Cholesterol - friend or foe? Episode 27

Monika Rachtan:
Good afternoon. My name is Monika Rachtan and I would like to welcome you to another episode of the programme 'Patient First'. It turns out that 60% Poles have lipid disorders, which means that 21 million of us could die of a stroke or heart attack. The year 2023 has been declared the Year of the Fight against Hypercholesterolaemia by the Polish Lipid Society and the Cardiovascular Society. Today I would like to talk about this hypercholesterolaemia with my guest, Professor Maciej Banach. A very warm welcome to you, Professor.

Maciej Banach:
Good morning, Madam Editor, and welcome to you.

Monika Rachtan:
Professor, I said at the beginning that lipid disorders and hypercholesterolaemia are a big problem in our country. The scientific societies are aware of this, but are the Poles too?

Maciej Banach:
This is a key question. The Year of the Fight against Hypercholesterolaemia, which we have established together with the Polish Cardiovascular and Lipid Society, is dedicated to the fight against hypercholesterolaemia. Above all, we want to reach out to patients and patient organisations. Unfortunately, we observe low public awareness of cholesterol and its potential metabolism-related disorders. If we asked ten Poles about their cholesterol levels, only two of them would know their values. This is certainly very low awareness.


Monika Rachtan:
Where does this situation come from?

Maciej Banach:
This is the result of a historical approach. For many years, doctors focused on treating hypertension and diabetes. However, in the case of cholesterol disorders, patients have often heard from doctors that all they need to do is follow a diet and not worry. This is a mistake, as dietary treatment, or lifestyle change, is crucial alongside drug treatment. It is equally important that the patient is treated early.

Monika Rachtan:
So it's a question of when to implement drug therapy?

Maciej Banach:
Exactly. The rule is simple: the lower the LDL cholesterol, the better. If we keep our levels of bad LDL cholesterol at the right level throughout our lives, we can avoid many cardiovascular incidents. It is important to recognise as soon as possible that cholesterol levels are too high and then to implement treatment, first with non-drug therapy and then with drug therapy if indicated.

Monika Rachtan:
Poles do not know their cholesterol levels. And are GPs aware of the problem?

Maciej Banach:
I have had good experience of working with GPs, especially with the College of General Practitioners in Poland. However, I cannot speak on behalf of all GPs, of whom there are approximately 20,000-25,000 in Poland. Awareness among doctors about hypercholesterolaemia is insufficient, and the emphasis on recognition and proper treatment of these disorders is weak. But I want to emphasise that it is not only GPs who are responsible for this. As a cardiologist, I acknowledge that many cardiologists do not use appropriate doses of statins. The problem is general and affects different specialists. We need to work better together. GPs should refer patients to specialists, who in turn should allow treatment to continue in the GP's practice if possible.

Monika Rachtan:
Is it not also the case that a systemic problem obviously exists? Doctors make some mistakes in the process too. However, these extortions by patients, i.e. simply coming to the GP and asking for a referral to a cardiologist, or even requiring the doctor to send me to a cardiologist. Or the situation, as I'm quoting here from what I'm reading on patient groups, that the cardiologist has handed me back to the PCP because he doesn't want to treat me anymore, because I'm already well, he doesn't want me anymore. And that is.

Maciej Banach:
Probably this mistake of many generations that was made by the Ministry of Health, the National Health Fund, us doctors, and scientific societies. We have put too little emphasis on patient education. Of course, it is very important that we educate ourselves. It's such a continuous education for doctors, we need to keep up to date with research, guidelines, etc. We know that the doctor is a lifelong learner. However, I wouldn't want that to be an excuse for not trying to educate patients. I have been going around the various ministries of the Ministry of Education for 20 years trying to introduce health knowledge in schools. Simple knowledge about healthy lifestyles, e.g. what is cholesterol, why we need to treat ourselves, not to change medication without a doctor's approval. Knowledge about preventive screenings, e.g. detection of breast cancer in women or testicular cancer in boys.

Maciej Banach:
All the ministries of the Ministry of Education I spoke to praised the idea, but there was no follow-up. And we have experiences from other countries where the introduction of such health knowledge has brought positive results. Then a healthy society is shaped that understands how to take care of itself. This doesn't require the introduction of restrictive legislation, because people make healthy decisions themselves.

