Cholesterol Unveiled Separating Fact from Fiction in Heart Disease – Adapt Your Life® Academy



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Heart Disease

Cholesterol Unveiled Separating Fact from Fiction in Heart Disease

For the new year, I thought I would take a little time to address the most common issue for people coming to me these days. What do you think that might be? The worry about a certain blood test is on just about everyone’s mind. It’s not unsurprising because, for the longest time, we’ve been told to worry about blood cholesterol.

An old professor that I went to meet, when I was interviewing as a young doctor, was also a biostatistician. He wasn’t really ever in the clinic; he was an MD, but more of a professorial person. He said, “Dr. Westman, how do you know something?” I said, as a teaching Internal Medicine resident, “To teach something. That’s how you know it.” He looked at me and said, “No, no, no. Guess again, Dr. Westman.” I didn’t know how you truly know something. He said, “Dr. Westman, the way you know something is to write it, not to teach it.” I have to say that’s one of those things that just stuck with me through the years.

I was at a seminar where we were learning how to speak, and how to be effective communicators as teachers and researchers. In this class that I took, the teacher got up in front of us and gave a five-minute talk with slides. It was pretty clear that he was a nephrologist talking about kidney failure. This was a workshop on how to learn how to be an effective communicator. He asked at the end of his little talk, “How did I do?” And we all said, “Well, that’s great. What a wonderful nephrologist you are.” He said, “I didn’t know anything about what I was just telling you. I was reading those slides. I’m not a nephrologist. I’m a teacher of how you communicate.” We were all snookered by just how a great communicator can make you think that they’re just great teachers. You can just mouth the same thing, and then you’re a teacher and seem like you know everything. So, it was writing.

Getting to the course, writing the cholesterol course – and I blame you guys – was quite an experience. I knew cholesterol was a little controversial and that we’re in a paradigm shift from an old way to a new way, but I didn’t know the extent to which the small amount of change that happens in a clinical trial when you use a drug to treat cholesterol. I didn’t really know how small that was until I wrote it in the course. In a test of whether there’s evidence, a court of law, Professor Feinman at SUNY Downstate and I have been thinking through the years we should put cholesterol on trial and have a judge and have a jury and have a prosecutor and a defense attorney and have them litigate whether cholesterol causes heart disease. It could be total, it could be LDL, or any of those things. It was clear to us that the standard of legal requirement of proof has never been reached for cholesterol and heart disease. Never. And yet, you read articles that say that cholesterol is the cause of heart disease. You have to realize now that this really is a belief system that we hold beyond the science. And a lot of that is required for us to be able to do similar things and think that we’re helping people.

One of the highlights of last year was the long-awaited results of a study on people with high LDLs in the context of a low-carb diet. I’ve been involved in the shepherding of the study through the years and know Dave Feldman, the computer programmer who has raised the money for the study and now is collaborating with one of the world’s leaders in CT angiography in LA. Dr. Budoff gave the first results of the study. The most common question people who come in today have – even before they’re starting the low-carb or keto diet – is, “What is it going to do to my cholesterol?” 25 years ago, I was worried about it. I even took someone out of a study because their LDL went up midway through. Now, if I see your LDL goes up, I say, “Great.” But it took me a long time of seeing people with cholesterol levels. It took me writing a course to really reinforce how little benefit there is, if any, from drug treatment of cholesterol.

Recently, a clinical discussion that I had was all about the lifestyle treatment of cholesterol, not the medication treatment. That’s an important place to start because if you are addressing cholesterol or metabolic syndrome, the new way to look at the blood panel – the lipid panel, you could take a drug, or you could make a lifestyle change. You don’t have to take drugs. And yet that’s all our doctors have been taught to do. Even today at Duke, the internal medicine residents and family doctors, my colleagues, and the attendings, teach young doctors how to use drugs and how to use medications. It’s not that that’s the best way to do it. It’s not that there’s a large benefit from doing those sorts of things. It’s just all they know.

Even before you worry about whether you’re going to make a change of a drug treatment or lifestyle change, cholesterol is not a disease. It’s atherosclerosis that we’re trying to prevent, not cholesterol. If ever a doctor or friend or relative or well-intentioned neighbor is worrying about cholesterol, hang on. What we’re worried about, really, is the prevention of arterial disease. If it’s in the neck or the carotid artery, that might lead to a stroke. If it’s a small artery in the brain, that could lead to a stroke. If it’s an artery in the heart, it might lead to a heart attack. Those are all terrible things. What I’m hearing over and over again is what’s called fear-mongering and bullying, where the anxious, panicked doctor is trying to persuade you to take a medicine to change the cholesterol level when they don’t even know if you have a disease called atherosclerosis or not.

