Dr. Alex Verge, ND
Episode Summary
What actually raises your risk of cardiovascular disease—and how much do cholesterol, LDL, ApoB, blood pressure, sodium, saturated fat, exercise and statin medications matter for preventing a heart attack or stroke?
In this episode of Girls Gone Wellness, Jeanette and Victoria are joined by Dr. Alex Verge, ND, a naturopathic doctor with more than two decades of clinical experience and a focus on cardiovascular health. The conversation explores cardiovascular disease prevention, atherosclerosis, high cholesterol, elevated LDL cholesterol, apolipoprotein B (ApoB), HDL cholesterol, triglycerides, high blood pressure (hypertension), statins, sodium intake, saturated fat, cardiovascular nutrition, exercise and common heart-health myths.
Dr. Verge begins by explaining that cardiovascular disease is broader than heart attacks alone. The episode discusses atherosclerosis and atherosclerotic heart disease, ischemic stroke, heart failure, atrial fibrillation and congenital heart conditions, while focusing primarily on modifiable cardiovascular risk. High cholesterol, high blood pressure, smoking, nutrition, physical activity, sleep, family history and certain pregnancy complications are discussed as pieces of an individual's overall cardiovascular risk profile.
A major focus is the idea of lifetime exposure to cholesterol and elevated blood pressure. Dr. Verge explains why a young adult may have a low 10-year risk of having a heart attack while still accumulating cardiovascular risk over decades. The conversation explores when cholesterol testing should begin, why family history may justify earlier testing and why waiting until cholesterol is “high enough” to act can represent a missed prevention opportunity.
The episode then breaks down a standard lipid panel. What is the difference between LDL cholesterol, HDL cholesterol, non-HDL cholesterol, triglycerides and ApoB? Dr. Verge uses a highway analogy to explain the difference between the amount of cholesterol being transported and the number of atherogenic particles carrying it. She also challenges the longstanding belief that having high HDL—the so-called “good cholesterol”—cancels out elevated LDL.
Jeanette, Victoria and Dr. Verge also discuss how cardiovascular risk is calculated using tools such as the Framingham Risk Score, and how LDL levels may be interpreted alongside risk-enhancing factors such as elevated ApoB and C-reactive protein (CRP) when considering treatments including statins.
Nutrition myths make up another major part of the episode. Dr. Verge discusses dietary cholesterol and eggs, saturated fat, red meat, sodium and electrolyte powders, keto and low-carbohydrate diets, the carnivore diet and seed oils. She explains why blood sodium levels do not tell you how much sodium you are consuming and discusses the relationship between higher sodium intake and blood pressure. The episode also covers changes in cholesterol and sodium sensitivity during menopause.
For heart-healthy eating, Dr. Verge focuses less on one rigid diet and more on common features of evidence-based dietary patterns such as the Mediterranean diet, DASH diet, MIND diet and Portfolio diet: a plant-forward approach, legumes, higher potassium intake, lower sodium, lower saturated fat and room for lean animal proteins if desired.
Finally, the episode tackles statin stigma, plant sterols, niacin, cardiovascular supplements, exercise, aspirin and omega-3 fish oil. A recurring theme is the difference between improving a risk-factor number and actually reducing cardiovascular events such as heart attack or stroke. Dr. Verge also explains why both cardiovascular exercise and strength training can contribute to heart health and why sustainable lifestyle changes matter more than a short-term “perfect” plan.
The episode closes by challenging misinformation that portrays saturated fat as beneficial while demonizing seed oils, reinforcing the importance of looking at long-term cardiovascular outcomes rather than wellness trends.
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What is cardiovascular disease?
Cardiovascular disease is a broad category that includes more than heart attacks. Dr. Alex Verge discusses atherosclerosis and atherosclerotic heart disease, ischemic stroke, heart failure, atrial fibrillation and congenital heart conditions, while focusing primarily on preventing atherosclerotic cardiovascular events.
What are the major modifiable risk factors for cardiovascular disease?
Major modifiable cardiovascular risk factors discussed in the episode include high cholesterol, high blood pressure, smoking, nutrition, physical activity and sleep. Dr. Verge explains that risk is also influenced by non-modifiable or historical factors such as family history and certain pregnancy complications.
Should you have your cholesterol checked in your 20s or 30s?
It depends on individual risk, but Dr. Verge argues that earlier cholesterol testing can be useful in some people. She explains that Canadian recommendations have traditionally started routine cholesterol screening later than some U.S. recommendations, but significant family history, smoking or other risk factors may justify testing earlier.
What does lifetime cholesterol exposure mean?
Lifetime cholesterol exposure refers to both how high cholesterol is and how long it has been elevated. Dr. Verge compares this with smoking “pack-years”: two people can have the same cholesterol level today, but the person who has had elevated cholesterol for 15 or 20 years may have accumulated more cardiovascular risk than someone whose cholesterol only recently increased.
What is the difference between LDL, HDL, non-HDL cholesterol and ApoB?
LDL, HDL and other lipoproteins are particles that transport cholesterol through the bloodstream, while ApoB reflects the number of atherogenic particles capable of carrying cholesterol into the arterial wall. Dr. Verge describes LDL and non-HDL cholesterol as measures related to how much cholesterol is being transported, whereas ApoB can help represent how many potentially atherogenic particles are circulating.
Does high HDL cholesterol cancel out high LDL cholesterol?
No. Dr. Verge explains that having adequate HDL cholesterol does not erase the cardiovascular risk associated with elevated LDL cholesterol. While very low HDL may be relevant, having especially high HDL does not necessarily provide extra protection that compensates for high LDL.
How do doctors decide whether high cholesterol needs treatment with a statin?
Statin treatment is considered in the context of overall cardiovascular risk rather than one cholesterol number alone. The episode discusses the Framingham Risk Score, low-, intermediate- and high-risk categories, LDL cholesterol and risk-enhancing factors such as ApoB and CRP, while emphasizing that treatment decisions should be individualized.
Does eating too much sodium increase blood pressure?
Yes. Dr. Verge explains that, at a population level, higher sodium intake is associated with higher blood pressure, although individuals differ in sodium sensitivity. She also discusses how people with hypertension and people going through menopause may be particularly sensitive to sodium's effects on fluid balance and blood pressure.
