THE GREAT CHOLESTEROL MYTH,

 THE GREAT CHOLESTEROL MYTH, revised

 CHAPTER 1

WHY A NEW EDITION OF

THIS BOOK WAS NEEDED

A LOT HAS CHANGED IN THE WAY THE MEDICAL ESTABLISHMENT views cholesterol and heart disease since we first came together almost a decade ago to write the original version of The Great Cholesterol Myth — and most of those  changes have been for the better.

   We now have technology that allows us to clearly identify at least thirteen different subtypes of cholesterol, many of which behave in unique ways in the body: Being able to measure cholesterol with much greater specificity than ever before is good news indeed, because it gives us much more information and far greater accuracy when it comes to predicting future  cardiovascular events.

   The sad news is doctors are mostly still measuring it the old way. Which is equivalent to using a pad and pencil in the age of the smartphone. We'll return to this point throughout the book.

   We now have sophisticated lab tests to tease out risk factors that have been hiding in plain sight for decades factors we now understand are directly and profoundly connected to heart disease.

   So the good news is that we have all kinds of cool ways of measuring sophisticated risk factors that most people never heard of a decade or two ago. Ten years ago, for example, few people even knew about (much less understood) the microbiome -- a whole  ecological system of microbes that lives in our gut and profoundly affects so many areas of our health. Even genetic testing, still in its infancy, is nonetheless light-years ahead of where it was in the early days of 23 and Me.

There are now at least a dozen cardiac markers that we can test that influence the likelihood of you getting heart disease. And best of all, many of these risk factors can be strongly modified by our own life choices.

   Every year we meet more and more   physicians at conferences who are realizing the importance of inflammation and oxidation in making arteries vulnerable to plaque. Every year we meet more and more physicians who have come around to the notion that nutrition and diet - the redheaded stepsister of traditional medical education - can be powerful allies in the fight against heart disease (and not as previously believed,  by sticking to a low-fat diet!). 

   In fact, the connection between diabetes and heart disease - sugar, anyone?- is the central thesis of this book. Insulin resistance is something that nearly always precedes type-2 diabetes, and, as we will argue, is an early warning sign of heart disease

   Understanding insulin resistance -and   how to prevent, treat, and even reverse it - is one of the most important things you can do if you want to prevent heart disease. We've all heard of pre-diabetes, but we suggest that "pre-heart disease" is just as real a phenomenon, and that phenomenon is called diabetes. We will argue that if you catch the signs of diabetes early enough, you can prevent heart disease for many, if not most,people. By the end of chapter 12 we hope you will agree with us.

  And now for the bad news. Most doctors don't know this. Even worse, most are still prescribing powerful drugs for a condition known as "high cholesterol" that is a lab test, not a disease, and- to add insult to injury--is being measured in an antiquated way.

   Unfortunately for all of us a very high percentage of doctors practicing conventional medicine in the United States still think an LDL cholesterol reading of more than 100 is a big problem. They will reach for their  prescription pad the moment it creeps north of 129. A very high percentage of doctors practicing conventional medicine in this country also continue to believe that fat and cholesterol clog your arteries, that obesity is caused by eating too much fat, that low-fat diets are generally effective, and that cholesterol causes heart disease.

    All of which tells us we've got a heck of a lot more work to do. Many doctors continue to cling to the old technology, an antiquated method of classifying cholesterol into large gross categories of "good" and "bad." Worse, these same doctors are prescribing powerful drugs--statins--based almost entirely on the readout from a test that should have been dumped in the dustbin of out-of-date medical ideas a long time ago.

THE PROMISE OF THIS BOOK 

The promise of this book is that we are  going to set you straight on the subject of cholesterol and heart disease. We're probably going to anger a lot of the conventional medicine crowd, but we hope we're also going to win over a few converts. Like politics, nutrition and medicine are very polarized. But unlike politics, there is a large group of  "independent voters" in the fields of nutrition and medicine, doctors and patients alike, who look for the truth wherever it's to be  found and don't cling stubbornly to official talking points. It's those independents that we hope we can win over with our message that it's time to move beyond - way beyond  conventional cholesterol testing and conventional dietary prescriptions for heart disease.

   Which, if you haven't already noticed, don't work very well.

   We feel the message of this book is so   important - and so potentially life-saving   - we want you to hear it right now, on the first few pages. Maybe it will prompt a conversation with your doctor, or even  motivate you to consider a different approach to the prevention of your own heart disease. If our book has some small part in accomplishing that, we will consider our mission accomplished. Here's what you need to know:

• Cholesterol does not cause heart disease. Cholesterol is involved in heart disease, but not in the way most people think it is. Cholesterol levels - as currently measured - do not even predict heart disease (let alone cause it).

• The cholesterol test your doctor currently gives you--the one for "good" and "bad" "cholesterol"--is obsolete. There are at least thirteen identified subtypes of cholesterol-not two--making it all the more mystifying that doctors continue to stick to measuring two.

• Lowering cholesterol does not save lives and this has been shown in study after study.

