Is there a correlation between undiagnosed obstructive sleep apnea and adverse cardiac outcomes in South Asians at a rate higher than other ethnicities? Is there any research in this space? Hyperlipidemia seems to be the focus of attention, and perhaps rightly so, but curious a both OSA as a comorbidity.

ANSWER

1.⁠ ⁠Does OSA contribute to heart disease? Absolutely yes. It is an important risk factor (although associated with several confounders such as high BMI and other co-morbidities)….However direct mechanisms contribute to a high risk of ischemic heart disease among people with OSA: 

a) Each episode of apnea leads to adrenergic hormone release which increases BP and has direct adverse effects on blood vessels (inflammation similar to that caused by inflammatory foods etc)

b) OSA can cause direct disruption in cardiac function by changing normal fluctuations in HR and BP

2.⁠ ⁠Does OSA happen more often in South Asians (unrelated to confounders) is a more open question with conflicting studies from the US and UK, some showing an increased incidence and others refuting such an increased incidence.

I had a question about cardiac arrest attack ( not sure using  rights words). Does the body gives some indication of tiredness or any other symptoms so one can be alert of ??

ANSWER

This is a wonderful Question and an extremely important one. Framed in a simpler way: Are there ANY warning signs of SUDDEN CARDIAC DEATH? Sadly, the answer is no at this time. By it’s very nature SUDDEN implies that there is sudden and unexpected collapse (often from a massive heart attack or a related arrhythmia)…All that being said, ALL South Asians should be hyper-vigilant of the risks of silent cardiac disease and the FIRST steThis is a wonderful Question and an extremely important one. Framed in a simpler way: Are there ANY warning signs of SUDDEN CARDIAC DEATH? Sadly, the answer is no at this time. By it’s very nature SUDDEN implies that there is sudden and unexpected collapse (often from a massive heart attack or a related arrhythmia)…All that being said, ALL South Asians should be hyper-vigilant of the risks of silent cardiac disease and the FIRST step in that direction should be KNOW YOURSELF!!! (BMI, Waist Circ, LDL, Lpa, CAC score etc.)!!!

Sir what is the cause of cardiac arrests in India specially post covid.

ANSWER

Great question Harsh! Researched this extensively during our documentary , including detailed conversations with Dr. Prabhakaran Dorairaj (head of CCDC in India)……Overall the following conclusion: There was a definite increase in cardiac mortality from the direct inflammatory effects of Covid 19. However, the high risk of cardiac pathology in South Asians has a much more complex and nuanced origin (with multiple genetic and environmental life style contributions).

ANSWER:

Great Q. Detailed convo around this will be beyond the scope of this forum, but VERY thought provoking counter-arguments (and true scientific criticism) about the data from Blue Zones research is worth mentioning.  

https://jheor.org/post/2682-ig-nobel-prize-winning-research-longevity-claims-may-reflect-lousy-birth-and-death-recordkeeping-more-than-accurate-human-lifespans

Related NY Times article

www.nytimes.com/2024/10/24/well/live/blue-zones-longevity-aging.html?unlocked_article_code=1.bE8.WDxs.r8MD23XXktSG&smid=url-share 

Walnuts can increase HDL? 

ANSWER:

OVERALL, 10-12 nuts a day are recommended daily. Studies are mixed, but one study showed a 6.3% increase in HDL using 30 grams walnuts daily (which is 10 whole walnuts). By way of context, if your HDL is 35, this means a 2 point increase in HDL only.

Do we require a referral from our PCP to get a CAC scan done? 

ANSWER:

 Yes in the US. Costs around $100 (most insurances do not cover), In India costs around 3-4 thousand rupees

ANSWER:

Hi Vini , thank you for a great question. This is the story of my life and has been very well addressed in the documentary. There’s clear evidence from multiple studies ( SWAN  and others that there is an increase in LDL and apo Lipo protein B right around peri  menopause, and after menopause. This is attributed to a decrease in estrogen which improves the LDL clearance from the liver. It is also attributed to an average of 10 to 15 pound weight gain primarily visceral around the abdomen, which is associated with high LDL.

Is it important to focus on LDL rather than HDL ? How to improve HDL ?

ANSWER:

Out of the two big culprits LDL is the better one to focus on because you can easily improve it with medications and diet .Even with aggressive diet control you can improve the LDL by 20 to 30% .HDL is usually low in south Asians and is very hard to increase and only aggressive exercise can increase HDL. Some medications may increase a bit (such as Niacin) but have side effects. Walnuts may increase slightly as well

Statins normally would decrease the LDL.  But aren’t there a lot of side effects ?

ANSWER:

There are minimal and reversible side effects  . But  clearly overrated. The side effects typically happen more with higher dosages . There are also supplements like Vit D , Co Q 10 that can decrease side effects . This topic will be covered at length very soon.

Please address prediabetes and diabetes in relation to cardiovascular disease ?

ANSWER:

Yes, both pre-diabetes and diabetes are very clearly associated with increased cardiovascular risk. There’s tons of medical data behind it and it primarily has to do with insulin resistance, which can increase inflammation at the vessel wall, and it produces free fatty acid which directly is linked to development of plaque . Roughly one in four people have pre-diabetes and one in 11 have diabetes . The diabetes figure  is close to 1:8  for south Asians. So it is very important that we try to control both diabetes and pre-diabetes very aggressively. 

What is high dose of statins. Will it be 20 mg Rosuvastatin? will it also have an increased incidence of prediabetes/diabetes?

ANSWER:

Medication use is all about BALANCING risks and benefits and never a binary “good” or “bad”…so here is the low down:

BENEFIT: Remarkable heart attack prevention benefit: 30-50 people need treated to prevent one heart attack—so HIGHLY BENEFICIAL

POTENTIAL diabetes risk: about 300 people need treated before 1 new episode of diabetes happens

Add to that , that the potential risk above is in people already pre-disposed and are therefore at higher risk of heart attacks

 We strongly urge people to stay on statins (if indicated) to reduce heart attack risk and not to be overly concerned about the SMALL increased risk of pre-diabetes. 

Traditionally in Indian culture parents feel obliged to feed the children and make sure that they don't go hungry. But they struggle to understand that it is easily overdone and children are fed more than necessary calories and are not necessarily the right mix and nutritious food. The potential  guilt and clouded nature of love for children is leading or is going to lead to an epidemic of obesity and heart disease. With our own close relatives this is a very difficult topic to approach and talk about. The volumes of processed foods consumed is getting higher and higher constantly. Do you have any suggestions or techniques or ways to change this culture for the future. There is no quick solution to this but this has to be a generational shift in attitudes and expectations. 