Monika Rachtan:
Take the energiser that the professor mentioned. If young people had the habit of reading labels and, moreover, understanding the information on them and being aware of the consequences, they would make more informed decisions. Young people have the potential when it comes to using the internet, and it would be worthwhile for this capacity to be channelled into healthy habits. Young people are often not aware because the availability of products in shops makes them think something is safe. Health education should cover various aspects, including the ability to distinguish between healthy and unhealthy products.

Monika Rachtan:
I try, I try to ask questions. That's right.

Monika Rachtan:
I also noticed that let's go back to that internet again. I read again in the comments and again on our profile under the mentioned episode that the brain is made of cholesterol, therefore it needs to be fed, and high cholesterol is great because the brain then works better. I would like the professor to explain to whoever wrote this comment how the theory of these people, the flat earth theory, translates into how it really is in medicine.

Monika Rachtan:
If the brain was made of cholesterol, I really don't know what it would be made of, since neurons have a slightly different structure. If you look at the structure of the pineal gland, the pituitary gland, etc., these basic elements of the cerebral cortex, etc., what you find in all organisms is not cholesterol but fats, so-called fatty acids. At this point, there is one thing that cholesterol really plays a key role in the context of the blood-brain barrier. It really does. But note, note to that person who wrote about ensuring that all the metabolic processes in our body related to enzyme production, related to vitamin metabolism, related to transmission across the blood-brain barrier, our levels. Note, total cholesterol is enough when there is 70 milligrams of total cholesterol. This is a very low value. I don't know of a patient like that. I think I have had two patients with severe cancer where the cancer process was destroying the body and the cholesterol level was so low. That's why talking about it is again. Because you know editor, how it works, I'll say something that looks smarter, that's how it works, the anti-vaccine, anti-statin movements work, that I often remember reading.


Maciej Banach:
It was amazing to read the statements prepared by some supposedly super expert on the harmfulness of vaccination and I read them. It was a dozen or so pages. I stated that ok, I'll read it, I have to read it. By 95% of text. There were clever things in there that could not be disputed. But there were things in the highlights, in all that clever communication, that immediately put up and caused the interpretation to go in the wrong direction. So it's definitely prepared by people who have an idea of how to do it from the point of view of also influencing the subconscious of these people. So there is a buried dog somewhere that we are not fully aware of. On the other hand, indeed. On the other hand, after this text I really started. I said ok, the patient does not have the right not to have this information from the specialists and he does not have the right for us to, for us to run out of time, for us to explain things to him. Since I, after reading this, know perfectly well that any patient, if they have no medical knowledge, would say that this is the truth.

Monika Rachtan:
Yes.

Monika Rachtan:
Do you sometimes comment on such publications on the internet? When you see such misinformation, you go in.

Maciej Banach:
Especially when he wants to. I want a thousand likes straight away 1000 likes or 1000 comments straight away. So of course I go in and then I hear things like that already. Twitter is particularly difficult here, because on Twitter there are a lot of anonymous accounts really, where anyone can write anything with impunity, completely. And there are a lot of ambitionally unfulfilled people out there who don't quite realise it either. Because maybe this unfulfilled ambition is irrelevant from the point of view of offending other people. But I think a lot of people don't realise that by writing something they can hurt other people. That's why I often say it in different conversations, for example, I recently had cholesterol on this profile I said on Facebook. This is something that can be cured. Such conversations of note with a lady educated person who claimed to be a sociologist or a psychologist I'm sorry, I don't remember which one just tried to explain to me that statins do not harm and they said. I also tried to explain to her that categorical talk by her, even if she is a person interested in the subject but has no medical knowledge, she has psychological, sociological knowledge, which I don't go into and I don't feel competent to talk to her.

Maciej Banach:
And to write categorically that statins cause this, this, this and this is potentially hurting other people who may believe her to also take that responsibility for those words we write. And this is also where I say to you: if you have a doubt, ask. If you are in doubt, go to sites that can be considered reliable, i.e. sites of the Ministry of Health, the National Health Fund, sites of scientific societies.

Monika Rachtan:
These pages are also for patients exactly.

Maciej Banach:
From the hospitals' website. There, we assume that everything is there, but do not, do not, do not, do not try to read pages where you have doubts that the news may not be entirely true, because it is not prepared by specialists. Remember Ladies and Gentlemen, when I go to a lawyer I do not pretend to be a lawyer I just listen to myself and I can ask the question how? I have a doubt from the point of view of this legal advice. When I go to the tax office I do not discuss it at all with the lady from the tax office.

