Episode 107 Summary
- Dr. Bret Scher is a medical doctor and the Clinical Director of the Diet Doctor website. He is a cardiologist and an expert in the field of low carb lifestyles and cholesterol.
- It is important to note that the majority of individuals on a ketogenic diet who commence the diet to lose weight or improve their type 2 diabetes do NOT see an increase in their LDL levels.
- Lean Mass Hyper-responders - These are individuals who are often lean, fit and healthy when commencing a ketogenic diet. In this minority group LDL levels are sometimes seen to increase significantly
- Think beyond just LDL when it comes to cardiovascular risk - There is an underlying belief that lowering LDL will lower cardiovascular risk factors but it's important to look beyond this. When it comes to cardiovascular risk, first consider other risk factors beyond LDL. These may include things like blood sugar, blood pressure, insulin levels, and inflammatory markers. Once other potential risk factors have been considered, then look at tests that can give more information about the state of the arteries, such as calcium scores, carotid intima-media thickness (CIMT) testing, and CT angiograms. These tests can help to identify whether there is plaque present in the arteries and can give clues as to the type of plaque present. Based on the results of these tests, a decision can be made with the individual as to whether or not medications may be needed to help lower LDL or APO B levels.
- The level of elevation of LDL can still be significant as a risk factor - The higher volumes of LDL have a greater chance of being oxidated or glycated in the body.
- Lipoprotein(a) levels can be helpful in cardiac risk stratification for an individual.
- Dr Bret Scher mentions Zetia, Ezetimide and PCSK9 inhibitors as potential options for clinicians to look into.
- Mindfulness and meditation are invaluable tools in protecting cardiac health - Chronic stress can have physically detrimental effects on the body. We are often not able to remove the stressors but we can train our bodies to react less to those same stressors.
Dr. Bret Scher, MD:
Dr. Bret Scher is a board certified cardiologist and lipidologist practicing in San Diego and licensed to practice in seven states. He’s full-time Medical Director for dietdoctor.com, writes medical blogs, reviews guides and news stories for medical accuracy and hosts The Diet Doctor Podcast.
Dr. Scher’s main focus is on preventing and reversing heart disease naturally - rather than putting patients on medication and performing surgery. When he started his own preventative wellness center he was introduced to the whole low-carb world. Being a bit skeptical at first, he was soon convinced by the benefits of a low-carb diet.
In Dr. Scher’s many patients suffering from heart disease, he found that there was a big overlap with cardiovascular disease, diabetes, metabolic syndrome and insulin resistance. It was all very interrelated. When he started treating his patients who suffered from heart disease with a low-carb diet, he could quickly see signs of improvements or even full reversal in all of these diseases.
Dr. Scher has also obtained specialized certifications in functional medicine, nutrition, personal training, and behavior modification.
He is also the author of the book Your best health ever!
Dr Bret Scher has a blog and website at lowcarbcardiologist.com.
Dr. Bret Scher is on Twitter, Instagram and LinkedIn.
If you want to contact Dr. Scher you can also send an email to [email protected]. Please note that Dr. Scher can’t give personal medical advice about diet or health via email.
Show notes:
A Juicy Scientific Episode
Dr Mary Barson: (0:11) Hello, my lovely listeners. I'm Dr. Mary Barson.
Dr Lucy Burns: (0:15) And I'm Dr. Lucy Burns. Welcome to this episode of Real Health and Weight Loss. Good morning gorgeous friends. This is a bonus episode and you'll note that it's not dropping on our usual day. But I had the pleasure of interviewing Dr. Bret Scher from Diet Doctor podcast, who is a phenomenal human and the Medical Director of the Diet Doctor website, and many of my doctor colleagues who also listen to this podcast are very interested in some of the nuances of low carb lifestyle, in particular related to cholesterol. So I've asked him about some of the more technical aspects. Now, if you're a member of the general public, then you still will get much information out of this. If you're what we often call a citizen scientist, so if you've been learning about some of the more technical aspects, then you will definitely get more out of this. And if you're a medical doctor, then please listen to today's episode. Have a wonderful, wonderful day lovelies, and I'm pleased to welcome Dr. Bret Scher.