ANSWER:

This is a very true and insightful observation Anil! A lot of hard data also exists on this from work done by Ranjan Yajnik (Pune) and Dr. Usha Sriram (Chennai) , which is why preventive efforts in cardiac prevention are never too early to start—In fact ideal time is in childhood! This is the time the foundation is being laid for either good health behaviors and preventive methods , or conversely in development of childhood obesity and associated risks..

On the other hand, there is a lot of good information (MASALA study) on the positive effects of ADULT CHILDREN on the health habits of their PARENTS. In other words, children are encouraging and influencing positive health behaviors in their South Asian parents 

Been reading about Nattokinase for reducing LDL. Are any of these claims scientifically tested? What statins are better suited for south asians that cause minimal side effects? Appreciate your time for responding to all our questions .

ANSWER:

Dear Raj, Great Q on Nattokinase. There is some data on this from SMALL studies demonstrating improved lipid profiles, and also other benefits such as mild BP reductions and also antithrombotic activity. However, well done, large randomized controlled trials demonstrating clear efficacy are lacking. A few take home messages:

1) Data is not clear enough to recommend regular use

2) It may have effects on the coagulation pathways resulting in increased bleeding risk

3) It may interact with medications, particularly blood thinners, with potential resulting side effects.

Overall: wait for more data

On the second part of the question: STATINS AND SOUTH ASIANS:

1. Statins, particularly Rosuvastatin, may actually work somewhat MORE in South Asians. So it is recommended to start LOW in South asians (recommended starting dose for Rosu is 5 mg in South Asians)

2. ⁠STATINS SOMEWHAT LESS LIKELY TO CAUSE NUISANCE SIDE EFFECTS SUCH AS MUSCLE ACHES: Rosuvastatin (Most effective and potent in lowering LDL cholesterol)  and Pravastatin (less effective but also less chances of muscle side effects) 

Which of these two Olive oil / Avocado oil better for Indian cooking? 

ANSWER:

Both are “heart-friendly” oils Archana- and a bit of a preference. Olive oil is hard to do “high heat” cooking in (because of low smoke point), but is great for salad dressings and low heat cooking. (Regardless we need to be doing less high heat cooking!!)

 We have historically used the cheap and time tested “work horse” for Indian cooking: Canola Oil. For our other Western style cooking, including Italian cooking and salads, we use Olive Oil 

ANSWER:

My take on GHEE below….. (See the video)

youtu.be/hL306TMmJB4 

Any thoughts on cooking salt?

ANSWER:

From a PRACTICAL MEDICAL standpoint, there is NO difference in Sodium content between pink salt and table salt. If you prefer one, go ahead.

A common MYTH: Pink salt (Himalayan Salt) is lower in sodium. Fact: NOT TRUE (One tea spoon of both contain about 2200-2300 mg of Sodium.

The other “stuff” (Minerals etc.) in Himalayan salt—has little practical value

Which salt would you recommend for lower sodium level for daily cooking?

Unfortunately, salt substitutes found in the grocery stores are potassium salts where potassium is substituted for sodium. The springs with its own set of potential issues with the possibility of potassium levels rising in the blood, particularly in those people who are prone. Unfortunately, the best answer is to use the lowest amount of table salt Possible that allows a balance between reasonable taste, and low salt

I had a side effect from Statin and it was advised to stop it. Later on advised to start Zetia but was not effective for me and doctor advised me to stop it. Do you recommend other options?

ANSWER:

Want to steer away from specific clinical recommendations on the forum. Broadly, you may DISCUSS following potential options with your physician. They may nor may NOT apply to your specific situation:

1. Switching to a different statin

2. ⁠Use of concomitant Co-Q 10 or vitamin D (particularly if serum level is low)

3. ⁠Use of a class of medications called PCSK-9 inhibitors such as Repatha and Praluent

Again, these are not specific recommendations for you but areas to explore with your clinician

Nirmalji, what is the correlation between waist circumference and visceral fat. Does waist circumference also reflect cardiovascular health?

ANSWER:

 Yes. Several studies have demonstrated a linear relationship between waist circ and cardiac risk…The caveat remains that some folks (for unclear reasons, likely genetic) are remarkably immune (or conversely high risk) because of genetic predilection.  For most “regular mortals” like us: the above data holds!

I am taking Asprin Gastro-Resistant tablets  along with 10 mg Atorvastatin , so Is above gastro resistant as I am not sure helping for gas prevention so my question is we should take above or plain aspirin ? I have not asked my doctor but asking here so one can share their experience too

ANSWER:

 Good question: Enteric coated Aspirin (In US) or Gastric resistant aspirin (India) “supposedly” lowers risk of gastric irritation from aspirin, compared to aspirin without such coating. More recent trials show that BOTH have relatively similar side effect profiles and also probably work equally well! So either one is fine! 

Are there any signs or symptoms a person shows before having an cardiac arrest. Anything that we need to be on lookout for.
Also, when one is having a heart attack, is there any proper first aid that can be done at home before reaching the hospital?

ANSWER:

Chest Pain, “Indigestion” like discomfort in upper abdominal/chest area or shortness of breath are common symptoms. Best approach is to call an ambulance or try to get to a hospital quick and NOT ignore. 

Discuss with your doctor “ahead of time” (electively during a regular appointment) if it is appropriate for you to take sublingual (under tongue) nitroglycerin and chew -1-2 baby aspirin tablets. If so, keep those two things handy as first aid if you get chest pain. 

Renu and I during our hike in Uttarakhand, had kept aspirin and Nitroglycerin with us 

If a person is - 45+

Asymptomatic

Hypertension and Diabetes are controlled

Abdominal circumference is high

Lipid profile is mildly deranged. 

What routine investigations should he get done as a preventative measures and to know his cardiac status ?

ANSWER:

Dear Anoop, this person is HIGH RISK for cardiovascular disease and needs his/her LDL aggressively controlled to as low as possible below 70 (personally would like to see closer to 50’s). Would also consider Coronary CT (although hard evidence for this is somewhat lacking). There is no “mildly deranged” lipid panel—only specific LDL goals….This is where many South Asians err in management —the doctor tells them the lipid panel is “OK” or “mildly abnormal” but it is NOT OK. 

