During political poll, 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.
If you are one of the millions of people who got a clean bill of health because of low LDL, very high, you are at great risk and are going untreated. (This was exactly the case with Jonny.) Similarly, if you're one of the millions of people on a statin because of high LDL but your total particle number is actually very low, you're probably on a medication you don't need and putting up with side effects that you don't have to endure.
Study after study shows us that relying on LDL alone misses an awful lot of heart disease. That's a lot of people dying because they were diagnosed using an obsolete test. Our hope is that this book will change that. It's our mission to see the "good and bad cholesterol" test replaced by measures that do a far better job of accurately predicting cardiovascular disease than "LDL cholesterol."
A GUIDE TO USING THIS POST
In this first part of the post, you'll learn exactly what cholesterol is and what it isn't, and how it really works in the body (Be prepared to be surprised.) In clear understandable terms you'll learn how atherosclerosis actually develops, and you'll understand the critical role of chronic inflammation and oxidative damage.
Then in part two, we'll introduce the real villain of the heart disease story: sugar. You'll see why sugar got a free pass all these past few decades while fat was blamed for our health woes, and you'll come to see what a huge mistake that was. (And it's still going on.)
You'll see the clear lines from sugar and starch intake to diabetes, and the frighteningly short line from diabetes to heart disease. You'll also come to understand the very insignificant role dietary fat plays in all of this. Finally, you'll learn a lot about the real effects of statin drugs and how clever and insidious marketing has made them into the blockbuster drugs they are today.
In part three, we'll tell you the way to combat the real promoters of heart disease - inflammation and insulin resistance. We'll talk about the things you can do to build and maintain a healthy heart for decades and decades: food, supplements, activity, relationships, community. We kiddingly referred to this last section of the book as our "Eat-Play-Love" section, but only half in jest.
Both of us- with more than eighty years of combined experience in the health field- have firmly and independently concluded that it's not just what you eat and how you exercise that determines your health, though those things certainly matter. But it's also how you love, how you think, how you feel, how you digest, how you manage stress, how you contribute, how you sleep, how you kick back and relax, how you meditate, how you contemplate, and how you play. They are all related. They all matter. And every one of them has an impact on the health of your heart. A lot more than your cholesterol level does.
Enjoy the journey of discovery that awaits you.
"WHAT DOES MY CHOLESTEROL TEST MEAN?"
Dr. Jonny: A friend of mine recently brought me his cholesterol test. He showed me four measurements: total cholesterol, HDL, LDL, and triglycerides. He asked me, based on these numbers, to tell him whether or not I thought he was at a risk for an "event."
I explained that, based on these numbers, there was no way to tell.
Let me explain.
Let's say you' re playing poker against someone who has two deuces showing. What can you positively say about that hand? Not much really. You can say for sure that he doesn't have a royal flush or a straight. But without knowing the other three cards, there's no way you can predict whether he has a winning (or losing) hand. You have to decide to bet (or not bet) based on incomplete evidence, which is why poker is ultimately a game of "chance."
But you don't want guessing about heart disease to be a game of chance. And you don't want it to be based on incomplete evidence. HDL and LDL are like the visible two cards in a poker hand. Your doctor is "betting" on whether or not you're going to get heart disease based on this woefully incomplete information,
This is a tragedy for two reasons. One, because whether or not you're at risk for a heart attack is way more consequential than whether or not you have a winning poker hand. And two, because your doctor now has an easily accessible way to check the other three cards so she doesn't have to guess!
PART ONE
In part one, we tell you how we came together to write the original edition of The Great Cholesterol Myth. We'll take you on our own personal journeys of discovery when our suspicions were (independently) raised about whether we had been told the whole story about fat and cholesterol. You'll see how we went from being true believers in the low-fat diet and in the cholesterol hypothesis, to disrupters and challengers of conventional thinking about heart disease, cholesterol, and statin drugs.