(1:29) Wonderful, Bret, thank you so much for agreeing to chat with us. And for our lovely listeners. This is really aimed at the audience that we have that are doctors. So feel free to listen, but there may be some technicalities in there. So I just wanted to preface that for this episode. So don't worry if it goes over your head. But we have a lot of doctors that follow this podcast. So we wanted to get into some nitty gritty. So Bret, one of the things that I find, and I'm sure you do too, is that, you know, somebody goes on a low carb lifestyle, you know, their markers improve, blood sugar is much better, but cholesterol goes sky high. Now in Australia, and again, I'm not completely familiar with translating the numbers to Americans. But in Australia, you know, a normal cholesterol might be around about sixish, or under, in fact five they want. But you know, we see numbers that are 10, so double what would be considered an acceptable cholesterol result. And so the patient is sitting there going, Oh, my God, look at my cholesterol, what am I going to do? What's your approach?
Dr Bret Scher: (2:33) Yeah, it's a really good question. And I mean, it's sort of like, partially a joke, and partially not - if it weren't for LDL, everybody would be on a low carb diet. Kind of partially true. And to rewind for a second, though, one of the things that really bothers me is when physicians, well meaning physicians would say, “No, you shouldn't start a keto diet, because it's going to destroy your cholesterol and your LDL”. And that's completely false. I mean, if you look at the majority of the studies, where people are starting a keto diet for weight loss, or to improve type two diabetes, the average and the majority of the people do not see an increase in their LDL. So I think that's the first and most important message that we have to repeat over and over and over again, that is not the majority. Now, you know, this topic gets a lot of airtime, because it's sort of the one negative thing seen with a low carb diet, so it gets a lot of airtime. But the first thing I always like to start with is it's the minority, not the majority who get it. Now, it might be the majority of a certain subset of people who get it, so not those who are, you know, starting a keto diet for weight loss and for type two diabetes, but those who are doing it for some other reason who are already lean and already active. Of course, you know, Dave Feldman has coined it as the lean mass hyper responder and for good reason with a recent publication showing that they tend to be leaner, and more metabolically healthy who get this rise in LDL. So in that small subset of people, it could be the majority, but overall, it's the minority. Okay, so after clarifying that, what's the approach? Well, the approach is getting a better idea of cardiovascular risk. And the trap that cardiology has fallen into is that cardiovascular risk equals LDL period. And most doctors wouldn't say they believe that statement, but the way our guidelines are set up and the way most doctors practice, it's set up that way. And that's what we have to get past, that cardiovascular risk does not equal LDL. And metabolic health is probably more important for cardiovascular risk than just LDL. So there's definitely an offset that happens if LDL goes up but A1c goes down, blood sugar goes down, insulin goes down, triglycerides go down, ACL goes down, blood pressure goes down, which is frequently what you see, then is that rise in LDL concerning? But now we have to say, Okay, how big is that rise in LDL? And I think that's important. Not everybody agrees, but I think the absolute rise is important and the analogy I like to bring is homozygous familial hypercholesterolemia. versus heterozygous. Right, homozygous where LDLs are in the 5-600range from milligrammes per deciliter, sorry, we're talking different.
Dr Lucy Burns: (5:08) I know, that's alright. Okay.
Dr Bret Scher: (5:11) In homozygous it's almost uniformly 100%, they get cardiovascular disease. With heterozygous, it's a completely different disease process where it’s nowhere near 100%. Right. So, I'd like to draw that analogy. I get into trouble by drawing that analogy because elevated LDL with a low carb diet is not FH, they're not the same thing. So that's where I get into trouble drawing the analogy. But the point of the analogy is how high is the elevation because we talk about LDL elevation as if it's one thing which it is not. The second is, you know, actually calculating cardiovascular risk. Virta Health did a fantastic analysis of one of their studies, where LDL went up 10%. But their calculated cardiovascular risk went down 12%. Right. So why would you be concerned about an LDL rise of 10% if your cardiovascular risk went down 12%? And how did that happen? Well, Apo B didn't change. Apo B is a better marker than LDL. The small LDL particles went down, the VLDL particles went down, the triglycerides went down and HDL went up. So taken as a whole, it's a net cardiovascular benefit. So that's getting out of this realm of just LDL, to evaluating the better markers, and the more important in the broader markers of cardiovascular risk. And then beyond that, you can look at imaging, you know, calcium scores are very helpful. They also need to be treated carefully, though, right, a zero calcium score now doesn't mean it's always going to stay zero. And an elevated calcium score now, doesn't mean you're a quote, unquote, ticking time bomb, as so many doctors like to say, and it doesn't mean you're in immediate danger. But all these need to be factored in together and treated with some nuance. So I don't know, I guess maybe I'm at the risk of babbling here. But that's sort of like my process of just you have to think deeper and beyond just LDL.
