There isn't anyone with a pulse that is not aware of the alleged evils of dietary cholesterol and saturated fat. My generation grew up during the formative years of the whole anti-cholesterol/anti-saturated fat campaign. It is such an integral part of food marketing now that few of us really even notice or, for that matter, question the validity of such claims. Low fat and low cholesterol have been dietary buzz phrases for as long as I can remember. The merits of diets attendant to these issues have been touted in every nutrition course I have ever taken. Ginormous entities like the American Heart Association and the American Medical Association have been on board the "cholesterol causes heart disease" train from the beginning. And today, cholesterol-lowering drugs are a multi billion dollar industry. In fact, Lipitor, one such medication, is the most widely prescribed medication in the world today.
I got sucked in right along with everyone decades ago. I can remember my dad being told he had "high cholesterol" and I watched him suffer the unpleasant dietary sacrifices to get it down. I avoided saturated fat and cholesterol with the rest of the developed world thinking I was saving my health for my later years. No way I was getting heart disease. I remember getting my blood work back the first time I ever had my cholesterol checked and being so proud that it was 113. My professor pointed out that my HDL (high density lipoprotein), the so-called "good cholesterol" was on the low side but admitted that with such a low total cholesterol, I didn't have much of either (LDL, low density lipoprotein, being the other). Either way, whatever I was doing was working. I probably was not developing any life-threatening atherosclerotic plaques in my coronary arteries.
Today, in my orthopedic practice, I would say that over 80% of the patients I see over 50 years of age are on some cholesterol lowering agent. It's stunning, really. These are relatively young, healthy, athletic individuals on no other medication but their physician felt compelled to get them on these drugs because their cholesterol was just a tad over the mythical 200 mark. And like good, obedient and wholly ignorant patients, they take their little pill each day oblivious to the folly and potential harm they expose themselves to. WHAT? Yeah, time to blow the lid of this mutha and shed some light on this controversial topic.
High Cholesterol - the Non Disease
You may ask why I say this whole low fat, low cholesterol movement is controversial. I mean, it's been around longer than most of us can remember and the biggest medical entities in the country have been behind it forever. They're smart, right? How could they be wrong? We trust them to weigh the data and create policy with our nation's health in mind. At least that's what they're supposed to do but, in this case, they have failed miserably. What I'd like to do here is distill down the actual research on this topic and demonstrate how dietary policy got corrupted years ago and created a multi-billion dollar industry that has led to an obesity epidemic with no end in sight.
Let's start with a simple question that evokes some common sense in answering. Why have two food substrates, cholesterol and saturated fat, stuff we have evolved to eat over millions of years, suddenly become toxic to our health around thirty or forty years ago? I mean, really. Have you ever thought about that? There is no denying that humans are omnivores. We eat everything. In fact, our nutritional requirements are such that we NEED to eat everything. In spite of what the wacko vegan and vegetarian crowd will tell you, humans do best on a varied diet of vegetable and animal foods. We have evolved to do just that. Our digestive physiology copes with this variety very effectively and has for eons. Purposely avoiding certain foods for "health" reasons or ethical beliefs exposes humans to potential dietary deficiencies and detrimental health effects. So, for millions of years humans have eaten plenty of cholesterol and saturated-fat containing food with little problem.
Ten thousand years ago, a mere blink in evolutionary terms, our diets shifted from a hunter-gatherer existence to one involving agricultural subsistence. More recently, and probably more significantly, our dietary choices include a wide variety of heavily processes foods, numerous types of refined carbohydrates, animals fed unnatural diets of grain instead of grass and other such abominations. As I will demonstrate, these other complex interactions in dietary choices are more than likely responsible for the modern increase in cardiovascular-related deaths rather than cholesterol and saturated fat. In fact, the very research that the "lipid hypothesis" proponents hang their hat on actually demonstrates a lack of such a relationship. Wait a minute, what was that???? Yep, you heard me. Multi-country, medical research involving hundreds of thousands of patients investigating the relationship between serum cholesterol and cardiovascular disease often FAIL to demonstrate any positive correlation between the two and actually often indicate just the opposite.