CHAPTER 2
WHY YOU SHOULD
BE SKEPTICAL OF LDL
AS AN INDICATOR OF
HEART DISEASE
THE TWO OF US CAME TOGETHER TO WRITE THIS BOOK because we believe that you have been completely misled, misinformed, and in some cases, directly lied to about cholesterol.
We believe that misinformation, scientifically questionable studies, and corporate greed have created one of the most indestructible and damaging myths in medical history: that cholesterol causes heart disease and that statins are the answer.
The millions of marketing dollars spent on perpetuating this myth have successfully kep us focused on a relatively minor character in the heart disease story- and created a market for cholesterol-lowering drugs worth more than US$30 billion a year. The real tragedy is that by putting all of our attention on cholesterol, we've virtually ignored the real causes of heart disease: inflammation, oxidation, sugar, and stress.
In fact, as you'll learn in this book, cholesterol numbers as they are now tested --i.e. "HDL" and "LDL"- are a pretty poor predictor of heart disease; up to 70 percent of people hospitalized with heart attacks have perfectly normal cholesterol levels, and about half the people with elevated cholesterol levels have perfectly normal, healthy tickers.
(Those numbers might change if doctors used the much more modernized version of cholesterol tests, which we'll talk about throughout the book- but they continue to use the old-fashioned "good" and "bad" test that predicts about as accurately as flipping a coin.)
Many of the general dietary guidelines accepted and promoted by the government and by major health organizations such as the American Heart Association are either directly or indirectly related to cholesterol phobia. These standard guidelines warn us to limit the amount of cholesterol we eat, despite the fact that for at least 95 percent of the population, cholesterol in the diet has virtually no effect on cholesterol in the blood.
These guidelines warn us of the dangers of saturated fat, despite the fact that the relationship between saturated fat in the diet and heart disease has never been convincingly demonstrated, and despite the fact that research shows that replacing saturated fat in the diet with carbohydrates actually increases the risk for heart disease.¹
Both of us became skeptical of the cholesterol theory at different points in our careers, traveling different pathways to arrive at the same conclusion: Cholesterol does not cause heart disease.
We also believe that, unlike trans fat, for example, saturated fat is not the dietary equivalent of Satan's spawn (and we'll show you why). Finally, and most important, we strongly believe that our national obsession with lowering cholesterol has come at a considerable price. Cholesterolmania has caused us to focus all our energy around a fairly innocuous molecule with a marginal relationship to heart disease, while ignoring the real causes of heart disease.
We're each going to tell you in our own words how we became cholesterol skeptics and why we fervently believe the information contained in this book could save your life.
DR. JONNY
Before I became a nutritionist and ultimately an author, I was a personal trainer. I worked at Equinox Fitness Clubs in New York City, and the vast majority of my clients were there for one thing: weight loss. It was 1990. Fat was considered dietary enemy number one, and saturated fat was considered especially bad because we all "knew" it clogged your arteries, raised your cholesterol, and led to heart disease. So, like most trainers, I put my clients on low-fat diets and encouraged them to do a ton of aerobics plus a little bit of weight training.
Which worked.
Sometimes.
More often than not, the strategy bombed.
Take Al, for example. Al was an incredibly successful, powerful businessman in his early sixties with a huge belly he just couldn't get rid of. He was eating a very low-fat diet, doing a ton of aerobics on the treadmill in his house, and yet his weight was hardly budging. If everything I had been taught as a personal trainer was right, that shouldn't have been happening.
But it was.
Then Al decided to do something I didn't approve of. He went on the Atkins diet. Remember, those were the days when all of us were taught that fat, especially saturated fat, was pure evil. We had been taught that we "need" carbohydrates for energy and survival.
We had been taught that diets such as the Atkins diet were dangerous and damaging, largely because all that saturated fat would clog your arteries, raise your cholesterol, and lead to a heart attack.
So I was pretty sure Al was headed for disaster.
