I am close with someone who has chronic high cholesterol, in addition to a 6-pack abs. She exercises 5x/week and eats .5kg of animal products/week at most, usually white meat. She just visited her heart Dr and was told that her cholesterol is too high and that she needs to cut out animal products entirely as a next step.
I am thinking...is this really the modern answer to someone's high cholesterol if they consistently exercise, are nearly underweight, and rarely eat animal products to begin with?
It doesn't add up to me.
It's amazing how little we still know about heart disease - the #1 killer in the US. As someone who will inevitably inherit chronic high-cholesterol as well, I'm excited to read and share this ongoing research. Thank you for posting this.
It may not. Her doctor could be erring on the side of caution. Also, cutting out animal products completely could demonstrate that her high cholesterol is due to something besides her diet which should open up referrals to a specialist and other kinds of testing.
In my experience, as a patient with some unknown problem, the less experienced a physician is, even if they are a specialist, the more likely they are to try to match up your issues with what they know and hand wave away any inconsistencies. When you get to an expert, if there are inconsistencies they will straight up say they don't know what's going on and will start looking into it (running tests, trying different meds, etc).
It could be entirely genetic. Worst case could be that some groups just tend to die earlier from these diseases... There could be some somewhat invasive medications to fix thigs. But they are likely very far away...
I have high cholesterol. Used to eat normally. Was on statins. Highest dose doctor would prescribe. Got muscle problems. Doctor took me off statin coz it might be the heart muscle at some point.
Unrelated to this I tried Keto a bit later. I did actual real keto with less than 20g of carbs. Probably higher on the protein side than normal but loooots of fat definitely and eggs and bacon and all the other cholesterol stuff.
All of my other bad blood values completely normalized. Cholesterol went down slightly but not much but LDL/HDL ration improved. I didn't get the test to check for size and makeup of the cholesterol molecules done (not covered/done here) but I bet you it would've confirmed that I had a lot of but mostly the fluffy type of cholesterol (the good type).
My LDL dropped by three quarters once I switched to a keto(ish) diet a decade ago and stayed down. My HDL remained stable, almost like the body manufactures it for cell walls or something...
Similar - my grandfather is my only grand parent with high cholesterol, he's now 93 and has out lived all my other grand parents and his sister. It's clear to me that there's a lot here that we still don't understand.
In my family all the cooking/frying is done with clarified butter. Butter, cheese, definitely no margarine/crisco, plant oil only for salads. So far no cardiovascular problems.
What kind of exercise: cardio, yoga, resistance/weight training, other? There have been a number of studies showing that regular weight training improves cholesterol numbers (1,2) and I have seen it personally. Regular weight training causes cells to repair/recycle their cholesterol, removing it from the bloodstream. (Cardio may or may not do this as well but I'm a proponent of weight training as the foundation of health.)
Also: after reading the article, I think that cholesterol turnover rate is the key here. Cholesterol that is regularly used up and replaced does not have time to damage your vascular system like cholesterol that hangs around and hardens on your walls.
1) https://pubmed.ncbi.nlm.nih.gov/24174305/ -- Differential effects of aerobic exercise, resistance training and combined exercise modalities on cholesterol and the lipid profile: review, synthesis and recommendations
2) https://pubmed.ncbi.nlm.nih.gov/33343671/ -- Regular training has a greater effect on aerobic capacity, fasting blood glucose and blood lipids in obese adolescent males compared to irregular training
I've always had high-ish cholesterol. I dramatically cut down on carbs and animal protein (no meat at all, but still some dairy and eggs) which resulted in only modest improvement to LDL.
I do cardio at least 3 times a week and train a form of calisthenics (push ups, pull ups, dips, etc) at least three days a week.
It doesn't really do much for the numbers. I think some people just draw the short straw on cholesterol.
The trick to it is that cholesterol is only one of many subtle risk factors in cardiovascular health. As this article suggests, it's obviously not the case that high cholesterol is universally associated with worse outcomes, and there's no guarantee that improving the test scores will provide any benefit for an otherwise healthy patient. Does the doctor look at the whole person and their exercise regimen and conclude it's not worth medicating for the cholesterol risk? Or do they consider that lowering cholesterol can improve risk even further and so recommend medication? There's actually a protocol here that includes cholesterol as only one factor.
Ideally, a model like the one in this article could help better understand who to actually treat. We know cholesterol is a reliable proxy for risk at population levels, but if it could be ruled out for individual parents that would be very helpful.