Monika Rachtan:
Just a head

Maciej Banach:
I bend down and wait for the verdict. In truth, half joking, half serious. So I don't know why it is that in Poland 99% doctors.

Monika Rachtan:
Yes, that's right.

Maciej Banach:
Young people can be very engaged in searching for information, especially if something interests them, like new shoes or clothes. But unfortunately, they don't always do the same in the context of health information. Therefore, health education is key. We need to counter fake news and misconceptions, because often young people make decisions based on false information. This also applies to statins. Statins are safe and effective, but there are myths about their harmfulness. Patients are often afraid to take them because of false information.

Monika Rachtan:
I'm still asking about those statins. Can they actually kill? Does the leaflet say that in a clinical trial taking this drug caused death?

Maciej Banach:
Of course not. Any drug can have side effects, even vitamin C or carrot juice. Statins are among the safest drugs in cardiology. The problem is often due to the so-called nocebo effect, that is, patients expect negative effects and often cause them themselves psychologically. We need to educate patients that statins are safe and prolong life, especially in the prevention of cardiovascular disease.

Monika Rachtan:
I have a diagnosis that these myths around statins were created by rare cases of muscle pain. In reality, 91-93% patients can take statins without complications. The psychological approach of patients and the expectation of a nocebo effect is also key. There is a need to distinguish between muscle symptoms resulting from increased physical activity and not related to statins themselves. It is important that patients understand that statins are safe and contribute to a longer life. Professor Kiro Endo, the creator of statins, is turning 90, a testament to their safety and efficacy.

Monika Rachtan:
Thank you for the clarification on statins. The last question is whether young people are aware of how to take care of their health. As part of the programme, we try to educate young people by using social media, such as Facebook and TikTok. Young people are active online, so we want to provide short and useful information about health. Health education is an investment in the future, especially in terms of a healthy lifestyle from a young age

Maciej Banach:
Young people have great potential, but it needs to be channelled in the right direction. It is important that the information is factual, as young people often do not check sources. It is also a matter of combating fake news, which often appears in health messages. Young people need proper education to make informed health decisions. It is not just a question of getting older, but of investing in their own health from a young age.

Maciej Banach:
Certainly. Having had long experience, we know very well that there are only three main side effects. The first is muscle pain, which we know all too well and how to respond - you can reduce the dose, change the formulation, add another drug to still keep the patient on therapeutic levels of LDL cholesterol. The second is temporarily elevated liver enzymes, which can occur while taking statins. Usually after four weeks the levels return to normal and there is no cause for concern. In 99% cases of chronic liver disease, statins are even indicated rather than contraindicated.

Monika Rachtan:
Does the patient experience any symptoms during these four weeks?

Maciej Banach:
He does not feel any. There may be a slight feeling of pressure in the liver area, but this is usually associated with statins. A final issue is new cases of diabetes, especially with very high doses of statins. The risk of new cases of diabetes is five times less than the benefit of reducing cardiovascular incidents. Even if diabetes occurs, we treat it because diabetes is an indication for treatment with statins. So don't focus on the side effects when taking statins, but remember that they can help you live longer. This should protect you from the negative attitude, or placebo effect, that there is bound to be an adverse symptom.

Monika Rachtan:
I've talked to older people about statins and indeed, they often have a negative attitude, especially when it comes to joint pain. I've even heard this while sitting in the queue at the doctor's. This seems to be the most common theme among these people. My impression is that they just heard about it and it started to hurt.

Maciej Banach:
That is exactly right. I would like to give an example that illustrates the situation well. We had a patient, a young man with an early myocardial infarction. This is a very serious case because he has no collateral circulation. The damage to the heart was great, but he was able to be saved. He had all the vessels changed atherosclerosis, but thanks to a two-stage procedure and good rehabilitation, he was treated well. When he comes for a check-up...


Monika Rachtan:
...what next?

Maciej Banach:
What I mean by this is the intention of the statement. A patient comes in and I look at his LDL cholesterol result and ask, "Why did you go off statins?" He replies that of course he didn't wean off. I ask, "What happened? Please tell me and I will explain to you." It turns out that his wife had forbidden him to take statins because she had read somewhere that they damage the liver. I suggested that he invite his wife to talk to him. At first I heard a lot of negative things from her about statins, but then I started to explain everything step by step. She seemed to understand that it was about her husband's health. So sometimes we have to listen to unpleasant things, but on the other hand we always have to find the time to explain to the patient his doubts.