Additionally aggressive weight reduction and lifestyle change is critical—if BMI is particularly high—also consideration for Semaglutide like medication. 

I am 47 . My father is cardiac patient   aged 81,mother is diabetic, and having hypothyroidism aged 70.  

I have lab records as early as 2004 , since then i am having high lipid levels .

In 2016-17 ,I got to know I have high hba1c.

Some how I didn't took medicines for diabetes. 

In 2022-23 , I reduced my weight from 90 kg to 68 kg in around 1 year with marathon practice ( daily 7-8 km walk, weekly 22 km walk and run, simultaneously high intensity workout) AND off course diet

With this my BP, LIPID PROFILE,  and HBA1C WAS within normal range.

 But somehow I lost the control my daily routine and I now, 1 year down the line I am Hypertensive,diabetic and facing hyperlipidemia.

 From having metabolic syndrome to normal and again back to metabolic syndrome within 3 years is really distressing.

 Would love to hear and practical tips to balance ( avoiding extremes- )

ANSWER:

Hi Jay, thank you for your question. The first thing you need to see is how high your cholesterol and the  blood pressures. You need  to improve them in normal

Range whether it is taking medication for short term for controlling both problems. At the same time you should start your lifestyle and diet again, but in moderation, the extremes  for wt loss is usually not successful because the rebound happens quickly. The first thing to start is you calculate your total daily energy expenditure and decrease the calories by 300 to 500 and start exercise program 150 minutes a week in zone two. You should aim for a slow and study weight loss and make the lifestyle changes which you will adhere to in long-term . Some diet part we will cover in the webinar as well. Hope that will help.

Jay one more thing. We learnt and talked about SAHC in the documentary. This is a virtual program where they work on diet, exercise, meditation and sleep with a coach for 1 yr. Their goal is to prevent cardiac disease in SA population. You might want to connect with them . Anyone who is interested can check them out . South Asian Heart Center .

Kindly please provide any information/ suggestions regarding the Lipoprotein A (LP(a))specially what age you need to check, any diet or lifestyle changes and if currently there are any medication available to maintain it’s normal level.

 ANSWER:

Great Q Swati…Lp(a) is a risk factor we discuss quite a bit in the docu. It is a risk factor for ischemic heart disease, and over 25% of Indians may have high levels (over 50). Current meds however, have little impact (maybe with exception of some PCKS9 inhibitors)..but a lot of research is under way in this area. I find it very helpful in South Asians in following way: If high: it is a yet another tremendous motivator to change lifestyle (or start statins if LDL is already high

Current recs only suggest a SINGLE determination (NO need to repeat)

“Extended” Lipid profiles include it, but if done separately can cost around USD 25-50 depending on the lab. In INdia, extended lipid panles inlcude Lp(a) and Apo B

 https://wapo.st/4mxWFWE (more about Lipoprotein(A)

Any recommendations for an app that can help calculate calories for indian homemade food? 

ANSWER:

Dr. Ashwini Wagle from California has written a whole book on it and has measured everything  in her lab. MyFitnessPal also gives a lot of Indian dishes calories

 Available on Amazon. (Carbohydrate Counting Traditional South Asians Food Lists)

Indian Diets – Drs Nirmal and Renu Joshi.

 https://youtube.com/live/XgFZ0EOIhQ0?feature=share

How much rice, dal, roti each is healthy per day and week and how do you measure 1 cup of that cooked or uncooked. And how much is excess. 

 ANSWER:

There is no magic amount that is “healthy”. Just go back to the basics of calculating for yourself, the amount of proteins, carbohydrates, and fat. Apps or Google searches will indicate to you whether they’re referring to cook or uncooked. When it comes to calories or macro nutrients. Also remember, this is not an exact science. Rough ideas are absolutely fine.

Is Canola oil healthy to use?

ANSWER:

Yes, canola oil is perfectly health and is in top 3 oils to use. canola or vegetable oil, olive oil, avocado oil 

My vegetarian protein powder by Dr. Renu Joshi

Roasted Chana 200 Grams

Hemp Seeds: 3 tablespoons

1/2 cup almonds

2 table spoon Chia seeds

Small amount of Pepita (Pumpkin) seeds (this has same amount of protein as Hemp seeds)

I calculated this concoction to have roughly 2-2.5 gm protein per tablespoon

So 2 table spoons added about 5 grams protein 

So if you take 3/4 cup of Indian Low fat “Dahi” (Yogurt) —It has 8 Gram protein. If you add 2 tablespoon of above, it will make total protein at about 13 Grams (this compares to a GREEK YOGURT 3/4 cup which has protein of 16 Gram.

Bottom Line: 

Greek Yogurt is a wonderful source of protein (particularly at breakfast). A cheap alternative (with somewhat less protein), can be the home made concoction added to low fat yogurt. 

I have 2 questions 1. Is mustard oil better choice over other oil ?

2. Raw milk is fine as we boil and take the cream off and then use the milk? As felt homogenized milk has all fat molecules in the milk. Which milk will you recommend?

 ANSWER:

If you look at our seminar, the mustard oil properties are listed there. Unfortunately, it has a specific compound more than 80%, which is banned across all USA and UK because there is some animal data that is causes Hardening of arteries . If you want to use it occasionally that’s fine but I would not recommend on a daily basis.

About the raw milk and boiling and taking out the cream, it probably will lower the fat content of the milk, but there’s no way to measure it.

We usually advise to use the milk, which has the milk fat written like a 2%  or skim which has the same amount of calcium and vitamin D, but has much lower fat 

Are Samosas Unhealthy? Some Indians Find Official Advice Hard to Swallow.

ANSWER:

www.nytimes.com/2025/08/12/world/asia/india-samosas-unhealthy.html?unlocked_article_code=1.fU8.1SaQ.Ar_jSeavvNEl&smid=url-share
This has been doing the rounds in Indian social media …..A nice one drawing attention to the health consequences of eating SAMOSA!!

 Samosa and Jalebi and their ill effects on cardiac health, were a very active topic on our BROWN HEART DOCUMENTARY 

Predictive value of HRV?