Can a blood sodium test tell you if you eat too much salt?
No. Blood sodium is tightly regulated by the body and is not a direct measure of dietary sodium intake. Dr. Verge explains that research assessing sodium intake often uses urine sodium measurements, with repeated 24-hour urine collections providing different information from a single spot urine sample.
Are eggs bad for high cholesterol?
For most people, Dr. Verge explains that dietary cholesterol from foods such as eggs is not the primary dietary driver of elevated blood cholesterol. A smaller group may be more sensitive to dietary cholesterol, but the episode places greater emphasis on saturated fat intake when discussing dietary influences on cholesterol.
Does saturated fat raise cholesterol, and what does that mean for the carnivore diet?
Dr. Verge explains that saturated fat can increase blood cholesterol and discusses why the amount consumed relative to total energy intake matters. She raises concern about long-term carnivore-style diets because they can contain large amounts of saturated fat, while cardiovascular disease may take decades to become clinically apparent.
What is the best diet for cardiovascular health?
There is no single required heart-health diet, but several evidence-based dietary patterns share similar features. Dr. Verge discusses the Mediterranean, DASH, MIND and Portfolio diets, which generally emphasize plant foods, legumes, potassium-rich foods, lower sodium, lower saturated fat and flexible inclusion of lean proteins.
Can supplements such as niacin or plant sterols replace statins?
Not necessarily. Dr. Verge emphasizes the difference between improving a cardiovascular risk factor, such as lowering LDL cholesterol, and demonstrating that an intervention actually reduces heart attacks or strokes. She uses niacin as an example of an intervention that can improve lipid numbers without necessarily producing the cardiovascular outcome people expect, while discussing plant sterols in the broader context of the Portfolio diet.
Is cardio exercise better than strength training for heart health?
Not necessarily. Dr. Verge explains that different forms of regular physical activity can support cardiovascular health, allowing exercise recommendations to be tailored to what a person enjoys and can sustain. She discusses approximately 150 minutes of moderate-intensity activity per week as a common cardiovascular target while emphasizing that some activity is better than none.
Should everyone at risk of heart disease take a daily aspirin?
No. Dr. Verge explains that aspirin has a clearer role in secondary prevention for some people who have already experienced a cardiovascular event, but the benefit is much smaller for primary prevention in people who have never had an event and must be weighed against potential harms. Someone already taking daily aspirin should discuss any change with their healthcare provider rather than stopping it independently.
Should everyone take an omega-3 or fish-oil supplement for heart health?
No. Dr. Verge distinguishes omega-3 intake from routinely giving everyone an omega-3 supplement. She discusses emerging concerns about higher-dose EPA and DHA supplementation and atrial fibrillation risk, while expressing greater enthusiasm for obtaining omega-3s through fish when appropriate.
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This transcript has been edited for clarity and readability while preserving the substance of the conversation.
Jeanette
Welcome to Girls Gone Wellness, Dr. Verge.
Dr. Alex Verge
Hi, you two. I'm so glad to be here.
Victoria
We are so thrilled to have you on our podcast today to talk about a very big topic, and that is cardiovascular health.
It's a super important topic because cardiovascular disease is still the number one cause of death. Unfortunately, it's not the sexiest of topics, but I feel like we absolutely have to cover it because there is boatloads of misinformation out there.
More importantly, talking about our risks and prevention can literally save lives. So there's a lot of ground to cover. I want to dive right in.
Dr. Alex Verge
That sounds great. And come on, it's kind of a sexy topic.
Victoria
We're going to make it sexy.
Dr. Alex Verge
It could be!
I think it's extremely interesting, and part of my goal in my practice is to make it interesting to everyone. So thank you for having me and allowing me to talk about it.
Jeanette
One hundred percent.
Before we get into it, can you tell us a little bit about how you got into naturopathic medicine and then how you decided to focus on cardiovascular health?
Dr. Alex Verge
Sure. I've been in practice for 22 years now.
I have to credit a couple of people for getting me into naturopathic medicine in the first place. My family were early adopters of what I would call a stereotypically integrative approach. We had a family doctor, but we also had a naturopathic doctor, which was a little unusual when I was growing up.
That naturopathic doctor was amazing. I was a curious child, just as I'm a curious adult, and I peppered him with questions nonstop. He was so generous with his time and with answering my questions, and I think that really got the ball rolling for me.
By the time I got to university, I was really interested in nutrition. I did essentially a biochemistry degree in nutrition and discovered that I didn't necessarily want to do the work associated with that, but I was really interested in the health aspect.
I was able to reconnect with those past interests and think, “You know what? I think this is actually going to bring all the pieces together for me.”
Like many people, when I first started my practice, we were jacks-of-all-trades. We were the family practice of naturopathic medicine.
Over time, I really grew to love talking about proactive care and prevention. As you rightly mentioned, cardiovascular health is such a big deal. It's still the number one killer globally for men and women.
These were the questions that would come up and the areas I tended to focus on. I spent more time talking about cholesterol panels, what blood pressure is all about and cardiovascular prevention, and I developed a real affinity and interest in the area.
That's my journey in a nutshell.
Jeanette
That's amazing.
Like so many other naturopathic doctors we've interviewed on this podcast, there's that history of seeing a naturopathic doctor themselves and having that experience influence their future career.
It's interesting to see how much of an impact that can make.
Dr. Alex Verge
For me, that was almost 40 years ago.
It's amazing how meeting somebody can direct your journey and how important it is to meet people in our lives who can be mentors and be generous with their time.
Jeanette
One hundred percent.
As Vic said, this is a big topic. Let's start with a general overview. What really is cardiovascular disease? When people say that, what does it encompass?
Dr. Alex Verge
There's what cardiovascular disease encompasses and then there's what people think it is.
Usually, when I'm talking about cardiovascular disease, I'm also alluding to what people tend to think of, which is typically atherosclerotic heart disease.
When people think about heart disease, they think, “Am I going to have a heart attack? Am I going to have a stroke?”
Particularly when we're talking about an ischemic stroke, we're in that atherosclerotic heart-disease umbrella.
But cardiovascular disease encompasses much more than that. Atherosclerosis and atherosclerotic heart disease are a huge component, particularly when we start talking about cholesterol.