Could be also something like https://en.wikipedia.org/wiki/Familial_hypercholesterolemia where it's just due to genes and bad luck. You can do generic tests for it, but they're relatively expensive. Statins mostly help bring the numbers down.
Emphasis on mostly. Check my post above. It's genetic for me most probably (I'm the 4th generation w/ high cholesterol and we cover most of the combinations of vegan/carnivore/fat/thin). Statins have bad side effects that can kill you outright. To think I'd been on statins since 16 years old (for round about 25 years... )
Did the doc do any kind of test to determine current levels of plaque in the arteries? There's a test that's done via ultrasound (IIRC) on the carotid artery that can give a pretty good idea of current plaque levels.
My paternal grandfather and great grandfather both died of cardiac arrest in their 50s. My Dad has always had high cholesterol but went on drugs as soon as they were available - first Niacin, then statins. He's still doing great at 75 and very much thinks the pills are to thank.
It may be that she has insulin intolerance / resistance, it may be worth to check for it. I've heard a similar case, and after the insulin intolerance treatment was ongoing for a while, the cholesterol level dropped.
So much nutrition research is all correlation and no causation. Statements like this, which over-infer, kill me:
"There is little doubt that people with high cholesterol have an increased risk of disease."
It's just as valid to say that people with heart disease are more likely to have high cholesterol. When all you have is correlation, there is a heart disease group, and a high cholesterol group, and all you shown with correlation is that there is a third overlapping group of people with both. With only correlation, you don't know how/why, or even if, members of one group transform into the other. Which is partly the underpinning of the article.
It's possible that high cholesterol is a result of underlying heart disease (which the article says is possible), rather than a cause. But what shocks me is that people, even researchers, seem surprised to realize such possibilities.
We know that high cholesterol is a cause of heart disease rather than a mere correlation because people with genetic Hypercholesterolemia have a rate of heart disease 10-20x that of the general population, independent of other risk factors: https://www.acc.org/latest-in-cardiology/articles/2020/06/01...
That doesn't rebut my assertion or complaint at all, since you are referring to a specific type of genetic disorder.
The research in general on nutrition and hearth health is still mostly correlation. Definitely someone with a specific disorder could have a more obvious causal link with cholesterol and cardiac events, but I've read a bunch of different papers, many from respected institutions, and the conclusions usually are, IMHO (I studied physics), garbage.
PROBLEM #1: High saturated fat diet correlated to high serum cholesterol
ANSWER #1: Serum cholesterol is transferred back-and-forth between the blood and cell membranes to maintain a constant cell rigidity; normal behavior
PROBLEM #2: High serum cholesterol correlated to cardiovascular disease
ANSWER #2: Chronic inflammation associated with metabolic disorders upsets the various regulatory systems
I find the second answer unsatisfactory. Any chronic condition that damages arteries leads to plaque and this, in my opinion, accounts for all the other associations. The arterial wall damage can be due to excess blood sugar, oxidation, or pathogens (SARS-CoV-2?). The damage causes an inflammatory response and extra serum cholesterol is needed to repair the damage (forms the plaque). The chronic plaque formation reduces the arterial cross-section and reduces elasticity which both increase blood pressure.
The underlying cause is arterial wall damage. This can be measured non-intrusively using the Ankle-Brachial Pressure Index:
PROBLEM #2: high serum cholesterol is correlated to cardiovascular disease, but eating high saturated fat-diets is not.
ANSWER #2: It appears that studies that assess the effect of a particular diet depends a lot upon the health of the individual prior to the study start; thus, using a random population results in non-significant results.
Note that I agree with you otherwise. I would suspect that a diet high in saturated fats without any supplemental unsaturated fats would result in cell walls becoming so stiff that removal of cholesterol can no longer benefit the cell walls; if this happens in arteries, you get hardened arteries that can lead to heart disease.
My key takeaway is that the ratio of saturated:unsaturated fat in the diet does control the concentration of serum cholesterol but any ratio between 1:0 and 0:1 (provided you get enough essential fats) is perfectly normal and does not impact health negatively either way. The function of serum cholesterol is maintaining cell rigidity throughout the body, not just in arteries. I have never heard this explanation before; it makes sense. This claim should be easy to verify experimentally.
The question then turns to the underlying cause of atherosclerosis. The arguments, to me, seem circular. Ultimately, the important question is how much of the plaque is due to a damaging agent like sugar and how much is due to a hyperactive inflammatory response. Measuring inflammation independent of arterial wall damage seems incomplete.