ANSWER:

@~Dr BSR thanks for your Q about HRV (Heart Rate Variability) and it's predictive value in assessing cardiac health. High HRV is generally considered better than low when it comes to overall health. However, because there are many things that can affect it, it is hard to “hang your hat” on it a sole and independent indicator. I think more data will come out over time before it establishes its approrpiate place

Good afternoon

It’s not relating to heart but a general question 

What is the best vitamins to take everyday. Never taken any till today. Specially for bones

ANSWER:

In most individuals vitamin supplementation is not necessary if a diet is balanced. However, vitamin D and calcium supplementation is encouraged in postmenopausal women for bone health. Further vitamin D levels in south Asian populations are often low. Would suggest getting a vitamin D level and supplementing to keep normal levels. For calcium in postmenopausal women approximately 1200 mg a day is recommended. This can be from natural sources and if not adequate, by supplementation.

Why BMI May Be Replaced With BRI?

 https://share.google/Yqs6pSnA0fuZ8Ze3U

Very appropriate and research-based article. Makes a lot of sense and along the lines of emphasizing “roundness” including waist circumference as a surrogate marker for visceral fat and poor health outcomes.

Dr Joshi, curious if there has been any published study on MI emergency vs BMI in large populations.  Ie, of all the emergency hospitalization cases in a hospital, what percentage are directly predictable based on BMI alone as an independent variable.

ANSWER:

Vishal this is a complex question because obesity confers heart attack risk in multiple ways that include visceral fat, diabetes, high BP and other risks. So although there is a direct relationship between obesity and heart attack rates, detailed causation is more complex

Question for the doctors - Should we use cold pressed oil versions for oils such as Olive or Peanut or Acocado vs refined (probably on shelf’s) version of these from stores like Costco? My guess is cold pressed version will have a shorter shelf life hence will never be available in standard stores and supply chains. Thank you in advance.

ANSWER:

Theoretical benefits have been reported but published data on better clinical outcomes in large trials is not available. Additionally you rightly point out practical barriers such as shelf life and smoke point as issues. Not quite enough data to recommend in favor of refined oils currently available

Is eating spices good or bad for heart?  Black pepper , cloves  (basic ingredients of garam masala ) or chilli power , turmeric, cinnamon, etc

ANSWER:

All (except chili powder) in theory have anti-inflammatory properties related to blood vessels and are good. To my knowledge though, clinical trials that regular consumption have positive cardiac outcomes are not available

Renu and Nirmal 

TIR ( time in range ) vs HbA1C in type 2 diabetes .. can you please tell more in detail the comparison between both these parameters ..

ANSWER:

Hi Madhu, there’s a lot of research going on on time in range or TIR. For people who do not know what that means is that how much time your glucose remains in the normal range during the day before and after eating . For eg hemoglobin of A1c 7 means your average blood sugar is 150. but that 150 average could be a time in range between 125 to 175 or between 50 to 225 throughout the day so the time in range 125 to 175 has been shown to be associated with less development of diabetic complications, including eye disease, kidney disease, and cardiovascular disease. The time range range has recently been in research so longitude studies will be needed to see if the data pans out for 10 years or longer . A lot of data is in type one diabetes, but type two diabetes data is now starting to come out as well. Hope that answers your question. All of us should try to keep the range low anyway, because the high and the low fluctuations are not good for general well being as well .

Hi Dr. Joshi. I have been following this group all along and I have to say the discussions are amazing and the passion from you and Dr. Renu Joshi is tremendous!

I have a question about MCT oil. Could you explain the health benefits of using this?

ANSWER:

Hi Navitha! So glad you’re part of the group! I look at MCT oils ( concentrated derivatives of high saturated fats ) similar to their “parent” oils such as coconut oil. Although short term data exists on mixed lipid results, I continue to worry about long term use of high saturated fat amounts. So our recommendation continues to follow AHA guidelines of restricting saturated fats to less than 7% of caloric intake..

Plant based D3 + K2 ready made. Is it good for Vitamin D deficiency?

ANSWER:

1. If you do NOT have deficiency (found by checking levels, typically normal levels are over 50 in most labs in the US): daily requirement should be around 600-800 IU per day.

2. ⁠If you are found to be deficient, check with your doctor as far as dosage. Depending on how low your levels are, your physician will provide dosage

3. ⁠In many Indians, levels can be VERY low (in the teens or even below 10)

4. ⁠For treatment: HIGH amounts are often given (up to 50,000 units) per week, until the levels return to normal and then lower maintenance doses are given

For doses higher than the daily requirement (600-800 IU per day), you MUST consult with your doctor, since high doses can HARM. (Vitamins A, D, E, and K are fat soluble and high levels can cause harm)

Vitamin K2:

The use of Vitamin K2 is certainly NOT universal with Vitamin D. The FDA in the US does not formally approve health claims of K2 yet, but promising information is coming out on certain health benefits including cardiovascular benefits and use with Vitamin D (see below article from the Cleveland Clinic). It may help MANY people use Vitamin D better. If you do decide to use it, make sure that you are not on blood thinners such as Warfarin (Coumadin) since it may lower its effectiveness.

https://health.clevelandclinic.org/vitamin-k2 

Is Iron glycinate is better option to take over just iron supplement ?

ANSWER:

Hi, there are a few studies evaluating the iron glycinate comparing with fumarate. Many of them are observational studies so class two evidence but there is at least a couple of studies with good  evidence that they’re better absorbed and the stomach side effect may be a little less so that over all absorption  is a little bit better. However, at the end of six months, the results were the same in the levels of iron and hemoglobin.

So yes, if your stomach gives you your problem and you have difficulty tolerating definitely worth a try

Kishore sent information on what makes up your Total Daily Energy Expenditure (TDEE)

Basal Metabolic Rate (BMR) refers to the number of calories your body is burning at rest when doing nothing. It includes breathing, heartbeat, brain function, circulation, and other maintenance physiological processes.

The BMR makes up 60-70% of TDEE.

Muscle burns 2-3 times more calories than fat mass[310], which means that having more lean tissue raises your BMR.

Exercise Activity Thermogenesis (EAT) refers to calories burned during deliberate exercise. EAT typically contributes 0-10% of TDEE, depending on the duration and intensity of the exercise.

 Exercise does increase your TDEE but most people only workout for about 30 minutes per day.

For professional athletes and fitness enthusiasts, this number can certainly be a lot higher, but the average person doesn’t typically dedicate a lot of time to exercise. Thus, one should certainly exercise frequently and build muscle but it’s equally important to focus on creating an energy deficit through other less strenuous means.

Non-Exercise Activity Thermogenesis (NEAT) refers to the number of calories burned while doing spontaneous non-exercise-like activities throughout the day, such as walking, taking the stairs, fidgeting, house chores, etc. NEAT contributes around 20% of TDEE, depending on your amount of spontaneous movement

With low thyroid and chronic low-calorie intake, you may see a large reduction in NEAT, which does reduce your TDEE as well.