Monika Rachtan:
The patient has the right...

Maciej Banach:
...to ignorance, to doubt. He has the right to believe fake news.

Monika Rachtan:
There are many, especially when it comes to statins. When I typed the word "statins" into a search engine, questions like "do statins kill, do they have side effects?" came up. This is a group of drugs surrounded by a lot of myths. Even recently, Professors Aleksander Prejbisz and Piotr Dobrowolski were guests on our programme.

Maciej Banach:
I admire them, they always perform together.

Monika Rachtan:
For them, it is distinctive.

Maciej Banach:
Yes, they always appear together on webinars. But they also talked about statins, and the comments on Facebook or Twitter were amazing. There were no scientific facts there.

Maciej Banach:
The facts are not there. We have a closed Facebook channel 'Cholesterol, it cures' where patients share their results and we discuss. There are often comments questioning the need for statins. We need to talk and educate because we are losing the battle with social media. Patients find it easier to believe that drugs are unnecessary or that high LDL cholesterol is good for health. Unfortunately, some believe this and even write books about it.

Maciej Banach:
I don't know who is issuing it to them, but they are undermining the results of hundreds of thousands of studies. We make mistakes without paying attention to wording, which is how we formulate statements. We need to educate and explain, even using more difficult phrases. It is important that patients understand the difference between relative and absolute risk reduction. It should be explained that statins are effective in reducing the risk of cardiovascular incidents. Also, I actually work at a computer all my day, so I have a chance to realise that. And they were a bit motivated by that at the beginning, so that's why we said let's finally do a proper study. We had access to 17 huge studies, so we did the biggest metabolic study in the world of 230,000 patients, which is a huge number of patients that showed us directly. To have a health effect, you only need 4,000 steps, four thousand steps. That is actually about 2 and 670 km. And then we have we are already regular, we are doing this minimum of 4,000 steps, then we have a reduction in the risk of death, that is, we prolong life and death due to the cause of cardiovascular disease. The second very important message was that the more of these steps we take, the better, i.e. we get even better results. We were able to do this research up to a figure of 20,000 steps on average per day. However, due to our very few patients and colleagues who were involved in these studies above 20,000, we did not have these patients. Now we do. Because when I look at my smartphone, at my friends, I have at least a dozen people that I include who have above 20,000 steps a day. That's the average. So in relation to that, we'll be able to assess what happens next, because up to 20,000 steps we knew perfectly well that it works and that it extends our life. Well, and now we've noticed one other thing, that as we improve our performance, so we're not just looking at doing these minimums, but we're trying to improve by 500,000 steps a day, we're additionally reducing that mortality by 7,15% and slightly more. If the last two things, so as not to bore you. Because what was the point of the 10,000? It turns out that the 10,000 is also true. But no, it wasn't about the minimum number above which we have these health effects, but the optimum number. And we also came up with between 6,000 and 13,000, and in the middle is 10,000. That's that optimal number of steps where we have the greatest observed reduction in mortality. So if we do between 6 and 13, we can have the greatest mortality reduction, which is a benefit to our own, to our own health. So that was those results. Anyway, I didn't expect that kind of response because it was the first time I'd been on the BBC live, so it was also an interesting, interesting experience for me.

Monika Rachtan:
And also what you said earlier about people claiming to be someone on the internet. In creating this programme, I thought about what to do to best educate patients. I knew that I needed to meet you, but also give our viewers confirmation that you were real. The fact that I would read your professor's long affiliation, which lists many societies, does not give patients as much as seeing your professor's face. They can now check on the internet whether such a doctor really exists and what his scientific achievements are. I was very keen for us to be here together in person and for the audience to be able to see us too, because that is extremely important. I think by doing that we are giving a testimony that you are for the people, right?

Maciej Banach:
Of course. I stress all the time that we have to be very credible. We can talk about any subject. I have been angry with many colleagues who, in the age of pandemics, made the mistake of going unprepared to programmes where they met anti-vaccinationists. Listening to an unprepared expert who seemed to know all the answers, I often came to the conclusion that after such a discussion I would have been on the side of the anti-vaccinationist who was more articulate and better prepared. Credibility also lies in the fact that I tell the patient, "Do you know what your LDL cholesterol level should be?" The patient often surprises me with the question: "And what level do you profess to have, since you are urging me so?". As a man and a doctor, I know my results very well. I can say that my LDL cholesterol level is 86. According to a recent study, my risk is low, so I should be below 100. I try to maintain regular exercise and a healthy diet.