Problem #1 is not actually observed though. We know from many, many studies that dietary cholesterol is not directly correlated with serum cholesterol. The article even alludes to the point that the body regulates cholesterol on its own regardless of diet.
Cholesterol reduction is big business. Pfizer’s Lipitor alone raked in $125 billion between 1996 to 2012. This amount of money can be very corrupting. It’s almost impossible to find experts who are not influenced by money from industry.
If true then aspirins may be just as useful as statins while being cheaper and safer. (But you won't see anyone funding a clinical trial to prove this, any time soon!)
I find this article quite fascinating. It provides a bit of a glimpse into how science can work, and how difficult it is to gain valid knowledge on some topics. It's also a reminder that "science" isn't just a simple process that you follow to find the truth. Sometimes people ask the wrong question, or draw the wrong conclusion from experiments. It seems that research related to nutrition and health has a fair amount of this.
It reminds me of my own experience earlier this week where I needed to call a certain service. The API has 2 parameters. I thought that one was required and one was optional. But whenever I called the service with 1 parameter, it failed. Eventually I thought "maybe both parameters are required" and called the service with 2 parameters, and it worked. So I concluded "both parameters are required". But later I discovered that the service was just flaky and it was a coincidence that it started working just at the moment when I added the second parameter. After that experience it's difficult to know what to trust, when everything could be due to randomness and unreliability.
We have known for many decades that it is oxidized blood cholesterol that correlates with heart disease. Fred Kummerow showed this back in the '50s, 60+ years ago. But you can't get a blood test for oxidized cholesterol.
Fred Kummerow spent his whole working life getting trans fats out of the US food pipeline. He proved trans fat was poison in 1957, and finally in 2009, under compulsion of a lawsuit, the FDA declared it toxic. Then, they issued no regulations restricting their use until forced by another lawsuit, in 2014. Then, they gave vendors 3 more years to put poison in stuff being sold as if it were food. In 2018 it was supposed to be illegal to sell trans fats as food, but a number of companies still do, under waivers.
He died in 2017, at age 102. He spent the final two years of his life working on Parkinson's, which had taken his wife, since trans fats had (he thought) finally been outlawed. He was a great hero of experimentally-grounded health science.
India and Brazil are still struggling to get it outlawed. The big corporations have resisted because selling poison as if it were food remains profitable.
We are still confused about fats. But a takeaway should be that nobody has ever found any evidence of harm from eating saturated fat, or benefit from eating unsaturated fat, despite decades trying.
Robert Lustig is right that fructose (half of common sugar) is responsible for a variety of ills: exactly the ones Americans die of, by the millions. There is a lot of Lustig material on youtube, all of it excellent, all thoroughly grounded in rigorous experimental science. We need more Robert Lustigs.
The normal metabolic route is that excess fructose, beyond what the liver can afford to process immediately or store itself, is carried wrapped in cholesterol to fat cells to be stored.
If you take statins, excess fructose gets dumped into your bloodstream not wrapped in cholesterol, which is much worse. It causes oxidation of blood lipids, which have long been known to cause heart and circulatory problems.
Can you share a good article about the misconceptions of cholesterol and the dangers of statins? I've been looking for a decent source. I have a family member on a statin now.
Cholesterol is is not the problem. HDL and LDL differences not withstanding.
Cholesterol is used by the body to patch damaged arterial walls which can cause clogging if the there is excessive damage to the arteries.
The problem is high sugar levels in the blood by eating high sugar content foods and high glycemic index foods like highly processed carbohydrates which turn to sugar quickly raising blood suggar levels.
High sugar levels cause damage to the arterial walls and bodies response is to patch the damage.
Other issues interfere with the ability of lipids entering the wall properly in the repair process and cause the atherosclerosis exaserbated by ldl presence also caused by high sugar levels amongst others
Readit News
I am thinking...is this really the modern answer to someone's high cholesterol if they consistently exercise, are nearly underweight, and rarely eat animal products to begin with? It doesn't add up to me.
It's amazing how little we still know about heart disease - the #1 killer in the US. As someone who will inevitably inherit chronic high-cholesterol as well, I'm excited to read and share this ongoing research. Thank you for posting this.
In my experience, as a patient with some unknown problem, the less experienced a physician is, even if they are a specialist, the more likely they are to try to match up your issues with what they know and hand wave away any inconsistencies. When you get to an expert, if there are inconsistencies they will straight up say they don't know what's going on and will start looking into it (running tests, trying different meds, etc).
