Good Eggs

We're going to talk cholesterol in a bit, but here is a recap of my weekend's workouts and monthly totals.

Friday (5/29)

Cycle (City Bike - Cannondale Bad Boy Ultra)
27.2 miles/18.0 MPH average

Saturday (5/30)

Swim
3000 yards - 2x300 warm-up with 30-sec rest inverval; 6x200 moderate with 20-sec RI; 2x400 hard with 20-sec RI; 8x25 hard with 20-sec RI; 4x50 hard with 10-sec RI

Sunday (5/31)

Cycle (Time Trial - Cervélo P3 bike)
13.58 miles/22.0 MPH average
Elevation Gain: 601 ft
Avg Heart Rate: 167 bpm
See Ride via Garmin Connect player

Month of May

Bike
313.75 miles (new monthly record)

Swim
16,450 yards

Now, to the meat of this blog's entry: cholesterol. As a pharmacist, I have been suspect of focus on ever lowering targeted levels. Levels that have been dropping every few years. When one actually digs into who is sponsoring studies that seemingly validate the need to drop cholesterol releated levels even lower, it should come as no surprise to see drug companies footing the bill for these case studies.

A number of skeptical health professionals like myself — including a variety of doctors and academic researchers — have long insisted that the establishment doctrine on cholesterol is misguided, has been manipulated by pharmaceutical interests, and that the so-called scientific conclusions supporting the now-accepted-as-fact hypotheses are, in fact, deeply flawed.

The advice we’ve been given (to cut out all foods high in saturated fat and cholesterol and embrace diet foods instead) has actually made our heart-disease problems far worse, these experts say. It has distracted us from understanding cholesterol’s health-supporting roles in the body, robbed us of our pleasure in eating, given rise to obesity and resulted in widespread overmedication. It has also dissuaded us from taking more effective and sustainable steps — like embracing a high-nutrition, anti-inflammatory diet and exercising more — that would have improved national health and dramatically lowered healthcare costs.

Now that the important health-supporting role played by natural dietary fats has become better understood, the characterization of dietary cholesterol as a big health-risk factor has been called into serious doubt.

Robert Knopp, MD, an endocrinologist and the endowed professor of lipid research at the University of Washington in Seattle, puts it bluntly: “Cholesterol in the diet is a minor player in heart disease.”

Let's take a quick step back for a second and look at how we got here.

The case against cholesterol traces back to the mid-20th century, when scientists first found its sticky fingerprints inside plaque-filled arteries. The leap from having located blood-borne cholesterol in arterial plaques to assuming it came from the cholesterol in food (and was a root cause of arterial damage) was a short and notoriously unscientific one.

Nevertheless, the medical and dietary-advice establishments put out a loud all-points bulletin: If you eat fat-rich, cholesterol-rich foods, like beef, butter and egg yolks, you’re digging your own grave — one forkful at a time.

Myth No. 1: Cholesterol is just plain bad for the body
Contrary to popular belief, cholesterol is actually vital for human life and health. Technically a type of alcohol, cholesterol is water insoluble, which allows it to serve as a stable ingredient in a variety of structures within the body. Cholesterol is a component in the membrane of every living cell, preventing the cell's contents from leaking out and keeping harmful chemicals outside the cell from getting in. It plays a role in forming several key hormones as well as synapses, the circuitry through which nerve cells communicate.

"Cholesterol is also an important repair substance," notes Mary Enig, PhD, a biochemist and the author of Know Your Fats (Bethesda Press, 2000). "When the body has an infection or inflammation or wound, cholesterol is concentrated in the areas that are getting healed." In other words, it's possible that the presence of cholesterol may be an indicator of inflammation rather than a root cause.

Because cholesterol is essential to so many functions, inadequate cholesterol levels may lead to a number of health problems, including depression. A Finnish study of men between the ages of 50 and 69, published in the British Journal of Psychiatry, found that those reporting depression had significantly lower blood-cholesterol levels than those who were not.