Monika Rachtan:
And can I ask you about exercise? While watching your webinars, I saw that there was a treadmill.

Maciej Banach:
The treadmill no longer stands. The reason is that doctors also make mistakes. My problem was due to a knee injury, a medial meniscus, which I caused myself. It's difficult for us to accept that we are entering a certain age and various ailments can occur. Running on a treadmill is not the best exercise for the joints because there are no height differences like in the field. My knee started to hurt so much that one day I woke up with a stiff knee. I had two choices: surgery or changing the type of exercise. So I switched to cycling. Now I do about 400 kilometres a month, whether on a stationary bike or with my wife on regular bikes. I also walk a lot, which gives me great pleasure. I have an average of 9600 steps a day.

Monika Rachtan:
This is a great deal.

Maciej Banach:
Yes, I try to walk in a way that is good for my health.

Monika Rachtan:
And what is it about walking? I know that you have conducted research on the effects of walking on health. What are the findings from them?

Maciej Banach:
It absolutely follows that it does. Any kind of exercise is good for health, except for extreme efforts like 24-hour running or Iron Man. When it comes to steps, we have different tools to monitor them. There used to be a marketing message about taking 10,000 steps for a longer life, but this was not scientifically validated. Studies have shown that mortality reduction is associated with taking 6,000-7,000 steps. Therefore, when a patient asks me how much to walk, I say that 7,000 steps is about 5km a day. This may seem like a lot, but....

Monika Rachtan:
...can be difficult to achieve.

Monika Rachtan:
I find the steps engaging, and I'm a big fan of walking myself. I will admit that I don't like running. I like cycling and walking the most.

Maciej Banach:
But the editor raised one point. Sorry to interrupt, but it is important. We doctors often make the mistake of telling a patient to start a certain exercise or to follow a certain diet. If we are too restrictive, the patient will not be willing. For example, if we tell a patient who has never run to start running, they may say they don't like it, they get tired and so on. Ask the patient what kind of physical exercise he or she enjoys. If it's dancing, great, let him dance. If it's walking, like your editor, great. If cycling or swimming, great too. The same with diet. If a patient comes to see me, I ask about the type of diet they have. You have to talk and gradually change the diet so that it is acceptable to the patient. If it is not acceptable, the patient will not follow it.

Monika Rachtan:
But this patient will also feel all the time that he is on a diet, not that he has changed his lifestyle.

Monika Rachtan:
After all, we often say that the basis for improving health is precisely to change your lifestyle, not to be on a diet or to do something by force.

Maciej Banach:
The worst thing is that we often follow diets that give quick results but are not at all healthy. For example, the ketogenic diet is not healthy for healthy people, but has indications, for example, for people with diabetes, overweight, obesity or children with epilepsy. In healthy people, it is not healthy. Therefore, it is worth remembering not to go in these directions, but to use the experience of great nutritionists. We have many of them, and their experience is really valuable.

Monika Rachtan:
And I'll also ask you about the cooked diet, because it's quite an interesting topic that's flooding the internet today. If we go into social media, whether it's Facebook, whether it's Instagram, whether it's any other channel, we can see that there people are just massively arranging different meals that are included in the cooked diet, recommending them to everybody. Can people with linear disorders, Those who have high cholesterol, high cholesterol can follow such a diet.

Maciej Banach:
No. Well, that's the point: there are 4 types of diet already played out here. I don't want to list them because it's very important. However, the biggest problem with the most common keto diet, which is a little bit due to the unpreparedness of these people, because there is a conversation with a dietician, there are indications, it is possible to prepare such a diet that it will be beneficial for health, but most often it is one that is low in carbohydrates and high in fat, because the most common restriction is that we avoid one ingredient and often unconsciously increase the content of another dietary ingredient and then it is not beneficial for health at all. And in this case of most patients who have follow the keto genom diet we have an increase in LDL cholesterol. If we have an increase in LDL cholesterol, we know very well after many studies that if we have an increase of one millimetre, that translates into a 22 per cent risk of death, so that I don't need to explain to you what happens next.