This can make it seem that weight loss has plateaued but, you’re just burning less calories due to moving less. To overcome this, you’d have to either move more or adjust your food intake accordingly. It’s also possible to maintain high NEAT even during low calorie intakes but for that you would need to be getting all the necessary micro- and macronutrients that promote vitality and energy production.

Maintaining high NEAT with a nutrient-deprived ultra-processed diet would be harder because the body lacks the necessary resources to function at its peak.

Thermic Effect of Food (TEF) describes the number of calories spent on digestion. Protein has a TEF of 20-30%, carbs 7-15%, alcohol 15% and fat 2-4%[313]. Overall, TEF on a regular diet with mixed macros contributes about 5-15% to your total daily energy expenditure.

ANSWER / COMMENTS BY DR Nirmal :

Dear Kishore, this is generally accurate physiologic information, but critical to understand how one INTERPRETS it (see #3 above) to affect change. Non-physicians can interpret in many different ways, and some of the physiologic facts have not borne out in clinically meaningful studies. I make the following interpretations:

1. The information is helpful though ONE important lens: BODY WEIGHT

2. ⁠Through that lens of weight alone: exercise is not the most efficient way to lose weight (well known) but a CRITICAL AND INDISPENSABLE activity for overall health, including cardiac health)

3. ⁠Random, small activities in the day (“activity” in general) is very helpful

4. ⁠Increasing muscle mass is wise idea for a number of different reasons (In Indians even more so!!)

5. ⁠Processed food and ultra-processed food (as food moves “away from source”) is easily digestible and less desirable

6. ⁠Despite many different smaller details: OVERALL caloric restriction is well documented to lower body weight and visceral fat

Question: Share the Recipe.

Answer: 

Healthy Leechi Kulfi Recipe  ( https://youtu.be/hq1kn3oIoKQ)

Answer:

My overall take: Intermittent fasting remains a good way to lose weight and works for many. Long term effects remain a topic of scientific study and more meaningful scientific info will come out. For those pursuing this method, I have no reason to tell them to stop. One important thing : if you like to intermittent fast, make sure your protein intake remains adequate over time.

This simply worded article in the New York Times nicely summarizes the issues involved.

https://www.nytimes.com/2024/03/20/well/eat/intermittent-fasting-study.html?unlocked_article_code=1.iE8.0OHK.O9oq5cyscvq1&smid=url-share 

Dr. Nirmal - is the wheat flour (atta) we purchase at the Indian grocery store considered whole grain wheat flour? And how about the milled whole wheat floor in an American super market which is much coarser. Is that also whole grain? Which one is better?

ANSWER:

To my knowledge, from a nutritional standpoint they are similar—both are considered whole grain (since they include the entire grain)—it is just the milling process that is different…….Atta works well for Indian cooking (Roti) but can be very difficult to make Western bread out of.

So depending on which kind of cooking you are doing—you may choose one or another.

Another factor is the glycemic index of different types of atta—a function of how much fiber they have—so those such as bajra with more fiber are healthier because they blunt blood sugar spikes after consumption…..

Renu often combines whole wheat flour with chana atta for example to lower the glycemic index…

So you can “play with” the different types of “healthier” options to arrive at a good compromise of taste, texture and healthiness.

Besan is fine  flour compared to Kala Chana flour  . It has more fiber . So mixing that is better .

Dr. Joshi - Another question, with regards to Ancel Keys multi nation study that led to the demonization of saturated fat (not stating whether it is right or wrong, but just saying) and elevated serum cholesterol levels; was it a valid study and are saturated fat and cholesterol really the only culprits? Or are sugar and insulin also equally critical and associated with heart disease?

If so what is the role of elevated sugar and insulin levels in the progression of heart disease.

Your educated/expert opinion will be much appreciated.

ANSWER:

Great Q, Samir. It is a complex answer but I will try to summarize:

1. The OVERALL evidence continues to favor limiting saturated fat intake (American Heart Association recommends to have no more than 6% of calories come from saturated fat)

2. ⁠More and more evidence is linking SIMPLE sugars and related rapid blood sugar spikes to inflammation and related heart disease

3. ⁠So BOTH are important

Now to the nuances:

1. Conflicting evidence is present in the literature with SOME studies NOT demonstrating any relationship between heart disease and saturated fat , but several of those are LESS high quality (In other words, they are observational studies and meta-analyses as opposed to randomized controlled trials)

2. ⁠A lot of data suggests REPLACING calories from saturated fat with those from polyunsaturated fat gets the real benefit

NOW to the most exciting NEW information:

More recent research is beginning to emerge that “Not all sources of Saturated Fat are created equal”—In one excellent study from the UK for example, food sources of saturated fat such as RED MEAT AND BUTTER were linked to heart disease, but YOGURT, CHEESE AND FISH were not.

I am quoting the authors of the above study (very well done from Cambridge):

"We found that people who ate more saturated fats from red meat and butter were more likely to develop heart disease. The opposite was true for those who ate more saturated fats from cheese, yoghurt and fish – which were actually linked to a lower risk of heart disease. These findings are in line with what earlier research has shown about the link between these foods and heart disease. These findings show us that the link between heart disease and saturated fats depends on what food sources it comes from.”

I know one of the authors of this study and may try to get her for one of our upcoming Podcasts.

Posting a recipe for healthy quinoa Upma 

I boiled the quinoa separately. I put one large onion, one or two bell pepper, one broccoli and chopped them and added shelled Edemame and sauté  them on low heat in 1 TSF of vegetable oil so their nutrients do  not get spoiled. 

 Then I added the usual Masala like turmeric and a teaspoon of oil along with mustard and curry leaves . Then I Added tofu which I do air fry before hand and the quinoa. Mix them all together for 3 to 5 minutes and add chili and lime juice and peanuts your very healthy Upma is ready. It serves a great lunch for me and keeps me full . You can add any other  vegetables according to your choice.

Is home made white butter is healthy? Is Avocado oil good for deep frying?

ANSWER:

Home made butter has roughly same saturated fat as that in commercial butter. Both high is saturated fat. So be moderate

@ -Dr Renu , which is the best oil for cooking Dry vegetables and curry vegetables, 

I use extra virgin olive oil but Dr joshi said evo is not good for cooking . Can I use refined olive oil to cook dry and curried vegetables ? If not which oil is good to cook vegetables?