Except he wasn't.
Not only did he start shedding weight and losing his substantial "apple-shaped" belly, but he also had more energy and was feeling better than he had in decades. I, meanwhile, was impressed with Al's results, but I was convinced he was paying a huge price and that once he got the blood test results from his annual physical, I would be vindicated.
I wasn't.
Al's triglycerides-a type of fat found in the bloodstream and elsewhere--had dropped, his blood pressure had gone down, and his cholesterol had risen slightly, but his "good" cholesterol (HDL) had gone up more than his "bad" cholesterol (LDL), so overall his doc was pretty happy.
Right around this time, Dr. Barry Sears the MIT-trained biochemist and creator of the Zone diet- -came to give workshop at Equinox. It was there, thirty years ago, that I first learned this critical lesson: Food has a hormonal effect.
When it comes to gaining and losing weight, it's hormones-even more than calories-that control the show.
And hormones are controlled by food.
For example: Carbs in general stimulate hormones that promote weight gain; fat does not. Ergo, up the fat in the diet a bit and reduce the carbs a bit. It's a way better approach to hormone management.
But conventional medicine argued that fat would raise your cholesterol, which, of course, would eventually kill you. In the end, the argument against high-fat diets always hinged on cholesterol. Conventional medicine collectively thought that a high fat diet like the one my client Al was on would produce disastrous results.
Right around this time, a biochemist named Barry Sears came to New York City to give a workshop at Equinox, which, of course, I eagerly attended. Sears, whose Zone diet books have sold millions, had a novel approach that can be summed up in four words: eat fat, lose weight. If Sears had been anything but an MIT-trained biochemist, he probably would have been laughed out of the room. But given his credentials and remarkable knowledge of the human body, he was pretty hard to dismiss.
Now Sears wasn't the first one to embrace fat and protein in the diet and recommend that we eat fewer carbs. Atkins, whose original diet was the one Al had tried so successfully, had been saying similar things since 1972. But the whole rap against Atkins was that his diet was high in saturated fat and would therefore likely cause heart disease.
So even though many people grudgingly admitted that you could lose weight easily following his program, everyone (including me) believed that the cost would include a hugely increased risk for heart disease.
What If the Whole Theory That Cholesterol Causes Heart Disease Was Wrong in the First Place?
Meanwhile, my eyes were telling me something very different, and it wasn't just because of what I had seen happen with Al. It was happening with other clients as well. Sick of not getting results on low-fat high-carb diets, they threw caution to the wind and embraced the Atkins diet and the Protein Power diet and other diets that had in common that they limited carbohydrate intake. They were eating more fat- even more saturated fat- but nothing bad was happening at all, unless, of course, you count feeling better and getting slimmer as nothing.
Which got me thinking.
Why weren't we seeing consistent results with our clients who were faithfully following low-fat diets and getting plenty of aerobic exercise? Conversely, why were our clients who were going on low-carb diets getting such high marks on their blood tests and astonishing their doctors? What if everything we'd been told about the danger of saturated fat wasn't exactly correct? And- if what we'd been taught about saturated fat wasn't the complete truth — what about this relationship between fat and cholesterol? Was it really all as simple as I'd been taught?
After all, even back in the early 1990s when people only talked about "good" and "bad" cholesterol, it was still obvious that, overall, saturated fat had a positive effect on Al's cholesterol, as it did on the cholesterol levels of so many of my other clients. Saturated fat raised folks HDL much more than it did their LDL, which, by the standard of the day, was a good thing. Could this whole cholesterol issue be a little more complicated than I and everyone else had previously believed?
Eventually, I thought-going way out on a limb here what if the whole theory that cholesterol causes heart disease was wrong in the first place? If that were the case, the effect of saturated fat on cholesterol would be pretty much irrelevant, wouldn't it?
Then I began reading the studies.