There's also heart failure, different arrhythmias, congenital heart conditions and a whole other world of heart disease.
There's overlap too. Just because someone has an arrhythmia doesn't mean they don't have to worry about atherosclerosis.
The main focus I have in my practice is the atherosclerotic piece. That's usually what people are most concerned about, and it is a major component of cardiovascular disease.
Victoria
That specific section—which I'm not going to say because I'll butcher the word—is more of the preventable side, correct me if I'm wrong?
There are obviously aspects of cardiovascular disease that you can't prevent.
Dr. Alex Verge
Yes, there are certainly pieces that aren't preventable.
An obvious example would be congenital heart disease. If somebody is born with an anatomical defect, that's simply what they're born with, although we can still be cautious around the development of additional risk factors.
But with atherosclerosis, and even things like atrial fibrillation or heart failure, there are distinctly known risk factors and opportunities for proactive prevention.
When we're talking about reducing the risk of heart disease, we're talking about managing things such as cholesterol, blood pressure, smoking, nutrition and movement.
Those modifiable risk factors often get lumped into the atherosclerosis conversation, but they're also important for other types of heart disease, including heart failure and arrhythmias such as atrial fibrillation.
Victoria
Who is at risk? Looking at both modifiable and non-modifiable risk factors, who is at the highest risk for cardiovascular events?
Dr. Alex Verge
That's a complex question because, in a way, we're all at risk. That's one reason cardiovascular disease is so common worldwide.
That sounds discouraging, but there are components that put some people at greater risk than others.
If somebody has higher cholesterol or higher blood pressure, those modifiable factors increase the risk of several heart conditions, including atherosclerosis, heart failure and atrial fibrillation.
People often don't think of heart failure or atrial fibrillation as conditions they can become more likely to develop because of a risk factor such as high blood pressure, but they can.
We also talk about certain scenarios that highlight greater risk. Pregnancy is one I discuss quite a bit.
Pregnancy is a big stress test. Blood volume goes up and a lot is happening physiologically. It can highlight whether someone has a predisposition toward cardiovascular issues. It doesn't necessarily cause that predisposition; it may uncover it.
People who develop preeclampsia or another hypertensive disorder of pregnancy, or who have a low-birth-weight baby, may be at greater cardiovascular risk later in life.
When I speak with patients, I'm going through the standard modifiable risk factors: Do you know your blood pressure? Do you know your cholesterol levels? Are you a smoker? What does your nutrition look like? What about your other lifestyle factors?
Sleep also has an impact on cardiovascular health.
Then I'm going through family history.
If there is a family history of premature heart disease—for example, a father or brother who had an event before age 55, or a woman in the family who had an event before 65—I'm paying much more attention.
Pregnancy-related risk factors and all of those other pieces funnel into this overarching risk assessment.
It isn't always as straightforward as saying one group is at risk and another isn't. It's about weaving the different factors together.
Victoria
It is scary to know that, at the end of the day, we're all at some risk for cardiovascular disease.
But it's also empowering to know that there are things we can do to minimize that risk. Simply being aware can help us address things earlier.
Dr. Alex Verge
Absolutely.
Every once in a while, I can see the conversation taking a turn where somebody gets that deer-in-the-headlights look.
I always come back to “knowledge is power.” Knowing something can empower us to do something about it.
I'm also very sensitive to the fact that knowledge can be scary.
But I have conversations with people further down the road who say, “I really wish I had known this earlier.”
I take that to heart.
Sometimes I'll tell somebody, “This may not resonate with you now, but I want to put it out there in case there's a time when it resonates long before you actually need it to.”
Victoria
I think it's difficult because we live in a society where, when we're talking about our health and going to a practitioner for a health-related reason, we usually want fast results that we can see.
That makes it difficult for patients to commit to changes when they aren't necessarily going to see the benefits immediately.
We talked to Dr. Kim Bretz about this. If you have irritable bowel syndrome (IBS) or something related to your gut, you're feeling it all the time.
When you make a change and physically feel better, you're more likely to continue that diet or lifestyle change.
But when it comes to cardiovascular health, it's easy to think, “I'm 30. Maybe changing my diet will reduce my risk, but I kind of want this brownie. None of this is affecting me right now.”
Dr. Alex Verge
That's the core of the problem.
Cardiovascular disease is a very slow-moving ship. It takes a long time to develop.
That's a good thing, not a bad thing.
But the twist is that staying motivated to make changes is harder when you don't feel anything right now.
If you're making dietary changes you believe are heart healthy, you're not doing them for a week. You're doing them for the long term and hoping they pay off.
That's why understanding the information and feeling confident in it is so important. Otherwise, how do you stick with it?
We have to find sustainable pieces—something you can incorporate not just for two weeks, three months or two years, but for decades.
That's challenging, but it's also really rewarding.
And the changes we find that are sustainable for cardiovascular health generally benefit overall health in many other ways too.
Jeanette
That's a good point.
It's a lifestyle change. If you're exercising, sleeping better and getting your nutrition in check, that's going to affect other aspects of your health while also improving cardiovascular risk.
Even if cardiovascular prevention itself isn't what motivates you, it can be a side benefit.
Going back to what we were talking about, everyone thinks heart disease is something that happens when we age.
Should we be checking our blood pressure in our 20s and 30s? Should we be getting cholesterol panels? How do you talk to younger patients about that?
Dr. Alex Verge
The recommendations in Canada are different from those in the United States, particularly when it comes to cholesterol.
Let me take a step back.
Heart disease takes a long time to develop.
Even if somebody has elevated cholesterol or moderately elevated blood pressure, it's rarely going to have a major immediate impact on that person's health in their 20s or 30s.
This is an exposure-over-time issue.
They're also unlikely to have a heart attack or stroke at a young age, even if they have those risk factors.
Different organizations and guidelines therefore have different recommendations.
As it stands, Canada has traditionally not recommended routine cholesterol testing before age 40 unless there are reasons for earlier testing, such as smoking or other risk factors.
In the United States, they've taken a different approach, starting earlier and retesting periodically. I think that's more proactive for obvious reasons.
For most people, testing at 40 may be okay—except for the people who have elevated cholesterol before then.
The traditional argument has been that even if someone has elevated cholesterol at 20, their risk of a heart attack between 20 and 40 or even 50 is very low.
