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The truth about cholesterol, statins and heart disease
I've always been curious, wanting to know why things are the way they are. I was frustrated by teachers who hid the truth from their pupils for fear of confusing them. When we stop speaking the truth, oversimplification is dangerous. As Albert Einstein said:
There are some big gaps in our knowledge around saturated fat and cholesterol. Thanks to years of misinformation and substandard education, our understanding of cholesterol is lacking.
In part 1 we looked at saturated fat and in part 2 we look at cholesterol and the prescription of Statins for cardiovascular disease. Since cardiovascular disease is the most common cause of death in the modernised world, one could say it’s pretty important.
So let’s begin…
Here I am, a self-confessed health geek. I have a 2:1 Bachelor of Science degree in Sport and Exercise Science and a Postgraduate Certificate in Education in Physical Education. Since then I’ve learnt from books and used the internet to track down authorities and experts in health. I listen to hours of podcasts and lectures on YouTube every week. Health, happiness and optimal performance are my obsessions.
That said, I am not a doctor, nutritionist or certified expert in anything other than myself! So the information I present here is for information and education purposes. I assume no responsibility or liability for any consequence resulting directly or indirectly from any action or inaction you take based on the information contained in this article.
Now, let me introduce Dr Ronald Krauss:
He is the director of atherosclerosis research at Children’s Hospital Oakland Research Institute, Adjunct Professor at University of California San Francisco (UCFC) and University of California Berkeley. Dr Krauss is a pioneering scientist who changed the way we think about cholesterol and saturated fat.
Next is Dr Rhonda Patrick:
She has a PhD in biomedical science from the University of Tennessee Health Science Center, Memphis TN and St. Jude Children’s Research Hospital, Memphis TN. She also has a Bachelor’s of Science degree in biochemistry from the University of California, San Diego. She has done extensive research on ageing, cancer, and nutrition. Dr Patrick trained as a postdoctoral fellow at Children’s Hospital Oakland Research Institute with Dr Bruce Ames. She investigated the effects of micronutrient (vitamins and minerals) inadequacies on metabolism, inflammation, DNA damage, and ageing and whether supplementation can reverse the damage.
Once upon a time these two had a chat about saturated fat and cholesterol, they uploaded the interview to the internet and I listened to it. The interview reinforced much of what I learnt at university. Sadly, not much has changed since 2006, so here’s my attempt to change the paradigm.
What do we know about cholesterol?
First, there’s "good" cholesterol or HDL cholesterol:
And then 'bad' cholesterol or LDL cholesterol:
Good cholesterol is good and bad cholesterol is responsible for blocking arteries, strokes, heart attacks and ultimately death. Biology is rarely as simple as good and bad, so let's take a closer look.
What do LDL and HDL represent?
They stand for low-density and high-density lipoproteins. But what is a lipoprotein? A lipoprotein is a structure in the blood that transports fat. Let’s imagine lipoproteins to be like cargo ships carrying oil and the body as the oceans, lakes and rivers of the world.
Since fat and water don’t mix, we need lipoproteins (cargo ships) to securely transport fat (oil) through the blood and extracellular fluids of the body (oceans, lakes and rivers). Lipoproteins are made in the liver and travel around the blood distributing triglycerides (fat) and cholesterol to cells all over the body.
The four major types of lipoproteins are chylomicrons, very low-density lipoprotein (VLDL), low-density lipoprotein (LDL), and high-density lipoprotein (HDL). Dr Ronald Krauss discovered that cargo ships aren’t just good or bad. He discovered that ‘bad’ cholesterol (LDL particles) should be further divided into two particle sizes:
- Large buoyant LDL particles - 'good'
- And smaller, dense LDL particles - 'bad'
After further research, he found that smaller, dense LDL particles have a greater tendency to develop into atherosclerotic plaques on the cell wall of arteries. Since they’re not absorbed back into the liver as readily as other LDL particles, they become oxidised more rapidly. Or in layman's terms they clog arteries and cause cardiovascular disease.
