 And welcome to the latest edition of Telehealth in Hawaii. I'm your host, Vikram Acharya. I'm the chief executive officer of Cloudwell Health and all virtual telemedicine provider based in Hawaii. We have a great show for you today. It's a very important month. It is National Cholesterol Education Month. Cholesterol is a very important subject when it comes to maintaining our physical health. And who better to talk about cholesterol than Dr. Neil Chauhan. Dr. Chauhan is a physician and co-founder of Cloudwell Health. Dr. Chauhan, how you doing today? Good, thanks for having me on here. Appreciate it. Oh, we appreciate you. To get the conversation started, tell us a little bit about your background, your physician, but you also have a lot of expertise in telemedicine. Yeah, so my background is in family medicine. So I trained in England and then I moved to Hawaii seven or eight years ago now. It was around that time I got involved with telehealth. And I still do. I work remotely for England and Europe. And a few years ago, we started up a telehealth company here in Hawaii as well to help the local community. Yeah, it's a great service to the community. To get things started, Dr. Chauhan, what is cholesterol exactly? I mean, we hear about it all the time, high cholesterol, good cholesterol, bad cholesterol. What is it exactly? Yeah, so cholesterol is a type of fat that's kind of in the body. Our liver produces it and we get it from our diet as well. A lot of what we hear out there is about bad cholesterol, but we do need cholesterol. There's good cholesterol and cholesterol actually provides a lot of functions in our body. It produces hormones and helps with cellular regeneration. And so it's more about getting an understanding of what is good and bad cholesterol and changes that you can make to kind of improve your overall health. Now, when it comes to the good cholesterol, what are the types of measurements or things that are done to make sure you have good cholesterol? Yeah, so there's blood tests that can be done to help measure your cholesterol levels. And so we have HDL, which is high-density lipoprotein and that's your good cholesterol. And then you have LDL, which is your low-density lipoprotein and that's the bad cholesterol. And so it's kind of getting those numbers right. So, you know, if you've got more of the bad cholesterol or that's bad, and that's the type that can lead to issues like heart attacks and strokes and causes something called atherosclerosis, which is where you can get a buildup of kind of cholesterol and other plaques and so on in the vessels in your body. Yeah. Now, in order to get these cholesterol checks, what typically happens to check the cholesterol levels? Yeah, so, I mean, there's different types of tests that can be done. Often, if we're really looking at your cholesterol levels, we'll do a fasting blood test. So there'll be a period of time that you don't kind of eat. So it doesn't skew the results. And then from those, you can kind of see what the ratios are. So things like the total cholesterol levels, the good cholesterol, the bad cholesterol, things like triglycerides as well. And that gives us a bit of a bird's-eye view in terms of where we're at, whether you've got enough of the good cholesterol versus the bad or whether that needs a bit of help. And there's lots of things that can be done to try and modify that so that you do reduce your risks. Yeah, yeah. Now, when you see patients in your telehealth platform, are you seeing a lot of patients that have not gotten their cholesterol check at least in a couple of years because of the COVID pandemic? Has that been an issue? Definitely, yeah. And I think, I mean, definitely has been increased in terms of the number of people not checking through the pandemic, but even minusing the pandemic, I think it's not necessarily on everyone's radar to kind of check their cholesterol levels. You don't necessarily feel unwell if you have high cholesterol levels. And that's extreme. And so it's a bit of a silent kind of issue. You really don't even know about it once it starts causing issues with things like your blood pressure or if you have a catastrophic event like a heart attack or a stroke. So it's more of a, to me, I try and explain it to patients that it's something similar to a service, right? When you get your car serviced and you wanna make sure everything's running well, it's a good thing to check your cholesterol levels and kind of get that baseline every few years. That being said, the frequency at which the check should be done vary according to your risk factors. So if you've got risk factors like family history or you've got other illnesses like diabetes, then we should be checking those more frequently. And for those that are on medications to help lower cholesterol or have had kind of cardiac related issues, we will check them even more frequently. Sometimes even a few times through the year. The people that have zero issues, very healthy, have good cholesterol levels. Even for those, I would still recommend getting a check done once a year or once every couple of years. Now, you're an expert and you see a lot of telemedicine patients. How do you check someone's cholesterol through telemedicine? How does that work? Yeah, that's a great question. And so we have here in Hawaii with our kind of Cloudwell Health Telehealth Service, we're able to help coordinate getting those blood tests done, all the kind of local lab sensors. So we can help figure out what's closest or what's most convenient. And then we can coordinate that with you, explain what the fasting piece of it is. And then it's a very quick test in terms of if you get the results within the day, within a couple of days at latest, and then we