That's technically true.
But they've also spent 20 or 30 years exposed to that risk factor.
This is where we get into the concept of cholesterol exposure or the “area under the curve” for blood pressure.
In the research world, people are talking much more about the need to pay attention to cumulative exposure.
If we can identify younger people with elevations and make them aware of those levels, we may be able to start lifestyle changes earlier. That doesn't automatically mean medication.
I use that exposure conversation frequently, not just with people in their 40s and 50s but with people in their 20s and 30s.
If somebody has a significant family history, for example, I may advocate for earlier testing.
Victoria
I wanted to clarify that because I had read about lifetime cholesterol exposure.
Say one person has had higher cholesterol for years, while another person enters menopause and their cholesterol goes up for the first time.
Is the length of exposure part of what makes the first situation riskier?
Dr. Alex Verge
I would say it's both the length of exposure and the absolute elevation.
I often explain cholesterol exposure by comparing it to the old concept of smoking “pack-years.”
If one person smokes a pack of cigarettes a day and another smokes three cigarettes, you can intuitively understand that the amount matters.
But duration matters too.
Imagine two people both smoke a pack a day. One has done it for 20 years and the other started last week.
On paper, they're both smoking a pack a day today, but we clearly recognize that the person who's done it for 20 years has accumulated much more exposure.
Apply that to cholesterol.
One person may have had very modest cholesterol for years and then experiences an increase through the menopausal transition, which is common.
Another person's records may show that their cholesterol has been on the high side for 15 years, but each time they've been told, “It's not high enough for us to worry about yet.”
Then 15 years later, suddenly it's, “I guess we should do something about it.”
Even if those two people have the same cholesterol number today, the person who has been exposed to the elevated level for 15 years may be at greater risk.
That's something I think we're missing at the practical clinical level right now.
Jeanette
That's so interesting because I don't remember being taught the exposure piece.
I remember learning, “You're this age and your cholesterol is this high, so now we have to talk about it.”
It really highlights the importance of preventive medicine.
If somebody's cholesterol is elevated but “not high enough” for medication, that's where we may still have an opportunity to make meaningful changes.
Dr. Alex Verge
Exactly.
That phrase—“It's high, but it's not high enough”—can become really frustrating for patients when they eventually hear, “Now it's high enough, so you need to do something.”
They're thinking, “I didn't realize I could have been doing something about it all along.”
Maybe 10 or 15 years earlier we could have been discussing evidence-based nutrition, lifestyle and movement strategies for reducing cholesterol.
Instead, the first time it feels urgent is when somebody is being told they may now need medication.
Jeanette
I'm glad we touched on this.
When we talk about laboratory testing for cardiovascular health, we hear so many terms: triglycerides, HDL, LDL, ApoB.
They all tell us something different.
Can you break them down and explain what these tests tell us and which ones may increase cardiovascular risk?
Dr. Alex Verge
The first place to start is that cholesterol is something our bodies make.
Cholesterol travels through the bloodstream in different vehicles.
I think of cholesterol as the passengers in cars travelling down a highway.
When we look at things such as LDL cholesterol and HDL cholesterol, the cholesterol itself is still cholesterol. LDL and HDL refer to the type of vehicle transporting it.
You have HDL particles travelling with cholesterol inside them. You have LDL particles travelling with cholesterol inside them. You also have other particles, including intermediate-density lipoprotein (IDL) and very-low-density lipoprotein (VLDL).
Then there are triglycerides, which are another type of fat and an energy source for tissues.
Historically, we've called LDL the “bad cholesterol.”
The reason is that LDL particles can enter tissues, including the subendothelial space of the blood vessel, and deposit cholesterol in a way that can contribute to plaque formation.
HDL particles can participate in moving cholesterol away from places where we don't want it and back toward pathways involved in getting rid of it.
I'm simplifying here, but that's where the traditional “LDL is bad, HDL is good” language came from.
What we've learned over time is that LDL isn't the only particle capable of bringing cholesterol into places where we don't want it.
IDL and VLDL-related particles matter too.
That's why non-HDL cholesterol and ApoB can give us additional information.
Non-HDL cholesterol includes LDL plus other atherogenic cholesterol-containing particles, so it can be a more comprehensive measure than LDL alone.
ApoB is another way of looking at it.
Going back to the highway analogy, imagine every potentially atherogenic vehicle has one sticker on it identifying it as a vehicle.
ApoB gives us an idea of the number of those vehicles.
You could have ten passengers packed into one large van, but it's still only one vehicle.
So LDL or non-HDL cholesterol tells us more about how much cholesterol is being transported, whereas ApoB gives us information about the number of atherogenic particles carrying it.
Both matter.
The amount of cholesterol matters, and the number of vehicles matters.
Sometimes I'll say that ideally we want an emptier highway.
But if you're from Toronto, instead you've got the 401 on any given day—cars everywhere. Some have one passenger, some have multiple passengers, but there are a lot of vehicles capable of carrying cholesterol to places we don't want it to go.
Jeanette
No, you did great. The analogy works.
Dr. Alex Verge
Then we have HDL, which we historically called the “good” cholesterol.
For years, we thought that if HDL was high, that was extra-protective.
I used to have conversations where somebody was told their LDL cholesterol was high but that it was okay because their HDL was also high—as though one buffered the other.
I've said that myself. That's what we believed.
You don't know what you don't know, and we learn more all the time.
What we've learned is that having enough HDL is important. We don't want it to be too low.
But having more and more HDL doesn't necessarily continue giving you extra benefit. I often describe it as a Goldilocks zone.
Once you have enough, having extra doesn't give you endless bonus points.
So if somebody says, “I've been told my LDL is a little high, but my HDL is good, so I don't have to worry,” unfortunately, that's not how I would frame it anymore.
It's great that the HDL isn't too low, but it doesn't cancel out high LDL.
We have to treat elevated LDL as its own issue.
Victoria
That's really helpful for Jeanette and me.
I have a lot of patients with high cholesterol, and lipid panels can get confusing.
I've been caught in that situation too. If a patient has high LDL and low HDL, obviously I'm concerned.
But then somebody has high LDL and high HDL, and you're wondering, “Does the high HDL make this okay?”
It's helpful to understand that high LDL still deserves attention regardless of the HDL.