Monika Rachtan:
If I said today, as a 30-year-old, that I absolutely want to have my cholesterol checked tomorrow, where would I do it most quickly? How should I prepare for such a test?

Maciej Banach:
Is it not necessary to be fasting in the first place? Please note that the only element when it comes to cholesterol testing that. If we are not fasting that affects, is the triglyceride level. They are extremely, extremely sensitive, that is, sensitive to what we eat, and if we want to have the right level of triglycerides, however, we should also be fasting in fact. However, ok. If we want to have the right level, if we don't have to, we can't be fasting ok. But it doesn't affect LDL cholesterol levels. If we can, it is best to be fasting and now that is enough. On the other hand, we can ask virtually any GP if we would like to have our lipid profile done. And I am very glad that you said 30 years old, because I think that we should actually know our cholesterol levels at any age. Why? Because we have something called familial hyper cholesterol, which is a genetically determined disease, where even in Poland in the hetero form, which is the less malignant form, I would say, so that we understand it properly, there may be as many as 150 000 people in Poland, and we have diagnosed less than 8 000 so far, so a lot of people in Poland are walking around with familial hyper cholesterol without realising it.

Maciej Banach:
And what does this involve? It is related to the fact that throughout our lives we have genetically increased levels of this bad LDL cholesterol. Throughout life the process of atherosclerosis builds up gradually, but nonetheless. And that very often these people are 100 times more likely to be diagnosed with heart disease at the age of 20 40 and much more likely to die at the age of 50 60. So that's why I encourage us to get our cholesterol levels checked at every age. That is why, together with a wonderful person like Professor Mysliwiec from Gdańsk, a fantastic paediatrician and paediatric diabetologist, we are fighting for this and I hope it will be successful. In the six-year-old's balance sheet there will be a need for lipid profile testing for all children.

Monika Rachtan:
That is, at one such.

Monika Rachtan:
The child can also already be detected with.

Monika Rachtan:
Cholesterol?

Maciej Banach:
Definitely yes, and this is the best moment. Why? Because if we detect hyper cholesterol and the child's family know what to do from the point of view of non-pharmacological management, that is, to change lifestyle, that is, to introduce diet precisely and also perhaps some small dose of medicine, and then to monitor and look at it properly. And then, if we recognise it earlier, it turns out that the family, hyper cholesterol I am speaking now metaphorically can be cured. I mean this person has this genetic defect in him all the time, of course, but we do not reduce his life expectancy. He lives just as long then as a person without this disease. But everything depends on starting early and treating effectively.

Monika Rachtan:
In the media.

Monika Rachtan:
Such headlines just cholesterol can be familial And I was wondering about this when the professor said hyper cholesterol and familial. Isn't that the explanation for a lot of people when this disease entity appeared? Because I was also reading on the internet just such opinions and on the other hand it turned out that the woman who wrote 50 years old was suffering from obesity, which was visible. Her sister was ill with obesity, which was evident. Her mum died of a heart attack, but she also suffered from obesity and she says she has this family cholesterol, genetic. And isn't it the case that she socially this environment has shaped her that way? In which one? In which she was brought up, that she observed people who were struggling, who were suffering from obesity, it became the norm for her. And it's also as if nobody thinks about the fact that obesity is responsible for 200 disease complications, and that hyper cholesterol is part of the metabolic syndrome that affects people with obesity.

Maciej Banach:
First of all, thank you for saying obesity, because it is a disease. We have been trying to teach for a long time that it is a disease, obesity, and not obesity as a risk factor. This is simply very important. And the second thing is, ladies and gentlemen, remember that most of the diseases we deal with have a secondary or environmental basis, or result from some other elements. There is no primary cause, which is genetically determined, and this applies to most obesity. In fact, in most cases of obesity, there is no genetic basis. Most patients who talk about it make a brilliant excuse for it. Of course, there is a predisposition. If my parents have obesity, there is a greater predisposition in me, but a predisposition does not mean that I will have obesity disease. And most of the time, I always tell it as a form of joke, but it's nothing to laugh at, that we have, for example, a patient and we say You know, you really need to lose weight, because we're going to put you on a diet here. Please tell us at each stage if something is okay or not, okay, because now you are in your 60s or 50s and this obesity will cause this, this, this, this, this and this.