Dubious Science
In spite of this rather startling fact, we continue to be force fed doctrine telling us that elevated serum cholesterol and dietary saturated fat is bad. How did this come to pass? Well, it all started back in the 1950's following a series of animal experiments that demonstrated an increase in artery-clogging atherosclerotic plaques in subjects (rabbits not humans) fed a diet rich in cholesterol and fat. One investigator, Ansel Keys, wondered if this process could occur in humans and set out to look for such a relationship in a couple of famous epidemiological studies. At first blush, this not an unreasonable quest. However, any scientist worth his salt should be careful to extrapolate a disease process inflicted upon a strict herbivore by feeding it an animal-based diet and such a relationship in omnivorous humans.
Let's ignore the conceptual short-comings for a moment and look at what Keys did. He actually had food-intake data for twenty-two countries but chose only six to analyze. The critical observer alarms should be ringing right now. Still, he was able to demonstrate that, in these six countries, there was a positive relationship between dietary fat and coronary mortality. Unfortunately, many of his peers noted that Keys selected only the countries where such a relationship supported his hypothesis. Using data from all twenty-two countries, a similar relationship failed to materialize. In fact, looking at all the data, physical activity became the best predictor of heart disease. It's also important to note that when looking at dietary fat and disease WITHIN each country, there was a wide variation in the relationship even though dietary fat was constant. What this means, simply, is that other factors are at play.
In spite of numerous peers citing Keys' studies' short-comings, his conclusions enjoyed much more media attention. This may be due in no small part to the fact that he was an advisory committee member of the highly influential American Heart Association. For reasons that likely involve complex political relationships, Keys' controversial theories were adopted in 1961 and set in motion a 40+ year nutritional boondoggle we still suffer today.
So, that's just the dirt on Ansel Keys. It's astounding that a government's nutritional policy is based on bad science such as this. Not only is policy driven here but also a multi-billion dollar pharmaceutical movement aimed treating a problem that actually doesn't exist. Most citizens have no idea. Now, I've probably already given you more detail than you could ever want. It gets way thicker. If you want to read it all then check out Anthony Colpo's "The Great Cholesterol Con". Instead of bludgeoning you with the minutia, I will give you what I feel are the most interesting bullet points.
Carbohydrate Toxicity
So, if cholesterol and dietary fat do not cause heart disease, what does? I mean, we've all heard the population-based studies that show that cultures that eat a diet low in animal fat (Japanese) have low rates of heart disease. Well, true but dietary fat is only one factor. What about the rest of the diet (fruit, vegetables)? How about exercise? Refined carbohydrate consumption? Refined fat usage? Sedentary habits? Television in the home? All of these factors and their interrelationships play a role. Funny thing is, there are other populations that eat diets high in saturated fat that have low rates of heart disease. Can't mention those because that would screw up the prominent theory!
The amount of political wrangling that goes on behind the scenes is staggering and goes beyond the scope of this little article. Both Colpo and Gary Taubes cover these details at length in various pieces they have written. These complexities almost always involve money and reputations of "important" people. Research underwritten by various industries (corn, diary, beef, pharmaceutical) will undoubtedly demonstrate an outcome favorable to the sponsor.
Certainly, the aim of serum cholesterol management has always been to bring it DOWN. Whether it's through dietary interventions (remember the oatmeal craze?) or through drug therapy (statins, anyone?), lowering one's cholesterol is supposed to save your life. Unfortunately, a good deal of the data involving these kinds of manipulations indicate no such effect. In fact, in several studies, individuals with the lowest readings had the highest death rates from all causes. That's right, get cholesterol down and die! This was especially true for subjects older than 50 years. And individuals who lowered their cholesterol over the course of these multi-year trials were more likely to die. Crazy, right? Has anyone, like maybe your doctor, brought these facts to light in any meaningful way? Not likely. And the funny thing is that these conclusions are reached simply by analyzing the data. Crazier still is that the authors will often publicly claim conclusions contradictory to their own findings. These "conclusions" can be reached by selectively scrutinizing certain data sets while ignoring contradicting others. Now that is some messed up shit!