It's possible the correlation exists because of the role cholesterol plays in the metabolism of serotonin, an important mood-regulating chemical in the brain that is lower in people with low cholesterol. In addition to causing health problems, abnormally low cholesterol levels are frequently an indication of serious infirmities. These include overactive thyroid gland, liver disease, anemia, malnutrition, cancer and poor absorption of foods from the digestive tract.

The good news is that abnormally low cholesterol levels are rare, because a healthy liver can manufacture all the cholesterol we need. Furthermore, only a fraction of cholesterol consumed in foods is actually absorbed into the body.

What about the much-hyped distinction between "good" cholesterol and "bad" cholesterol? These labels, too, are a bit simplistic. High-density lipoproteins (HDL, or "good" cholesterol) and low-density lipoproteins (LDL, or "bad" cholesterol) are actually not cholesterol at all; they are the fat molecules that transport cholesterol through the bloodstream.

LDL is responsible for shuttling cholesterol from the liver (where it is made) through the bloodstream and then depositing it in the tissues where it's needed. HDL transports cholesterol from the tissues back to the liver, where the majority of it is secreted in the bile that is used to break down food. What's more, both HDL and LDL are indispensable. In the proper ratios, both are good. The reason LDL is called "bad" is that a too-high ratio of LDL to HDL cholesterol in the blood is associated with a higher risk of coronary heart disease. But make no mistake: You couldn't live without LDL.

Myth No. 2: High blood cholesterol is caused by eating too much fat and cholesterol
The theory that there is a direct relationship between the amount of saturated fat and cholesterol in one's diet and the incidence of high blood pressure and coronary heart disease (CHD) is known as the "lipid hypothesis" – and it's hotly debated.

While some saturated fats (particularly animal fats) do appear to negatively impact lipid blood profiles, there's a lot more to the diet-and-heart-disease connection. We know, for example, that the old concept of cholesterol coating or clogging the arteries is a flawed one (see Myth No. 4), and that (when eaten in moderation) eggs and red meat needn't be off-limits to cholesterol-concerned people.

Saturated fat does appear to raise LDL by down-regulating LDL receptors in the liver, which are then cleared out of the bloodstream more slowly. On the other hand, it also raises "good" HDL. The most important thing to remember is that cholesterol levels and heart-disease risk are affected to a much greater degree by a combination of other dietary factors:

- Trans-fatty acids raise LDL and lower HDL and thus have a worse effect than saturated fats on the overall cholesterol ratio. Also, the medium-chain fatty acids in some plant-based saturated fats (like coconut oil) appear not to be implicated in raising cholesterol.

- Monounsaturated and other healthy fats (like those found in nuts, fish, olive oil and avocados) increase the activity of LDL receptors in the liver and thereby lower LDL levels in the blood.

- Overeating and underexercising raise cholesterol levels by increasing abdominal fat stores. Abdominal fat also decreases insulin sensitivity, causing excess glucose to accumulate in the bloodstream and exacerbate the formation of arterial plaques.

- B vitamins (especially folate) reduce blood levels of homocysteine, an intermediate in amino acid metabolism. Elevated homocysteine levels are an important risk factor for CHD.

- Plant sterols and stanols (the plant equivalents of cholesterol) reduce cholesterol levels by blocking cholesterol absorption, as does dietary fiber. (For more on sterols, see the July/August 2004 issue of Experience Life.)

- Antioxidants do not reduce cholesterol levels, but, just as important, they do reduce the oxidation of LDLs in the bloodstream.

Based on these dietary facts, it's safe to say that the problem is not so much that we are eating too much saturated fat but that we're eating too much food – period. And yet we're still not eating enough fruits, vegetables, nuts and whole grains – which are some of the best sources of monounsaturated fats, B vitamins, fiber, plant sterols, plant stanols and antioxidants.