Dr. Alex Verge
Exactly.
The way laboratory reports present cholesterol has changed over time, which has been confusing for practitioners and patients.
When I started practice, there were reference ranges. Then the ranges changed, and for a while they disappeared.
Now, at least in Ontario through LifeLabs, some ranges have returned in a specific way.
It's helpful on one hand but challenging on the other because it doesn't tell the whole story.
People understandably ask, “How high is too high? Why won't somebody just tell me the number?”
The reason is that cholesterol is interpreted in the context of someone's overall cardiovascular risk.
Historically, if somebody's 10-year risk was low, we might accept a higher LDL than we would in somebody with a higher calculated risk.
The problem is that somebody can be low-risk today and still be exposed to that elevated cholesterol for 10, 20 or 30 years.
Eventually their calculated risk changes, and suddenly everyone panics about the same cholesterol number they've had for years.
The patient understandably asks, “Why didn't we talk about this then?”
That's the missed opportunity.
We're increasingly bringing cumulative exposure into the conversation.
This isn't a binary state where one number never contributes to heart disease and the number directly above it always does.
That's frustrating for everybody.
Victoria
We were taught the 10-year risk assessment.
But I've always wondered whether there's an actual standard of care where it's, “At this point you absolutely have to treat.”
Different doctors seem to say different things. One might say, “I treat everything above this,” while somebody else says they only care about a ratio.
Is there a standard of care, or are we all making it up?
Dr. Alex Verge
You have gone right to the heart of one of my frustrations.
There is a standard of care, although there are challenges with how it gets applied.
If we're using the Canadian Cardiovascular Society guidelines, the standard is relatively clear.
You calculate the person's 10-year cardiovascular risk. Canadian guidelines use the Framingham Risk Score, so someone is categorized as low, intermediate or high risk.
Then different LDL thresholds are used within those risk categories.
For example, in a low-risk person, the LDL threshold for guideline-directed statin consideration has historically been much higher than I personally would be comfortable simply ignoring.
In an intermediate-risk person, that threshold comes down.
And in somebody considered high-risk, the treatment conversation becomes much more aggressive regardless of the individual LDL number.
It can get more complicated when you have somebody who hasn't technically crossed an LDL threshold but has other risk-enhancing factors.
For example, maybe ApoB is elevated or there is evidence of inflammation such as an elevated CRP.
Those factors may increase overall risk enough to change the medication conversation.
So there are distinct lines in the sand, but there are also risk-enhancing pieces.
There isn't one perfect cholesterol number where everything below it is harmless and everything above it is harmful.
That creates room for the public and practitioners to make different judgement calls, so you end up seeing a mishmash of approaches.
Victoria
That makes sense.
We're going to talk more about the stigma around statin medication, but while we're on labs, I want to talk about another myth I see online.
There's this idea that society isn't getting enough sodium and that everyone should be supplementing with high-sodium electrolyte powders.
When we test sodium on a standard electrolyte panel, does that tell us anything about our dietary sodium intake or cardiovascular risk?
And do we actually need more sodium?
Dr. Alex Verge
This is what makes the conversation challenging: we don't have easily accessible blood testing that gives us the information people think it gives us.
When research looks at sodium intake and cardiovascular risk, the better measurement has generally involved urine sodium, not serum sodium.
The sodium level on standard blood work is not an appropriate way to determine somebody's sodium intake or whether their sodium intake is increasing cardiovascular risk.
The same confusion happens with things such as potassium, calcium and magnesium.
People ask, “My doctor checked my sodium or magnesium. Can't we just look at that?”
Electrolytes in the bloodstream have to be very tightly controlled, in part because the heart is an electrical organ that requires a narrow range of these electrolytes to function.
The body has mechanisms to keep blood concentrations within that zone.
Because of that, blood sodium doesn't simply rise and fall in proportion to how much salt you ate.
In sodium research, urine sodium is therefore much more useful.
But even urine testing has nuances.
Your sodium intake changes throughout the day, and so does sodium excretion.
A single spot urine sample can give a different answer from a 24-hour urine collection, particularly if repeated 24-hour measurements are used to estimate someone's average intake.
Some of the research used to argue that sodium isn't associated with cardiovascular risk has problems right at that measurement stage.
It's not practical for me to send every patient for repeated 24-hour urine sodium collections, so clinically I'm more likely to assess dietary intake through a careful dietary history or tracking.
Victoria
That answers the testing part.
What about the electrolyte powders? Does the idea that too much sodium can increase blood pressure and cardiovascular risk still stand?
Dr. Alex Verge
Absolutely.
The short answer is yes.
You'll sometimes see claims based on a “J-shaped curve,” where lower sodium appears to be associated with higher mortality or cardiovascular risk.
Part of the problem in some of that research comes back to how sodium intake was measured.
There's also confusion around ketogenic and very-low-carbohydrate diets.
When somebody initially goes into ketosis, the drop in carbohydrate intake and insulin can alter fluid and electrolyte balance. People lose water and sodium and may feel unwell.
The mistake is taking that kernel of truth and turning it into an arbitrary recommendation that everybody needs a large amount of supplemental sodium indefinitely.
At a population level, we have very strong information showing that, to varying degrees, the higher sodium intake goes, the higher blood pressure tends to go.
That's true even in people whose blood pressure is normal to begin with.
People who already have hypertension may be more sodium-sensitive.
There is individual variability. Some people are more sensitive to sodium than others.
But variation between individuals doesn't invalidate the population-level relationship.
This becomes particularly relevant around menopause.
Along with cholesterol increases being common during the menopausal transition, blood pressure can rise too.
The decline in estrogen can contribute to greater sodium sensitivity and water retention, which can increase blood volume and blood pressure.
This is also a time when some people are concerned about body composition and may move toward lower-carbohydrate diets.
If they're combining a lower-carbohydrate approach with a very high sodium intake because they were told to add electrolyte packets, that may create another issue for blood pressure.
Jeanette
I'm glad we touched on that.
I've seen electrolyte packets containing huge amounts of sodium, and people are taking them multiple times a day.
It's also such a good example of why we have to look at research methods, not just an abstract or conclusion.
Dr. Alex Verge
Exactly, and that's hard work.