I use a lot of metaphors. I try to just bring it out of the context of medicine and the health world because sometimes that’s confusing. You might not think you’re qualified to think about the arteries as pipes and the heart has a pump and all, but that’s really all they are. If you were inspecting a house before you bought it, you would make sure that the pipes worked and that the water flowed through. What doctors are trained to do now is to just not even be worried about inspecting your arteries. They’re just giving you medicine because they assume you have, or you’re going to have, atherosclerosis. That’s the disease. Cholesterol is not a disease. The disease we’re trying to prevent is atherosclerosis, or hardening of the arteries or narrowing of the arteries or blockage of the arteries.

The only blood cholesterol level that we worry about like danger is the triglyceride being super high. There’s never been a case of the LDL or total cholesterol being so high that it caused anyone to immediately keel over. If the triglyceride is thousands – 5,000, 10,000, 15,000 – that can cause pancreatitis. We hospitalize people who have super high triglycerides. Never be worried or have fear given to you for not treating a cholesterol number. There’s time to wait. There’s no urgency.

In a recent encounter, it was even worse because the patient was being treated with a drug. It was one of the statin drugs, and he was having lots of side effects from the drugs. The response of the doctors was, “Well, just take a drug to treat the side effects of the drug” There is an irony in treating the medicine side effect with a side effect drug and then another drug in it. That’s one way to do things.

You can get your arteries measured by ultrasound, CAT scan, or even by invasive cardiac catheterization, meaning they insert a tube into an artery and thread it up to the heart. They inject some contrast dye material and they can see the arteries of the heart. That’s usually reserved for people who are having chest pain or they’re at high suspicion of having a heart attack. Many of you may have already had that kind of test done, which is the best way to examine these tubes or pipes of coronary arteries. Ultrasound is not good enough to see the arteries of the heart, but it’s good enough to see the neck arteries and the aorta or the abdominal arteries and even give you an idea of how well the heart is squeezing.

I’m a big fan of looking at your own arteries because doctors generally won’t do it for you, or the health system isn’t set up for prevention. The doctor will say, “Well, I can’t order that unless you have a symptom.” Our medical world generally waits until it’s too late. It’s not oriented to prevention. Some companies go around and measure your arteries for you. Yes, you have to pay a little bit of money. Recently, it cost $150 generally for these ultrasound tests. That is the coronary artery calcium score, which is a measure of the coronary arteries but doesn’t tell you about blockages. It tells you about calcium. It’s a bit of a Pandora’s box because if you do have calcium, it doesn’t mean you have blockage unless the calcium is really high. But a lot of people are using it to rule out disease, meaning if the calcium score is zero, it reassures you that you’re at very low risk even without treatment or with medication, even in the context of a high LDL.

Cardiologists who are writing papers about that, who do all these scans, are in the fringe element of the cardiology world. While these are cardiologists saying those sorts of things, they’re not the mainstream. The thinking is that Westerners will get heart disease, so you’re probably going to get it. Since the cholesterol level is correlated with it, you have high cholesterol, so we’ll just treat you with a drug for the cholesterol, even though I have no idea if you have the disease atherosclerosis. It’s crazy. Is that the logic? It’s not logical.

Now see if you buy this one: “Just about every American or Canadian or Australian, gets cancer so it’s just a matter of time. I’m going to give you radiation treatment so that we can prevent cancer for you.” Would you take it? No. In fact, cancer doctors are well known to be so picky that they need a tissue diagnosis. They wouldn’t open their tool chest of toxic therapies – surgery, radiation, or chemotherapy – unless they had true evidence that there was disease.

Cardiologists, family doctors, and internists are giving you treatment for a disease that they don’t know you have or don’t have. If they’re giving you treatment for a cholesterol level, cholesterol is not the disease. Don’t expect your doctor to understand this level of reasoning. Most of the time, they’ll be just following a guideline. Most doctors have never been on a guideline panel. I have been on a guideline panel. It was for smoking cessation within the Veterans Affairs hospital. There was no agreement when we were trying to come up with this guide. There were ten different experts and ten different opinions. Somehow, we had to come up with a consensus. In that situation, it was the person who yelled the loudest and said, “No, I won’t give up this little piece” of what she was talking about that got into the final guideline. Guidelines and guideline panels are fraught with human disagreement. To think that you would then tell a cohort of doctors, nurse practitioners, and PAs to follow a guideline without customization or personalization is not thinking about the individual; it’s thinking about the entire group.