Dr Lucy Burns: (7:05) Absolutely. And, yeah, I love that. And I think so, possibly like you I do a little formula where, you know, if I think they're at cardiovascular, if they're at risk of high cardiovascular high risk, cardiovascular disease - God talk about babbling! Then, you know, I will often do a calcium score. And if it's zero, it's like, Oh, good, you know, and if their LDL is, you know, all large particles, you can kind of go, “Oh, good”. And so you put them away, you go, good, excellent, you feel very confident in reassuring the patient and reassuring yourself that all is well. But what happens when people fall into that mid range? So maybe their calcium score is not zero? Maybe it's not 1000. But maybe it's, you know, 120, or something, and maybe their LDL particle size is borderline or low? What do you do with those people?
Dr Bret Scher: (7:57) So I want to answer that question. But first, let me go back to the first patient, you mentioned where the calcium score is zero, and they don't have many small particles. So I would push back a little bit to saying they're fine, and instead say they're fine for now. And it doesn't mean forget about it, you know, you don't have to worry about it anymore. But I still want to keep close eyes on those patients, because we don't know what's going to happen, right? We don't know what the natural history of this is. Now, I don't think it's going to be dangerous and harmful, but I don't have any evidence to prove that. So I don't want to cut them loose and make them think you've got your stamp of approval, don't worry about it. Instead, I want to say, look, let's keep monitoring you. These are the things we're going to keep following etc. So just that small, little caveat, which most people agree with, but I just want to make sure it's very explicit that we're saying that.
(8:44) So the second one you presented where they don't fit in that category, they have a slightly elevated calcium score, and their particle size isn't perfect. Yeah, I mean, that's definitely more troublesome to try and figure out what the right thing to do is and then the discussion is, well, you know, is it the low carb lifestyle that caused this? You can't prove that but my gut says it almost never is, right? If they've been on low carb for six months, but they've been on a standard Western diet for 30 years, and insulin resistant metabolic syndrome for 30 years, what's more likely to have contributed to that calcium score? Right? So there's one game you have to play to try and figure out what's the contributing factors? And are those contributing factors still present? So that's where you have to ask what's your blood sugar? What's your blood pressure? What's your insulin level? What are your inflammatory markers, looking for something that can still be present that is a clear cardiovascular risk factor that you can try and intervene upon.
(9:40) Then the next thing is, well, what other testing can you follow? Because what I want to know is, if that's their first calcium score, that's their baseline. What I really want to know is what happens over time. Now, you can't get calcium scores every two or three months or four months, right? One they're not going to change and two, it's just a lot of radiation to do it that much. So calcium scores might be good on a year, two year basis. Something like the carotid intima media thickness testing can be helpful to follow more regularly because there's no radiation involved. If you compare a one time test of the CIMT to the calcium score, the calcium score is far more predictive than CIMT. But where I find the use of a CIMT is following it serially and much shorter time intervals because it changes quicker than calcium scores, and there's no radiation involved so you can follow it. So it's another way sort of just to keep a closer tab on the patients and how they're progressing. And then another one that I really like is actually a CT angiogram and this is also a little controversial. One because there's more radiation but with technology now, you can get a CT angiogram for 2, 3, 4 millisieverts, you know, whereas calcium scores are one. Whereas when I started doing CT angiograms 20 years ago, it was like, you know, 15 millisieverts, right, so there's a much bigger difference, but they're much lower now. But also, they're much more expensive. Like if a calcium score is 150 bucks, you know, a CT angiogram is a thousand dollars US, right? So insurance isn't gonna cover it here in the US for these types of indications. But with that run in, the reason I like to get them is because you can actually see what the plaque looks like. For calcium score, all you see is calcium in the wall of the artery, you know nothing about what's going on in the lumen and you know, nothing about soft plaque or mixed plaque. So if you get that CT angiogram, and there's no luminal plaque, it's all calcium in the wall, and it's all calcified with no soft plaque. To me, that feels very different than having actual luminal plaque and having a mix of soft and calcified plaque. Now, I can't point to studies showing 10 year outcome data that these are different, but to me with the data we have, you know, it just makes sense. And sometimes we have to admit that we're, you know, working outside of what the evidence shows in a way that we're trying to help our patients beyond what the guidelines say. So this is one of those areas where I think CT angiograms can be helpful in that way. But then, sort of like we've talked about before, then the question becomes, do medications have a role here? And I think there are times where medications have a role, where yes, someone should be on a low carb diet, because it's improving their life and improving their metabolic health. And yes, maybe they need a medication to lower their Apo B particles, because they've shown that they're prone to developing plaque in their arteries. And Apo B is one of the risk factors, not the only risk factor, but one of the risk factors that can contribute to plaque in the artery. So along with treating all those other risk factors, you also want to treat the Apo B in some patients because that is one of the risk factors. So there's room for both of those.