I don't blame the average consumer—or even the busy clinician—for not automatically knowing that a spot urine test isn't equivalent to repeated 24-hour urine measurements.
At some point, we have to do our due diligence and find trustworthy resources that can explain those nuances.
One of my “favourite”—and by favourite I mean frustrating—things that happens in studies is comparing two sodium-intake groups and saying, “We lowered sodium and there was no change in blood pressure, therefore sodium doesn't matter.”
Then you look more closely and realize the “high sodium” group was already consuming an amount near or below recommended targets.
If you take a group consuming 2,000 milligrams and lower them to 1,500 milligrams, you may not see much blood-pressure change because both groups are already on the lower end.
But the headline becomes, “Reducing sodium doesn't reduce blood pressure.”
That's not necessarily the story the study tells.
These things can look completely legitimate on the surface and be very difficult for people to discern.
Jeanette
Let's switch gears to diet in general.
We've all heard things across generations like eggs being a problem, saturated fat from dairy or red meat increasing cholesterol and so on.
Do these claims still stand? What have we learned?
And I also have to hear your opinion on the carnivore diet.
Dr. Alex Verge
You're setting me up here. When are we going to get the hate mail?
The egg story is actually one reason some people became distrustful of the medical profession.
People were given information very confidently and told to follow it.
Then 10 or 15 years later it was, “Actually, we got that wrong.”
Then it became, “Well, we sort of got it right.”
People understandably think, “Do you actually know what you're talking about?”
That's where seeds of misinformation can grow.
But the beauty of science is that we don't know what we don't know. We learn more all the time, research builds on research and we continually triangulate toward a better answer.
With eggs and dietary cholesterol, the original thinking made sense on the surface: if somebody has high cholesterol and they eat more cholesterol, wouldn't that add to their total cholesterol load?
Egg yolks are rich in cholesterol, so people were told to avoid them.
What we eventually learned is that, for most people, dietary cholesterol doesn't translate directly into a comparable rise in blood cholesterol.
Instead, saturated fat intake has a more meaningful influence on blood cholesterol.
Sometimes dietary cholesterol and saturated fat come packaged together.
Egg yolks contain some saturated fat. A fatty cut of beef may contain both cholesterol and a substantial amount of saturated fat.
That made it harder to separate the effects historically.
There are still people who are more sensitive to dietary cholesterol. We're not all metabolically identical.
For a smaller subset of people, the amount of dietary cholesterol they consume may have a more meaningful effect.
But that isn't where I put the main focus for the general population.
Saturated fat is different.
Despite what parts of the online wellness space may suggest, the saturated-fat conversation is real.
The nuance is in the amount.
We often talk about saturated fat as a proportion of total energy intake, with roughly 10% of total calories commonly used as an important reference point.
If somebody is substantially above that, they're more likely to see an increase in cholesterol. Bringing saturated fat down below that range can matter.
This is also why studies can be misleading.
If a study lowers somebody from 20% of calories from saturated fat to 15%, that's a substantial reduction, but both intakes are still relatively high.
You may not see the same result as lowering somebody from 13% to 8%.
That's where the carnivore diet becomes concerning from a cardiovascular perspective.
If a diet contains a lot of saturated fat and you don't believe saturated fat raises cholesterol, then you're not going to be worried about it.
If it does raise your cholesterol but you're currently young and have a low short-term cardiovascular risk, you still may not care.
And because atherosclerosis develops over decades rather than overnight, you aren't necessarily going to see obvious cardiovascular disease during the first few years of eating that way.
That combination can create a false sense of security.
Jeanette
I'm glad we talked about that.
There are a lot of different dietary patterns recommended for cardiovascular health: the DASH diet, Mediterranean diet, high-fibre diets, olive oil.
If you had to describe a general eating pattern for heart health, what would it look like?
Dr. Alex Verge
Any of the above, which is actually a nice position to be in.
I talk more about dietary patterns now than about one specific named diet.
If you look at the Mediterranean diet, DASH diet, MIND diet or Portfolio diet, the bottom line is remarkably similar.
They're generally lower in saturated fat, often inherently lower in dietary cholesterol, higher in potassium, lower in sodium and very plant-forward without necessarily being exclusively plant-based.
They can include lean proteins.
That can look a lot of different ways.
I often talk about the Mediterranean diet because people know it and there are a lot of resources available.
But it absolutely does not have to be “the Mediterranean diet.”
Those labels aren't always culturally sensitive either.
Someone may look at a Mediterranean meal plan and say, “I would never eat this way. Does that mean the foods from my culture can't be heart healthy?”
Of course not.
If we focus on being plant-forward, including legumes, eating potassium-rich foods, keeping sodium and saturated fat lower and adding lean animal protein if somebody chooses to eat it, that opens up almost every cultural combination of foods.
The named diets are useful frameworks because they're familiar and resource-rich.
But it always comes back to the person sitting in front of us and creating something sustainable over the long term.
Victoria
I love that.
We've highlighted Mediterranean-style eating on several episodes because it focuses on prioritizing nutritious whole foods without being unnecessarily restrictive.
It's easier than telling a 30-year-old, “Let's focus on preventing the heart attack you might have in 30 years.”
You can experience benefits from eating well now, and cardiovascular prevention comes along with it.
And going back to my brownie example—you can still eat the brownie.
If the overall pattern is strong, you don't have to eliminate every food you love to reduce cardiovascular risk.
Dr. Alex Verge
Exactly. Cardiovascular prevention as the icing on the cake.
Victoria
What about supplements?
From a cholesterol standpoint, we were taught about things that were sometimes described as alternatives to statins.
For lower-risk people, you hear about red yeast rice, niacin and plant sterols.
Are these really alternatives? Do they play a role in cardiovascular-risk reduction?
Dr. Alex Verge
There are a couple of components to think about.
First, what are we trying to accomplish?
Are we trying to reduce a risk factor, or are we choosing something because we have evidence that it actually reduces an outcome, such as a heart attack or stroke?
Take plant sterols.
We have evidence that plant sterols can help reduce cholesterol, so they can reduce a risk factor involved in atherosclerotic heart disease.
We also have data around plant sterols in the broader context of the Portfolio diet and cardiovascular outcomes.
The problem with many nutritional supplements is that we may have data showing an improvement in a risk factor without data showing an improvement in the outcome the patient actually cares about.