Large buoyant LDL Particles
These features are not the same for the larger more buoyant LDL particles. These LDL particles aren’t bad, instead, they are incredibly important to our health. These particles transport vital fuel (fats) to every cell in the body. They help us make new cells and repair the damage to faulty cells. And they help us make hormones such as testosterone, oestrogen (estrogen), progesterone and vitamin D.
According to Dr Ronald Krauss, problems occur only when we cannot remove cholesterol from the blood as fast as it is produced. Unlike other species, humans do not have an effective mechanism for removing LDL particles, which over time makes us susceptible to heart disease.
Let me say that bit again:
Problems only occur when we cannot remove cholesterol from the blood.
So the problem is not cholesterol, the problem is an overproduction of small dense LDL particles and an inability to remove cholesterol fast enough.
Keep this in your mind and we’ll come back to it soon...
The role of inflammation in lipoprotein metabolism
This is an important side story. Inflammation features in many diseases, including heart disease. Inflammation can turn a relatively benign cholesterol particle into a more dangerous formation that can clot blood and create blockages in artery walls.
Inflammation is designed to help the body defend itself. When the body is under attack we need to promote inflammation. Ordinarily, this attack would come from a parasite or infectious agent, like a virus. But today, our body is under attack from toxic food, gut dysbiosis, autoimmune disease and chronic stress. All this causes the liver to up-regulate the production of cholesterol and as a byproduct smaller dense LDL particles are left circulating in the blood.
At this point in time, doctors do not screen their patients for their LDL particle size. They see high total cholesterol and a poor ratio of 'good' to 'bad' cholesterol, weigh up familial risk factors and then push Statins.
- Small dense LDL particles - create plaques in arteries that can lead to heart disease
- Large buoyant LDL particles - an important aspect of healthy cellular biology, help us with many important aspects of health, including fighting inflammation.
What about good cholesterol or HDL?
High-Density Lipoproteins (HDL) are great scavengers that clear up the mess left behind by LDL particles. Although high HDL is a positive blood marker, it doesn’t protect us if we also have high small LDL particles. Drugs that increased HDL production were found to be ineffective at preventing heart disease.
That said, it is important to be physically active which increases production of HDL cholesterol in the body. A healthy diet also plays an important role in HDL production. Stress, smoking and being overweight significantly reduce HDL production.
So what’s next?
We know that the problem is an overproduction of small dense LDL particles and a problem removing cholesterol from the blood. So what is increasing small dense LDL production in the first place?
The Role of Diet
We’re currently stuck in nutritional limbo and suffering from cognitive dissonance. This is a form of mental stress (discomfort) experienced by simultaneously holding two or more contradictory beliefs, ideas, or values.
For years we were taught that fat and cholesterol are bad, so in their place, we ate more refined carbohydrates like flour and sugar. But we also created hydrogenated oils/ trans fats found in margarine, which significantly increases the risk of heart disease.
Now if we're told that fat is beneficial to our health, and cholesterol is not a problem, we're left in limbo. We have to hold both ideas simultaneously. In one hand we have our recent fat-phobia trend and in the other we have a new pro-fat camp. Which one wins is up to you.
Since the internet has sped up the transfer of information from the world’s leading scientists to the layperson, large organisations are being left behind. The internet has also helped expose the immoral actions of the sugar industry, the pharmaceutical industry and government lead institutions.
Take for example, last year, when we learned how the sugar industry paid top scientists to blame saturated fat and cholesterol for heart disease.
We are hardwired to trust authority figures and so many of us still believe that eating food high in fat and cholesterol, like eggs, will increase fat and cholesterol in the body. This is not the case, as we are about to learn...
The vast majority of cholesterol in your body is made by YOU! The impact of dietary cholesterol on blood cholesterol is therefore very small. In the interview, Dr Ron Krauss, admits to his astonishment, at how small the effect is. He said:
So who is to blame for rising cholesterol?