Proponents of the lipid hypothesis continue to cling to their beliefs in spite of having no supporting evidence for them. As I pointed out at the beginning, it seems unlikely that food substrates that we have evolved to eat are suddenly killing us. More likely, and the scientific evidence supports this, is that refined carbohydrates and polyunsaturated fats, something rather new in our diets, account for the disturbing rise in cardiovascular disease. Gary Taubes, in "Good Calories, Bad Calories" thoroughly examines these ideas citing reams of supporting research.
Show me the money!
Just to give you an idea at how corrupt the politics of nutrition are, I submit this little item. Within the last decade, you have probably seen the little "Heart Check" logo on various foods in the grocery store. The American Heart Association (AHA) awarded some 630 foods with this dubious designation. Foods like Cocoa Puffs, Count Chocula, Frosted Mini Wheats, Chocolate Moose milk chocolate drinks, Honey Graham Squares and other such crap proudly display this emblem of healthy eating. Well, they don't just give that away, you know. The AHA reportedly earned about two million dollars for their backing.
Various pharmaceutical firms manufacturing popular lipid-lowering agents all contribute massive sums to the AHA. The American Dietetic Association is equally in bed with big industry. They receive millions from the food and pharmaceutical industry. Colpo lists these in detail in The Great Cholesterol Con. I will spare you the details here.
One only needs to think about the money involved in the anti-fat, anti-cholesterol movement to understand its momentum. Pro-cereal, pro-soy, pro-corn oil, anti-tropical oil, dietary fad books and lectures, expensive spas touting certain dietary fixes to heart disease all stand to gain with perpetuation of the lipid hypothesis. It's funny. In spite of all this inertia, the humble egg caught a break a few years ago and the media briefly and quietly admitted that it was okay to eat eggs. They have been vilified for decades and now, oops, we were wrong. Strange how under the radar that whole revelation was. Eggs won't raise your cholesterol. No shit! And if you're starting to get what I'm telling you here, what difference would it make if they did?? The truth seems to be, when all the data is considered, that for most healthy people, serum cholesterol is a poor predictor of cardiac disease. Period.
So, you might ask what's all this talk about these statin drugs saving lives by lowering cholesterol. Well, it's true. They do seem to lower mortality. However, one should not assume that this result is due to lowering blood lipid levels. If you recall your college statistics class, correlation does not mean causation. In other words, the lower mortality seen with these drugs is most likely NOT due to the lower cholesterol but something else. We already know that lowering cholesterol does not save lives. In fact, it may actually kill you. Turns out these drugs have powerful anti-inflammatory effects that probably account for the lower death rates. They also have been known to kill people but more on the that later. In terms of reducing inflammation, there are much better, healthier and cheaper ways to accomplish this without the risky side effects of statin drugs.
Simple interventions like lowering dietary Omega-6 fatty acid and increasing Omega-3 (think fish oil here), eliminating refined carbs, avoiding all trans-fats and exercising all have been shown to do the same job at reducing systemic inflammation. And what is the use of this, you ask? Turns out that systemic inflammation is probably what starts the whole cascade of physiologic mayhem that gets heart disease going in the first place. Of course, getting lazy, fat Americans to change how they eat and live is a real trick. Just gimme a freakin' pill and leave me alone! Oh, bring me another beer and that bag of pork rinds before you leave!
Statin Safety
Careful examination of the data from the drug trials for statins is revealing. In men and the elderly, they do seem to reduce death from cardiovascular disease. Of course, this effect is only seen in subjects with pre-existing disease, hypertension and diabetes. The important thing to note here is that even though cardiac death was reduced, death from all causes like cancer was up and negated any benefit. In healthy individuals, women and non-diabetics there is no benefit in taking these drugs and their use may actually increase death rates from other causes!