I sometimes use mustard oil to cook dry vegetables

ANSWER:

Hi Renuka, any kind of vegetable oil is good for dry and curried vegetables I use canola but you can also use sunflower. As we had spoken mustard oil does have one component which has bad rats data for cardiac disease and that’s why it has been banned in both Europe as well as USA. However, occasional use of mustard oil is not a problem. Everything should be in moderation

www.economist.com/science-and-technology/2025/08/29/the-truth-about-seed-oils 

There are many things that fall foul of Robert F. Kennedy junior, America’s health secretary, and his vocal supporters. One that really upsets them, and some wellness influencers, is seed oils. In their telling, the oils are “toxic” and can wreck your health. Now some American fast-food chains have swapped the oils for other fats, such as beef tallow or avocado oil, a more bougie option. Is the stuff as bad as they make out?

Seed oils, usually called “vegetable oils” on food labels, are extracted from corn, rapeseed (canola), soyabean, sunflower and other seeds. Critics worry most about two things. The first is that harmful chemicals used in oil processing may end up in the finished product. The second is the oils’ content of omega-6 fatty acids. This particular type of fat, opponents claim, is pro-inflammatory and causes cancer, heart attacks and obesity. On both counts, however, the scientific evidence says otherwise.

It is true that manufacturers use chemicals such as hexane, a solvent that when inhaled can irritate the airways and cause lightheadedness, to extract extra oil from the seeds after pressing. But the oil is filtered and heated to evaporate hexane and various other molecules that can give it strong flavors or make it go rancid. The result is the ideal kitchen staple: a cheap, longer-lasting product with a neutral taste. For the levels of oil ingested by the typical American, any trace hexane that may remain is “toxicologically insignificant”, according to an assessment published in April by the federal government. Nor is it clear that the omega-6 fatty acids cause inflammation. A chief concern for seed-oil opponents is that linoleic acid, the main omega-6 fat in seed oils, can turn into inflammatory compounds in the body. Yet linoleic acid is also broken down into some anti-inflammatory compounds, says Thomas Sanders, an expert on dietary fats at King’s College London. That makes it hard to work out whether it is pro- or anti-inflammatory overall. It is better, then, to look at the net effects of consuming omega-6 fats.

In randomised trials, increasing participants’ consumption of linoleic acid had no e!ect on inflammatory markers in their bodies. There are also clear benefits: seed oils are high in healthy polyunsaturated fats, meaning that choosing them over saturated fats like butter lowers cholesterol levels, which cuts the risk of heart attacks. Long-term observational studies reach equally reassuring conclusions. A recent one in Nature Medicine looked at 100,000 American health professionals. It found that those following diets high in vegetable oils lived longer, healthier lives than those whose diets were low in vegetable oils (and who might have replaced them with more unhealthy, saturated fats). A round-up of earlier such cohort studies, published in 2022 by the World Health Organization, found that higher intake of omega-6 fats was linked with lower mortality. In short, seed oils are unlikely to cause harm—in fact, they are probably good for you, especially if eaten in moderation and supplemented by other, healthy fats such as the omega-3s found in fish and walnuts. Overconsumption is usually the consequence of a generally unhealthy diet, full of fried or ultra processed foods, which there are plenty of other reasons to avoid.

Spoon for spoon, seed oils are much more healthy than some of the alternatives championed by their critics, not least butter, lard and beef tallow.

Doctors, what is your opinion on Apple Cider Vinegar as a supplement for gut health and weight loss?

ANSWER:

Hi Anshul, I did  research and it does look like that in  a meta analysis( which means they combine multiple studies to get an aggregate report) the apple cider vinegar was associated with the weight loss and some improvement in blood glucose. A lot of the studies are from Iran on an average 15 to 20 ML of apple cider vinegar was used. Unfortunately, because of the acid nature, there’s no major study on gut health. There are some linked reports to hepatitis and pancreatitis in small population.

Interestingly, in the same meta analysis cinnamon in 500 mg to 2 g daily , fenugreek seeds in the dose of 10 to 30 mg daily has somewhat similar  report . But most of the data  are small from four weeks to six months. Meta  analysis is usually done when the individual studies are small.

@Drs Nirmal Joshi: Since gut health and the composition of the microbiome also affect general inflammation in the body, would you have recommendations for pre-biotics and probiotics that might help create a better balance between bad bacteria and good bacteria? Are tests of the microbiome composition useful?

ANSWER:

Dear Tajan. This is a very important question and the subject of intense current research at multiple academic health centers. It is being increasingly understood that gut bacteria have a significant role to play in multiple diseases. However, the problem has been that the POTENTIAL benefits and DETAILS around it are only currently being worked on and not available yet for general public use in a safe and effective manner. Several complementary health providers are doing these tests and making numerous recommendations around the results, that are not fully based on rigorously tested scientifically data. 

Three of the most reputed health centers in the country continue to NOT recommend such testing for routing use. Summary below:

HOPKINS: Johns Hopkins researchers have NOT endorsed specific direct-to-consumer (DTC) gut microbiome tests and instead have called for greater regulation of the industry due to significant concerns about validity, reliability, and misleading claims

CLEVELAND CLINIC: Cleveland Clinic does NOT currently recommend or use consumer gut microbiome tests for routine health maintenance, citing a lack of evidence for their utility due to the absence of a benchmark for a "normal" gut microbiome.

MAYO CLINIC: primary applications are in research to understand the microbiome's role in disease and treatment response, NOT  yet as a routine clinical diagnostic tool for everyone

My own take: The path of gut microbiome testing and related recommendations is currently being defined, and is not recommended for regular use. If you do decide to pursue, it can be EXPENSIVE and result in multiple recommendations on supplementation, not backed by high quality scientific evidence

Likely to change as more data evolves! Stay tuned!!! Exciting area

What is the relation between “Ankle brachial Index”  and cardiac problems ? Is abnormal ABI indicator of future heart attacks?

ANSWER:

The Ankle Brachial Index (Ratio of BP in leg vs arm) is a simple test, typically used in people over 50 (or those with risks such as diabetes, smoking etc.) to screen for PERIPHERAL VASCULAR DISEASE (arterial disease involving arteries of the legs). However, It can also predict heart disease in these same populations. The problem with using it for heart disease screening is that in MANY instances it is normal and yet the person has heart disease (this is often called a “Low sensitivity” for the test). However, if you get the test for other reasons like above, AND it is ABNORMAL, your risk of heart disease is high and must be investigated further.