I often pull up the Mayo Clinic Statin Decision Aid tool. It’s a website, and I’ll put in the values of an individual. It gives you a percent likelihood that you might have a heart attack in the next 10 years, and then it graphically shows you what that risk will be. And then if you took a statin treatment, what would the risk reduction be? In this recent discussion, the entire visit was spent just talking about cholesterol, and the worry and the fear. The other doctor made this person freak out about it. For that individual, the risk over the next 10 years of having a heart attack was 6%, and in a graphical display, that means 94 of these little circles are smiley faces, and then six little circles are the frowny faces of someone having a problem. With statin treatment, the risk went down to 4%. Showing it in a visual form and then with the numbers, it was pretty clear that this individual didn’t think that was a big change. That’s my perspective talking about it for one individual. It’s up to you whether you would want to take treatment; whether you think 6 out of 100 is a risk high enough to take action about is a personal decision. In fact, he said, “I was expecting more like 40% to 20%.” No, it was 6% to 4%. What you want to do is have some sort of calculation of your personalized risk and then see what the estimate of a drug treatment effect would be.

We don’t have those tools about what will happen or what we predict will happen with lifestyle change. Diabetes is the most powerful risk for heart disease. Diabetes, pre-diabetes, obesity, high triglycerides in the blood, low HDL, and blood pressure being elevated, are high-risk factors for heart disease. And they all get better on a low-carb keto diet. So while there aren’t clinical trials showing that these changes will definitely work for you, the rationale and the theory are pretty solid that this will be okay in the long run. But you don’t know, so that’s where I get back to measuring the arteries.

Let me take you back to the study that came out and was presented by Dr. Budoff in LA. They took a hundred people on a keto diet by self-report for about five years on average. These people said they’d been on keto for five years. They didn’t get ultrasounds here or assume that the coronaries were a certain way. They did a CT scan of the coronary arteries of the heart. The idea was that these people were supposedly at super high risk for heart disease, meaning coronary artery atherosclerosis. For the longest time, they couldn’t find anyone to do the research, and there was no academic collaborator who would. They all said, “This is unethical. Those people should get off that diet. It’s going to kill them.” Well, it turns out that Dave Feldman has that phenotype, meaning his LDL is high. What you’re finding in this group that they’re studying is that the HDL is high too, and the triglyceride is low. In comparison to a group of people in Miami who had the same scan and who didn’t have any clinical evidence of heart disease, the scans were the same, but the values in the blood of the LDL, the HDL, and the triglyceride were different. The study itself is: let’s follow a hundred people over a year and let’s see if there’s a change in this scan result. The baseline data that was presented is just the beginning of it. However, a lot of information can be gleaned from it because when I was thinking about it, when have there ever been a hundred people with coronary artery angiograms on the same type of diet? I’m not aware of this study being done on any diet, even Mediterranean, or vegan. No one’s ever taken the time to study a hundred people to see what their arteries are like. It’s truly groundbreaking.

20 people, for some reason, did not have the right information so they presented 80 people, even though there are 100 total. Of those 80 people, 40 of them had no evidence of coronary disease at all. Even though their LDLs were high – at 250 and 300 mg/dL (6.4 and 7.7 mmol/L), there was one person with an LDL of 590 mg/dL (15.2 mmol/L) – there was no evidence of coronary artery disease. If having high LDL means you’re going to die, then everyone would have had heart disease in this study! On average, they’ve been following for five years with super high LDLs. The highest score was 13. The range of the score was from 0 to 45. What’s a little discouraging, but it’s the best we do, is that the score is determined by a human looking at 15 different areas of the coronary arteries and giving it a score of 0, 1, 2, or 3. I asked Dave about this. I said, “Is that the best you can do?” He said, “No, there’s actually going to be a computer quantifying it to verify the human estimate.” The highest one had a score of 13. Zero being no plaque, 1 being mild plaque, 2 being moderate, 3 being severe. It could be that that person had a severe plaque because that’s only 3 and there was a 13 of the score. Or that person could have had a 1, 1, 1, 1, 1, 1, 1, 1, 1, 13 times out of the 15 different places. What I’m just trying to explain is that the measurement has its limitations, and to go from a 0, no plaque, to a 1, over a year is a lot of plaque when you think about it. Over this one-year period, we have at least 40 people now in a study, and they’re going to be 40 people with a 0. The other people had a 1 or 2 or the highest being 13. The comparison will be, did it change from this current baseline to a change in the artery themselves? This isn’t the cholesterol level; this is the atherosclerosis in the artery itself. People have super high cholesterol levels.

If you take on points, if your LDL cholesterol level is 600 mg/dL15.5 mmol/L), it’s okay, don’t freak out. There was one person in this study so far whose LDL was that high for years and had a zero coronary score. So yes, it means that you have to pause the whole concern about LDL in the context of doing a low-carb diet. To totally match to see if you fall into this group, your HDL should be either already high or going up, and your triglyceride should be really low. That’s why I typically talk about changing from the old way (total cholesterol and LDL), to the new way (triglyceride and HDL). You want the triglyceride to be really low; you want the HDL to be as high as you can.