As for these drugs and their safety…now that's pretty interesting all by itself. We assume as consumers that these drugs are safe. I guess it depends how you define "safe". Most of us would assume that drugs like aspirin, Aleve, Motrin and the like are "safe" but their use causes somewhere between 7,000 and 17,000 deaths per year. Safe? That ibuprofen you eat after a hard day in the mountains could kill you. Nice! So, statin drugs have a pretty interesting side effect profile. The most publicized one is rhabdomyolisis. This is a sudden increase in muscle breakdown products that can lead to renal (kidney) failure and death. A more mild side effect and one much more common is muscle pain. This is usually associated in a reduction in athletic performance in those who would notice such a thing.
The incidence of these events is reported to be rare or low. If one looks at the FDA trial data it's interesting to see that test subjects used for the human trials were of generally better health than the regular population that would eventually be given these drugs. One would predict that these "rare" events might pop up more frequently in a more varied and less healthy cohort. Turns out that this is probably true. Internet forums are full of regular folks stricken by unusual muscle symptoms related to statin use. Gee, doc, gimme some of that shit! So, why would you bother taking a drug with significant and potentially life-threatening side effects when you could achieve the other beneficial effects from dietary and lifestyle modifications? Uh, I think the answer would be that I'm a fat, lazy slug of a human who would rather take a pill than change the way I eat and live. Funny thing is that adopting this alternative would have far-reaching benefits to one's health beyond reducing cardiovascular disease risk.
Another problem with reducing cholesterol and fat in one's diet either by drugs or diet is the negative impact such modifications has on the absorption of fat-soluble nutrients. Statin drugs also reduce the amount of Co-enzyme Q-10 found in cardiac muscle. Co-Q10 is an important cardiac anti-oxidant and is involved in ATP (energy) production in highly metabolic organs such as the liver, heart and kidneys. People on statins have been shown to have 40% less Co-Q10 in their tissues. Not good.
It never ceases to amaze me after learning all this that conventional medicine doctors continue to focus on the cholesterol levels of their patients. The information quoted above is available to anyone interested in looking for it and yet most "authorities" are wholly ignorant to it. The great medical machine of this country, admittedly controlled by Big Pharma, continues on it's lumbering way, pushing drugs instead of lifestyle because that's where the money is. As I indicated earlier, there are many non-pharmacological interventions for most of these problems that cost little but also make big industry little so they are essentially ignored by the media. When picking a news headline, some new pill is way sexier than 30 minutes of exercise per day and yet they may actually be therapeutically equivalent.
So, what can you do? Well, the readers of this blog probably need to change nothing. However, I venture that most of us are related to someone who could benefit from this knowledge. Instead of adding a bunch of drugs to one's life, there are several less-risky and cheaper interventions that can have a more profound impact:
- Exercise vigorously at least 30 minutes each day
- Reduce or manage stress. Get your act together, whether it be relationship, job or money.
- Use supplements with a demonstrated track record for improving cardiovascular health. These include fish oil, selenium, L-carnitine, magnesium and Co-enzyme Q10.
- Keep your blood sugar, and thus, your insulin level low. Eat foods with a low glycemic index. Avoid refined carbohydrates except during intense exercise.
- Eat a diet of pasture-raised meat, fish, vegetables, nuts and seeds. Limit gluten-containing grains and cereals.
- Get adequate, quality sleep
- Don't smoke
- Don't get fat
Most of these recommendations seem like no-brainers to most of us but applying them to your average American would create major lifestyle changes. And that would be a good thing. There is intermittent talk within the health care world about wellness and prevention but as long as there are billions of dollars to be made on drug-based treatments to major health concerns, the above recommendations will continue to take a back seat to the doctor's prescription pad. Sad but true. - Brian