There are many culprits we could discuss here including diet, stress, natural light, environmental toxins, exercise and sleep. But let's start with food. Highly refined carbohydrate-rich diets, especially those high in sugar, are to blame. Dr Ron Krauss makes it clear that sugar increases the lipoprotein production towards the small dense LDL particles. Simple sugars and fructose, in particular, are the major driving force in this (not the sugar found in fruit but in added sugar).
When I go to teach in a secondary school you can be sure that I will see kids drinking these toxic drinks:
These drinks are laden with sugar and high-fructose corn syrup. The fact that school children across the country are drinking these drinks daily is a huge concern for the future health of a nation. As Dr Rhonda Patrick puts it:
“The effect of refined sugar, high fructose corn syrup and sugar-sweetened beverages on the risk of heart disease is incredible. In a study of over 400,000 people, those with the highest sugar intake had a four-fold increase in heart attacks. And it’s not just heart disease and heart attack, but it’s cancer, diabetes and depression.”
Does saturated fat cause heart disease?
There have been many associative studies between saturated fat and heart disease. That said, correlation does not imply causation. What does that mean? Well take a look at the following examples:
a) 100% of people who breathe, die.
b) Scientists in Australia found a correlation between ice cream sales and shark attacks. On days when ice cream sales are high, shark attacks are more common.
Does this mean that breathing kills us? Nope! What about ice cream sales causing shark attacks? Don’t be daft! When the weather is good, people buy more ice creams but they also go to the beach more and swim in the sea. What causes more shark attacks is more people swimming in the sea.
In 2014 a meta-analysis in the Annals of Internal Medicine looked at 72 studies from 18 different countries. They found that the current evidence does not support cardiovascular guidelines that encourage high consumption of polyunsaturated fatty acids and low consumption of total saturated fats.
As discussed previously, these studies look at correlation and not causation. For causation we have to look at the gold standard of clinical trials: double blind randomised placebo controlled trials. Unfortunately studying human beings in controlled lab situations like this is challenging, to say the least. We cannot keep humans locked up in labs for a lifetime and when we let them out, we get up to all sorts. Compliance is a huge issue when studying human beings and we are bad at reporting our own behaviour.
As with many things, it all comes down money. And there simply isn’t enough funding available for studying the long-term effects of diet on health. Which is why many scientists prefer to study roundworms in a petri dish or mice in a cage.
Based all my reading, our evolutionary history and current research, I am confident that saturated fat is not to blame for heart disease.
Fat and Sugar
According to Dr Rhonda Patrick there seems to be a double whammy effect of combining refined sugar and fat. The refined sugar raises the small dense LDL particles and increases systemic inflammation. The fat then raises the large buoyant LDL particles and together they create what in the business is called atherogenic dyslipidemia (or high cholesterol as the doctors put it). This is the pattern most strongly associated with heart disease and is categorised by elevated levels of triglycerides and small dense LDL particles and low levels of large buoyant HDL cholesterol.
So you might want to ease off the cheesecake for a while!
The drugs don’t work
Benjamin Franklin reportedly once said:
I’d say that an ounce of prevention is worth more than an ounce of cure. When it comes to taking drugs to prevent disease, I’d say we’re being incredibly naive. Due to various reasons, too many people are being prescribed cholesterol-lowering Statins.
Statins are a group of medicines designed to help lower the level of low-density lipoprotein (LDL) cholesterol in the blood. There are five types available via prescription in the UK:
- Atorvastatin (Lipitor)
- Fluvastatin (Lescol)
- Pravastatin (Lipostat)
- Rosuvastatin (Crestor)
- Simvastatin (Zocor)
The NHS website says that “In most cases, treatment with Statins continues for life, as stopping the medication causes your cholesterol to return to a high level within a few weeks.” Do you really want a lifetime prescription to Statins?