can kind of go through the results. And kind of discuss what we need to do next. And the cholesterol level by themselves, that's helpful, but to me, it's part of the whole kind of assessment of the patient. So you're kind of assessing a patient's risk, what their family history, their health, other health conditions, what their weight is, what the exercise levels are doing. And all of that gives you a bit of a kind of score in terms of what needs to happen to kind of help get those numbers to a healthier level or help the patient become more healthy. Yeah. So by the time you see the patient, just like you and I are talking right now, you already have their cholesterol levels in front of you when you're talking to the patient. Yeah. So usually we would have kind of gone through all the risk factors and all the history-taking that we want to at the initial consultation, then we're going to arrange those blood tests. And then by the time they kind of come to that follow-up, we've got all the information to be able to go through it in a nice easy to kind of follow fashion. That's interesting. That's just like a regular visit then. Yeah, it's identical. Obviously it gives patients the convenience of being able to do them, whether they're at work or on their lunch break or at home or running around after the kids. So that convenience factor is huge and it helps save time. And actually, that ease of booking a consultation means patients are more likely to follow up. What I'm hoping is by creating these kind of easy access pathways for patients to be able to kind of get the care they need, there's a high chance that people will do things like their cholesterol checks. And what it takes is that one patient to identify those risk factors that we should do some things to really kind of modify that. And if that helps prevent a stroke or a heart attack, that's a huge, huge thing. Yeah, yeah, no, definitely. Now, when it comes to National Cholesterol Education Month, there's a lot of literature that says you should schedule an annual wellness exam to start the process around managing your cholesterol. What exactly is an annual wellness exam? Yeah, good question. So an annual wellness is, I always bring it back to cars, but it's like having the service done. So, you know, everyone's busy. Everyone's got hundreds of things that they're juggling. And so this is taking that bit of time out to have a wellness check to assess your health, right? And that includes, you know, talking with a clinician, getting a history, getting a sense of how things are. And then that's both physical as well as the kind of emotional outside of things, right? So kind of seeing how we're doing, whether there's areas that need help. And sometimes, you know, people or patients will know where they kind of need to focus or help on. Otherwise, it's also doing things like the blood tests and checking things like cholesterol levels and blood pressures and so on, so that we can really do preventative care well. And what I mean by preventative care is identifying health issues before they really become a problem, right? You don't want to have, you know, undiagnosed, high blood pressure and raised cholesterol. And for that to, you know, essentially cause issues, let's say a decade later, where it becomes a lot harder to reverse the issues, right? So that earlier you can pick those things up by doing an annual wellness. That's where you can identify these things and have a healthier life. Yeah. And is annual wellness different from a primary care appointment, seeing a primary care doctor? I mean, they're very similar, right? You know, there's overlaps in terms of, you know, ongoing management and taking care of, you know, a patient, but it's kind of focusing on that kind of service, right? So it's about looking at a patient as a whole, arranging certain blood tests, checking things like, you know, where have we got a current height, weight, a blood pressure, so that it's almost setting a good foundation for the rest of those care needs through the year. Yeah, yeah. That's interesting. Now, if you're trying to manage a patient and, you know, you're trying to get them to manage their cholesterol and things, but it's just not working. You know, you're seeing the patient multiple times and their cholesterol is either staying flat or going up on the bad cholesterol. What do you normally do? What would you normally recommend to the patient? What would be the next steps? Yeah, I mean, so first you would, you know, depending on the levels. So let's say they're mildly elevated in terms of the bad cholesterol and we've got some risk factors. According, you know, the first option would be things like lifestyle modification. So looking at things like how can we lose some weight? What can we do from an exercise standpoint? And what can we do from a dietary standpoint, right? And, you know, there's certain foods, you know, trans fats and so on that we know are bad. Whereas things like, you know, foods and vegetables and plant-based and so on, those things are better from a cholesterol standpoint. So we would typically, you know, help get that information to a patient, educate them in terms of the things that can help. And then we give it a period of time to see if that helps. So that's one option. Another option would be, you know, if a patient's, you know, got significantly elevated results or there's risk factors, then you might look at medication-based treatments. You know, one of the, I think most prescribed medications in the world now are statins, right? And those are cholesterol lowering medications. And so they make a huge difference. And usually it's a combination. So the lifestyle modifications as well as medication-based treatment and then regular