The Lyon Diet Heart Study² found that certain dietary and lifestyle changes were able to reduce deaths by 70 percent and reduce cardiovascular deaths by an even more impressive 76 percent, all without making as much as a dent in cholesterol levels. The Nurses' Health Study³ found that 82 percent of coronary events were attributable to five factors, none of which had anything to do with lowering cholesterol. And that was just the tip of the ever-growing iceberg.
Study after study on high-protein, low-carb diets-including those rich in saturated fat- showed that the blood tests of people on these diets were similar to Al's. Their health actually improved on these diets. Triglycerides went down. Other measures that indicated heart pdisease risk also improved.
In the mid-90s I went back to school for nutrition, ultimately earning a Ph.D. in what was then called "holistic" (integrative) nutrition and a C.N.S. (certified nutrition specialist) certification from the Certification Board for Nutrition Specialists, which is associated with the American College of Nutrition. During my studies, I talked to many other health professionals who shared my concerns, including one of the top lipid biochemists in the country, the late Mary Enig, Ph.D. She did some of the early research on trans fats and fervently believed that it is trans fats, not saturated fats, that are the real villains in the American diet; I wholeheartedly agree Enig was hardly alone in thinking that we have been collectively brainwashed on the subject of saturated fat and cholesterol.
When Americans were consuming whole, full-fat foods such as cream, butter, pasture-raised meats, raw milk, and other traditionalfoods, the rate of heart disease was a fraction of what it is now. Many of us began to wonder whether it was a coincidence that the twin global pandemics of obesity and diabetes just happened to occur around the time we collectively banished these foods because of the phobia about cholesterol and saturated fat in the diet and began to replace them with vegetable oils, processed carbs, and, ultimately, trans fats.
Study after study has shown that lowering the risk for heart disease has very little to do with lowering cholesterol. And more and more studies reports were coming out demonstrating that the real initiators of damage in the arteries were oxidation and inflammation. These factors, along with sugar and, were clearly what aged the human body the most. These were the culprits we should be focused on.
In my career, I have examined the strategies that seemed to work for the healthiest, longest-living people on earth and found that lowering cholesterol has almost nothing to do with reducing heart disease, and definitely nothing to do with extending life. One of the greatest frustrations I experienced was trying to reassure my clients that with a higher-protein, higher-fat diet they'd see significant improvements in their weights and the health of their hearts. I was constantly butting heads with my clients' doctors, who completely bought into the myth that saturated fat will kill you by clogging your arteries, raising your cholesterol, and ultimately leading to heart disease. And that anyone who thought otherwise was clearly a whack job or at the very least "anti-science."
Fast-forward to 2010. Fair Winds Press —my publisher for thirteen books over the course of seven years came to me with an idea. "How about a book on how to lower cholesterol with food and supplements?" they asked.
To which I replied, "I'm probably not the guy to write that one, I don't think lowering cholesterol matters very much.'"
As you can imagine, that was met with a collective startle. My publishers were more than a little curious. "How can lowering cholesterol not be important?" they wanted to know. "Don't doctors believe high cholesterol is the cause of heart disease? Don't they believe that lowering it is the most important thing you can do when it comes to preventing heart attacks?"
"They do indeed," I replied, "and they're wrong.
The book I wanted to write reveals the truth about cholesterol and heart disease. To do it, I joined forces with my friend Steve Sinatra, a board-certified cardiologist, trained psychotherapist, and nutritionist.
DR. SINATRA
Most doctors today will recommend that you take a statin drug--they might even nag you to do so-if your cholesterol numbers are high. They will do so whether or not you have evidence of arterial disease and are a man or woman, and despite your age. In their minds, you prevent heart disease by lowering cholesterol.