According to Dr Ronald Krauss, Statins work on larger LDL particles, not the small dense LDL particles. That said, reducing total cholesterol seems to have a beneficial effect on reducing risk of heart disease. Which consequently might keep patients alive for a few more years.
Are Statins over prescribed?
According to many experts including Dr Ron Krauss and Dr Rhonda Patrick they are.
Meanwhile in a parallel universe, super docs like this...
...discover high cholesterol in their patients and then immediately give the patient the support they need to lower their cholesterol. They're given a free nutritionist and personal trainer. They get access to counsellors and meditation teachers to manage stress. And they're encouraged to find jobs they enjoy, drink more water and get to bed on time.
Now back to reality. Doctors have ten minutes per patient and people want quick fixes. We're also much better at taking drugs than changing our lifestyle. This paradigm has contributed to the massive proliferation of the pharmaceutical industry. An industry that holds incredible financial power, despite being shrouded in repeated controversy.
Big BAD Pharma
Take the infamous British company, GlaxSmithKleine, who in August 2016, had a market capitalisation of £81 billion (fourth largest on the London Stock Exchange). In 2012, GSK pleaded guilty to promotion of drugs for unapproved uses, failure to report safety data, and kickbacks to physicians in the United States and agreed to pay a $3 billion (£1.9bn) settlement, the largest settlement in the country by a drug company.
GSK were also fined $490m (£297m) by China after a court found it guilty of bribery. The drug giant paid out bribes to doctors and hospitals in order to have their products promoted (source: BBC news).
If GSK were a local business they would be OUT of business. Yet despite their immoral track record, we swallow their pills by the billion. We put our trust in them indirectly by trusting our doctors who apparently know what's best for our health. Who you trust is up to you but personally, I’d rather not support these companies, directly or indirectly, even if it means dying at 66 instead of 69.
Is there a case for Statins?
Despite all my big pharma bashing, Dr Ron Strauss seems to think they are of use and can extend life expectancy by reducing the incidence of heart attacks. As the expert, we should recognise his opinion. That said, in the same interview he also says not all Statins are effective and many have significant side effects. Such as developing diabetes and muscle pain. So what to do?
One last expert
Dr John Briffa is a practising doctor in London, UK, author and international speaker. He is a prize-winning graduate of University College London School of Medicine, where he also gained a BSc degree in Biomedical Sciences. Dr John Briffa is a leading authority on the impact of nutrition and other lifestyle factors on health and illness.
Dr John Briffa, with his holistic mindset, has written several articles on Statins and their negative effects. He is very critical of their over-prescription and recommends a cautious approach to Statin use. Below is a section from one such article:
"Here’s a quote from one of the letter’s signatories Dr David Newman, Assistant Professor of Emergency Medicine and Director of clinical research at Mount Sinai School of medicine in New York:
“I am always embarrassed when I have to tell patients that our treatment guidelines were written by a panel filled with people who stood to gain financially from their decisions. The UK certainly appears to be no different to that of the United States. The truth is for most people at low risk of cardiovascular disease a Statin will give them diabetes as often as it will prevent a non-fatal heart attack - and they won’t live any longer taking the pill. That’s not what patients are looking for."
Sums it up nicely, I reckon."
For those who wish to education themselves further, I would recommend visiting his website (links at the end of the article).
When I set out to write this, I wanted to achieve a few different things. The first was to teach people the important role cholesterol plays in health as well as disease. I wanted to help people learn that cholesterol is complex and has been falsely accused and misunderstood.
Secondly, I wanted to highlight the issue of over-prescribing Statins as preventative medicine. And touch on the questionable activities of pharmaceutical companies that make profits from our collective suffering.
I know it is easier to take a pill and harder to manage what we eat and how we live. But if we learn to manage our weight and remain healthy in the first place, then we won’t need to tell GP’s where to stick their drugs!
Thanks for getting through this monster of a blog and hope it was worth it.