Maciej Banach:
For now, we are at a stage where we can still avoid all this. But doctor, I eat like a mouse. Nothing, I hardly eat a day, just drink tea and everything. And then half jokingly, half seriously we look in the cupboard. In that cupboard you see what. Obviously it's a bit of a simplification, what I'm saying, but I also wish that we ourselves could look at our food, at our menus and say OK, there may be certain factors that predispose us to being at higher risk of obesity. Once we have that obesity, of course we have to do everything to minimise the other risk factors and also try to lose weight using non-drug methods or the wonderful, very good drug methods that we have now.

Maciej Banach:
I say and I say, after all, you are unreliable because you are urging the patient to make sacrifices, to take medication, you are explaining about obesity, and you have obesity yourself. This is a serious problem. How will the patient ask why you are effective in treating obesity, having it yourself? Obesity is a serious disease problem, as you said, with many complications and psycho-sociological aspects, like exclusion and so on. This is why I repeat that in any disease, including libido disorders or obesity, there should be a treatment team. This is something that a future health minister will probably want to introduce. We often say that the doctor does not give all the information to the patient. If he has 60-70 patients in an hour and a half, it is difficult. But the treatment team is the support and education that the nurse, the dietician, the psychologist do. Now, editor, if I talk about this, everyone laughs, saying: "Maciek, what are you saying when neither the psychologist nor the dietician are contracted by the National Health Service?". If the hospital director wants to employ them, he does it from his own resources. This calls for change. This does not mean that we should not create such a team. Then there is the pharmacist, who is the last link when buying medicines. Pharmacists also sometimes make mistakes, for example telling a patient not to buy statins because they damage the kidneys. This therapeutic team, if well prepared, collectively has one message and the patient is motivated to fight diseases. We should talk about prevention, about avoiding diseases.

Monika Rachtan:
What are the three most important things from our talk that our audience should remember?

Maciej Banach:
The first is to invest in your health, not just when problems arise, because that's when it's easiest. The second is to trust the doctors, because no one wants better for your health than they do. Not all doctors are the same, but everyone wants the good for the patient. The third thing is to avoid fake news and educate yourself. Read from reliable sources, like scientific societies, the National Health Service, the Ministry of Health. If you read something, ask your doctor about it. An educated patient cooperates better with the doctor. I wish you much good health.

Monika Rachtan:
I will now thank you for these wishes for good health and I will also lend you one myself, but I will not let the Professor go, because there is one more question and questions from the Facebook groups. Your partner in this programme is the Institute for Patients' Rights and Health Education, which talks a lot about the humanisation of medicine. What is humanisation to you Professor?

Maciej Banach:
This is a very difficult question, but at the same time it's first and foremost at every stage. I remember, I had a lot of fantastic mentors and advisors and at every stage whatever we didn't do, they told us to be human momento, that is, to be human no matter what we do, that is, no matter if we are a doctor, no matter if we have a degree and so on. It is on the other side that we have the human being. I remember many times the situation when I go back to my hometown of Płock and I meet my friends, where we grew up, on the block of flats, etc., and I often talk to them and they are very happy. And I often talk to them and I also remember such funny situations that they appreciate it terribly, because suddenly they see a man who has achieved something in his life and suddenly he stops to talk to them, despite the fact that we don't see each other as often as I do at my parents', and unfortunately I'm not. I beat my breast as often as I would like. And, for example, I remember such cool situations that a friend like that, who I used to practice with, comes to see me. If I saw him probably on the street I would be very scared, but because I know him well, so he also says to me Maciek, listen, what about these vaccines?

Maciej Banach:
Should I be vaccinated or not? If you tell me to vaccinate, I will definitely vaccinate. I then, of course, not only tell him that you also need to vaccinate, but I explain to him why. And that's so cool, that's part of the approach, because now yes I wouldn't ever want a doctor to be treated as God, to feel like God. Of course he decides about human life in many ways, but he has to be a partner and the patient has to be a partner and the doctor a partner for the patient. And we have to learn a lot from patients from the point of view of passing on knowledge. Because please remember that famous saying. A joke that goes around somewhere. Was there a stool? No, it didn't come today In fact, it comes from the fact that the patient doesn't necessarily understand everything. And that is why we should always ask the question at the end whether you are sure you have understood everything from this meeting today? Please don't be ashamed if it was even a question that you think would be some, that you think would be perhaps not entirely wise? There are no unwise questions.