Once upon a time I used to believe that, too. It made sense, based on the research and information that was promoted to doctors. I believed it to the extent that I even lectured on behalf of drug makers. was a paid consultant to some of the biggest manufacturers of statin drugs, lecturing for hefty honorariums. I became a cholesterol choirboy, singing the refrain of high cholesterol as the big, bad villain of heart disease. Beat it down with a drug, and you cut your risks. My thinking changed years ago when I began seeing conflicting evidence among my own patients. I saw, for instance, many patients with low total cholesterol — as low as 150 mg/dL! — develop heart disease.
In those days we pushed patients to undergo angiograms (invasive arterial catheterization imaging) if they had sufficient symptoms of chest pain, borderline exercise tests, and especially cholesterol readings of greater than 280 mg/dL. We did this because our profession believed that all people with high cholesterol were in danger of having a heart attack.
We did the imaging to see how bad their arteries were. And, indeed, sometimes we found diseased arteries. But just as often we didn't. Many arteries were perfectly healthy. These results were telling me something different than the establishment message — that it wasn't just a simple cholesterol story.
Faced with these discrepancies I began questioning and investigating conventional thinking about cholesterol and looking at the cholesterol research more closely. I found other doctors who had made similar discoveries on their own and heard about how study findings were being manipulated.
For example, biochemist George Mann, M.D., of Vanderbilt University, who participated in the development of the world-famous Framingham Heart Study, later described the cholesterol-as-an-indicator-of-heart disease hypothesis as "the greatest scam ever perpetrated on the American public."
These and other dissenting voices were drowned out by the cholesterol chorus. To this day, practically all of what has been published and receives media attention — supports the cholesterol paradigm and appears to have the backing of the pharmaceutical and low-fat industries along with leading regulatory agencies and medical organizations.
However, I stopped being a choirboy for cholesterol. I stopped believing. Here's why:
I found that life can't go on without cholesterol, a basic raw material made by your liver, brain, and almost every cell in your body. Enzymes convert it into vitamin D, steroid hormones (such as our sex hormones estrogen, progesterone, and testosterone and stress hormones), and bile salts for digesting and absorbing fats. It makes up a major part of the membranes surrounding cells and the structures within them.
The brain is particularly rich in cholesterol and accounts for about a quarter of all the cholesterol we have in our bodies. The fatty myelin sheath that coats every nerve cell and fiber is about one-fifth cholesterol. Neuronal communication depends on cholesterol. It is not surprising that a connection has been found between naturally occurring cholesterol and mental function. Lower levels are linked to poorer cognitive performance. I remember one patient- a federal judge I'll call Silvio---who came to see me. He was taking a statin drug and complained that his memory had gone to pot, so much so that he voluntarily took himself off the bench. His LDL level was down to 65 mg/dL. I took him off the statin, told him to eat a lot of organic, cholesterol-rich eggs, and within a month got his LDL level up above 100 mg/dL. His memory came roaring back. (Memory loss is one potential side effect of cholesterol-lowering drugs.)
Some researchers suggest that doctors should be extremely cautious about prescribing statin drugs to the elderly, particularly those who are frail. I totally agree. I have seen frail individuals become even frailer and much more prone to infections. Though that surprised me at the time, it no longer does. Cholesterol plays a big role in helping fight bacteria and infections. A study that included 100,000 healthy participants in San Francisco over a fifteen-year period found that those with low cholesterol values were much more likely to be admitted to hospitals with infectious diseases.⁴
strong pumping action of the heart, which gobbles the stuff up. And in the early 1990s I discovered something that shook my belief in statin drugs to the core — they depleted the body of CoQ10.
That fact is widely known now, but it wasn't then. And it certainly gave me pause. How could these miracle drugs that were believed to be the answer to heart disease be good for you in the long run if they depleted the very nutrient upon which the heart depends?
Even today, many doctors aren't aware of the effect that statin drugs have on CoQ10 levels. How ironic that the very drug they prescribe to reduce the likelihood of a heart attack actually deprives the heart of the fuel it needs to perform properly? No wonder fatigue, low energy, and muscle pain are such frequent accompaniments to statin drug use.