Can u pls comment on millet meals compared to rice for diabetic diet?

ANSWER:

Millets are higher in fiber (and protein) and therefore raise blood sugar more gradually than white rice. They therefore have a lower glycemic index and are known to have a beneficial effect on blood sugar control compared to rice.

We have talked a lot about CARBS and FATS, but have given less attention to SALT. Want to turn to that. Sometime ago we had done several short videos on key topics. Reposting one of them on reading food labels for Sodium.

www.youtube.com/watch?v=7sC_sbargmw 

Is Calories requirement dependant on age? What will be Daily Calory requirement for South Asian male age 75?

ANSWER:

Yes , caloric requirement changes with age for a variety of reasons (lower muscle mass being one of them), but if you calculate the TDEE (Total Daily Energy Expenditure) it already accounts for age….

https://tdeecalculator.net 

Drugs for dissolving any plaque without risk?

ANSWER: Unfortunately, no!

How to measure sodium in the home cooked food. Sorry I know I did post this question but also wanted to post it on this forum

ANSWER: Digging more into this. Unfortunately, no easily available resources are available, but our “Brown Heart” expert Professor of Nutrition is sending me a good resource soon. I will post it when available

Are weight loss drugs like Ozempic, Wegovy, and Mounjaro the miracle breakthrough for obesity and metabolic health—or a dangerous quick fix with hidden risks? 

Answer:

My recent podcast on weight loss drugs which I did with a nutritionist from CA , and Plastic surgeon from London

VIDEO PODCAST

https://youtu.be/ZVvA2tezp2Q?si=HZjOfbtDVenTE0KK

AUDIO PODCAST

https://open.spotify.com/episode/3xgLzSRQo1vwg225Sorvwn?si=Q0Ta-PPGQSSAb3w397opPg 

1.⁠Does Factor V Liden- positive affect on  heart health?

Factor five Laden  does  actually just the opposite . In young females and smokers with positive factor V  laden , there’s actually slightly increased risk of coronary artery disease and stroke, but in general population in good studies, it has not shown any worse effects. This was shown in a recent meta-analysis . Clearly no beneficial effects.

 2.⁠ ⁠Is Indians South Asians  having narrower arteries a factor?

The original data did show that Indians have narrower arteries, but that data has not been proven in the recent studies specially Masala study. . Having said that, Indians do have more Plaques  and blockages in their arteries so the  overall lumen of the artery is narrower than their counterparts 

 3.⁠ ⁠Anything specific that we can do to promote measure collateral arteries....why do some folks develop collaterals at an early age versus those who do not at all?

Yes , there is some genetic difference in developing collaterals but there is no clinical testing for that. DM and Female sex is associated with poor development of collaterals and calcium channel blockers drugs like Verapamil and  statins are associated with better collateral circulation.

the development of collateral circulation in the coronary arteries can be promoted by physical exercise. One paper showed > 10 hrs of exercise per week ( not intensity related) can develop more collaterals . The other pharmacological stimulation (e.g., G-CSF), mechanical interventions (e.g., external counter pulsation) are very tedious and can be only done in patients with EXTREME angina  only.

 4.⁠ ⁠Can we consider GLP 1 supplement to lose weight for insulin resistance to avoid any such obesity risks

GLP 1 are good to reduce weight for obesity although they are typically used for a BMI above 29. I have done a full podcast on GLP1 recently with an influencer in London along with a holistic nutritionist and Plastic surgeon , which I can post here. They should be used with caution and unfortunately, when you stop the GLP 1  if you have not changed the lifestyle completely the weight will come back. Also 20-30% of wt loss is Muscle because it is lost rapidly. 

  5.⁠ ⁠From the limited research I had done re: Ayurvedic centers in South India start their treatments with Ghee to cleanse the body.  Is that dated methodology?

This is the clinical guidelines from American societies 

In summary, while ghee is traditionally used for "cleansing" in some cultures like Morocco and India , there is no evidence-based clinical guideline or consensus in modern medicine supporting the use of ghee to cleanse the body.

This is such a controversial topic that is hard to give answers. It does have more saturated fat than the other oils. There are small studies on Ghee from Ayurveda literature that say that Ghee  may not be the wrong kind of saturated fat, but there’s no long-term data available so I would still stay with the American health association guideline at keeping the daily Ghee in moderate amount at less than half a tablespoon per day so that your saturated fat is less than 7%. 

6.⁠ ⁠Can creatine help in reducing Tg and bad cholesterol?

There is no evidence and data that creatine lowers Cholesterol or help cardiac disease. One old paper show a decrease of 5 % but recent data does not show improvement. 

 7.⁠ ⁠Is doing high intensity. Exercise for an extended period like running a marathon or a triathlon or climbing a mountain  inflammatory and increasing the risk of a cardiac event? By high intensity I mean being continuously in zone 4 and zone 5.

These are recommendations from AHA. The American Heart Association emphasizes that while vigorous physical activity confers superior cardiovascular adaptations and outcomes compared to moderate-intensity exercise, the relative risk of acute cardiovascular events is transiently increased during vigorous activity, especially in habitually sedentary individuals or those with known or occult cardiovascular disease.[1] Overall, the consensus is that the benefits of regular exercise outweigh the risks for most individuals, but high-volume, high-intensity endurance exercise may create a substrate for adverse cardiovascular adaptations in susceptible populations.

 8.⁠ ⁠Is Coconut oil bad, period...or is cooking in it not recommended?  Also, is goat meat similarly bad, or certain cuts?

We always say that nothing is good or bad. Yes, you can clearly use Goat meat  once a week and you can also use coconut oil for certain special cooking. Maybe once a week. What we recommend against is continuous daily use of these on daily basis. Even with  Goat ,beef and pork there are lean cuts which are fat free and they are heathier . 

9.⁠ ⁠Calcium score is high but LDL is low .. what to do ?

With high calcium score and low LDL, it is exactly important to know what actual LDL is and I would like to keep it as low as possible like less than 55

10.⁠ ⁠There is a lot of discussion on Autophagy. Any views on it for prevention or reduction of key vitals and heart disease

Autophagy in layman's terms, it is like the cell's internal "clean-up crew," where unwanted or damaged parts are packaged into small sacs and then sent to a recycling center (the lysosome) to be broken down and reused for energy or building new cell parts. This process helps cells stay healthy, adapt to stress, and remove potentially harmful material, such as damaged organelles or invading microbes. Autophagy happens with fasting for 12 hours or exercising 

 There are several papers  that say  autophagy in moderation  is important for cardiac disease. but when done excessive can damage cardiac cells  so giving a gap for 12 hrs is not a bad thing. Prolonged fasting or prolonged Exercise may not be as good.  