Dr Lucy Burns: (12:37) Yes, wonderful. I love that. And so what do you use to treat the small particles and Apo B?
Dr Bret Scher: (12:44) Well, so small particles and Apo B you would usually use two different things because if you're just treating Apo B, statins can certainly be helpful. But statins are not good for treating the small particles. In fact, statins can increase small particles, paradoxically, which is one of those things that drive people crazy, or you know, sort of against statins as they see this increase small particles. So I usually like to use statins at the lowest effective dose. I also like to use Zetia or Ezetimibe because it works with a completely different mechanism of action than statins and does not have near the side effects of statins. And what I've found in my practice, for people eating low carb or keto it's very effective, it can reduce LDL or Apo B by 40-50%. Whereas in the general population, it's about 15 to 20%, which is why many cardiologists don't like it. But I think in the Keto world, it's more effective than that.
(13:37) So I, I really like the combination of a low dose statin and Zetia to lower Apo B but again, you know, there's no formula, I'm not going to use that in everybody who's got a calcium score above x, right, you really need to individualise this with your patients. You know, the PCSK9 inhibitors are, I guess, one of the newer LDL lowering medications. And I've got to say I really like them because of their mechanism of action. Again, it's got nothing to do with cholesterol production. I like the body being able to produce more cholesterol if it needs to. But instead, the way the PCSK9 inhibitors work is by increasing the receptors on the liver to clear the LDL from the system. And I think residence time of LDL does have something to do with plaque development. Because the longer LDL is in the system, the longer it's around to get glycated or oxidated or retained in the vessel wall. But if you're having a quicker turnover of LDL, to me, it just again mechanistically makes sense that that should be a lower risk. So if you're clearing more LDL through the receptor, to me, that seems like a good mechanism if you want to lower your LDL or Apo B. So you know all three of those have a role and again, dealing with the individual to figure out what's the best approach is for them. And there are supplements too, like sometimes I'll use Berberine or red yeast rice if you just want to get like a small effect and not as much of a dramatic effect. Those can be really helpful. But it's all part of the treatment program and not the treatment, end all and be all and it's got to be used with nutrition, with exercise, with stress management, with prioritising sleep. All those things have to come into play and not just here's your prescription, see you later.
Dr Lucy Burns: (15:17) Wonderful. I love that. I'll loop back to stress in a minute. But I also have a question about lipoprotein(a), because that comes up time and time again, in our doctors Facebook group. What are your thoughts on its significance? And, you know, do you test for it? And what do you do with it?
Dr Bret Scher: (15:34) Yeah I absolutely test for it. I mean, I think it's definitely, I guess you could say an emerging risk factor, has probably always been a risk factor. But now that they're developing drugs for it now, some people are studying it, because there are drugs in development, which is kind of sad that that's what it takes to study it. But yes, I think the risks of elevated Lp(a) are significant. It's really interesting to see a couple of studies show that the risk is reduced or even not even present, if there's no inflammation. I find those, they’re, I think there may be two studies, one looking at CRP and one looking at LpA2 showing that association, which I find really interesting, but I still take it seriously, even in the absence of inflammation as something to look into. You know, it's frustrating that there isn't a great way to lower it, you know, lifestyle is not going to do it, you know, keto diet is probably the best diet to do it. But even then it's a little inconsistent and not really all that dramatic in terms of the lowering of it. So that can be a little frustrating, because if you identify it, it's one more risk factor. So I would, you know, put that as a, if you're trying to better risk stratify someone I think is very important. Niacin can help to a degree, you know, proline, lysine, carnitine combination can help to a degree, but it's like a fistful of supplements for a small change. PCSK9 inhibitors can lower it as well. That's probably the go to for someone who has very high Apo B and high Lp(a) who has known coronary disease, I would probably favour that as a first intervention. But I think its biggest utility is just helping risk stratify someone a little bit further.