monitoring to see if we're getting those levels down to a healthy level. And then you've got, you know, you might have more complicated issues. For example, you know, multiple comorbidities or other risk factors. There might be a genetic component, right? So sometimes bad cholesterol or high bad cholesterol levels can be something that runs through families and there's a genetic component to it. We call that familial hypercholesterolemia. And that might need more intensive therapy and there's other medications and kind of more frequent checks and so on. And, you know, we're very fortunate we have, you know, a deep network with kind of specialists in that area. So if we identify a patient like that, then we would do our bits and then we would also get the specialist involved so that the patient gets that kind of specialist care that they need. Now, what type of specialist would you transfer them to in this particular situation? Yeah, so I mean, when it comes to kind of cholesterol and the cardiac risk factors, that would usually be a cardiologist that would help kind of manage that. And yeah, we work very closely with kind of cardiologists in terms of helping manage patients that, you know, we might not be able to fully manage from a primary care standpoint and need that kind of additional specialist care. Yeah, now the, so you would have the ability to see the patient virtually and then seamlessly transition them to an in-person cardiologist that's pretty innovative. Yeah, so that's exactly what we try and do. So, you know, it's about making that journey as easy as possible for patients, right? We know how I've been a patient myself, you know, how painful it can be when you have a busy schedule and kind of going back and forth to multiple office visits and, you know, then you've got to go get your bloods and then you've got to wait several weeks to see a specialist and so on. So we wanted to make it as easy and efficient as possible. And there's a lot of steps that aren't necessary now that we have the technology and telehealth and so on. So, you know, once we've kind of done our video consultations and if you do need to see a specialist, we coordinate that from our end very efficiently. And, you know, you'll be seeing a specialist as quickly as within a week or two. And then they would see you in person if needs be and you get that specialist kind of element that you need. So it saves a lot of trips and you kind of get that direct focus care as and when you need it. In a couple of weeks is pretty good because most of the time, if you need to see a specialist, that can take months. It can, yeah. And, you know, that's not just a US thing, that that's what I've experienced in the UK as well. And, you know, we're fortunate with the, you know, the network that we've developed with the technology that we have and the referral pathways, you know, we're able to help expedite that process. Yeah. Is high cholesterol also correlated with high blood pressure too? Is it generally kind of the same? If your cholesterol is high, your blood pressure is high, which puts you at higher risk, like you said, of heart disease, stroke. Yeah. So, you know, there's definitely a correlation between the two and kind of the hardening that can happen in your blood vessels is essentially what we're checking for when we check your blood pressure, right? So, they can definitely correlate. And so, you know, if you've got the high bad cholesterol, which is the LDL and you've got raised blood pressure, well, you know, we should be aggressive about kind of bringing those things down because let's say it's the first time it's been picked up, you might not feel anything. You feel fine, you're fit, you're kind of doing, you know, doing your daily stuff, but that's what creeps up on you, right? And that's the stuff that can suddenly cause things like heart attacks and strokes. I mean, I'm happy to go into that. Essentially what can happen is the blood vessels, which carry blood, which carries oxygen and nutrients to your organs, you know, think of it from a plumbing standpoint, if the bad cholesterol is the stuff that throws up those vessels, right? And essentially the whole, the pipe where the blood's going to get smaller and smaller. And so eventually you can compromise blood getting to certain organs, like the heart, and that's what causes a heart attack, right? Or a bit of cholesterol, the bad cholesterol that's fed up the vessel can flake off and that can float somewhere and then that can cause a stroke, which is where you've prevented blood getting to the brain. So, you know, sometimes these things, especially cholesterol, you don't know about it until it's too late. So that's why it's important to check these things regularly. So it's almost like it's creating a sludge or blockage in your body. And when there's blockage, there cannot be, there is no appropriate circulation that it sounds like. Exactly, and what can happen is it's not just the sludge from the cholesterol. We build a bit of cholesterol and then things like proteins and so on kind of get attracted to that. And then you form like a hard plaque, right? And it's hard to get, you can't get rid of it. And so if it builds up and builds up, it compromises the blood flow through that vessel. Now the interesting thing is, is that the good cholesterol, which is the HDL, actually helps get rid of the cholesterol from those areas, right? So that's why it is important to have that balance. You want good cholesterol, that kind of gets rid of the bad cholesterol and takes it away from, you know, these vessels and the furring of them. And so you can increase your HDL through kind of diet, you know, lots of fruits and vegetables, sterols and also by exercising. Yeah, now there's