11.⁠ ⁠Is there any truth to 'Biological Age' that is calculated using many data points including resting HR? This is to deal with “act as per your age (chronological age)... ?”

While there are a lot of tests that calculate Biologic age ( functional age) vs real age ,their use in modern day assessment has not been proven and they are not clinically indicated. 

12.⁠ ⁠L-Arginine  helpful to reduce cardiovascular risk?

Arginine is currently not recommended to use as a supplement for lowering cardiovascular risk. While the older study showed very good data, the current literature showed conflicting results so large studies needs to be done.

Q1. I have H1Ac 6.8 -consistent almost since Feb 25 (get tested in sept 25is same) do I need to start taking medicine or can try controlling diet etc-pl advise-thanks

ANSWER
The answer is if you have not followed  diet and  exercise , the very first step is to follow a  low carb, low fat and high protein diet. . You can listen to the diet seminar if you have not heard . Also at least incorporate 150 minutes of exercise per week. Do it for three months and not only you will lose weight, but you will also improve your A1c. If at that time if the A1c does not improve the very first drug we start is metformin, which is very safe, lowers the appetite, and also improve A1c.

Q Does pink salt has enough iodine for daily use ?

A The pink salt does not have enough iodine in fact, most of the natural salts, including sea salt, do not have enough iodine because the normal salt is  fortified  with extra iodine. So the pink salt does not meet your iodine requirement unless you are eating other things fortified with iodine

Pleaze give insights on Endothelial dysfunction post covid infection with either with covid infection or covid vaccination.  How to manage this . Perhaps there will be paradigm shift in overalll approach for cardiac disease mangagment and overall health too.  

ANSWER

 This is a very important question and I will just try to give a short answer . COVID-19 acute infection is clearly associated with the endothelial dysfunction, leading to arterial stiffness and inc risk of clots etc but the long-term sequelae only happens in people who have long Covid and symptoms persisting more than six months. This is a very active area of research and if people have persistent endothelial dysfunction  months and years after Covid, which is clinically seen as decreased exercise capability, cognitive dysfunction, and extreme fatigue they will need to be evaluated by a physician .

There are a lot of medications being tested and I probably would not discuss details here but can separately answer your question . 

Covid vaccine on the other hand, actually lower the endothelial dysfunction caused by COVID-19. A transient endothelial dysfunction can occur which last only 48 hours to a month and vaccination does not lead to long-standing endothelial dysfunction.

Having said that cardiac disease has been happening for last 40 years and will continue to happen in SA and it’s more a lifestyle issue than Covid itself

Please let us know about substituting regular cow/ buffalo  milk and dairy products to plant based milk , yogurt from  almond,  soya , oat etc 

Thanks 🙏

ANSWER

There are several studies now available comparing the different plant based milk like almond ,oat ,rice and Soy  milk  comparing with cow milk. I did not find a whole lot of data with buffalo milk. The interesting findings are that cow milk and soya milk are the only one that contain > 3% protein and all the other milk had < 1% protein despite fortification. Also the other nutrient like vitamin B12 vitamin B six and some other micro nutrients were much lower.  The calories are much lower in all plant base milk.

So if you clearly have dairy allergy these are good substitutes, but we really do not have long-term data on what kind of nutritional deficiencies might occur by using plant-based milks overall . Hope that helps .

Yesterday I had angiography done it reveals no major blocks ,LAD Type 3 VESSEL3 , slow flow ,Minor plaq.  I have HTN, DM, DISLIPIDEMIA SINCE 2005, AGE 47, WEIGHT 85 HEIGHT 5'7" INCH. SUGGEST DIETATRY CHAGES AND FURTHER RECOMMENDATION .WANT TO STOP MEDICATION IN NEAR FUTURE AS SYMPTOMS MINIMIZES. 

ANSWER

Thank you for all your details. . However, given that you have three vessel disease even though it is minor, you definitely need to keep your LDL less than 70, blood pressure less than 120 x 80. And a BMI less than 23. From my calculation, your BMI came to be around 29 . We have a full diet seminar that you can listen to regarding all the dietary changes along with  aerobic  exercise  150 min per week . But one thing we will clearly emphasize  is not to stop statin at all  because of your heart disease . That is  life saving  and you will need statin long-term to prevent a heart attack. Hope that helps .

Q: How relevant is TriG/HDL-C ratio and if its value above 2 suggests higher risk in an individual?

ANSWER: The ratio is a marker of insulin resistance, and does portend a higher risk of heart disease. One meta-analysis, identified a “cut off” of 2.8 for men and 2.5 in women. All that being said, the ratio is not used very often by us in clinical practice. I continue to recommend people focus on LDL cholesterol as an absolute number as the single most important marker since evidence-based recommendations are clear cut on what do regarding LDL and heart disease.

Q: What are the iodine fortified food for vegetarian to fulfill daily iodine requirements 

ANSWER: A good  source is iodized table salt. Only a quarter teaspoon gets almost 50% of daily requirement met. Needless to say, total salt intake has to be moderate (I have previously posted our video on Salt). Dairy products such as milk and yogurt also provide iodine.

My HA1C is at 5.4 (likely pre-diabetic), I'm overweight with belly fat. Not on any meds, but I'm contemplating trying low dose of GLP to help lose 20-30 pounds & then maintain once I'm closer to my ideal weight. Should I start with calorie restriction/intermittent fasting before going down GLP path?

ANSWER: 

Would strongly advice a full-throttle effort at weight reduction by diet and exercise FIRST for at least 4-6 months (The South asian Heart Center Coaching program may be a perfect “hand holder” for you to get help). Such lifestyle change will serve you well long term, regardless.

I would LATER (after 6 months) consider medication use (based on more clinical details in close consultation with your primary care doctor). I would definitely NOT use any medications from compounding companies (without an ongoing relationship with a primary care physician)

Medications in this class, while having great weight loss and cardio-protective data, also have other issues and side effect profiles that are troubling and need careful supervision. 

Keep us posted of your weight loss journey and do consider joining the next Podcast from the South Asian Heart Center and /or contacting them for help