Myth No. 3: A cholesterol level above 200 is too high
Determining what constitutes an unhealthy cholesterol level is probably the most confused and controversial aspect of current science on the subject. The National Heart, Lung, and Blood Institute still uses the following guidelines:

However, the National Cholesterol Education Program Adult Treatment Panel recently published new, lower guidelines recommending that LDL levels be brought below 100 mg for high- and moderate-risk patients.

Even the less aggressive guidelines have been attacked on a number of fronts. So-called cholesterol skeptics believe that the numbers are simply irrelevant. "A total cholesterol level of 200 is normal," says Enig. "For some individuals, 220 is normal. For others, 240 and even 260 is normal." Enig and others base their views on the fact that many studies have established a less-than-airtight connection between high cholesterol levels and heart disease.

For example, in the famous Framingham study, which is considered the cornerstone of the cholesterol-CHD connection, the "correlation coefficient" between high cholesterol and coronary heart disease was only 0.36 – about half of that between smoking and lung cancer.

Some researchers even believe that relatively high cholesterol levels may actually prevent coronary heart disease by defending against the infections that may contribute to atherosclerosis. Uffe Ravnskov, a well-known cholesterol skeptic and author of The Cholesterol Myths (New Trends, 2000), recently presented evidence for this case in the Quarterly Journal of Medicine (December 2003). And in a University of Hawaii study, men over age 70 were much more likely to develop heart disease if their total cholesterol level was below 200 than if it was between 200 and 219.

Another problem for the most common cholesterol guidelines is that elderly people (and especially women) with moderately high cholesterol levels tend to be healthier than their peers with lower levels. In the Framingham study, although individuals with high cholesterol were more likely to die from CHD, their overall mortality rate was actually lower than that of individuals with lower cholesterol.

What's more, there is now growing evidence that the quality of LDL particles is as important as their number. Some are big and fluffy and less likely to deposit in an arterial wall. Others are small and dense and are more likely to get trapped. "If two people have borderline cholesterol and one has a good profile [i.e., good-quality particles] and one has a bad one, I would be much more inclined to treat the bad one," says William Kraus, MD, of Duke University.

Kraus has conducted experiments demonstrating that moderate exercise improves the quality of LDL particles. It has long been known that exercise reduces the risk of CHD without directly lowering LDL levels (although it does lower them indirectly by inducing weight loss).

Myth No. 4: Cholesterol is the root cause of coronary heart disease (CHD)
You might think that all doctors agree on this assertion. You'd be wrong. In fact, it is a point of enormous contention and debate. "The majority of the risk [for coronary heart disease] is not explained by cholesterol," says Jeffrey Anderson, MD, a cardiologist and professor of medicine at the University of Utah. The old belief – still widely held by many opinion leaders of medical science – was that cholesterol coated and clogged arteries, which in turn caused potentially fatal problems such as heart attacks and strokes. The real story is not so simple.

"What we've learned in recent years is that the problem is not just passive infiltration of cholesterol, but the fact that it provokes an inflammatory/immune process," Anderson explains. "Some people have a greater inflammatory process going on than others. We're still trying to track down the factors that make one group prone to this and others less so."

Here's what's known: Low-density lipoproteins are small particles, and those that are especially small can infiltrate the lining of an artery and get deposited in its wall. There are a number of reasons cholesterol might end up there, including preceding damage to the artery caused by infection, previous inflammation or the presence of free radicals.

Some of the LDL that does get trapped in artery walls can then get oxidized (i.e., damaged) by any number of factors and then provoke a complex (secondary) inflammatory response. These trapped fats are subsequently ingested by the immune system's white blood cells, which accumulate (along with fibrous material, calcium and other substances) within the artery wall. Over the years, these areas of accumulation form scab-like plaques, which partially or even completely block the artery. This condition is known as atherosclerosis. Either a complete blockage or a ruptured plaque can cut off blood supply to the heart or brain, resulting in a heart attack or stroke.