a lot of literature out there that says that just a moderate amount of exercise on a daily basis can bring down your weight, which then helps reduce lower cholesterol levels. How much of a weight difference can really have an impact on your cholesterol? Good question. I don't know the exact kind of numbers in terms of how much weight, but it's moderate activity. It's more about the consistency, right? So it's not something you're gonna see an immediate change in, let's say, after you've exercised for a few days or a couple of weeks. But if it's, you know, if you kind of commit yourself to, you know, doing 30 minutes of exercise a day, whether that's kind of doing a jog, you know, a brisk walk, those that over a period of time has been proven to make a difference to the cholesterol in a good way in terms of boosting the good cholesterol and reducing the bad cholesterol. Yeah. What happens during the exercise that combats the cholesterol? It's pumping out more blood or what exactly is going on to it? Yeah, so it helps promote or increases your level of the HDL, which is the good cholesterol. And so think of the good cholesterol as your work obese, right? And so what they do is they're kind of tidying things up that the bad cholesterol are doing, like, you know, sticking things to the walls of your blood vessels and so on. And so obviously the exercise helps you lose weight, helps increase your HDL levels, which in turn helps reduce your bad cholesterol levels, which reduces your risk factors. Yeah, that's a good analogy. So the more somebody exercises, it generates more good cholesterol worker bees, which help combat the bad cholesterol then. Exactly, yeah, yeah. That's good. That's a good analogy. Now, what about diet? Now, if I want to, you know, obviously improve my diet, what types of things, you know, fruits, is it fruits, vegetables, grains, things, what kinds of things can we eat? Yeah, so all the things you mentioned. So, you know, it's essentially trying to moderate or reduce all the yummy stuff, right? Which we typically all deviate too. So, you know, that you're, you know, saturated fats, your baked goods, the fried stuff, you know, all those things are the no-nos because they increase your bad cholesterol. Whereas, you know, fruits, vegetables, plants don't have the cholesterol, you know, when we eat it, there's no cholesterol in there, right? In terms of, in the bad form. So, it's increasing your kind of plant-based intake, making sure you are getting lots of fruits and vegetables, definitely grains, you know, switching to things like, you know, instead of white pasta, having kind of whole grains, having kind of whole wheat bread versus white bread, those sorts of things can make a big difference. Yeah, yeah. And does that also generate higher levels of good cholesterol? What happens to the body when you eat those things? Yeah, so same thing. It can help kind of increase the good cholesterol and, you know, it doesn't contain the bad cholesterol. So, like I mentioned, you know, your liver produces the cholesterol that you need, right? But you also get it from your diet. And if you're going to be eating stuff, you should eat the stuff that has either the good cholesterol or doesn't have the bad cholesterol in it. Yeah. Now, a lot of the, we're also seeing a lot of high cholesterol and, you know, in the patients you see, I'm sure we're like adolescents or like it's happening earlier and earlier now, isn't it? Where people are presenting with higher levels? Yeah, we are noticing that. And it's hard to know whether some of it is, you know, perhaps the, maybe these age groups are more cognizant. And so, are kind of getting the checks done more earlier, right? I'm not sure about that piece, especially because in general, I think we've seen a bit of a downtick in terms of patients accessing care, especially through the pandemic. But there could be an element of that. I think the more predominant pieces, it's just become so easy to have the bad foods, right? So, you know, the fast foods, the snacks and so on, they're not necessarily conducive to that healthy diet that we mentioned. And so, I think that's a big contributor to the kind of increase in high cholesterol levels in younger age groups. Yeah. So especially during the past year and a half, two years during COVID, a lot of people were not as physically active. Like you said, eating a lot of foods that maybe were just easily available, chips or, you know, chocolate and candies. And that just over time has built up higher levels of cholesterol and put them at higher risk, huh? Yeah, yeah. And it takes a big mind shift to kind of change that lifestyle, right? So sometimes you can kind of get into that, what I call a rut, where it's easy. It's convenient. It's kind of almost a habit in terms of, you know, not doing as much exercise, living more of a sedentary life and having the easy foods, right? But I think what I've noticed is once patients understand the repercussions or the ripple effect from some of those choices, that's what can make the change, right? So getting more exercise, you know, keeping an eye on weight, trying to kind of stay at a healthy level and kind of eating healthier foods. Those are the kind of key elements there. And when you see patients, how much of an impact does mental health have? So folks that might have depression, anxiety, they often, do they present to you and then in turn because of their lifestyle choices also have high cholesterol levels. Is there a correlation there too? That's a great question. And I would say from my own clinical work and seeing patients all around 100%, you know, I think we've seen much more of that through the pandemic. And, you know, I think it's affected a lot, but if not everyone