Maciej Banach:
Let's ask ourselves everything, because if we leave the doctor's office and we have a doubt, then unfortunately we increase the chances that we won't be treated properly, that we won't take the right doses of medication or maybe we'll put them off because we have a doubt somewhere, because we read something on the internet that's wrong. So let's be human at every stage of the patient encounter and I think then it's a huge opportunity that we will have more patients treated well and we will all be smiling more. Which I wish for myself and for you.

Monika Rachtan:
And let us as patients remember that there is a doctor sitting on the other side of the table and we can also ask him or her anything and say that I have any doubts. Professor, questions from Facebook groups I will ask for 30 second answers. I decided to take statins because the doctor scared me of having a heart attack and I have been taking them for three months now, but my cholesterol is dropping very little. The doctor prescribed me more cholesterol drugs at my last appointment. I don't know whether to take them at all. Already these statins feel like they are harming me.

Maciej Banach:
This is certainly not true. Please bear one thing in mind. I, of course, cannot say from this question what the risk is. On the other hand, if the doctor said that it was to protect against a heart attack, so I assume that this is already a person who has some risk factors and that there were indications. Perhaps the statin dose is inappropriate. Here I would encourage you to remember, however, that statins do not work well if taken once every three days. That is, here you need to remember to take statins every day, and this drug second. And in addition, please remember that there is also something called responder and responder does not want to lead somehow very, very complicated concepts, but that there is a certain group of patients, which is probably about 7%, which responds less well to statins, as to any other medication than the other group. And at that point here was probably a good decision, because the other drug that you got was certainly. And at this point the statins with these I know complement each other's effects, so I would encourage you to try it though. And I also encourage you that there will be a therapeutic effect, which is a lowering of that bad LDL cholesterol.

Monika Rachtan:
And another question They used to say you can't eat eggs because of the cholesterol, then they said margarine. Now they make a margarine that treats cholesterol. Can it help instead of tablets?

Maciej Banach:
Definitely not. I am already saying one thing. Ladies and gentlemen, if we do not have an indication for medication, then as much as possible diet, diet, exercise has a chance to lower our LDL cholesterol on average around 20-25%. What does that mean on average? That there will be people who will respond better to it and there will be 42 who will have 10%. Remember that while diet alone lowers cholesterol directly, exercise only does so if there is weight loss that is a consequence of the exercise. On the other hand, if there are already indications for statins, at this point nothing can replace these drugs. That is, this cholesterol of ours is already so high and has been so long, high despite this diet, that we already have to take these drugs. We have this golden rule in low-risk patients. If the LDL level, the cholesterol is the world guideline, which by the way we have introduced ourselves. It's above 140 milligrams per decision then ok, on average then we decide. And there are already such borderline indications for pharmacological treatment, then we give ourselves 3 to 6 months. We tell the patient in great detail what a low cholesterol diet is and what needs to be changed qualitatively in this diet.

Maciej Banach:
That is, to have more of those polyunsaturated fatty acids that we talked about. And at that point, if after these six months at the maximum there is not this effect, unfortunately only one in four patients is adherent to the dietary recommendations, then at that point we turn on a low dose of just statin. Because remember, the earlier we have this therapeutic target, the lower we are, what I said at the very beginning 60% people may not have any cardiovascular incident, the longer we live.

Monika Rachtan:
And last question in the pharmacy the lady recommended me a cholesterol supplement. I have also seen similar ones on the internet. Which one should I choose?

Maciej Banach:
Ladies and Gentlemen, this is a question probably for another whole programme, because we as the International Lipid Expert Panel in 2015 started our work, because we knew that Poland is the biggest market for supplements in the world I this part of Europe, and by we researched de facto we processed about 2,500 supplements, most of the supplements I will say right away, which are advertised on TV, hardly work at all, so you can forget about them. There is a huge amount of marketing that goes behind it. On the other hand, I admire these pharmaceutical companies, because they are able to sell everything. On the other hand, of the supplements that do work, if there is no indication for medication, because supplements cannot replace medication, I immediately repeat these are the red rice preparations, that is, which have contain on the next duck natural lowa statin in a small dose of up to 3 milligrams. Currently according to. System of the year it is Burberry, it is bergamot, it is actually of the three that have the strongest effect on cholesterol, it is just these three. So if you are already very keen to support your diet, if there is no indication for a drug, I repeat then look for good quality formulations containing red rice, bergamot or Burberry. And that is then the chance that you will help your diet just to lower LDL cholesterol. But remember we don't replace statins with dietary supplements.