The important point here is that high LDL levels alone are not sufficient, nor even necessary, for atherosclerosis to develop. Atherosclerosis is common in individuals with low LDL levels as well, perhaps because there is a disproportionate number of small LDL particles or because too many are being oxidized. Likewise, individuals with high LDL levels often have perfectly healthy arteries, because one or more of the many other causes of plaque formation are not a contributing factor.

As is the case with many other diseases, genetic predisposition is one of the main culprits in causing CHD. Some of us are simply more prone to high LDL levels, LDL oxidation, easily damaged arteries and blood clotting. Other strong predictors of CHD are family history of the disease, high blood pressure, diabetes and smoking. (Stress and anger are weaker, but still significant, predictors.)

Myth No. 5: Statin drugs like Lipitor prolong life by lowering cholesterol
Widely regarded as wonder drugs, statins slow cholesterol production in the liver. More than 20 million Americans now take them, and the statin Lipitor is the most prescribed cholesterol-lowering medicine in the world. It's interesting to note, though, that while statins lower LDL in everyone, they slightly lower coronary heart-disease death rates only in middle-aged men who already have CHD or are at high risk for it. When it comes to women, the elderly and middle-aged men at a lower risk of CHD, "there isn't even a trend toward total mortality benefit," says Beatrice Golomb, MD, PhD, of the University of California, San Diego.

Worse, statins cause a number of side effects, which Golomb is currently studying. "The most common side effects associated with the statins are muscle pains and weakness, fatigue, deteriorating cognitive function, liver toxicity, and neuropathy [pain from damaged nerves]," she says. "The problems in some cases can be very serious, with some people actually losing the ability to walk."

These problems are probably due to the fact that statins lower the level of coenzyme Q10, a vitamin-like nutrient that plays a pivotal role in providing energy to the muscles and brain. Golomb feels that middle-aged men at high risk for CHD should still try statins, but they should be aware of the risks and be prepared to get off the drugs if side effects emerge.

Cholesterol is also an important repair substance: It concentrates wherever the body has an infection, wound or other source of inflammation. The average person ingests between 200 and 300 milligrams (mg) of cholesterol a day from animal-derived foods, such as cheese, egg yolks and meat. But that’s only a small portion of the body’s normal cholesterol requirement. The liver makes up the difference (roughly 1,000 mg daily in a normal, healthy person), generating cholesterol from a variety of fats, proteins and carbohydrates available in the bloodstream.

When you eat large amounts of cholesterol, your body’s production goes down. When you eat small amounts, it goes up. So your body regulates its cholesterol production — and, thus, the concentration of cholesterol in your blood — based on its needs for the substance. And one of the things that dictates the body’s level of need is the presence of free radicals, infection and inflammation. The more inflammation, oxidation or irritation present in the body, the more cholesterol the body produces in an effort to help tackle the problem.

There are now some views that high LDL cholesterol is not the cause of arterial inflammation but is actually a noble knight that, working with other lipoproteins, is an important actor in our immune system valiantly striving to repair damage already done.

Now for the truly skilled marketing departments of drug companies. In part because attempts to control cholesterol by conventional low-fat dietary recommendations have not been effective, pharmaceutical companies are raking in record profits selling cholesterol-lowering drugs, called statins, to an ever-expanding market, which now includes young children and individuals with only slightly elevated cholesterol levels.

15 million people currently take cholesterol-lowering drugs in the United States, and many policymakers want to extend that to 36 million more adults, including those who don’t even have high cholesterol. They want folks to use them prophylactically, and currently children are the next target market.

But forcing cholesterol levels down with drugs may not deliver the benefits we’ve been led to believe, and it may also pose some real dangers. Although the potential risks of artificially depressed cholesterol levels are still being debated, critics point to research showing it can lead to memory loss, erectile dysfunction, depression, severe nutritional deficiencies, even cancer. A recent study published in the Canadian Medical Association Journal links low levels of LDL cholesterol to higher rates of cancer and premature death.

