October 26, 2020

Preventing Chronic Disease

#134 – James O’Keefe, M.D.: Preventing cardiovascular disease and the risk of too much exercise

If exercise were a drug, it would be the best drug we have for preventing heart disease . . .. But like with any drug, you've got to get the dose right.” — James O’Keefe

Read Time 22 minutes

James O’Keefe is a preventative cardiologist and bestselling author of The Forever Young Diet and Lifestyle. In this episode, James discusses cardiac physiology and what makes the human heart susceptible to disease. He provides evidence for what supports his approach to exercise–elucidating both positive and negative kinds of exercise for heart health. He also discusses the role of nutrition, specific nutrients, and pharmacological interventions to support heart and brain longevity.


We discuss:

  • James’ background and why he favors a preventative approach to cardiology [3:15];
  • Understanding atherosclerosis and the misconception that it’s a “plumbing problem” [10:15];
  • The danger in excessive exercise—a reverse J-shaped mortality curve [21:15];
  • The story of Micah True—a case study of excessive exercise [49:15];
  • The best kinds of exercise for longevity—The Copenhagen City Heart Study [53:00];
  • Being a more balanced athlete and finding the right exercise intensity [58:45];
  • Heart rate during exercise, resting heart rate, and other important metrics [1:04:00];
  • Nutrition for cardiovascular health [1:09:45];
  • Important nutrients: Magnesium, potassium, calcium, sodium, and collagen [1:19:30];
  • SGLT2 inhibition for diabetes, cardio-protection, and general longevity [1:24:15];
  • GLP-1 agonists for weight loss and reducing cardiovascular risk [1:34:15];
  • Statins—mechanism of action, safety, and useful alternatives [1:37:25];
  • A 40-year view on cardiovascular risk, and the possibility of reversing arterial calcification [1:45:45];
  • Evidence for high dose EPA and DHA for the reduction of cardiovascular disease risk [1:53:30];
  • The impact of omega-3, curcumin, and other compounds on mental health and dementia [1:59:00];
  • James’ focus beyond cardiology [2:02:15]; and
  • More.


James’ background and why he favors a preventative approach to cardiology [3:15]

How Peter and James met

  • Peter first met James more than ten years ago at a conference James spoke at
  • Peter was shocked to learn from James’ talk that the 20-23 hours per week of cycling he was doing may be harmful

James’ background

  • Based on his fascination with the heart, he knew as young as age 13 or 14 that he wanted to become a cardiologist
  • He started out as an interventional cardiologist, which is a cardiologist who focuses on corrective procedures such as installing stents and pacemakers and replacing heart valves
  • He trained at the Mayo Clinic 
  • In 1988, he started working at the Mid America Heart Institute with Geoffrey Hartzler, who invented infarct angioplasty
  • A year or two into his career, he realized that angioplasty was not the ideal way to treat cardiovascular disease, which led to his interest in a more preventative approach

Even though it’s the leading killer in America, [coronary disease] should be an entirely preventable, medically-managed disease. Unless you have an MI [heart attack], you don’t need to be going in having procedures, stents electively. We have the tools.


Understanding atherosclerosis and the misconception that it’s a “plumbing problem” [10:15]

Balloon angioplasty and stents

  • Coronary arteries are narrow – the left coronary artery for example is less than a half centimeter or a third of an inch wide
  • During angioplasty, a catheter with a deflated balloon is inserted into the narrowing artery and the balloon is inflated with saline to restore flow
  • In some cases, a stent is left behind to preserve the opening
  • In cases of asymptomatic blockage, there is no evidence of benefit for stents (and only some evidence of benefit in an acute MI situation)
  • Yet, stents are used frequently — 
    • partly because of the economic incentive to do the procedure
    • But also because of this flawed paradigm: That this it’s a “plumbing” issue

The flawed paradigm is this: That blocked arteries are simply a plumbing issue—

{end of show notes preview}

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James O'Keefe, M.D.

James is a cardiologist and Medical Director of the Charles and Barbara Dubok Cardio Health & Wellness Center at Saint Luke’s Mid American Heart Institute, an enormous practice of more than 60 cardiologists. He is also a Professor of Medicine at the University of Missouri, Kansas City. James has authored best-selling cardiovascular books for health professionals, including the Complete Guide to EKGs, Dyslipidemia Essentials, and Diabetes Essentials. James has also coauthored with his wife, Joan, the best-selling consumer health book, The Forever Young Diet and Lifestyle. He is actively involved in patient care and research and has published numerous peer-reviewed articles.

Disclaimer: This blog is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this blog or materials linked from this blog is at the user's own risk. The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard, or delay in obtaining, medical advice for any medical condition they may have, and should seek the assistance of their health care professionals for any such conditions.


  1. I would be interested in a follow-up on this podcast which interrogates some of what said Dr O’Keefe more closely. I would like to hear from an exercise scientist. Perhaps more could be said on the principle of adaption and the fact that the cardiovascular stress of, for example, running 15 miles/week will not be the same for any 2 people. There is a great deal of variability between people and so cardiovascular strain has to be taken into context with what the athlete has adapted to doing.

  2. Terrific information as usual. Heard Dr. O’Keefe a few years ago and reduced cycling from several long rides per week to HIIT and slow/fun rides. Feel so much better and enjoy gift of more hours to do other things.

    Any recommended brands for EVOO? Or items to look for on label? Also eat Macadmia nuts daily — any other recommendations?

    Thank you — most informative podcast/web site on health.

  3. What would be helpful in the notes is a reference in direction or manufacturer to these (and the same on other podcasts) things we should be taking….otherwise trying to navigate what to buy, where, is a nightmare.

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