It wasn't until the mid-1990s that statin drugs really took off, but before then physicians had other go-to drugs for lowering cholesterol. Many research studies were conducted using these drugs, and in 1996 the U.S.Government Accountability Office evaluated these trials in a publication titled Cholesterol Treatment: A Review of the Clinical Trials Evidence. The report explained that though some trials showed a reduction in cardiovascular-related deaths (primarily among those who entered the studies with existing heart disease), there was a corresponding increase in non-cardiovascular- related deaths across the trials. "This finding, that cholesterol treatment has not lowered the number of deaths overall, has been worrisome to many researchers and is at the core of much of the controversy on cholesterol policy,"' the authors wrote.
It was also quite clear from the report that those who benefited the most from lowering their cholesterol levels were middle-aged men who already had heart disease. "The trials focused predominantly on middle-aged white men considered to be at high risk of coronary heart disease," the report stated." They provide very little information on women, minority men and women, and elderly men and elderly women."
It's been more than a decade since that report was written, but it remains true that lowering cholesterol has a very limited benefit in populations other than middle-aged men with a history of heart disease. Yet doctors continue to prescribe statin drugs for women and the elderly, and, shockingly, many are arguing for treating children with statins as well.
By now my conversion from cholesterol true believer to cholesterol skeptic is complete, I still prescribe statins- -but only on occasion, and almost exclusively to middle-aged men who've already had a first heart attack, coronary intervention (e.g., bypass, stent, angioplasty), or coronary artery disease.
I've come to believe that cholesterol is a minor player in the development of heart disease and that whatever good statin drugs accomplish has very little to do with their cholesterol-lowering ability. Statin drugs are anti-inflammatory, and their power to reduce inflammation is much more important than their ability to lower cholesterol. But we can lower inflammation (and the risk for heart disease) with natural supplements, a better diet, and lifestyle changes such as managing stress. Best of all, none of these come with the growing laundry list of troubling symptoms and side effects associated with statin drugs and cholesterol lowering.
LIKE DEAD MEN WALKING
So there you have it. Two individuals with very different journeys arriving at the same conclusion. And because that conclusion may be pretty hard to swallow if you've been brainwashed by the cholesterol establishment — and who hasn't? — it might be helpful to take a moment and talk about a study we alluded to earlier — the Lyon Diet Heart Study.
In the early 1990s, French researchers decided to run an experiment — known as the Lyon Diet Heart Study- -to test the effect of different diets on heart disease.
They took 605 men and women who were prime candidates for heart attacks. These folks had every risk factor imaginable. All of them had already survived a first heart attack. Their cholesterol levels were through the roof, they smoked, they ate junk food, they didn't exercise, and they had high levels of stress. People like this give insurance underwriters nightmares. To be frank, these folks were "dead men walking."
The researchers divided the participants into two groups. The first group was counseled (by the research cardiologist and the dietician during a one-hour session) to eat a Mediterranean-type diet that emphasizes fresh fruit and vegetables, whole grains, legumes, nuts, healthy fats such as olive oil, and seafood. The second group was the control group and received no dietary advice from the investigators but was advised, nonetheless, to follow a prudent diet by their attending physicians.
What was this prudent diet, you ask?
Pretty much the standard (and, as we shall see, useless) diet that doctors have been recommending for decades: Eat no more than 30 percent of your calories from fat, no more than 10 percent from saturated fat, and no more than 300 mg of cholesterol a day (about the amount in two eggs). So what happened with the study?
Lowering cholesterol has a very limited benefit in populations other than middle-aged men with a history of heart disease.
Actually, it was stopped.
Why? Because the reduction in heart attacks in the Mediterranean diet group was so pronounced that the researchers decided it was unethical to continue. To be precise, the Mediterranean diet group had a whopping 70 percent reduction in deaths and an even more impressive 7 6 percent