Dr Lucy Burns: (17:14) Oh, good. Yeah, that's a great point. Because I must say, in my mind, I've gone oh, well, we can't do much about it. So you know, I often think, well, if you know, when I decide to order a test, it's because I have an action that I'm going to do, you know, I don't just order a barrage of tests for just fun. You go, right, well, what do we get? How are we going to change these, but I hadn't thought of just using it as part of your risk management strategy. So that's excellent. Thank you.
Dr Bret Scher: (17:40) Yeah. So for that, in that setting a one time measurement is probably all you need. Right? If you're not going to intervene to try and change it, you measure it once for risk stratification, and you're done. If you're going to treat them with PCSK9 inhibitors to see what effect it has, okay, then, then it's something to follow. But otherwise, you don't need to follow it if it's just for risk stratification.
Dr Lucy Burns: (17:58) Yeah. And how much of a risk do you think it adds to people's risk for cardiovascular disease?
Dr Bret Scher: (18:06) That's a tough question to answer. But, you know, when you look at studies, and they're imperfect studies, but you look at studies, people have had heart attacks, and they, you know, what were their risk factors beforehand? And what are the odds ratio, if you have elevated this and that. Lp(a) will usually come out higher than LDL in terms of an odds ratio, you know, maybe about the same as Apo B, but definitely higher than LDL in terms of odds ratio for risk? So, yeah, I think it's, it's significant, something to pay attention to.
Dr Lucy Burns: (18:34) And it's interesting, because I know in my, you know, just standard medical community that if somebody, if a GP, for example, is aware of the significance of Lp(a) and not all of them are, but what they'll do is go Oh, they've got Lp(a), I'll put them on a statin. What are your thoughts on that?
Dr Bret Scher: (18:54) Yeah, that's guideline therapy. Guideline therapy is treatment of elevated Lp(a) is a statin, even though that can increase Lp(a), wait a second, what? Yeah, it makes no sense, right? On the surface, it makes no sense. But, but that's where this belief that cardiovascular risk equals LDL, so all you have to do is lower LDL and you're improving their cardiovascular risk. Well, I don't know that I agree with that. Like, I'm not sure you know, if LDL is automatically cardiovascular risk, and therefore, you know, it would be like saying you have high blood pressure. Okay, let's put you on, leave your blood pressure where it is, leave it at 160 over 100. But we'll put you on a statin and that's the treatment for high blood pressure. To me, it's like the same analogy right there. But I would never do that. I would never do that. You would find a way to treat the blood pressure, hopefully with lifestyle, medications if needed. But since you can't do that, as well for Lp(a) they say, Oh just go on a statin. I don't know if that's the right thing to do. Now, I would say the approach is to reduce cardiovascular risk as much as you can in as many areas as you can. But that doesn't equal LDL.
Dr Lucy Burns: (20:03) Excellent, which is a lovely segue into my next question on, on stress and its effect on cardiovascular health. So when I was going through medical school, which was, you know, last millennium we had in our risk factors, so, you know, obviously smoking and the usual things, but we had type A personality was considered to be a risk factor for cardiovascular disease, and that's dropped off. Nobody puts that in their risks anymore. But I'm really interested to hear your take on our current stressful lives, like, where do you think that falls into risk? And what's the mechanism?
Dr Bret Scher: (20:39) Yeah, well, I think, you know, the mechanism sort of makes sense. If you're, if you're chronically hyper adrenergic, you've got your adrenaline pumping, and you get your cortisol going and that can raise insulin that can be increased pro thrombotic factors, you know, all that cascade of effects can is not where you want to be clearly. So there are a couple of things I mean, it can acutely lead to problems, again, if you're increasing thrombotic factors or inflammatory factors that can acutely happen. And it can chronically cause problems, if you have chronic, if it's worsening insulin resistance, and then that leads to a cascade effect chronically. So I think it can affect you in two different ways. And when we talk about stress, you have to really differentiate acute stress from chronic stress. And, you know, if you've got a work project that's got to be done, acute stress is what you need, right? You need that adrenaline rush, you need that hyper focus, but then you need to be able to turn it off. And that's the problem I think Modern society has for us, is that we're not ever turning off that stress, because then we go on Twitter and see what's going on, you know, people yelling at each other and see about this shooting, and this bad news happening over here and this environmental disaster over there. And how can you not be stressed with all that, right? And so, I mean, if nothing else, what it does for your mental health, forget about your physical health, your mental health, it's, I think, really detrimental for that as well. And that's where being able to teach your body to sort of not respond to these things as emotionally and as strongly and that's, you know, whether it's a mindfulness or meditation or some sort of practice, to just teach your body to acknowledge things and not react so strongly to them, and be able to blunt that adrenaline response, be able to blunt that blood pressure rise, and that heart rate rise chronically right to still have it happen acutely, when it's for your benefit to but be able to blunt it from a chronic standpoint, I think that's a vital health intervention that not enough people pay attention to.