in some way, shape or form, right? In terms of kind of, you know, behavioral health, you know, mental struggles and so on. And, you know, we know a third of patients there might be more of patients that have, you know, a chronic health disease suffer from some sort of mental health issue too, whether that's depression, anxiety and that it's all confounding, right? So, you know, it makes one thing worse after another, right? And so it can make it much harder to get out of that rough or kind of make those kind of decisions or kind of choices, especially if you're not feeling motivated to do that or you feel low or you're anxious, you know, people can eat because they feel anxious. Sometimes they use that as a crutch and so on. So there's definitely a huge correlation between the two. And so it's really important as a clinician to address both a patient's kind of physical health as well as their behavioral health because they're definitely intertwined and you can't have one healthy without the other, right? You kind of wanna be able to help everyone with both of those things. Yeah. So you're working, you know, for example, with the Cloudwell model, a primary care physician is working in partnership with a therapist to manage a patient, to work with them. Yeah. And for me, that's always been really important because there's always things you can do from a physical standpoint, but if we haven't got a review or kind of looked at a patient's behavioral health and why they're making certain decisions and so on, less chance of success, right? In terms of getting a patient to where they want to be from a health standpoint, longevity and so on. So what I call is a biopsychosocial approach, you know, it's looking at a patient as a whole. And so yeah, I recommend every patient that comes to us to have both the physical side of things, the wellness check, the primary care kind of model, and also to kind of have a mindfulness check where they kind of, they check in with a therapist. And like I said, everyone's gone through a really difficult time. And so I think having that forum, that chance to speak to someone, that specializes in behavioral health is healthy. Yeah, and when you see the patient on a follow-up visit, if they go through with the mental health, that means that you could probably have a good conversation with them around, you know, making sure that not only you're addressing their physical needs, but also that they're appropriately cared for on the mental health side, so you have more comprehensive conversation. Exactly, it makes everything more fluid. And I think it allows a much better alignment in terms of kind of the doctor-patient relationship. And it's helping break down barriers. You know, there's still stigmas attached to someone accessing behavioral health services. And it's trying to break that down where everyone needs help. And sometimes it can be more of an issue of accessing that care, but if we can make it easy, then we would encourage everyone to do it. Right, right. I'm sure over the years you've seen many patients have very positive progression, you know, from maybe a combination, you know, had depression and, you know, the lifestyle reflected that, but over time they really improved and became... 100%. Yeah. And it's subtle, you know, it's not someone that's, you know, got severe depression necessarily or kind of severe anxiety. It's normal people with normal lives, right? Who are having a stressful time, whether it's relationships or work, and they're not sleeping as well, or they're just feeling a little bit antisocial, or they're just not getting as much enjoyment from the things that they were, or they're thinking twice about going for that jog that they do once or twice a week, right? So these little subtle things that can then become more of a more of an issue. And I think it's trying to break down those barriers and increase the ease of access to care so that when you start noticing those little things, you know, to kind of get some help. And I think stubbing those things out or getting the right help is what then allows a kind of successful, healthy journey. Yeah. And like you said, it's subtle and it takes time. It's not a, you know, I'm gonna go run for a week, eat just fruits and vegetables and within a week I'm gonna see changes. It probably takes several months, I would think, to really start to see changes. Yeah, yeah. And so a lot of it's gonna mindset getting yourself in the right place, both physically and mentally. And I think the more support we can give anyone around those things, the better chance of success. And you know, I'd say that these aren't kind of quick fixes. It's the more if I kind of think if your health is a journey, right? You wanna look after your body, not just when you're feeling unwell, right? Or when you've had something big happen, you should be doing it from as young as possible so that, you know, it's a good machine that lasts you your whole life, right? Closing too many issues. Yeah, Dr. Chauhan, it's always a pleasure to talk to, you know, your knowledge of telehealth, how it works, how it functions, the benefits it can bring to everyone in Hawaii, also your medical knowledge, you know, good cholesterol, bad cholesterol, how to manage, you know, oneself, not only from a physical standpoint, but from a mental behavioral standpoint is all encompassing and always appreciate you being on the show. Thank you, Nick, I appreciate it. Have a great day, Mahalo. Thank you so much for watching Think Tech Hawaii. If you like what we do, please like us and click the subscribe button on YouTube and the follow button on Vimeo. You can also follow us on Facebook, Instagram, Twitter and LinkedIn and donate to us at thinktechhawaii.com. Mahalo.