Unrelated to this I tried Keto a bit later. I did actual real keto with less than 20g of carbs. Probably higher on the protein side than normal but loooots of fat definitely and eggs and bacon and all the other cholesterol stuff.
All of my other bad blood values completely normalized. Cholesterol went down slightly but not much but LDL/HDL ration improved. I didn't get the test to check for size and makeup of the cholesterol molecules done (not covered/done here) but I bet you it would've confirmed that I had a lot of but mostly the fluffy type of cholesterol (the good type).
She's 104 years old and survived COVID this summer.
What kind of exercise: cardio, yoga, resistance/weight training, other? There have been a number of studies showing that regular weight training improves cholesterol numbers (1,2) and I have seen it personally. Regular weight training causes cells to repair/recycle their cholesterol, removing it from the bloodstream. (Cardio may or may not do this as well but I'm a proponent of weight training as the foundation of health.)
Also: after reading the article, I think that cholesterol turnover rate is the key here. Cholesterol that is regularly used up and replaced does not have time to damage your vascular system like cholesterol that hangs around and hardens on your walls.
1) https://pubmed.ncbi.nlm.nih.gov/24174305/ -- Differential effects of aerobic exercise, resistance training and combined exercise modalities on cholesterol and the lipid profile: review, synthesis and recommendations
2) https://pubmed.ncbi.nlm.nih.gov/33343671/ -- Regular training has a greater effect on aerobic capacity, fasting blood glucose and blood lipids in obese adolescent males compared to irregular training
Check Dr. Malcolm Kendrick long series on "What Causes Heart Disease" (list of all posts from drmalcolmkendrick.org):
https://www.emotionsforengineers.com/2018/01/dr-malcolm-kend...
I do cardio at least 3 times a week and train a form of calisthenics (push ups, pull ups, dips, etc) at least three days a week.
It doesn't really do much for the numbers. I think some people just draw the short straw on cholesterol.
The trick to it is that cholesterol is only one of many subtle risk factors in cardiovascular health. As this article suggests, it's obviously not the case that high cholesterol is universally associated with worse outcomes, and there's no guarantee that improving the test scores will provide any benefit for an otherwise healthy patient. Does the doctor look at the whole person and their exercise regimen and conclude it's not worth medicating for the cholesterol risk? Or do they consider that lowering cholesterol can improve risk even further and so recommend medication? There's actually a protocol here that includes cholesterol as only one factor.
Ideally, a model like the one in this article could help better understand who to actually treat. We know cholesterol is a reliable proxy for risk at population levels, but if it could be ruled out for individual parents that would be very helpful.
I suppose there's a genetic component, as no man in my known family lineage has made it past 60.
This shows that doctor's actually know that a diet and other lifestyle factors are the key to health. Not eating pills.
"There is little doubt that people with high cholesterol have an increased risk of disease."
It's just as valid to say that people with heart disease are more likely to have high cholesterol. When all you have is correlation, there is a heart disease group, and a high cholesterol group, and all you shown with correlation is that there is a third overlapping group of people with both. With only correlation, you don't know how/why, or even if, members of one group transform into the other. Which is partly the underpinning of the article.
It's possible that high cholesterol is a result of underlying heart disease (which the article says is possible), rather than a cause. But what shocks me is that people, even researchers, seem surprised to realize such possibilities.
The research in general on nutrition and hearth health is still mostly correlation. Definitely someone with a specific disorder could have a more obvious causal link with cholesterol and cardiac events, but I've read a bunch of different papers, many from respected institutions, and the conclusions usually are, IMHO (I studied physics), garbage.
Dead Comment
ANSWER #1: Serum cholesterol is transferred back-and-forth between the blood and cell membranes to maintain a constant cell rigidity; normal behavior
PROBLEM #2: High serum cholesterol correlated to cardiovascular disease
ANSWER #2: Chronic inflammation associated with metabolic disorders upsets the various regulatory systems
I find the second answer unsatisfactory. Any chronic condition that damages arteries leads to plaque and this, in my opinion, accounts for all the other associations. The arterial wall damage can be due to excess blood sugar, oxidation, or pathogens (SARS-CoV-2?). The damage causes an inflammatory response and extra serum cholesterol is needed to repair the damage (forms the plaque). The chronic plaque formation reduces the arterial cross-section and reduces elasticity which both increase blood pressure.