Less than 10 years ago, an LDL cholesterol level of under 130 mg was considered fine. But the guidelines, updated in 2004, lowered the “optimal” level of LDL to less than 100 mg and nudged doctors with patients at very high risk of heart disease to aim for less than 70. At there seems to be no stopping point. A more recent study suggests 55 mg is an even better target.

The only way to push levels that low is with drug therapy. And if every doctor followed the guidelines to the letter, 36 million Americans would be on statins.

That’s a windfall for the drug makers, but is it a boon for patients? Not according to a review published last year in the British health journal Lancet. When researchers looked at the drugs’ ability to prevent heart attacks, they found no evidence showing statins can protect women (for whom HDL is the key lipoprotein), nor did they find a benefit in men and women over age 69 — presumably the same group many doctors are trying to help.

My doc has been trying to get me on a statin for years. I've yet to do it. Same for my wife. We have adjusted our life-styles and eating habits and our levels have come down on their own. We look to our family history....our genetic tree...as well. All parents and siblings have had mild to moderately elevated cholesterol levels and to date the family members are living well into their 80's and 90's. My aunt, a nurse for years and years, agrees that our family has raised levels but since we're all living well into old age, there is no need to address with shoving yet another pill down our throats.

Here are five ways to right-size your cholesterol, reduce your heart-disease risk factors and get a whole lot healthier in the process:

- Eat less sugar and flour. Refined flours and sugars not only spark inflammation, they elevate triglycerides, a potentially dangerous form of cholesterol. Too many triglycerides in the blood impede the circulation of healthy cholesterol, causing the entire system to break down. When choosing grain products, look for those made with whole and sprouted grains. Avoid sugary cereals, cookies, cakes and other sweets, and minimize your intake of pastas and breads made with refined flours.

- Eat more vegetables, fruits and whole foods. The antioxidants and phytonutrients in vegetables, fruits, legumes and whole grains help protect cholesterol in the blood from free-radical damage. They are also high in fiber (see below), which assists the body in ridding itself of cholesterol-laden bile.

- Prioritize quality fats over junk fats. That means nixing trans fats entirely, and avoiding high-fat processed and fried foods in favor of healthy, nutrient-dense whole foods. Enjoy nuts, seeds, fish, avocados and olive oil — fis tacos anyone! And don’t feel you need to cut out saturated fats entirely, either. The body craves these and requires them for proper cell, nerve and brain function. Plus, when people don’t satisfy their flavor and satisfaction desires for saturated fats, they’ll often substitute processed carbohydrates instead, thereby increasing weight gain and inflammation. When selecting meat and dairy, choose minimally processed foods, ideally from pastured, free-range and grass-fed animals. And whole eggs are fine: Research published in the American Journal of Clinical Nutrition shows that people eating up to seven eggs a week are no more likely to experience heart attacks or strokes than those who eat less than an egg a week.

- Befriend fiber. Eating more soluble fiber is one of the easiest ways to lower your cholesterol naturally. That’s because fiber binds to bile, which is composed of cholesterol and triglycerides, and escorts it (along with a variety of pro-inflammatory toxins) out of the body. The body then produces fresh bile, making use of cholesterol and triglycerides that would otherwise accumulate in the bloodstream. Nuts, whole grains, vegetables and berries are all high in fiber, but legumes (like kidney, lima, pinto beans and black-eyed peas) are perhaps the very best source. Not a big fan of beans? You can substitute 2 teaspoons of psyllium husk mixed in a glass of water for one or more of those servings.

- Get a Move On. Moderate to intense exercise lowers cholesterol overall and raises the relative levels of protective HDL. Exercise also helps reduce excess weight and moderate the negative, inflammatory effects of stress. A 2006 Duke study that examined the effects of exercise on inactive, overweight adults found that, after six months, many of the factors putting them at risk for heart disease had reversed or improved.

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