Dr Lucy Burns: (22:35) 100,000,000% agree. It's a bit like, you know, when patients sometimes feel dismissed, if they go to the doctor, and the doctor says it's a virus, and they go, the doctor just said it was a virus. And it's like, you know, it's almost like they think the doctor doesn't believe me, of course, we now know, in recent time, what viruses can do. But it’s the same, if you say to somebody, this is stress related, they'll sometimes feel like you're dismissing them that it's not real. Whereas we know, their stress response is entirely real. And it's physical.
Dr Bret Scher: (23:08) The mind body connection is, you know, I think part of the problem is like, when people think of mind body connection, sometimes they think of like, ooh, that's really woowoo. That's really new age. But no, I mean, it's simple. Like, what happens to your body affects your mind, what happens, your mind affects your body. Like, it's, that's not complicated. It doesn't have to be some ethereal concept out there. It's very simple.
Dr Lucy Burns: (23:29) Absolutely, yes. Just. And I think also, sometimes people think they have no control over their stress, like they think, because they've got a lot of stuff going on in their life, that they're helpless to do anything about that. Yeah. And what are your thoughts on that?
Dr Bret Scher: (23:42) Yeah, and that's where it's not about removing the stress, it's about controlling how you react to the stress. You know, if you're in a bad job, a bad relationship, you know, you can try and get out of those, but you can't always and you're certainly not going to be able to fix the global environmental crisis or the you know, what's going on in politics or you know, whatever's going on on Twitter, you're not going to be able to fix that. But you can fix how you're, you can't fix, you can control how your body reacts to that. So it's, yeah, not saying eliminate, you're just kind of like with the thing with meditation, right to say clear your mind. No, you don't have to clear your mind with meditation, thoughts come and thoughts go, you recognise them. And then you don't react to them and you go back to your breathing, you don't try and eliminate because then you're like, Okay, clear, my mind, clear my mind, Clear my mind, right. Same sort of thing. You're not trying to eliminate stress, you're trying to acknowledge that stress is there, but alter how your body and how you react to it.
Dr Lucy Burns: (24:36) Absolutely. And I think probably for most of our medical colleagues, that it is something that we don't address enough in our clinical practice, and we probably don't address enough for even ourselves.
Dr Bret Scher: (24:48) Yes, yes. Very good point.
Dr Lucy Burns: (24:51) Wonderful. Well, Bret, this has been so helpful. And I'm sure that as I said, not, you know, my medical colleagues will be really helped by your information, but actually yeah, I think probably general public as well, because really it all, you know, I loved the line that you you said, which was that, you know, lifestyle and medicine in the lowest effective dose.
Dr Bret Scher: (25:11) Yeah.
Dr Lucy Burns: (25:12) you know, and lifestyle can help you lower that dose. And that's really where the magic happens. Absolutely. Well said. Wonderful. Thank you. Thank you once again, and I'm sure everyone will enjoy this episode.
Dr Bret Scher: (25:25) Thank you. It's been my pleasure.
Dr Lucy Burns: (25:32) So my lovely listeners that ends this episode of Real Health and Weight Loss. I'm Dr. Lucy Burns.
Dr Mary Barson: (25:39) And I'm Dr. Mary Barson. We’re from Real Life Medicine. To contact us, please visit rlmedicine.com.
Dr Lucy Burns: (25:50) And until next time, thanks for listening. The information shared on the Real Health and Weight Loss podcast, including show notes and links provides general information only. It is not a substitute, nor is it intended to provide individualised medical advice, diagnosis or treatment, nor can it be construed as such. Please consult your doctor for any medical concerns.