Niacin is a perfect example.
Niacin improves cholesterol numbers. It can reduce LDL cholesterol, increase HDL cholesterol and lower triglycerides.
On paper, it looks great, and it was used conventionally for a long time.
Then studies asked the more important question: does adding niacin and achieving those favourable lipid changes actually reduce heart attacks?
The answer wasn't what people expected.
At the end of the day, we might cheer when cholesterol goes down, but that's not ultimately what we care about.
We care about whether you have a heart attack or stroke.
That's why I think this distinction is a fair part of an informed-consent conversation.
If somebody tells me they don't want a statin, their cholesterol is high enough that I think medication is warranted, and they want to try something else, I want them to understand that we may not know whether the alternative tool will reduce their risk of a cardiovascular event.
That doesn't mean it definitely won't.
It means we don't know.
And if you're asking somebody to take and pay for something for decades, that's important information.
Most supplements that lower cholesterol or blood pressure also tend to be more useful when the risk factor is modestly elevated.
Let's say, best-case scenario, we can achieve around a 30% cholesterol reduction with well-selected supplements, excellent adherence and good nutrition.
A 30% reduction may get somebody with a modest elevation to an appropriate target.
But if their cholesterol is extremely high, a 30% reduction may still leave them well above the number we're aiming for.
So the goal isn't simply, “Did the number improve?”
It's, “Did we get the risk factor to an appropriate target, and do we know that the intervention improves the outcome we actually care about?”
Victoria
I think that's such an important part of being an integrative practitioner.
It's great that we have natural or herbal tools that may change someone's cholesterol on paper.
But as the practitioner, I care about whether that person lives longer.
There may be a point where the appropriate thing to say is, “I think a statin is necessary, and here's how I'm going to support you alongside it with diet, exercise and everything else.”
Sometimes naturopathic medicine feels like it has to prove its place by finding a natural replacement for everything.
We do have a place. We just have to know what that place is.
As a future ND, I want to say, “I'm going to help reduce your cardiovascular risk,” not just, “I'm going to move your cholesterol number a little with this herb.”
Dr. Alex Verge
You're not wrong.
What we offer can be enormous.
A big part of my work is simply helping somebody understand what cholesterol means, what cardiovascular disease means and what their lab work says.
That “doctor as teacher” role is huge, and people are hungry for it.
Family doctors would love to have more time to do that too, but the medical model often doesn't give them that time.
That's a gap we can help fill.
Then, within risk-factor management, we're looking across a spectrum of care.
Even if that leads to medication, there is still a huge role for the rest of the plan.
How do we get to the numbers we're aiming for with the best support possible? Can we use lifestyle to minimize how much medication is required and potentially minimize side effects?
To me, including medication when appropriate actually supports the definition of holistic care.
It's pulling all the pieces together in a practical and useful way to achieve the goal the patient is trying to achieve.
Jeanette
Another pillar you mentioned earlier was exercise.
For cardiovascular health, we hear a lot about cardio training and running, but we don't hear as much about strength training.
What kind of exercise do you recommend? Is it mostly cardio, strength training or a combination?
Dr. Alex Verge
I joke that it's right in the word: “cardio.” Obviously that's all you have to do, right?
Marketing 101.
But no.
We have evidence showing that different forms of exercise can support cardiovascular health.
That's amazing because, just like with dietary patterns, it means we can find something the person actually enjoys doing and build on it.
There's always nuance depending on the person.
If I'm working with somebody in their 60s who has osteopenia, our exercise conversation may put additional emphasis on bone health.
That looks different from the conversation I'd have with a 40-year-old man with very high triglycerides, where intensity and frequency might be emphasized differently.
But in both cases, increasing regular physical activity improves cardiovascular health.
For sedentary people, I emphasize that some is better than none.
Adding more movement than you're currently doing is beneficial.
Then we can build toward the stereotypical target of roughly 150 minutes of moderate-intensity exercise per week.
That target comes largely out of cardiovascular research, and it gives people something concrete to work toward.
With Fitbits, Apple Watches and other devices, it can also be relatively easy to track now.
Victoria
That's helpful for someone sitting at a desk eight hours a day.
Maybe you start with little exercise “snacks.”
Every hour, get up. Do ten squats on your way to the washroom. Walk around.
There are easy ways to begin.
If somebody has gone their entire life without thinking about exercise, they can work gradually toward that 150-minute target.
It's going to look different for everyone.
Dr. Alex Verge
It absolutely is.
Victoria
Before we get to myth-busting, I want to ask how we change the conversation around medication.
I don't know why it's so prevalent with statins specifically, but I feel like statins and antidepressants are two medications where people sometimes feel like they've failed if they need to take them.
How do we change that?
Dr. Alex Verge
This conversation in my office has changed over time.
Creating space for a very neutral conversation has been incredibly helpful.
I tell people that I'm focused on goals.
The tools, in a sense, don't matter.
Obviously we want to match the right tool to the right situation, and sometimes a particular tool can't get us all the way to the goal.
But medications are part of that spectrum of tools.
I don't attach a different emotional meaning to them.
They're tools.
At the same time, I'm very aware that there is a lot of emotion around statins.
Depending on the patient, we may specifically talk about shame.
That sounds like a strange word to use, but when so much of the cholesterol conversation focuses on lifestyle, people can hear a diagnosis of high cholesterol as, “You've done something wrong.”
They feel blamed, even when nobody actually intended to blame them.
Imagine somebody hears for the first time that their cholesterol is high.
They're told, “Work on your diet and lifestyle, come back in three months, and if the number hasn't improved, we'll put you on medication.”
Even though it isn't meant this way, it can feel like, “You're a naughty child. Get your act together, and if you can't, too bad—you need medication.”
That's how some people receive it.
I talk about how genetics can play a huge role and how our modern food and lifestyle environment can make this incredibly difficult.
Sodium is a great example. There is a lot of sodium added to processed food.
There are many reasons why somebody may have a risk factor even if they're health-conscious.
I try to remove that shame and say, “You haven't failed.”
There may be strategies we can use that you didn't even know about.
Let's look at those while also considering medication when appropriate.
I have patients who tell me they will never take a medication under any circumstances.
Patient autonomy and informed consent are extremely important to me.
