just don't have long-term data. So if we're using that for years and years, again, that's where we just need longer term study. So that's what I like to say to my patients. The other thing is that we have proven efficacy with many, many different products.
Number one being retinoids, they're the mainstay first line treatment for our skin. We have decades of research on retinoids and science behind them. They are really proven to work. We have research on DNA repair enzymes on vitamin C using broad spectrum sunscreen. So I think there's many, many different ⁓ ways and like really good research that we have on other tools. And I don't think this has to be part of the skin toolkit, but I do know that a lot of my patients will.
will use this based on what they see on social media. Again, if we're tapping a small amount under eyes, I don't think it's a huge concern if we're using some of that vaginal cream, but please don't lather it everywhere.
Mikelle Ethier (54:40)
Yeah, because we just don't know the risks, right? Yeah. Thank you.
Daiana Castleman (54:43)
We don't know. Yeah.
You're welcome. Yeah.
Michelle Stainton (54:46)
Okay,
let's hit stop and then we just need to wait for it to upload.