• Problematic blood measurements, such as high blood sugar, are actually markers of dysfunction that show up fairly late in the game. By the time these traditional red flags show up on your annual blood test, you could already be well on the road to pre-diabetes. And remember, pre-diabetes is diabetes; it's just not official yet. And diabetes is pre-heart disease. You cannot ignore the early warning signs of diabetes, and unfortunately, most doctors only look for the ones that show up after the damage has already started.

   Fully one-third of those with full-blown  diabetes don't know they have it, and the vast majority of those with early signs of diabetes are utterly clueless about their condition and the disaster that may await them further down the path. We'll explain the relationship between diabetes and heart disease throughout the book, but for now just keep in mind that more than 80 percent of diabetics  die of cardiovascular disease. Do the math.

   Insulin resistance is diabetes' first  metabolic footprint, the clue that shows up well before things go deeply south.[The use of south as in the phrase go south stems from the 1920s (from the Oxford English Dictionary):colloq. (orig. Stock Market). Downward or lower in value, price, or quality; in or into a worse condition or position. Esp. in to head (also go) south .  Go deeply south can be substituted for harsher language with words like "terrible," "dire," or "catastrophic."]  Insulin resistance syndrome more than doubles the risk of diabetes, which in turn more than doubles the risk of dying of heart disease or stroke. The good news: Insulin resistance itself can be detected many years before an official diagnosis of diabetes or heart disease, which means you can interrupt the path of  heart disease for a double-digit percentage of the population.

If this book has one single, actionable   takeaway, it's this: Get tested for insulin   resistance. There are many ways to test for insulin resistance - we'll discuss them all in chapter 9 - but test for it you must. It can reveal problems years, or even decades, before you get a diagnosis of either diabetes or cardiovascular disease.

   The best news is that you can stop insulin resistance - and most often reverse it - with diet. Really. You won't need a single pharmaceutical drug to reverse insulin resistance if you get it early enough and insulin resistance -we'll discuss them all in chapter 9- but test for it you must. It can reveal problems years, or even decades, before you get a diagnosis of either diabetes or   cardiovascular disease.

   The best news is that you can stop insulin resistance-and most often reverse it- with diet. Really. You won't need a single pharmaceutical drug to reverse insulin resistance if you get it early enough and make the right dietary changes. And if you do identify insulin resistance early, you can probably prevent it from morphing into a heart attack down the road. Researchers   writing in the medical journal Diabetes Care said it eloquently: "Insulin resistance is likely the most important single cause of coronary artery disease," adding that in young adults preventing insulin resistance would prevent  approximately 42 percent of heart attacks!

NOW LET'S TALK ABOUT STATINS

Are you on a statin drug?

   If you are, it's almost certainly because your doctor was worried about your LDL cholesterol number being too high. And if you aren't on a statin drug, it's probably because your doctor thought your LDL cholesterol number was just fine, hence no need for  preventive treatment. 

   In both cases, there's an excellent chance that your doctor was dead wrong. This book will explain why. 

   Remember, the only real importance of  the HDL-LDL cholesterol test is to predict an outcome - in this case heart disease. And if the HDL-LDL cholesterol test did in fact predict whether a given patient is likely to get heart disease, there'd be no reason for this discussion.

   But it doesn't. 

   Sorry to be the bearer of bad news, but the test--which, back in the 1960s, was considered state-of-the-art-has become obsolete. Given the far more accurate measures we now have at our disposal, the old-fashioned HDL-LDL test is long past its expiration date. The prescription you got from your doctor to prevent heart disease was very likely based on a test that's just about as  useful as a horoscope from People magazine.

   How do we know this? Because when you plug in the other, far more accurate predictors of heart disease-- which we'll talk about  throughout this book--it turns out many people with "high LDL" actually have very low risk for heart disease. Conversely, many people with "low LDL" can have a very high risk for a cardiovascular event. (This was true for one of the authors.)

   The danger of continuing to rely on this  obsolete test cuts both ways-many people who have "high LDL" but are actually at low risk are being overtreated with powerful  medications that come with a long list of side effects (see chapter 8). Meanwhile, many people who have "low LDL,' but actually have a high risk for an event, are walking around  untreated, thinking everything's just fine.  And that's tragic.

  Think of it this way: Knowing someone's HDL and LDL is like knowing their political party. But political party does not always predict the way someone is going to vote. In fact, on many important issues, if you want to make an accurate prediction on how someone is going to vote, it's far more important to know their age, sex, and whether or not they're married than it is to know whether they're a Republican or a Democrat.

   And it's the same thing with heart  disease. Except it's far more serious that your predictions be accurate. Make a mistake predicting how someone's going to vote and it's not really a big deal. Make a mistake about whether someone is at risk for heart disease and, well, it's a very big deal--especially if that someone is you or a member of your family.

   That is exactly why we want to see the   "HDL-LDL" test retired forever, replaced  by the far more sophisticated and accurate measures of cardiovascular risk that we now have available. These measures include ApoB, total particle number, and insulin resistance all of which we will go over during the course of this book.