We'll discuss the framework, all of the options and why, in some cases, I think medication is the best option.
If the patient still says no, then we look at what they are willing to do and work toward the goal with those tools.
Sometimes we revisit the conversation six months or a year later.
They've had time to think, they've encountered more information and maybe the conversation changes.
Sometimes it doesn't.
Maybe we reduce cholesterol by 20 or 25% without medication even though a larger reduction would have been ideal.
That's still a risk reduction.
I try to approach the entire conversation openly, transparently and neutrally.
Jeanette
You answered that beautifully.
I think people often feel like they aren't given the opportunity to have that kind of conversation.
Okay, it's time for rapid fire.
We're going to give you statements and you can say myth, truth or “it depends.”
First: People at risk for cardiovascular events should take aspirin every day to prevent a heart attack.
Dr. Alex Verge
It depends.
This conversation has changed over time.
People of a certain age will remember when everybody was being told that a baby aspirin or low-dose aspirin was the thing to do.
Our evidence for secondary prevention—somebody who has already had a heart attack or another cardiovascular event—is quite good in appropriate patients.
For primary prevention, meaning somebody who has never had an event and we're trying to prevent the first one, the benefit is much more modest.
At this point, the general consensus is that for many primary-prevention patients, that modest benefit does not automatically outweigh the potential risks.
That doesn't mean somebody who was placed on aspirin years ago should simply stop it.
That's a conversation to have with their healthcare provider to determine whether continuing or discontinuing it is appropriate.
But we're no longer routinely telling every primary-prevention patient to start aspirin.
Jeanette
Interesting.
Next one: Everyone should take an omega-3 or fish-oil supplement to reduce their risk of heart disease. Every single person.
Dr. Alex Verge
Myth.
Omega-3 intake has a modest cardiovascular benefit at a population level. Notice I'm saying intake, not necessarily supplementation.
The supplement conversation has changed over the last few years because we've started to appreciate potential risks associated with higher-dose fish-oil or omega-3 supplementation.
A lot of the initial data came from prescription omega-3 products given at higher doses, but we're now looking more closely at supplements too.
The major concern is atrial fibrillation and arrhythmia risk.
It appears to be dose-dependent.
Around the one-gram-per-day EPA plus DHA range is where the conversation becomes particularly relevant, with risk appearing to increase as doses go higher.
It's a developing story, which is exciting scientifically and frustrating clinically.
My approach has increasingly been to encourage people to enjoy eating fish when appropriate because we see cardiovascular benefits without the same concern we've been discussing around high-dose supplements.
When I do use omega-3 supplements, I'm also much more conscious of the total EPA plus DHA dose.
Jeanette
I'm glad we touched on that.
On social media, you always see “three supplements everybody should take,” and omega-3s are almost always on the list.
Last one: 120 over 80 is the ideal blood pressure.
Dr. Alex Verge
It depends.
Much like cholesterol, there isn't one magical line where everything changes.
We use 120/80 mmHg because it approximates a good, relatively safe place for many scenarios.
There are data suggesting cardiovascular risk may begin to climb even from lower levels, around the 110/70 range.
But treatment isn't only about saying, “Lower is always better.”
If somebody is at 120/80 or 130/80 and we've already addressed modifiable factors such as sodium intake, stress and lifestyle, we have to ask whether using medication to push the number even lower creates more benefit than risk.
That's different from somebody sitting at 150/90, where the risk of leaving that blood pressure untreated is much greater.
So 120/80 is a great place to be, but there's nuance around what we call “ideal” and what requires treatment.
Victoria
That was a tough round of rapid fire—questions completely off the top of my head based on the topics we covered—and you did a wonderful job.
We end every episode with this question:
What is one myth in the cardiovascular space that you want to clarify or debunk once and for all? It can be something we've already talked about or something else.
Dr. Alex Verge
Because cholesterol is the love of my life, it would probably be something about saturated fat or statins.
Saturated fat really can make a difference.
There's this back-and-forth online where saturated fat is portrayed as really good for you and seed oils as really bad for you.
That's basically the opposite of how I think that conversation should go.
The statin piece is really frustrating to me as well.
But within nutrition, where we spend a lot of time working with patients, I wish there wasn't so much misinformation about fats in general, saturated fat and the purported dangers of seed oils.
Victoria
That's Jeanette's favourite conversation. If you ask her about seed oils, you'll never hear the end of it.
Dr. Alex Verge
Maybe we need to do a separate podcast just about that.
Jeanette
One hundred percent.
Victoria
Our Instagram algorithm right now seems to show us nothing but people eating a carnivore diet and avoiding seed oils.
We're stuck in the algorithm. We can't get out.
So I'm glad you clarified that.
This was an amazing episode.
I knew we were going to go over because cardiovascular health is such a massive topic, and I think everything we covered needed to be discussed.
It was such an honour to have you on.
Where can our listeners find you, and where can they book with you?
Dr. Alex Verge
Mostly Instagram.
I'm hit and miss, but I try to be more hit than not.
You can find me at Alex Verge, ND on Instagram.
Victoria
Amazing. Are you taking patients?
Dr. Alex Verge
I am.
I'm a big fan of setting people up sustainably, like we talked about earlier, and then allowing people to carry on with periodic check-ins.
That means there's always space to help support the next person in their heart-health journey.
Victoria
I love it.
Thank you so much, Dr. Verge, for being here with us.
Dr. Alex Verge
It's been my pleasure.
I really appreciate the great work that you two are doing.
Victoria
Thank you.
Jeanette
Thank you.
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Dr. Alexandra Verge is a naturopathic doctor based in downtown Guelph. She holds a Bachelor of Science in Nutritional Sciences (with distinction) from the University of Guelph and is a graduate of the Canadian College of Naturopathic Medicine. She is registered in both Ontario and Nova Scotia, and a member of both her provincial and federal naturopathic associations.
After almost 25 years in private practice, Dr. Verge remains dedicated to providing an integrative space to help patients make sense of their health through thoughtful, evidence-informed care.
She has extensive experience in cardiovascular and preventive medicine, with particular expertise in hypertension, cholesterol management, and women’s heart health in midlife.
In addition to her clinical work, Dr. Verge regularly lectures and presents on integrative cardiovascular care to healthcare professionals across North America.