The other difference between this group of LMHR, lean mass hyper-responder, and the Miami heart blood profile is that the CRP or the marker of inflammation was much lower for the higher LDL, low-carb keto followers. That was statistically significantly different from the Miami Heart Group. The explanation we might one day come up with is that this is an anti-inflammatory diet and we now know that inflammation is the root or the first cause toward that atherosclerosis cascade. This may just be reducing the cardiometabolic risk by reducing inflammation as opposed to reducing LDL or some other mechanism.

We have a medical group that just believes that LDL is the cause, and they believe it so much that they will fear monger you to take medicine for treating cholesterol, which is not a disease, because you’re probably going to get atherosclerosis, even though cholesterol might not be the reason. It could be that the statin drugs reduce inflammation. That doesn’t seem to matter. I got letters from the pharmacy saying, “Your diabetic patient isn’t on a statin. It’s the government guideline that all people with diabetes should be on statin medicine.” Doctors are getting pushed to provide medicines. Remember, if you’re doing a lifestyle change, you are taking action. Avoiding the sugar and ultra-processed food blizzard that we have out there is actually taking action.

I’ve been waiting for this study for a long time. Dave Feldman is a poker player. He’s one who knows how to calculate risk, which is fascinating because he probably wouldn’t have gotten into this if he didn’t have a high expectation that he was going to win. Poker players know when to fold. It’s not an open-shut case. To get back to the course that I wrote at the end of that mock trial, I basically wrote it, but the logic was such that the judge let cholesterol off because there really was no proof that cholesterol did cause heart disease, and there these all these other perpetrators who are around who could have done it as well. Just because there’s a gun next to the body that doesn’t mean the gun killed the person. Even if there’s a hole in the heart, did the gun do it, or the person with the trigger? This is more complicated than it’s been made out to be.

In this discussion with my patient, they explained that the other doctors said, “Don’t worry about the disease. Just take the medicine.” But that didn’t persuade this person who thought it through long enough to come spend an hour with me talking about this. The idea of the other doctor being worried for you, and the other doctor is going to feel better when you’re being treated for cholesterol with a pill that they prescribe because that’s what they’re taught to do. They’re taught to follow these guidelines. Although, more and more other doctors are understanding how lifestyle can be very powerful.

If you are just getting started, the most common change in lipid profile for those on a keto diet who are losing weight as well, everything gets better across the board. The most common change is the total cholesterol goes down, the LDL goes down, the triglycerides go down, and the HDL goes up. What we’re talking about in terms of the high LDL levels is maybe 10% of folks. The main thing you want, if you are looking at the triglyceride-HDL ratio or at the blood lipid profile, is to look at triglyceride and HDL and the inflammation markers, like CRP. Although the triglyceride-HDL ratio, if it’s under one or 1.5 or 1, then that correlates really well with low inflammation. If asked, I look at the triglyceride and HDL ratio as well.

At the end of the day, though, I leave the discussion at, “Let’s not just talk about cholesterol. Let’s talk about whether you have the arterial disease.” Remember, repeat after me: cholesterol is not a disease. The disease we’re trying to prevent is atherosclerosis. If you go in and tell that to your doctor, I’d love to know what the response is.

Regarding Dave’s study, again, these are just the baseline data. It’s self-reported that the participants did keto diets. I don’t know why they would lie about it, but the real study now has started, so the clock’s ticking. People have to verify that they’re in ketosis by measurements and blood and then weight measurements. They’re hopefully all going to come back and get another scan to be compared again. It’s a score of 0-1-2-3 in 15 different areas of the arteries. 40 of the people had zeros over the entire coronary artery system, which I think is the take home point of the baseline data. If LDL was as bad as everyone said and everyone needs a reduction in it, then everyone should have had some sort of disease. That’s not the case.

I went through this 25 years ago when everyone told me that I would kill people if I put them on the Atkins diet. Did I ever tell you the story that the hospital director wanted to shut down the first study because a dietitian complained about it? One day, hopefully, the whole story will come out, but my friends who were on the research committee – they made young professors like me be on the research committee to do all the grunt work – said, “No, we’re not going to make Westman do the study, but we’re going to make him file more reports.” I had to file monthly reports. They hassled me to show that I wasn’t killing people. Now, I laugh at it. At the time, I didn’t know. I was like on Christopher Columbus’s boat up high looking to make sure the end of the world isn’t coming. We haven’t gotten to the end of the world in terms of the low-carb keto diet.

I’m afraid what we have are our silos of people. If you go into the “church of LDL cholesterol” and say there is no relationship of LDL to heart disease, you’re not welcome there. There’s a whole society, the National Lipid Association, which all they do is treat the intermediate marker of cholesterol with drugs. I presented there a few times and never was asked back because, again, they don’t really want to know about lifestyle. They’re just trying to find drugs. The doctor said, “My patients don’t want to change their diet.” I asked, “Do you give them a choice?” “No.” “Well, what do you expect?”

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