The underlying cause is arterial wall damage. This can be measured non-intrusively using the Ankle-Brachial Pressure Index:
https://en.wikipedia.org/wiki/Ankle–brachial_pressure_index
PROBLEM #2: high serum cholesterol is correlated to cardiovascular disease, but eating high saturated fat-diets is not.
ANSWER #2: It appears that studies that assess the effect of a particular diet depends a lot upon the health of the individual prior to the study start; thus, using a random population results in non-significant results.
Note that I agree with you otherwise. I would suspect that a diet high in saturated fats without any supplemental unsaturated fats would result in cell walls becoming so stiff that removal of cholesterol can no longer benefit the cell walls; if this happens in arteries, you get hardened arteries that can lead to heart disease.
The question then turns to the underlying cause of atherosclerosis. The arguments, to me, seem circular. Ultimately, the important question is how much of the plaque is due to a damaging agent like sugar and how much is due to a hyperactive inflammatory response. Measuring inflammation independent of arterial wall damage seems incomplete.
https://harvardmagazine.com/2019/05/inflammation-disease-die...
Huh. Is this something one’s GP could do or does it require specialized training? The article says it’s unpopular at general practitioner’s offices.
However I imagine they’d be able to perform a simplified version, just measuring the BP at the arm and the ankle and dividing.
Presumably using the ultrasound just allows you to get a more precise reading.
Dead Comment
Also see collection of links at bottom of this article: https://medium.com/@petilon/cholesterol-and-statins-e7d9d8ee...
Cholesterol reduction is big business. Pfizer’s Lipitor alone raked in $125 billion between 1996 to 2012. This amount of money can be very corrupting. It’s almost impossible to find experts who are not influenced by money from industry.
It reminds me of my own experience earlier this week where I needed to call a certain service. The API has 2 parameters. I thought that one was required and one was optional. But whenever I called the service with 1 parameter, it failed. Eventually I thought "maybe both parameters are required" and called the service with 2 parameters, and it worked. So I concluded "both parameters are required". But later I discovered that the service was just flaky and it was a coincidence that it started working just at the moment when I added the second parameter. After that experience it's difficult to know what to trust, when everything could be due to randomness and unreliability.
Deleted Comment
Fred Kummerow spent his whole working life getting trans fats out of the US food pipeline. He proved trans fat was poison in 1957, and finally in 2009, under compulsion of a lawsuit, the FDA declared it toxic. Then, they issued no regulations restricting their use until forced by another lawsuit, in 2014. Then, they gave vendors 3 more years to put poison in stuff being sold as if it were food. In 2018 it was supposed to be illegal to sell trans fats as food, but a number of companies still do, under waivers.
He died in 2017, at age 102. He spent the final two years of his life working on Parkinson's, which had taken his wife, since trans fats had (he thought) finally been outlawed. He was a great hero of experimentally-grounded health science.
https://www.drmirkin.com/histories-and-mysteries/fred-kummer...
India and Brazil are still struggling to get it outlawed. The big corporations have resisted because selling poison as if it were food remains profitable.
We are still confused about fats. But a takeaway should be that nobody has ever found any evidence of harm from eating saturated fat, or benefit from eating unsaturated fat, despite decades trying.
The normal metabolic route is that excess fructose, beyond what the liver can afford to process immediately or store itself, is carried wrapped in cholesterol to fat cells to be stored.
If you take statins, excess fructose gets dumped into your bloodstream not wrapped in cholesterol, which is much worse. It causes oxidation of blood lipids, which have long been known to cause heart and circulatory problems.
My understanding was that other classes of medicine that reduce serum cholesterol levels have shown no effects on heart disease in clinical trials.
Cholesterol is used by the body to patch damaged arterial walls which can cause clogging if the there is excessive damage to the arteries.
The problem is high sugar levels in the blood by eating high sugar content foods and high glycemic index foods like highly processed carbohydrates which turn to sugar quickly raising blood suggar levels.
High sugar levels cause damage to the arterial walls and bodies response is to patch the damage.
https://www.adwdiabetes.com/articles/repeated-sugar-spikes-d...
Other issues interfere with the ability of lipids entering the wall properly in the repair process and cause the atherosclerosis exaserbated by ldl presence also caused by high sugar levels amongst others
https://pubmed.ncbi.nlm.nih.f gov/1222702/
Unfortunately all these issues get conflated together to produce misunderstanding and alot of misunderstanding